Lorenzo Rinaldo

Transfer to High-Volume Centers Associated With Reduced Mortality After Endovascular Treatment of Acute Stroke

Background and Purpose— Some have argued that it may be beneficial to expand the availability of endovascular revascularization services to lower-volume hospitals to minimize the morbidity associated with transfer to larger endovascular centers. We compared the outcomes after revascularization of patients directly admitted to a low-volume center and those transferred to a high-volume center. Methods— We searched a national database of hospital-reported outcomes for patients who underwent endovascular revascularization for acute ischemic stroke. Hospitals were categorized as low, medium, or high procedural volume hospitals. Outcomes of inpatient admissions were collected and compared on the basis of admission source and hospital procedural volume. Results— A total of 118 institutions with 8533 patients were included. Mortality rate (14.9% versus 18.6%; P=0.049) and mortality index (1.1 versus 1.6; P=0.048) were significantly lower among directly admitted relative to transferred patients. For all patients, there were significant differences in institutional mortality rate (low: 19.7%, medium: 14.9%, high: 9.8%; P=0.003) and mortality index (low: 1.5, medium: 1.1, high: 0.8; P=0.004) between low-, medium-, and high-volume hospitals. For transferred patients to high-volume centers, both mortality rate (high: 10.0% versus low: 20.4%; P=0.005) and mortality index (high: 0.8 versus low: 1.5; P=0.034) were significantly lower than that observed for directly admitted patients to low-volume hospitals. Conclusions— We report a beneficial effect of treatment at high-volume hospitals in spite of the detrimental effects of transfer. These findings argue for the centralization of care.

Hospital transfer associated with increased mortality after endovascular revascularization for acute ischemic stroke

Background Patients with an acute ischemic stroke (AIS) due to large vessel occlusion often require transfer to an endovascular center for treatment. Objective To assess the effect of hospital transfer on outcomes after endovascular revascularization. Methods Outcomes of endovascular revascularization were compared between directly admitted and transferred patients using data from a national database and our own institution. Results 118 institutions within the database reported outcomes of 8533 inpatient admissions for endovascular treatment of AIS. Mortality rate (14.9% vs 18.6%; p=0.049) and mortality index (1.1 vs 1.6; p=0.048) were significantly lower among directly admitted patients than among transferred patients. Within our institutional cohort of 140 patients who underwent endovascular therapy, directly admitted patients had a significantly faster time to revascularization than transferred patients (277.4 vs 420.4 min; p≤0.0001). Among transferred patients, an increasing distance of transferred hospital to our home institution was associated with an increasing risk of mortality (unit OR=1.26, 95% CI 1.07 to 1.54; p=0.0061). Conclusions Outcomes of revascularization may improve with methods to identify patients with large vessel occlusion before hospital admission, thus increasing the likelihood of initial triage to a comprehensive stroke center for patients eligible for endovascular intervention.

Discharge to a rehabilitation facility is associated with decreased 30-day readmission in elective spinal surgery

The aim of our study was to determine independent predictors of discharge disposition to rehabilitation or skilled care (SC) facilities and investigate whether discharge location is associated with unplanned readmission and/or reoperation rates. All elective spinal surgery patients in a national surgical registry were analyzed using between 2011 and 2012. Multivariable logistic regression analysis was used to assess for predictors of discharge to rehabilitation or SC facilities versus home as well as to determine whether discharge disposition was significantly associated with the 30-day unplanned readmission or reoperation. Of 34,023 elective spinal surgery patients, the distribution of discharge locations was as follows: 30,606 (90.0%) discharged home, 1674 (4.9%) discharged to rehabilitation, and 1743 (5.1%) discharged to SC. Patients discharged home were associated with the lowest complication rate relative to rehabilitation and SC facilities. Following multivariable regression analysis, there was a significant increase in the odds of discharge to rehabilitation associated with age, male gender, current smoking, ASA class three and four, history of diabetes, operative time, total hospital length of stay, preoperative neurologic morbidity and having at least one postoperative morbidity event. Moreover, there were 804 (4.06%) 30-day unplanned readmissions and 822 (2.45%) unplanned reoperations. After risk adjustment, discharge to rehabilitation was independently associated with decreased odds of 30-day unplanned readmission (OR=0.41; p=0.008) but not reoperation.

