Citations

BACKGROUND AND OBJECTIVES: Symptomatic hydrocephalus (HCP) requiring cerebrospinal fluid diversion by shunting is routinely performed through ventriculoperitoneal or ventriculoatrial (VA) shunting. The optimal method of distal catheter placement for a VA shunt is not well defined. We detail a novel surgical technique for VA shunt placement using intraoperative digital subtraction angiography (DSA). METHODS: The aim of this single-institution, retrospective review was to describe a unique technique of distal catheter placement in a series of the initial 50 consecutive adult patients who underwent VA shunt placement with DSA at our institution between 2021 and 2024. Detailed procedural techniques and outcomes are described. RESULTS: Accurate surgical placement of the distal VA shunt was achieved in 48 patients (96%). Five patients required shunt revisions for delayed shearing of distal catheter (1), suboptimal distal catheter placement (3), and suboptimal proximal catheter placement (1). Four instances of post-VA shunt bacteremia were found when patients were routinely cultured for febrile episodes; all completed appropriate antibiotic course, and none resulted in meningitis or required shunt revision. Kaplan-Meier analysis demonstrated overall VA shunt success of 92% at 3 years after initial surgery. CONCLUSION: This series of 50 consecutive patients demonstrated use of intraoperative DSA yields safe and accurate placement VA shunts with acceptable long-term outcomes. As more neurosurgeons have endovascular training, this surgical technique may be more readily adopted.

BACKGROUND AND OBJECTIVES: Single-session stereotactic radiosurgery (SRS) has limited role for large arteriovenous malformations (AVM). Volume-staged SRS (VS-SRS) is used to optimize outcomes, but studies reporting results are limited. METHODS: This multicenter retrospective cohort of 378 patients from 21 centers reports results of VS-SRS for the entire AVM nidus. We report favorable outcome, obliteration, hemorrhage, and permanent symptomatic adverse radiation effect rates. RESULTS: The median age was 31 years (IQR: 19-44) at the first volume stage, with patients treated in 2–4 stages. The median total nidus volume was 21 cm 3 (IQR: 13.9-30.1 cm 3 ), and a median prescription dose of 17 Gy (IQR: 16-18 Gy) was used. The median radiographic and clinical follow-up were 48 and 55 months, respectively. Seventy-seven patients (20.4%) had a favorable outcome, with the 3-year and 5-year rates being 3.9% and 18%, respectively. 127 patients (33.6%) achieved obliteration, with the 3-year and 5-year rates being 6.8% and 26%, respectively. Obliteration rates of AVMs <15 cm 3 were 81% and 31%, respectively. The latency period hemorrhage incidence rate was 3.02 cases per 100 patient-years; 52 patients (13.8%) had a bleed. Seventy-two patients (19%) had symptomatic adverse radiation effect; in 38 patients (10.1%), these were permanent. Total nidus volume, prescription dose at first stage, diffuse nidus, and prior hemorrhage were all independent affecting outcome rates. CONCLUSION: VS-SRS can be used to treat large AVMs as a standalone treatment. Obliteration rates and favorable outcomes are lower than that with smaller AVMs, and repeat treatment is often required. Optimizing treatment plans, by increasing prescription doses, reducing treatment volume at each stage, and increasing the number of stages, may lead to better outcomes.

ABSTRACT Rationale Longer duration of epilepsy before surgery is a predictor of poor outcome. While referral delays of surgical candidates are well documented, factors causing delay during the presurgical evaluation remain unclear and may vary depending on institutional characteristics. By benchmarking the duration of presurgical evaluation across multiple centers and identifying patient and evaluation characteristics contributing to duration, we can ascertain best practices and address modifiable contributors to reduce delays. Methods We queried the Pediatric Epilepsy Research Consortium Surgery Database, a prospective, observational multicenter study enrolling children 0–18 years at 27 US pediatric epilepsy centers, for all patients undergoing initial presurgical evaluation for drug‐resistant epilepsy (DRE). We included patients with completed evaluations and data on duration from initiation of presurgical evaluation to final surgical decision. We compared patient characteristics and evaluation components between those with long duration evaluations (> 75% quartile) and those with short evaluations (< 25% quartile). Akaike information criteria selection identified variables associated with longer duration. From these, we developed a logistic prediction model for evaluation duration, using a random 80/20 training/testing split of the entire cohort. The model was tested among institutions with ≥ 10 patients in the cohort to assess its accuracy in predicting long durations. Linear models for each site assessed each variable's impact on duration. Variables with < 10% of the patient population at each site were excluded. Beta values were compared to identify intra‐ and inter‐institution variability and to delineate institutions with the shortest added duration for each variable. Results Of 2318 patients undergoing surgical evaluation, 1655 (71%) from 23 sites had complete data. Median evaluation duration was 8 weeks (interquartile range 3–22); 453 (27%) were short‐duration evaluations and 414 (25%) were long‐duration evaluations. Multiple patient and evaluation characteristics were associated with duration (Table 1). Table 6 provides the average duration each variable contributes to evaluation by site, highlighting the shortest durations compared with other groups. Conclusions Duration of presurgical evaluation for DRE can be accurately modeled using multiple patient characteristics and testing strategies commonly employed in epilepsy surgery evaluations. This predictive model can not only estimate evaluation duration but also identify opportunities to improve systemic efficiency. Institution‐level modeling identifies specific program strengths, providing an opportunity to learn from successful processes. Subsequent research will focus on institutional process mapping to better understand systemic practices that lead to improved efficiencies, then sharing these processes across the consortium to shorten evaluation durations.

