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Introduction. Diversity, equity, and inclusion and the goal of reducing healthcare disparities in neurosurgery

William W. Ashley Jr., Sonia Eden, Richard T. Benson, Jeffrey L. Nadel, William A. McDade, Wale Sulaiman, and Sandra Elizabeth Ford

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Letter to the Editor. Tonsillectomy in Chiari malformation type I: is it always the right choice?

Francesca Rizzo, Raffaele De Marco, Gianluca Piatelli, and Marco Pavanello

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The neurosurgeon workforce: a geographical gender-focused analysis of the trends in representation of neurosurgeons and choices in training over 70 years

Alexander D. Smith, Alexa R. Lauinger, Maxine Arnush, Annabelle Shaffer, Aliya Siddiqui, Ashutosh Nayak, Paul M. Arnold, Suguna Pappu, Albert Yu, Ann Stroink, and Wael Hassaneen

OBJECTIVE

Neurosurgeons frequently move throughout their careers, with moves driven by personal and professional factors. In this study, the authors analyzed these migration trends through a dynamic migratory map and statistical review, with a particular focus on differences in education and practice patterns between male and female neurosurgeons.

METHODS

A list containing all board-certified and -affiliated US neurosurgeons practicing in 2019 was obtained from the American Association of Neurological Surgeons. The list was augmented to include demographic and location information for medical school, residency, fellowship(s), and current practice for all neurosurgeons with publicly available data. Migration heatmaps were generated, and migration patterns over 10-year intervals were plotted. A web tool was additionally created to allow for dynamic visualization of this database.

RESULTS

The database included 5307 neurosurgeons with a mean age of 57.2 ± 11.3 years. The female population made up 8.93% of all neurosurgeons, and were found to be more likely to complete fellowships than their male counterparts, at 54.2% and 39.1%, respectively (p < 0.0001). A total of 39.5% of all neurosurgeons completed at least one fellowship. A large proportion of currently practicing US neurosurgeons completed medical school internationally in the 1990s. Recently, there has been a trend in neurosurgeons choosing to practice in the South, emigrating from the Northeast and the Western US Census regions. By population, the Western US region trained the fewest neurosurgeons at 1 per 115,000 residents, and the Northeastern US region trained the most at 1 per 49,000. The web tool provides a simple interface to visualize the database on a world map.

CONCLUSIONS

Diversity, equity, and inclusion in neurosurgery have been a strong point of discussion in recent literature, with neurosurgeons comprising one of the most gender-disparate workforces in the US medical system. This study provides additional metrics to assess these disparities to help motivate further action toward a larger, more diverse neurosurgical community.

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Racial and gender disparities in traumatic brain injury clinical trial enrollment

Momodou G. Bah, Anant Naik, Umaru Barrie, Rajiv Dharnipragada, Sonia V. Eden, and Paul M. Arnold

OBJECTIVE

Despite the increasing number of women and racial/ethnic minorities sustaining traumatic brain injuries (TBIs), they are underrepresented in TBI clinical trials. This study aimed to evaluate gender and racial diversity in enrolled cohorts of TBI clinical trials to identify trends and predictors of increased disparity over time.

METHODS

The authors reviewed TBI clinical trials with reported results registered on the website ClinicalTrials.gov between 2008 and 2022. The studies were assessed for the proportion of women and racial/ethnic minorities enrolled as well as their reporting of race- and gender-specific characteristics such as gender ratio (GR) and Racial Diversity Index (RDI). Further study parameters, including year and duration, phase, trial design, type of funding, and trial completion, were also included.

RESULTS

One hundred thirty-five clinical trials met inclusion criteria, of which 65 and 134 reported race and gender, respectively. Twenty-five trials were found to have existing racial disparity (RDI < 1). Comparatively, industry-funded trials had a 26% greater likelihood of racial disparities (p = 0.026), whereas federally funded trials were 30% less likely to demonstrate racial disparities (p = 0.031). Sixty-six trials had gender disparities (GR < 0.4) present, with federally funded trials showing 37.1% greater rates of gender disparity (p < 0.001, adjusted OR 5.47, 95% CI 2.26–14.25). The impact of funding source on race and gender remained significant despite adjusting for other covariates in the multivariate analyses. Racial disparity was negatively correlated with trial completion rate (p < 0.001). Disparities were not found to improve over the 14-year time span.

CONCLUSIONS

Racial and gender disparities in TBI clinical trial enrollment persist, and the lack of diversity may lead to biased evidence-based medicine. Efforts should be made to increase the representation of women and racial/ethnic minorities in TBI clinical trials to ensure equitable access to effective treatments for all populations.

