Adela Wu

All Publications

• The surgeon's role in delivering palliative care practices: a narrative review. Annals of palliative medicine Wu, A., Aslanian, R. E., Bradley, S. E., Suwanabol, P. A. 2025; 14 (4): 369-378

  Abstract

  BACKGROUND AND OBJECTIVE: Palliative care aims to improve quality of life and reduce suffering among patients facing serious illnesses and their families. Patients with surgical conditions have various palliative care needs, although the incorporation of palliative care principles in perioperative care may be suboptimal. The aims of this narrative review are to define and delineate the surgeon's role in integrating palliative care in surgical practice, through highlighting strategies and opportunities for surgeons to engage with patients, families, and interdisciplinary palliative care providers.METHODS: We searched PubMed and EMBASE databases for English-language publications dated between January 2010 to May 2024, according to the search terms: "palliative care", "surgery", and "surgeon". Inclusion criteria were: (I) studies involving adult patients (given differing considerations in pediatric populations); (II) original quantitative or qualitative research (i.e., those with primary data), including case reports and series; and (III) a primary focus on palliative care in the context of surgical conditions. A total of 713 manuscripts were initially identified to be potentially relevant and a total of 43 articles were included for this review. In addition, we describe an illustrative case involving a patient with a surgical condition facing critical illness to highlight opportunities for surgeons to engage in serious illness communication and palliative care.KEY CONTENT AND FINDINGS: We emphasize the surgeon's roles in both perioperative communication and shared decision-making with patients and families regarding surgical interventions, along with potential strategies for improved communication and enhanced primary palliative care skills. In addition, we describe valuable opportunities for surgeons to collaborate with interdisciplinary palliative care teams in the care of patients with surgical conditions.CONCLUSIONS: Opportunities for surgeons to utilize palliative care approaches and engage with palliative care specialists in surgical and perioperative care exist, which may improve the patient and family experience.

  View details for DOI 10.21037/apm-25-27

  View details for PubMedID 40769732

• Prediction of seizure risk after repetitive mild traumatic brain injury in childhood. Journal of neurosurgery. Pediatrics Jin, M. C., Ravi, K., Wu, A., Garcia, C. A., Rodrigues, A. J., Savchuk, S., Ruiz Colón, G. D., Kakusa, B. W., Parker, J. J., Grant, G. A., Prolo, L. M. 2025: 1-10

  Abstract

  Despite the known negative physiological impact of repeated mild head trauma events, their multiplicative impact on long-term seizure risk remains unclear. The objective of this study was to evaluate how multiple mild traumatic brain injuries (mTBIs) impact long-term seizure risk by testing 3 distinct machine learning approaches. Baseline and injury-specific characteristics were incorporated to enhance prognostication of individual seizure risk.Children with at least 1 mTBI event without prior evidence of seizure or antiepileptic drug treatment, from 2003 to 2021, were identified from a nationally sourced administrative claims database. The primary outcome of interest was a seizure event after mTBI, defined by qualifying principal diagnosis codes. Time-varying multivariable Cox regression was used to assess the impact of repeated mTBI.A total of 156,118 children (mean age 11.7 ± 4.7 years) were included, with a median follow-up duration of 22.6 months (IQR 9.2-45.4 months). Among patients who experienced seizure after mTBI, the median time to seizure was 306 days. Seizures among those with radiographic findings and/or loss of consciousness occurred earlier (median time to seizure 112.5 days [imaging findings only, IQR 5-526.25 days], 80 days [loss of consciousness only, IQR 7-652 days], 22 days [both, IQR 5-192 days]). Both mTBI without and with short-term loss of consciousness resulted in increasing seizure risk with repeated trauma (HR 1.196, 95% CI 1.082-1.322; HR 2.025, 95% CI 1.828-2.244; respectively). The random survival forest approach achieved fixed-time areas under the receiver operating characteristic curve of 0.780 and 0.777 at 30 and 90 days after mTBI, and children predicted at high risk by the final model experienced a significantly higher burden of early seizure after mTBI (46.7% within the first 30 days vs 17.7% and 19.9% of children at low and medium risk). A simplified model using the top 12 contributing features achieved 95% of the full model's performance in the validation set.A novel machine learning model was developed and validated for personalized prediction of long-term seizure risk following multiple mTBIs. Model performance remained robust with a limited feature set, suggesting the feasibility of real-time incorporation into clinical workflows for individualized prognostication following each repeat mTBI event. In children predicted to be at high risk, early intervention should be considered.

  View details for DOI 10.3171/2025.1.PEDS2436

  View details for PubMedID 40279715

• Improved Survival and Symptom Relief Following Palliative Cerebrospinal Fluid Diversion for Leptomeningeal Disease from Brain Cancers: A Case Series and Systematic Review. Cancers Wu, A., Zhou, J., Skirboll, S. 2025; 17 (2)

  Abstract

  Leptomeningeal disease (LMD) from cancer indicates advanced cancer and can lead to obstructive hydrocephalus, for which palliative cerebrospinal fluid (CSF) diversion may be indicated to alleviate symptoms. We investigated surgical outcomes for hydrocephalus for adult patients with LMD and conducted a systematic review on pediatric and adult cases.We analyzed outcomes from a 10-year period of patients with neoplastic LMD, obstructive hydrocephalus, and documented date of death. We also searched databases from inception until 20 August 2022, using search terms including 'cancer', 'hydrocephalus', and 'shunt'. Preferred reporting items for systematic reviews and meta-analyses guidelines were followed.Among 50 patients, 30 (60%) underwent CSF diversion after LMD diagnosis with comparable median age in both the surgery (58.4 ± 14.4 years) and non-surgery (57.8 ± 14.5 years) groups. Twenty-three patients (76.7%) achieved symptom relief. The surgery group lived longer after LMD diagnosis than the non-surgery group (6.6 ± 6.0 vs. 1.3 ± 4.3 months, p < 0.001) and had a higher likelihood of survival (hazard ratio 2.49, 95% confidence interval 1.37-4.52, p = 0.002). Median survival after surgery was 2.8 ± 3.8 months. From 23 articles, 995 patients (34.3%) presented with LMD. Complication rates were 0-37.7% with no extraneural metastases. Symptom relief rates were 50-100%. Three studies reported median survival after surgery (2-3.3 months).A rare entity with dismal prognosis, LMD can present as symptomatic hydrocephalus in patients with cancer. Symptom relief and improved survival can be achieved with palliative CSF diversion with low complication rates. Prospective studies are needed to assess the outcomes and needs of these patients.

  View details for DOI 10.3390/cancers17020292

  View details for PubMedID 39858073

• "It's Traumatic for All of Us": A Qualitative Analysis of Providers Caring for Seriously Ill Veterans With Surgical Conditions. Annals of surgery open : perspectives of surgical history, education, and clinical approaches Wu, A., Bradley, S. E., Vitous, C. A., Millis, M. A., Suwanabol, P. A. 2024; 5 (4): e518

  Abstract

  We aimed to characterize sources of moral distress among providers in the context of surgery.Moral distress is defined as psychological unease generated when professionals identify an ethically correct action to take but are constrained in their ability to take that action. While moral distress has been reported among healthcare providers, the perspectives of providers working in surgery specifically are not often explored and reported. Our study was developed from an overarching effort to investigate end-of-life care for seriously ill patients with surgical conditions.Using convenience sampling, we conducted 48 semistructured interviews with providers who provide high-intensity care (eg, surgeons, anesthesiologists, intensivists, and midlevel providers) for seriously ill patients with surgical conditions across 14 Veterans Affairs hospitals. Interviews were analyzed iteratively using thematic content analysis.Providers described clinical encounters that generated moral distress while caring for seriously ill patients with surgical conditions: (1) difficulties in conflict resolution with and among patients and families; (2) specific types of patients or situations; (3) systemic factors hindering appropriate end-of-life care; (4) surgical culture and expectations of the surgeon's role.Providers caring for seriously ill patients with surgical conditions report emotions and reactions consistent with moral distress. Our study highlights important triggers for providers and hospital systems to identify and address throughout a surgical provider's training and career.

