Saturday, August 30, 2014

Effect of Direct Neuroradiologist Participation in Physician Marketing on Imaging Volumes in Outpatient Radiology

Effect of Direct Neuroradiologist Participation in Physician Marketing on Imaging Volumes in Outpatient Radiology
AJNR Blog

Editor's Choice

August 2014

(2 of 3)

This study assessed the benefits of using a sales representative and a neuroradiologistas a marketing and sales team for referrals in outpatient imaging. When referring practices were visited by the 2-person team, referral volumes were 2.5 times greater than when they were visited by the sales representative alone. This impact on imaging referral volumes with the use of the neuroradiologist for direct physician-to-physician marketing supports the concept that neuroradiologist visits are important in establishing and maintaining a relationship with the referring clinician's office and maximizing imaging referrals.

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Abstract

BACKGROUND AND PURPOSE
Over the past several years, decreased demand for and increased supply of imaging services has increased competition among outpatient imaging centers in the United States. This study hypothesizes that using a radiology sales representative and neuroradiologist as a team in marketing and sales will increase imaging referrals in outpatient imaging.

MATERIALS AND METHODS
From January to December 2009, baseline monthly physician referral data of CT and MR scans of 19 referring clinicians (neurologists, neurosurgeons, and anesthesiologists) to an outpatient radiology group were collected. During that time, a nonphysician radiology sales representative visited the referring clinicians' offices every 2 weeks. From January to June 2010, the same radiology sales representative visited the referring clinicians' offices every 2 weeks but was accompanied by a neuroradiologist once a month. From July 2010 to June 2011, the same radiology sales representative visited the referring clinicians' offices twice a month without a neuroradiologist.

RESULTS
Cross-sectional imaging referral volumes were approximately 2.5 times greater during the 6-month period using the neuroradiologist for direct physician-to-physician marketing when compared with the volumes achieved with the sales representative alone, and continued neuroradiologist involvement in marketing and sales is required to maintain referral volumes over time.

CONCLUSIONS
The impact on imaging referral volumes during the 6-month use of the neuroradiologist for direct physician-to-physician marketing in this study supports the assertion that neuroradiologist visits are an important element in establishing and maintaining a relationship with the referring clinician's office and thereby maximizing imaging referrals.

Full text

The post Effect of Direct Neuroradiologist Participation in Physician Marketing on Imaging Volumes in Outpatient Radiology appeared first on AJNR Blog.



Original Article: http://www.ajnrblog.org/2014/08/30/effect-direct-neuroradiologist-participation-physician-marketing-imaging-volumes-outpatient-radiology/

Friday, August 29, 2014

Após um tumor cerebral - iBook e Android

APÓS UM TUMOR CEREBRAL

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APÓS UM TUMOR CEREBRAL

Júlio Pereira

Category: Medical

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Cancer survivors' uptake and adherence in diet and exercise intervention trials: An integrative data analysis

Cancer survivors' uptake and adherence in diet and exercise intervention trials: An integrative data analysis
Cancer

BACKGROUND

The health benefits of diet and exercise interventions for cancer survivors are well documented. However, little is known regarding demographic and medical predictors of survivors' willingness to participate in diet and exercise intervention trials, study enrollment, intervention adherence, and study completion. To assist in interpreting the generalizability of trial findings and to improve the design of future trials, this study examined predictors of these process measures.

METHODS

An integrative data analysis was performed on data from 3 of the largest home-based diet and exercise intervention trials for cancer survivors (n = 23,841). Demographic and medical factors (ie, sex, race, age, time since diagnosis, and cancer type) were examined as predictors of willingness to participate, study enrollment, intervention adherence, and study completion in the pooled sample. A 99% confidence interval was used to determine statistical significance.

RESULTS

Across trials, 11.1% of contacted survivors were willing to participate, and 5.7% were eligible and enrolled. Among enrollees, 53.4% demonstrated ≥75% adherence to the intervention, and 91.1% completed the study. Race (Caucasian vs others), age, time since diagnosis, and cancer type predicted survivors' willingness to participate (P < .01). All examined predictors were associated with the likelihood of study enrollment (P < .01). No significant predictors of intervention adherence or study completion were found among study enrollees (P ≥ .01).

CONCLUSIONS

Cancer survivors' demographic and medical characteristics predicted their interest and participation in diet and exercise intervention trials. These findings have implications for the generalizability of results and can help to guide procedures used in future trials to enhance patient representation. Cancer 2014. © 2014 American Cancer Society.



