ReportWire

Tag: Surgery

  • Black patients more likely to get emergency colorectal cancer surgery

    Black patients more likely to get emergency colorectal cancer surgery

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    Newswise — In an analysis of data from hospitals across the state of Michigan, University of Michigan researchers found that Black, non-Hispanic patients were more likely to undergo emergency surgery for colorectal cancer than other races and ethnicities.

    Undergoing emergency surgery was associated with a higher rate of complications, including death. Out of close to 5,000 patients who underwent any type of surgery for colorectal cancer, 23% had emergency surgery — but those patients made up 63% of the deaths.

    Patients who underwent emergency surgery also received less complete evaluations and testing as part of their workup by surgeons and their medical teams.

    “Overall, these results suggest that racial and ethnic differences persist in presentation and management of colorectal cancer and that these differences likely contribute to disparities in postoperative outcomes among these groups,” said Ryan Howard, M.D., M.S., a general surgery resident at University of Michigan Health and the first author of the study.

    Howard and his research team used data from the Michigan Surgical Quality Collaborative, a statewide initiative funded by Blue Cross Blue Shield of Michigan that aims to improve the quality and cost of surgical care across the state. 

    Their goal was to identify opportunities to improve patient care earlier in the process of cancer diagnosis and treatment.

    “We can spend all day working on, say, reducing complications right after surgery,” Howard said. “But if we’re still not getting the right treatment to the right patient at the right time, then we’re not doing a good enough job.”

    “Colorectal cancer is universally screened for and develops fairly slowly. So if someone is plugged into the health care system, the chances are very high that we will detect it and they will get the appropriate evaluation and work-up,” he added. “The fact that we found patients who are not getting that suggests that there is an opportunity to improve the care we deliver to patients, even before they get to the surgical episode.”

    Howard points to patient navigators and targeted community outreach as proven strategies to help reduce disparities in cancer care and believes the state of Michigan, with its network of collaborative quality initiatives, is well positioned to incorporate these solutions into future projects.

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    Michigan Medicine – University of Michigan

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  • After Years of Ankle Pain and Limited Mobility, Life-Changing Surgery at HSS

    After Years of Ankle Pain and Limited Mobility, Life-Changing Surgery at HSS

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    Newswise — After years of searching for answers and numerous doctor consultations, 59-year-old Kathleen Kaler finally found relief from the severe ankle pain and instability that had plagued her for years. At Hospital for Special Surgery (HSS), Constantine Demetracopoulos, MD, performed successful ankle replacement surgery.

    Kaler, who is from Long Island, says the surgery changed her life. She can now engage in activities most people take for granted – walking normally without pain, wearing shoes she likes, being able to do her job, working in her backyard.

    “You have no idea how grateful I am. Before the surgery, my left ankle was collapsing, it could barely support my weight,” says Kaler, a slim 5 foot 7. “All my shoes were worn out on one side.” Her ankle was so unstable, she lived in fear that she would fall or break it, despite the rigid plastic brace she wore from her foot to her knee, day in and day out. She could only wear one type of shoe that she needed to replace every three months.

    As a child, Kaler recalls constantly twisting her ankle. Her parents took her to several doctors, and she was given a shoe insert to help with her high foot arches. Years later, arthritis set in, and the pain worsened and became more debilitating. Cortisone shots could only do so much, and she resumed the search for a long-lasting solution. Four doctors said nothing could be done. One orthopedic surgeon said the problem might be corrected with four separate surgeries, which she declined.

    Then she learned about total ankle replacement during an appointment with a doctor at HSS Long Island. It’s a complex surgery performed by relatively few orthopedic surgeons, and she was referred to Dr. Demetracopoulos, director of the HSS Total Ankle Replacement Center at the main hospital in Manhattan.

    “One of the few centers of its kind, we have a team of foot and ankle specialists, anesthesiologists, radiologists, nurses and physical therapists who have extensive experience in ankle replacement,” he explains. “We strive to provide the best possible care for each of our patients and have grown our volume to become one of the top institutions nationwide in ankle replacement.”

    Kaler says her consultation with Dr. Demetracopoulos gave her hope, and she would not be disappointed. She had the surgery in April 2021. “He saved my life. I never cry, but I cried in front of him, I was so grateful,” she says.

    “Ankle replacement is considered when patients are no longer able to manage arthritis pain with nonsurgical treatments such as physical therapy, appropriate footwear, an ankle brace or anti-inflammatory medication,” Dr. Demetracopoulos explains. “They have consistent pain that limits their activities and affects their quality of life.”

    Like other types of joint replacements, the surgery involves replacing the damaged bone and cartilage in the ankle with a prosthesis. The implant, made of metal and plastic, has the shape of a natural joint and seeks to provide normal, pain-free movement.

    The last 15 years have brought vast improvements in ankle replacement implants, technology and surgical techniques, making it a viable option for many patients suffering from severe arthritis, says Scott Ellis, MD, another orthopedic surgeon specializing in foot and ankle surgery at HSS.

    One of the most noteworthy advances in ankle replacement is patient-specific instrumentation, or PSI, Dr. Ellis says. It entails obtaining a CT scan of the patient’s ankle and developing a customized presurgical plan tailored to the individual’s anatomy. “PSI has been a game changer. It enables us to choose an implant that is the perfect size and map out a very precise surgery for optimal alignment and positioning,” he says.

    For people considering an ankle replacement, the first step is a thorough assessment of the ankle and the foot, and a discussion of patient goals and expectations. Imaging and other tests determine if a patient is a candidate. For someone whose ankle is very stiff with limited mobility or a severe deformity, a fusion of the ankle bones might be a better option and is also very successful in relieving pain, the HSS experts say. An ankle fusion would also be a better option for someone with weakened bones or osteoporosis. The benefit of ankle replacement over fusion is better movement after surgery.

    Sometimes an ankle replacement needs to be combined with another procedure, as it was in Kaler’s case. “Hers was a complex surgery. She had a type of foot that predisposed her to ankle instability,” Dr. Demetracopoulos explained. “In addition to treating her arthritis with the ankle replacement, we needed to treat the instability by repairing the ligaments in her ankle and by correcting the alignment in her foot, so it was in the right position.” 

    Kaler says she experienced no pain after surgery, which Dr. Demetracopoulos attributes to advances in nerve block anesthesia and pain management protocols after the procedure. He notes that each patient experiences pain differently, though.

    The HSS doctors expect 90 percent of ankle replacements to last 10 years. If the implant wears out, patients could be candidates for a revision ankle replacement or an ankle fusion. The physicians follow and monitor patients in a joint replacement registry at HSS. “One of our core missions at HSS is not only to deliver the care and do the best surgery we can for our patients, but to collect data over time that we can share with other surgeons and clinicians,” Dr. Demetracopoulos says.

    Kaler says the surgery has enabled her to regain her confidence. She can now drive her stick-shift Mini Cooper and carry out her demanding job responsibilities at a major home improvement store. “I’m all over the place, to the point where my friends and colleagues are saying, ‘slow down,’” she adds, making up for lost time and living life to the fullest.

    About HSS

    HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 13th consecutive year), No. 3 in rheumatology by U.S. News & World Report (2022-2023), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2022-2023). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a third consecutive year (2023). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 145 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.

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    Hospital for Special Surgery

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  • NREF Announces New Grant Program for Early Career Neurosurgeons

    NREF Announces New Grant Program for Early Career Neurosurgeons

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    Newswise — December 5, 2022 (Rolling Meadows, Ill.) – The Neurosurgery Research & Education Foundation (NREF) is pleased to announce a new grant program – the NREF Early Career Neurosurgeon Fellowship. Applications will be available through the NREF website beginning December 1, 2022.

    The NREF Early Career Neurosurgeon Traveling Fellowship is designed for neurosurgical residents, fellows and early-career neurosurgeons interested in a subspecialty experience away from their home neurosurgery program.

    The fellowships consist of a rotation away from one’s home institution for periods of one week up to one month in duration, focused on a subspecialty experience with a Board-certified Neurosurgeon(s) or subspecialty surgeon(s) from another primary specialty. The supervising surgeon(s) will provide supervision to awardees and structured feedback to the awardee’s home program. The fellowship will include hands-on clinical exposure to the subspecialty in the operating room and clinic environment.

    The fellowship has received enthusiastic support from the corporate community for providing support that will establish the program. “Neurosurgery has benefited greatly from technological advances. The NREF is grateful to Medtronic – our industry partner in launching this program – for their commitment to the NREF mission to ensure that tomorrow’s neurosurgical leaders continue to receive cutting-edge experience to expand their knowledge and improve patient care,” sates NREF Fellowship Committee chair, Charles L. Branch, Jr., MD, FAANS.

    “The application of technology to medicine has yielded tremendous advances in the diagnosis and treatment of disease, and Medtronic is delighted to partner with the NREF to introduce innovative technology into neurosurgical training for early career neurosurgeons,” says Ashley M. Owens, sr. director, Global Physician Relations, Medtronic Cranial & Spinal Technologies.

    To qualify, applicants must be neurosurgical residents (PGY-4 and above) or fellows in ACGME-accredited neurosurgery programs or neurosurgeons in their first five years of practice.

    Applications will be accepted on a year-round basis with fellowships being awarded based on available funding. In addition to a CV, budget and support letters, applicants will submit a one-page statement describing the proposed fellowship experience and what they will accomplish during the away rotation, including including any relevant information regarding specific products to be used, techniques to be studied and what they hope to learn. Proposals will be screened for appropriateness as well as for feasibility of completion within the time frame and budget.

    The grant award will depending on the size, scope and budget of the project.

    To apply or for more information about the NREF Early Career Neurosurgeon Traveling Fellowship, please click here.

    For more information about other NREF grant programs, visit the NREF online at www.nref.org or contact NREF at 847.378.0500 or [email protected].

     

    About the NREF The NREF is a not-for-profit 501(c)(3) organization created in 1980 by the American Association of Neurological Surgeons (AANS) to support research and education efforts that enhance and confirm the critical role neurosurgeons play in improving lives.

    The NREF is dedicated to providing education to neurosurgeons at all stages of their careers, as well as funding research into new and existing neurosurgical treatments, in order to identify links between best practices and improved outcomes in patient care. Through voluntary public donations, corporate support and donations from allied groups, the NREF supports endeavors that impact the lives of those suffering from epilepsy, stroke, brain tumors, spinal disorders, sports-related head injuries, lower back pain and Parkinson’s disease.

    For more information about NREF, visit www.nref.org.

    ###

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    Neurosurgery Research and Education Foundation (NREF)

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  • Research helps seniors make informed decisions about risks, benefits of major surgery | CNN

    Research helps seniors make informed decisions about risks, benefits of major surgery | CNN

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    Nearly 1 in 7 older adults die within a year of undergoing major surgery, according to an important new study that sheds much-needed light on the risks seniors face when having invasive procedures.