  View details for DOI 10.1097/AS9.0000000000000518

  View details for PubMedID 39711686

  View details for PubMedCentralID PMC11661713

• Dorsolateral Transdural Surgical Management of Spontaneous Intracranial Hypotension From Ventral Dural Cerebrospinal Fluid Leaks: Case Series and Technical Report. Operative neurosurgery (Hagerstown, Md.) Wu, A., Mamlouk, M. D., Sedrak, M. F. 2024

  Abstract

  BACKGROUND AND OBJECTIVES: Spontaneous intracranial hypotension is an uncommon but debilitating condition that commonly involves positional headaches and vertigo. One cause is cerebrospinal fluid (CSF) leakage from ventral dural defects from calcified spinal discs. Patients can undergo epidural blood or fibrin glue patches as treatment; however, in cases where the leak does not resolve, surgical repair of the dural tear may be warranted. We aim to describe a case series and technical notes for these patients.METHODS: Patients with spontaneous intracranial hypotension because of myelography-confirmed ventral dural defect from calcified thoracic disc, who were treated surgically between June 2020 and March 2024, were included in the study cohort. Demographic information, clinical course, and postoperative outcomes were collected. The surgical technique was also described based on an illustrative case.RESULTS: Twelve consecutive patients underwent surgery between June 2020 and March 2024 with postoperative records. The median age at the time of surgery was 41.5 years (range: 28-58 years). Male patients comprised 50% of the cohort. Dural defects were spread throughout the thoracic spine in the cohort. While all patients reported positional headaches, other symptoms included vertigo, pulsatile tinnitus, and neck pain. Median length of follow-up time was 6.5 weeks. There were no surgical complications or permanent neurologic deficits. All patients had radiologic cure of their leaks with absence of extradural CSF on postoperative MR imaging. Ten patients (83.3%) had complete resolution of spontaneous intracranial hypotension-related symptoms. Two patients did suffer from rebound headaches postoperatively.CONCLUSION: The dorsolateral transdural surgical approach is a safe and effective method to repair type 1 CSF leaks caused by ventral dural defects. Our case series of 12 patients did not involve any surgical or immediate postoperative complications, and all patients had radiologic resolution of their leaks with relief of positional headaches. Two patients experienced continued headaches after treatment.

  View details for DOI 10.1227/ons.0000000000001431

  View details for PubMedID 39993255

• "You have to hold their hand": experiences of providers integrating virtual care and communication methods while caring for ICU patients during the COVID-19 pandemic. Annals of palliative medicine Bradley, S. E., Aslanian, R. E., Ferguson, C., Vitous, C. A., Wu, A., Duby, A., Millis, M. A., Suwanabol, P. A. 2024; 13 (6): 1332-1342

  Abstract

  The rapid expansion of synchronous telephone and video virtual care options allowed the Veterans Health Administration (VHA) to adapt to the coronavirus disease 2019 (COVID-19) pandemic and provided a unique opportunity to assess the potential for integration and utility of virtual care in VHA systems. The objective of this study was to highlight the perspectives of VHA providers caring for intensive care unit (ICU) patients during the COVID-19 pandemic and their views on the use of virtual care and communication for palliative and end-of-life patients.Forty-eight semi-structured qualitative interviews were conducted with providers between April 2021 and March 2022 and were analyzed using steps informed by thematic content analysis. Participants were eligible if they delivered ICU care to surgical patients at VHA hospitals. Participants were recruited from 14 VHA facilities across the United States. Participants were asked questions about their experiences as providers working with ICU patients, including about the impacts of the COVID-19 pandemic and ways in which virtual care was adapted to deal with emerging challenges.When asked about their experiences with ICU patient care during the COVID-19 pandemic, participant experiences showed: (I) disruption of staff roles and responsibilities, (II) reduced opportunities for communication and rapport building with family members, and (III) increased patient isolation. In each case, virtual options were adapted to overcome these emerging barriers, but limitations for the utility of those options for palliative and end-of-life care patients remain.Virtual options were an important adaptation for providers during the COVID-19 pandemic, but their use can be limited in palliative and end-of-life care settings. However, when visitation is limited, virtual options can support communication between providers, family members, and caregivers.

  View details for DOI 10.21037/apm-24-98

  View details for PubMedID 39632814

• Cross-cultural serious neurological illness communication: qualitative analysis of multidisciplinary perspectives. Annals of palliative medicine Wu, A., Giannitrapani, K. F., Ruiz Colón, G. D., Adams, A. S., Li, G., Lorenz, K. A. 2024

  Abstract

  Cultural competence is important in approaching serious illness communication with diverse patients about goals of care. Culture colors patients' perspectives on many healthcare issues, including end-of-life care, and impacts how clinicians make decisions with patients. Communication about serious neurological illnesses can be additionally challenging due to disease impact on patients' cognition and decision-making abilities. We aim to understand provider experiences regarding cross-cultural serious neurological illness communication with diverse patients and families.Using non-stratified purposive and snowball sampling, we conducted semi-structured interviews with 17 multidisciplinary participants, including neurosurgeons, neurologists, and social workers, who provide care for patients diagnosed with serious neurological disorders, at three hospital settings between 2021 and 2022. We used standard qualitative content analysis methods with dual review.Five themes reflected provider perspectives about serious neurological illness communication with diverse patients and families. Theme 1: providers recognize that patients' personal biases and lived experiences impact attitudes about healthcare and communication. Theme 2: challenges in communication can arise when providers miss chances to identify important cultural values. Theme 3: understanding how to engage with family members is important for effective communication about serious neurological illness. Theme 4: providers want to accommodate patients. Theme 5: cultivating trust builds a strong patientprovider partnership, even when racial or cultural discordance is present.Our study highlights elements of cross-cultural communication and opportunities for providers to approach diverse patients and families within a racial or culturally discordant context. Effective communication, fostered through respecting individual experiences and variation, eliciting cultural perspectives, engaging family, and cultivating trust reflects processes and learned skills required of highquality teams caring for patients with serious neurological conditions.

  View details for DOI 10.21037/apm-24-37

  View details for PubMedID 39129523

• Primary BAP1-absent atypical meningioma arising from median nerve within infraclavicular brachial plexus: illustrative case. Journal of neurosurgery. Case lessons Wu, A., Ring, A. C., Ziskin, J., Nguyen, T., Pezeshkian, P. 2024; 8 (5)

  Abstract

  The authors present the only known case of a World Health Organization grade II ectopic meningioma occurring in the infraclavicular brachial plexus, causing pain within the axilla not associated with a primary malignant meningioma of the central nervous system. Peripheral nerve sheath tumors are rare entities, the majority of which are schwannomas or neurofibromas. Ectopic meningiomas only represent 1%-2% of all meningiomas. To date, there is one other published case specifically of a primary ectopic meningioma located in the brachial plexus.Following the dissection of the left axilla, a dominant rubbery tumor involving the median nerve was encountered. The tumor capsule contained areas of hemorrhage and a soft core with nerve fascicles coursing through, which were not compromised during internal tumor debulking. The tumor lacked a clear pseudocapsule that is characteristically seen in schwannomas. Histopathological studies confirmed an atypical epithelioid neoplasm with elevated numbers of mitotic figures and BAP1 gene deletion.Primary meningiomas arising outside the central nervous system are exceedingly rare. For this unusual higher-grade primary ectopic meningioma located in the distal brachial plexus, surgery with the goal of gross-total resection, adjuvant radiation, additional imaging, and genetics screening were recommended. Close follow-up is warranted. https://thejns.org/doi/10.3171/CASE24226.