Original Article: http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1002/cncr.28978

Evaluation of high-fidelity simulation training in radiation oncology using an outcomes logic model

Evaluation of high-fidelity simulation training in radiation oncology using an outcomes logic model
Radiation Oncology - Latest Articles

Purpose: To evaluate the feasibility and educational value of high-fidelity, interprofessional team-based simulation in radiation oncology. Methods: The simulation event was conducted in a radiation oncology department during a non-clinical day. It involved 5 simulation scenarios that were run over three 105 minute timeslots in a single day. High-acuity, low-frequency clinical situations were selected and included HDR brachytherapy emergency, 4D CT artifact management, pediatric emergency clinical mark-up, electron scalp trial set-up and a cone beam CT misregistration incident. A purposive sample of a minimum of 20 trainees was required to assess recruitment feasibility. A faculty radiation oncologist (RO), medical physicist (MP) or radiation therapist (RTT), facilitated each case. Participants completed a pre event survey of demographic data and motivation for participation. A post event survey collected perceptions of familiarity with the clinical content, comfort with interprofessional practice, and event satisfaction, scored on a 1-10 scale in terms of clinical knowledge, clinical decision making, clinical skills, exposure to other trainees and interprofessional communication. Means and standard deviations were calculated. Results: Twenty-one trainees participated including 6 ROs (29%), 6 MPs (29%), and 9 RTTs (43%). All 12 cases (100%) were completed within the allocated 105 minutes. Nine faculty facilitators, (3MP, 2 RO, 4 RTTs) were required for 405 minutes each. Additional costs associated with this event were 154 hours to build the high fidelity scenarios, 2 standardized patients (SPs) for a total of 15.5 hours, and consumables.The mean (+/-SD) educational value score reported by participants with respect to clinical knowledge was 8.9 (1.1), clinical decision making 8.9 (1.3), clinical skills 8.9 (1.1), exposure to other trainees 9.1 (2.3) and interprofessional communication 9.1 (1.0). Fifteen (71%) participants reported the cases were of an appropriate complexity. The importance of further simulation events was rated highly at 9.1/10. Conclusions: High-fidelity simulation training is feasible and effective in a radiation oncology context. However, such educational activities require significant resources, including personnel and equipment.

Original Article: http://www.ro-journal.com/content/9/1/189

Friday, August 22, 2014

Tweet of the Week: Illicit Psychoactive Web

Tweet of the Week: Illicit Psychoactive Web
MedPage Today Neurology

(MedPage Today) -- Welcome to another edition of the MedPage Today Tweet of the Week! Every Friday, the editorial team highlights its favorite 140-character contribution from the healthcare twittersphere.

Original Article: http://www.medpagetoday.com/Psychiatry/Addictions/47339

Thursday, August 21, 2014

Whole-Sellar Stereotactic Radiosurgery for Functioning Pituitary Adenomas

Whole-Sellar Stereotactic Radiosurgery for Functioning Pituitary Adenomas
Neurosurgery - Current Issue

imageBACKGROUND: Functioning pituitary adenomas (FPAs) can be difficult to delineate on postoperative magnetic resonance imaging, making them difficult targets for stereotactic radiosurgery (SRS). In such cases, radiation delivery to the entire sella has been utilized as a radiosurgical equivalent of a total hypophysectomy. OBJECTIVE: To evaluate the outcomes of a cohort of patients with FPA who underwent SRS to the whole-sellar region. METHODS: This is a retrospective review of patients who underwent whole-sellar SRS for FPA between 1989 and 2012. Sixty-four patients met the inclusion criteria: they were treated with whole-sellar SRS following surgical resection for persistently elevated hormone levels, and (1) no visible lesions on imaging studies and/or (2) tumor infiltration of dura or adjacent venous sinuses observed at the time of a prior resection. The median radiosurgical volume covering sellar structures was 3.2 mL, with a median margin dose of 25 Gy. RESULTS: The median endocrine follow-up was 41 months; 22 (68.8%) patients with acromegaly, 20 (71.4%) patients with Cushing disease, and 2 (50.0%) patients with prolactinoma achieved endocrine remission. The 2-, 4-, and 6-year actuarial remission rates were 54%, 78%, and 87%, respectively. New-onset neurological deficit was found in 4 (6.3%) patients following treatment. New-onset hypopituitarism was observed in 27 (43.5%) patients, with panhypopituitarism in 2 (3.2%). Higher margin/maximum dose were significantly associated with a higher remission rate and development of post-SRS hypopituitarism. CONCLUSION: Whole-sellar SRS for invasive or imaging-negative FPA following failed resection can offer reasonable rates of endocrine remission. Hypopituitarism following whole-sellar SRS is the most common complication. ABBREVIATIONS: ACTH, adrenocorticotropic hormone FPA, functioning pituitary adenoma CD, Cushing disease FSR, fractionated stereotactic radiotherapy GH, growth hormone GKS, Gamma-knife radiosurgery Gy, gray IGF-1, insulin-like growth factor-1 SRS, stereotactic radiosurgery TSH, thyroid-stimulating hormone UFC, urine free cortisol

