Universal Health Care Coverage in Massachusetts: A Follow-up on the Effects on Neurosurgical Practice

Background: It has been four years since the introduction of universal health care coverage in Massachusetts. Our initial assessment performed from 2007-2008 demonstrated largely positive results. Objectives: We performed a follow-up study to assess the long term financial impact of universal health care on hospital charges associated with neurosurgical operative cases at our institution. Methods: The billing records from July 1, 2009 – June 30, 2010 were compared to those from 2007 and 2008. Records were analyzed for length of stay, case mix, patient age, hospital charge, reimbursement, and procedure. Results: Case volume increased by 31% and mean acuity increased from 2.3 to 3.1 (p \u3c 0.005). Hospital stays lengthened by 1 day (p \u3c 0.005). Payor mix changed over this time with Commonwealth Care and Medicaid comprising 2.9% and 12.4%, respectively, of neurosurgical inpatients; neither had significantly different acuity or lengths of stay. Despite an increase in case volume by 31% and significantly increased acuity in 2010, revenue increased 14% over early reform data. When volume was normalized, extrapolations of pre-reform and early reform coverage on current financials demonstrated that the change in payor mix alone had decreased revenue by 30% and 24%, respectively. When modifying 2010 financials by considering 2007 reimbursement rates and 2007 payor mix, these changes together resulted in a revenue reduction of 36%. Conclusions: Taken together, our data suggests that revenue associated with hospital charges for neurosurgical inpatients has decreased significantly since health care reform went into effect

Clinical Outcome and Characterization of Local Field Potentials in Holmes Tremor Treated with Pallidal Deep Brain Stimulation

Background: Holmes tremor (HT) is an irregular, low-frequency rest tremor associated with prominent action and postural tremors. Currently, the most effective stereotactic target and neurophysiologic characterization of HT, specifically local field potentials (LFPs) are uncertain. We present the outcome, intraoperative neurophysiologic analysis with characterization of LFPs in a patient managed with left globus pallidus interna deep brain stimulation (Gpi DBS). Case Report: A 24-year-old male underwent left Gpi DBS for medically refractory HT. LFPs demonstrated highest powers in the delta range in Gpi. At the 6-month follow-up, a 90% reduction in tremor was observed. Discussion: Pallidal DBS should be considered as an alternative target for management of refractory HT. LFP demonstrated neuronal activity associated with higher power in the delta region, similarly seen in patients with generalized dystonia

DBS-implanted Parkinson\u27s Disease Patients Show Better Olfaction Than Those Treated Medically

Dysosmia in PD (Parkinson’s Disease) may result from changes in the olfactory apparatus or in structures involved in olfactory perception. Previous work1,2 has suggested that deep brain stimulation (DBS) pa-tients have improved odor discrimination in stimulation-on/medication-off state in comparison to their own scores in a stimulation-off/medication-off state. What remains unclear is whether it is the ON state itself or an effect of stimulation that leads to improved olfaction. In this study we evaluate dysosmia in two PD cohorts in the ON state, those treated with medication alone and those treated with medication and DBS. A prospective study geared at improving predictive value of olfactory testing with a battery of psychological tests enrolled 45 PD patients and 44 controls. Of the PD patients, 9 had bilateral STN (subthalamic nucleus) DBS and 36 were medically treated. Subset analysis of PD patients with and without DBS placement revealed no difference in apathy or depression. DBS patients had better olfaction on UPSIT (Univ of Pennsylvania Smell Identification Test) (p This study provides further data that DBS patients have improved ol-faction. It also provides preliminary evidence that DBS with medica-tion improves dysosmia to a greater extent than medication alone. This may result from indirect stimulation of olfactory processing cen-ters or changes in olfactory circuitry metabolism