    Especially vulnerable are older patients with probable dementia (33% die within a year) and frailty (28%), as well as those having emergency surgeries (22%). Advanced age also amplifies risk: Patients who were 90 or older were six times as likely to die than those ages 65 to 69.

    The study in JAMA Surgery, published by researchers at Yale School of Medicine, addresses a notable gap in research: Though patients 65 and older undergo nearly 40% of all surgeries in the U.S., detailed national data about the outcomes of these procedures has been largely missing.

    “As a field, we’ve been really remiss in not understanding long-term surgical outcomes for older adults,” said Dr. Zara Cooper, a professor of surgery at Harvard Medical School and the director of the Center for Geriatric Surgery at Brigham and Women’s Hospital in Boston.

    Of particular importance is information about how many seniors die, develop disabilities, can no longer live independently, or have a significantly worsened quality of life after major surgery.

    “What older patients want to know is, ‘What’s my life going to look like?’” Cooper said. “But we haven’t been able to answer with data of this quality before.”

    In the new study, Dr. Thomas Gill and Yale colleagues examined claims data from traditional Medicare and survey data from the National Health and Aging Trends study spanning 2011 to 2017. (Data from private Medicare Advantage plans was not available at that time but will be included in future studies.)

    Invasive procedures that take place in operating rooms with patients under general anesthesia were counted as major surgeries. Examples include procedures to replace broken hips, improve blood flow in the heart, excise cancer from the colon, remove gallbladders, fix leaky heart valves, and repair hernias, among many more.

    Older adults tend to experience more problems after surgery if they have chronic conditions such as heart or kidney disease; if they are already weak or have difficulty moving around; if their ability to care for themselves is compromised; and if they have cognitive problems, noted Gill, a professor of medicine, epidemiology, and investigative medicine at Yale.

    Two years ago, Gill’s team conducted research that showed 1 in 3 older adults had not returned to their baseline level of functioning six months after major surgery. Most likely to recover were seniors who had elective surgeries for which they could prepare in advance.

    In another study, published last year in the Annals of Surgery, his team found that about 1 million major surgeries occur in individuals 65 and older each year, including a significant number near the end of life. Remarkably, data documenting the extent of surgery in the older population has been lacking until now.

    “This opens up all kinds of questions: Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient’s priorities and determining whether surgery would achieve them?” said Dr. Clifford Ko, a professor of surgery at UCLA School of Medicine and director of the Division of Research and Optimal Patient Care at the American College of Surgeons.

    As an example of this kind of decision-making, Ko described a patient who, at 93, learned he had early-stage colon cancer on top of preexisting liver, heart, and lung disease. After an in-depth discussion and being told that the risk of poor results was high, the patient decided against invasive treatment.

    “He decided he would rather take the risk of a slow-growing cancer than deal with a major operation and the risk of complications,” Ko said.

    Still, most patients choose surgery. Dr. Marcia Russell, a staff surgeon at the Veterans Affairs Greater Los Angeles Healthcare System, described a 90-year-old patient who recently learned he had colon cancer during a prolonged hospital stay for pneumonia. “We talked with him about surgery, and his goals are to live as long as possible,” said Russell. To help prepare the patient, now recovering at home, for future surgery, she recommended he undertake physical therapy and eat more high-protein foods, measures that should help him get stronger.

    “He may need six to eight weeks to get ready for surgery, but he’s motivated to improve,” Russell said.

    The choices older Americans make about undergoing major surgery will have broad societal implications. As the 65-plus population expands, “covering surgery is going to be fiscally challenging for Medicare,” noted Dr. Robert Becher, an assistant professor of surgery at Yale and a research collaborator with Gill. Just over half of Medicare spending is devoted to inpatient and outpatient surgical care, according to a 2020 analysis.

    What’s more, “nearly every surgical subspecialty is going to experience workforce shortages in the coming years,” Becher said, noting that in 2033, there will be nearly 30,000 fewer surgeons than needed to meet expected demand.

    These trends make efforts to improve surgical outcomes for older adults even more critical. Yet progress has been slow. The American College of Surgeons launched a major quality improvement program in July 2019, eight months before the covid-19 pandemic hit. It requires hospitals to meet 30 standards to achieve recognized expertise in geriatric surgery. So far, fewer than 100 of the thousands of hospitals eligible are participating.

    One of the most advanced systems in the country, the Center for Geriatric Surgery at Brigham and Women’s Hospital, illustrates what’s possible. There, older adults who are candidates for surgery are screened for frailty. Those judged to be frail consult with a geriatrician, undergo a thorough geriatric assessment, and meet with a nurse who will help coordinate care after discharge.

    Also initiated are “geriatric-friendly” orders for post-surgery hospital care. This includes assessing older patients three times a day for delirium (an acute change in mental status that often afflicts older hospital patients), getting patients moving as soon as possible, and using non-narcotic pain relievers. “The goal is to minimize the harms of hospitalization,” said Cooper, who directs the effort.

    She told me about a recent patient, whom she described as a “social woman in her early 80s who was still wearing skinny jeans and going to cocktail parties.” This woman came to the emergency room with acute diverticulitis and delirium; a geriatrician was called in before surgery to help manage her medications and sleep-wake cycle, and recommend non-pharmaceutical interventions.

    With the help of family members who visited this patient in the hospital and have remained involved in her care, “she’s doing great,” Cooper said. “It’s the kind of outcome we work very hard to achieve.”

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  • Research helps seniors make informed decisions about risks, benefits of major surgery | CNN

    Research helps seniors make informed decisions about risks, benefits of major surgery | CNN

    [ad_1]

    Nearly 1 in 7 older adults die within a year of undergoing major surgery, according to an important new study that sheds much-needed light on the risks seniors face when having invasive procedures.

    Especially vulnerable are older patients with probable dementia (33% die within a year) and frailty (28%), as well as those having emergency surgeries (22%). Advanced age also amplifies risk: Patients who were 90 or older were six times as likely to die than those ages 65 to 69.

    The study in JAMA Surgery, published by researchers at Yale School of Medicine, addresses a notable gap in research: Though patients 65 and older undergo nearly 40% of all surgeries in the U.S., detailed national data about the outcomes of these procedures has been largely missing.

    “As a field, we’ve been really remiss in not understanding long-term surgical outcomes for older adults,” said Dr. Zara Cooper, a professor of surgery at Harvard Medical School and the director of the Center for Geriatric Surgery at Brigham and Women’s Hospital in Boston.

    Of particular importance is information about how many seniors die, develop disabilities, can no longer live independently, or have a significantly worsened quality of life after major surgery.

    “What older patients want to know is, ‘What’s my life going to look like?’” Cooper said. “But we haven’t been able to answer with data of this quality before.”

    In the new study, Dr. Thomas Gill and Yale colleagues examined claims data from traditional Medicare and survey data from the National Health and Aging Trends study spanning 2011 to 2017. (Data from private Medicare Advantage plans was not available at that time but will be included in future studies.)

    Invasive procedures that take place in operating rooms with patients under general anesthesia were counted as major surgeries. Examples include procedures to replace broken hips, improve blood flow in the heart, excise cancer from the colon, remove gallbladders, fix leaky heart valves, and repair hernias, among many more.

    Older adults tend to experience more problems after surgery if they have chronic conditions such as heart or kidney disease; if they are already weak or have difficulty moving around; if their ability to care for themselves is compromised; and if they have cognitive problems, noted Gill, a professor of medicine, epidemiology, and investigative medicine at Yale.

    Two years ago, Gill’s team conducted research that showed 1 in 3 older adults had not returned to their baseline level of functioning six months after major surgery. Most likely to recover were seniors who had elective surgeries for which they could prepare in advance.

    In another study, published last year in the Annals of Surgery, his team found that about 1 million major surgeries occur in individuals 65 and older each year, including a significant number near the end of life. Remarkably, data documenting the extent of surgery in the older population has been lacking until now.

    “This opens up all kinds of questions: Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient’s priorities and determining whether surgery would achieve them?” said Dr. Clifford Ko, a professor of surgery at UCLA School of Medicine and director of the Division of Research and Optimal Patient Care at the American College of Surgeons.

    As an example of this kind of decision-making, Ko described a patient who, at 93, learned he had early-stage colon cancer on top of preexisting liver, heart, and lung disease. After an in-depth discussion and being told that the risk of poor results was high, the patient decided against invasive treatment.

    “He decided he would rather take the risk of a slow-growing cancer than deal with a major operation and the risk of complications,” Ko said.

    Still, most patients choose surgery. Dr. Marcia Russell, a staff surgeon at the Veterans Affairs Greater Los Angeles Healthcare System, described a 90-year-old patient who recently learned he had colon cancer during a prolonged hospital stay for pneumonia. “We talked with him about surgery, and his goals are to live as long as possible,” said Russell. To help prepare the patient, now recovering at home, for future surgery, she recommended he undertake physical therapy and eat more high-protein foods, measures that should help him get stronger.

    “He may need six to eight weeks to get ready for surgery, but he’s motivated to improve,” Russell said.

    The choices older Americans make about undergoing major surgery will have broad societal implications. As the 65-plus population expands, “covering surgery is going to be fiscally challenging for Medicare,” noted Dr. Robert Becher, an assistant professor of surgery at Yale and a research collaborator with Gill. Just over half of Medicare spending is devoted to inpatient and outpatient surgical care, according to a 2020 analysis.

    What’s more, “nearly every surgical subspecialty is going to experience workforce shortages in the coming years,” Becher said, noting that in 2033, there will be nearly 30,000 fewer surgeons than needed to meet expected demand.

    These trends make efforts to improve surgical outcomes for older adults even more critical. Yet progress has been slow. The American College of Surgeons launched a major quality improvement program in July 2019, eight months before the covid-19 pandemic hit. It requires hospitals to meet 30 standards to achieve recognized expertise in geriatric surgery. So far, fewer than 100 of the thousands of hospitals eligible are participating.

    One of the most advanced systems in the country, the Center for Geriatric Surgery at Brigham and Women’s Hospital, illustrates what’s possible. There, older adults who are candidates for surgery are screened for frailty. Those judged to be frail consult with a geriatrician, undergo a thorough geriatric assessment, and meet with a nurse who will help coordinate care after discharge.

    Also initiated are “geriatric-friendly” orders for post-surgery hospital care. This includes assessing older patients three times a day for delirium (an acute change in mental status that often afflicts older hospital patients), getting patients moving as soon as possible, and using non-narcotic pain relievers. “The goal is to minimize the harms of hospitalization,” said Cooper, who directs the effort.

