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Background: Deep brain stimulation (DBS) is an approved treatment option for Parkinson's Disease (PD), essential tremor (ET), dystonia, obsessive-compulsive disorder and epilepsy in the United States. There are disparities in access to DBS, and clear understanding of the contextual factors driving them is important. Previous studies aimed at understanding these factors have been limited by single indications or small cohort sizes. The aim of this study is to provide an updated and comprehensive analysis of DBS utilization for multiple indications to better understand the factors driving disparities in access. Methods: The United States based National Inpatient Sample (NIS) database was utilized to analyze the surgical volume and trends of procedures based on indication, using relevant ICD codes. Predictors of DBS use were analyzed using a logistic regression model. DBS-implanted patients in each indication were compared based on the patient-, hospital-, and outcome-related variables. Findings: Our analysis of 104,356 DBS discharges from 1993 to 2017 revealed that the most frequent indications for DBS were PD (67%), ET (24%), and dystonia (4%). Although the number of DBS procedures has consistently increased over the years, radiofrequency ablation utilization has significantly decreased to only a few patients per year since 2003. Negative predictors for DBS utilization in PD and ET cohorts included age increase and female sex, while African American status was a negative predictor across all cohorts. Significant differences in patient-, hospital-, and outcome-related variables between DBS indications were also determined. Interpretation: Demographic and socioeconomic-based disparities in DBS use are evident. Although racial disparities are present across all indications, other disparities such as age, sex, wealth, and insurance status are only relevant in certain indications. Funding: This work was supported by Alan & Susan Hudson Cornerstone Chair in Neurosurgery at University Health Network.
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BACKGROUND: We aimed to determine the outcomes and prognostic factors in pediatric craniocerebral gunshot injury (CGI) patients. Pediatric patients may have significantly different physiology, neuroplasticity, and clinical outcomes in CGI than adults. There is limited literature on this topic, mainly case reports and small case series. METHODS: We queried the National Trauma Data Bank for all pediatric CGI between 2014 and 2017. Patients were identified using International Classification of Diseases, Ninth Revision, codes. Demographic, emergency department, and clinical data were analyzed. Subgroup analysis was attempted for groups with Glasgow Coma Scale (GCS) scores of 9 to 15 and ages 0 to 8 years. RESULTS: In a 3-year period, there were 209 pediatric patients (aged 0-18 years) presenting to American hospitals with signs of life. The overall mortality rate was 53.11%. A linear relationship was demonstrated showing a mortality rate of 79% by initial GCS in GCS score of 3, 56% in GCS scores of 4 to 8, 22% in GCS scores of 9 to 12, and 5% in GCS scores of 13 to 15. The youngest patients, aged 0 to 8 years, had dramatically better initial GCS and subsequently lower mortality rates. Regression analysis showed mortality benefit in the total population for intracranial pressure monitoring (odds ratio, 0.267) and craniotomy (odds ratio, 0.232). CONCLUSION: This study uses the National Trauma Data Bank to quantify the prevalence of pediatric intracranial gunshot wounds, with the goal to determine risk factors for prognosis in this patient population. Significant effects on mortality for invasive interventions including intracranial pressure monitoring and craniotomy for all patients suggest low threshold for use of these procedures if there is any clinical concern. The presence of a 79% mortality rate in patients with GCS score of 3 on presentation suggests that as long as there is not a declared neurologic death, intracranial pressure monitoring and treatment measures including craniotomy should be considered by the consulting clinician. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.