Assessment of Olfactory Processing in Parkinson’s Disease Patients

Background: Hyposmia is an early symptom of Parkinson’s Disease (PD) that often predates motor symptoms by years. Hyposmia has been shown to have a more consistent link to idiopathic PD than to other movement disorders. Olfaction has the potential to be used as a biomarker for PD, either through clinical evaluation or imaging. Objectives: This study uses functional magnetic resonance imaging (fMRI) to assess differences in olfaction pathways between anosmic early PD patients and age and gender-matched controls. Methods: 12 PD patients and 12 age- and gender-matched control subjects were recruited from the subject panel of a previous UMMS study on olfaction and PD. All PD patients were determined to be anosmic, and all controls were determined to have normal olfaction for their age and gender. All subjects underwent fMRI including periods with and without odorant exposure. Statistical analysis was performed using SPM8, using a general linear model to calculate BOLD signal changes for each scent relative to room air. A random effect model was used to infer general population effects. Results: Control subjects showed significant activation in the piriform cortex, anterior olfactory nucleus, insula, hippocampus and temporal lobe, all regions associated with olfactory processing. Relative to control subjects, PD patients showed no significant BOLD activation in the olfactory pathways of the brain. In response to a citrus scent, PD patients showed activation in the superior and middle frontal lobe, as well as the cingulate gyrus. In response to a cinnamon scent, PD patients showed significant activation in the precuneus and paracentral lobule as well as lower levels of activation in the frontal lobe. PD patients showed no significant areas of activation in response to a mint scent. Conclusion: Our results suggest that anosmic PD patients do not show activation of the olfactory pathways in the brain on exposure to these odorants. Taken together with previous studies, this suggests that BOLD activation in these regions of the brain can reflect clinical olfactory capability. In addition, PD patients show areas of increased activation, particularly in the frontal lobe. These distinct patterns of BOLD activation allow us to consider the feasibility of fMRI as a biomarker for diagnosis and evaluation of PD

Experience with a hybrid recruitment approach of patient-facing web portal screening and subsequent phone and medical record review for a neurosurgical intervention trial for chronic ischemic stroke disability (PISCES III)

Background: Recruitment of participants is the greatest risk to completion of most clinical trials, with 20–40% of trials failing to reach the targeted enrollment. This is particularly true of trials of central nervous system (CNS) therapies such as intervention for chronic stroke. The PISCES III trial was an invasive trial of stereotactically guided intracerebral injection of CTX0E03, a fetal derived neural stem cell line, in patients with chronic disability due to ischemic stroke. We report on the experience using a novel hybrid recruitment approach of a patient-facing portal to self-identify and perform an initial screen for general trial eligibility (tier 1), followed by phone screening and medical records review (tier 2) prior to a final in-person visit to confirm eligibility and consent. Methods: Two tiers of screening were established: an initial screen of general eligibility using a patient-facing web portal (tier 1), followed by a more detailed screen that included phone survey and medical record review (tier 2). If potential participants passed the tier 2 screen, they were referred directly to visit 1 at a study site, where final in-person screening and consent were performed. Rates of screening were tracked during the period of trial recruitment and sources of referrals were noted. Results: The approach to screening and recruitment resulted in 6125 tier 1 screens, leading to 1121 referrals to tier 2. The tier 2 screening resulted in 224 medical record requests and identification of 86 qualifying participants for referral to sites. The study attained a viable recruitment rate of 6 enrolled per month prior to being disrupted by COVID 19. Conclusions: A tiered approach to eligibility screening using a hybrid of web-based portals to self-identify and screen for general eligibility followed by a more detailed phone and medical record review allowed the study to use fewer sites and reduce cost. Despite the difficult and narrow population of patients suffering moderate chronic disability from stroke, this strategy produced a viable recruitment rate for this invasive study of intracranially injected neural stem cells

Methodological considerations in PISCES 3: a randomized, placebo-controlled study of intracerebral stem cells in subjects with disability following an ischemic stroke

Background and hypothesis: At present, there are no medical interventions proven to improve functional recovery in patients with subacute stroke. We hypothesize that the intraparenchymal administration of CTX0E03, a conditionally immortalized neural stem cell line, linked with a standardized rehabilitation therapy regimen for the upper limb, would improve functional outcomes in patients 6–12 months after an index ischemic stroke. Study design: PISCES III was designed as a multicenter prospective, sham-controlled, outcome-blinded randomized clinical trial. Eligibility required a qualifying ischemic stroke 6–12 months prior to surgical intervention. Patients must be between 35 and 75 years of age and have residual moderate or moderately severe disability (mRS 3 or 4), with the preservation of some residual upper limb movement. All patients received a standardized regimen of home physical therapy following the intervention. Study outcomes: The primary outcome measure is improvement in the modified Rankin Scale (mRS) of disability at 6 months post treatment. Secondary outcomes include assessment of activities of daily living (Barthel Index), functional mobility (Timed Up and Go; Fugl Meyer Assessment), neurological impairment (NIHSS), upper limb function (Chedoke Arm and Hand Inventory), as well as patient related quality of life and global rating scales. Discussion: PISCES III was designed as a randomized trial directly comparing the effects of intraparenchymal injection of a conditional stem cell line vs. sham procedure in patients with subacute stroke. This is one of the first studies of this type to include a standardized minimum rehabilitation protocol. As there are a limited number of studies evaluating invasive stem cell administration in the chronic setting of CNS injury, study design considerations are discussed