    She told me about a recent patient, whom she described as a “social woman in her early 80s who was still wearing skinny jeans and going to cocktail parties.” This woman came to the emergency room with acute diverticulitis and delirium; a geriatrician was called in before surgery to help manage her medications and sleep-wake cycle, and recommend non-pharmaceutical interventions.

    With the help of family members who visited this patient in the hospital and have remained involved in her care, “she’s doing great,” Cooper said. “It’s the kind of outcome we work very hard to achieve.”

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  • Newer Cementless Knee Replacements Could Last Longer

    Newer Cementless Knee Replacements Could Last Longer

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    Newswise — Newer “Cementless” Knee Replacement Could Last Longer

    Knee replacement surgery is considered one of the most effective and predictable procedures in orthopedic surgery today. Hundreds of thousands of patients opt for the procedure each year to relieve arthritis pain and restore function and mobility.

    The standard knee implant used in joint replacement generally lasts a long time—15 years—but it doesn’t last indefinitely. When the implant wears out or loosens, patients generally need a second knee replacement, known as a revision surgery. Now a newer kind of “cementless” knee replacement could change that, according to Dr. Geoffrey Westrich, research director emeritus in the Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery.

    CEMENTLESS KNEE REPLACEMENT FOR YOUNGER PATIENTS

    Implant longevity is an important consideration, especially for younger patients with arthritis who opt for joint replacement to maintain their active lifestyle. “Increasing numbers of people in their 50s and even 40s are coming in for joint replacement because they don’t want arthritic knee pain to slow them down. Once they have a knee replacement, these active patients generally put more demands on their joint, causing more wear and tear,” Dr. Westrich explains. “With a conventional cemented prosthesis, chances are they’ll need another surgery down the road. This often has to do with loosening of the implant.”

    In a standard knee replacement, the components of the implant are secured in the joint using bone cement. It’s a tried-and-true technique that has worked well for decades. But eventually, over time, the cement starts to loosen from the bone and/or the implant. “With the new cementless prosthesis, the components are press fit into place for “biologic fixation,” which basically means that the bone will grow into the implant. Perfect positioning of the implant is critical, and we use robotic guidance for pinpoint accuracy,” Dr. Westrich explains.

    ADVANCES IN CEMENTLESS IMPLANT DESIGN AND TECHNOLOGY

    Dr. Westrich believes that with biologic fixation, implant loosening over time will be less likely and a total knee replacement could potentially last much longer, even indefinitely. “Cementless implants have been used in total hip replacement surgery for many years,” he says. “Because of the knee’s particular anatomy, it has been much more challenging to develop a cementless prosthesis that would work well in the knee.”

    Dr. Westrich now believes the time has come. Major advances in design, technology and biomaterials have paved the way for a viable cementless knee implant. The cementless knee system Dr. Westrich utilizes is FDA‐approved for use with the MAKO Robot, combining two of the most recent knee replacement advancements into one high tech procedure that aims to benefit patients.

    Candidates for the cementless procedure are generally patients under 70 with good bone quality to promote biological fixation. In addition to younger patients, Dr. Westrich notes that the cementless implant may also prove to be a good option for very overweight patients who tend to put more stress on their joint replacement.

    To date, Dr. Westrich has seen good results with the cementless prosthesis. However, he says more studies are needed to see how patients with cementless knee replacements do over the long term.

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    Geoffrey Westrich, MD

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  • Study Examines Total Knee Replacement in Patients Under 21

    Study Examines Total Knee Replacement in Patients Under 21

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    Newswise — A new study from researchers at Hospital for Special Surgery (HSS) has evaluated trends in the use of total knee arthroplasty (TKA) in patients under 21 in the United States. The study was reported at the American College of Rheumatology (ACR) Convergence 2022 meeting (abstract number 08780).

    According to Cynthia A. Kahlenberg, MD, MPH, an orthopedic surgeon at HSS and a coauthor of the study, TKA is rarely performed in patients under 21 years old but may be done in this population due to conditions such as inflammatory arthritis or juvenile idiopathic arthritis (JIA), malignant or non-malignant tumors, or trauma. However, the number of patients under the age of 21 undergoing TKA in the U.S. is unknown. In one of the largest U.S. studies of an institutional arthroplasty registry, only 19 TKAs were performed in patients under the age of 21 out of approximately 30,000 primary TKAs over 34 years—a majority of which were for JIA.

    The researchers retrospectively analyzed the Kids’ Inpatient Database (KID), a national weighted sample of all inpatient hospital admissions of patients under 21 years old in approximately 4,200 hospitals in 46 states. The researchers used International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes to identify patients undergoing TKA from 2000-2016 and determine primary diagnosis. Descriptive statistics such as means and percentages, along with their 95% confidence intervals (95% CI), were calculated using the appropriate sample weights as recommended by the Agency for Healthcare Research and Quality for use with the KID dataset.

    The total weighted number of TKAs performed in patients younger than 21 from 2000-2016 was 1,331; the number of TKAs performed per year in this age group remained relatively stable. The mean age of patients undergoing TKA was 14.8 years (95% CI, 14.4-15.2); 48.8% of the cohort was female. Among tumor patients, a higher proportion identified as Hispanic (22.1%) or other race (12.6%) compared to the non-tumor cohort; 70.3% of TKAs were performed for a primary diagnosis of a tumor; and the number of TKAs for malignant tumors increased slightly over the study period. In contrast, use of TKA for inflammatory arthritis / JIA decreased by more than 70% over the study period, likely due to improvements in medical management of inflammatory arthritis / JIA patients. The majority of TKAs were performed in urban teaching hospitals and in facilities with a large bed size, which likely reflects the complexity and rarity of these procedures.

    “This was one of the first studies to take an in-depth look at TKA in this very young population,” said Dr. Kahlenberg. “Our study was able to confirm that tumors were the most common reason for knee arthroplasty in this population.”

    “I think the biggest takeaway as a rheumatologist is that we are doing a good job treating these patients and over the years the treatments for inflammatory arthritis are really working well in this young population,” said Bella Mehta, MBBS, MS, rheumatologist at HSS and senior study author.

    About HSS

    HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 13th consecutive year), No. 3 in rheumatology by U.S. News & World Report (2022-2023), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2022-2023). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a third consecutive year (2023). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 145 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.

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    Hospital for Special Surgery

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  • Desperate for heart surgery for their baby, a family feels the effects of pediatric hospital shortages | CNN

    Desperate for heart surgery for their baby, a family feels the effects of pediatric hospital shortages | CNN

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    CNN
     — 

    Even before their daughter was born in June, Aaron and Helen Chavez knew she would need heart surgery. Doctors expected her to have an operation around 6 months of age.

    When it became apparent in September that it would have to happen much sooner than expected, the Chavezes said, they endured an agonizing monthlong wait for a bed to open at their local children’s hospital so baby MJ could have the procedure she needed.

    “They said, ‘Well, we would love to get her in as soon as possible. However, right now, we don’t have beds,’ ” Aaron said.

    Space for children in hospitals is at a premium across the country. Data reported to the US government shows that as of Friday, more than three-quarters of pediatric hospital beds and 80% of intensive care beds for kids are full. That’s up from an average of about two-thirds full over the past two years.

    Federal data shows that the strain on hospital beds for kids began in August and September, which is right around the start of the school year in many areas.

    Hospitals are seeing higher than normal numbers of sick infants and children due to a particularly early and severe season for respiratory infections in kids, including respiratory syncytial virus, or RSV, and influenza.

    As of Friday, Golisano Children’s Hospital in Rochester, New York, the facility that treated the Chavezes’ daughter, was over capacity. Federal data shows that it has been consistently more full than the national average over the past few months. Golisano went from having 85% of its beds occupied in August to over 100% now.

    Like many other hospitals across the country, Golisano has seen a sharp increase in children who are severely ill with RSV. Dr. Tim Stevens, the chief clinical officer, said 35% of the hospital’s current patients – excluding those in the neonatal intensive care unit – have RSV.

    A lack of available beds means patients are sometimes held in the emergency department to wait for a bed to open so they can be admitted, Stevens says.

    It may also mean children who have chronic conditions and need procedures or hospital care, but whose conditions are stable, may have to wait.

    MJ was born in June with a ventricular septal birth defect – a hole between the pumping chambers of her heart. It’s a relatively common problem affecting about 1 in every 240 infants in the United States, according to the US Centers for Disease Control and Prevention.

    Doctors could see the defect on prenatal ultrasounds, but because MJ was never in the right position to get a good image, they weren’t sure of its size.

    If they’re small enough, these holes usually close on their own soon after birth. But the hole in MJ’s heart was not small.

    It caused the oxygen-rich blood coming from her lungs to mix with oxygen-poor blood returning from the rest of her body. Too much blood got squeezed back into her tiny lungs with each heartbeat, straining her respiratory system.

    Everything exhausted her, even nursing or drinking from a bottle. “She would stop eating before she was full and before she got the calories that she needed,” Aaron said.

    Typically, babies will take a bottle for 15 to 20 minutes at a time, but MJ would doze off after six or seven minutes, her mother recalls.

    They didn’t worry, Helen says, because they were trying hard not to be anxious newbies. “All those websites, they say sometimes you just have a sleepy baby, and it’s OK,” she said.

    Other signs that MJ might be hungry could be explained away, too. They mistook her constant fussing for colic. Her scalp started to get dry and flaky, and they thought it might be a common skin condition called cradle cap.

    As first-time parents, the Chavezes didn’t realize at first that MJ wasn’t eating enough. Doctors didn’t immediately catch it, either. MJ got three checkups during her first month, one within a few days of coming home from the hospital, the other at two weeks and another at one month.

    It’s normal for babies to lose weight after birth, especially if Mom got IV fluids during labor and delivery. They typically return to their birth weights by 2 to 3 weeks of age. And at first, MJ did regain weight, climbing back to her birth weight by 2 weeks old.

    But babies with heart conditions like hers can have faster-than-normal metabolisms, and it was between weeks two and four that her parents say the feeding issues really began to cause problems.

    “We were frustrated and we were scared, because she looked like she was losing weight, not gaining weight. She was very thin for a baby,” Aaron said.

    The doctors had advised them to count the number of wet and dirty diapers she was having each day as a way to judge whether she was eating enough. Her parents didn’t know it was not as much as she should have been.

    “One day, I was holding her, sitting in our recliner. I looked down at her and I was like, ‘this baby looks puny. Like, she does not look like she feels good,’ ” Helen said.

    She called their pediatrician, who saw them the same day. The pediatrician immediately notified their cardiologist, who arranged for a feeding tube to help MJ get more nutrition.

    Helen says they had been told MJ would need surgery to repair the hole in her heart around 6 months of age.

    “Once the feeding issues started, though, that I think that we all kind of realized that, OK, she’s probably not going to hit that six-month mark,” she says.