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Racial disparities in incidence, treatment, and survival in adult brain metastases: a 10-year national database analysis

Sam H. Jiang, Mounika Bhaskara, Daniel Deysher, Morteza Sadeh, John Souter, and Ankit I. Mehta

OBJECTIVE

The aim of this study was to assess demographic and racial disparities in incidence, treatment, and survival of adults with metastatic malignancy to the brain.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) Program database, the authors identified adults with nonprimary brain metastases between 2010 and 2019. Incidence was calculated for all 10 years while data from 2010 to 2014 were used for survival analysis. The primary outcome measure was all-cause mortality within 5 years, assessed by 6-month, 1-year, 2-year, and 5-year survival rates. Chi-square tests of independence and one-way ANOVA were used to compare categorical and continuous measures, respectively, between non-Hispanic White (NHW), Hispanic White (HW), Black, and Asian/Pacific Islander (API) patients. A multivariable Cox proportional hazards model was developed to evaluate the risk of death within 5 years.

RESULTS

A total of 64,690 patient records were identified and analyzed following exclusion based on age (patients > 84 years or < 18 years were excluded), missing race data, and missing survival data. Incidences are reported per 100,000 adults. The incidence of brain metastases increased from 2.59 in 2010 to 2.78 in 2019, with an average 10-year incidence of 2.72. API patients had the highest population-adjusted incidence (3.52), followed by NHW (2.99), Black (2.32), and HW (1.59) patients. Black patients were the most likely to have low income and single status, while API patients were the most likely to have high income and married status. Subsequently, Black patients had the shortest survival time (9.05 months vs 9.19 months for NHW vs 12.93 months for HW vs 15.89 months for API patients, p < 0.001). After controlling for the effect of socioeconomic factors on survival, the multivariable analysis showed that Black (HR 0.91, 95% CI 0.88–0.94), HW (HR 0.73, 95% CI 0.69–0.76), and API (HR 0.69, 95% CI 0.66–0.73) patients all had a survival advantage compared with NHW patients. Surgery also conferred a strong survival advantage (HR 0.47, 95% CI 0.44–0.49).

CONCLUSIONS

The incidence of brain metastases has increased slightly between 2010 and 2019, with the highest rate in API patients. Black patients had the lowest survival, potentially due to poor socioeconomic status and lower rates of surgery and chemotherapy. Black patients were the most likely to not be recommended surgery, suggesting a discrepancy in services offered to these patients. More research is warranted to understand the underlying causes of these disparities.

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Reducing implicit bias in the neurosurgery application and interview process: a single-institution experience

Georgia M. Wong, Kelsey Cobourn, Kitara Smith, Michael M. Covell, Ehsan Dowlati, Jeffrey M. Breton, Gnel Pivazyan, and M. Nathan Nair

OBJECTIVE

The neurosurgical match is a challenging process for applicants and programs alike. Programs must narrow a wide field of applicants to interview and then determine how to rank them after limited interaction. To streamline this, programs commonly screen applicants using United States Medical Licensing Examination (USMLE) Step scores. However, this approach removes nuance from a consequential decision and exacerbates existing biases. The primary objective of this study was to demonstrate the feasibility of effecting minor modifications to the residency application process, as the authors have done at their institution, specifically by reducing the prominence of USMLE board scores and Alpha Omega Alpha (AΩA) status, both of which have been identified as bearing racial biases.

METHODS

At the authors’ institution, residents and attendings holistically reviewed applications with intentional redundancy so that every file was reviewed by two individuals. Reviewers were blinded to applicants’ photographs and test scores. On interview day, the applicant was evaluated for their strength in three domains: knowledge, commitment to neurosurgery, and integrity. For rank discussions, applicants were reviewed in the order of their domain scores, and USMLE scores were unblinded. A regression analysis of the authors’ rank list was made by regressing the rank list by AΩA status, Step 1 score, Step 2 score, subinternship, and total interview score.

RESULTS

No variables had a significant effect on the rank list except total interview score, for which a single-point increase corresponded to a 15-position increase in rank list when holding all other variables constant (p < 0.05).

CONCLUSIONS

The goal of this holistic review and domain-based interview process is to mitigate bias by shifting the focus to selected core qualities in lieu of traditional metrics. Since implementation, the authors’ final rank lists have closely reflected the total interview score but were not significantly affected by board scores or AΩA status. This system allows for the removal of known sources of bias early in the process, with the aim of reducing potential downstream effects and ultimately promoting a final list that is more reflective of stated values.

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The role of limited access to students from more diverse nonfeeder medical schools in creating diversity inequities in neurosurgical residency

Benjamin R. Klein, Mareshah N. Sowah, and Allan D. Levi

OBJECTIVE

Improving racial/ethnic diversity in neurosurgery is a long-standing issue that needs to be addressed. The positive correlation between medical students with home neurosurgery programs and successful matriculation into neurosurgical residency is well documented. In this article, the authors explored the relationship between decreased racial/ethnic diversity in neurosurgery residency programs and racial/ethnic diversity in feeder medical schools.