  View details for DOI 10.3171/CASE24226

  View details for PubMedID 39074391

• Frequency and distribution of ophthalmic surgical procedures among patients with inherited retinal diseases. Ophthalmology. Retina Mees, L., Li, M., Antonio-Aguirre, B., Liu, T. Y., Wu, A., Kong, X., Singh, M. S. 2024

  Abstract

  OBJECTIVE OR PURPOSE: In this study, we aimed to characterize the frequency and distribution of ocular surgeries in patients with inherited retinal diseases (IRDs) and evaluate associated patient and disease factors.DESIGN: Retrospective cohort.PARTICIPANTS: Subjects 18 years and older who were followed at the Johns Hopkins Genetic Eye Disease (GEDi) Center.METHODS: We studied a retrospective cohort of patients with an IRD diagnosis to analyze the occurrence of laser and incisional surgeries. Subjects were categorized into two groups: central dysfunction (macular/cone/cone-rod dystrophy, "MCCRD group") and panretinal or peripheral dysfunction (retinitis pigmentosa-like, "RP group"). Genetic testing status was recorded. The association of patient and disease factors on the frequency, distribution, and timing of surgeries was analyzed.MAIN OUTCOME MEASURE: Prevalence, prevalence odds ratio (POR), hazard ratio (HR) of ophthalmic procedures by phenotype.RESULTS: A total of 1472 eyes of 736 subjects were evaluated. Among them, 31.3% (n = 230) had undergone ocular surgery, and 78.3% of those (n=180/230) had a history of more than one surgery. A total of 602 surgical procedures were analyzed. Cataract extraction with intraocular lens implantation (CEIOL) was the most common (51.2%), followed by YAG capsulotomy, refractive surgery, retinal surgery, and others. CEIOL occurred more frequently in RP than in MCCRD subjects (POR 2.59, p = 0.002). RP subjects underwent CEIOL at a younger age than MCCRD patients (HR = 2.11, p < 0.001).CONCLUSION: Approximately one-third of IRD patients had a history of laser or incisional surgery. CEIOL was the most common surgery; its frequency and timing may be associated with IRD phenotype. This data may inform the design of prospective research. Such efforts may illuminate routine clinical decision-making and contribute to surgical strategy development for cell and gene therapy delivery.

  View details for DOI 10.1016/j.oret.2024.03.005

  View details for PubMedID 38485090

• Neurosurgical Outcomes Among Non-English Speakers: A Systematic Review and a Framework for Future Research. World neurosurgery Ruiz Colon, G. D., Barros Guinle, M. I., Wu, A., Grant, G. A., Prolo, L. M. 2024

  Abstract

  OBJECTIVE: In 2019, 22% of adults in the United States reported speaking a language other than English at home, representing 52% growth since 2000. This diversity in languages - and resulting possible communication barriers - represents a potential challenge to effective care. In this manuscript, we summarize clinical outcomes and healthcare utilization patterns of adult and pediatric neurosurgical patients who are non-English primary language speakers (NEPLS).METHODS: We systematically queried five databases from inception through October 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to identify studies for inclusion. The Newcastle-Ottawa Scale was used to assess the quality of studies. Additionally, a retrospective chart review was conducted to assess differences in postoperative communication patterns in a cohort of English and Spanish speaking patients with craniosynostosis at our institution.RESULTS: Our search yielded 442 abstracts; ten were included in the final cohort. Outcomes for 973 unique NEPLS with a neurosurgical condition were included; Spanish was the most represented language. Delivery and timing of surgical treatment was the most frequently reported metric; 75% of studies demonstrated a statistically significant delay in time to surgery or decreased likelihood for NEPLS to receive surgical treatment. Length of stay (LOS) was reported in three studies; all demonstrated that NEPLS had longer LOS.CONCLUSION: There is a paucity of literature reporting outcomes among NEPLS. It is critical to examine NEPLS patients' outcomes and experiences, as language barriers are potentially modifiable demographic factors. We present a framework that demonstrates opportunities for further research to improve quality of care.

  View details for DOI 10.1016/j.wneu.2024.02.068

  View details for PubMedID 38387790

• Disparities in Preoperative Goals of Care Documentation in Veterans. JAMA network open Wu, A., Giannitrapani, K. F., Garcia, A., Bozkurt, S., Boothroyd, D., Adams, A. S., Kim, K. M., Zhang, S., McCaa, M. D., Morris, A. M., Shreve, S., Lorenz, K. A. 2023; 6 (12): e2348235

  Abstract

  Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk.To assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans.This retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022.Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors.Preoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression.In this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P <.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P <.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P <.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P <.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001).In this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.

  View details for DOI 10.1001/jamanetworkopen.2023.48235

  View details for PubMedID 38113045

  View details for PubMedCentralID PMC10731481

• OUTCOMES FOLLOWING PALLIATIVE CEREBROSPINAL FLUID DIVERSION FOR NEOPLASTIC LEPTOMENINGEAL DISEASE: A SYSTEMATIC REVIEW Wu, A., Zhou, J., Skirboll, S. OXFORD UNIV PRESS INC. 2023

  View details for Web of Science ID 001115245401014

• Treatment Course and Outcomes of Intracranial Teratomas in Pediatric Patients: A Retrospective 15-Year Case Series Study. Pediatric neurosurgery Wu, A., Jin, M. C., Vogel, H., Hiniker, S., Campen, C., Prolo, L. M., Grant, G. A. 2023; 58 (6): 429-438

  Abstract

  There is no standard treatment paradigm for intracranial teratomas, a rare subset of primary intracranial non-germinomatous germ cell tumors (NGGCT), which comprise less than 1% of pediatric brain tumors. This case series retrospectively analyzes treatment and outcomes of pediatric intracranial teratomas from a single institution.Authors reviewed a comprehensive pathology database at Stanford's Lucile Packard Children's Hospital for intracranial teratomas in pediatric patients treated from 2006 to 2021; their demographics, treatment, and clinical course were analyzed.Among 14 patients, median follow-up time was 4.6 years and mean age at diagnosis was 10.5 years. Ten had elevated tumor markers and underwent chemotherapy as initial treatment for NGGCT. Ultimately, these patients all required surgery for progressive or residual disease. Two patients did not undergo radiation. After biopsy or resection, 8 patients had pure mature teratoma, five had mixed germ cell tumor with teratoma component, and one had immature teratoma. The patient with immature teratoma died during chemotherapy from septic shock. No patients experienced recurrence. Common sequelae were endocrine (42.8%) and eye movement (50.0%) abnormalities.We highlight the variable treatment course and outcome for pediatric patients with intracranial teratomas. Elevated tumor markers at presentation, along with imaging findings, favor chemotherapy initiation for presumed NGGCT. Resection of residual tumor is recommended even if tumor markers return to normal. Prognosis remains excellent; no patients had recurrence with a median follow-up of 4.6 years.

  View details for DOI 10.1159/000534721

  View details for PubMedID 37879310

• Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. Journal of pain and symptom management Giannitrapani, K. F., Sasnal, M., McCaa, M., Wu, A., Morris, A. M., Connell, N. B., Aslakson, R. A., Schenker, Y., Shreve, S., Lorenz, K. A. 2023

  Abstract

  CONTEXT: Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively.OBJECTIVES: To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons.METHODS: We conducted semi-structured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8).RESULTS: Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: (1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; (2) establish risk assessment processes to identify patients who may benefit from a PC consult; (3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; (4) provide sufficient resources to allow for an interdisciplinary sharing of care.CONCLUSION: The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.

  View details for DOI 10.1016/j.jpainsymman.2023.08.021

  View details for PubMedID 37643653

• Serum Methamphetamine Positivity in Trauma Patients Undergoing Surgery has No Negative Effect on Postoperative Morbidity and Mortality. Journal of emergencies, trauma, and shock Zhou, J., Wu, A., Miao, J., Singh, H. 2023; 16 (3): 102-108

  Abstract

  The link between methamphetamine (METH) use and mortality or morbidity, particularly perioperative complications, associated with trauma surgery are not well characterized. This study aims to address this by performing a comparison of surgical outcomes between METH-negative (METH-) and METH-positive (METH+) trauma patients.An Institutional Review Board-approved retrospective chart review was performed on all trauma patients admitted to our Level 1 trauma center who underwent surgical operations between 2015 and 2020. Patients were categorized into METH- and METH+ groups. Patient characteristics such as age, sex, race, Injury Severity Score (ISS), presence of peri-operative complications, and mortality, amongst others, were used to perform univariate comparisons. Additional multi-variate comparisons were performed across both the whole cohort and with age, sex, and ISS-matched groups.Of 571 patients who met the final inclusion criteria, 421 were METH- and 150 METH+. The METH+ group also possessed a lower median ISS (P = 0.0478) and did not possess significantly different mortality or morbidity than their METH- counterparts in univariate analysis. Multivariate analysis in whole-group and matched-group cohorts indicated that METH was not a positive predictor of mortality or morbidity. Instead, ISS predicted mortality (P = 0.048) and morbidity (P < 0.001).Our results suggest that METH use does not exert a positive effect on mortality or morbidity in the acute trauma surgery setting and that ISS may be a more significant contributor, suggesting severity, and etiology of injury are also important considerations for trauma surgery evaluation.