    MJ got the feeding tube when she was around 6 weeks old, in August. Her doctors started talking about moving the operation up but advised her parents that she would need to gain some weight first.

    The feeding tube helped for a time, but by the time MJ was 3 months old, her condition had deteriorated.

    “Every breath came with a grunt,” Aaron said. “She was fairly regularly sweating, no matter the ambient temperature in the room or whether we were holding her or not.”

    Every time MJ drew a breath, the skin around her collarbone would suck in and her abdomen would pull under ribcage, a symptom known as a retraction. Retractions are a sign that someone is working very hard to breathe.

    “It looked like her chest was almost scooping under her lungs with each breath. The retractions were getting really bad. It was around that point that they told us, ‘Hey, yeah, this is accelerating faster. We’re going to need to get her in for surgery soon,’ ” Aaron said.

    Helen said their cardiologist first discussed getting MJ’s case reviewed – a key step her doctors needed to prepare for her surgery – on September 14.

    “He said, ‘it might take a couple of weeks to get her in because we’ve been really slammed with emergencies, but we’ll get her in,’ ” Helen said.

    Doctors put MJ on medications called diuretics to help drain excess fluid off her lungs and ease her breathing – but then, at the end of September, she caught a cold.

    It wasn’t a bad cold, and Helen Chavez, a pharmacist, thinks that if the baby had been healthy, she probably could have fought it off at home with no problems. But Helen was worried, so she took she MJ to the ER.

    The doctors checked her, determined she was stable and sent the family home with supportive care.

    At a follow-up doctor’s visit, Helen said, she asked again, “Where are we on the surgery?”

    Helen said the cardiologist said they had not been able to review MJ’s case.

    “And they said, ‘Well, we would love to get her in as soon as possible. However, right now we don’t have beds,’ ” Aaron said.

    “Throughout that time, she kept getting worse. More symptoms would pop up in terms of the breathing would get worse, the retractions would get worse, that kind of a thing. Like there was more and more and more piling up,” Aaron said.

    Helen said she understood that MJ’s condition was still stable, but she was worried it wouldn’t stay that way.

    “I was like, ‘I’m worried she’s going to crash and that’s how we’re going to get in for this surgery is, it’s going to take this kid crashing and burning before we can get her in,’ ” Helen told the doctor, who reassured her.

    ” ‘No, no, no, she is not going to get to that point before we get her in,’ ” she says they were told.

    On October 10, things took a turn.

    The baby slept in a bassinet beside her parents’ bed. Helen nudged Aaron awake around midnight to look at their daughter, and his first thought was to reassure his wife that yes, the doctors had told them that her breathing was going to look bad. But then he rolled over and peered at MJ, who was asleep.

    “That was the moment that I was wide awake,” Aaron said, and he was terrified.

    “It was the raggedness of her breathing and the noise. Every breath, there was a strange sound coming from her. It sounded like she was fighting for, like, struggling for every breath.”

    They raced to the hospital.

    “We were sitting in the ER, and every other kid in that pediatric ER was hacking, coughing, sneezing,” Helen said. “Clearly, respiratory viruses hit Rochester early and very hard.”

    Helen said it was clear by the end of that visit that medications had done all they could do and that MJ would continue to get worse without the operation.

    “Our understanding is, it took an extra ER visit to push the timeline,” Helen said.

    That visit prompted an emergency appointment with the cardiologist.

    “That’s where they were like, ‘OK, we’ve got her in for conference,’ ” Helen said.

    The hospital says it can’t comment on the specifics of MJ’s case.

    “The Golisano Children’s Hospital cardiology and cardiac surgery teams review the status of all pediatric patients who need heart surgery twice a week,” the hospital said in a statement to CNN. “We cannot comment on a specific case, but once surgery becomes necessary, it is scheduled as quickly as needed based on the medical condition of the child. The current high census of pediatric inpatients at our hospital has not affected our ability to schedule non-elective pediatric cardiac surgeries in a timely way.”

    Stevens, the chief clinical officer, says those decisions are made on a case-by-case basis.

    “Each of those are reviewed by our medical and surgical team to determine whether or not they’re time-sensitive,” he said. “Things that are time-sensitive or certainly urgent or emergent, they get done.”

    When it becomes clear that a child needs to be admitted, Stevens said, hospital officials find ways to open beds, and they try to do it so it doesn’t exhaust their nurses.

    Stevens says he’s hopeful the situation will improve, that infections will die down, “because this is not sustainable.”

    Aaron Chavez agrees that there was no delay once MJ’s case got the necessary review – but says that review itself kept getting put off.

    “We were essentially told that her case review was being delayed because they simply didn’t have the beds,” he said.

    The surgical team reviewed MJ’s case on October 13, and she had surgery 12 days later, according to Aaron.

    Aaron says the family has no complaints about the quality of care their daughter received, and they’re grateful to the entire team of doctors, nurses and other staff who treated their daughter.

    “Once push came to shove, they definitely got her in, but the last four weeks were really, really harrowing,” Helen said. “It was just kind of hard to watch your baby have trouble breathing and know that there’s not a whole lot you can do.”

    On the morning of October 25, the Chavezes brought MJ to the hospital, where doctors walked them through the operation. A piece of synthetic material would be sewn into her heart to patch the hole. Over time, the material would allow her own cells to grow on it and cover the defect.

    The procedure could take as long as 12 hours. But it went faster than anticipated, and MJ was finished in half that time. The surgeon came out to tell them the good news: The operation had been a success.

    “Her surgeon said that it was the biggest hole that he has seen in 2022 and one of the biggest he has ever seen,” Aaron said.

    The Chavezes then went to the pediatric intensive care unit to wait for MJ. As soon as they saw her, they could see she was better.

    Before the surgery, her skin had been pale and mottled; after, she was a healthy pink.

    “Just in that short amount of time, her skin had that pinkness and redness in places that you expect like the nose, and her fingers were proper pink,” he said. “That color you expect out of a healthy baby. It was really nice to see that.”

    She was in the hospital for six days, and her recovery amazed her care team.

    “She kind of crushed recovery milestones like it was her job,” Aaron said.

    Now back home, MJ is playing catch-up with the developmental milestones she missed while she was sick. Her muscles are weak, she can’t sit up or roll over yet, and she may never switch back from the feeding tube to a bottle. A team of occupational and physical therapists comes over to help. They expect she will eventually make up for the time she missed, but it will take some work.

    Still, Aaron says the surgery has had an amazing effect.

    Before her operation, MJ was very uncomfortable and always tired.

    “The baby that I have now, that returned from surgery, is constantly smiling at us. She’s almost laughed three different times in the last couple of days, right? She’s so close to a laugh. She seems like an entirely different baby,” Aaron said.

    The Chavezes were nervous about sharing their story, but in the end, they decided it was important to shed light on the effects of the ongoing hospital bed shortage.

    “Everybody we have told about the bed shortage, that we have told about the nurses and the staff and the doctors telling us how burnt-out and frustrated they are and how tired they are, everybody’s surprised,” Aaron said.

    “Everybody’s shocked. Everybody thinks that this is over. The pandemic is over. Our health care system’s back to normal. ‘What are you talking about? What shortages?’ “

    In the end, they felt powerless. What could they – two exhausted working parents with a sick infant – do to solve a national crisis?

    After all, after nearly three years of a viral pandemic, doesn’t everyone already know what to do? Stay home if you’re sick. Put on a mask in public places while viral illnesses are running rampant. Get vaccinated.

    “I don’t know how I’m supposed to help tell 330 million people, ‘Hey, you should care about each other,’ ” Aaron says.

    Their story is one reminder of why all those simple but effective measures are important.

    “In the end, we believe the information getting out there is better than not,” Aaron said. “Hopefully, it will help push those in power to do better.”

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  • Balancing the Safety and Education of Pregnant Neurosurgeons

    Balancing the Safety and Education of Pregnant Neurosurgeons

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    Newswise — Rolling Meadows, IL (NOVEMBER 8, 2022). Because there are unique circumstances that may impact the training, safety, and career trajectory of pregnant neurosurgeons, as well as risks inherent to the pregnant neurosurgical resident from occupational exposures and pregnancy physiology, the authors of this paper have come up with recommendations for both pregnant residents and their residency programs to mitigate these risks, focusing on the impact on their education as well as on their colleagues. Detailed findings of this study are described in the article “Best practices for the pregnant neurosurgical resident: balancing safety and education” by Krystal L. Tomei et al., published today in the Journal of Neurosurgery (https://thejns.org/doi/abs/10.3171/2022.9.JNS221727).

    As neurosurgery moves to improve diversity, including attracting women to the field, and as policies supporting parental leave are written into training and board certification requirements, it is imperative to consider the additional barriers to childbearing inherent in residency training.

    Noting the stigma associated with pregnant residents and the impact of their pregnancy on colleagues, the lack of policy and financial support regarding parental leave, postpartum challenges, and the higher medical complication rates in pregnant surgeons, including higher rates of pregnancy loss, a higher need for assisted reproductive technology, more frequent nonelective cesarean deliveries, and increased rates of postpartum depression, the authors set out to provide interventions for each of the three trimesters and the postpartum “fourth trimester,” as well as best practices for residency programs. These recommendations can be carried forward by the pregnant resident and residency programs, with specific consideration of situations unique to neurosurgical training. The accommodations proposed by the authors take into account the bodily needs of pregnant residents and the nausea they may experience, the levels of radiation and teratogen they may be exposed to, their postpartum parental leave and breastfeeding needs, and the possibility of medical and bereavement leave (in the case of pregnancy loss), with the goal of aiding pregnant residents in meeting their residency educational and training requirements in a safe and inclusive environment. Furthermore, the authors suggest that additional policies should strive to accommodate other pregnancy-related needs, including egg preservation and fertility treatments. In examining best practices, they also stress the need to support partner presence at prenatal appointments for neurosurgical residents whose partners are expecting, as well as normalizing and encouraging parental leave equally among all residents.

    When asked about the study, Dr. Tomei said, “Recently, our program had three residents over 3 years who became pregnant during various stages of their training. It was very important for me as a program director to balance their safety as well as their education and the impact upon their coresidents. When I started looking for resources to help guide this process, there was very limited information to go by. With the new changes put forth by the ABMS, ABNS, and ACGME, it was the opportune time to compile information for programs to be able to reference. I truly hope this is just the beginning as there are so many more opportunities to explore how we can best support our trainees during these milestones.”

     

    Article: Tomei KL, Hodges TR, Ragsdale E, Katz T, Greenfield M, Sweet JA. Best practices for the pregnant neurosurgical resident: balancing safety and education.  Journal of Neurosurgery, published online, ahead of print, November 8, 2022; DOI: 10.3171/2022.9.JNS221727.