Increased Operative Time for Benign Cranial Nerve Tumor Resection Correlates with Increased Morbidity Postoperatively

OBJECTIVES Operative time, previously identified as a risk factor for postoperative morbidity, is examined in patients undergoing benign cranial nerve tumor resection. DESIGN/SETTING/PARTICIPANTS This retrospective cohort analysis included patients enrolled in the ACS-NSQIP registry from 2007 through 2013 with a diagnosis of a benign cranial nerve neoplasm. MAIN OUTCOME MEASURES Primary outcomes included postoperative morbidity and mortality. Readmission and reoperation served as secondary outcomes. RESULTS A total of 565 patients were identified. Mean (median) operative time was 398 (370) minutes. The 30-day complication, readmission, and return to the operating room rates were 9.9%, 9.9%, and 7.3%, respectively, on unadjusted analyses. CSF leak requiring reoperation or readmission occurred at a rate of 3.1%. On multivariable regression analysis, operations greater than 413 minutes were associated with an increased odds of overall complication (OR 4.26, 95% CI 2.08-8.72), return to the operating room (OR 2.65, 95% CI 1.23-5.67), and increased length of stay(1.6 days, 95% CI 0.94-2.23 days). Each additional minute of operative time was associated with an increased odds of overall complication (OR 1.004, 95% CI 1.002-1.006) and increased length of stay (0.006 days, 95% CI 0.004-0.008). CONCLUSION Increased operative time in patients undergoing surgical resection of a benign cranial nerve neoplasm was associated with an increased rate of complications.

Coma and Stroke Following Surgical Treatment of Unruptured Intracranial Aneurysm: An American College of Surgeons National Surgical Quality Improvement Program Study

OBJECTIVE A large national surgical registry was used to establish national benchmarks and associated predictors of major neurologic complications (i.e., coma and stroke) after surgical clipping of unruptured intracranial aneurysms. METHODS The American College of Surgeons National Surgical Quality Improvement Program data set between 2007 and 2013 was used for this retrospective cohort analysis. Demographic, comorbidity, and operative characteristics associated with the development of a major neurologic complication (i.e., coma or stroke) were elucidated using a backward selection stepwise logistic regression analysis. This model was subsequently used to fit a predictive score for major neurologic complications. RESULTS Inclusion criteria were met by 662 patients. Of these patients, 57 (8.61%) developed a major neurologic complication (i.e., coma or stroke) within the 30-day postoperative period. On multivariable analysis, operative time (log odds 0.004 per minute; 95% confidence interval [CI], 0.002-0.007), age (log odds 0.05 per year; 95% CI, 0.02-0.08), history of chronic obstructive pulmonary disease (log odds 1.26; 95% CI, 0.43-2.08), and diabetes (log odds 1.15; 95% CI, 0.38-1.91) were associated with an increased odds of major neurologic complications. When patients were categorized according to quartile of a predictive score generated from the multivariable analysis, rates of major neurologic complications were 1.8%, 4.3%, 6.7%, and 21.2%. CONCLUSIONS Using a large, national multi-institutional cohort, this study established representative national benchmarks and a predictive scoring system for major neurologic complications following operative management of unruptured intracranial aneurysms. The model may assist with risk stratification and tailoring of decision making in surgical candidates.

