Publications by authors named "Shawn Adams"

31 Publications

Patterns and Impact of Electronic Health Records-Defined Depression Phenotypes in Spine Surgery.

Neurosurgery 2021 Apr 16. Epub 2021 Apr 16.

Pacific Northwest University of Health Sciences, Yakima, Washington, USA.

Background: Preoperative depression is a risk factor for poor outcomes after spine surgery.

Objective: To understand effects of depression on spine surgery outcomes and healthcare resource utilization.

Methods: Using IBM's MarketScan Database, we identified 52 480 patients who underwent spinal fusion. Retained patients were classified into 6 depression phenotype groups based on International Classification of Disease, 9th/10th Revision (ICD-9/10) codes and use/nonuse of antidepressant medications: major depressive disorder (MDD), other depression (OthDep), antidepressants for other psychiatric condition (PsychRx), antidepressants for physical (nonpsychiatric) condition (NoPsychRx), psychiatric condition only (PsychOnly), and no depression (NoDep). We analyzed baseline demographics, comorbidities, healthcare utilization/payments, and chronic opioid use.

Results: Breakdown of groups in our cohort: MDD (15%), OthDep (12%), PsychRx (13%), NonPsychRx (15%), PsychOnly (12%), and NoDep (33%). Postsurgery: increased outpatient resource utilization, admissions, and medication refills at 1, 2, and 5 yr in the NoDep, PsychOnly, NonPsychRx, PsychRx, and OthDep groups, and highest in MDD. Postoperative opioid usage rates remained unchanged in MDD (44%) and OthDep (36%), and reduced in PsychRx (40%), NonPsychRx (31%), and PsychOnly (20%), with greatest reduction in NoDep (13%). Reoperation rates: 1 yr after index procedure, MDD, OthDep, PsychRx, NonPsychRx, and PsychOnly had more reoperations compared to NoDep, and same at 2 and 5 yr. In NoDep patients, 45% developed new depressive phenotype postsurgery.

Conclusion: EHR-defined classification allowed us to study in depth the effects of depression in spine surgery. This increased understanding of the interplay of mental health will help providers identify cohorts at risk for high complication rates, and health care utilization.
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http://dx.doi.org/10.1093/neuros/nyab096DOI Listing
April 2021

Health Care Utilization and Associated Economic Burden of Postoperative Surgical Site Infection after Spinal Surgery with Follow-Up of 24 Months.

J Neurol Surg A Cent Eur Neurosurg 2021 Apr 12. Epub 2021 Apr 12.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States.

Background:  Surgical site infection (SSI) may lead to vertebral osteomyelitis, diskitis, paraspinal musculoskeletal infection, and abscess, and remains a significant concern in postoperative management of spinal surgery. SSI is associated with greater postoperative morbidity and increased health care payments.

Methods:  We conducted a retrospective analysis using MarketScan to identify health care utilization payments and risk factors associated with SSI that occurs postoperatively. Known patient- or procedure-related risk factors were searched across those receiving spine surgery who developed postoperative infection.

Results:  A total of 33,061 patients who developed infection after spinal surgery were identified in Marketscan. Overall payments at 6 months, including index hospitalization for those with infection, were $53,573 and $46,985 for the cohort with no infection. At 24 months, the infection group had overall payments of $83,280 and $66,221 for no infection. Risk factors with largest effect size most likely to contribute to infection versus no infection were depression (4.6%), diabetes (3.7), anemia (3.3%), two or more levels (2.8%), tobacco use (2.2%), trauma (2.1%), neoplasm (1.8%), congestive heart failure (1.3%), instrumentation (1.1%), renal failure (0.9%), intravenous drug use (0.8%), and malnutrition (0.5%).

Conclusions:  SSIs were associated with significant health care utilization payments at 24 months of follow-up. The following clinical and procedural risk factors appear to be predictive of postoperative SSI: depression, diabetes, anemia, two or more levels, tobacco use, trauma, neoplasm, congestive heart failure, instrumentation, renal failure, intravenous drug use, and malnutrition. Interpretation of modifiable and nonmodifiable risk factors for infection informs surgeons of expected postoperative course and preoperative risk for this most common and deleterious postoperative complication to spinal surgery.
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http://dx.doi.org/10.1055/s-0040-1720984DOI Listing
April 2021

Minimally Invasive Endoscopy for Acute Subdural Hematomas: A Report of 3 Cases.

Oper Neurosurg (Hagerstown) 2021 Feb;20(3):310-316

Department of Neurological Surgery, Indiana University School of Medicine, IU Health Physicians Neurosurgery, Indianapolis, Indiana.

Background: Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time.

Objective: To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study.

Methods: We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018.

Results: The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3).

Conclusion: Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.
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http://dx.doi.org/10.1093/ons/opaa390DOI Listing
February 2021

Combining Hypothermia and Oleuropein Subacutely Protects Subcortical White Matter in a Swine Model of Neonatal Hypoxic-Ischemic Encephalopathy.

J Neuropathol Exp Neurol 2021 Jan;80(2):182-198

Department of Pathology, Johns Hopkins University, Baltimore, Maryland.

