Rapid-sequence MRI for evaluation of pediatric traumatic brain injury: a systematic review.

OBJECTIVE: Rapid-sequence MRI (RSMRI) of the brain is a limited-sequence MRI protocol that eliminates ionizing radiation exposure and reduces imaging time. This systematic review sought to examine studies of clinical RSMRI use for pediatric traumatic brain injury (TBI) and to evaluate various RSMRI protocols used, including their reported accuracy as well as clinical and systems-based limitations to implementation. METHODS: PubMed, EMBASE, and Web of Science databases were searched, and clinical articles reporting the use of a limited brain MRI protocol in the setting of pediatric head trauma were identified. RESULTS: Of the 1639 articles initially identified and reviewed, 13 studies were included. An additional article that was in press at the time was provided by its authors. The average RSMRI study completion time was variable, spanning from 1 minute to 16 minutes. RSMRI with "blood-sensitive" sequences was more sensitive for detection of hemorrhage compared with head CT (HCT), but less sensitive for detection of skull fractures. Compared with standard MRI, RSMRI had decreased sensitivity for all evidence of trauma. CONCLUSIONS: Protocols and uses of RSMRI for pediatric TBI were variable among the included studies. While traumatic pathology missed by RSMRI, such as small hemorrhages and linear, nondisplaced skull fractures, was frequently described as clinically insignificant, in some cases these findings may be prognostically and/or forensically significant. Institutions should integrate RSMRI into pediatric TBI management judiciously, relying on clinical context and institutional capabilities.

Limitations on Postoperative Opioid Prescriptions and Effects on Health Care Resource Use Following Elective Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To curb the misuse of postoperative prescription opioids, the state of North Carolina enacted the Strengthen Opioid Misuse Prevention (STOP) Act of 2017 limiting the duration of initial postoperative opioid prescriptions. The purpose of this study was to evaluate the STOP Act's effect on health care resource use by comparing patient outcomes and opioid prescribing practices following elective anterior cervical discectomy and fusion (ACDF). METHODS: Outcomes and opioid prescribing data were retrospectively evaluated for Pre-Law (January 1, 2017, to December 31, 2017) and Post-Law (January 1, 2018, to December 31, 2018) elective 1- to 4-level anterior cervical discectomy and fusion patient cohorts. Outcome measures included hospital and clinic resource use in the form of emergency department visits, readmissions, major postoperative complications, number of clinic visits, or number of clinic phone calls by patients reporting uncontrolled pain or requesting new opioid prescriptions. Opioid-prescribing practices in the form of discharge prescription number of pills and total morphine milliequivalents also were recorded. RESULTS: Surrounding the STOP Act's implementation, there was no significant difference (P > 0.05) in emergency department visits, readmissions, major complications, number of postoperative clinic visits, or number of clinic phone calls for uncontrolled pain or new prescription requests. There was a significant decline in mean discharge prescription number of pills (89.7 vs. 67.0, P < 0.001), and average morphine milliequivalents (683.4 vs. 509.6, P < 0.001). CONCLUSIONS: This may reflect overprescribing in this population, where larger opioid prescriptions were likely not needed to manage pain that would otherwise require a return to care.

Gender Disparities in Surgical Treatment of Axis Fractures in Older Adults.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Gender appears to play in important role in surgical outcomes following acute cervical spine trauma, with current literature suggesting males have a significantly higher mortality following spine surgery. However, no well-adjusted population-based studies of gender disparities in incidence and outcomes of spine surgery following acute traumatic axis injuries exist to our knowledge. We hypothesized that females would receive surgery less often than males, but males would have a higher 1-year mortality following isolated traumatic axis fractures. METHODS: We performed a retrospective cohort study using Medicare claims data that identified US citizens aged 65 and older with ICD-9 (International Classification of Diseases, Ninth Revision) code diagnosis corresponding to isolated acute traumatic axis fracture between 2007 and 2014. Our primary outcome was defined as cumulative incidence of surgical treatment, and our secondary outcome was 1-year mortality. Propensity weighted analysis was performed to balance covariates between genders. Our institutional review board approved the study (IRB #16-0533). RESULTS: There was no difference in incidence of surgery between males and females following acute isolated traumatic axis fractures (7.4 and 7.5 per 100 fractures, respectively). Males had significantly higher 1-year weighted mortality overall (41.7 and 28.9 per 100 fractures, respectively, P < .001). CONCLUSION: Our well-adjusted data suggest there was no significant gender disparity in incidence of surgical treatment over the study period. The data also support previous observations that males have worse outcomes in comparison to females in the setting of axis fractures and spinal trauma regardless of surgical intervention.