  View details for DOI 10.4103/jets.jets_39_23

  View details for PubMedID 38025508

  View details for PubMedCentralID PMC10661571

• Serum methamphetamine positivity in trauma patients undergoing surgery has no negative effect on postoperative morbidity and mortality Journal of Emergencies, Trauma, and Shock Zhou, J., Wu, A., Miao, J., Singh, H. 2023; 16 (3): 102-108

  Abstract

  The link between methamphetamine (METH) use and mortality or morbidity, particularly perioperative complications, associated with trauma surgery are not well characterized. This study aims to address this by performing a comparison of surgical outcomes between METH-negative (METH-) and METH-positive (METH+) trauma patients.An Institutional Review Board-approved retrospective chart review was performed on all trauma patients admitted to our Level 1 trauma center who underwent surgical operations between 2015 and 2020. Patients were categorized into METH- and METH+ groups. Patient characteristics such as age, sex, race, Injury Severity Score (ISS), presence of peri-operative complications, and mortality, amongst others, were used to perform univariate comparisons. Additional multi-variate comparisons were performed across both the whole cohort and with age, sex, and ISS-matched groups.Of 571 patients who met the final inclusion criteria, 421 were METH- and 150 METH+. The METH+ group also possessed a lower median ISS (P = 0.0478) and did not possess significantly different mortality or morbidity than their METH- counterparts in univariate analysis. Multivariate analysis in whole-group and matched-group cohorts indicated that METH was not a positive predictor of mortality or morbidity. Instead, ISS predicted mortality (P = 0.048) and morbidity (P < 0.001).Our results suggest that METH use does not exert a positive effect on mortality or morbidity in the acute trauma surgery setting and that ISS may be a more significant contributor, suggesting severity, and etiology of injury are also important considerations for trauma surgery evaluation.

  View details for DOI 10.4103/jets.jets_39_23

  View details for PubMedCentralID PMC10661571

• Advancing combination therapy for recurrent glioblastoma. Nature medicine Wu, A., Lim, M. 2023

  View details for DOI 10.1038/s41591-023-02350-3

  View details for PubMedID 37188784

  View details for PubMedCentralID 9629431

• Factors Perpetuating Racial Disparities in Veterans Completing Preoperative Goals of Care Documentation Wu, A., Giannitrapani, K., Garcia, A., Bozkurt, S., Boothroyd, D., Adams, A., Shreve, S., Lorenz, K. ELSEVIER SCIENCE INC. 2023: E517

  View details for Web of Science ID 001006227200006

• Patient Characteristics Associated With Occurrence of Preoperative Goals-of-Care Conversations. JAMA network open Kim, K. M., Giannitrapani, K. F., Garcia, A., Boothroyd, D., Wu, A., Van Cleve, R., McCaa, M. D., Yefimova, M., Aslakson, R. A., Morris, A. M., Shreve, S. T., Lorenz, K. A. 2023; 6 (2): e2255407

  Abstract

  Communication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery.To evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery.This retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022.Patient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more.Preoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation.Of 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score <80, 98.3% vs 96.9%); or to undergo neurosurgical (9.8% vs 6.2%) or urologic surgical procedures (5.9% vs 2.0%). Over the 3-year interval, unadjusted rates of LST note completion before surgery increased from 0.1% to 9.6%. Covariate-adjusted estimates of LST note completion indicated that veterans at a relatively elevated risk of hospitalization or death (CAN score ≥80) had higher odds of completing an LST note before surgery (odds ratio [OR], 1.29; 95% CI, 1.09-1.53) compared with those with CAN scores less than 80. High-risk surgery was not associated with increased LST note completion before surgery (OR, 0.93; 95% CI, 0.86-1.01). Veterans who underwent cardiothoracic surgery had the highest likelihood of LST note completion before surgery (OR, 1.35; 95% CI, 1.24-1.47).Despite increasing LST note implementation, a minority of veterans completed an LST note preoperatively. Although doing so was more common among veterans with an elevated risk compared with those at lower risk, improving proactive communication and documentation of goals, particularly among higher-risk veterans, is needed. Doing so may promote goal-concordant surgical care and outcomes.

  View details for DOI 10.1001/jamanetworkopen.2022.55407

  View details for PubMedID 36757697

• Quality and patient safety research in pediatric neurosurgery: a review. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery Ruiz Colón, G. D., Wu, A., Ratliff, J. K., Prolo, L. M. 2023

  Abstract

  In 2001, the National Academy of Medicine, formerly known as the Institute of Medicine (IOM), published their seminal work, Crossing the Quality Chasm: A New Health System for the 21st Century. In this work, the authors called for improved safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity in the United States' healthcare system. Two decades after the publication of this work, healthcare costs continue to rise, but outcomes lag other nations. The objective of this narrative review is to describe research efforts in pediatric neurosurgery with respect to the six quality aims proposed by the IOM, and highlight additional research opportunities.PubMed, Google Scholar, and EBSCOhost were queried to identify studies in pediatric neurosurgery that have addressed the aims proposed by the IOM. Studies were summarized and synthesized to develop a set of research opportunities to advance quality of care.Twenty-three studies were reviewed which focused on the six quality aims proposed by the IOM. Out of these studies, five research opportunities emerged: (1) To examine performance of tools of care, (2) To understand processes surrounding care delivery, (3) To conduct cost-effectiveness analyses for a broader range of neurosurgical conditions, (4) To identify barriers driving healthcare disparities, and (5) To understand patients' and caregivers' experiences receiving care, and subsequently develop tools and programs to address their needs and preferences.There is a growing body of literature examining quality in pediatric neurosurgical care across all aims proposed by the IOM. However, there remains important gaps in the literature that, if addressed, will advance the quality of pediatric neurosurgical care delivery.

  View details for DOI 10.1007/s00381-022-05821-z

  View details for PubMedID 36695845

• "It's Not Us Versus Them": Building Cross-Disciplinary Relationships in the Perioperative Period. Journal of pain and symptom management Sasnal, M., Lorenz, K. A., McCaa, M., Wu, A., Morris, A. M., Schenker, Y., Shreve, S. T., Giannitrapani, K. F. 2023

  Abstract

  CONTEXT: Palliative care (PC) interventions improve quality outcomes for surgical patients, yet they are underutilized in the perioperative period. Developing cross-disciplinary provider relationships increases PC consults. However, the attributes of collaborative relationships and how they evolve are unclear.OBJECTIVES: To identify perceptions of PC providers and surgeons on how collaborative cross-disciplinary relationships are built and maintained in the perioperative period.METHODS: This cross-sectional multiphase qualitative study included 23 semi-structured interviews with 10 PC teams (20 providers) and 13 surgeons at geographically distributed Veteran Health Administration (VHA) sites. An analytic approach relied on team-based thematic analysis with a dual review.RESULTS: Respondents defined successful collaborative work relationships between PC and surgeons as having the following features: (1) mutual trust; (2) mutual respect; (3) perceived usefulness; (4) shared clinical objectives; (5) effective communication; and (6) organizational enablers. In addition, the analysis elucidated a framework of six strategies for developing collaborative relationships between PC and surgical teams in the perioperative period: (1) Being present, available, and responsive; (2) Understanding roles; (3) Establishing communication; (4) Recognizing an intermediary and connecting role of supporting team members; (5) Working as a team; and (6) Building on previous experiences.CONCLUSIONS: The study informs future interventions to improve the quality of care for seriously ill patients by better-involving palliative care in the perioperative period. Future work will extend this approach to incorporate the perspectives of patients on their providers' collaboration and how it impacts patient-related outcomes at the intersection of PC and surgery.

