Debraj Mukherjee

Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme

OBJECTIVEBalancing the benefits of extensive tumor resection with the consequence of potential postoperative deficits remains a challenge in malignant astrocytoma surgery. Although studies have suggested that increasing extent of resection may benefit survival, the effect of new postoperative deficits on survival remains unclear. We set out to determine whether new-onset postoperative motor or speech deficits were associated with survival in our institutional experience with glioblastoma multiforme (GBM). METHODSWe retrospectively reviewed records of all patients (age range, 18–70 years; Karnofsky Performance Scale score, 80–100) who had undergone GBM resection between 1996 and 2006 at a single institution. Survival was compared between patients who had experienced surgically acquired motor or language deficits versus those who did not experience these deficits. RESULTSThree hundred six consecutive patients (age, 54 ± 11 years; median Karnofsky Performance Scale score, 80) underwent primary GBM resection. Nineteen patients (6%) developed surgically acquired motor deficits and 15 (5%) developed surgically acquired language deficits. Median survival was decreased in patients who acquired language deficits (9.6 months; P < 0.05) or motor deficits (9.0 months; P < 0.05) versus patients without surgically acquired deficits (12.8 months). Two-year survival was 8% and 0% for patients with surgically acquired motor or language deficits, respectively, versus 23% for patients without new-onset deficits. CONCLUSIONIn our experience, the development of new perioperative motor or language deficits was associated with decreased overall survival despite similar extent of resection and adjuvant therapy. Although it is well known that surgically induced neurological deficits affect quality of life, our results suggest that these surgical morbidities may also affect survival. Care should be taken to avoid surgically induced deficits in the management of GBM.

Surgical intervention for thoracic outlet syndrome improves patient's quality of life

OBJECTIVE To assess long-term quality of life outcomes in patients following transaxillary first-rib resection and scalenectomy for thoracic outlet syndrome (TOS). METHODS This was a prospective observational study using the Short-Form 12 (SF-12) and Disability of Arm, Hand, and Shoulder (DASH) instruments between February 2005 and March 2008 in patients with TOS presenting to an academic medical center for preoperative surgical evaluation after failing physical therapy protocol. Surveys were conducted preoperatively and then again at 3, 6, 12, 18, and 24 months after surgery. Longitudinal data analysis was performed with population-averaged models using generalized estimating equations (GEE) method for average rate of recovery. Kaplan-Meier method was used to analyze time to return to work. RESULTS A total of 70 out of 105 eligible patients (66.7%) completed the study protocol (44 neurogenic; 26 venous), returning 243 valid SF-12 surveys (162 neurogenic; 81 venous) and 188 valid DASH surveys (124 neurogenic; 64 venous). Half (50%) of the neurogenic patients and 77% of the venous patients returned to full-time work or activity within the study follow-up, with half of them doing so by 4 months and 75% of them by 5 months. There was no statistically significant difference in return to work between the neurogenic or venous patients. Neurogenic patients had baseline SF-12 Physical Component Scores (PCS) similar to chronic heart failure patients and were significantly worse than venous patients (33.8 vs 43.6, P < .001). In contrast, no difference existed in Mental Component Scores (MCS) (44.5 vs 43.5, P = .78). In follow-up, on average, PCS scores for neurogenic patients improved 0.24 points (P < .001) and MCS scores improved 0.15 points per month (P = .01); while PCS scores for venous patients improved 0.40 points (P = .004) and MCS scores improved 0.55 points per month (P < .001). Additionally, neurogenic patients had baseline DASH scores that were similar to patients with rotator cuff tears, and they were also significantly worse than venous patients (50.2 vs 25.0, P < .001). DASH scores, on average, also improved 0.85 points (P < .001) for neurogenic patients and 0.81 points (P < .001) for venous patients per month. CONCLUSION The use of the SF-12 and DASH instruments in patients with TOS demonstrated significant improvement in patients postoperatively. Venous TOS patients typically improved both physical and mental scores in shorter periods of time than their neurogenic counterparts. Neurogenic and venous TOS patients returned to full-time work/activity within the same length of time postoperatively. However, neurogenic patients required more secondary interventions. We conclude that in appropriately selected patients with either neurogenic or venous TOS, surgical intervention can improve their quality of life over time.

