I-Wen Pan

Patient and treatment factors associated with survival among adult glioblastoma patients: A USA population-based study from 2000–2010

In this study, we utilized the USA surveillance, epidemiology, and end results (SEER) database to examine factors influencing survival of glioblastoma multiforme (GBM) patients. GBM is the most common primary malignant brain tumor in adults and despite advances in treatment, prognosis remains poor. Using the SEER database, we defined a cohort of adult patients for the years 2000-2009 with confirmed GBM and minimum follow-up of 12 months. A total of 14,675 patients with GBM met the inclusion criteria. Demographic, clinical, and treatment variables were examined. Death was the primary outcome. Median survival time was 11 months. Patients had increasingly longer survival over the decade span. We found, on multivariate analysis, that significantly worse survival was associated with age >75 years, male sex, unmarried status, and non-Hispanic Caucasian race/ethnicity. Patients in the Northeast had a significantly lower risk of mortality. Patients with tumors that were non-lateralized and >3 cm fared worse. Patients who did not receive adjuvant radiation also had worse outcomes. Gross total resection imparted a survival advantage for patients compared to biopsy or partial resection. Thus, this report adds to the growing body of literature supporting the positive role of maximal resection on patient survival.

Complications after craniosynostosis surgery: comparison of the 2012 Kids’ Inpatient Database and Pediatric NSQIP Database

OBJECT Research conducted using large administrative data sets has increased in recent decades, but reports on the fidelity and reliability of such data have been mixed. The goal of this project was to compare data from a large, administrative claims data set with a quality improvement registry in order to ascertain similarities and differences in content. METHODS Data on children younger than 12 months with nonsyndromic craniosynostosis who underwent surgery in 2012 were queried in both the Kids Inpatient Database (KID) and the American College of Surgeons Pediatric National Surgical Quality Improvement Program (Peds NSQIP). Data from published clinical craniosynostosis surgery series are reported for comparison. RESULTS Among patients younger than 12 months of age, a total of 1765 admissions were identified in KID and 391 in Peds NSQIP in 2012. Only nonsyndromic patients were included. The mean length of stay was 3.2 days in KID and 4 days in Peds NSQIP. The rates of cardiac events (0.5% in KID, 0.3% in Peds NSQIP, and 0.4%-2.2% in the literature), stroke/intracranial bleeds (0.4% in KID, 0.5% in Peds NSQIP, and 0.3%-1.2% in the literature), infection (0.2% in KID, 0.8% in Peds NSQIP, and 0%-8% in the literature), wound disruption (0.2% in KID, 0.5% in Peds NSQIP, 0%-4% in the literature), and seizures (0.7% in KID, 0.8% in Peds NSQIP, 0%-0.8% in the literature) were low and similar between the 2 data sets. The reported rates of blood transfusion (36% in KID, 64% in Peds NSQIP, and 1.7%-100% in the literature) varied between the 2 data sets. CONCLUSIONS Both the KID and Peds NSQIP databases provide large samples of surgical patients, with more cases reported in KID. The rates of complications studied were similar between the 2 data sets, with the exception of blood transfusion events where the retrospective chart review process of Peds NSQIP captured almost double the rate reported in KID.

Thirty-day outcomes for posterior fossa decompression in children with Chiari type 1 malformation from the US NSQIP-Pediatric database.