METHODS

The authors conducted a standardized review of the literature to evaluate potential causes for decreased racial/ethnic diversity within neurosurgery. Additionally, they calculated the average enrollment of Black/African American medical students at the top 5 neurosurgery feeder medical schools (determined by Antar et al. following the 2014–2020 match cycles) during the 2021–2022 school year and compared that with the enrollment at US allopathic medical schools with the highest enrollment of Black/African American students. They also compared these two groups in terms of how many students they sent into neurosurgery residency programs from 2014 to 2020. For each of these comparisons, the authors conducted a two-sample t-test to evaluate correlation between these two variables.

RESULTS

There was significantly lower average enrollment of Black/African American students at the top 5 feeder medical programs into neurosurgery residency (80.6 ± 8.32) compared with the top 5 medical schools with Black/African American enrollment in the 2021–2022 school year (279 ± 122.00, p < 0.05). The authors also found a significant increase in the number of students entering neurosurgery residency programs between the top 5 feeder medical programs into neurosurgery residency (30.8 ± 6.06) and the top 5 medical programs for Black/African American enrollment (6 ± 6.16, p < 0.0001).

CONCLUSIONS

In this paper, the authors examined, through a Black/African American lens, the role of racial/ethnic diversity in medical schools that historically send many students to neurosurgery residency. This study sought to provide insight into this problem and examine how Black/African American students from nonfeeder medical schools are disproportionately affected. The authors’ findings suggest that the lack of Black/African American representation in neurosurgery is strongly correlated with the diversity efforts of medical schools. Lastly, the authors highlight the University of Miami’s Summer Research Scholarship in Neurosurgery for Medical Students and other programs as potential solutions to combat the lack of racial/ethnic diversity in neurosurgery.

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Scoping review on the state of racial disparities literature in the treatment of neurosurgical disease: a call for action

Edwin Owolo, Andreas Seas, Brandon Bishop, Jacob Sperber, Zoey Petitt, Alissa Arango, Seeley Yoo, Sharrieff Shah, Julia B. Duvall, Eli Johnson, Nancy Abu-Bonsrah, Samantha Kaplan, Sonia Eden, William W. Ashley Jr., Theresa Williamson, and C. Rory Goodwin

OBJECTIVE

Racial disparities are ubiquitous across medicine in the US. This study aims to assess the evidence of racial disparities within neurosurgery and across its subspecialties, with a specific goal of quantifying the distribution of articles devoted to either identifying, understanding, or reducing disparities.

METHODS

The authors searched the MEDLINE, EMBASE, and Scopus databases by using keywords to represent the concepts of neurosurgery, patients, racial disparities, and specific study types. Two independent reviewers screened the article titles and abstracts for relevance. A third reviewer resolved conflicts. Data were then extracted from the included articles and each article was categorized into one of three phases: identifying, understanding, or reducing disparities. This review was conducted in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

Three hundred seventy-one studies published between 1985 and 2023 were included. The distribution of racial disparities literature was not equally spread among specialties, with spine representing approximately 48.3% of the literature, followed by tumor (22.1%) and general neurosurgery (12.9%). Most studies were dedicated to identifying racial disparities (83.6%). The proportion of literature devoted to understanding and reducing disparities was much lower (15.1% and 1.3%, respectively). Black patients were the most negatively impacted racial/ethnic group in the review (63.3%). The Hispanic or Latino ethnic group was the second most negatively impacted (25.1%). The following categories—other outcomes (28.0%), the offering of treatment (21.6%), complications (18.6%), and survival (16.7%)—represented the most frequently measured outcomes.

CONCLUSIONS

Although strides have been taken to identify racial disparities within neurosurgery, fewer studies have focused on understanding and reducing these disparities. The tremendous rise of literature within this domain but the relative paucity of solutions necessitates the study of targeted interventions to provide equitable care for all patients undergoing neurosurgical treatment.

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Utility of the material community deprivation index as a metric to identify at-risk children for severe traumatic brain injury

Amber L. Gaulden, Stephen Trinidad, Suzanne Moody, Meera Kotagal, Francesco T. Mangano, and Smruti K. Patel

OBJECTIVE

Pediatric traumatic brain injury (TBI) is a significant cause of morbidity and mortality with lasting effects including neurological deficits and psychological comorbidities. Recent studies have shown that social determinants of health are key factors that impact clinical outcomes in other pediatric traumatic injuries, suggesting that these health disparities may have a significant impact on patients sustaining TBI as well. The purpose of this study was to retrospectively review a cohort of pediatric patients diagnosed with TBI and elucidate the relationships among socioeconomic deprivation, patient-specific demographics, and morbidity and mortality.

