Nitin Agarwal, Phillip A. Choi, David O. Okonkwo, Daniel L. Barrow, and Robert M. Friedlander
Application for a residency position in neurosurgery is a highly competitive process. Visiting subinternships and interviews are integral parts of the application process that provide applicants and programs with important information, often influencing rank list decisions. However, the process is an expensive one that places significant financial burden on applicants. In this study, the authors aimed to quantify expenses incurred by 1st-year neurosurgery residents who matched into a neurosurgery residency program in 2014 and uncover potential trends in expenses.
A 10-question survey was distributed in partnership with the Society of Neurological Surgeons to all 1st-year neurosurgery residents in the United States. The survey asked respondents about the number of subinternships, interviews, and second looks (after the interview) attended and the resultant costs, the type of program match, preferences for subinternship interviews, and suggestions for changes they would like to see in the application process. In addition to compiling overall results, also examined were the data for differences in cost when stratifying for region of the medical school or whether the respondent had contact with the program they matched to prior to the interview process (matched to home or subinternship program).
The survey had a 64.4% response rate. The mean total expenses for all components of the application process were US $10,255, with interview costs comprising the majority of the expenses (69.0%). No difference in number of subinternships, interviews, or second looks attended, or their individual and total costs, was seen for applicants from different regions of the United States. Respondents who matched to their home or subinternship program attended fewer interviews than respondents who had no prior contact with their matched program (13.5 vs 16.4, respectively, p = 0.0023) but incurred the same overall costs (mean $9774 vs $10,566; p = 0.58).
Securing a residency position in neurosurgery is a costly process for applicants. No differences are seen when stratifying by region of medical school attended or contact with a program prior to interviewing. Interview costs comprise the majority of expenses for applicants, and changes to the application process are needed to control costs incurred by applicants.
Nir Shimony, Travis Dailey, David Barrow, Anh Bui, Mohammad Hassan A. Noureldine, Meleine Martínez-Sosa, Luis F. Rodriguez, Carolyn M. Carey, Gerald F. Tuite, and George I. Jallo
Pediatric traumatic brain injury (TBI) is the leading cause of death among children and is a significant cause of morbidity. However, the majority of injuries are mild (Glasgow Coma Scale score 13–15) without any need for neurosurgical intervention, and clinically significant neurological decline rarely occurs. Although the question of repeat imaging within the first 24 hours has been discussed in the past, the yield of short-term follow-up imaging has never been thoroughly described. In this paper, the authors focus on the yield of routine repeat imaging for pediatric mild TBI (mTBI) at the first clinic visit following hospital discharge.
The authors conducted a retrospective review of patients with pediatric brain trauma who had been admitted to Johns Hopkins All Children’s Hospital (JHACH). Patients with mTBI were identified, and their presentation, hospital course, and imaging results were reviewed. Those pediatric patients with mTBI who had undergone no procedure during their initial admission (only conservative treatment) were eligible for inclusion in the study. Two distinct groups were identified: patients who underwent repeated imaging at their follow-up clinic visit and those who underwent only clinical evaluation. Each case was assessed on whether the follow-up imaging had changed the follow-up course.
Between 2010 and 2015, 725 patients with TBI were admitted to JHACH. Of those, 548 patients qualified for analysis (i.e., those with mTBI who received conservative treatment without any procedure and were seen in the clinic for follow-up evaluation within 8 weeks after the trauma). A total of 392 patients had only clinic follow-up, without any diagnostic imaging study conducted as part of their clinic visit, whereas the other 156 patients underwent repeat MRI. Only 1 patient had a symptomatic change and was admitted after undergoing imaging. For 30 patients (19.2%), it was decided after imaging to continue the neurosurgical follow-up, which is a change from the institutional paradigm after mTBI. None of these patients had a change in neurological status, and all had a good functional status. All of these patients had one more follow-up in the clinic with new MRI, and none of them required further follow-up.
Children with mTBI are commonly followed up in the ambulatory clinic setting. The authors believe that for children with mTBI, normal clinical examination, and no new symptoms, there is no need for routine ambulatory imaging since the clinical yield of such is relatively low.
Ofer Sadan, Hannah Waddel, Reneé Moore, Chen Feng, Yajun Mei, David Pearce, Jacqueline Kraft, Cederic Pimentel, Subin Mathew, Feras Akbik, Pouya Ameli, Alexis Taylor, Lisa Danyluk, Kathleen S. Martin, Krista Garner, Jennifer Kolenda, Amit Pujari, William Asbury, Blessing N. R. Jaja, R. Loch Macdonald, C. Michael Cawley, Daniel L. Barrow, and Owen Samuels
Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, the authors describe their experience with intrathecal (IT) nicardipine for this indication.
Patients admitted to the Emory University Hospital neuroscience ICU between 2012 and 2017 with nontraumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Using a propensity-score model, this patient cohort was compared to patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository who did not receive IT nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events.
The analysis included 1351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n = 859), the treated group was significantly younger (mean age 51.1 ± 12.4 years vs 56.7 ± 14.1 years, p < 0.001), had a higher World Federation of Neurosurgical Societies score and modified Fisher grade, and were more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs 11.3%, p < 0.001). Treatment with IT nicardipine decreased the daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increased rate of bacterial ventriculitis (3.1% vs 2.7%, p > 0.1), yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs 8.8%, p < 0.01). In a propensity score comparison to the SAHIT database, the odds ratio (OR) to develop DCI with IT nicardipine treatment was 0.61 (95% confidence interval [CI] 0.44–0.84), and the OR to have a favorable functional outcome (modified Rankin Scale score ≤ 2) was 2.17 (95% CI 1.61–2.91).
IT nicardipine was associated with improved outcome and reduced DCI compared with propensity-matched controls. There was an increased need for permanent CSF diversion but no other safety issues. These data should be considered when selecting medications and treatments to study in future randomized controlled clinical trials for SAH.