Shortfalls in pediatric hydrocephalus clinical outcome analysis.

BACKGROUND: In this paper, we used search engine technology to study outcome analysis and cost awareness of child hydrocephalus in the literature. METHODS: The aggregate hospital charges of hydrocephalus treatment procedures for patients <18 years old was extracted from the Nationwide Inpatient Sample (NIS) data. Hydrocephalus literature was probed through the PubMed biomedical search engine. RESULTS: Aggregate hospital charges associated with ventriculo-peritoneal shunting as the principle procedure for patients <18 years old have increased 1.7-fold over a 13-year period to 235.6 million in 2009. Hospital discharges, however, decreased from 3,390 in 1997 to 2,525 in 2009 (25.5% decrease over 13 years). The number of papers in English language indexed by PubMed in relation to child hydrocephalus in humans increased from 81 papers in 1996 to 133 in 2010 (1.6-fold increase), totaling 1,694 over 15 years. Randomized controlled trials published in relation to child hydrocephalus totaled 16 over the same period (0.94% of child hydrocephalus papers). Papers related to child hydrocephalus with "costs and cost analysis" as medical subject heading totaled 13 papers (0.77%). CONCLUSIONS: Over the past 15 years, disappointingly the number of printed child hydrocephalus papers appeared to have only plateaued. Strikingly, only a very small number of these papers were directed toward randomized control studies, the sine qua non of high-grade clinical evidence. Moreover, very few papers make reference to cost analysis or economics in the treatment of hydrocephalus - an issue coming increasingly before the nation at this point.

The role of drains in lumbar spine fusion.

OBJECTIVE: To study the role of drains in lumbar spine fusions. METHODS: The charts of 402 patients who underwent lumbar decompression and fusion (LDF) were retrospectively reviewed. Patients were classified per International Classification of Diseases, 9th Edition (ICD-9) procedure code as 81.07 (lateral fusion, 74.9%) and 81.08 (posterior fusion, 25.1%). The investigators studied the prevalence of drain use in lumbar fusion procedures and the impact of drain use on postoperative fever, wound infection, posthemorrhagic anemia, blood transfusion, and hospital cost. RESULTS: No significant differences in wound infection rates were noted between patients with and without drains (3.5% vs 2.6%, P = 0.627). The difference in postoperative fever rates between patients with and without drains (63.2% vs 52.6%, P = 0.05) was of borderline significance. Posthemorrhagic anemia was statistically more common in patients with drains (23.5% vs 7.7%, P = 0.000). Allogeneic blood transfusion was also statistically more common in the drained group (23.9% vs 6.8%, P = 0.000). Postoperative hemoglobin levels were lower in patients with drains who underwent one-level (9.5 g/dL vs 11.3 g/dL) or two-level (9.3 g/dL vs 10.2 g/dL) spine fusions. In this series in which drains were liberally used, no patient had to return to the operating room because of postoperative hematoma. An increased rate of allogeneic blood transfusion was noticed with posthemorrhagic anemia and drain use. The rate of allogeneic blood transfusion increased from 5.6% in patients without drains or posthemorrhagic anemia to 38.8% in patients with drains and posthemorrhagic anemia as a secondary diagnosis. The use of drains was associated with statistically insignificant increases in length of stay and cost in posterior procedures. Drain use was associated with shorter length of stay and hospital charges in lateral fusions of three or more levels. CONCLUSIONS: Drain use did not increase the risk of wound infection in patients undergoing LDF, but it had some impact on the prevalence of postoperative fever. Drain use was significantly associated with posthemorrhagic anemia and allogeneic blood transfusion. Drain use did not have a significant economic impact on hospital length of stay and charges except in lateral procedures involving three or more levels.

Uterine peaking--sonographic sign of vesico-uterine adhesion.