ABSTRACT Objective We sought to characterize patients presenting to emergency departments (EDs) with abdominal pain and to validate risk categories defined by the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) for low‐risk recurrent abdominal pain. Methods We conducted a retrospective cohort study of patients presenting with abdominal pain between November 2019 and November 2023 across 21 EDs in Arizona, the Midwest, and Florida. Patients were categorized per GRACE‐2 into recurrent and non‐recurrent pain as well as low‐ and high‐risk groups. Primary outcomes included 72‐h returns and mortality at 30 and 90 days. Results The study included 162,494 visits (112,896 unique patients; median age 46 years; 61.2% female). Among these, 4.3% had low‐risk recurrent abdominal pain. Patients with recurrent and non‐recurrent low‐risk pain had similar ED length of stay and discharge rates to each other, compared to patients with high‐risk pain who had longer length of stay and lower discharge rates. At 30 days after the ED encounter, patients with low‐risk recurrent abdominal pain had similar mortality to patients with low‐risk non‐recurrent pain (0.4% vs. 0.3%; adjusted RR = 1.31, 95% CI: 0.85–2.03), while they had significantly lower mortality than patients with high‐risk recurrent abdominal pain (0.4% vs. 2.3; adjusted RR = 3.14, 95% CI: 2.02–4.89). Conclusions This study highlights the heterogeneity in patients presenting to the ED with abdominal pain. Among these patients, those with low‐risk recurrent pain demonstrated similar lengths of stay, discharges, and mortality rates to those with low‐risk non‐recurrent pain and less favorable lengths of stay, discharges, and mortality rates compared to those with any high‐risk features. These findings suggest that low‐ and high‐risk features may be more useful than recurrent or non‐recurrent pain in identifying patients who could benefit from more robust ED evaluations.

Abstract The treatment patterns and clinical outcomes for patients experiencing progression of disease (POD) following CD19-directed chimeric antigen receptor (CAR) T-cell therapy for relapsed or refractory (R/R) mantle cell lymphoma (MCL) are undefined. We identified all patients who received CD19-directed CAR T-cell therapy for R/R MCL therapy across 15 international centers, and studied those experiencing POD post–CAR T-cell therapy in detail. We extracted clinical/treatment/pathologic variables, and associated these features with survival outcomes. In total, 384 patients received CAR T-cell therapy, and 135 (35%) experienced POD. POD occurred at a median of 6 months following CAR T-cell therapy infusion, and most (64%) patients with POD had complete response as best response to CAR T-cell therapy. Tumor features at POD included blastoid/pleomorphic morphology in 29 of 78 (37%) patients, and TP53 mutation in 21 of 41 (51%) patients. Following POD, 17 patients received no further therapy, 13 underwent local therapy, and 105 received systemic therapy. The most common first-line systemic therapies were chemo(immuno)therapy (22 patients; overall response rate [ORR], 40%), pirtobrutinib (17 patients; ORR, 36%), and bispecific antibodies (13 patients; ORR, 67%). Among patients experiencing POD, the median progression-free survival and overall survival (OS) were 2.5 months and 5.4 months, respectively, from POD. Lack of response to CAR T-cell therapy and short time from CAR T-cell therapy infusion to POD (&lt;3 vs 3-6 vs &gt;6 months), among other factors, were associated with inferior OS after POD. In conclusion, we confirm the challenging prognosis for patients experiencing POD following CD19 CAR T-cell therapy for R/R MCL, and establish a benchmark for future investigations in this patient population.

AbstractDocumentation burden contributes to health professional burnout and negatively impacts health professional well-being and patient care quality. Yet, there is a gap in the literature regarding an effective measure to assess the perceived documentation burden of health professionals in a wide range of care settings over time.We developed and administered a pulse survey to trend, with subsequent administrations, the perceived documentation burden of health professionals in all care settings in the United States over time.A multimethods approach was used which included conducting a scoping review of the literature to identify and then curate a set of potential survey items based on scoping review results. Next, a modified Delphi approach was used with clinical informatics experts for consensus-driven item selection and pulse survey development. Finally, we administered the pulse survey nationally using snowball sampling through professional listservs and networks of organizations.The scoping review helped to identify constructs and items to include on the pulse survey. After four iterations of the modified Delphi approach, consensus was reached on five final items for the pulse survey, labeled “TrendBurden.” The first administration of “TrendBurden” was completed by 1,253 healthcare professionals in April 2024. Most respondents (73.26%) disagreed that the time and effort spent documenting patient care is appropriate, with 77.42% reporting finishing work later or needing to work from home due to excessive documentation tasks. Seventy-four point three-eight percent agreed that the effort or time required to complete documentation tasks impedes patient care, and less than one-third (31.76%) agreed that the EHR is easy to use.The “TrendBurden” Pulse Survey was developed through a scoping review of the literature and expert consensus. The resulting five-question pulse survey was administered nationally and provided insight into current perceptions of documentation burden among healthcare professionals.

