Abstract Objective Variation in emergency department head computed tomography (CT) use in patients with atraumatic headaches between hospitals is being measured nationwide. However, the magnitude of ...interphysician variation within a hospital is currently unknown. We hypothesized that there was significant variation in the rates of physician head CT use, both overall and for patients diagnosed with atraumatic headaches. Methods This cross-sectional study was conducted in the emergency department of a large urban academic hospital, and institutional review board approval was obtained. All emergency department visits from 2009 were analyzed, and the primary outcome measure was whether or not head CT was performed. Logistic regression was used to control for patient, physician, and visit characteristics potentially associated with head CT ordering. The degree of interphysician variability was tested, both before and after controlling for these variables. Results Of 55,286 emergency department patient encounters, 4919 (8.9%) involved head CT examinations. Unadjusted head CT ordering rates per physician ranged from 4.4% to 16.9% overall and from 15.2% to 61.7% in patients diagnosed with atraumatic headaches, with both rates varying significantly between physicians. Two-fold variation in head CT ordering overall (6.5%-13.5%) and approximately 3-fold variation in head CT ordering for atraumatic headaches (21.2%-60.1%) persisted even after controlling for pertinent variables. Conclusion Emergency physicians vary significantly in their use of head CT both overall and in patients with atraumatic headaches. Further studies are needed to identify strategies to reduce interphysician variation in head CT use.
Abstract Objective The study objective was to determine whether previously documented effects of clinical decision support on computed tomography for pulmonary embolism in the emergency department ...(ie, decreased use and increased yield) are due to a decrease in unwarranted variation. We evaluated clinical decision support effect on intra- and inter-physician variability in the yield of pulmonary embolism computed tomography (PE-CT) in this setting. Methods The study was performed in an academic adult medical center emergency department with 60,000 annual visits. We enrolled all patients who had PE-CT performed 18 months pre- and post-clinical decision support implementation. Intra- and inter-physician variability in yield (% PE-CT positive for acute pulmonary embolism) were assessed. Yield variability was measured using logistic regression accounting for patient characteristics. Results A total of 1542 PE-CT scans were performed before clinical decision support, and 1349 PE-CT scans were performed after clinical decision support. Use of PE-CT decreased from 26.5 to 24.3 computed tomography scans/1000 patient visits after clinical decision support ( P < .02); yield increased from 9.2% to 12.6% ( P < .01). Crude inter-physician variability in yield ranged from 2.6% to 20.5% before clinical decision support and from 0% to 38.1% after clinical decision support. After controlling for patient characteristics, the post-clinical decision support period showed significant inter-physician variability ( P < .04). Intra-physician variability was significant in 3 of the 25 physicians ( P < .04), all with increased yield post-clinical decision support. Conclusions Overall PE-CT yield increased after clinical decision support implementation despite significant heterogeneity among physicians. Increased inter-physician variability in yield after clinical decision support was not explained by patient characteristics alone and may be due to variable physician acceptance of clinical decision support. Clinical decision support alone is unlikely to eliminate unwarranted variability, and additional strategies and interventions may be needed to help optimize acceptance of clinical decision support to maximize returns on national investments in health information technology.