Reducing the Reported Mortality Index Within a Neurocritical Care Unit Through Documentation and Coding Accuracy.

BACKGROUND: The mortality index, or the ratio of observed to expected mortality, is a reported quality metric that has been assumed to directly reflect patient care. However, documentation and coding that does not use knowledge of how a reported mortality index is derived could reflect poorly on a hospital or service line. We present our effort at reducing the reported mortality index of neurosurgery and neurology patients within a neurocritical care unit through documentation and coding accuracy with direct incorporation of mortality modeling. METHODS: Using a reported method from Vizient Inc., we generated a spreadsheet tool to enable direct manipulation of the data to identify documentation and coding issues that influenced the reported mortality index in a retrospective set of patients. Subsequently, we implemented the prospective changes to documentation and coding and compared our calculated mortality index to the reported Vizient mortality index. RESULTS: Prospective implementation of the documentation and coding issues identified through our spreadsheet tool resulted in a drastic reduction of both our calculated and the reported Vizient mortality index. CONCLUSIONS: Incorporating knowledge of mortality index modeling into the documentation and coding resulted in impressive reductions in the reported mortality index for our patients, serving as a both an internal benchmark and a method of comparison with other institutions.

Cost of prenatal versus postnatal myelomeningocele closure for both mother and child at 1 year of life.

OBJECTIVE: Prenatal myelomeningocele (MMC) closure has been performed in the United States for 2 decades. While prior work has focused on clinical outcomes of prenatal MMC closure, the cost of this procedure in comparison with that of postnatal MMC closure is unclear. The authors' aim was to compare the cost of prenatal versus postnatal MMC closure for both the child and mother at 1 year. METHODS: A prospective database of patients undergoing prenatal and postnatal MMC closure between 2011 and 2018 with 1-year follow-up was retrospectively reviewed. Charge data for relevant admissions were converted to a cost estimate using the authors' institution's Medicare hospital-specific cost-to-charge ratio. Children, mothers, and mother/child pairs were considered separately. The primary outcome was cost. Secondary outcomes included the need for hydrocephalus treatment, length of stay (LOS), and readmissions. Other covariates included gestational age at birth, MMC lesion level, and obstetric complications. RESULTS: The median cost of care for children in the prenatal group was greater, although not significantly so, at $58,406.71 (IQR $16,900.24-$88,951.01) compared with $49,889.95 (IQR $38,425.18-$115,163.86) for children in the postnatal group (p = 0.204). The median cost for mothers in the prenatal group was significantly greater at $24,548.29 (IQR $20,231.55-$36,862.31) compared with $5087.30 (IQR $4430.72-$5362.56) (p < 0.001). The median cost for mother/child pairs in the prenatal group was $102,377.75 (IQR $37,384.30-$118,527.74) compared with $55,667.82 (IQR $42,840.78-$120,058.06) (p = 0.45). Children in the prenatal group had a lower gestational age at birth (235.81 days vs 265.77 days, p < 0.001) and fewer readmissions (33.3% vs 72.7%, p < 0.001), and hydrocephalus treatment was less common (33.3% vs 90.9%, p < 0.001). Index LOS did not differ between children in the prenatal and postnatal groups (26.8 days vs 23.5 days, p = 0.63). Mothers in the prenatal group had longer LOS (15.92 days vs 4.68 days, p < 0.001) and more readmissions (18.5% vs 0.0%, p = 0.06). CONCLUSIONS: The median cost of prenatal versus postnatal MMC closure did not significantly differ from a hospital perspective at 1 year, although variability in cost was high for both groups. When considering the mother alone, prenatal MMC closure was costlier. Future work is needed to assess cost from a patient and societal perspective both at 1 year and beyond.

Disseminated oligodendroglial-like leptomeningeal tumor with anaplastic progression and presumed extraneural disease: case report.

We report the neuroimaging and histopathologic findings of a 12-year-old female patient with a disseminated oligodendroglial-like leptomeningeal tumor with anaplastic progression and presumed extraneural metastatic disease. These tumors may represent distinct pathology primarily seen in pediatric patients. Neuroimaging demonstrates diffuse, progressive enhancement of the leptomeninges often with interval development of intraparenchymal lesions on follow-up. Disease is typically confined to the central nervous system, though diffuse peritoneal disease was seen in our case, possibly through metastatic seeding of the abdomen via ventriculoperitoneal shunt.