OBJECTIVE: In this paper we present our observation of a specific sign on transvaginal ultrasound that may help basic minimal invasive surgeons diagnose vesico-uterine adhesions preoperatively. METHODS: The ultrasound images of the latest eleven patients who were preoperatively diagnosed with vesico-uterine adhesions using transvaginal ultrasound were compared with their intraoperative findings. RESULTS: Ultrasonography showed a spectrum of changes from obliterated anterior cul-de-sac to dense fibrosis between the lower uterine segment and cervix with the bladder. Horn- or beak-shaped streaks of tissue with the same density of uterine myometrium is a sign of fundal attachment of vesico-uterine adhesions or of complete anterior cul-de-sac obliteration with adhesions going between the uterus and the anterior abdominal wall. Fine papillary peaking is seen in cases of dense lower uterine segment and cervical fibrosis without fundal involvement. These signs combined with limited mobility of the cervix and bladder base correlated with the presence of dense vesico-uterine adhesions. CONCLUSION: The described sonographic signs, two static and the other dynamic, may help basic minimal invasive gynecological surgeons who do not have advanced laparoscopic skills and do not feel comfortable dealing with an obliterated anterior cul-de-sac or dense vesico-uterine space fibrosis predict the presence of dense vesico-uterine adhesions allowing them to choose another route that they may be more comfortable with such as vaginal or abdominal hysterectomy or request assistance from a more experienced colleague.

Higher comorbidity rates in unemployed patients may significantly impact the cost of spine surgery.

Chronic back pain is commonly associated with physical and mental comorbidities, which create a considerable burden on the healthcare system. We examined the differences in comorbidity rates of 619 spinal surgery patients of employment age, and the impact of comorbidity rates on length of hospital stay and cost. The charts of patients aged >25 years and <65 years were reviewed retrospectively. Type of surgery, employment status, comorbidities, length of stay and hospital charges were studied using chi-square, Fisher, Student's t-test, Wilcoxon-Mann-Whitney test and multivariate analysis. The unemployment rate among employment-aged spinal surgery patients was 44.7%. Unemployed patients who underwent any of the three types of surgery (anterior cervical decompression and fusion, lumbar decompression and fusion, and lumbar microdiscectomy [LMD]) stayed longer in hospital but had higher hospital charges in the minimally invasive LMD group only. There were higher rates of some comorbidities in unemployed compared to employed patients: asthma (12.2% vs. 5.9%), coronary artery disease (20.4% vs. 12.8%), diabetes mellitus (58.0% vs. 47.3%), history of coronary artery bypass surgery or stent placement (18.2% vs. 11.6%), hypothyroidism (14.4% vs. 8.2%), knee joint disease (43.1% vs. 33.6%), chronic renal disease (12.9% vs. 2.9%) and opioid (55.2% vs. 45.9%) antidepressant (37.0% vs. 25.3%) anxiolytic (16.0% vs. 8.9%) use. Charlson comorbidity scores were significantly different (p<0.001) between unemployed (1.72 ± 1.90) and employed patients (1.03 ± 1.55). Multivariate analysis showed that a history of coronary artery bypass/stent procedure, chronic renal disease or preoperative opioid use had a significant impact on length of stay and hospital charges in unemployed spine surgery patients. Thus, unemployment in spinal surgery candidates is associated with higher comorbidity rates with a significant impact on healthcare cost. More research is needed into the relationship between unemployment and consumption of healthcare resources.

The effect of age and body mass index on cost of spinal surgery.

Complex shifts in demography combined with drastic advancements in spinal surgery have led to a steep increase in often expensive spinal interventions in older and obese patients. A cost analysis, based on hospital charges, was performed retrospectively on the spinal surgery of 787 randomly selected patients who were operated at The Medical Center of Central Georgia, a large urban hospital in Central Georgia. The types of surgery included anterior cervical decompression and fusion (ACDF), lumbar decompression and fusion (LDF), and lumbar microdiscectomy (LMD). The distribution of patient age followed a Gaussian form. The peak age for patients was 50-59 years (28.8%), and there was no statistical difference in age between men and women. The body mass index (BMI) differed (p<0.01) between males (28.86 kg/m(2); range: 18-47 kg/m(2)) and females (30.69 kg/m(2); range: 17-58 kg/m(2)). The BMI data did not follow a Gaussian distribution for either gender. The hospital cost for spinal surgery increased with age except for male patients who underwent ACDF. For male patients who underwent LDF, the increase in hospital cost was statistically significant between the 40-49-year and the ≥ 70-year age groups. Univariate analysis with type of surgery as a covariate showed that age was a significant determinant of hospital cost (p=0.000), and BMI was not (p=0.110); however, the interaction between age and BMI was significant (p=0.000). Older patients undergoing spinal surgery had lower BMI, more so in males (r=-0.047, p=0.426) than in females (r=-0.038, p=0.485). There were linear trends in all gender-spinal surgery categories between age, BMI and hospital cost. Older female patients who underwent LDF tended to have a lower BMI but higher hospital cost, confirming that age was more important than BMI in determining hospital cost in these patients. The increments in cost of spinal surgery in relation to age especially and BMI were, nevertheless, small. We believe that spinal surgery in the elderly should be viewed as a public investment, as the modern concept of retirement involves people working intermittently up to their 80s. Thus, where clinical research on medical costs is to be conducted, cost analysis needs to be expanded to include returns to government in the form of taxes.