Neonatal hypoxia-ischemia (HI) causes white matter injury that is not fully prevented by therapeutic hypothermia. Adjuvant treatments are needed. We compared myelination in different piglet white matter regions. We then tested whether oleuropein (OLE) improves neuroprotection in 2- to 4-day-old piglets randomized to undergo HI or sham procedure and OLE or vehicle administration beginning at 15 minutes. All groups received overnight hypothermia and rewarming. Injury in the subcortical white matter, corpus callosum, internal capsule, putamen, and motor cortex gray matter was assessed 1 day later. At baseline, piglets had greater subcortical myelination than in corpus callosum. Hypothermic HI piglets had scant injury in putamen and cerebral cortex. However, hypothermia alone did not prevent the loss of subcortical myelinating oligodendrocytes or the reduction in subcortical myelin density after HI. Combining OLE with hypothermia improved post-HI subcortical white matter protection by preserving myelinating oligodendrocytes, myelin density, and oligodendrocyte markers. Corpus callosum and internal capsule showed little HI injury after hypothermia, and OLE accordingly had minimal effect. OLE did not affect putamen or motor cortex neuron counts. Thus, OLE combined with hypothermia protected subcortical white matter after HI. As an adjuvant to hypothermia, OLE may subacutely improve regional white matter protection after HI.
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http://dx.doi.org/10.1093/jnen/nlaa132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819717PMC
January 2021

Woven Endobridge device for treatment of dissection-related PICA aneurysm.

Interv Neuroradiol 2020 Oct 18:1591019920968349. Epub 2020 Oct 18.

Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, USA.

Ruptured vertebrobasilar dissecting aneurysms require urgent, often challenging treatment as they have with a high re-hemorrhage rate within the first 24 hours. The patient is a 57-year-old woman who presented with severe-sudden onset headache. Further work up showed a ruptured dissecting aneurysm of the caudal loop of the posterior inferior cerebellar artery (PICA) with associated narrowing distally, in the ascending limb. The aneurysm was immediately occluded with a Woven Endobridge (WEB) device (MicroVention, Tustin, CA, USA) while flow diversion treatment of the diseased ascending limb was postponed. Follow-up angiography three months later showed complete occlusion of the aneurysm, as well as healing of the diseased distal vessel, obviating the need for further intervention. WEB embolization of a ruptured dissecting posterior circulation aneurysm provided an excellent outcome for this patient.
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http://dx.doi.org/10.1177/1591019920968349DOI Listing
October 2020

Factors Impacting Outcomes and Health Care Utilization in Osteoporotic Patients Undergoing Lumbar Spine Fusions: A MarketScan Database Analysis.

World Neurosurg 2020 09 22;141:e976-e988. Epub 2020 Jun 22.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Objective: To identify factors impacting long-term complications, reoperations, readmission rates, and health care utilization in patients with osteoporosis (OP) following lumbar fusions.

Methods: We used International Classification of Disease, Ninth Revision, International Classification of Disease, Tenth Revision , and Current Procedural Terminology codes to extract data from MarketScan (2000-2016). Patients undergoing lumbar spine fusion were divided into 2 groups based on preoperative diagnosis: OP or non-OP. We used multivariable generalized linear regression models to analyze outcomes of interest (reoperation rates, readmissions, complications, health care utilization) at 1, 6, 12, and 24 months after discharge.

Results: MarketScan identified 116,749 patients who underwent lumbar fusion with ≥24 months of follow-up; 6% had OP. OP patients had a higher incidence of complications (14% vs. 9%); were less likely to be discharged home (77% vs. 86%, P < 0.05); had more new fusions or refusions at 6 months (2.9% vs. 2.1%), 12 months (5% vs. 3.8%), and 24 months (8.5% vs. 7.4%); incurred more outpatient services at 12 months (80 vs. 61) and 24 months (148 vs. 115); and incurred higher overall costs at 12 months ($22,932 vs. $17,017) and 24 months ($48,379 vs. $35,888). Elderly OP patients (>65 years old) who underwent multilevel lumbar fusions had longer hospitalization, had higher complication rates, and incurred lower costs at 6, 12, and 24 months compared with young non-OP patients who underwent single-level lumbar fusion.

Conclusions: Patients of all ages with OP had higher complication rates and required revision surgeries at 6, 12, and 24 months compared with non-OP patients. Elderly OP patients having multilevel lumbar fusions were twice as likely to have complications and lower health care utilization compared with younger non-OP patients who underwent single-level fusion.
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http://dx.doi.org/10.1016/j.wneu.2020.06.107DOI Listing
September 2020

Mean Diffusivity in Striatum Correlates With Acute Neuronal Death but Not Lesser Neuronal Injury in a Pilot Study of Neonatal Piglets With Encephalopathy.

J Magn Reson Imaging 2020 10 12;52(4):1216-1226. Epub 2020 May 12.

Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA.

Background: Diffusion MRI is routinely used to evaluate brain injury in neonatal encephalopathy. Although abnormal mean diffusivity (MD) is often attributed to cytotoxic edema, the specific contribution from neuronal pathology is unclear.

Purpose: To determine whether MD from high-resolution diffusion tensor imaging (DTI) can detect variable degrees of neuronal degeneration and pathology in piglets with brain injury induced by excitotoxicity or global hypoxia-ischemia (HI) with or without overt infarction.