    Disclosure: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

    ###

     Embargoed Article Access and Author/Expert Interviews: Contact JNSPG Director of Publications Gillian Shasby at [email protected] for advance access and to arrange interviews with the authors and external experts who can provide context for this research.

    ###

     The global leader for cutting-edge neurosurgery research for more than 75 years, the Journal of Neurosurgery (www.thejns.org) is the official journal of the American Association of Neurological Surgeons (AANS) representing over 12,000 members worldwide (www.AANS.org).

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  • UC San Diego Health Awarded Advanced Certification in Spine Surgery

    UC San Diego Health Awarded Advanced Certification in Spine Surgery

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    Newswise — UC San Diego Health has earned The Joint Commission’s Gold Seal of Approval for Advanced Certification in Spine Surgery (ACSS) by meeting or exceeding the highest level of national performance standards. The Gold Seal represents a symbol of quality that reflects a health care organization’s demonstrated ability to implement result-driven processes and advance patient outcomes.

    “As the region’s only academic medical center, we proactively seek advanced certifications in specialty care that confirm our commitment to providing extraordinary care for all of our patients,” said Patty Maysent, CEO, UC San Diego Health. “This designation celebrates and recognizes UC San Diego Health as a premiere destination for routine or complex spine surgery cases.”

    To be eligible for ACSS, organizations must implement evidence-based care, clinical practice guidelines and participate in the American Spine Registry, a national quality improvement registry for spine care. Additionally, organizations need to collect performance measurement data on surgical site infection rates, new neurological deficits, unplanned return visits to the operating room, and pre-operative and post-operative patient reported outcomes.

    “This certification affirms the presence of highly reliable processes successfully implemented by a multidisciplinary team of expert specialists, whose organized focus provides the best level of care for each patient,” said Alexander Khalessi, MD, MBA, neurosurgeon and chair of the Department of Neurological Surgery at UC San Diego Health.

    The certification was achieved through an interdisciplinary collaboration between the Department of Neurological Surgery and the Department of Orthopedic Surgery at UC San Diego Health.

    “More than 100 people came together as part of our spine care teams to prepare for this certification process,” said Susan Bukata, MD, orthopedic surgeon and chair of the Department of Orthopedic Surgery at UC San Diego Health. “The team-centered approach ensured coordination of best practices and brought diverse perspectives and expertise together to provide the highest quality of care to patients with spine disorders.”

    The multidisciplinary team included specialists from orthopedics, neurosurgery, medicine, nursing, anesthesia, pharmacy, rehabilitative services and case management.

    Offered in collaboration with the American Academy of Orthopedic Surgeons, the certification is granted to organizations with data-driven care processes, patient safeguards and demonstrated high quality patient outcomes with low complication profiles.

    “This certification demonstrates our institution is strongly positioned to hit the mark for every patient, every time,” said Khalessi. “We also meticulously track outcomes and follow-up to allow for continuous improvement that elevates the standard of care in the field.”

    UC San Diego Health underwent a rigorous, unannounced onsite review in September 2022. During the visit, a Joint Commission reviewer evaluated compliance with related certification standards, including anonymized patient cases, surgical outcomes, quality data collection methods and a review of care pathway processes.

    Joint Commission standards are developed in consultation with health care experts and providers, measurement experts and patients. The reviewer also conducted onsite observations and interviews with team members.

    “As a private accreditor, The Joint Commission surveys health care organizations to protect the public by identifying deficiencies in care and working with those organizations to correct them as quickly and sustainably as possible,” says Mark Pelletier, RN, MS, chief operating officer, Accreditation and Certification Operations, and chief nursing executive, The Joint Commission. “We commend UC San Diego Health for its continuous quality improvement efforts in patient safety and quality of care.”

    UC San Diego Health is the regional referral center for complex spine reconstructions and a national leader in minimally invasive spine surgery, as well as other surgical and non-surgical treatments for spinal disorders.

    In the 2022-2022 U.S. News & World Report “Best Hospitals” survey, UC San Diego Health was ranked the #1 hospital system in San Diego and #5 in California. The hospital system was ranked 21st for neurology and neurosurgery care and 39th for orthopedics, among the nation’s top 50 programs out of more than 4,500 hospitals nationwide.

    # # #

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  • November 2022 Issue of Neurosurgical Focus: “Evolution of Radiation Therapy Technique”

    November 2022 Issue of Neurosurgical Focus: “Evolution of Radiation Therapy Technique”

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    Newswise — November 2022 Issue of Neurosurgical Focus: “Evolution of Radiation Therapy Technique”

    Rolling Meadows, IL (November 1, 2022). The November issue of Neurosurgical Focus (Vol. 53, No. 5 [https://thejns.org/focus/view/journals/neurosurg-focus/53/5/neurosurg-focus.53.issue-5.xml]) presents one editorial and 10 articles on the history and development of radiation therapy in neurosurgical treatment.

    Topic Editors: Arjun Sahgal, Jason P. Sheehan, Ajay Niranjan, Lola B. Chambless, Lijun Ma, and Daniel M. Trifiletti

    The Topic Editors of this issue note that, “Radiation technology has undergone dramatic changes over the past 3 decades.” Therefore, this issue of Neurosurgical Focus aims to “further our understanding of stereotactic radiosurgery and stereotactic radiotherapy for primary brain tumors and functional conditions, as well as new developments for patients with brain metastases.”

    Contents of the November issue: 

    • “Introduction. Evolution of radiation therapy techniques” by Arjun Sahgal et al.
    • “Stereotactic radiosurgery for recurrent pediatric brain tumors: clinical outcomes and toxicity” by Elyn Wang et al.
    • “Stereotactic radiosurgery for trigeminal neuralgia secondary to tumor: a single-institution retrospective series” by Jennifer C. Hall et al.
    • “CyberKnife radiosurgery for trigeminal neuralgia: a retrospective review of 168 cases” by Albert Guillemette et al.
    • “Adjuvant stereotactic radiosurgery with or without postoperative fractionated radiation therapy in adults with skull base chordomas: a systematic review” by Othman Bin-Alamer et al.
    • “Outcomes following stereotactic radiosurgery for foramen magnum meningiomas: a single-center experience and systematic review of the literature” by Constantine L. Karras et al.
    • “Risk factors for peritumoral edema after radiosurgery for intracranial benign meningiomas: a long-term follow-up in a single institution” by Sheng-Han Huang et al.
    • “Neoadjuvant stereotactic radiosurgery for brain metastases: a new paradigm” by Yuping Derek Li et al.
    • “Stereotactic radiosurgery and resection for treatment of multiple brain metastases: a systematic review and analysis” by Uma V. Mahajan et al.
    • “A quantitative and comparative evaluation of stereotactic spine radiosurgery local control: proposing a consistent measurement methodology” by Ran Harel et al.
    • “Editorial. Assessing treatment response following stereotactic body
    • radiotherapy for spinal metastases” by Steven G. Roth and Lola B. Chambless
    • “The role of radiation therapy in the treatment of spine metastases from hepatocellular carcinoma: a systematic review and meta-analysis” by Gianluca Ferini et al.

     Please join us in reading this month’s issue of Neurosurgical Focus.

     ***

     ###

     

    The global leader for cutting-edge neurosurgery research since 1944, the Journal of Neurosurgery (www.thejns.org) is the official journal of the American Association of Neurological Surgeons (AANS) representing over 12,000 members worldwide (www.AANS.org).

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  • Chlorhexidine Disinfectant May Perform Best in Killing Bone Tumor Cells After Surgery

    Chlorhexidine Disinfectant May Perform Best in Killing Bone Tumor Cells After Surgery

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    Newswise — October 28, 2022 – The widely used disinfectant chlorhexidine gluconate (CHG) appears to be the most effective irrigation solution for use as part of the surgical treatment of bone tumors, suggests an experimental study in The Journal of Bone & Joint Surgery. The journal is published in the Lippincott portfolio in partnership with Wolters Kluwer.

    Of the various solutions used to eliminate remaining tumor cells after surgery, a 0.05% CHG solution appears to be most effective in killing cultured bone tumor cells, according to the laboratory study by Matthew J. Thompson, MD, of the University of Washington, Seattle, and colleagues.

    CHG shows highest cytotoxicity against chondrosarcoma and giant cell tumors

    Some patients with bone tumors undergo a surgical procedure called intralesional curettage. In this procedure, the tumor is scraped away while preserving as much healthy bone as possible. A common adjuvant treatment is to irrigate the operative area of the bone with some kind of chemical solution. This irrigation is performed to reduce the number of remaining cells that could potentially lead to tumor recurrence and reseeding.

    Several different solutions have been used for irrigation of the tumor bed, including saline, ethanol, and various disinfectants. Dr. Thompson and colleagues performed a series of experiments to determine which of these solutions has the greatest cytotoxic (cell-killing) effects against bone tumor cells.

    The experiments used cultures of two types of bone tumors: giant cell tumor, a benign but aggressive tumor; and chondrosarcoma, a type of bone cancer. Tumor cell cultures were treated with one of six different solutions – sterile water, 0.9% saline, 70% ethanol, 3% hydrogen peroxide, 0.05% CHG, and 0.3% povidone-iodine. Cytotoxicity was compared for the different treatments.

    Of the six treatments, only CHG had cell-killing effectiveness equivalent to a control solution with 100% cytotoxicity, and this outcome was observed regardless of the treatment period (i.e., 2 minutes or 5 minutes).

    None of the other solutions approached the cell-killing effectiveness of CHG. Only two solutions (sterile water and hydrogen peroxide) were superior to a control treatment with low cytotoxicity. The other three solutions tested – saline, ethanol, and povidone-iodine – showed little or no cytotoxicity.

    Chlorhexidine is a familiar disinfectant with various medical uses, including as a topical antiseptic agent before surgery. The researchers write, “[CHG] is commonly used and readily available, with demonstrated in vivo safety in other surgical applications and a lower predicted toxicity compared with some currently used agents.”

    The new study shows that CHG is highly effective in killing bone tumor cells – at least under laboratory conditions. “Therefore, the use of a 0.05% CHG solution clinically could serve as a potential chemical adjuvant during intralesional curettage of chondrosarcoma and [giant cell tumors],” Dr. Thompson and coauthors conclude.

    The researchers emphasize that further studies will be needed to evaluate the outcomes of CHG irrigation in patients undergoing surgery.  Dr. Thompson comments: “We believe it is important to continue to explore better ways to achieve durable local control of benign aggressive tumors like giant cell tumor of bone, which are associated with a high risk of local recurrence when treated with conventional extended intralesional curettage.”

    Read [Cytotoxic Effects of Common Irrigation Solutions on Chondrosarcoma and Giant Cell Tumors of Bone]

    DOI: 10.2106/JBJS.22.00404

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    About The Journal of Bone & Joint Surgery

    The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, The Journal publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal.

