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Balraj S. Jhawar

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Balraj S. Jhawar, Charlie S. Fuchs, Graham A. Colditz, and Meir J. Stampfer

Object. The goal of this study was to investigate the risk of meningioma in relation to exogenous and endogenous sex hormones.

Methods. The study participants were female registered nurses from 11 US states who were between 30 and 55 years of age when they enrolled in the Nurses' Health Study cohort. These women completed biennial questionnaires between 1976 and 1996. All participants were free from cancer and other major medical illness at the onset of the study. The primary endpoint was meningioma as self-reported in biennial and supplemental questionnaires.

During 1,213,522 person-years of follow-up review, 125 cases of meningioma were confirmed. After adjusting for age and body mass index (BMI), compared with postmenopausal women who had never used postmenopausal hormones, the relative risk (RR) for premenopausal women was 2.48 (95% confidence interval [CI] 1.29–4.77; p = 0.01) and the RR for postmenopausal women who received hormone therapy was 1.86 (95% CI 1.07–3.24; p = 0.03). The authors found no excess risk associated with past hormone use. In models that additionally controlled for hormone use and menopausal status, the authors found that, compared with women whose menarche occurred before they were 12 years of age, the RR for women whose menarche occurred at ages 12 through 14 years was 1.29 (95% CI 0.86–1.92; p = 0.21) and the RR for women whose menarche occurred after age 14 years was 1.97 (95% CI 1.06–3.66; p = 0.03). The authors also observed a tendency, albeit nonsignificant, for increased risk of meningioma in parous as opposed to nulliparous women (multivariate RR = 2.39, 95% CI 0.76–7.53; p = 0.14). A trend toward an increasing risk of meningioma with increasing BMI was also noted (p for trend = 0.06). No association was found for past or current use of oral contraceptives.

Conclusions. The risk for meningiomas was increased among women exposed to either endogenous or exogenous sex hormones. An unexpected relationship with increasing age at menarche was also noted; this remains unexplained.

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Balraj S. Jhawar, Demytra Mitsis, and Neil Duggal


Perhaps the single greatest error that a surgeon hopes to avoid is operating at the wrong site. In this report, the authors describe the incidence and possible determinants of incorrect-site surgery (ICSS) among neurosurgeons.


The authors asked neurosurgeons to complete an anonymous survey. These surgeons were asked to report the number of craniotomies and lumbar and cervical discectomies performed during the previous year, as well as whether ICSS had occurred. They were also asked detailed questions regarding the potential determinants of ICSS.


There was a 75% response rate and a 68% survey completion rate. Participating neurosurgeons performed 4695 lumbar and 2649 cervical discectomies, as well as 10,203 craniotomies. Based on this self-reporting, the incidence of wrong-level lumbar surgery was estimated to be 4.5 occurrences per 10,000 operations. The ICSSs per 10,000 cervical discectomies and craniotomies were 6.8 and 2.2, respectively. Neurosurgeons recognized fatigue, unusual time pressure, and emergent operations as factors contributing to ICSS. For spine surgery, in particular, unusual patient anatomy and a failure to verify the operative site by radiography were also commonly reported contributors.


Neurosurgical ICSSs do occur, but are rare events. Although there are significant limitations to the survey-based methodology, the data suggest that the prevention of such errors will require neurosurgeons to recognize risk factors and increase the use of intraoperative imaging.

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Nasser M. F. El-Ghandour, Ahmed A. M. Ezzat, Mohamed A. Zaazoue, Pablo Gonzalez-Lopez, Balraj S. Jhawar, and Mohamed A. R. Soliman


The coronavirus disease 2019 (COVID-19) pandemic has caused dramatic changes in medical education. Social distancing policies have resulted in the rapid adoption of virtual learning (VL) by neurosurgeons as a method to exchange knowledge, but it has been met with variable acceptance. The authors surveyed neurosurgeons from around the world regarding their opinions about VL and how they see the future of neurosurgical conferences.


The authors conducted a global online survey assessing the experience of neurosurgeons and trainees with VL activities. They also questioned respondents about how they see the future of on-site conferences and scientific meetings. They analyzed responses against demographic data, regions in which the respondents practice, and socioeconomic factors by using frequency histograms and multivariate logistic regression models.


Eight hundred ninety-one responses from 96 countries were received. There has been an increase in VL activities since the start of the COVID-19 pandemic. Most respondents perceive this type of learning as positive. Respondents from lower-income nations and regions such as Europe and Central Asia were more receptive to these changes and wanted to see further movement of educational activities (conferences and scientific meetings) into a VL format. The latter desire may be driven by financial savings from not traveling. Most queried neurosurgeons indicated that virtual events are likely to partially replace on-site events.


The pandemic has improved perceptions of VL, and despite its limitations, VL has been well received by the majority of neurosurgeons. Lower-income nations in particular are embracing this technology. VL is still evolving, but its integration with traditional in-person meetings seems inevitable.