Study Type: Prospective.

Animal Model: Excitotoxic brain injury was induced in six neonatal piglets by intrastriatal stereotaxic injection of the glutamate receptor agonist quinolinic acid (QA). Three piglets underwent global HI or a sham procedure. Piglets recovered for 20-96 hours before undergoing MRI (n = 9).

Field Strength/sequence: 3.0T MRI with DTI, T - and T -weighted imaging.

Assessment: MD, fractional anisotropy (FA), and qualitative T injury were assessed in the putamen and caudate. The cell bodies of normal neurons, degenerating neurons (excitotoxic necrosis, ischemic necrosis, or necrosis-apoptosis cell death continuum), and injured neurons with equivocal degeneration were counted by histopathology.

Statistical Tests: Spearman correlations were used to compare MD and FA to normal, degenerating, and injured neurons. T injury and neuron counts were evaluated by descriptive analysis.

Results: The QA insult generated titratable levels of neuronal pathology. In QA, HI, and sham piglets, lower MD correlated with higher ratios of degenerating-to-total neurons (P < 0.05), lower ratios of normal-to-total neurons (P < 0.05), and greater numbers of degenerating neurons (P < 0.05). MD did not correlate with abnormal neurons exhibiting nascent injury (P > 0.99). Neuron counts were not related to FA (P > 0.30) or to qualitative injury from T -weighted MRI.

Data Conclusion: MD is more accurate than FA for detecting neuronal degeneration and loss during acute recovery from neonatal excitotoxic and HI brain injury. MD does not reliably detect nonfulminant, nascent, and potentially reversible neuronal injury.

Evidence Level: 1 TECHNICAL EFFICACY: Stage 2 J. Magn. Reson. Imaging 2020;52:1216-1226.
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http://dx.doi.org/10.1002/jmri.27181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492395PMC
October 2020

Inverse National Trends in Decompressive Craniectomy versus Endovascular Thrombectomy for Stroke.

World Neurosurg 2020 06 13;138:e642-e651. Epub 2020 Mar 13.

Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA. Electronic address:

Objective: Endovascular thrombectomy (ET) for acute large vessel occlusion reduces infarct size, and it should hypothetically decrease the incidence of major ischemic strokes requiring decompressive craniectomy (DC). The aim of this retrospective cohort study is to determine trends in the utilization of ET versus DC for stroke in the United States over a 10-year span.

Methods: We extracted data from the Nationwide Inpatient Sample using International Classification of Diseases-9/10 codes from 2006-2016. Patients with a primary diagnosis of stroke were included. Baseline demographics, outcomes, and hospital charges were analyzed.

Results: The study cohort comprised 14,578,654 patients diagnosed with stroke. During the study period, DC and ET were performed in 124,718 and 62,637 patients, respectively. The number of stroke patients who underwent either ET or DC increased by 266% from 2006 to 2016. During that time period, the ET utilization rate increased (0.19% in 2006 to 14.07% in 2016, P < 0.0004), whereas the DC utilization rate decreased (7.07% in 2006 to 6.43% in 2016, P < 0.0001). In 2015, the utilization rate of ET (9.73%) exceeded that of DC (9.67%). ET-treated patients had shorter hospitalization durations (mean 8.8 vs. 16.8 days, P < 0.0001), lower mortality (16.2% vs. 19.3%), higher likelihood of discharge home (27.1% vs. 24.1%, P < 0.0001), and reduced hospital charges (mean $189,724 vs. $261,314, P < 0.0001).

Conclusions: We identified an inverse relationship between national trends in rising ET and diminishing DC utilization for stroke treatment over a recent decade. Although direct causation cannot be inferred, our findings suggest that ET curtails the necessity for DC.
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http://dx.doi.org/10.1016/j.wneu.2020.03.022DOI Listing
June 2020

Impact of Surgical Timing and Approaches to Health Care Utilization in Patients Undergoing Surgery for Acute Traumatic Cervical Spinal Cord Injury.

Cureus 2019 Nov 15;11(11):e6166. Epub 2019 Nov 15.

Neurosurgery, University of Louisville School of Medicine, Louisville, USA.

Objective Acute traumatic cervical spinal cord injury (AcSCI) causes significant morbidity and has an impact on health care utilization. The aim of our study was to analyze health care utilization in patients undergoing surgical decompression and fusion for AcSCI based on timing and type of surgical approaches.  Patient and methods Data were extracted using ICD9/10 and CPT codes from MarketScan (IBM Corp. Armonk, New York [v. 2000-2015]). We defined the comparative groups based on the timing of surgery (early <24 hours and late >24 hours) and surgical approaches: anterior, posterior and circumferential. Outcomes of interest were: length of hospital stay, discharge disposition and health care utilization in the index hospitalization, within 30 days after discharge and 12 months following injury. Results Of 1604 patients, 80.9% had early procedures and 55.7% of these had anterior-only procedures. Overall, the median age was 46 years in the early surgery group and 47 years in the late surgery group. Patients in the early surgical group incurred higher outpatient services and there was no difference in cumulative median payments (index + 12 months) across the cohorts (early: $127,379, late: $121,049). The incidence of repeat surgery at the index level did not differ based on the timing of surgery (early 5% vs. late 7%). Complications were higher in the circumferential surgery cohort irrespective of the timing of surgery. Overall, combined median payment (index hospitalization + 12 months) was significantly higher for early circumferential cohorts compared to the anterior or posterior-only cohort ($195,990 and $109,977 vs. $121,236 respectively). Conclusion Late (>24 hours) surgeries were associated with a higher likelihood to be discharged home, lower utilization of outpatient services, higher hospital readmissions and no differences in payments (index and cumulative) compared to early surgeries. Circumferential approaches were associated with higher complication rates, lesser likelihood to be discharged home, higher utilization of outpatient services compared to anterior-only approaches.
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http://dx.doi.org/10.7759/cureus.6166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913951PMC
November 2019