    About Wolters Kluwer

    Wolters Kluwer (WKL) is a global leader in professional information, software solutions, and services for the clinicians, nurses, accountants, lawyers, and tax, finance, audit, risk, compliance, and regulatory sectors. We help our customers make critical decisions every day by providing expert solutions that combine deep domain knowledge with advanced technology and services.

    Wolters Kluwer reported 2021 annual revenues of €4.8 billion. The group serves customers in over 180 countries, maintains operations in over 40 countries, and employs approximately 19,800 people worldwide. The company is headquartered in Alphen aan den Rijn, the Netherlands.

    Wolters Kluwer provides trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers and students in effective decision-making and outcomes across healthcare. We support clinical effectiveness, learning and research, clinical surveillance and compliance, as well as data solutions. For more information about our solutions, visit https://www.wolterskluwer.com/en/health and follow us on LinkedIn and Twitter @WKHealth.

    For more information, visit www.wolterskluwer.com, follow us on Twitter, Facebook, LinkedIn, and YouTube.

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  • Cannabis use increases pain after surgery, study shows

    Cannabis use increases pain after surgery, study shows

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    Newswise — NEW ORLEANS — Adults who use cannabis have more pain after surgery than those who don’t use cannabis, according to a study presented at the ANESTHESIOLOGY® 2022 annual meeting. 

    “Cannabis is the most commonly used illicit drug in the United States and increasingly used as an alternative treatment for chronic pain, but there is limited data that shows how it affects patient outcomes after surgery,” said Elyad Ekrami, M.D., lead author of the study and clinical research fellow of the Outcomes Research Department at Cleveland Clinic’s Anesthesiology Institute. “Our study shows that adults who use cannabis are having more — not less — postoperative pain. Consequently, they have higher opioid consumption after surgery.” 

    Researchers analyzed the records of 34,521 adult patients — 1,681 of them cannabis users — who had elective surgeries at Cleveland Clinic from January 2010 to December 2020. The cannabis users had used the drug within 30 days before surgery, while the other patients had never used cannabis. The patients who used cannabis experienced 14% more pain during the first 24 hours after surgery compared to the patients who never used cannabis. Additionally, patients who used cannabis consumed 7% more opioids after surgery, which the authors note was not statistically significant, but is likely clinically relevant.  

    “The association between cannabis use, pain scores and opioid consumption has been reported before in smaller studies, but they’ve had conflicting results,” Dr. Ekrami added. “Our study has a much larger sample size and does not include patients with chronic pain diagnosis or those who received regional anesthesia, which would have seriously conflicted our results. Furthermore, our study groups were balanced by confounding factors including age, sex, tobacco and other illicit drug use, as well as depression and psychological disorders.”

    Dr. Ekrami noted that additional research is needed to further define cannabis’ effects on surgical outcomes. “Physicians should consider that patients using cannabis may have more pain and require slightly higher doses of opioids after surgery, emphasizing the need to continue exploring a multimodal approach to post-surgical pain control,” he said.  


    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/madeforthismoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

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  • Systemic racism plays role in much higher maternal mortality rate among Black women

    Systemic racism plays role in much higher maternal mortality rate among Black women

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    Newswise — NEW ORLEANS —  Black women have a 53% increased risk of dying in the hospital during childbirth, no matter their income level, type of insurance or other social determinants of health, suggesting systemic racism seriously impacts maternal health, according to an 11-year analysis of more than 9 million deliveries in U.S. hospitals being presented at the ANESTHESIOLOGY® 2022 annual meeting. 

    “This study is the most up-to-date and extensive study — factoring in various states, insurance types, hospital types and income levels — to determine that the much higher maternal mortality rate among Black women often cannot be attributed to differences in health, income or access to care alone,” said Robert White, M.D., M.S., lead author of the study and assistant professor of anesthesiology at Weill Cornell Medicine, New York. “Clearly there’s a need for legislation to improve access to health care throughout pregnancy and improve funding among safety-net hospitals. But it’s also essential that hospitals train their employees to provide culturally appropriate care, offer translation services and conduct implicit bias association testing.”

    Causes of maternal death include the development of blood clots, heart failure, postpartum hemorrhage (excessive blood loss) and pre-eclampsia (extremely high blood pressure). The U.S. maternal mortality rate of 17.3 deaths per 100,000 births is higher than any other developed nation, with a huge disparity gap between Black and white mothers. The Centers for Disease Control and Prevention defines maternal mortality as death during pregnancy, delivery or within one year of the end of the pregnancy. This study focused on maternal death during childbirth in a hospital. 

    The researchers analyzed 9.5 million deliveries occurring in hospitals between 2007 and 2018, based on State Inpatient Databases from California, Florida, Kentucky, Maryland, New York and Washington. Of those, 49,472 mothers (0.5%) died in the hospital or experienced injury to the heart, eyes, kidney, brain or other organ, including 0.8% of all Black women, 0.5% of all Hispanic women and 0.4% of all white women. The researchers determined that compared to white women, Black women had a 53% increased risk of dying in the hospital, even after adjusting for insurance type, hospital type, income and other societal factors. Hispanic women and white women had the same risk of dying in the hospital.

    “Physician anesthesiologists are leaders in quality, safety and perioperative medicine and are working very hard to help decrease racial differences through science and implementation of protocols that treat everyone the same — with a focus on those who are worse off to achieve health equity,” said Dr. White. “We not only provide pain management during childbirth, but our training in critical and emergency care help us to proactively handle complications, prevent death and ensure the health and safety of the mother and baby.” 

    Anesthesiologists are working on standardizing practices, which help reduce disparities. For example, the Society for Obstetric Anesthesia and Perinatology (SOAP) developed a protocol for enhanced recovery after cesarean delivery focusing on pain relief, movement, maternal-infant bonding, decreased opioid use and shorter length of stay. Anesthesiologists also have played a key role in the Alliance for Innovation on Maternal Health (AIM), a national data-driven quality improvement effort. This includes the development of patient safety bundles — a collection of evidence-informed, best practices to be implemented in all care settings, for every patient, in each episode of care — to improve outcomes. 

    Additionally, anesthesiologists have participated in state maternal mortality review committees to determine trends and system issues that can be improved, helped coordinate care for high-risk maternal disease and placenta implantation disorders, and organized and led simulations for obstetrical (OB) hemorrhage. This is of particular importance since the maternal mortality rate from OB hemorrhage is higher in Black women. Anesthesiologists have devised algorithms using point of care ultrasound (POCUS) that are especially helpful during OB hemorrhage and can be quickly used when a woman does not have a pulse to determine if there is activity in the heart.  

    The research in the abstract presented at ANESTHESIOLOGY 2022 was supported by a Foundation for Anesthesia Education and Research (FAER) Mentored Research Training Grant [FAER Grant ID:  MRTG-08-15-2021-White (Robert)].

     

    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

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  • Opioid prescribing after surgery remains the same for seniors, but doses are lower, study shows

    Opioid prescribing after surgery remains the same for seniors, but doses are lower, study shows

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    Newswise — NEW ORLEANS — Although there has been no decrease in the number of opioid prescriptions seniors receive after surgery, the doses of those prescriptions are lower, according to a study of more than a quarter million Canadian patients being presented at the ANESTHESIOLOGY® 2022 annual meeting.

    “While it’s good news that the doses in opioid prescriptions are being reduced, the fact that the actual number of opioid prescriptions filled has remained the same shows there is still an opportunity for improvement,” said Naheed Jivraj, MBBS, MS, FRCPC, lead author of the study and a critical care medicine fellow at the University of Toronto, Ontario. “That’s particularly true for procedures associated with low postoperative pain that can be effectively controlled with non-opioid medications such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs).”

    While opioids can be an important part of pain management after surgery, limiting their use, including by lowering the dose, is important since they can cause major side effects and lead to addiction, as well as a potentially deadly overdose.

    To assess trends in filling pain prescriptions in the week after surgery, the researchers studied the records of 278,366 patients representing all adults in Ontario older than 65 who had one of 14 surgical procedures between 2013 and 2019. The surgical procedures in the study included: thyroid removal, appendix removal, hernia repair, laparoscopic or open removal of the gallbladder, removal of the prostate, open-heart surgery, laparoscopic or open colon removal, laparoscopic vaginal or abdominal hysterectomy, removal of the breast, hip replacement and knee replacement. 

    They identified an increase in patients filling non-opioid prescriptions (e.g., acetaminophen or NSAID) from 9% in 2013 to 28% in 2019. They found most patients also continued to receive a prescription that contained an opioid — 76% in 2013 and 75% in 2019. However, the dose of the opioid prescriptions decreased, from an average of 317 MME (morphine milligram equivalent) in 2013 to an average of 260 MME in 2019. 

    Most patients undergoing procedures such as removal of the appendix or thyroid can get pain relief from acetaminophen or an NSAID; however, few patients who had these procedures filled prescriptions for those non-opioid alternatives, researchers noted.

    “Our study highlights how pain management practices are changing after surgery,” said Dr. Jivraj. “The increase in seniors filling non-opioid prescriptions and the lower opioid dose may reflect the development of surgery-specific prescribing guidelines and the increasing use of anesthesiologist-championed Enhanced Recovery After Surgery protocols and other programs that focus on improving patient outcomes.”

     

    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

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  • Enhanced Recovery After Surgery program enables same-day hip and knee replacement surgeries during pandemic

    Enhanced Recovery After Surgery program enables same-day hip and knee replacement surgeries during pandemic

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    Newswise — NEW ORLEANS — Adaptations to a program that helps ensure the best possible outcomes from surgery allowed eligible patients to receive their hip and knee replacement surgeries during the COVID-19 pandemic without spending the night in the hospital. The changes were so successful that they have been implemented permanently at the institution, according to a quality improvement study being presented at the ANESTHESIOLOGY® 2022 annual meeting.

    Championed by physician anesthesiologists, Enhanced Recovery After Surgery (ERAS) programs ease the effects of surgery and fast-track patient recovery.

    In 2019, Stony Brook Medicine in New York implemented an ERAS program for elective hip and knee replacement surgeries, with all patients spending at least one night in the hospital after the procedure. However, during the pandemic the team revised the ERAS program so that selective patients could have an outpatient procedure, meaning they didn’t spend the night in the hospital.

    The new ERAS protocol included: 

    • Developing a highly selective screening process to identify patients who would be good candidates for same-day surgery (i.e., relatively healthy, highly motivated with a good home-support system).
    • Using a shorter-acting spinal anesthetic. 
    • Hydrating patients before the procedure and restricting the fluids used during surgery.
    • Minimizing the use of urinary catheters to prevent infection.
    • Improving pain management by sending patients home on a non-opioid pain pump.
    • Providing home follow-up, including visits by nurses and physical therapists.