Holistic treatment response: an international expert panel definition and criteria for a new paradigm in the assessment of clinical outcomes of spinal cord stimulation

Background: Treatment response to spinal cord stimulation (SCS) is focused on the magnitude of effects on pain intensity. However, chronic pain is a multidimensional condition that may affect individuals in different ways and as such it seems reductionist to evaluate treatment response based solely on a unidimensional measure such as pain intensity. Aim: The aim of this article is to add to a framework started by IMMPACT for assessing the wider health impact of treatment with SCS for people with chronic pain, a ”holistic treatment response”. Discussion: Several aspects need consideration in the assessment of a holistic treatment response. SCS device data and how it relates to patient outcomes, is essential to improve the understanding of the different types of SCS, improve patient selection, long-term clinical outcomes, and reproducibility of findings. The outcomes to include in the evaluation of a holistic treatment response need to consider clinical relevance for patients and clinicians. Assessment of the holistic response combines two key concepts of patient assessment: (1) patients level of baseline (pre-treatment) unmet need across a range of health domains; (2) demonstration of patient-relevant improvements in these health domains with treatment. The minimal clinical important difference (MCID) is an established approach to reflect changes after a clinical intervention that are meaningful for the patient and can be used to identify treatment response to each individual domain. A holistic treatment response needs to account for MCIDs in all domains of importance for which the patient presents dysfunctional scores pre-treatment. The number of domains included in a holistic treatment response may vary and should be considered on an individual basis. Physiologic confirmation of therapy delivery and utilisation should be included as part of the evaluation of a holistic treatment response and is essential to advance the field of SCS and increase transparency and reproducibility of the findings

The Impact of Multidisciplinary Conferences on Healthcare Utilization in Chronic Pain Patients.

Approximately 100 million adults in the United States have chronic pain, though only a subset utilizes the vast majority of healthcare resources. Multidisciplinary care has been shown to improve outcomes in a variety of clinical conditions. There is concern that multidisciplinary care of chronic pain patients may overwhelm existing resources and increase healthcare utilization due to the volume of patients and the complexity of care. We report our findings on the use of multidisciplinary conferences (MDC) to facilitate care for the most complex patients seen at our tertiary center. Thirty-two of nearly 2,000 patients seen per year were discussed at the MDC, making up the top 2% of complex patients in our practice. We evaluated patients\u27 numeric rating score (NRS) of pain, medication use, hospitalizations, emergency department visits, and visits to pain specialists prior to their enrollment in MDC and 1 year later. Matched samples were compared using Wilcoxon\u27s signed rank test. Patients\u27 NRS scores significantly decreased from 7.64 to 5.54 after inclusion in MDC

Pediatric cranioplasty: lessons from a 1940s neurosurgical procedure

No clear consensus exists regarding the best material and technique for use in pediatric cranioplasty. The immature bone in pediatric patients poses several challenges, such as rapid growth, skull growth restriction, plate migration, and tissue erosion. We present a pediatric cranioplasty from the 1940s, and examine the characteristics of the plating and anchoring used. The patient suffered a skull fracture after falling from a swing in 1946 at age six, requiring cranioplasty. Sixty-seven years later, she noted drainage from the old incision site, requiring reoperation. During surgery, the skull appeared normally shaped, and the area under the plate exhibited complete bone growth. The plate was noted to have several innovative design features that contributed to this outcome, notably that the plate and its anchors were “semi-rigid”; the hardware was softer than surrounding bone and easily pliable, deforming to accommodate skull growth and prevent restriction. The structure of the plate was also such that it allowed growth of underlying bone tissue to close the defect. This case contains unique features that can foster discussion regarding plate design and surgical technique that might avoid traditional complications