Correlation of preoperative depression and somatic perception scales with postoperative disability and quality of life after lumbar discectomy: Clinical article

OBJECT Lumbar discectomy is the most common surgical procedure performed in the US for patients experiencing back and leg pain from herniated lumbar discs. However, not all patients will benefit from lumbar discectomy. Patients with certain psychological predispositions may be especially vulnerable to poor clinical outcomes. The goal of this study was therefore to determine the role that preoperative depression and somatic anxiety have on long-term back and leg pain, disability, and quality of life (QOL) for patients undergoing single-level lumbar discectomy. METHODS In 67 adults undergoing discectomy for a single-level herniated lumbar disc, the authors determined quantitative measurements of leg and back pain (visual analog scale [VAS]), quality of life (36-Item Short Form Health Survey [SF-36]), and disease-specific disability (Oswestry Disability Index) preoperatively and at 6 weeks, 3, 6, and 12 months after surgery. The degree of preoperative depression and somatization was assessed using the Zung Self-Rating Depression Scale and a modified somatic perception questionnaire (MSPQ). Multivariate regression analyses were performed to assess associations between Zung Scale and MSPQ scores with achievement of a minimum clinical important difference (MCID) in each outcome measure by 12 months postoperatively. RESULTS All patients completed 12 months of follow-up. Overall, a significant improvement in VAS leg pain, VAS back pain, Oswestry Disability Index, and SF-36 Physical Component Summary scores was observed by 6 weeks after surgery. Improvements in all outcomes were maintained throughout the 12-month follow-up period. Increasing preoperative depression (measured using the Zung Scale) was associated with a decreased likelihood of achieving an MCID in disability (p = 0.006) and QOL (p = 0.04) but was not associated with VAS leg pain (p = 0.96) or back pain (p = 0.85) by 12 months. Increasing preoperative somatic anxiety (measured using the MSPQ) was associated with decreased likelihood of achieving an MCID in disability (p = 0.002) and QOL (p = 0.03) but was not associated with leg pain (p = 0.64) or back pain (p = 0.77) by 12 months. CONCLUSIONS The Zung Scale and MSPQ are valuable tools for stratifying risk in patients who may not experience clinically relevant improvement in disability and QOL after discectomy. Efforts to address these confounding and underlying contributors of depression and heightened somatic anxiety may improve overall outcomes after lumbar discectomy.

Postoperative Venous Thromboembolism Rates Vary Significantly After Different Types of Major Abdominal Operations

BackgroundVenous thrombolism (VTE) is a significant cause of morbidity for surgical patients. Comparative risk across major procedures is unknown.MethodsRetrospective analysis of the Nationwide Inpatient Sample (2001–2005) was conducted. Eight surgeries were identified: bariatric surgery, colorectal surgery, esophagectomy, gastrectomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy. Age < 18, patients with multiple major surgeries, and those admitted for treatment of VTE were excluded. Primary outcome was occurrence of VTE. Independent variables included age, gender, race, Charlson score, hospital teaching status, elective procedures, cancer/metastasis, trauma, and year.ResultsPatients, 375,748, were identified, 5,773 (1.54%) with VTE. Overall death rate was 3.97%, but 13.34% after VTE. Unadjusted rate (0.35%) and adjusted risk for VTE were lowest among bariatric patients. On multivariate analysis, highest risk for VTE was splenectomy (odds ratio 2.69, 95% CI 2.03–3.56). Odds ratio of in-hospital mortality following VTE was 1.84 (1.65–2.05), associated with excess stay of 10.88days and

Preoperative Charlson Comorbidity Score Predicts Postoperative Outcomes Among Older Intracranial Meningioma Patients

9,612 excess charges, translating into

Disparities in Access to Neuro-oncologic Care in the United States

55 million/year nationwide.ConclusionHighest risk for VTE was associated with splenectomy, lowest risk with bariatric surgery. Since bariatric patients are known to have greater risk for this complication, these findings may reflect better awareness/prophylaxis. Further studies are necessary to quantify effect of best-practice guidelines on prevention of this costly complication.

Disparities in access to pediatric neurooncological surgery in the United States.

