J. Manuel Sarmiento

Does 30-day readmission affect long-term outcome among glioblastoma patients?

BACKGROUND Research on readmissions has focused mainly on the economic and resource burden it places on hospitals. OBJECTIVE To evaluate the effect of 30-day readmission on overall survival among newly diagnosed glioblastoma multiforme (GBM) patients. METHODS A nationwide cohort of GBM patients diagnosed between 1991 and 2007 was studied using the Surveillance, Epidemiology and End Results Medicare database. Multivariate models were used to determine factors associated with readmission and overall survival. Odds ratio, hazard ratio, 95% confidence interval, and P values were reported. Complete case and multiple imputation analyses were performed. RESULTS Among the 2774 newly diagnosed GBM patients undergoing surgery at 442 hospitals nationwide, 437 (15.8%) were readmitted within 30 days of the index hospitalization. Although 63% of readmitted patients returned to the index hospital where surgery was performed, a significant portion (37%) were readmitted to nonindex hospitals. The median overall survival for readmitted patients (6.0 months) was significantly shorter than for nonreadmitted (7.6 months; P < .001). In a confounder-adjusted imputed model, 30-day readmission increased the hazard of mortality by 30% (hazard ratio, 1.3; P < .001). Neurological symptoms (30.2%), thromboembolic complications (19.7%), and infections (17.6%) were the leading reasons for readmission. CONCLUSION Prior studies that have reported only the readmissions back to index hospitals are likely underestimating the true 30-day readmission rate. GBM patients who were readmitted within 30 days had significantly shorter survival than nonreadmitted patients. Future studies that attempt to decrease readmissions and evaluate the impact of reducing readmissions on patient outcomes are needed.

Multiple resections and survival of recurrent glioblastoma patients in the temozolomide era

Glioblastoma (GBM) is the most prevalent and aggressive primary brain tumor in adults for which recurrence is inevitable and surgical resection is often recommended. We investigated the relationship between multiple tumor resections and overall survival (OS) in adult glioblastoma patients who received adjuvant radiotherapy and temozolomide following initial surgery. We retrospectively reviewed the records of all newly diagnosed adult GBM patients with tumor recurrence at our institution from March 2003 to October 2012. Kaplan-Meier survival estimates and multivariate analysis using Coxs proportional hazards model were utilized to evaluate the impact of multiple resections on OS. A total of 202 GBM patients were analyzed; 83 (41.1%), 94 (46.5%), and 25 (12.4%) patients underwent one, two, and three or more total resections, respectively. Patients who underwent multiple resections were significantly younger (p<0.0001) and had higher perioperative Karnofsky Performance Status scores (p<0.0001) than single resection patients. The median OS in months was 21.1, 25.5, and 29.0 for patients who had one, two, and three or more resections, respectively (Wilcoxon p=0.03). In a confounder-adjusted multivariate model, patients with multiple resections did not have significantly improved survival (p=0.55). Older age was strongly associated with poorer OS (hazard ratio 1.34, p<0.0001). Age at diagnosis was the only predictor of survival for recurrent GBM patients. After adjusting for age at diagnosis, multiple resections were not an independent predictor of OS in our glioblastoma cohort treated in the temozolomide era.

Interspinous device versus laminectomy for lumbar spinal stenosis: a comparative effectiveness study.

BACKGROUND CONTEXT Currently no studies directly compare effectiveness between interspinous devices (IDs) and laminectomy in lumbar spinal stenosis (LSS) patients. PURPOSE To compare reoperations, complications, and costs between LSS patients undergoing ID placement versus laminectomy. STUDY DESIGN Retrospective comparative study. PATIENT SAMPLE The MarketScan database (2007-2009) was queried for adults with LSS undergoing ID placement as a primary inpatient procedure. OUTCOME MEASURES Reoperation rates, complication rates, and costs. METHODS Each ID patient was matched with a laminectomy patient using propensity score matching. Reoperations, complications, and costs were analyzed in patients with at least 18 months postoperative follow-up. The authors did not receive funding from any external sources for this study. RESULTS Among 498 inpatients that underwent ID placement between 2007 and 2009; the average age was 73 years. The cumulative reoperation rates after ID at 12 and 18 months were 21% and 23%, respectively. The average inpatient hospitalization lasted 1.6 days with an associated cost of

Cystic glioblastoma: An evaluation of IDH1 status and prognosis

17,432. Two propensity-matched cohorts of 174 patients that had undergone ID versus laminectomy were analyzed. Longer length of stay was observed in the laminectomy cohort (2.5 days vs. 1.6 days, p<.0001), whereas ID patients accrued higher costs at index hospitalization (

Effectiveness of radiotherapy for elderly patients with anaplastic gliomas

17,674 vs.

