Sader, Nicholas

OBJECTIVE Spinal ultrasound is used to investigate occult dysraphism in neonates with sacrococcygeal dimples. Inappropriate imaging studies may be performed despite the Choosing Wisely Canada guidelines. The objective of this study was to assess the appropriateness of spinal ultrasounds performed in 2 Canadian provinces and to compare the diagnostic accuracy of spinal ultrasound and MRI in predicting the need for neurosurgical intervention. METHODS This multicenter retrospective cohort study identified spinal ultrasounds in neonates younger than 6 months of age from January 1, 2017, to December 30, 2018, in Alberta and British Columbia, Canada. The authors collected data on patient demographic characteristics, reasons for requested imaging, the presence of any imaging abnormalities, and the ultimate need for intraspinal surgery. Ultrasounds were deemed appropriate if the Choosing Wisely guidelines were followed for ordering. The authors compared high-risk findings on spinal ultrasound and MRI to the need for surgery using sensitivities, specificities, positive predictive values (PPV), and negative predictive values (NPV). RESULTS A total of 1043 ultrasounds were ordered in 1042 neonates, most commonly by pediatricians (49%), family doctors (27%), and neonatologists (16%). Three hundred eighty-three ultrasounds (37%) were deemed inappropriately ordered. Sixty-nine infants (7%) of the cohort received an MRI and 11 (1%) ultimately underwent neurosurgical intervention. None of the patients who had an inappropriately ordered ultrasound underwent surgery. Spinal ultrasound, compared to surgery, had a sensitivity of 36%, specificity of 98%, PPV of 17%, and NPV of 99%. Spinal MRI, compared to surgery, had a sensitivity of 73%, specificity of 76%, PPV of 38%, and NPV of 94%. CONCLUSIONS Although spinal ultrasound has an acceptable specificity in predicting surgery, it remains a poor screening test (36% sensitivity). Given that approximately 37% of spinal ultrasounds were inappropriately ordered in this study period, the authors estimate that if physicians followed the Choosing Wisely Guidelines more closely, it would result in an estimated potential cost savings of CAD$1,856,769 over a decade for Canada with minimal surgical impact and a very low risk of missing surgically relevant spinal dysraphism.

Abstract Background Subsequent to a diagnosis of a brain tumor, psychological distress has been associated with negative effects on mental health as well as suicidality. The magnitude of such impact has been understudied in the literature. We conducted a systematic review to examine the impact of a brain tumor on suicidality (both ideation and attempts). Methods In accordance with the PRISMA guidelines, we searched for relevant peer-reviewed journal articles on PubMed, Scopus, and Web of Science databases from inception to October 20, 2022. Studies investigating suicide ideation and/or attempt among patients with brain tumors were included. Results Our search yielded 1,998 articles which were screened for eligibility. Seven studies consisting of 204,260 patients were included in the final review. Four studies comprising 203,906 patients (99.8%) reported elevated suicidal ideation and suicide attempt incidence compared with the general population. Prevalence of ideation and attempts ranged from 6.0% to 21.5% and 0.03% to 3.33%, respectively. Anxiety, depression, pain severity, physical impairment, glioblastoma diagnosis, male sex, and older age emerged as the primary risk factors associated with increased risk of suicidal ideation and attempts. Conclusion Suicidal ideation and attempts are increased in patients and survivors of brain tumors compared to the general population. Early identification of patients exhibiting these behaviors is crucial for providing timely psychiatric support in neuro-oncological settings to mitigate potential harm. Future research is required to understand pharmacological, neurobiological, and psychiatric mechanisms that predispose brain tumor patients to suicidality.

OBJECTIVE The management of excess CSF in patients with hydrocephalus typically requires using a shunt to divert CSF. Unfortunately, there is a high rate of shunt failure despite improvements in device components and insertion techniques. Reoperation is frequently necessary, which contributes to patient harm and increased healthcare costs. While factors affecting shunt failure are well defined in the pediatric population, information regarding adults is lacking. The authors undertook a systematic review and meta-analysis to determine how shunt failure in the adult population is reported and investigated the etiologies of shunt failure. METHODS This review is reported according to PRIMSA and utilized the MEDLINE, Embase, and Google Scholar databases. Abstracts were screened by two independent reviewers, and data were extracted in duplicate by two independent reviewers. Statistical analyses were performed using SPSS and Stata. RESULTS The pooled rates of shunt failure were 10% (95% CI 5%–15%) in studies with a mean follow-up time of less than 1 year, 12% (95% CI 8%–14%) with a follow-up time between 1 and 2 years, and 32% in studies with a follow-up time of 2 years or greater (95% CI 19%–43%). The pooled rate of failure was 17% across all studies. The most common cause of shunt failure was obstruction at 3.0% (95% CI 2%–4%), accounting for 23.2% of shunt failures. Infection was the second most common at 2.8% (95% CI 2%–3%), accounting for 22.5% of shunt failures. The most common location of shunt failure was the distal catheter, with a failure rate of 4.0% (95% CI 3%–5%), accounting for 33.4% of shunt failures. The definition of shunt failure was heterogeneous and varied depending on institutional practices. The combination of symptoms with either CT or MRI was the most frequently reported method for assessing shunt failure. CONCLUSIONS Important variation regarding how to define, investigate, and report shunt failure was identified. The overall shunt failure rate in adults is at least 32% after 2 years, which, while lower than that typically reported in the pediatric population, is significant. The most common causes of shunt failure in adults are infection and obstruction. The most common site of failure occurred at the distal catheter, highlighting the need to develop strategies to both report and mitigate distal shunt failure in adult shunt patients.