Posterior reversible encephalopathy syndrome with lumbar drainage and surgery: coincidence or correlation? A case report.

BMC Neurol 2019 Aug 30;19(1):214. Epub 2019 Aug 30.

Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA.

Background: Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder usually associated with specific medical conditions that cause a disturbance of the CNS homeostasis. It has seldom been reported to be a consequence of an iatrogenic intervention causing intracranial hypotension.

Case Presentation: We report the case of an individual 69-year-old male presenting with headache and blurred vision following cerebrospinal fluid (CSF) leak from resection of a sellar mass. The patient developed the condition following removal of the lumbar drain post-operatively. Magnetic Resonance Imaging showed bilateral occipital, parieto-occipital, and cerebellar T2 FLAIR hyper-intensities, suggesting a radiological diagnosis of posterior reversible encephalopathy syndrome (PRES). The patient's symptoms started to improve shortly afterwards and had completely resolved at 3 months follow-up.

Conclusions: The absence of severe hypertension and presence of an intraoperative CSF leak requiring placement of the lumbar drain suggests that decreased CSF volume and associated reactive hyperemia could have a role in the pathophysiology of the disease.
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http://dx.doi.org/10.1186/s12883-019-1438-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716908PMC
August 2019

Association of diastolic blood pressure with survival during paediatric cardiopulmonary resuscitation.

Resuscitation 2019 10 4;143:50-56. Epub 2019 Aug 4.

Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center Suite 6302, Baltimore, MD 21287 United States. Electronic address:

Aim: To examine the relationship between survival and diastolic blood pressure (DBP) throughout resuscitation from paediatric asphyxial cardiac arrest.

Methods: Retrospective, secondary analysis of 200 swine resuscitations. Swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS, respectively). DBP was recorded every 30 s. Survival was defined as 20-min sustained return of spontaneous circulation (ROSC).

Results: During BLS, DBP peaked between 1-3 min and was greater in survivors (20.0 [11.3, 33.3] mmHg) than in non-survivors (5.0 [1.0, 10.0] mmHg; p < 0.001). After this transient increase, the DBP in survivors progressively decreased but remained greater than that of non-survivors after 10 min of resuscitation (9.0 [6.0, 13.8] versus 3.0 [1.0, 6.8] mmHg; p < 0.001). During ALS, the magnitude of DBP change after the first adrenaline (epinephrine) administration was greater in survivors (22.0 [16.5, 36.5] mmHg) than in non-survivors (6.0 [2.0, 11.0] mmHg; p < 0.001). Survival rate was greater when DBP improved by ≥26 mmHg after the first dose of adrenaline (20/21; 95%) than when DBP improved by ≤10 mmHg (1/99; 1%). The magnitude of DBP change after the first adrenaline administration correlated with the timetoROSC (r = -0.54; p < 0.001).

Conclusions: Survival after asphyxial cardiac arrest is associated with a higher DBP throughout resuscitation, but the difference between survivors and non-survivors was reduced after prolonged BLS. During ALS, response to adrenaline administration correlates with survival and time to ROSC. If confirmed clinically, these findings may be useful for titrating adrenaline during resuscitation and prognosticating likelihood of ROSC. Institutional Protocol Numbers: SW14M223 and SW17M101.
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http://dx.doi.org/10.1016/j.resuscitation.2019.07.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6769417PMC
October 2019

Enhanced Recovery After Surgery (ERAS) for Spine Surgery: A Systematic Review.

World Neurosurg 2019 Oct 2;130:415-426. Epub 2019 Jul 2.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Background: Enhanced recovery after surgery (ERAS) represents an evidence-based multidisciplinary approach to perioperative management after major surgery that decreases complications and readmissions and improves functional recovery. Spine surgery is a traditionally invasive intervention with an extended recovery phase and may benefit from ERAS protocol integration.

Methods: We analyzed the use of ERAS in spine surgery by completing a search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PICOS (Participants, Intervention, Comparison, Outcomes, Study Design) model through PubMed and Ovid databases to identify studies that fit our search criteria. We assess the outcomes and ERAS elements selected across protocols as well as the study design and internal validation methods.

Results: A total of 19 studies met the inclusion criteria and were used in our analysis. Patient populations differed significantly across all 4 studies. Reduction in length of stay was reported in 7 studies using the ERAS protocol. Comparative studies between ERAS and non-ERAS show improved pain scores and reduced opioid consumption postoperatively, but no differences in complications or readmissions between groups. Complication rates under ERAS protocols ranged from 2.0% to 31.7%. Significant pain reduction in visual analog scale scores was observed with 3 ERAS protocols. Direct, indirect, and total cost decreases were also observed with implementation of ERAS protocols.