    “We found for many patients, same-day surgeries are a safe alternative to an extended hospital stay,” said Sunitha Singh, M.D., lead author of the quality improvement project and coordinator for the ERAS program at Stony Brook Medicine. “Education, prehabilitation and patient engagement are critical to the recovery process. Patients often feel more rested recovering at home in familiar surroundings, and we have made the ERAS changes permanent due to the high success.”

    Elective surgeries at Stony Brook Medicine were stopped during the peak of the pandemic (April-May 2020). The hospital implemented the new ERAS protocol beginning in June 2020 to provide continuity of care. 

    Over a one-year period, 152 patients had knee or hip replacement under the new program. Compared to patients who had the traditional ERAS protocol, patients in the new ERAS program stayed in the hospital an average of eight hours vs. an average of 1.7 days. No readmissions were reported. Currently, about 40% of the hospital’s hip and knee replacement patients participate in the same-day surgery ERAS program. 

    “Our findings demonstrate the adaptability of our health care system — including leveraging ERAS programs to respond to health care emergencies — while improving the quality of care,” Dr. Singh said.

     

    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

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  • New Flexible, Steerable Device Placed in Live Brains by Minimally Invasive Robot

    New Flexible, Steerable Device Placed in Live Brains by Minimally Invasive Robot

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    Newswise — The early-stage research tested the delivery and safety of the new implantable catheter design in two sheep to determine its potential for use in diagnosing and treating diseases in the brain.  

    If proven effective and safe for use in people, the platform could simplify and reduce the risks associated with diagnosing and treating disease in the deep, delicate recesses of the brain.   

    It could help surgeons to see deeper into the brain to diagnose disease, deliver treatment like drugs and laser ablation more precisely to tumours, and better deploy electrodes for deep brain stimulation in conditions such as Parkinson’s and epilepsy.  

    Senior author Professor Ferdinando Rodriguez y Baena, of Imperial’s Department of Mechanical Engineering, led the European effort and said: “The brain is a fragile, complex web of tightly packed nerve cells that each have their part to play. When disease arises, we want to be able to navigate this delicate environment to precisely target those areas without harming healthy cells.  

    “Our new precise, minimally invasive platform improves on currently available technology and could enhance our ability to safely and effectively diagnose and treat diseases in people, if proven to be safe and effective.” 

    Developed as part of the Enhanced Delivery Ecosystem for Neurosurgery in 2020 (EDEN2020) project, the findings are published in PLOS ONE. 

    Stealth Surgery  

    The platform improves on existing minimally invasive, or ‘keyhole’, surgery, where surgeons deploy tiny cameras and catheters through small incisions in the body.   

    It includes a soft, flexible catheter to avoid damaging brain tissue while delivering treatment, and an artificial intelligence (AI)-enabled robotic arm to help surgeons navigate the catheter through brain tissue.   

    Inspired by the organs used by parasitic wasps to stealthily lay eggs in tree bark, the catheter consists of four interlocking segments that slide over one another to allow for flexible navigation. 

    It connects to a robotic platform that combines human input and machine learning to carefully steer the catheter to the disease site. Surgeons then deliver optical fibres via the catheter so they can see and navigate the tip along brain tissue via joystick control. 

    The AI platform learns from the surgeon’s input and contact forces within brain tissues to guide the catheter with pinpoint accuracy. 

    Compared to traditional ‘open’ surgical techniques, the new approach could eventually help to reduce tissue damage during surgery, and improve patient recovery times and length of post-operative hospital stays. 

    While performing minimally invasive surgery on the brain, surgeons use deeply penetrating catheters to diagnose and treat disease. However, currently used catheters are rigid and difficult to place precisely without the aid of robotic navigational tools. The inflexibility of the catheters combined with the intricate, delicate structure of the brain means catheters can be difficult to place precisely, which brings risks to this type of surgery.   

    To test their platform, the researchers deployed the catheter in the brains of two live sheep at the University of Milan’s Veterinary Medicine Campus. The sheep were given pain relief and monitored for 24 hours a day over a week for signs of pain or distress before being euthanised so that researchers could examine the structural impact of the catheter on brain tissue.  

    They found no signs of suffering, tissue damage, or infection following catheter implantation.   

    Lead author Dr Riccardo Secoli, also from Imperial’s Department of Mechanical Engineering, said: “Our analysis showed that we implanted these new catheters safely, without damage, infection, or suffering. If we achieve equally promising results in humans, we hope we may be able to see this platform in the clinic within four years.   

    “Our findings could have major implications for minimally invasive, robotically delivered brain surgery. We hope it will help to improve the safety and effectiveness of current neurosurgical procedures where precise deployment of treatment and diagnostic systems is required, for instance in the context of localised gene therapy.”  

    Professor Lorenzo Bello, study co-author from the University of Milan, said: “One of the key limitations of current MIS is that if you want to get to a deep-seated site through a burr hole in the skull, you are constrained to a straight-line trajectory. The limitation of the rigid catheter is its accuracy within the shifting tissues of the brain, and the tissue deformation it can cause. We have now found that our steerable catheter can overcome most of these limitations.” 

    This study was funded by the EU Horizon 2020 programme.  

    “Modular robotic platform for precision neurosurgery with a bio-inspired needle: system overview and first in-vivo deployment” by Riccardo Secoli, Eloise Matheson, Marlene Pinzi, Stefano Galvan, Abdulhamit Donder, Thomas Watts, Marco Riva, Davide Zani, Lorenzo Bello, and Ferdinando Rodriguez y Baena. Published 19 October 2022 in PLOS ONE. 

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  • Telemedicine reduces odds of no-show clinic visits by more than two-thirds for surgical patients

    Telemedicine reduces odds of no-show clinic visits by more than two-thirds for surgical patients

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    Key takeaways 

    • Telemedicine significantly lowers likelihood of no-show clinic visits among surgical patients and follow-up care during the post-surgery period.   
    • Telemedicine is a convenient tool that can help improve healthcare for all patients, successfully increasing access among vulnerable populations.  

    Newswise — SAN DIEGO: Surgical patients who use telehealth services are much more likely to show up for their initial clinic visit or follow-up appointment during the post-surgery period than those who rely on in-person visits only. Research findings were presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. During the early months of the COVID pandemic, when everything shut down, telemedicine became an effective tool to reach patients. Building on those successes, more hospitals and clinics are implementing telehealth technology into their patient care practices.  

    Telehealth consists of an at-home interactive video and audio telecommunications system, allowing real-time connection between patients, nurses, and doctors. One major benefit to patients is that they avoid the trouble of travel to and from an appointment at a distant hospital or clinic. 

    “Low access to transportation is the number one reason for patient no-show visits.* Telemedicine is a feasible way for us to reach out to patients who would otherwise have a lot of barriers to access the healthcare system,” said lead study author Connie Shao, MD, a general surgery resident at the University of Alabama Birmingham.  

    “Maintaining routine healthcare such as clinic visits helps prevent emergent visits, which are typically at a point in time when a patient’s condition is much worse. Staying engaged with the healthcare system with timely care before and after surgery improves quality care, reduces costs for the patient, and helps ensure our patients are able to maintain a higher level of health.”  

    Even so, little is known about telemedicine use among surgical patients. 

    About the study  

    For this analysis, researchers evaluated the association between telemedicine use and patient no-show visits. They looked at data collected from seven clinics at the University of Alabama Birmingham among a diverse population of patients, with an average age of 60, undergoing all types of surgery between January 2018 and December 2021. 

    Researchers divided the patients into three categories:  

    1. a historical control of in-person visits from January 2018 to March 2020 
    2. a contemporary control of in-person visits from March 2020 to December 2021 
    3. a contemporary group of patients scheduled for telemedicine visits between March 2020 to December 2021  

    March 2020 was the start of the COVID-19 pandemic and, with that, a ramping up of telemedicine appointments. The three groups were compared for no-show visits.  

    Key findings 

    • Of the 553,475 total visits, 11.3% were no-shows. 
    • Most clinic visits were in the historical control (54.1%), compared with contemporary control (41.5%), and telemedicine visits—which included audio only and video (4.4%  for both types). 
    • The no-show rate was highest among in-person appointments (11.7%) compared to telemedicine visits (2.5%). 
    • Telemedicine was effective at reducing no-show visits. Of the small group of telemedicine visits, a multivariable adjusted analysis found a reduction in odds by 79% of no-show visits.  
    • No-show visits were also less common among older patients, those insured with Medicare, and the historical in-person visits from January 2018 to March 2020, compared with the contemporary in-person visits from March 2020 to December 2021.  
    • Disparities in no-show visits exist. For all visits, male patients were 12% more likely to not complete the appointments than women. Black patients, compared with white patients, were 68% more likely to be no-shows, and Asian patients were 32% more likely to be no-shows.  
    • Compared with private insurance, Medicaid patients were twice as likely to not complete the appointment. And patients from counties with a higher Social Vulnerability Index were 13% more likely to not complete the appointment. 

    Addressing the digital divide for patients  

    “Hopefully with the convenience of telemedicine now, the only bridge that we have to cross is the digital divide. We’ve partnered with a grassroots community program to train people in our community, especially older and more vulnerable people, on how to use telemedicine,” Dr. Shao said. “We can help keep these patients engaged in the healthcare system without having to take up their entire day to come and see us in the hospital.” 

    Giving all patients the option to use telehealth services may be of great benefit to surgical patients in the future. Dr. Shao is also developing best practice guidelines for the use of telemedicine for different surgical specialties during the post-surgery period.  

    “Telemedicine interventions such as training patients and offering more low-tech options, such as audio only, especially for patients who live far away, is an easier option. Some care is better than no care. And it’s far better for us to get some information at a telemedicine visit to take care of our patients in a timely interval than to wait to see the patient later on when they are sicker and have to be admitted to a hospital,” Dr. Shao said. “There is a time and place to use telemedicine. It certainly is an intervention worth considering to reduce no-show visits and to improve quality care across the board.” 

    The main limitation of the study is that the populations that are using telehealth technology are more likely, in general, to show up for a clinic visit (patients with better health literacy and access to the healthcare system disproportionately benefit from telemedicine).  Future studies that incorporate telemedicine training into patient visits will eliminate this confounding.  

    The study was supported by the ACS and the University of Alabama Birmingham Health Services and Outcomes Research Group.  

    Study coauthors are Marshall C. McLeod, PhD; Andy Hare, BS; Isabel C. Marques, MD; Lauren Gleason, MD, MSPH; Burkely P. Smith, MD; Eric L. Wallace, MD, FACS; and Daniel I. Chu, MD, FACS.   