ABSTRACT Objectives Multicenter research of geriatric emergency department (GED) care remains limited. Our objectives were to: 1. Prospectively collect data prioritized by the Geriatric Emergency care Applied Research (GEAR) network, a transdisciplinary taskforce for GED care, and create a multicenter GED research repository of prospective and electronic health record (EHR) data, 2. Assess concordance between prospective and EHR data. Methods The GEAR Standardization Study (GEARSS) is a multicenter, prospective study of older emergency department (ED) patients (65+) focusing on the 4Ms of age‐friendly care (mobility, medication safety, mentation, what matters) and elder mistreatment. Demographic and clinical data were collected via interviews by trained research assistants (RA) on Days 0, 4, 30, and 90 and linked to EHR. Prevalence of chronic comorbidities and incident delirium were measured and reported using descriptive statistics. Prospective and EHR data concordance was assessed with Cohen's Kappa. Results 999 participants were recruited from 5 EDs (3/25/2021–6/30/2022) across 3 institutions: Grady Health System, Northwestern Memorial Hospital, and Yale New Haven Health. The cohort was 57.0% female, 55.2% White, 39.1% Black, and 3.4% Hispanic, and the mean age was 75.1 years. For rheumatologic disease, peptic ulcer disease, diabetes, renal disease, and cancer, prevalence differed between prospective and EHR data by > 10%. About two‐thirds of participants were at risk for falls. Concordance between prospective and EHR data was good for ethnicity ( K = 0.73); excellent for sex ( K = 1.00), age ( K = 1.00), and race ( K = 0.98); fair for disposition ( K = 0.53); slight for ED observation status ( K = 0.33) and dementia diagnosis ( K = 0.24); poor for delirium presence ( K = 0.07). Conclusion In GEARSS, demographic variables aligned strongly between prospective and EHR data, while diagnosis, disposition, and mentation factors did not. This multicenter data source provides preliminary findings for common geriatric syndromes and conditions. Choice of measures using these data should be driven by GED research questions.

BACKGROUND There is a scarcity of artificial intelligence models trained on frozen pathology. One way to expand the clinical utility of models trained on permanent pathology is by applying them to frozen sections and fine-tune based on weaknesses. OBJECTIVE To qualitatively evaluate a deep learning model trained on permanent pathology to classify squamous cell carcinoma on Mohs surgery frozen sections to learn model shortcomings and inform retraining and fine-tuning. MATERIALS AND METHODS The authors trained a model for classification of tumor on 746 skin biopsy slides and tested it on 15 Mohs surgery frozen sections. The authors estimated performance metrics and compared the regions of interest generated by the model with the original H&E slides. RESULTS The model achieved an AUC-ROC of 0.985 and 0.796 for tumor classification in permanent pathology and in frozen sections, respectively. Regions of interest for frozen sections with scarce tumor areas were inaccurate, focusing on normal tissue for slides classified as false negative, or highlighting structures different from tumor (e.g., inflammation, muscle, and nerves) for slides classified as true positive. CONCLUSION Deep anatomical structures more commonly present in Mohs frozen pathology might represent data out-of-distribution for models trained on permanent pathology, potentially leading to inadequate model outputs.

Context.— After-death care can be complicated and time-consuming for clinical staff, and frustrating for bereaved families. Delays and errors can have damaging legal and reputational consequences for hospitals. Offices of Decedent Affairs (ODAs) have been proposed as a solution, and their potential benefits have been described in several single institution reports. The literature lacks a contemporary and comprehensive review of existing ODAs and their approaches. Objective.— To describe the process of establishing a new ODA and to provide a snapshot of the spectrum of structure, function, and impact of existing ODAs in the United States. Design.— A survey was administered to 11 established ODAs spread across the continental United States. Programs were identified through the College of American Pathologists Autopsy Committee and a Medical Autopsy Listserv. Results.— Eleven ODAs returned the survey, representing more than 190 cumulative years of experience in decedent care in the hospital setting (median, 10 years). There was a wide range in staffing (both staff size and background) as well as scope of services offered. The median ratio of hospital deaths to full-time equivalent (FTE) staffing was 360 deaths per FTE. Respondents reported that ODAs unburden clinical providers and facilitate decedent management. Some respondents reported a quicker turnover of hospital beds and shorter intervals between pronouncement of death and autopsy. ODAs increased autopsy rates when the autopsy services were part of the ODA. Conclusions.— This survey provides practical information for hospitals considering establishing a new ODA and useful benchmarks for existing ODA programs.