PurposeThe multicenter National Surgical Quality Improvement Program—Pediatric (NSQIP-P) database maintained by the American College of Surgeons was used to describe 30-day outcomes following Chiari type 1 decompression in children and to identify risk factors for readmission, reoperation, and perioperative complications.MethodsWe identified patients aged 0–18xa0years who underwent posterior cranial fossa decompression for Chiari type 1 malformation in 2012, 2013, and 2014 in the NSQIP-Pediatric database. Multivariate regression analysis was performed using preoperative and perioperative data to determine risk factors for perioperative adverse events within 30xa0days of the index procedure.ResultsWe identified 1459 patients from the NSQIP-P database for the years 2012–2014. Fifty-five percent of the patients were female. Mean age was 9.8xa0years (median 10xa0years). Median operative time was 141xa0min (IQR 107–181xa0min). Postoperative complications were noted in 5.3xa0% and unplanned reoperations in 3.4xa0% of the patients. Postoperative ventriculoperitoneal shunt placement occurred in 0.9xa0% of the patients. Wound problems were the most common complication (3.8xa0% of all patients). Univariate analysis showed the following factors were associated with perioperative adverse events: longer operative times, hospital stay ≥5xa0days, hydrocephalus, and neurological, renal, and congenital comorbidities. On multivariate analysis, female sex (OR 1.46, 95xa0% CI 1.01–2.11), increased operative time (OR 1.01, 95xa0% CI 1.00–1.01), and hospital stay ≥5xa0days (OR 2.62, 95xa0% CI 1.55–4.43) were independent factors associated with perioperative adverse events.ConclusionThe NSQIP-P database was used to describe surgical outcomes of posterior cranial fossa decompression in a US nationwide sample of 1459 children with Chiari type 1 malformation. The overall recorded adverse rate was low. Longer operative times and length of hospital stay ≥5xa0days during the index admission were associated with perioperative adverse events.

The Impact of Insurance, Race, and Ethnicity on Age at Surgical Intervention among Children with Nonsyndromic Craniosynostosis

OBJECTIVEnTo examine the impact of demographic factors, including insurance type, family income, and race/ethnicity, on patient age at the time of surgical intervention for craniosynostosis surgery in the US.nnnSTUDY DESIGNnThe Kids Inpatient Database was queried for admissions of children younger than 3 years of age undergoing craniosynostosis surgery in 2009. Descriptive data regarding age at surgery for various substrata are reported. Multivariate regression was used to evaluate the effect of patient and hospital characteristics on the age at surgery.nnnRESULTSnChildren with private insurance were, on average, 6.8 months of age (95% CI 6.2-7.5) at the time of surgery; children with Medicaid were 9.1 months old (95% CI 8.4-9.8). White children received surgery at mean age of 7.2 months (95% CI 6.5-8.0) and black and Hispanic children at a mean age of 9.1 months (95% CI 8.2-10.1). Multivariate regression analysis found Medicaid insurance (beta coefficient [B]=1.93, P<.001), black or Hispanic race/ethnicity (B=1.34, P=.022), and having 2 or more chronic conditions (B=2.86, P<.001) to be significant independent predictors of older age at surgery.nnnCONCLUSIONnPublic insurance and nonwhite race/Hispanic ethnicity were statistically significant predictors for older age at surgery, adjusted for sex, zip code median family income, year, and hospital factors such as size, type, region, and teaching status. Further research into these disparities is warranted.

Patient-, procedure-, and hospital-related risk factors of allogeneic and autologous blood transfusion in pediatric spinal fusion surgery in the United States.

Study Design. Cross-sectional study using data from the Health Care Cost and Utilization Project Kids Inpatient Database. Objective. Blood loss during spinal fusion surgery may lead to the need for transfusion. Preoperative identification of patient-related, procedure-related, or hospital-related risk factors for blood transfusion would allow for implementation of interventions designed to control excessive bleeding. Summary of Background Data. Several studies have analyzed predictors associated with transfusion in spinal fusion. Identified predictors include age, female sex, anemia, comorbidities, number of fusion levels, osteotomy, and greater hospital volume. There have been few studies examining these predictors in children undergoing spinal fusion. Methods. Using Kids Inpatient Database data, univariate and multivariate logistic regression was used to calculate unadjusted and adjusted odds ratios (aOR). P values of less than 0.05 were considered statistically significant. Results. We identified 9538 pediatric hospitalizations (patients <21 yr) with spinal fusion in 2009. Overall, 25.1% were associated with blood transfusion. The following factors were associated with transfusions: female sex (aOR 1.14, P = 0.023), black race (aOR 1.35, P = 0.005), length of hospital stay (aOR 1.03, P < 0.001), anterior approach/lumbar segment (aOR 2.11, P = 0.011) and posterior approach/lumbar segment (aOR 2.75, P < 0.001) compared with anterior approach/cervical segment, midlength fusion (aOR 1.71, P < 0.001), and long length fusion (aOR 2.85, P < 0.001) compared with short length. Higher transfusion rates were observed in patients with complications of fever and hematoma but not wound infection. Conclusion. This study showed significant patient-, procedure-, and hospital-related predictors of allogeneic and autologous blood transfusion in spinal fusion in the pediatric age group. Higher health care resource utilization of length of stay and additional procedures are directed toward care of this transfused subgroup. Therapies to reduce blood loss and transfusion requirement are necessary for this pediatric population. Level of Evidence: 4