  View details for DOI 10.1016/j.jpainsymman.2022.12.140

  View details for PubMedID 36646332

• Early palliative care consultation offsets hospitalization duration and costs for elderly patients with traumatic brain injuries: Insights from a Level 1 trauma center. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia Wu, A., Zhou, J., Quinlan, N., Dirlikov, B., Singh, H. 2022; 108: 1-5

  Abstract

  We identified factors and outcomes associated with inpatient palliative care (PC) consultation, stratified into early and late timing, for patients over age 65 with traumatic brain injuries (TBI). Patients over age 65 presenting to a single institution with TBI and intracranial hemorrhage from January 2013-September 2020 were included. Patient demographics and various outcomes were analyzed. Inpatient PC consultation was uncommon (4% out of 576 patients). Characteristics associated with likelihood of consultation were severe TBI (OR=5.030, 95% CI 1.096-23.082, p=.038) and pre-existing dementia (OR=6.577, 95% CI 1.726-25.073, p=.006). Average consultation timing was 8.6 (standard deviation±7.0) days. Patients with PC consults had longer overall (p=.0031) and intensive care unit (ICU) length of stays (LOS) (p<.0001), more days intubated (p<.0001) and higher costs (p=.0006), although those with earlier-than-average PC consultation had shorter overall (p=.0062) and ICU (p=.011) LOS as well as fewer ventilator days (p=.030) and lower costs (p=.0003). Older patients with TBI are more likely to receive PC based on pre-existing dementia and severe TBI. Patients with PC consultations had worse LOS and higher costs. However, these effects were mitigated by earlier PC involvement. Our study emphasizes the need for timely PC consultation in a vulnerable patient population.

  View details for DOI 10.1016/j.jocn.2022.12.013

  View details for PubMedID 36542995

• Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study. BMC palliative care Wu, A., Huang, R. J., Colon, G. R., Zembrzuski, C., Patel, C. B. 2022; 21 (1): 203

  Abstract

  BACKGROUND: Proper advance care planning (ACP) documentation both improves patient care and is increasingly seen as a marker of high quality by governmental payers. The transition of most medical documentation to electronic health records (EHR) allows for ACP documents to be rapidly disseminated across diverse ambulatory practice settings. At the same time, the complexity and heterogeneity of the EHR, as well as the multiple potential storage locations for documentation, may lead to confusion and inaccessibility. There has been movement to promote structured ACP (S-ACP) documentation within the EHR.METHODS: We performed a retrospective cohort study at a single, large university medical center in California to analyze rates of S-ACP documentation. S-ACP was defined as ACP documentation contained in standardized locations, auditable, and not in free-text format. The analytic cohort composed of all patients 65 and older with at least one ambulatory encounter at Stanford Health Care between 2012 and 2020, and without concurrent hospice care. We then analyzed clinic-level, provider-level, insurance, and temporal factors associated with S-ACP documentation rate.RESULTS: Of 187,316unique outpatient encounters between 2012 and 2020, only 7,902 (4.2%) contained S-ACP documentation in the EHR. The most common methods of S-ACP documentation were through problem list diagnoses (3,802; 40.3%) and scanned documents (3,791; 40.0%). At the clinic level, marked variability in S-ACP documentation was observed, with Senior Care (46.6%) and Palliative Care (25.0%) demonstrating highest rates. There was a temporal trend toward increased S-ACP documentation rate (p<0.001).CONCLUSION: This retrospective, single-center study reveals a low rate of S-ACP documentation irrespective of clinic and specialty. While S-ACP documentation rate should not be construed as a proxy for ACP documentation rate, it nonetheless serves as an important quality metric which may be reported to payers. This study highlights the need to both centralize and standardize reporting of ACP documentation in complex EHR systems.

  View details for DOI 10.1186/s12904-022-01099-9

  View details for PubMedID 36419072

• Updates in intraoperative strategies for enhancing intra-axial brain tumor control. Neuro-oncology Wu, A., Wu, J. Y., Lim, M. 2022; 24 (Supplement_6): S33-S41

  Abstract

  To ensure excellent postoperative clinical outcomes while preserving critical neurologic function, neurosurgeons who manage patients with intra-axial brain tumors can use intraoperative technologies and tools to achieve maximal safe resection. Neurosurgical oncology revolves around safe and optimal extent of resection, which further dictates subsequent treatment regimens and patient outcomes. Various methods can be adapted for treating both primary and secondary intra-axial brain lesions. We present a review of recent advances and published research centered on different innovative tools and techniques, including fluorescence-guided surgery, new methods of drug delivery, and minimally invasive procedural options.

  View details for DOI 10.1093/neuonc/noac170

  View details for PubMedID 36322098

• Trends and outcomes of early and late palliative care consultation for adult patients with glioblastoma: A SEER-Medicare retrospective study. Neuro-oncology practice Wu, A., Ugiliweneza, B., Wang, D., Hsin, G., Boakye, M., Skirboll, S. 2022; 9 (4): 299-309

  Abstract

  Glioblastoma (GBM) carries a poor prognosis despite standard of care. Early palliative care (PC) has been shown to enhance survival and quality of life while reducing healthcare costs for other cancers. This study investigates differences in PC timing on outcomes for patients with GBM.This study used Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1997 to 2016. Based on ICD codes, three groups were defined: (1) early PC within 10 weeks of diagnosis, (2) late PC, and (3) no PC. Outcomes were compared between the three groups.Out of 10 812 patients with GBM, 1648 (15.24%) patients had PC consultation with an overall positive trend over time. There were no significant differences in patient characteristics. The late PC group had significantly higher number of hospice claims (1.06 ± 0.69) compared to those without PC, in the last month of life. There were significant differences in survival among the three groups (P < .0001), with late PC patients with the longest mean time to death from diagnosis (11.72 ± 13.20 months).We present the first investigation of PC consultation prevalence and outcomes, stratified by early versus late timing, for adult GBM patients. Despite an overall increase in PC consultations, only a minority of GBM patients receive PC. Patients with late PC had the longest survival times and had greater hospice use in the last month of life compared to other subgroups. Prospective studies can provide additional valuable information about this unique population of patients with GBM.

  View details for DOI 10.1093/nop/npac026

  View details for PubMedID 35859543

  View details for PubMedCentralID PMC9290893

• Exploration of Clinician Perspectives on Multidisciplinary Tumor Board Function Beyond Clinical Decision-making. JAMA oncology Wong, B. O., Blythe, J. A., Wu, A., Batten, J. N., Kennedy, K. M., Kouaho, A. S., Wren, S. M. 2022

  View details for DOI 10.1001/jamaoncol.2022.1763

  View details for PubMedID 35653129

• Modifiers of and Disparities in Palliative and Supportive Care Timing and Utilization among Neurosurgical Patients with Malignant Central Nervous System Tumors. Cancers Jin, M. C., Hsin, G., Ratliff, J., Thomas, R., Zygourakis, C. C., Li, G., Wu, A. 2022; 14 (10)

  Abstract

  Patients with primary or secondary central nervous system (CNS) malignancies benefit from utilization of palliative care (PC) in addition to other supportive services, such as home health and social work. Guidelines propose early initiation of PC for patients with advanced cancers. We analyzed a cohort of privately insured patients with malignant brain or spinal tumors derived from the Optum Clinformatics Datamart Database to investigate health disparities in access to and utilization of supportive services. We introduce a novel construct, "provider patient racial diversity index" (provider pRDI), which is a measure of the proportion of non-white minority patients a provider encounters to approximate a provider's patient demographics and suggest a provider's cultural sensitivity and exposure to diversity. Our analysis demonstrates low rates of PC, home health, and social work services among racial minority patients. Notably, Hispanic patients had low likelihood of engaging with all three categories of supportive services. However, patients who saw providers categorized into high provider pRDI (categories II and III) were increasingly more likely to interface with supportive care services and at an earlier point in their disease courses. This study suggests that prospective studies that examine potential interventions at the provider level, including diversity training, are needed.