Syringomyelia: a complication of an underlying pathology.

UNLABELLED: Patients with syringomyelia may have diverse etiology and experience a variety of symptoms. This report describes two cases of syringomyelia in patients with different profiles, presentations and pathomechanisms. KEYWORDS: Syrigomyelia; Syrinx; Arachnoid cyst; Arnold-Chiari.

Dyspareunia: a complex problem requiring a selective approach.

Dyspareunia frequently has a multifactorial aetiology. The problem with the term is that it is not specific enough and does not allow for proper discussion of the very important problem of pain with sexual intercourse, a problem that can be very disturbing to a couple's relationship. We present two cases of patients who had multiple potential anatomic reasons for dyspareunia. The clinical picture, treatment strategy and the complex nature of deep penetration pain was discussed. We also proposed a new way of defining dyspareunia to allow a more adequate way of studying and discussing the problem.

Bilateral dermoid cysts of the ovary in a pregnant woman: case report and review of the literature.

OBJECTIVE: Most nonphysiological ovarian masses discovered during pregnancy are benign dermoid cysts. The association of dermoid cysts with pregnancy has been increasingly reported since 1918. They usually present the dilemma of weighing the risks of surgery and anesthesia versus the risks of untreated adnexal mass. METHOD: We are reporting an illustrative case and presenting a review of the literature for recommendations regarding the management of such cases. RESULT: The bilateral dermoid cysts were surgically treated in the second trimester. CONCLUSION: Most references state that it is more feasible to treat bilateral dermoid cysts of the ovaries discovered during pregnancy if they grow beyond 6 cm in diameter. This is usually performed through laparotomy or very carefully through laparoscopy and should preferably be done in the second trimester.

Early screening for IUGR: comparison of two related echographic markers.

INTRODUCTION: Can ultrasonography be performed in pregnant women as a screening test to predict IUGR? To justify its use, it must have a high enough positive predictive value. MATERIALS AND METHODS: This study addresses the concept of early prediction of IUGR using echographic measurements in the first trimester. We studied one traditional and one new marker, the crown-rump length (CRL) and the cerebro-corporal coefficient (CCC). We retrospectively reviewed the charts of 139 pregnancies that gave birth to babies with IUGR and 25 charts of normal pregnancies that made the control group. Screening in the first trimester of pregnancy was done in 125 (89.9%) pregnant women between 10 and 14 weeks. We calculated the diagnostic and predictive values of these two parameters in IUGR. RESULTS: The sensitivity and specificity for reduced CRL were 29 and 100%, respectively, and for the CCC>0.6, 46 and 100%, respectively. Using IUGR prevalence (10%) and the Bayes equation we calculated the positive predictive value of reduced CRL and >0.6 CCC in general, moderate and severe IUGR and severe IUGR alone. They were 1, 1, 9%, 13, 19 and 29%, respectively. CONCLUSION: The positive predictive value of the crown-rump length and the cerebro-corporal coefficient for IUGR in the general population increases with the severity of the disease. Using these two parameters, however, would be more useful in high-risk pregnancies.

Lymphoma of the base of the tongue: an incidental finding on the preoperative workup for a spine surgery.