341 Diabetes Mellitus and Back Pain: Markers of Diabetes Disease Progression Are Associated With Chronic Back Pain.

INTRODUCTION Recent studies suggest that diabetic patients may be more likely to exhibit back pain. Correlating diabetic disease progression to the presence of back pain could provide insight into the relationship between these conditions. METHODS A total of 67 132 patients within our institutional database were identified as having the diagnosis of either diabetes mellitus type I (DMI) or diabetes mellitus type II (DMII). Within this larger cohort, patients diagnosed with chronic back pain (CBP) were identified. In addition, patients with a history of spinal surgery were also identified. Clinical and laboratory measures of diabetic disease burden were then collected on all patients. Multinomial logistic regression analysis using a backward stepwise selection algorithm was then implemented for multivariable analysis to determine whether patient variables were associated with the diagnosis of CBP or history of spinal surgery among diabetic patients. RESULTS On unadjusted analysis, highest recorded values of hemoglobin A1C (HgbA1C), low-density lipoprotein (LDL), triglycerides, and total cholesterol were significantly greater in diabetic patients with CPB and diabetic patients with CBP that underwent spinal surgery. Highest recorded value of high-density lipoprotein (HDL) was significantly lower in diabetic patients with CPB and diabetic patients with CBP that underwent spinal surgery. Highest recorded body mass index (BMI) was also greater in patients with CBP (36.67) and patients with CBP who underwent surgery (36.63) compared with patients without CBP (34.06, P < .001). On multinomial logistic regression analysis, increased age at time of DM diagnosis, increased duration of time with DM, presence of hypertension, presence of neuropathy, increased BMI, increased levels of HgbA1C, LDL, and triglycerides, and decreased levels of HDL were independently associated with the presence of CBP. CONCLUSION Our results suggest that markers of diabetes disease progression are associated with the presence of back pain, suggesting that uncontrolled DM may be a contributing factor to the development of CBP.INTRODUCTION:Recent studies suggest that diabetic patients may be more likely to exhibit back pain. Correlating diabetic disease progression to the presence of back pain could provide insight into the relationship between these conditions.METHODS:A total of 67 132 patients within our institutional d

199 Multiple Concussions in Young Athletes: Identifying Patients at Risk for Repeat Injury

INTRODUCTION Concussion diagnosis and management is a topic of interest for health care, education, and government professionals. Given the evidence concerning the association of long-term effects and cumulative insult of multiple concussions, we sought to identify risk factors in young athletes for repeat injury. METHODS This study is a retrospective cohort analysis of our institutions series of pediatric sports related concussions. Patient demographics, characteristics, and clinical features of concussion were analyzed in an unadjusted fashion. Bivariate analysis examined these variables in relation to occurrence of subsequent concussion. Multivariable analysis was then used to evaluate for predictors of repeat injury. RESULTS One hundred ninety-one patients with a mean age of 13.5 years were included for analysis. Relative to patients whose injury was associated with football, patients playing soccer (odds ratio [OR], 5.36; 95% confidence interval [CI], 1.18-24.5), ice hockey/skating (OR, 6.97; 95% CI, 1.60-30.37), and basketball (OR, 5.99; 95% CI, 1.23-29.07) were associated with a significant increased odds of having a subsequent concussion. History of prior concussion was also significantly associated with an increased odds of repeat injury following the index concussion, defined as the first concussion evaluated at our institution (OR, 12.54; 95% CI, 3.78-41.62). Relative to a concussion resulting from a mechanism involving blunt force to the head, patients with a concussion in the setting of a fall were significantly less likely to experience a subsequent concussion (OR, 0.19; 95% CI, 0.05-0.71). CONCLUSION Efforts to protect young athletes are of immeasurable value given the potential life years at risk for productivity and quality of life. With the identification of specific sports, prior injury, and mechanism influencing risk of repeat injury, clinicians are more informed to assess and discuss both risk and potential consequences of concussions with young athletes and their families.