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/09000/Whole_Sellar_Stereotactic_Radiosurgery_for.4.aspx

Calendar of Events

Calendar of Events
Neurosurgery - Current Issue

imageNo abstract available

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/09000/Calendar_of_Events.21.aspx

Relationship Between ICU Bed Availability, ICU Readmission, and Cardiac Arrest in the General Wards

Relationship Between ICU Bed Availability, ICU Readmission, and Cardiac Arrest in the General Wards
Critical Care Medicine - Most Popular Articles

imageObjective: The decision to admit a patient to the ICU is complex, reflecting patient factors and available resources. Previous work has shown that ICU census does not impact mortality of patients admitted to the ICU. However, the effect of ICU bed availability on patients outside the ICU is unknown. We sought to determine the association between ICU bed availability, ICU readmissions, and ward cardiac arrests. Design: In this observational study using data collected between 2009 and 2011, rates of ICU readmission and ward cardiac arrest were determined per 12-hour shift. The relationship between these rates and the number of available ICU beds at the start of each shift (accounting for census and nursing capacity) was investigated. Grouped logistic regression was used to adjust for potential confounders. Setting: Five specialized adult ICUs comprising 63 adult ICU beds in an academic medical center. Patients: Any patient admitted to a non-ICU inpatient unit was counted in the ward census and considered at risk for ward cardiac arrest. Patients discharged from an ICU were considered at risk for ICU readmission. Interventions: None. Measurements and Main Results: Data were available for 2,086 of 2,190 shifts. The odds of ICU readmission increased with each decrease in the overall number of available ICU beds (odds ratio = 1.06; 95% CI, 1.00–1.12; p = 0.03), with a similar but not statistically significant association demonstrated in ward cardiac arrest rate (odds ratio = 1.06; 95% CI, 0.98–1.14; p = 0.16). In subgroup analysis, the odds of ward cardiac arrest increased with each decrease in the number of medical ICU beds available (odds ratio = 1.26; 95% CI, 1.06–1.49; p = 0.01). Conclusions: Reduced ICU bed availability is associated with increased rates of ICU readmission and ward cardiac arrest. This suggests that systemic factors are associated with patient outcomes, and flexible critical care resources may be needed when demand is high.

Original Article: http://journals.lww.com/ccmjournal/Fulltext/2014/09000/Relationship_Between_ICU_Bed_Availability,_ICU.9.aspx

Saturday, August 16, 2014

Thoughts from the Hospital

Thoughts from the Hospital
Neurosurgery Blog

Thoughts from the Hospital

em breve
Description
I remember several times when coming home tired after being on call , but I was always wanting to write something. Sometimes I had had an unusual scene, listened an interesting phrase or experienced a sad case. We are not able to express ourselves in a hospital, even when seriously ill, we don't have time. But that's how the book "Thoughts from the hospital" emerged. My book contains texts that I wrote during college, medical school and during my residency of neurosurgery. I could set the book "Thoughts from the hospital" as clippings thoughts

iBook – AppleStore – http://goo.gl/v4cZb8
Amazon – kindle: http://goo.gl/asLdXw
Google Play: http://goo.gl/yZ3iPw
Cultura: http://goo.gl/eFgq5s
IBA – http://goo.gl/q9U6S7

The post Thoughts from the Hospital appeared first on NEUROSURGERY BLOG.