UNLABELLED: Lymphoma of the tongue is very rare and accounts for 1% of all malignant tumors of the oral cavity. We present a patient who presented with weakness and difficulties with ambulation who was a known cervical spine spondylosis and stenosis patient. During the preoperative workup for cervical spine surgery a tumor at the base of the tongue was discovered which was confirmed by pathology to be a lymphoma. KEYWORDS: Lymphoma; Tongue; Spine surgery; Preoperative workup.

Prevalence of urinary incontinence in female residents of american nursing homes and association with neuropsychiatric disorders.

BACKGROUND: Urinary incontinence (UI) is most common in older women. METHODS: We studied the prevalence of UI among female residents of nursing homes and the influence of associated neuropsychiatric problems on the rates of UI using the results of the 2004 National Nursing Home Survey (NNHS). RESULTS: Analysis shows that 37% of female nursing home residents are incontinent, especially those with dementia. Residents with depression or schizophrenia are also more likely to have UI whereas those with anxiety, paranoia, or obsessive-compulsive disorder have less UI rates. There are significant associations with neuropsychiatric disorders except for bipolar disease. CONCLUSIONS: We recommend prioritizing behavioral interventions and environmental manipulations for female residents with dementia, depression, and schizophrenia to increase the cost-effectiveness of UI management programs in nursing homes. KEYWORDS: Urinary incontinence; Female residents; Nursing home; Neurodegenerative; Psychiatric.

Successful treatment with intravenous immunoglobulin of acute flaccid paralysis caused by west nile virus.

West Nile virus (WNV) is one of the leading causes of insect-borne encephalitis and acute flaccid paralysis in the US. Acute flaccid paralysis is a potentially serious illness, which manifests itself as a Guillain-Barré-like syndrome with generalized weakness and shortness of breath. We report a case involving a patient who presented with acute flaccid paralysis due to WNV infection and was successfully treated with intravenous immunoglobulin from Israeli donors.

Neurosarcoidosis--the great mimicker.

INTRODUCTION: Neurosarcoidosis is rare and difficult to diagnose especially in the absence of systemic involvement. CASE REPORT: A 22-year-old African-American man presented with inability to gaze laterally. He underwent magnetic resonance imaging (MRI) the day before that revealed "a 5-mm enhancing mass with surrounding edema in the pons anterior to the fourth ventricle most likely compatible with pontine glioma." CT angiography of the brain was negative. Two days later, the patient developed right facial droop. During craniotomy, a small lesion of rubbery consistency was identified at the mid-portion of the floor of the fourth ventricle. Frozen-section study came suggestive of lymphoma. Further pathological examination revealed sarcoidosis. The patient was discharged on prednisone, and he recovered quickly and completely. CONCLUSION: Neurosarcoidosis can mimic common neurosurgical entities. It is important to keep neurosarcoidosis in mind when making the diagnosis, which often requires biopsy.

The fifth vital sign--what does it mean?

Acute pain is reported as a presenting symptom in over 80% of physician visits. Chronic pain affects an estimated 76.2 million Americans--more than diabetes, heart disease, and cancer combined. It has been estimated to be undertreated in up to 80% of patients in some settings. Pain costs the American public more than $100 billion each year in health care, compensation, and litigation. That's why pain was officially declared "The Fifth Vital Sign." Henceforth the evaluation of pain became a requirement of proper patient care as important and basic as the assessment and management of temperature, blood pressure, respiratory rate, and heart rate. The numeric pain scale certainly has a place in care and in pain management; however, it is important to assess the patient's communication and self-management style and to recognize that patients, like pain, are on a continuum with varied styles of communication and adaptation. It is easy to get lost in the process, even when the process is initiated with the best of intentions. In the quest for individualized medicine, it might be best to keep pain assessment in the individualization arena.

Brain metastasis from thymic carcinoma in association with SIADH and pituitary enlargement: a case report.

A 49-year-old white female presented to the emergency room complaining of severe headaches. A brain computed tomography (CT) showed a large right temporal mass that measured 2.9 x 5 cm. Sodium was low at admission, which indicated syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Her pituitary gland was enlarged. Thorax CT revealed a large anterior mediastinal mass measuring 6.3 x 3.6 cm. Pathology revealed a poorly differentiated carcinoma arising from the thymus. This case is unique because thymic cancer rarely results in brain metastases and very rarely causes SIADH with changes in pituitary volume and signal quality.