Comparative Effectiveness of Surgical Treatments for Pediatric Hydrocephalus

BACKGROUNDnPediatric hydrocephalus represents a high health care burden in the United States (US). Surgery is the mainstay of treatment.nnnOBJECTIVEnTo perform a comparative effectiveness analysis for endoscopic third ventriculostomy (ETV) and cerebrospinal fluid shunt placement in pediatric hydrocephalus patients in the US using a large administrative claims database through the application of propensity scores matching.nnnMETHODSnThe MarketScan® database (Truven Health Analytics, Atlanta, Georgia) 2003 to 2011 was used. Patients 19 yr or younger at first occurrence of ETV or shunt during the study period were included. The study outcome, surgery failure, was defined as further surgical treatment for hydrocephalus subsequent to initial ETV or shunt procedure. Age, etiology of hydrocephalus, and history of shunt were used to create matched samples for the ETV and shunt cohorts. Kaplan-Meier survival curves, stratified log-rank test, and Cox proportional-hazard models were used to analyze samples.nnnRESULTSnThere were 3231 eligible cases (478 ETV; 2753 shunt). Propensity scores matching produced 455 balanced pairs. For matched samples, 326 of 455 (72%) pairs were concordant, while 129 pairs were discordant in surgery outcomes within 3 mo. Among discordant pairs, ETV patients were more likely to experience surgery failure compared to patients receiving shunt (relative risk = 1.4, P value = .011). Furthermore, patients age < 1 yr had lower ETV success rates than those with shunt (P value = .009). No similar pattern was found in patients age ≥ 1 yr.nnnCONCLUSIONnThere was no significant effect on time to failure between patients undergoing ETV and shunt, except in infants age <1 yr.

Patient and treatment factors associated with survival among pediatric glioblastoma patients: A Surveillance, Epidemiology, and End Results study

Glioblastoma (GBM) is a rare malignancy in children. The United States Surveillance, Epidemiology, and End Results (SEER) database allows large-scale analyses of clinical characteristics and prognostic features. We used it to study patients aged <20u202fyears with histologically confirmed GBM (2000-2010) and examined the relationship between patient demographics, tumor characteristics, patterns of treatment, and outcomes. The primary outcome was disease-specific survival. 302 subjects were identified, with median age 11u202fyears. Median follow-up was 32u202fmonths (95% CI 27-39). 34.4% had gross total resection (GTR). 61% underwent radiation after surgery (17% of subjects <3u202fyears, 67% of those aged 4-19u202fyears). Median survival and 2-year survival rates were 20u202fmonths and 46.9%, respectively. In multivariate analyses, age, tumor location, extent of resection, and year of diagnosis were significantly associated with the primary outcome. Compared to those aged 0-4u202fyears, subjects aged 5-9u202fyears and 10-14u202fyears had higher risk of mortality. Infratentorial tumor location (HR 2.0, 95% CI 1.2-3.3, pu202f=u202f0.007) and subtotal resection (HR 2.04, 95% CI 1.4-3.0, pu202f<u202f0.001) were associated with increased mortality. Later year of diagnosis was significantly associated with decreased risk of death (HR 0.93, 95% CI 0.9-0.99, pu202f=u202f0.031). There was no association between sex, race, region, or tumor size and the primary outcome. Repeat analyses examining all-cause mortality identified the same risk factors as for CNS cancer-specific mortality. Younger age, supratentorial location, GTR, and later year of diagnosis were associated with improved survival.

Readmission and complications within 30 days after intrathecal baclofen pump placement

To describe 30‐day outcomes after intrathecal baclofen (ITB) pump placement in children and identify risk factors for readmission, reoperation, and perioperative complication using the National Surgical Quality Improvement Program‐Pediatric (NSQIP‐P) database.