Risk factors for dural tears: a study of elective spine surgery*

Abstract Objective: This study moves beyond previous cohort studies and benchmark data by studying a population of elective spine surgery from a multicenter registry in an effort to validate, disprove, and/or identify novel risk factors for dural tears. Methods: A retrospective cohort analysis queried a multicenter registry for patients with degenerative spinal diagnoses undergoing elective spinal surgery from 2010–2014. Multivariable logistic regression analysis interrogated for independent risk factors of dural tears. Results: Of 104,930 patients, a dural tear requiring repair occurred in 0.6% of cases. On adjusted analysis, the following factors were independently associated with increased likelihood of a dural tear: ankylosing spondylitis vs. intervertebral disc disorders, greater than two levels, combined surgical approach and posterior approach vs. anterior approach, decompression only vs. fusion and decompression, age groups 85+, 75–84 and 65–74 vs. <65, obesity (BMI ≥30), corticosteroid use and preoperative platelet count <150,000. Conclusions: This multicenter study identifies novel risk factors for dural tears in the elective spine surgery population, including corticosteroids, thrombocytopenia, and ankylosing spondylitis. The results of this analysis provide further information for surgeons to use both in operative planning and in preoperative counseling when discussing the risk of dural tears.

The Effect of Epidural Steroid Injections on Bone Mineral Density and Vertebral Fracture Risk: A Systematic Review and Critical Appraisal of Current Literature

Objective The aim of this paper is to review the available literature investigating the effect of epidural steroid injections (ESIs) on bone mineral density (BMD) and vertebral fracture risk. Study design Systematic review of current literature. Methods The sources of the data were PubMed, Embase, Cochrane, and Scopus. Papers included in the review were original research articles in peer-reviewed journals. Results A total of 7,233 patients (eight studies) with a mean age ranging between 49 and 74 years and an average follow-up between six and 60 months were studied. Steroids that were used included triamcinolone, dexamethasone, and methylprednisolone (MP), with a mean number of injections ranging from one to 14.7 and an average cumulative dose in MP equivalents between 80 and 8,130 mg. Epidural steroids were associated with significantly decreased BMD in four out of six included studies, and with increased risk of vertebral fracture in one out of two included studies. Significant reductions in BMD were associated with a cumulative MP dose of 200 mg over a one-year period and 400 mg over three years, but not in doses of less than 200 mg of MP equivalents for postmenopausal women and at least 3 g for healthy men. The risk of osteopenia and osteoporosis was lower in patients who were receiving anti-osteoporotic medication during the treatment course. Conclusions ESIs should be recommended with caution, especially in patients at risk for osteoporotic fractures, such as women of postmenopausal age. Anti-osteoporotic medication might be considered prior to ESI.

Quantitative analysis of the effect of institutional case volume on complications after surgical clipping of unruptured aneurysms

OBJECTIVE The mechanism by which greater institutional case volume translates into improved outcomes after surgical clipping of unruptured intracranial aneurysms (UIAs) is not well established. The authors thus aimed to assess the effect of case volume on the rate of various types of complications after clipping of UIAs. METHODS Using information on the outcomes of inpatient admissions for surgical clipping of UIAs collected within a national database, the relationship of institutional case volume to the incidence of different types of complications after clipping was investigated. Complications were subdivided into different categories, which included all complications, ischemic stroke, intracerebral hemorrhage, medical complications, infectious complications, complications related to anesthesia, and wound complications. The relationship of case volume to different types of complications was assessed using linear regression analysis. The relationships between case volume and overall complication and stroke rates were fit with both linear and quadratic equations. The numerical cutoff for institutional case volume above and below which the authors found the greatest differences in mean overall complication and stroke rate was determined using classification and regression tree (CART) analysis. RESULTS Between October 2012 and September 2015, 125 health care institutions reported patient outcomes from a total of 6040 cases of clipping of UIAs. On linear regression analysis, increasing case volume was negatively correlated to both overall complications (r2 = 0.046, p = 0.0234) and stroke (r2 = 0.029, p = 0.0557) rate, although the relationship of case volume to the complication (r2 = 0.092) and stroke (r2 = 0.067) rate was better fit with a quadratic equation. On CART analysis, the cutoff for the case number that yielded the greatest difference in overall complications and stroke rate between higher- or lower-volume centers was 6 cases/year and 3 cases/year, respectively. CONCLUSIONS Although the authors confirm that increasing case volume is associated with reduced complications after clipping of UIAs, their results suggest that the relationship between case volume and complications is not necessarily linear. Moreover, these results indicate that the effect of case volume on outcome is most evident between very-low-volume centers relative to centers with a medium-to-high volume.