Accessing Meckel’s cave (MC) is surgically challenging. Open approaches are complex and often correlated with high morbidity. Endoscopic approaches emerged in the last decade as feasible alternatives ...to open approaches, especially for sampling indeterminate lesions. This article first analyses available routes to approach Meckel’s cave and presents furthermore an illustrative case. We conducted a systematic review and reported according to the guidelines for preferred reporting items for systematic reviews and meta-analyses (PRISMA). Various surgical approaches identified through the search are evaluated and discussed in detail. Additionally, we report on a case of woman with a lesion in MC, which was accessed through an endoscopic transpterygoid approach subsequently diagnosed as a diffuse large B cell lymphoma. Our search delivered 75 articles that included case reports (
n
= 21), cadaveric studies (
n
= 32), clinical articles (
n
= 16), review of the literatures (
n
= 3), as well as technical notes (
n
= 2) and a radiological manuscript (
n
= 1). Open routes included lateral approaches with many variations, mainly intra- and extradural pterional approaches and anterior petrosal, as well as a retrosigmoid intradural suprameatal and a lateral transorbital approach. Endoscopically, MC was reached via approaches that included transpterygoid, transorbital or infraorbital fissure routes. Percutaneous approaches, e.g. through the foramen ovale, were also described. Multiple surgical approaches to MC are currently available. Their different characteristics as well as individual patient factors, such as clinical history and the localization of the disease, have to be considered when choosing a surgical corridor. Studies included in this review highlight the endonasal endoscopic transpterygoidal technique as an excellent corridor for biopsies in the ventral MC.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract Cho Ray Hospital is the premier tertiary care center in Ho Chi Minh City, Vietnam’s most populous city. The neurosurgical department was founded in 1958 and is currently one of the busiest ...in the world. Last year the department was responsible for over 10,000 neurosurgical operations, excluding neuroendovascular cases. Most of the elective cases are craniotomies for complex lesions such as aneurysms, AMV’s, skull base tumors, gliomas and meningiomas. While the neurosurgeons within the department are technically gifted, doing more with less predominates as the mantra at Cho Ray Hospital. The necessity to minimize costs and the scarcity of resources creates many unique circumstances, some of which lag decades behind the rest of the world. Nonetheless, the progress and trajectory of the department has been impressive as the neurosurgical care provided to the Vietnamese public continues to improve. This article describes the current state and future direction of The Department of Neurological Surgery at Cho Ray Hospital.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Abstract Objective In the present study we aim to provide further definition of a group of rare sellar pathologies treated by the endoscopic endonasal approach. Matherial and Methods A retrospective ...analysis of data obtained from a series of 1729 patients who underwent endoscopic endonasal surgery at two academic institutions (Università degli Studi di Napoli Federico II, Naples, Italy - between January 1997 and December 2013, and The Wexner Medical Center at The Ohio State University – between July 2010 and September 2015). Clinical charts, operative notes and pathology reports were examined. Results A total of 346 cases were identified to have non-adenomatous pathologies. Applying the Rosner test for outliers assisted to exclude relatively frequent lesions. The final cohort of rare sellar pathologies comprised 78 patients. Arachnoid cysts were the most frequently encountered sellar lesion (12 patients, 15%), followed by metastasis (11 cases, 14%), followed by hypophysitis (8 cases, 10%), oncocytoma and glioma (6 cases, 8% each). The most frequent clinical findings were headache (28%) and visual disorders (80%). A standard endoscopic endonasal approach was performed in 44 cases (56%), whereas, an extended approach was carried out in 34 patients (44%). Tumor removal was gross-total in 53% of patients, subtotal in 19 %, and partial in 21%. Post-operative endocrinologic and visual deficit evaluation revealed improvements in endocrine function in 8 patients (10%), visual disorders in 13 (16%). Postoperative complications arose in 28% of cases, mostly represented by diabetes insipidus (10%). Conclusion Endoscopic endonasal approaches offer some specific benefits in the treatment of these patients.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Extradural anterior clinoidectomy (eAC) is key to expose the paraclinoid region. Several authors have pointed limitations of performing an eAC through a supraorbital craniotomy. In this article, we ...aim to provide educational material and discuss the technical nuances to successfully perform an eAC throughout a modification of the supraorbital approach, the extradural extended eyebrow approach (xEBA+eAC).
Four embalmed heads were used for anatomic dissection and perform the xEBA+eAC. Additionally, one head was used for a video demonstration of the surgical approach.