Perioperative antibiotic use in vagus nerve stimulator implantation: a clinical series

PurposePreoperative antibiosis contributes up to one third of total antibiotic use in major hospitals. Choice of antibiotic is not uniformly standardized, and polypharmacy regimens may be used without knowing the effect on rates of surgical site infection, nonsurgical infections, or antibiotic resistance. Careful examination of trends in surgical prophylaxis is warranted. In this study, we aimed to examine our institution’s experience with vagus nerve stimulator (VNS) implantation, focusing on association between perioperative antibiotic practices and postoperative infectious outcomes.MethodsWe conducted a single-center case-control study using a retrospective chart review of 50 consecutively operated patients undergoing VNS implantation over 24xa0months by two experienced surgeons at our institution from April 2014 to March 2016. In each surgery, the technical procedure, operating room, and surgical team were the same, while surgeon’s preference in antibiotic prophylaxis differed. Group 1 received a single dose of intravenous (IV) cefazolin (nxa0=xa026), and Group 2 received IV cefazolin, paired with one or both of gentamicin/vancomycin, in addition to a 10-day outpatient oral course of clindamycin (nxa0=xa024). Patient demographics, perioperative details, and minimum 3-month follow-up for infection and healthcare utilization were recorded. Student t tests were computed for significance.ResultsGroup 1 patients on average were older than group 2 patients (10.2, 7.1xa0years, pxa0=xa00.01), and length of surgery was longer (115.5, 91.9xa0min, pxa0=xa00.007). There were no differences in number of surgeons gowned (pxa0=xa00.11), presence of tracheostomy (pxa0=xa00.43) or gastrostomy (pxa0=xa00.20) tube, nonsurgical infections (pxa0=xa00.32), and number of postoperative emergency department (ED) visits (pxa0=xa00.22) or readmissions (pxa0=xa00.23). Neither group had VNS infections in the follow-up period.ConclusionSingle preoperative dosing of one antibiotic appropriately chosen to cover typical skin flora conferred equal benefit to perioperative prophylactic polypharmacy in this study. There were no differences in postoperative infection events or ED visits/readmissions. Restraint with preoperative antibiosis shows equipoise in postoperative infection and overall resource utilization.

Thirty-day outcomes in pediatric epilepsy surgery

PurposeThe aim of this study was to use the multicenter American College of Surgeons National Surgical Quality Improvement Program–Pediatric (NSQIP-P) to evaluate and identify risk factors for 30-day adverse events in children undergoing epilepsy surgery.MethodsUsing the 2015 NSQIP-P database, we identified children (age 0–18xa0years) undergoing pediatric epilepsy surgery and analyzed NSQIP-defined complications, unplanned reoperations, and unplanned readmissions. Multivariable logistic regression analysis was performed using perioperative data to identify risk factors for adverse events within 30xa0days of the index procedure.ResultsTwo hundred eight pediatric patients undergoing epilepsy surgery were identified for the year 2015 in the NSQIP-P database. The majority of patients were male (51.8%) and white (72.9%). The median age was 10xa0years. Neurological and neuromuscular comorbidities were seen in 62.5% of patients. Surgical blood loss and transfusion was the most common overall NSQIP-defined event (15.7%) and was reported in 40% with hemispherectomy. Nineteen patients (6.8%) had an unplanned reoperation and 20 patients (7.1%) had an unplanned readmission. Multivariable logistic regression analysis showed that African American patients (OR 3.26, 95% CI 1.29–8.21, pxa0=xa00.01) and hemispherectomy (OR 3.05, 95% CI 1.4–6.65, pxa0=xa00.01) were independently associated with NSQIP-defined complications. Patients undergoing hemispherectomy (OR 4.11, 95% CI 1.48–11.42, pxa0=xa00.01) were also at significantly higher risk of unplanned readmission after pediatric epilepsy surgery.ConclusionsData from the 2015 NSQIP-P database showed that hemispherectomy was significantly associated with higher perioperative events in children undergoing epilepsy surgery. Quality improvement initiatives for hemispherectomy should target surgical blood loss and wound-related complications. Racial disparities in access to cranial pediatric epilepsy surgery and perioperative complications were also highlighted in the present study.