Conclusions: A limited cohort of studies with significant variability in patient population and ERAS protocol implementation have evaluated the integration of ERAS within spine surgery. ERAS in spine surgery may provide reductions in complications, readmissions, length of stay, and opioid use, in combination with improvements in patient-reported outcomes and functional recovery.
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http://dx.doi.org/10.1016/j.wneu.2019.06.181DOI Listing
October 2019

Minimally Invasive Surgery for Spontaneous Cerebellar Hemorrhage: A Multicenter Study.

World Neurosurg 2019 Sep 28;129:e35-e39. Epub 2019 Apr 28.

Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA. Electronic address:

Background: Spontaneous intracranial hemorrhage (ICH) of the cerebellum can be life threatening because of mass effect on the brainstem and fourth ventricle. Suboccipital craniectomy is currently the treatment of choice for cerebellar ICH evacuation. Minimally invasive surgery (MIS) is currently being investigated for the treatment of supratentorial ICH. However, its utility for cerebellar ICH is unknown. The aim of this multicenter, retrospective cohort study is to evaluate the outcomes of MIS for cerebellar ICH.

Methods: We retrospectively reviewed the records of all patients with cerebellar ICH who underwent MIS using either the Apollo or Artemis Neuro Evacuation Device (Penumbra Inc., Alameda, California, USA) at 3 institutions from May 2015 to July 2018. Data from each contributing center were deidentified and pooled for analysis.

Results: The study cohort comprised 6 patients with a median age of 62.5 years. The median pre- and postoperative Glasgow Coma Scale scores were 10.5 and 15, respectively. The median degree of hematoma evacuation was 97.5% (range, 79%-100%). There were no procedural complications, but 1 patient required subsequent craniectomy (retreatment rate 17%). The median discharge modified Rankin scale score was 4, including 3 patients who improved to functional independence at follow-up durations of 3 months. Two patients died from medical complications (mortality rate 33%).

Conclusions: MIS could represent a reasonable alternative to conventional surgery for the treatment of appropriately selected patients with cerebellar ICH. However, further studies are needed to clarify the perioperative and long-term risk to benefit profiles of this technique.
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http://dx.doi.org/10.1016/j.wneu.2019.04.164DOI Listing
September 2019

Traumatic Ventral Cervical Spinal Cord Herniation: A Case Report.

Cureus 2019 Feb 13;11(2):e4070. Epub 2019 Feb 13.

Neurological Surgery, University of Louisville School of Medicine, Louisville, USA.

Spinal cord herniation (SCH) is an uncommon traumatic event that should be considered in patients with vertebral fractures who develop an unusual constellation of autonomic and motor deficits. Herein, we describe a case of rapidly deteriorating neurological function following cervical spine fracture including sequelae such as bilateral lower-extremity weakness, loss of upper extremity motor function, and priapism. Decompression of the spinal cord allowed for the identification of the unusual herniation of the spinal cord and prevention of any further worsening of the neurological injury. Hyperflexion of the cervical spine upon traumatic impact provided the impetus for vertebral retropulsion and subsequent incarceration of the spinal cord. This phenomenon should be considered in the setting of acute traumatic injury to the cervical spinal cord. Surgical intervention is likely to allow the preservation of the remaining neurological function.
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http://dx.doi.org/10.7759/cureus.4070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464141PMC
February 2019

Endoscopic Endonasal Surgery for the Resection of a Cavernous Hemangioma with a Sellar Extension.

Cureus 2018 Nov 30;10(11):e3663. Epub 2018 Nov 30.

Neurological Surgery, University of Louisville School of Medicine, Louisville, USA.

Cavernous hemangiomas with an intrasellar extension are very rare, generally benign lesions that manifest by the compression of nearby structures. The presenting symptoms usually range from visual disturbances to an endocrine imbalance. Occasional extension into the cavernous sinus has been reported, which can cause cranial nerve compression. We present the case of a 69-year-old man presenting with facial pain and decreased libido. On investigation, a lesion was identified and the parasellar region was homogeneously hyper-intense on gadolinium-enhanced magnetic resonance imaging (MRI). Endoscopic endonasal surgery remains one of the favored approaches for the resection of sellar lesions. Such pathology needs to remain on the neurosurgeon's differential diagnosis, making an intraoperative frozen section of these lesions a useful tool in the surgeon's armamentarium, to guide further surgical resection.
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http://dx.doi.org/10.7759/cureus.3663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6355302PMC
November 2018

Republished: MRI SPACE sequence confirmation of occluded MCA M2 dissection stump masquerading as a ruptured MCA aneurysm.

J Neurointerv Surg 2019 Nov 24;11(11):e10. Epub 2019 Jan 24.

Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA.

