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Ahmed Jorge, Michael D. White and Nitin Agarwal

OBJECTIVE

Individuals with a spinal cord injury (SCI) in socioeconomically disadvantaged settings (e.g., rural or low income) have different outcomes than their counterparts; however, a contemporary literature review identifying and measuring these outcomes has not been published. Here, the authors’ aim was to perform a systematic review and identify these parameters in the hope of providing tangible targets for future clinical research efforts.

METHODS

A systematic review was performed to find English-language articles published from 2007 to 2017 in the PubMed/MEDLINE, EMBASE, and SCOPUS databases. Studies evaluating any outcomes related to patients with an SCI and in a low-resource setting were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a flowchart was created. Of the 403 articles found, 31 underwent complete review and 26 were eligible for study inclusion. According to the current study criteria, any case studies, studies in less developed countries, studies including and not separating other types of neurological disorders, studies not assessing the effects of a low-resource setting on outcomes in patients with SCI, and studies evaluating the causes of SCI in a low-resource setting were excluded.

RESULTS

In SCI patients, a lower income was a predictor of death (OR 2.1, 95% CI 1.7–2.6, p = 0.0002). Moreover, secondary outcomes such as pain intensities (OR 3.32, 95% CI 2.21–4.49, p < 0.001), emergency room visits (11% more likely, p = 0.006), and pressure ulcer formation (OR 2.1, 95% CI 1.5–3.0, p < 0.001) were significantly higher in the lower income brackets. Rurality was also a factor and was significantly associated with increased emergency room visits (OR 1.5, 95% CI 1.1–2.1, p = 0.01) and lower outpatient service utilization (incidence rate ratio [IRR] 0.57, 95% CI 0.35–0.93, p < 0.05).

CONCLUSIONS

The authors showed that individuals in a low-resource setting who have suffered an SCI have significantly different outcomes than their counterparts. These specific outcomes are promising targets for future research efforts that focus on improving health conditions among this population.

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A longitudinal survey of adult spine and peripheral nerve case entries during neurosurgery residency training

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Nitin Agarwal, Michael D. White and D. Kojo Hamilton

OBJECTIVE

Currently, there is a lack of research assessing residents’ operative experience and caseload variability. The current study utilizes data from the Accreditation Council for Graduate Medical Education (ACGME) case log system to analyze national trends in neurosurgical residents’ exposure to adult spinal procedures.

METHODS

Prospectively populated ACGME resident case logs from 2013 to 2017 were retrospectively reviewed. The reported number of spinal procedures was compared to the ACGME minimum requirements for each surgical category pertaining to adult spine surgery. A linear regression analysis was conducted to identify changes in operative caseload by residents graduating during the study period, as well as a one-sample t-test using IBM SPSS software to compare the mean number of procedures in each surgical category to the ACGME required minimums.

RESULTS

A mean of 427.42 total spinal procedures were performed throughout residency training for each of the 877 residents graduating between 2013 and 2017. The mean number of procedures completed by graduating residents increased by 19.96 (r2 = 0.95) cases per year. The number of cases in every procedural subspecialty, besides peripheral nerve operations, significantly increased during this time. The two procedural categories with the largest changes were anterior and posterior cervical approaches for decompression/stabilization, which increased by 8.78% per year (r2 = 0.95) and 9.04% per year (r2 = 0.95), respectively. There was also a trend of increasing cases logged for lead resident surgeons and a decline in cases logged for senior resident surgeons. Residents’ mean caseloads during residency were found to be vastly greater than the ACGME required minimums: residents performed at least twice as many procedures as the required minimums in every surgical category.

CONCLUSIONS

Graduating neurosurgical residents reported increasing case volumes for adult spinal cases during this 5-year interval. An increase in logged cases for lead resident surgeons as opposed to senior resident surgeons indicates that residents were logging more cases in which they had a more critical role in the procedure. Moreover, the average resident was noted to perform more than twice the number of procedures required by the ACGME in every surgical category, indicating that neurosurgical residents are getting greater exposure to spine surgery than expected. Given the known correlation between case volume and improved surgical outcomes, this data demonstrates each graduating neurosurgical residency class experiences an augmented training in spine surgery.

