Yi-Ren Chen

Acute Lung Injury in Patients with Subarachnoid Hemorrhage: A Nationwide Inpatient Sample Study

OBJECTIVE To determine national trends for patients with subarachnoid hemorrhage (SAH) and pulmonary complications including acute respiratory distress syndrome (ARDS). METHODS The Nationwide Inpatient Sample database was used to sample 193,209 admissions for SAH with and without ARDS during the period 1993-2008 using International Classification of Diseases, Ninth Revision, Clinical Modification coding. A multivariate stepwise regression analysis was performed. RESULTS The incidence of ARDS in patients with SAH increased from 35.51% in 1993 to 37.60% in 2008. However, the overall mortality in patients with SAH and in patients with SAH and ARDS decreased in the same period, from 42.30% to 31.99% and from 75.13% to 60.76%, respectively. Multivariate analysis showed that the predictors of developing ARDS in patients with SAH include older age; larger hospital size; and comorbidities such as epilepsy, cardiac arrest, sepsis, congestive heart failure, hypertension, chronic obstructive pulmonary disease, hematologic dysfunction, renal dysfunction, and neurologic dysfunction. Predictors of mortality in patients with SAH include age and hospital complications, such as coronary artery disease, ARDS, cancer, hematologic dysfunction, and renal dysfunction. CONCLUSIONS Patients with SAH are at increased risk of developing ARDS. The identification of certain risk factors may alert and aid practitioners in preventing worsening disease.

Impact of age, injury severity score, and medical comorbidities on early complications after fusion and halo-vest immobilization for C2 fractures in older adults: a propensity score matched retrospective cohort study.

Study Design. Propensity score matched retrospective cohort study. Objective. To report early complication rates and associated risk factors in patients with C2 fractures who underwent fusion or halo immobilization. Summary of Background Data. There is limited data on the impact of age, injury severity score, and medical comorbidities on overall complication rates from surgical fixation versus halo-vest immobilization of C2 fractures. Methods. The Nationwide Inpatient Sample database from 2002 to 2008 was queried to identify cohorts of adult patients (age ≥ 18 years) with C2 fractures without spinal cord injury who were treated with either fusion or halo-vest immobilization. Complication rates, hospital length of stay, and costs were compared in a propensity score matched sample. Multivariate analysis was used to identify predictors of in-hospital complications. Results. A total of 3758 patients (1627 fusion and 2131 halo) were identified. Fusion was associated with greater overall complication rates (20.2% vs. 10.1%, P < 0.0001), increased length of stay (8.9 d vs. 6.4 d, P < 0.0001), higher charges (

Perspectives of Mobile Versus Fixed Mammography in Santa Clara County, California: A Focus Group Study

80,000 vs.

The effect of postoperative infection on survival in patients with glioblastoma

41,000, P < 0.0001), but a lower rate of nonroutine discharge (52.6% vs. 62.6%, P < 0.0001). There was no difference in mortality between the fusion group (2.75%) and the halo group (3.33%). Age, injury score, and comorbidity increased complication rates by a similar degree (odds ratio) in both cohorts. Patients aged 80 years and older were 3.5 times more likely to have a complication than those younger than 60 years. Conclusion. Fusion patients had greater overall complication rates, increased length of stay, and greater resource utilization but were discharged home in a greater proportion. Both fusion and halo were associated with significant (more than 3-fold) increase in complication rates in elderly patients aged 80 years or older. Given the similar mortality rate between the fusion group and the halo group and the higher cost and complication rate in the fusion group, our study supports the use of halo-vest immobilization in patients where operative therapy is contraindicated.

CyberKnife stereotactic radiosurgery for the treatment of symptomatic vertebral hemangiomas: a single-institution experience

Objective: Our aim was to examine underserved women’s perceptions on mobile versus fixed mammography in Santa Clara, California through a focus group study. Background: Research has shown that medically underserved women have higher breast cancer mortality rates correlated with under-screening and a disproportional rate of late-stage diagnosis. The Community Health Partnership in Santa Clara County, California runs the Community Mammography Access Project (CMAP) that targets nearly 20,000 medically underserved women over the age of 40 in the county through the collaborative effort of an existing safety net of healthcare providers. However, little data exists on the advantages or disadvantages of mobile mammography units from the patient perspective. Methods: We assessed underserved women’s perspectives on mammography services in Santa Clara County through two focus groups from women screened at mobile or fixed site programs. Patients were recruited from both CMAP clinics and a county hospital, and focus group data were analyzed using content analysis. Results: We found that women from both the mobile and fixed sites shared similar motivating factors for getting a mammogram. Both groups recognized that screening was uncomfortable but necessary for good health and had positive feedback about their personal physicians. However, mobile participants, in particular, appreciated the atmosphere of mobile screening, reported shorter wait times, and remarked on the good communication from the clinic staff and empathetic treatment they received. However, mobile participants also expressed concern about the quality of films at mobile sites due to delayed initial reading of the films. Conclusions: Mobile mammography offers a unique opportunity for women of underserved populations to access high satisfaction screenings, and it encourages a model similar to CMAP in other underserved areas. However, emphasis should be placed on providing a warm and welcoming environment for patients and ensuring the quality of mammography images.