Intracranial vascular pathologies often have overlapping clinical presentations. Dissected vessel occlusions and bifurcation aneurysms can appear similar on pretherapeutic imaging. The medical management of these two entities is drastically different. The patient is a 51-year-old man who presented with severe, sudden-onset headache. Initial presentation was consistent with a ruptured middle cerebral artery (MCA) aneurysm and surgical clipping was recommended. However, further review of radiographic findings could not definitively differentiate an aneurysmal origin of the symptoms as opposed to intracranial dissection followed by occlusion of the M2 branch of the MCA. MRI sampling perfection with application optimised contrasts using different flip angle evolution (SPACE) was performed and showed thin flow signalling distal to the dissected vessel stump confirming the diagnosis. Accurate diagnosis is a crucial step in directing treatment for intracranial vascular lesions. MRI SPACE is a simple tool in the diagnostic armamentarium to adequately direct treatment and avoid the potential for unnecessary interventions.
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http://dx.doi.org/10.1136/neurintsurg-2018-013996.repDOI Listing
November 2019

Proteasome Biology Is Compromised in White Matter After Asphyxic Cardiac Arrest in Neonatal Piglets.

J Am Heart Assoc 2018 10;7(20):e009415

1 Department of Anesthesiology and Critical Care Medicine Johns Hopkins University Baltimore MD.

Background Neurological deficits in hypoxic-ischemic encephalopathy, even with therapeutic hypothermia, are partially attributed to white matter injury. We theorized that proteasome insufficiency contributes to white matter injury. Methods and Results Neonatal piglets received hypoxia-ischemia ( HI ) or sham procedure with normothermia, hypothermia, or hypothermia+rewarming. Some received a proteasome activator drug (oleuropein) or white matter-targeted, virus-mediated proteasome knockdown. We measured myelin oligodendrocyte glycoprotein, proteasome subunit 20S (P20S), proteasome activity, and carbonylated and ubiquitinated protein levels in white matter and cerebral cortex. HI reduced myelin oligodendrocyte glycoprotein levels regardless of temperature, and myelin oligodendrocyte glycoprotein loss was associated with increased ubiquitinated and carbonylated protein levels. Ubiquitinated and carbonyl-damaged proteins increased in white matter 29 hours after HI during hypothermia to exceed levels at 6 to 20 hours. In cortex, ubiquitinated proteins decreased. Ubiquitinated and carbonylated protein accumulation coincided with lower P20S levels in white matter; P20S levels also decreased in cerebral cortex. However, proteasome activity in white matter lagged behind that in cortex 29 hours after HI during hypothermia. Systemic oleuropein enhanced white matter P20S and protected the myelin, whereas proteasome knockdown exacerbated myelin oligodendrocyte glycoprotein loss and ubiquitinated protein accumulation after HI . At the cellular level, temperature and HI interactively affected macroglial P20S enrichment in subcortical white matter. Rewarming alone increased macroglial P20S immunoreactivity, but this increase was blocked by HI . Conclusions Oxidized and ubiquitinated proteins accumulate with HI -induced white matter injury. Proteasome insufficiency may drive this injury. Hypothermia did not prevent myelin damage, protect the proteasome, or preserve oxidized and ubiquitinated protein clearance after HI .
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http://dx.doi.org/10.1161/JAHA.118.009415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6474957PMC
October 2018

MRI SPACE sequence confirmation of occluded MCA M2 dissection stump masquerading as a ruptured MCA aneurysm.

BMJ Case Rep 2018 Sep 18;2018. Epub 2018 Sep 18.

Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA.

Intracranial vascular pathologies often have overlapping clinical presentations. Dissected vessel occlusions and bifurcation aneurysms can appear similar on pretherapeutic imaging. The medical management of these two entities is drastically different. The patient is a 51-year-old man who presented with severe, sudden-onset headache. Initial presentation was consistent with a ruptured middle cerebral artery (MCA) aneurysm and surgical clipping was recommended. However, further review of radiographic findings could not definitively differentiate an aneurysmal origin of the symptoms as opposed to intracranial dissection followed by occlusion of the M2 branch of the MCA. MRI sampling perfection with application optimised contrasts using different flip angle evolution (SPACE) was performed and showed thin flow signalling distal to the dissected vessel stump confirming the diagnosis. Accurate diagnosis is a crucial step in directing treatment for intracranial vascular lesions. MRI SPACE is a simple tool in the diagnostic armamentarium to adequately direct treatment and avoid the potential for unnecessary interventions.
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http://dx.doi.org/10.1136/bcr-2018-013996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150126PMC
September 2018

Validation of noninvasive photoacoustic measurements of sagittal sinus oxyhemoglobin saturation in hypoxic neonatal piglets.

J Appl Physiol (1985) 2018 10 21;125(4):983-989. Epub 2018 Jun 21.

Division of Maternal-Fetal Medicine, Department of Gynecology-Obstetrics, Johns Hopkins University School of Medicine , Baltimore, Maryland.