  View details for DOI 10.3390/cancers14102567

  View details for PubMedID 35626171

• An integrated risk model stratifying seizure risk following brain tumor resection among seizure-naive patients without antiepileptic prophylaxis. Neurosurgical focus Jin, M. C., Parker, J. J., Prolo, L. M., Wu, A., Halpern, C. H., Li, G., Ratliff, J. K., Han, S. S., Skirboll, S. L., Grant, G. A. 2022; 52 (4): E3

  Abstract

  The natural history of seizure risk after brain tumor resection is not well understood. Identifying seizure-naive patients at highest risk for postoperative seizure events remains a clinical need. In this study, the authors sought to develop a predictive modeling strategy for anticipating postcraniotomy seizures after brain tumor resection.The IBM Watson Health MarketScan Claims Database was canvassed for antiepileptic drug (AED)- and seizure-naive patients who underwent brain tumor resection (2007-2016). The primary event of interest was short-term seizure risk (within 90 days postdischarge). The secondary event of interest was long-term seizure risk during the follow-up period. To model early-onset and long-term postdischarge seizure risk, a penalized logistic regression classifier and multivariable Cox regression model, respectively, were built, which integrated patient-, tumor-, and hospitalization-specific features. To compare empirical seizure rates, equally sized cohort tertiles were created and labeled as low risk, medium risk, and high risk.Of 5470 patients, 983 (18.0%) had a postdischarge-coded seizure event. The integrated binary classification approach for predicting early-onset seizures outperformed models using feature subsets (area under the curve [AUC] = 0.751, hospitalization features only AUC = 0.667, patient features only AUC = 0.603, and tumor features only AUC = 0.694). Held-out validation patient cases that were predicted by the integrated model to have elevated short-term risk more frequently developed seizures within 90 days of discharge (24.1% high risk vs 3.8% low risk, p < 0.001). Compared with those in the low-risk tertile by the long-term seizure risk model, patients in the medium-risk and high-risk tertiles had 2.13 (95% CI 1.45-3.11) and 6.24 (95% CI 4.40-8.84) times higher long-term risk for postdischarge seizures. Only patients predicted as high risk developed status epilepticus within 90 days of discharge (1.7% high risk vs 0% low risk, p = 0.003).The authors have presented a risk-stratified model that accurately predicted short- and long-term seizure risk in patients who underwent brain tumor resection, which may be used to stratify future study of postoperative AED prophylaxis in highest-risk patient subpopulations.

  View details for DOI 10.3171/2022.1.FOCUS21751

  View details for PubMedID 35364580

• Trends and outcomes of early and late palliative care consultation for adult patients with glioblastoma: A SEER-medicare retrospective study NEURO-ONCOLOGY PRACTICE Wu, A., Ugiliweneza, B., Wang, D., Hsin, G., Boakye, M., Skirboll, S. 2022

  View details for DOI 10.1093/nop/npac026

  View details for Web of Science ID 000808213500001

• Quality of Life and Role of Palliative and Supportive Care for Patients With Brain Metastases and Caregivers: A Review Frontiers in Neurology Wu, A., Ruiz Colon, G. D., Lim, M. 2022; 13

  View details for DOI 10.3389/fneur.2022.806344

• The Challenges and Future of Immunotherapy for Gliomas. Cancer journal (Sudbury, Mass.) Wu, A., Lim, M. 2021; 27 (5): 371-378

  Abstract

  ABSTRACT: Gliomas and glioblastoma comprise the majority of brain malignancies and are difficult to treat despite standard of care and advances in immunotherapy. The challenges of controlling glioma growth and recurrence involve the uniquely immunosuppressive tumor microenvironment and systemic blunting of immune responses. In addition to highlighting key features of glioma and glioblastoma composition and immunogenicity, this review presents several future directions for immunotherapy, such as vaccines and synergistic combination treatment regimens, to better combat these tumors.

  View details for DOI 10.1097/PPO.0000000000000544

  View details for PubMedID 34570451

• Risk of secondary neoplasms after external-beam radiation therapy treatment of pediatric low-grade gliomas: a SEER analysis, 1973-2015. Journal of neurosurgery. Pediatrics Rodrigues, A. J., Jin, M. C., Wu, A., Bhambhvani, H. P., Li, G., Grant, G. A. 2021: 1-9

  Abstract

  Although past studies have associated external-beam radiation therapy (EBRT) with higher incidences of secondary neoplasms (SNs), its effect on SN development from pediatric low-grade gliomas (LGGs), defined as WHO grade I and II gliomas of astrocytic or oligodendrocytic origin, is not well understood. Utilizing a national cancer registry, the authors sought to characterize the risk of SN development after EBRT treatment of pediatric LGG.A total of 1245 pediatric patient (aged 0-17 years) records from 1973 to 2015 were assembled from the Surveillance, Epidemiology, and End Results (SEER) database. Univariable and multivariable subdistribution hazard regression models were used to evaluate the prognostic impact of demographic, tumor, and treatment-related covariates. Propensity score matching was used to balance baseline characteristics. Cumulative incidence analyses measured the time to, and rate of, SN development, stratified by receipt of EBRT and controlled for competing mortality risk. The Fine and Gray semiparametric model was used to estimate future SN risk in EBRT- and non-EBRT-treated pediatric patients.In this study, 366 patients received EBRT and 879 did not. Forty-six patients developed SNs after an LGG diagnosis, and 27 of these patients received EBRT (OR 3.61, 95% CI 1.90-6.95; p < 0.001). For patients alive 30 years from the initial LGG diagnosis, the absolute risk of SN development in the EBRT-treated cohort was 12.61% (95% CI 8.31-13.00) compared with 4.99% (95% CI 4.38-12.23) in the non-EBRT-treated cohort (p = 0.013). Cumulative incidence curves that were adjusted for competing events still demonstrated higher rates of SN development in the EBRT-treated patients with LGGs. After matching across available covariates and again adjusting for the competing risk of mortality, a clear association between EBRT and SN development remained (subhazard ratio 2.26, 95% CI 1.21-4.20; p = 0.010).Radiation therapy was associated with an increased risk of future SNs for pediatric patients surviving LGGs. These data suggest that the long-term implications of EBRT should be considered when making treatment decisions for this patient population.

  View details for DOI 10.3171/2021.1.PEDS20859

  View details for PubMedID 34144522

• Palliative care service utilization and advance care planning issues for adult glioblastoma patients: A systematic review. Wu, A., Colon, G., Aslakson, R., Pollom, E. L., Patel, C. B. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for DOI 10.1200/JCO.2021.39.15_suppl.2036

  View details for Web of Science ID 000708120600321

• Large intramedullary bronchogenic cyst of the cervical spine: illustrative case. Journal of neurosurgery. Case lessons Wu, A., Patel, M., Darbonne, D., Singh, H. 2021; 1 (13): CASE2115

  Abstract

  Spinal bronchogenic cysts are rare entities arising from errors in embryogenesis and consisting of respiratory epithelial cells. To date, there are three other published accounts of intramedullary cysts, which were partially resected and thereby warrant close follow-up and monitoring. The authors present an illustrative case of a patient presenting with Klippel-Feil anomaly and a large intramedullary bronchogenic cyst in the upper cervical spine.The authors noted fusion of the C5-6 laminae as they performed the C2-6 laminectomy. After dural opening, an intramedullary lesion with a smooth, fibrous component emerging from the dorsal spinal cord was immediately observed. The dorsal spinal columns were not involved with this cyst wall or the other smaller cysts, which all contained gray fluid. The cyst walls were partially resected and sent for pathological examination.Spinal developmental cysts are associated with other anatomical anomalies, such as Klippel-Feil anomaly, arising from errors in embryogenesis. For intramedullary lesions such as this patient's bronchogenic cyst, partial resection and decompression are the goals of surgery because aggressive debulking may lead to neurological compromise. Close imaging follow-up is warranted.

  View details for DOI 10.3171/CASE2115

  View details for PubMedID 35855212

  View details for PubMedCentralID PMC9241354

• Large intramedullary bronchogenic cyst of the cervical spine: illustrative case Journal of Neurosurgery: Case Lessons Wu, A., Patel, M., Darbonne, D., Singh, H. 2021; 1 (13): 1-6

  Abstract

  Spinal bronchogenic cysts are rare entities arising from errors in embryogenesis and consisting of respiratory epithelial cells. To date, there are three other published accounts of intramedullary cysts, which were partially resected and thereby warrant close follow-up and monitoring. The authors present an illustrative case of a patient presenting with Klippel-Feil anomaly and a large intramedullary bronchogenic cyst in the upper cervical spine.The authors noted fusion of the C5-6 laminae as they performed the C2-6 laminectomy. After dural opening, an intramedullary lesion with a smooth, fibrous component emerging from the dorsal spinal cord was immediately observed. The dorsal spinal columns were not involved with this cyst wall or the other smaller cysts, which all contained gray fluid. The cyst walls were partially resected and sent for pathological examination.Spinal developmental cysts are associated with other anatomical anomalies, such as Klippel-Feil anomaly, arising from errors in embryogenesis. For intramedullary lesions such as this patient's bronchogenic cyst, partial resection and decompression are the goals of surgery because aggressive debulking may lead to neurological compromise. Close imaging follow-up is warranted.

