Anthony O. Asemota

Predictors of outcome in acute encephalitis

Objective: To investigate predictors of outcome in patients with all-cause encephalitis receiving care in the intensive care unit. Methods: A retrospective analysis of encephalitis cases at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center was performed. Using multivariate logistic regression analysis, we examined mortality and predictors of good outcome (defined as modified Rankin Scale scores of 1–3) and poor outcome (scores 4 and 5) in those surviving to hospital discharge. Results: In our cohort of 103 patients, the median age was 52 years (interquartile range 26), 52 patients (50.49%) were male, 28 patients (27.18%) had viral encephalitis, 19 (18.45%) developed status epilepticus (SE), 15 (14.56%) had cerebral edema, and 19 (18.45%) died. In our multivariate logistic regression analysis, death was associated with cerebral edema (odds ratio [OR] 18.06, 95% confidence interval [CI] 3.14–103.92), SE (OR 8.16, 95% CI 1.55–43.10), and thrombocytopenia (OR 6.28, 95% CI 1.41–28.03). Endotracheal intubation requirement with ventilator support was highly correlated with death (95%). In addition, in those patients who survived, viral, nonviral, and unknown causes of encephalitis were less likely to have a poor outcome at hospital discharge compared with an autoimmune etiology (viral encephalitis: OR 0.09, 95% CI 0.01–0.57; nonviral encephalitis: OR 0.02, 95% CI 0.01–0.31; unknown etiology: OR 0.18, 95% CI 0.04–0.91). Conclusions: Our study suggests that predictors of death in patients with encephalitis comprise potentially reversible conditions including cerebral edema, SE, and thrombocytopenia. Further prospective studies are needed to determine whether aggressive management of these complications in patients with encephalitis improves outcome.

Causes and Trends in Traumatic Brain Injury for United States Adolescents

Traumatic brain injury (TBI) is a leading cause of death and disability among United States adolescents. The authors sought to determine causes and trends for TBI-related hospitalizations in the United States adolescent population (10-19 years). The authors identified common causes and trends of adolescent TBI, overall and within 2-year age categories, using hospitalization data from 2005 to 2009 in the Nationwide Inpatient Sample. The leading cause of adolescent TBI overall was motor vehicle occupant accidents (35%), which are also the leading cause in the 14-15, 16-17, and 18-19 year age groups. Falls were the cause of most TBI in the 10-11 year (23%) and 12-13 year (20%) age groups. For both unintentional and intentional mechanisms of injury, there was evidence of increasing hospitalizations with increasing age. From 2005 to 2009, the overall annual incidence of adolescent TBI hospitalizations decreased 21% from an estimated 75.5-59.3 per 100,000 (p<0.001). These rates declined for mild, moderate, and severe TBI, and decreased for 2-year age groups, except for the 18-19 year-old group. For TBI attributable to motor vehicle occupants, rates declined 27% from 27.6 to 20.2 per 100,000 (p<0.001). Motor vehicle occupant injuries account for 42% of in-hospital mortality from adolescent TBI; however, firearms are the most lethal mechanism with 46% proportional mortality among victims of firearm-related TBI. Rates of adolescent TBI-related hospitalizations have decreased overall. Motor vehicle accidents and firearms were identified as leading causes of injury and mortality for adolescent TBI, and represent potential targets for intervention.

Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury.

Post-acute inpatient rehabilitation services are associated with improved functional outcomes among persons with traumatic brain injury (TBI). We sought to investigate racial and insurance-based disparities in access to rehabilitation. Data from the Nationwide Inpatient Sample from 2005-2010 were analyzed using standard descriptive methods and multivariable logistic regression to assess race- and insurance-based differences in access to inpatient rehabilitation after TBI, controlling for patient- and hospital-level variables. Patients with moderate to severe TBI aged 18-64 years with complete data on race and insurance status discharged alive from inpatient care were eligible for study. Among 307,675 TBI survivors meeting study criteria and potentially eligible for discharge to rehabilitation, 66% were white, 12% black, 15% Hispanic, 2% Asian, and 5% other ethnic minorities. Most whites (70%), Asians (70%), blacks (59%), and many Hispanics (49%) had insurance. Compared with insured whites, insured blacks had reduced odds of discharge to rehabilitation (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.75-0.95). Also, insured Hispanics (OR 0.52; 95% CI 0.44-0.60) and insured Asians (OR 0.54; 95% CI 0.39-0.73) were less likely to be discharged to rehabilitation than insured whites. Compared with insured whites, uninsured whites (OR 0.57; 95% CI 0.51-0.63), uninsured blacks (OR 0.33; 95% CI 0.26-0.42), uninsured Hispanics (OR 0.27; 95% CI 0.22-0.33), and uninsured Asians (OR 0.40; 95% CI 0.22-0.73) were less likely to be discharged to rehabilitation. Race and insurance are strong predictors of discharge to rehabilitation among adult TBI survivors in the United States. Efforts are needed to understand and eliminate disparities in access to rehabilitation after TBI.