Original Article: http://neurocirurgiabr.com/thoughts-from-the-hospital/?utm_source=rss&utm_medium=rss&utm_campaign=thoughts-from-the-hospital

No Link Between Sleep Apnea, Cancer, Study Finds

No Link Between Sleep Apnea, Cancer, Study Finds
Cancer: MedlinePlus

Risk factors for the two are similar, an expert says

HealthDay news image

Source: HealthDay

Original Article: http://www.nlm.nih.gov/medlineplus/news/fullstory_147689.html

A Pilot Study of Hypofractionated Stereotactic Radiation Therapy and Sunitinib in Previously Irradiated Patients With Recurrent High-Grade Glioma

A Pilot Study of Hypofractionated Stereotactic Radiation Therapy and Sunitinib in Previously Irradiated Patients With Recurrent High-Grade Glioma
International Journal of Radiation Oncology * Biology * Physics

Angiogenic blockade with irradiation may enhance the therapeutic ratio of radiation therapy (RT) through vascular normalization. We sought to determine the safety and toxicity profile of continuous daily-dosed sunitinib when combined with hypofractionated stereotactic RT (fSRT) for recurrent high-grade gliomas (rHGG).

Original Article: http://www.redjournal.org/article/S0360-3016(14)00683-X/abstract?rss=yes?rss=yes

Glioblastoma patients benefit from triple therapy

Glioblastoma patients benefit from triple therapy
Neurology News & Neuroscience News from Medical News Today

A triple therapy for glioblastoma, including two types of immunotherapy and targeted radiation, has significantly prolonged the survival of mice with these brain cancers, according to a new report by...

Original Article: http://www.medicalnewstoday.com/releases/280650.php

One in 10 Cancer Survivors Still Smoke Years Later, Study Finds

One in 10 Cancer Survivors Still Smoke Years Later, Study Finds
Cancer: MedlinePlus

Experts say finding shows how hard it is to quit, and that doctors need to make better effort to help

HealthDay news image

Source: HealthDay

Original Article: http://www.nlm.nih.gov/medlineplus/news/fullstory_147710.html

Health-related quality of life as a prognostic factor in patients with advanced cancer

Health-related quality of life as a prognostic factor in patients with advanced cancer
Cancer

BACKGROUND

Evidence continues to accumulate regarding the association between health-related quality of life (HRQoL) and survival across chronic diseases. The objectives of the current study were to investigate the prognostic value of HRQoL in patients with hepatocellular carcinoma and cholangiocarcinoma after adjusting for sociodemographics, disease-related factors, and treatment-related factors.

METHODS

A total of 321 patients diagnosed with hepatocellular or cholangiocarcinoma were administered the Functional Assessment of Cancer Therapy-Hepatobiliary instrument. Cox regression and Kaplan-Meier survival analyses were performed to test the association between the 5 domains of HRQoL and survival.

RESULTS

Using Cox regression, overall HRQoL was found to be significantly associated with survival (P = .003) after adjusting for demographics, disease-specific factors, and treatment. Subscales of the Functional Assessment of Cancer Therapy-Hepatobiliary, including the Physical Well-Being (P = .02) and the Symptoms and Side Effects subscales (P = .05), were also found to be significantly associated with survival after adjusting for demographics, disease-specific factors, and treatment.

CONCLUSIONS

HRQoL was found to be prognostic of survival in patients with hepatocellular and cholangiocarcinoma while covarying for demographics, disease-specific factors, and treatment. Stratifying patients based on HRQoL when testing novel treatments may be recommended.

Health-related quality of life was found to be prognostic of survival in patients with hepatocellular and cholangiocarcinoma while controlling for demographics, disease-specific factors, and treatment-related factors. Cancer 2014. © 2014 American Cancer Society.



Original Article: http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1002/cncr.28902

Do-Not-Resuscitate Status and Observational Comparative Effectiveness Research in Patients With Septic Shock*

Do-Not-Resuscitate Status and Observational Comparative Effectiveness Research in Patients With Septic Shock*
Critical Care Medicine - Current Issue

imageObjectives: To assess the importance of including do-not-resuscitate status in critical care observational comparative effectiveness research. Design: Retrospective analysis. Setting: All California hospitals participating in the 2007 California State Inpatient Database, which provides do-not-resuscitate status within the first 24 hours of admission. Patients: Septic shock present at admission. Interventions: None. Measurements and Main Results: We investigated the association of early do-not-resuscitate status with in-hospital mortality among patients with septic shock. We also examined the strength of confounding of do-not-resuscitate status on the association between activated protein C therapy and mortality, an association with conflicting results between observational and randomized studies. We identified 24,408 patients with septic shock; 19.6% had a do-not-resuscitate order. Compared with patients without a do-not-resuscitate order, those with a do-not-resuscitate order were significantly more likely to be older (75 ± 14 vs 67 ± 16 yr) and white (62% vs 53%), with more acute organ failures (1.44 ± 1.15 vs 1.38 ± 1.15), but fewer inpatient interventions (1.0 ± 1.0 vs 1.4 ± 1.1). Adding do-not-resuscitate status to a model with 47 covariates improved mortality discrimination (c-statistic, 0.73–0.76; p < 0.001). Addition of do-not-resuscitate status to a multivariable model assessing the association between activated protein C and mortality resulted in a 9% shift in the activated protein C effect estimate toward the null (odds ratio from 0.78 [95% CI, 0.62–0.99], p = 0.04, to 0.85 [0.67–1.08], p = 0.18). Conclusions: Among patients with septic shock, do-not-resuscitate status acts as a strong confounder that may inform past discrepancies between observational and randomized studies of activated protein C. Inclusion of early do-not-resuscitate status into more administrative databases may improve observational comparative effectiveness methodology.