Cardinal features of superior oblique myokymia: An infrared oculography study

OBJECTIVE Glioblastoma is a primary glial neoplasm with a median survival of approximately 1 year. There are anecdotal reports that postoperative infection may confer a survival advantage in patients with glioblastoma. However, only a few case reports in the literature, along with 2 retrospective cohort studies, show some potential link between infection and prolonged survival in patients with glioblastoma. The objective of this study was to evaluate the effect of postoperative infection in patients with glioblastoma using a large national database. METHODS The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database was searched to identify patients 66 years of age and older with glioblastoma, with and without infection, from 1997 to 2010. The primary outcome was survival after diagnosis. The statistical analysis was performed with a graphical representation using Kaplan-Meier curves, univariate analysis with the log-rank test, and multivariate analysis with proportional hazards modeling. RESULTS A total of 3784 patients with glioblastoma were identified from the database, and from these, 369 (9.8%) had postoperative infection within 1 month of surgery. In patients with glioblastoma who had an infection within 1 month of surgery, there was no significant difference in survival (median 5 months) compared with patients with no infection (median 6 months; p = 0.17). The study also showed that older age, increased Gagne comorbidity score, and having diabetes may be negatively associated with survival. CONCLUSIONS Infection after craniotomy within 1 month was not associated with a survival benefit in patients with glioblastoma.

Treatment of Nystagmus in Brainstem Cavernous Malformation with Botulinum Toxin.

OBJECTIVE Symptomatic vertebral hemangiomas (SVHs) are a very rare pathology that can present with persistent pain or neurological deficits that warrant surgical intervention. Given the relative rarity and difficulty in assessment, the authors sought to present a dedicated series of SVHs treated using stereotactic radiosurgery (SRS) to provide insight into clinical decision making. METHODS A retrospective review of a single institutions experience with hypofractionated radiosurgery for SVH from 2004 to 2011 was conducted to determine the clinical and radiographic outcomes following SRS treatment. The authors report and analyze the treatment course of 5 patients with 7 lesions, 2 of which were treated primarily by SRS. RESULTS Of the 5 patients studied, 4 presented with a chief complaint of pain refractory to conservative measures. Three patients reported dysesthesias, and 2 reported upper-extremity weakness. Following radiosurgery, 4 of 5 patients exhibited improvement in their primary symptoms (3 for pain and 1 for weakness), achieving a clinical response after a mean period of 1 year. In 2 cases there was 20%-40% reduction in lesion size in the most responsive dimension as noted on images. All treatments were well tolerated. CONCLUSIONS SRS for SVH is a safe and feasible treatment strategy, comparable to prior radiotherapy studies, and in select cases may successfully confer delayed decompressive effects. Additional investigation will determine future patient selection and how conformal SRS treatment can best be administered.

Transoral Endoscopic Resection of High Cervical Osteophytes with Long-Term Symptom Resolution: Case Series, Imaging, and Literature Review

Purpose Superior oblique myokymia (SOM) is a rare eye movement disorder characterized by unilateral oscillopsia and binocular diplopia. Our study aimed to better understand SOM using infrared oculography. Methods We examined and recorded five patients with SOM. Results Binocular infrared oculography showed that in primary gaze, all patients exhibited torsional oscillations, which worsened in infraduction and abduction and improved in supraduction and adduction. Saccades showed increased downward saccade amplitudes but normal peak velocities. During fixation in primary gaze, removal of target led to extorsion and supraduction, unmasking underlying superior oblique weakness. Conclusions and importance Our data suggest both weakness and activity-dependent hyperactivity of the trochlear motor unit, supporting a model of injury followed by aberrant regeneration.

Minimally Invasive Lumbar Pedicle Screw Fixation Using Cortical Bone Trajectory: Functional Outcomes

We report a long-term eye movement study of a 68-year-old female with pontomedullary junction cavernous malformation whose dysconjugate nystagmus was treated with retrobulbar botulinum toxin A injections. Sequential, bilateral retrobulbar injections of botulinum toxin A were performed. Injections immediately decreased oscillopsia and nystagmus, and improved visual acuities. One to three months following injection, three-dimensional infrared oculography measured a significant 39-100% (P = 0.001) decrease in nystagmus amplitudes at multiple dimensions. This improvement diminished by six months in the right eye but sustained for about one year in the left eye. Over two years, botulinum toxin A injections were performed twice in the left eye and five times in the right eye. Our study supported the safe and effective use of repetitive retrobulbar botulinum toxin A injections in symptomatic nystagmus that failed medical therapy.

Cervical Fracture/Subluxation in a Patient with a Prior C2-Sacrum Fusion: Case Report and Review of Literature

BACKGROUND Anterior cervical osteophytes (ACOs) are a common radiologic finding in the elderly; rarely, they can cause dysphagia, dysphonia, and dyspnea. Symptomatic ACOs are most commonly found between C4 and C7 and much less commonly at higher cervical levels. Here, we present a case series, with an example case of a 57-year-old woman with high cervical osteophytes at C1-C2 causing globus sensation, dysphagia, and dysphonia. Additionally, we provide a literature review regarding the causes, diagnosis, and treatment of ACOs, with a focus on management of high ACOs. CASE DESCRIPTION A 57-year-old smoker with a history of chronic neck pain and previous cervical spinal instrumentation presented with several months of globus sensation, dysphagia, and dysphonia. Imaging revealed 2 large anterior osteophytes at C1-C2. She underwent endoscopic transoral osteophytectomy, with resolution of symptoms. Five other patients are also presented who underwent similar procedures. CONCLUSIONS ACOs are a potential cause of dysphagia, and their diagnosis is best made with computed tomographic imaging and oropharyngeal swallow study. Although high ACOs at C1-C2 are a rare finding, here we show with an exemplary case and small case series that they can be effectively treated with transoral endoscopic osteophytectomy.