Comparison of Complications, Trends, and Costs in Endoscopic vs Microscopic Pituitary Surgery: Analysis From a US Health Claims Database.

BACKGROUND: Microsurgical and endoscopic techniques are commonly utilized surgical approaches to pituitary pathologies. There are limited data comparing these 2 procedures. OBJECTIVE: To evaluate postoperative complications, associated costs, and national and regional trends of microscopic and endoscopic techniques in the United States employing a nationwide database. METHODS: The Truven MarketScan database 2010 to 2014 was queried and Current Procedural Terminology codes identified patients that underwent microscopic and/or endoscopic transsphenoidal pituitary surgery. International Classification of Diseases codes identified postoperative complications. Adjusted logistic regression and matched propensity analysis evaluated independent odds for complications. RESULTS: Among 5886 cases studied, 54.49% were microscopic and 45.51% endoscopic. The commonest surgical indications were benign pituitary tumors. Annual trends showed increasing utilization of endoscopic techniques vs microscopic procedures. Postoperative complications occurred in 40.04% of cases, including diabetes insipidus (DI; 16.90%), syndrome of inappropriate antidiuretic hormone (SIADH; 2.02%), iatrogenic hypopituitarism (1.36%), fluid/electrolyte abnormalities (hypoosmolality/hyponatraemia [5.03%] and hyperosmolality/hypernatraemia [2.48%]), and cerebrospinal fluid (CSF) leaks (CSF rhinorrhoea [4.42%] and other CSF leak [6.52%]). In our propensity‐based model, patients that underwent endoscopic surgery were more likely to develop DI (odds ratio [OR] = 1.48; 95% confidence interval [CI] = 1.28–1.72), SIADH (OR = 1.53; 95% CI = 1.04–2.24), hypoosmolality/hyponatraemia (OR = 1.17; 95% CI = 1.01–1.34), CSF rhinorrhoea (OR = 2.48; 95% CI = 1.88–3.28), other CSF leak (OR = 1.59; 95% CI = 1.28–1.98), altered mental status (OR = 1.46; 95% CI = 1.01–2.60), and postoperative fever (OR = 4.31; 95% CI = 1.14–16.23). There were no differences in hemorrhagic complications, ophthalmological complications, or bacterial meningitis. Postoperative complications resulted in longer hospitalization and increased healthcare costs. CONCLUSION: Endoscopic approaches are increasingly being utilized to manage sellar pathologies relative to microsurgery. Postoperative complications occur in both techniques with higher incidences observed following endoscopic procedures.

Trends in incidence and severity of sports-related traumatic brain injury (TBI) in the emergency department, 2006–2011

Abstract Objective: To characterize and identify trends in sports-related traumatic brain injury (TBI) emergency department (ED) visits from 2006–2011. Methods: This study reviewed data on sports-related TBI among individuals under age 65 from the Nationwide Emergency Department Sample from 2006–2011. Visits were stratified by age, sex, injury severity, payer status and other criteria. Variations in incidence and severity were examined both between groups and over time. Odds of inpatient admission were calculated using regression modelling. Results: Over the period examined, 489 572 sports-related TBI ED visits were reported. The majority (62.2%) of these visits occurred among males under the age of 18. The average head Abbreviated Injury Severity score among these individuals was 1.93 (95% CI = 1.93–1.94) and tended to be lowest among those in middle school and high school age groups; these were also less likely to be admitted. The absolute annual number of visits grew 65.9% from 2006 until 2011, with the majority of this growth occurring among children under age 15. Hospitalization rates dropped 35.6% over the same period. Conclusion: Changes in year-over-year presentation rates vs. hospitalization rates among young athletes suggest that players, coaches and parents may be more aware of sports-related TBI and have developed lower thresholds for seeking medical attention.