METHODS

The authors conducted a retrospective cross-sectional analysis of pediatric patients (≤ 18 years of age) treated for TBI at a level I pediatric trauma center between 2016 and 2020. Patients with concussion-related injuries without intracranial findings and those with nonaccidental trauma were excluded from the study. In addition to evaluating basic patient demographics, the authors geocoded patient addresses to allow identification of the patient’s home census tract using the material community deprivation index (MCDI). The MCDI is a unique composite index score created by the combination of six census variables and ranges from 0 to 1 in severity.

RESULTS

Of the 513 patients included in this study, 71 (13.8%) were diagnosed with severe TBI, 28 (5.5%) with moderate TBI, and 414 (80.7%) with mild TBI. Patients in quartile 4 (MCDI ≥ 0.45) were at a significantly higher risk of having a severe TBI than patients in quartile 1 (OR 2.29, 95% CI 1.1–4.71; p = 0.02). Black patients were more likely to have a firearm-related TBI (OR 3.74, 95% CI 2.01–8.7; p = 0.018) than non-Black patients. Patients who lived in a neighborhood with a lower MCDI were significantly more likely to be discharged home than those who lived in an area with a higher MCDI (OR 2.78, 95% CI 7.90–32.93; p < 0.001).

CONCLUSIONS

This study demonstrated that inequities continue to exist within the pediatric TBI population and that the MCDI is a valuable tool to identify at-risk subpopulations. More specifically, patients who lived in a neighborhood with a higher MCDI were at higher risk of sustaining a severe TBI. By partnering with communities, families, and policymakers, healthcare providers could serve as advocates for these patients and work to minimize the social disparities that continue to exist.

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Anticoagulation for the treatment of septic cerebral venous sinus thrombosis in the setting of pediatric sinogenic and otogenic intracranial infections

Pearl A. Sutter, Megan G. Anderson, Ronald Sahyouni, Jillian Plonsker, Vijay M. Ravindra, David D. Gonda, Michael L. Levy, Klaudia Dziugan, Megan Votoupal, Michael DeCuypere, Nathan K. Leclair, Sophia J. Angelo, Patrick J. Halloran, Jonathan E. Martin, Markus J. Bookland, Ian C. Michelow, Laura McKay, and David S. Hersh

OBJECTIVE

Septic cerebral venous sinus thrombosis (CVST) is a recognized complication of pediatric sinogenic and otogenic intracranial infections. The optimal treatment paradigm remains controversial. Proponents of anticoagulation highlight its role in preventing thrombus propagation and promoting recanalization, while others cite the risk of hemorrhagic complications, especially after a neurosurgical procedure for an epidural abscess or subdural empyema. Here, the authors investigated the diagnosis, management, and outcomes of pediatric patients with sinogenic or otogenic intracranial infections and a septic CVST.

METHODS

All patients 21 years of age or younger, who presented with an intracranial infection in the setting of sinusitis or otitis media and who underwent neurosurgical treatment at Connecticut Children’s, Rady Children’s Hospital–San Diego, or Ann and Robert H. Lurie Children’s Hospital of Chicago from March 2015 to March 2023, were retrospectively reviewed. Demographic, clinical, and radiological data were systematically collated.

RESULTS

Ninety-six patients were treated for sinusitis-related and/or otitis media–related intracranial infections during the study period, 15 (15.6%) of whom were diagnosed with a CVST. Of the 60 patients who presented prior to the COVID-19 pandemic, 6 (10.0%) were diagnosed with a septic CVST, whereas of the 36 who presented during the COVID-19 pandemic, 9 (25.0%) had a septic CVST (p = 0.050). The superior sagittal sinus was involved in 12 (80.0%) patients and the transverse and/or sigmoid sinuses in 4 (26.7%). Only 1 (6.7%) patient had a fully occlusive thrombus. Of the 15 patients with a septic CVST, 11 (73.3%) were initiated on anticoagulation at a median interval of 4 (IQR 3–5) days from the most recent neurosurgical procedure. Five (45.5%) patients who underwent anticoagulation demonstrated complete recanalization on follow-up imaging, and 4 (36.4%) had partial recanalization. Three (75.0%) patients who did not undergo anticoagulation demonstrated complete recanalization, and 1 (25.0%) had partial recanalization. None of the patients treated with anticoagulation experienced hemorrhagic complications.

CONCLUSIONS

Septic CVST is frequently identified among pediatric patients undergoing neurosurgical intervention for sinogenic and/or otogenic intracranial infections and may have become more prevalent during the COVID-19 pandemic. Anticoagulation can be used safely in the acute postoperative period if administered cautiously, in a monitored setting, and with interval cross-sectional imaging. However, some patients exhibit excellent outcomes without anticoagulation, and further studies are needed to identify those who may benefit the most from anticoagulation.