Original Article: http://journals.lww.com/ccmjournal/Fulltext/2014/09000/Do_Not_Resuscitate_Status_and_Observational.10.aspx

Epidemiology of Death in the PICU at Five U.S. Teaching Hospitals*

Epidemiology of Death in the PICU at Five U.S. Teaching Hospitals*
Critical Care Medicine - Current Issue

imageObjective: To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States. Design: Prospective case series. Setting: Five U.S. teaching hospitals. Subjects: We concurrently identified 192 consecutive patients who died prior to discharge from the PICU. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures. Interventions: None. Measurements and Main Results: The overall mortality rate was 2.39% (range, 1.85–3.38%). One hundred thirty-three patients (70%) died following the withholding or withdrawal of life-sustaining treatments, 30 (16%) were diagnosed as brain dead, and 26 (14%) died following an unsuccessful resuscitation attempt. Fifty-seven percent of all deaths occurred within the first week of admission; these patients, who were more likely to have new onset illnesses or injuries, included the majority of those who died following unsuccessful cardiopulmonary resuscitation attempts or brain death diagnoses. Patients who died beyond 1-week length of stay in the PICU were more likely to have preexisting diagnoses, to be technology dependent prior to admission, and to have died following the withdrawal of life-sustaining treatment. Only 64% of the patients who died following the withholding or withdrawing of life support had a formal do-not-resuscitate order in place at the time of their death. Conclusions: The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved. Death is largely characterized by two fairly distinct profiles that are associated with whether death occurs within or beyond 1-week length of stay. Decisions not to resuscitate are often made in the absence of a formal do-not-resuscitate order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.

Original Article: http://journals.lww.com/ccmjournal/Fulltext/2014/09000/Epidemiology_of_Death_in_the_PICU_at_Five_U_S_.17.aspx

mRNA-based vaccines synergize with radiation therapy to eradicate established tumors

mRNA-based vaccines synergize with radiation therapy to eradicate established tumors
Radiation Oncology

Background: The eradication of large, established tumors by active immunotherapy is a major challenge because of the numerous cancer evasion mechanisms that exist. This study aimed to establish a novel combination therapy consisting of messenger RNA (mRNA)-based cancer vaccines and radiation, which would facilitate the effective treatment of established tumors with aggressive growth kinetics. Methods: The combination of a tumor-specific mRNA-based vaccination with radiation was tested in two syngeneic tumor models, a highly immunogenic E.G7-OVA and a low immunogenic Lewis lung cancer (LLC). The molecular mechanism induced by the combination therapy was evaluated via gene expression arrays as well as flow cytometry analyses of tumor infiltrating cells. Results: In both tumor models we demonstrated that a combination of mRNA-based immunotherapy with radiation results in a strong synergistic anti-tumor effect. This was manifested as either complete tumor eradication or delay in tumor growth. Gene expression analysis of mouse tumors revealed a variety of substantial changes at the tumor site following radiation. Genes associated with antigen presentation, infiltration of immune cells, adhesion, and activation of the innate immune system were upregulated. A combination of radiation and immunotherapy induced significant downregulation of tumor associated factors and upregulation of tumor suppressors. Moreover, combination therapy significantly increased CD4+, CD8+ and NKT cell infiltration of mouse tumors. Conclusion: Our data provide a scientific rationale for combining immunotherapy with radiation and provide a basis for the development of more potent anti-cancer therapies.