    Citation: Shao C, et al. Telemedicine Associated with Decreased No-show Visits among Surgical Specialties, Scientific Forum, American College of Surgeons Clinical Congress 2022.    

    ________________________ 

    * Mieloszyk RJ, Rosenbaum JI, Hall CS, et al. Environmental Factors Predictive of No-Show Visits in Radiology: Observations of Three Million Outpatient Imaging Visits Over 16 Years, J Am Coll Radiol, 2016; 16 (4,B) 554-559.  

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    About the American College of Surgeons 
    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • Livers have the potential to function for more than 100 years

    Livers have the potential to function for more than 100 years

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    Key takeaways 

    • Understanding the characteristics of livers that live to 100 could potentially expand the donor pool by using older liver donors more often. 
    • New surgical techniques and advances in immunosuppression lead to better outcomes for patients receiving a liver from an older donor.  
    • Optimizing both donor and recipient factors allow for much greater longevity for certain livers. 

    Newswise — SAN DIEGO: There is a small, but growing, subset of livers that have been transplanted and have a cumulative age of more than 100 years, according to researchers from University of Texas (UT) Southwestern Medical Center, Dallas, and TransMedics, Andover, Massachusetts. They studied these livers to identify characteristics to determine why these organs are so resilient, paving the way for considering the potential expanded use of older liver donors. The research team presented their findings at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. 

    The researchers used the United Network for Organ Sharing (UNOS) STARfile to identify livers that had a cumulative age (total initial age at transplant plus post-transplant survival) of at least 100 years. Of 253,406 livers transplanted between 1990-2022, 25 livers met the criteria of being centurion livers—those with a cumulative age over 100 years. 

    “We looked at pre-transplant survival—essentially, the donor’s age—as well as how long the liver went on to survive in the recipient,” said lead study author Yash Kadakia, a medical student at UT Southwestern Medical School. “We stratified out these remarkable livers with over 100-year survival and identified donor factors, recipient factors, and transplant factors involved in creating this unique combination where the liver was able to live to 100 years.” 

    Centurion livers came from older donors 

    For these centurion livers, the average donor age was significantly higher, 84.7 years compared with 38.5 years for non-centurion liver transplants. The researchers noted that for a liver to make it to 100, they expected to find an older average donor age as well as healthier donors. Notably, the donors from the centurion group had lower incidence of diabetes and fewer donor infections. 

    “We previously tended to shy away from using livers from older donors,” said study coauthor Christine S. Hwang, MD, FACS, associate professor of surgery, UT Southwestern Medical Center. “If we can sort out what is special amongst these donors, we could potentially get more available livers to be transplanted and have good outcomes.”  

    There are 11,113 patients on liver transplant waiting list as of September 22, 2022.* As Dr. Hwang noted, using older liver donors more often could potentially expand the liver donor pool. 

    Further study details 

    Centurion liver donors had lower transaminases, which are enzymes that play a key role in the liver. Elevated transaminases can cause problems in liver transplantation. Additionally, the recipients of centurion livers had significantly lower MELD scores (17 for the centurion group, 22 for the non-centurion group). A higher MELD score indicates that a patient is more urgently in need of a transplant.  

    “The donors were optimized, the recipients were optimized, and it takes that unique intersection of factors to result in a really good outcome,” Mr. Kadakia said. 

    The researchers found that no grafts in the centurion group were lost to primary nonfunction or vascular or biliary complications. There was notably no significant difference in rates of rejection at 12 months between the centurion group and the non-centurion group. Further, outcomes for the centurion group had significantly better allograft and patient survival.  

    “The existence of allografts over 100 years old is revealing of the dramatic resilience of the liver to senescent events,” the study authors concluded.  

    “Livers are incredibly resilient organs,” said Mr. Kadakia. “We’re using older donors, we have better surgical techniques, we have advances in immunosuppression, and we have better matching of donor and recipient factors. All these things allow us to have better outcomes.” 

    Study coauthors are Malcolm MacConmara, MBBCh, FACS; Madhukar S. Patel, MD; Jigesh A. Shah, DO; Steven I. Hanish, MD, FACS; and Parsia A. Vagefi, MD, FACS. 

    Citation: Kadakia Y, et al. Centurion Livers — Making It to 100 with A Transplant, Scientific Forum, American College of Surgeons Clinical Congress 2022. 

    ________________________  

    * Data. Organ Procurement & Transplantation Network. Accessed September 23, 2022. Available at: https://optn.transplant.hrsa.gov/data/ (.)  

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    About the American College of Surgeons  

    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • New palliative care screening tool for surgical ICU patients may facilitate decision-making processes, reduce burden on families, medical staff

    New palliative care screening tool for surgical ICU patients may facilitate decision-making processes, reduce burden on families, medical staff

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    Key takeaways 

    • Critically ill patients in the Surgical Intensive Care Unit (SICU) may benefit from palliative care, focusing on quality of life, when aggressive medical interventions will not improve outcomes or extend life. 
    • Across hospital systems, models and access to palliative care vary; identifying patients can be difficult, often occurring late in SICU stays.  
    • Using three key questions, a new screening tool, developed using a quality improvement process, helped the medical team identify which SICU patients may benefit from palliative care or goals of care consultations within seconds; all patients in the SICU could be screened in about 30 seconds. 

    Newswise — SAN DIEGO: To aid in decision-making processes and increase awareness around palliative care in the Surgical Intensive Care Unit (SICU), a research team at the University of North Carolina at Chapel Hill (UNC-Chapel Hill) has developed a screening tool to identify—within seconds—patients who may benefit from palliative care consultations or goals of care discussions. Their research findings, presented at the Scientific Forum during the American College of Surgeons (ACS) Clinical Congress 2022, show that the screening tool successfully identified SICU patients who were later deemed candidates for palliative care by their medical team.  

    As a general and trauma surgeon, Trista Day Snyder Reid, MD, MPH, FACS, an assistant professor of surgery at UNC Health, and the study’s medical advisor, explained that she often witnesses medical teams and families make agonizing decisions for patients in the SICU. When aggressive medical interventions will not improve outcomes or extend life, palliative care treatment, which focuses on symptom management and supportive communication, may improve a patient’s quality of life. Unfortunately, a medical team may hesitate to collectively identify appropriate patients or may refer patients to palliative care late in their SICU stay, increasing the burden and stress on the patient and their families.  

    “One of the things that we found at our institution was sometimes we would involve palliative care, but it would happen way down the line when the patient had been in the SICU for a long time already,” Dr. Reid said. “We want palliative care discussions to be happening sooner. And even if we’re not involving palliative care, we want goals of care discussions to happen early so the family has a rapport with the medical team and understands that their family member is really sick.” 

    Across hospital systems, screening criteria and access to palliative care vary. Research has shown that offering palliative care consultations early in an ICU stay can improve quality of life and even reduce the lengths of stay in the ICU.1 However, integrating palliative care into hospital systems remains challenging due to a lack of resources and insufficient training, among other factors.2 

    Study details  

    The UNC researchers initially developed a screening tool with 12 “yes/no” questions with input from SICU and palliative care physicians, nurses, and advanced practice providers. Fourth-year medical students at UNC-Chapel Hill completed the questionnaire after receiving feedback from the SICU medical team. Any question where the team answered “yes” was deemed a positive indicator that the patient would benefit from a palliative care consultation with a specialist or a goals of care discussion with the surgical team.  

    Three iterations of the screening tool were developed using the Plan-Do-Study-Act (PDSA) method before selecting three questions that the researchers found best correlated with a positive indicator: 

    1. Any team member (nursing, physician, pharmacist, etc.) expresses concern the patient may need palliative care. 
    2. ICU or surgical team answers ‘no’ to the question: “Would you be surprised if this patient died?” 
    3. Comorbidities: irreversible, progressive, or untreatable, severely impairing function. 

    If yes was answered to any of the three checklist questions, the researchers believed the patient would likely benefit from a palliative care consultation or goals of care discussion. 

    Key findings 

    • Screening tools from 282 patients in the SICU were recorded.  
    • Of those 282 patients, the screening tool successfully identified 22 patients, all of whom eventually received referrals for palliative care. 
    • Each patient could be screened in about three seconds; all patients in the SICU could be screened in about 30 seconds. 
    • The tool did not increase the burden on the palliative care team at UNC Health. 

    “The hope is that by using this screening tool, decisions traditionally made very late in the patient’s SICU stay, could be made much earlier,” said lead author Victoria Herdman, MD. Dr. Herdman was a fourth-year UNC-Chapel Hill medical student at the time of the study and is now completing her residency in cardiothoracic surgery at the University of Kentucky College of Medicine. “Physicians, physician assistants, nurse practitioners and nurses know early on who needs palliative care but sometimes that’s hard to jump into early in the stay. This screening tool is a way to guide everyone into it easier.” 

    The research was performed at a single site, but the team hopes to evaluate the tool within other ICU populations at UNC Health using a Quality Improvement process, possibly using an electronic medical record system or implementing it during daily rounds discussions with only one question. The study team also plans future research to analyze patient demographics to determine which marginalized populations are often left out of palliative care discussions. Simply discussing palliative care more often and educating team members and families, they said, can make a difference. 

    “I think as surgeons we tend to have a lot of ownership of our patients because they’re trusting us with their bodies. But I think that may also bias us a little bit in terms of palliative care. We hear the words ‘palliative care’ and may say, ‘Oh, no, no, no! We don’t want that. That’s like giving up on our patient,’” Dr. Reid said. “But the truth is, I think a lot of surgeons don’t truly understand the definition of palliative care—that the goal is to align what the patient wants with your treatments. Our long-term hope is to make discussions of palliative care more commonplace and to change the culture so that people feel comfortable involving palliative care, or at a minimum having a goals of care discussion, so that patients and their families understand all the possible treatment options.” 

    The study was supported by the UNC Institute for Healthcare Quality Improvement.  

    Study coauthors are Casey Olm-Shipman, MD, MS; Winnie Lau, MD; Kyle Lavin, MD; Marshall W. Fritz, BS; and Geoffrey Orme-Evans, JD, MPH. 

    Dr. Herdman and Dr. Reid have no disclosures to report.    

    Citation: Herdman V, et al. Surgical Intensive Care Unit (SICU) Palliative Care Screening-Tool: A Quality Improvement (QI) Project, Scientific Forum, American College of Surgeons Clinical Congress 2022. 

    ________________________  

    1Rotundo E, Braunreuther E, Dale M, et al. Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention. J Am Coll Surg 2022; 235(2): 278-284. 

    2Aslakson RA, Curtis JR, Nelson, JE, et al. The changing role of palliative care in the ICU. Crit Care Med 2014: 42(11):2418. 

    # # #  

    About the American College of Surgeons  

    The American College of Surgeons (ACS) is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.   

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    American College of Surgeons (ACS)

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