  View details for DOI 10.3171/CASE2115

  View details for PubMedCentralID PMC9241354

• Palliative Care Service Utilization and Advance Care Planning for Adult Glioblastoma Patients: A Systematic Review Cancers Wu, A., Ruiz Colón, G., Aslakson, R., Pollom, E., Patel, C. 2021; 13 (12)

  Abstract

  Glioblastoma (GBM) has a median overall survival of 16-21 months. As patients with GBM suffer concurrently from terminal cancer and a disease with progressive neurocognitive decline, advance care planning (ACP) and palliative care (PC) are critical. We conducted a systematic review exploring published literature on the prevalence of ACP, end-of-life (EOL) services utilization (including PC services), and experiences among adults with GBM. We searched from database inception until 20 December 2020. Preferred reporting items for systematic reviews guidelines were followed. Included studies were assessed for quality using the Newcastle-Ottawa Scale. The 16 articles were all nonrandomized studies conducted in six countries with all but two published in 2014 or later. ACP documentation varied from 4-55%, PC referral was pursued in 39-40% of cases, and hospice referrals were made for 66-76% of patients. Hospitalizations frequently occurred at the EOL with 20-56% of patients spending over 25% of their overall survival time hospitalized. Many GBM patients do not pursue ACP or have access to PC. There is a dearth of focused and high-quality studies on ACP, PC, and hospice use among adults with GBM. Prospective studies that address these and additional aspects related to EOL care, such as healthcare costs and inpatient supportive care needs, are needed.

  View details for DOI 10.3390/cancers13122867

  View details for PubMedCentralID PMC8228109

• Potential differences between monolingual and bilingual patients in approach and outcome after awake brain surgery. Journal of neuro-oncology ReFaey, K., Tripathi, S., Bhargav, A. G., Grewal, S. S., Middlebrooks, E. H., Sabsevitz, D. S., Jentoft, M., Brunner, P., Wu, A., Tatum, W. O., Ritaccio, A., Chaichana, K. L., Quinones-Hinojosa, A. 2020

  Abstract

  INTRODUCTION: 20.8% of the United States population and 67% of the European population speak two or more languages. Intraoperative different languages, mapping, and localization are crucial. This investigation aims to address three questions between BL and ML patients: (1) Are there differences in complications (i.e. seizures) and DECS techniques during intra-operative brain mapping? (2) Is EOR different? and (3) Are there differences in the recovery pattern post-surgery?METHODS: Data from 56 patients that underwent left-sided awake craniotomy for tumors infiltrating possible dominant hemisphere language areas from September 2016 to June 2019 were identified and analyzed in this study; 14 BL and 42 ML control patients. Patient demographics, education level, and the age of language acquisition were documented and evaluated. fMRI was performed on all participants.RESULTS: 0 (0%) BL and 3 (7%) ML experienced intraoperative seizures (P=0.73). BL patients received a higher direct DECS current in comparison to the ML patients (average=4.7, 3.8, respectively, P=0.03). The extent of resection was higher in ML patients in comparison to the BL patients (80.9 vs. 64.8, respectively, P=0.04). The post-operative KPS scores were higher in BL patients in comparison to ML patients (84.3, 77.4, respectively, P=0.03). BL showed lower drop in post-operative KPS in comparison to ML patients (-4.3,-8.7, respectively, P=0.03).CONCLUSION: We show that BL patients have a lower incidence of intra-operative seizures, lower EOR, higher post-operative KPS and tolerate higher DECS current, in comparison to ML patients.

  View details for DOI 10.1007/s11060-020-03554-0

  View details for PubMedID 32524393

• Evaluating Shunt Survival Following Ventriculoperitoneal Shunting with and without Stereotactic Navigation in Previously Shunt-Naïve Patients. World neurosurgery Jin, M. C., Wu, A. n., Azad, T. D., Feng, A. n., Prolo, L. M., Veeravagu, A. n., Grant, G. A., Ratliff, J. n., Li, G. n. 2020

  View details for DOI 10.1016/j.wneu.2020.01.138

  View details for PubMedID 31996335

• Patterns of Care and Age-Specific Impact of Extent of Resection and Adjuvant Radiotherapy in Pediatric Pineoblastoma. Neurosurgery Jin, M. C., Prolo, L. M., Wu, A. n., Azad, T. D., Shi, S. n., Rodrigues, A. J., Soltys, S. G., Pollom, E. L., Li, G. n., Hiniker, S. M., Grant, G. A. 2020

  Abstract

  Pediatric pineoblastomas are highly aggressive tumors that portend poor outcomes despite multimodal management. Controversy remains regarding optimal disease management.To evaluate patterns of care and optimal clinical management of pediatric pineoblastoma.A total of 211 pediatric (age 0-17 yr) histologically confirmed pineoblastoma patients diagnosed between 2004 and 2015 were queried from the National Cancer Database. Wilcoxon rank-sum statistics and chi-squared analyses were used to compare continuous and categorical variables, respectively. Univariable and multivariable Cox regressions were used to evaluate prognostic impact of covariates. Propensity-score matching was used to balance baseline characteristics.Older patients (age ≥ 4 yr) experienced improved overall survival compared to younger patients (age < 4 yr) (hazard ratio [HR] = 0.41; 95% CI 0.25-0.66). Older patients (adjusted odds ratio [aOR] = 5.21; 95% CI 2.61-10.78) and those residing in high-income regions (aOR = 3.16; 95% CI 1.21-8.61) received radiotherapy more frequently. Radiotherapy was independently associated with improved survival in older (adjusted HR [aHR] = 0.31; 95% CI 0.12-0.87) but not younger (aHR = 0.64; 95% CI 0.20-1.90) patients. The benefits of radiotherapy were more pronounced in patients receiving surgery than in those not receiving surgery (aHR [surgical patients] = 0.23; 95% CI 0.08-0.65; aHR [nonsurgical patients] = 0.46; 95% CI 0.22-0.97). Older patients experienced improved outcomes associated with aggressive resection (P = .041); extent of resection was not associated with survival in younger patients (P = .880).Aggressive tumor resection was associated with improved survival only in older pediatric patients. Radiotherapy was more effective in patients receiving surgery. Age-stratified approaches might allow for improved disease management of pediatric pineoblastoma.

  View details for DOI 10.1093/neuros/nyaa023

  View details for PubMedID 32110805

• Impact of Proton Radiotherapy on Treatment Timing in Pediatric and Adult Patients with Central Nervous System Tumors Neuro-Oncology Practice Jin, M. C., Shi, S., Wu, A., Sandhu, N., Xiang, M., Soltys, S. G., Hiniker, S., Li, G., Pollom, E. L. 2020

  View details for DOI 10.1093/nop/npaa034

• Adverse Events and Bundled Costs after Cranial Neurosurgical Procedures: Validation of the LACE Index Across 40,431 Admissions and Development of the LACE-Cranial Index. World neurosurgery Jin, M. C., Wu, A. n., Medress, Z. A., Parker, J. J., Desai, A. n., Veeravagu, A. n., Grant, G. A., Li, G. n., Ratliff, J. K. 2020