We hypothesize that noninvasive photoacoustic imaging can accurately measure cerebral venous oxyhemoglobin saturation (So) in a neonatal model of hypoxia-ischemia. In neonatal piglets, which have a skull thickness comparable to that of human neonates, we compared the photoacoustic measurement of sagittal sinus So against that measured directly by blood sampling over a wide range of conditions. Systemic hypoxia was produced by decreasing inspired oxygen stepwise (i.e., 100, 21, 19, 17, 15, 14, 13, 12, 11, and 10%) with and without unilateral or bilateral ligation of the common carotid arteries to enhance hypoxia-ischemia. Transcranial photoacoustic sensing enabled us to detect changes in sagittal sinus O saturation throughout the tested range of 5-80% without physiologically relevant bias. Despite lower cortical perfusion and higher oxygen extraction in groups with carotid occlusion at equivalent inspired oxygen, photoacoustic measurements successfully provided a robust linear correlation that approached the line of identity with direct blood sample measurements. Receiver-operating characteristic analysis for discriminating So <30% showed an area under the curve of 0.84 for the pooled group data, and 0.87, 0.91, and 0.92 for hypoxia alone, hypoxia plus unilateral occlusion, and hypoxia plus bilateral occlusion subgroups, respectively. The detection precision in this critical range was confirmed with sensitivity (87.0%), specificity (86.5%), accuracy (86.8%), positive predictive value (90.5%), and negative predictive value (81.8%) in the combined dataset. These results validate the capability of photoacoustic sensing technology to accurately monitor sagittal sinus So noninvasively over a wide range and support its use for early detection of neonatal hypoxia-ischemia. NEW & NOTEWORTHY We present data to validate the noninvasive photoacoustic measurement of sagittal sinus oxyhemoglobin saturation. In particular, this paper demonstrates the robustness of this methodology during a wide range of hemodynamic and physiological changes induced by the stepwise decrease of fractional inspired oxygen to produce hypoxia and by unilateral and bilateral ligation of the common carotid arteries preceding hypoxia to produce hypoxia-ischemia. This technique may be useful for diagnosing risk of neonatal hypoxic-ischemic encephalopathy.
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http://dx.doi.org/10.1152/japplphysiol.00184.2018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6335091PMC
October 2018

Novel Treatments in Neuroprotection for Aneurysmal Subarachnoid Hemorrhage.

Curr Treat Options Neurol 2016 Aug;18(8):38

Departments of Neurosurgery, Physiology and Pathology, University of Maryland School of Medicine, Baltimore, MD, USA.

Opinion Statement: New neuroprotective treatments aimed at preventing or minimizing "delayed brain injury" are attractive areas of investigation and hold the potential to have substantial beneficial effects on aneurysmal subarachnoid hemorrhage (aSAH) survivors. The underlying mechanisms for this "delayed brain injury" are multi-factorial and not fully understood. The most ideal treatment strategies would have the potential for a pleotropic effect positively modulating multiple implicated pathophysiological mechanisms at once. My personal management (RFJ) of patients with aneurysmal subarachnoid hemorrhage closely follows those treatment recommendations contained in modern published guidelines. However, over the last 5 years, I have also utilized a novel treatment strategy, originally developed at the University of Maryland, which consists of a 14-day continuous low-dose intravenous heparin infusion (LDIVH) beginning 12 h after securing the ruptured aneurysm. In addition to its well-known anti-coagulant properties, unfractionated heparin has potent anti-inflammatory effects and through multiple mechanisms may favorably modulate the neurotoxic and neuroinflammatory processes prominent in aneurysmal subarachnoid hemorrhage. In my personal series of patients treated with LDIVH, I have found significant preservation of neurocognitive function as measured by the Montreal Cognitive Assessment (MoCA) compared to a control cohort of my patients treated without LDIVH (RFJ unpublished data presented at the 2015 AHA/ASA International Stroke Conference symposium on neuroinflammation in aSAH and in abstract format at the 2015 AANS/CNS Joint Cerebrovascular Section Annual Meeting). It is important for academic physicians involved in the management of these complex patients to continue to explore new treatment options that may be protective against the potentially devastating "delayed brain injury" following cerebral aneurysm rupture. Several of the treatment options included in this review show promise and could be carefully adopted as the level of evidence for each improves. Other proposed neuroprotective treatments like statins and magnesium sulfate were previously thought to be very promising and to varying degrees were adopted at numerous institutions based on somewhat limited human evidence. Recent clinical trials and meta-analysis have shown no benefit for these treatments, and I currently no longer utilize either treatment as prophylaxis in my practice.
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http://dx.doi.org/10.1007/s11940-016-0421-6DOI Listing
August 2016

From the front line to the bottom line: building revenue integrity.

Healthc Financ Manage 2015 Jul;69(7):34-7

To improve trends in accounts receivable and a hospital's bottom line without fear of penalty or repayment, organizations should expand the definition of the revenue cycle team by: Engaging front-line clinical and business personnel. Training personnel to understand the roles they play in revenue integrity. Creating scorecards with measurable goals to promote accountability. Monitoring the outcomes and defining real-time, actionable responses to negative variances.
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July 2015

Primary care provider perceptions and use of a novel medication reconciliation technology.

Inform Prim Care 2011 ;19(2):105-18

Portland Informatics Center and Hospital and Specialty Medicine Division, Portland Oregon Veterans Affairs Medical Center, Portland, OR 97239, USA.

Background: Although medication reconciliation (MR) can reduce medication discrepancies, it is challenging to operationalise. Consequently, we developed a health information technology (HIT) to collect a patient medication history and make it available to the primary care (PC) provider. We deployed a self-service kiosk in a PC clinic that permits patients to indicate a medication adherence history. Patient responses are immediately viewable in the legacy electronic health record. This paper describes a survey developed to assess PC provider perceptions of our HIT and HIT implementation effectiveness.