Original Article: http://www.ro-journal.com/content/9/1/180

Sunday, August 10, 2014

Patterns of Failure After Proton Therapy in Medulloblastoma

Patterns of Failure After Proton Therapy in Medulloblastoma
International Journal of Radiation Oncology * Biology * Physics

Proton therapy centers and the pediatric oncology community will welcome the article by Sethi et al (1) published in the March 1, 2014, issue of this journal. The technical data regarding over- or underlapping of adjacent treatment fields are useful to prevent further tumor recurrences at these sites. Also, it is reassuring that an excess tumor recurrence risk was not found just beneath the meninges of the widest portion of the head, including after low, highly fractionated doses of 23.4 Gy (relative biological effect [RBE] = 1.1) and below, which provides nearly 70% of the population studied.

Original Article: http://www.redjournal.org/article/S0360-3016(14)00705-6/abstract?rss=yes?rss=yes

Sunday, August 3, 2014

Cognitive disorders in pediatric medulloblastoma: what neuroimaging has to offer

Cognitive disorders in pediatric medulloblastoma: what neuroimaging has to offer
Journal of Neurosurgery: Journal of Neurosurgery: Pediatrics: Table of Contents

Journal of Neurosurgery: Pediatrics, Volume 14, Issue 2, Page 136-144, August 2014.
Medulloblastomas are the most common malignant childhood brain tumors arising in the posterior fossa. Treatment improvements for these tumors have meant that there are a greater number of survivors, but this long-term patient survival has increased the awareness of resulting neurocognitive deficits. Impairments in attention, memory, executive functions, and intelligence quotient demonstrate that the cerebellum likely plays a significant role in numerous higher cognitive functions such as language, cognitive, and emotional functions. In addition, children with medulloblastoma not only have cerebellar lesions but also brain white matter damages due to radiation and chemotherapy. Functional neuroimaging, a noninvasive method with many advantages, has become the standard tool in clinical and cognitive neuroscience research. By reviewing functional neuroimaging studies, this review aims to clarify the role of the cerebellum in cognitive function and explain more clearly cognitive sequelae due to polytherapy in children with medulloblastoma. This review suggests that the posterior cerebellar lobes are crucial to maintaining cognitive performance. Clinical investigations could help to better assess the involvement of these lobes in cognitive functions.

Original Article: http://thejns.org/doi/abs/10.3171/2014.5.PEDS13571?ai=3f6&mi=3ba5z2&af=R

The use of simulation in neurosurgical education and training

The use of simulation in neurosurgical education and training
Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 121, Issue 2, Page 228-246, August 2014.
Object There is increasing evidence that simulation provides high-quality, time-effective training in an era of resident duty-hour restrictions. Simulation may also permit trainees to acquire key skills in a safe environment, important in a specialty such as neurosurgery, where technical error can result in devastating consequences. The authors systematically reviewed the application of simulation within neurosurgical training and explored the state of the art in simulation within this specialty. To their knowledge this is the first systematic review published on this topic to date. Methods The authors searched the Ovid MEDLINE, Embase, and PsycINFO databases and identified 4101 articles; 195 abstracts were screened by 2 authors for inclusion. The authors reviewed data on study population, study design and setting, outcome measures, key findings, and limitations. Results Twenty-eight articles formed the basis of this systematic review. Several different simulators are at the neurosurgeon's disposal, including those for ventriculostomy, neuroendoscopic procedures, and spinal surgery, with evidence for improved performance in a range of procedures. Feedback from participants has generally been favorable. However, study quality was found to be poor overall, with many studies hampered by nonrandomized design, presenting normal rather than abnormal anatomy, lack of control groups and long-term follow-up, poor study reporting, lack of evidence of improved simulator performance translating into clinical benefit, and poor reliability and validity evidence. The mean Medical Education Research Study Quality Instrument score of included studies was 9.21 ± 1.95 (± SD) out of a possible score of 18. Conclusions The authors demonstrate qualitative and quantitative benefits of a range of neurosurgical simulators but find significant shortfalls in methodology and design. Future studies should seek to improve study design and reporting, and provide long-term follow-up data on simulated and ideally patient outcomes.

Original Article: http://thejns.org/doi/abs/10.3171/2014.5.JNS131766?ai=ru&mi=0&af=R

Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions
Journal of Neurosurgery: Journal of Neurosurgery: Table of Contents

Journal of Neurosurgery, Volume 121, Issue 2, Page 262-276, August 2014.
Object On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures. Methods The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000–2002) and post-reform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method. Results A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre– and post–duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11–1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91–1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17). Conclusions The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

Original Article: http://thejns.org/doi/abs/10.3171/2014.5.JNS1314?ai=ru&mi=0&af=R