United States trends in thrombolysis for older adults with acute ischemic stroke

OBJECTIVE Thrombolysis for ischemic stroke has been increasing in the United States. We sought to investigate recent trends in thrombolysis use in older adults. METHODS A retrospective, observational analysis of hospitalization data from the Nationwide Inpatient Sample (NIS) in 2005-2010 was performed. Older adults (≥65 years) admitted with a primary diagnosis of acute ischemic stroke were included. Trends in the population-based rates of thrombolysis and outcomes from the NIS were evaluated using the Cochran-Armitage test. RESULTS Thrombolysis in older adult stroke patients increased from 1.7% to 5.4% (2005-2010; trend P<0.001). Large increases were observed among urban patients, urban hospitals, and high volume facilities. Individuals ≥85 years were less likely to receive thrombolysis than younger ages throughout the study period, although there was an increase from an odds ratio of 0.50 (95% CI: 0.44-0.57) to 0.75 (95% CI: 0.69-0.81) from 2005-2006 to 2009-2010 when compared to 65-74 year olds. For those receiving thrombolysis, no change was observed in intracerebral hemorrhage over time. In-hospital mortality rates did not change significantly over the study period for age subgroups and length of stay declined from 2005 to 2010 for the thrombolysis group (7.6 vs 7.0 days; trend P<0.001). CONCLUSIONS Rates of thrombolysis in older adults progressively increased, especially in the oldest old. Increases were largely driven by urban and high volume hospitals.

Why No Signals? Cerebral Anatomy Predicts Success of Intraoperative Neuromonitoring During Correction of Scoliosis Secondary to Cerebral Palsy

Background: Intraoperative neuromonitoring (IONM) is widely used to reduce postoperative neurological complications during scoliosis correction. IONM allows intraoperative detection of neurological insults to the spinal cord and enables surgeons to react in real time. IONM failure rates can reach 61% in patients with cerebral palsy (CP). Factors decreasing the quality of IONM signals or making IONM impossible in CP patients undergoing scoliosis correction have not been well described. Methods: We categorized IONM data from 206 children with CP who underwent surgical scoliosis correction at a single institution from 2002 through 2013 into 3 groups: (1) “no signals,” if neither somatosensory-evoked potentials (SSEP) nor transcranial motor-evoked potentials (TcMEP) could be obtained; (2) “no sensory,” if no interpretable SSEP were obtained regardless of interpretable TcMEP; and (3) “no motor,” if no interpretable TcMEP were obtained regardless of interpretable SSEP. We analyzed preexisting neuroimaging, available for 93 patients, and neurological status of the full cohort against these categories. Statistical analysis of univariate and multivariate associations was performed using logistic regression. Odds ratios (ORs) were calculated with significance set at P<0.05. Results: Multivariate analysis showed significant associations of periventricular leukomalacia (PVL), hydrocephalus, and encephalomalacia with lack of meaningful and interpretable signals. Focal PVL (Fig. 1) was associated with no motor (OR=39.95; P=0.04). Moderate hydrocephalus was associated with no signals (OR=32.35; P<0.01), no motor (OR=10.14; P=0.04), and no sensory (OR=8.44; P=0.03). Marked hydrocephalus (Fig. 2) was associated with no motor (OR=20.46; P<0.01) and no signals (OR=8.83; P=0.01). Finally, encephalomalacia (Fig. 3) was associated with no motor (OR=6.99; P=0.01) and no signals (OR=4.26; P=0.03). Conclusion: Neuroanatomic findings of PVL, hydrocephalus, and encephalomalacia are significant predictors of limited IONM signals, especially TcMEP. Level of Evidence: Level IV.

Comparative Cost Analysis of Single and Mutli-Stage Temporal Deformity Correction Following Neurosurgical Procedures

Purpose: Temporal hollowing deformity (THD) is a visible concavity/convexity in the temporal fossa; a complication often seen following neurosurgical/craniofacial procedures. Although numerous techniques have been described, no study to date has shown the healthcare costs associated with temporal hollowing correction surgery. Thus, the purpose here is to compare and contrast the direct costs related to temporal cranioplasty using various methods including: liquid poly-methyl-methacrylate (PMMA) implants with screw fixation, prebent, modified titanium mesh implants, and customized cranial implants (CCIs) with dual-purpose design. Understanding the financial implications related to this frequently encountered complication will help to motivate surgeons/healthcare facilities to better prevent and manage THD. Methods: This is a single-surgeon, single-institution retrospective review of 23 THD patients randomly selected from between 2008 and 2015. Cost analysis variables include length of hospital stay, facility/professional fees, implant material fees, payer information, reimbursement rate, and net revenue. Results: Of the 23 patients, ages ranged from 23 to 68 years with a mean of 48.3 years (SD 11.6). Within this cohort, 39.1% received dual-purpose PMMA CCIs (CCI PLUS), 17.4% received modified titanium mesh implants, and 43.5% received hand-molded, liquid PMMA implants with screw fixation. Total facility and/or professional charges ranged from

Conscious status is associated with the likelihood of trauma centre care and mortality in patients with moderate-to-severe traumatic brain injury

1978.00 to

Tackling causes and costs of ED presentation for American football injuries: a population-level study

126478.00. Average total facility charges per patient with dual-purpose CCIs were