Methods: We developed and administered a survey to all PC providers to assess technology implementation effectiveness. The survey included scales measuring (1) user attitudes towards MR, (2) perceptions of our HIT and (3) the local organisational climate for implementation. We also assessed the consistency and quality of tool use.

Results: Nearly 90% of PC providers responded to the survey and 58% indicated that they were familiar with the technology and had seen the tool output. Most providers believed that MR represented an important safety intervention, although 43% did not believe that they had the necessary resources to manage discrepancies. Composite scale scores for the 58% of respondents familiar with the HIT indicate that the majority favoured our tool over usual care. However, composite scale scores suggest that the climate for implementation at our facility was suboptimal. Overall, the quality and consistency of tool use among providers was very heterogeneous.

Conclusions: A patient self-service kiosk offers an efficient mechanism to collect a medication adherence history; provider survey responses indicate that they appreciated and used the MR kiosk output. Nonetheless, opportunities exist to improve data displays and embed decision support to facilitate discrepancy management.
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http://dx.doi.org/10.14236/jhi.v19i2.802DOI Listing
May 2012

Climbing the cognitive learning ladder.

Authors:
Shawn Adams

Occup Health Saf 2010 Jun;79(6):32, 34, 37-8

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June 2010

Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting.

Jt Comm J Qual Patient Saf 2009 May;35(5):264-70

Clinical Applications/Medicine Service, Portland Department of Veterans Affairs, Portland, OR, USA.

Background: Discrepancies in medication documentation most often occur at handoffs or transition points in care. A process improvement team at the Portland Department of Veterans Affairs developed a standardized medication reconciliation process for the Portland chemotherapy administration unit, a physically self-contained clinic with a standard intake process and a uniform patient traffic pattern.

Methods: The team developed the automated patient history intake device (APHID), a reconciliation software program accessed by the patient using a computer terminal kiosk in the clinic lobby. The program simultaneously checks in patients for an appointment and gathers a medication-adherence history by retrieving medication lists from all Veterans Affairs facilities and pairing each medication with a pill picture. Installation of the APHID kiosk included an initial two-week roll-in period beginning in February 2008.

Results: During the roll-in period, 91 (82.0%) of 111 patients completed check-in and performed medication reconciliation using the kiosk. Medication lists gathered at the kiosk were compared with existing health record documentation and clinician interviews. For each patient encounter, the process demonstrated an average of 4.59 discrepancies and an average of 1.61 clinically significant or potentially lethal discrepancies. The new process saved approximately 0.24 full-time equivalents of nursing time in the chemotherapy clinic-a nearly 50% reduction in nursing time dedicated to reconciliation activities without an apparent loss in data accuracy.

Discussion: A patient-centered reconciliation model using consumer-based kiosk technology helped providers efficiently retrieve a comprehensive list of medications across a geographically diverse area and improve patient medication recall using visual cues including medication pictures.
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http://dx.doi.org/10.1016/s1553-7250(09)35037-0DOI Listing
May 2009

Design and implementation of a medication reconciliation kiosk: the Automated Patient History Intake Device (APHID).

J Am Med Inform Assoc 2009 May-Jun;16(3):300-4. Epub 2009 Mar 4.

MBI, Technology and Information Management, Department of Hospital Specialty Medicine, Mail Code P3 MED, Portland VA Medical Center, 3710 SW U.S. Veterans Hospital Road, Portland, Oregon 97239, USA.

Errors associated with medication documentation account for a substantial fraction of preventable medical errors. Hence, the Joint Commission has called for the adoption of reconciliation strategies at all United States healthcare institutions. Although studies suggest that reconciliation tools can reduce errors, it remains unclear how best to implement systems and processes that are reliable and sensitive to clinical workflow. The authors designed a primary care process that supported reconciliation without compromising clinic efficiency. This manuscript describes the design and implementation of Automated Patient History Intake Device (APHID): ambulatory check-in kiosks that allow patients to review the names, dosage, frequency, and pictures of their medications before their appointment. Medication lists are retrieved from the electronic health record and patient updates are captured and reviewed by providers during the clinic session. Results from the roll-in phase indicate the device is easy for patients to use and integrates well with clinic workflow.
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http://dx.doi.org/10.1197/jamia.M2642DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2732234PMC
August 2009

A sound approach to safe lifting.

Authors:
Shawn Adams

Occup Health Saf 2008 Jul;77(7):99-101

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July 2008

The role of safety in business continuity.

Authors:
Shawn Adams

Occup Health Saf 2007 Jul;76(7):34, 36, 38

U.S. Department of Energy, Albuquerque, USA.

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July 2007

Complying with OSHA's fire safety standards.

Authors:
Shawn Adams

Occup Health Saf 2007 Apr;76(4):105-9

U.S Depatment of Energy, Albuquerque, USA.

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April 2007

Saving money by becoming a highly protected risk.

Authors:
Shawn Adams

Occup Health Saf 2006 Dec;75(12):36-8

Safety Training and Development, U.S. Department of Energy, USA.

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December 2006

Disaster roles and responsibilities for safety managers.

Occup Health Saf 2006 Mar;75(3):83-4, 86

Jacksonville State University, Alabama, USA.

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March 2006