Predictors of treatment delay in aneurysmal subarachnoid hemorrhage patients.

12,670, p=.0001). Index hospitalization (7.5% vs. 3.5%, p=.099) and 90-day (9.2% vs. 3.5%, p=.028) complications were higher in the laminectomy cohort compared with the ID cohort. The ID patients had significantly higher reoperation rates than laminectomy patients at 12 months follow-up (12.6% vs. 5.8%, p=.026) and incurred higher cumulative costs than laminectomy patients at 12 months follow-up (

Proposed Diagnostic Criteria, Classification Schema, and Review of Literature of Notochord- Derived Ecchordosis Physaliphora

39,173 vs.

A national perspective of adult gangliogliomas

34,324, p=.289). CONCLUSIONS Twelve-month reoperation rates and index hospitalization costs were significantly higher among patients who underwent ID compared with laminectomy for LSS.

Everolimus for astrocytomas in tuberous sclerosis

BACKGROUND Controversy exists regarding the prognostic significance of cystic features in newly diagnosed glioblastoma multiforme (GBM) and the pathological origin of cystic GBMs. OBJECTIVE To determine whether cystic GBMs develop from low-grade gliomas by evaluating IDH1 status and to evaluate the differences in overall survival between patients with cystic and noncystic tumors. METHODS We retrospectively reviewed the records of 351 consecutive newly diagnosed adult GBM patients treated at our institution from October 1997 to November 2011; patients with >50% cystic tumor composition were further identified. IDH1 mutation was determined by immunohistochemical staining. Patient characteristics and treatment were reported for cystic and noncystic tumors separately. Overall survival was reported for cystic and noncystic cohorts by using the Kaplan-Meier estimates. RESULTS Of 351 patients, 27 (7.7%) had cystic tumors and 324 (92.3%) had noncystic tumors. Tumor samples for patients with cystic GBMs were immunohistochemically analyzed for IDH1 mutations. Two (7.4%) of the 27 tumor samples were documented as having IDH1 mutations. Characteristics such as age, sex, perioperative Karnofsky Performance Status, tumor size, extent of resection, postsurgery radiation, and temozolomide therapy were comparable in the and noncystic cohorts. Patients in the cystic cohort had a median overall survival of 15.0 months compared with 18.2 months for the noncystic cohort (log-rank P = .77). CONCLUSION The low frequency of IDH1 mutation status in our cystic cohort strongly suggests that most newly diagnosed cystic GBMs do not arise from malignant transformation of previously undiagnosed low-grade gliomas. Furthermore, there is no difference in overall survival between patients newly diagnosed with cystic and noncystic GBMs.

Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases.

Postoperative radiotherapy (RT) is utilized routinely in the management of anaplastic World Health Organization Grade III gliomas (AG), including anaplastic astrocytoma (AA) and anaplastic oligodendroglioma (AO). However, the optimal role of RT in elderly AG patients remains controversial. We evaluated the effectiveness of RT in elderly AG patients using a national cancer registry. The USA Surveillance, Epidemiology, and End Results database (1990-2008) was used to query patients over 70 years of age with AA or AO. Independent predictors of overall survival were determined using a multivariate Cox proportional hazards model. Among 390 elderly patients with AG, 333 (85%) had AA and 57 (15%) had AO. Approximately two-thirds of AA patients (64%) and AO patients (65%) received RT. Most AO patients (58%) and many AA patients (41%) underwent surgical resection; the remainder had biopsy. The median overall survival for all patients who underwent RT was 6 months (95% confidence interval [CI], 5-7 months) versus 2 months (95% CI 1-6) in patients who did not have RT. Patients who had gross total resection (GTR) plus RT had a median overall survival of 11 months (95% CI 7-14). Multivariate analysis for all patients showed that undergoing RT was significantly associated with improved survival (hazard ratio [HR] 0.52, p<.0001). AA tumor type (HR 1.37, p=.03) was associated with worse survival than AO tumor type; female sex (HR 0.59, p<.0001) and being married (HR 0.66, p=.002) significantly improved survival. Patients that underwent GTR had a significant reduction in the hazards of mortality compared to biopsy (HR 0.72, p=.04). Elderly AG patients undergoing RT had better overall survival compared to patients who did not receive RT. Treatment strategies involving maximal safe resection plus RT should be considered in the optimal management of AG in elderly patients.