The anterior clinoid process was successfully removed, and the ophthalmic artery and paraclinoid region were exposed in all specimens. Drilling the sphenoid wing until exposing the meningo-orbital band and further interdural dissection are vital steps to expose the anterior clinoid process. Removal of the anterior clinoid process can be simplified in 3 osteotomies, including the optic canal unroofing, detachment from the lateral pillar, and drilling of the optic strut. Sectioning of the distal dural ring facilitates the mobilization of the internal carotid artery and the surgical exposure of the ophthalmic artery.
xEBA+eAC is a technically feasible approach that provides exposure to the paraclinoid region, along with anterior and middle cranial fossa.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Tuberculum sellae meningiomas are challenging lesions; their critical location and often insidious growth rate enables significant distortion of the superjacent optic apparatus before the patient ...notices any visual impairment. This article describes the technical nuances, selection criteria and complication avoidance strategies for the endonasal resection of tuberculum sellae meningiomas. A stepwise description of the surgical technique is presented; indications, adjuvant technologies, pitfalls and the relevant anatomy are also reviewed. Tuberculum sellae meningiomas may be safely and effectively resected through the endonasal route; invasion of the optic canals does not represent a limitation.
Purpose of the article: To determine whether intraoperative ventilation with pure oxygen during the last stage of surgery reduces the occurrence and volume of postoperative pneumocephalus when ...compared to conventional air/oxygen mixture in patients undergoing craniotomy.
Material and Methods: prospective randomized single-blinded study to compare the rate of occurrence and volume of postoperative pneumocephalus in patients undergoing craniotomy receiving intraoperative ventilation with pure oxygen (Group B) versus a conventional air/oxygen 1:1 mixture (Group A) during the last stage of surgery. This trial was registered in ClinicalTrials.gov #NCT02722928, protocol number 2015H0032.
Results: One hundred patients were randomized into group 'A' and group 'B'. Seventy patients were included in the final analysis with 39 patients allocated in group 'A' and 31 patients in group 'B'. Median and IQR were used for postoperative penumocephalus volume. Group A: 9.65 3.61-23.20; Group B: 7.06 2.70-20.1. Our study showed no prophylactic effect on postoperative pneumocephalus volume when using mechanical ventilation with higher oxygen concentrations than the standard FiO
2
during the last stage of surgery in patients undergoing craniotomy (p = .47). No statistical difference was found in SICU LOS between groups (median 1,380 min group A versus 1,524 min group B; p = .18).
Conclusion: The use of intraoperative mechanical ventilation with pure oxygen was not associated with a prophylactic effect on the occurrence and extent of postoperative pneumocephalus in our patient setting. Published literature describing the extent of postoperative pneumocephalus is limited or highly variable among institutions.
Full text
Available for:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Chondrosarcomas of the skull base are rare, locally invasive tumors that typically arise in the petroclival region, from degenerated chondroid cells located within the synchondrosis. Given their ...usually slow growth rate, they are capable of reaching sizable dimensions, promoting bone erosion and significant displacement of neurovascular structures before causing symptomatology that will eventually lead to diagnosis; cranial neuropathies and headaches are common complaints. This article discusses the pertinent surgical anatomy, patient selection criteria, technical nuances and complication management of the endonasal resection of skull base chondrosarcomas.
In 2005, the Fleischner Society guidelines (FSG) for managing pulmonary nodules detected on CT scans were published. The aim of this study was to evaluate adherence to the FSG, adjusting for ...demographic and clinical variables that may contribute to adherence.
Radiology reports were randomly obtained for 1,100 chest and abdominal CT scans performed between January and June 2010 in a tertiary hospital's emergency department and outpatient clinics. An automated document retrieval system using natural language processing was used to identify patients with pulmonary nodules from the data set. Features relevant to evaluating variation in adherence to the FSG, including age, sex, race, nodule size, and scan site (eg, the emergency department) and type, were extracted by manual review from reports retrieved using natural language processing. All variables were entered into a logistic regression model.
Three hundred fifteen reports were identified to have pulmonary nodules, 75 of which were for patients with concurrent malignancies or aged < 35 years. Of the remaining 240 reports, 34% of recommendations for pulmonary nodules were adherent to the FSG. Nodule size demonstrated an association with guideline adherence, with adherence highest in the >4-mm to 6-mm nodule group (P = .04) and progressively diminishing for smaller and bigger nodules.
Pulmonary nodules are prevalent findings on chest and abdominal CT scans. Although most radiologists recommend follow-up imaging for these findings, recommendations for pulmonary nodules were consistent with the FSG in 34% of radiology reports. Nodule size demonstrated an association with guideline adherence, after adjusting for key variables.
PDF