  Abstract

  Anticipating post-discharge complications following neurosurgery remains difficult. The LACE index, based on four hospitalization descriptors, stratifies patients by risk of 30-day post-discharge adverse events but has not been validated in a procedure-specific manner in neurosurgery. Our study sought to explore the utility of the LACE index in cranial neurosurgery population and to develop an enhanced model, LACE-Cranial.The Optum Clinformatics Database was used to identify cranial neurosurgery admissions (2004-2017). Procedures were grouped as trauma/hematoma/ICP, open vascular, functional/pain, skull base, tumor, or endovascular. Adverse events were defined as post-discharge death/readmission. LACE-Cranial was developed using a logistic regression framework incorporating an expanded feature set in addition to the original LACE components.A total of 40,431 admissions were included. Predictions of 30-day readmissions was best for skull-base (AUC=0.636) and tumor (AUC=0.63) admissions but was generally poor. Predictive ability of 30-day mortality was best for functional/pain admissions (AUC=0.957) and poorest for trauma/hematoma/ICP admissions (AUC=0.613). Across procedure types except for functional/pain, a high-risk LACE score was associated with higher post-discharge bundled payment costs. Incorporating features identified to contribute independent predictive value, the LACE-Cranial model achieved procedure-specific 30-day mortality AUCs ranging from 0.904 to 0.98. Prediction of 30-day and 90-day readmissions was also improved, with tumor and skull base cases achieving 90-day readmission AUCs of 0.718 and 0.717, respectively.While the unmodified LACE index demonstrates inconsistent classification performance, the enhanced LACE-Cranial model offers excellent prediction of short-term post-discharge mortality across procedure groups and significantly improved anticipation of short-term post-discharge readmissions.

  View details for DOI 10.1016/j.wneu.2020.10.103

  View details for PubMedID 33127572

• Prognostic Factors and Treatment Patterns in the Management of Giant Cell Glioblastoma WORLD NEUROSURGERY Jin, M. C., Wu, A., Xiang, M., Azad, T. D., Soltys, S. G., Li, G., Pollom, E. L. 2019; 128: E217–E224

  View details for DOI 10.1016/j.wneu.2019.04.103

  View details for Web of Science ID 000475895100024

• Efficacy and toxicity of particle radiotherapy in WHO grade II and grade III meningiomas: a systematic review. Neurosurgical focus Wu, A., Jin, M. C., Meola, A., Wong, H., Chang, S. D. 2019; 46 (6): E12

  Abstract

  OBJECTIVEAdjuvant radiotherapy has become a common addition to the management of high-grade meningiomas, as immediate treatment with radiation following resection has been associated with significantly improved outcomes. Recent investigations into particle therapy have expanded into the management of high-risk meningiomas. Here, the authors systematically review studies on the efficacy and utility of particle-based radiotherapy in the management of high-grade meningioma.METHODSA literature search was developed by first defining the population, intervention, comparison, outcomes, and study design (PICOS). A search strategy was designed for each of three electronic databases: PubMed, Embase, and Scopus. Data extraction was conducted in accordance with the PRISMA guidelines. Outcomes of interest included local disease control, overall survival, and toxicity, which were compared with historical data on photon-based therapies.RESULTSEleven retrospective studies including 240 patients with atypical (WHO grade II) and anaplastic (WHO grade III) meningioma undergoing particle radiation therapy were identified. Five of the 11 studies included in this systematic review focused specifically on WHO grade II and III meningiomas; the others also included WHO grade I meningioma. Across all of the studies, the median follow-up ranged from 6 to 145 months. Local control rates for high-grade meningiomas ranged from 46.7% to 86% by the last follow-up or at 5 years. Overall survival rates ranged from 0% to 100% with better prognoses for atypical than for malignant meningiomas. Radiation necrosis was the most common adverse effect of treatment, occurring in 3.9% of specified cases.CONCLUSIONSDespite the lack of randomized prospective trials, this review of existing retrospective studies suggests that particle therapy, whether an adjuvant or a stand-alone treatment, confers survival benefit with a relatively low risk for severe treatment-derived toxicity compared to standard photon-based therapy. However, additional controlled studies are needed.

  View details for DOI 10.3171/2019.3.FOCUS1967

  View details for PubMedID 31153145

• Combination anti-CXCR4 and anti-PD-1 immunotherapy provides survival benefit in glioblastoma through immune cell modulation of tumor microenvironment. Journal of neuro-oncology Wu, A., Maxwell, R., Xia, Y., Cardarelli, P., Oyasu, M., Belcaid, Z., Kim, E., Hung, A., Luksik, A. S., Garzon-Muvdi, T., Jackson, C. M., Mathios, D., Theodros, D., Cogswell, J., Brem, H., Pardoll, D. M., Lim, M. 2019

  Abstract

  BACKGROUND: Emerging evidence suggests that myeloid cells play a critical role in glioblastoma (GBM) immunosuppression. Disappointing results of recent checkpoint inhibitor trials suggest that combination immunotherapy with alternative agents could be fruitful in overcoming immunosuppression. Overexpression of chemokine receptor CXCR4 is associated with poor prognosis in GBM. We investigate the treatment effects of combination immunotherapy with anti-PD-1 and anti-CXCR4 in a murine glioma model.METHODS: C57BL/6 mice were implanted with GL261-Luc+ glioma cells and randomized into 4 arms: (1) control (2) anti-PD-1 (3) anti-CXCR4, and (4) anti-PD-1 and anti-CXCR4 therapy. Overall survival and median survival were assessed. Cell populations were assessed by flow cytometry.RESULTS: Combination therapy conferred a significant survival benefit compared to control and monotherapy arms. Mice that received combination therapy demonstrated immune memory and decreased populations of immunosuppressive tumor-infiltrating leukocytes, such as monocytic myeloid-derived suppressor cells and microglia within the brain. Furthermore, combination therapy improved CD4+/CD8+ ratios in the brain as well as contributed to increased levels of pro-inflammatory cytokines.CONCLUSIONS: Anti-CXCR4 and anti-PD-1 combination immunotherapy modulates tumor-infiltrating populations of the glioma microenvironment. Targeting myeloid cells with anti-CXCR4 facilitates anti-PD-1 to promote an antitumor immune response and improved survival rates.

  View details for DOI 10.1007/s11060-019-03172-5

  View details for PubMedID 31025274

• Prognostic Factors and Treatment Patterns in the Management of Giant Cell Glioblastoma. World neurosurgery Jin, M. C., Wu, A., Xiang, M., Azad, T. D., Soltys, S. G., Li, G., Pollom, E. L. 2019

  Abstract

  BACKGROUND: There is a lack of literature guiding treatment of giant cell glioblastoma (gcGBM), a rare subtype of glioblastoma (GBM). We used a national hospital-based registry to explore treatment patterns and outcomes associated with gcGBM.METHODS: Adult patients (age 18+) diagnosed with gcGBM or GBM between 2004-2014 were identified from the National Cancer Database (NCDB). Chi-squared analysis and Wilcoxon rank sum testing were used to compare characteristics between the gcGBM and GBM cohorts. Kaplan-Meier statistics, univariable and multivariable Cox regression, and propensity score matching were used to evaluate association between patient, tumor and treatment factors and survival outcomes. Correlation analysis was used to evaluate historical trends in the treatment of gcGBM. Landmark analysis allowed for accounting of immortal time.RESULTS: In total, 683 patients with gcGBM were identified. Patients with gcGBM had improved survival compared to patients with GBM (15.5 months from landmark vs 11.7, p < 0.001). Increased age (p < 0.001) was associated with worse survival while being of female sex (p = 0.023) and having a median income of higher than $63,000 (p = 0.004) predisposed patients to improved outcomes. Patients receiving trimodal therapy (biopsy and/or surgery, radiotherapy, and chemotherapy) experienced better outcomes compared to those receiving either biopsy and/or surgery only or biopsy and/or surgery and radiotherapy without systemic therapy (median survival 17.55 months vs 6.68 months; p < 0.001).CONCLUSION: gcGBM has favorable prognosis compared with GBM and should be aggressively managed with trimodal therapy. Prospective studies on gcGBM are warranted to better characterize gcGBM treatment outcomes.

  View details for PubMedID 31009783

• Thalamic gliomas: Advances in the surgical management NEW TECHNIQUES FOR MANAGEMENT OF INOPERABLE GLIOMAS Hung, A., Wu, A., Jackson, C., Lim, M. edited by Sughrue, M. E., Yang 2019: 117-135

  View details for DOI 10.1016/B978-0-12-813633-1.00011-6

  View details for Web of Science ID 000582656500012