OBJECTIVE Preoperative determinants of surgical risk in elderly patients with meningioma are not fully defined. This study was undertaken to determine whether the Charlson comorbidity index could be used to accurately predict postoperative outcomes among older patients with meningiomas undergoing neurosurgical resection and thereby make a selection for surgery easier. METHODS We performed a multi-institutional retrospective cohort analysis via the Nationwide Inpatient Sample (1998-2005). Patients 65 years of age and older who underwent tumor resection of intracranial meningiomas were identified by International Classification of Diseases, 9th revision, coding. The primary independent variable in multivariate regression was the Charlson comorbidity score, and the primary outcome was inpatient death. Secondary outcomes included inpatient complications, length of stay, and total hospital charges. RESULTS We identified 5717 patients (66.6% female, and 81.8% white) with mean age of 73.6 years. Mean Charlson comorbidity score was 0.99. Inpatient mortality was 3.2%. Mean length of stay was 9.1 days, and mean total charges were

Necrotizing Enterocolitis in 20 822 Infants: Analysis of Medical and Surgical Treatments

62,983. In multivariate analysis, the only factors consistently associated with worse outcome were increased Charlson comorbidity score and increased patient age (ie, >65 years of age). Only greater Charlson scores were additionally associated with greater odds of all major complications such as neurological, respiratory, and cardiac complications. Elective procedures were consistently associated with less inpatient death, length of stay, and total charges. All associations were statistically significant (P < 0.05). CONCLUSIONS The safe surgical resection of intracranial meningiomas among older patients is possible through the ninth decade of life. The Charlson comorbidity score has been shown to be a strong, consistent predictor of inpatient outcomes.

Variations in Referral Patterns to High-Volume Centers for Pancreatic Cancer

HYPOTHESIS Race/ethnicity and social status influence admission to high-volume hospitals among patients who undergo craniotomy for tumor biopsy or resection. DESIGN Retrospective analysis of the Nationwide Inpatient Sample (1988-2005), with additional factors from the Area Resource File. SETTING A 20% representative sample of all hospitals in 37 US states. PATIENTS A total of 76 436 patients 18 years or older who were admitted and underwent craniotomy for tumor biopsy or resection. MAIN OUTCOME MEASURES Odds ratios (ORs) for the association of age, sex, race/ethnicity, insurance status, Charlson Comorbidity Index, and county-level characteristics with admission to high-volume hospitals (>50 craniotomies per year) or low-volume hospitals. RESULTS A total of 25 481 patients (33.3%) were admitted to high-volume hospitals. Overall access to high-volume hospitals improved over time. However, racial/ethnic disparities in access to high-volume hospitals dramatically worsened for Hispanics (OR, 0.49) and African Americans (OR, 0.62) in recent years. Factors associated with better access to high-volume hospitals included years since 1988 (OR, 1.11), greater countywide neurosurgeon density (OR, 1.66), and higher countywide median household income (OR, 1.71). Factors associated with worse access to high-volume hospitals included older age (OR, 0.34 per year increase), increased countywide poverty rate (OR, 0.57), Hispanic race/ethnicity (OR, 0.68), and higher Charlson Comorbidity Index (OR, 0.96 per point increase). CONCLUSIONS African Americans and Hispanics have disproportionately worse access to high-quality neuro-oncologic care over time compared with whites. Higher countywide median household income and decreased countywide poverty rate were associated with better access to high-volume hospitals, implicating socioeconomic factors in predicting admission to high-quality centers.

Prognosis of patients with multifocal glioblastoma: a case-control study

OBJECTIVE: The objective of this study was to investigate whether disparities in access to high-volume centers for neurooncological care existed in the United States in 1988–2005. METHODS: A retrospective analysis of the Nationwide Inpatient Sample (1988–2005) was performed, with additional factors incorporated from the Area Resource File (2006). International Classification of Diseases, Ninth Revision, diagnosis/procedure coding was used to identify patients. High-volume centers were defined as those with ≥50 neurosurgical cases per year. Patients >18 years of age were excluded. Covariates included age, gender, race, Charlson Index score, insurance, and county-level characteristics (including median home value, proportion of foreign born residents, and county neurosurgeon density). Multivariate analysis was performed by using multiple logistic regression models. P values of <.05 were considered statistically significant. RESULTS: A total of 4421 patients were identified; 1651 (37.34%) were admitted to high-volume centers. Overall access to high-volume centers improved slightly over the 18-year period (odds ratio [OR]: 1.04). Factors associated with greater access to high-volume centers included greater county neurosurgeon density (OR: 1.72) and greater county home value (OR: 1.66). Factors associated with worse access included Hispanic ethnicity (OR: 0.68) and each 1% increase in foreign residents per county (OR: 0.59). All reported P values were <.05. CONCLUSION: This study demonstrates that racial and socioeconomic disparities in access to high-volume neurooncological care exist for the pediatric population. We also identify numerous prehospital factors that potentially contribute to persistent disparities and may be amenable to change through national health policy interventions.