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Nitin Agarwal, Michael D. White, Jonathan Cohen, L. Dade Lunsford and D. Kojo Hamilton

OBJECTIVE

The purpose of this study was to analyze national trends in adult cranial cases performed by neurological surgery residents as logged into the Accreditation Council for Graduate Medical Education (ACGME) system.

METHODS

The ACGME resident case logs were retrospectively reviewed for the years 2009–2017. In these reports, the national average of cases performed by graduating residents is organized by year, type of procedure, and level of resident. These logs were analyzed in order to evaluate trends in residency experience with adult cranial procedures. The reported number of cranial procedures was compared to the ACGME neurosurgical minimum requirements for each surgical category. A linear regression analysis was conducted in order to identify changes in the average number of procedures performed by residents graduating during the study period. Additionally, a 1-sample t-test was performed to compare reported case volumes to the ACGME required minimums.

RESULTS

An average of 577 total cranial procedures were performed throughout residency training for each of the 1631 residents graduating between 2009 and 2017. The total caseload for graduating residents upon completion of training increased by an average of 26.59 cases each year (r2 = 0.99). Additionally, caseloads in most major procedural subspecialty categories increased; this excludes open vascular and extracranial vascular categories, which showed, respectively, a decrease and no change. The majority of cranial procedures performed throughout residency pertained to tumor (mean 158.38 operations), trauma (mean 102.17 operations), and CSF diversion (mean 76.12 operations). Cranial procedures pertaining to the subspecialties of trauma and functional neurosurgery showed the greatest rise in total procedures, increasing at 8.23 (r2 = 0.91) and 6.44 (r2 = 0.95) procedures per graduating year, respectively.

CONCLUSIONS

Neurosurgical residents reported increasing case volumes for most cranial procedures between 2009 and 2017. This increase was observed despite work hour limitations set forth in 2003 and 2011. Of note, an inverse relationship between open vascular and endovascular procedures was observed, with a decrease in open vascular procedures and an increase in endovascular procedures performed during the study period. When compared to the ACGME required minimums, neurosurgery residents gained much more exposure to cranial procedures than was expected. Additionally, a larger caseload throughout training suggests that residents are graduating with greater competency and experience in cranial neurosurgery.

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Nitin Agarwal, Michael D. White, Susan C. Pannullo and Lola B. Chambless

OBJECTIVE

Resident attrition creates a profound burden on trainees and residency programs. This study aims to analyze trends in resident attrition in neurological surgery.

METHODS

This study followed a cohort of 1275 residents who started neurosurgical residency from 2005 to 2010. Data obtained from the American Association of Neurological Surgeons (AANS) included residents who matched in neurosurgery during this time. Residents who did not finish their residency training at the program in which they started were placed into the attrition group. Residents in the attrition group were characterized by one of five outcomes: transferred neurosurgery programs; transferred to a different specialty; left clinical medicine; deceased; or unknown. A thorough internet search was conducted for residents who did not complete their training at their first neurosurgical program. Variables leading to attrition were also analyzed, including age, sex, presence of advanced degree (Ph.D.), postgraduate year (PGY), and geographical region of program.

RESULTS

Residents starting neurosurgical residency from 2005 to 2010 had an overall attrition rate of 10.98%. There was no statistically significant difference in attrition rates among the years (p = 0.337). The outcomes for residents in the attrition group were found to be as follows: 33.61% transferred neurosurgical programs, 56.30% transferred to a different medical specialty, 8.40% left clinical medicine, and 1.68% were deceased. It was observed that women had a higher attrition rate (18.50%) than men (10.35%). Most attrition (65.07%) occurred during PGY 1 or 2. The attrition group was also observed to be significantly older at the beginning of residency training, with a mean of 31.69 years of age compared to 29.31 in the nonattrition group (p < 0.001). No significant difference was observed in the attrition rates for residents with a Ph.D. (9.86%) compared to those without a Ph.D. (p = 0.472).

CONCLUSIONS

A majority of residents in the attrition group pursued training in different medical specialties, most commonly neurology, radiology, and anesthesiology. Factors associated with an increased rate of attrition were older age at the beginning of residency, female sex, and junior resident (PGY-1 to PGY-2). Resident attrition remains a significant problem within neurosurgical training, and future studies should focus on targeted interventions to identify individuals at risk to help them succeed in their medical careers.

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Michael D. White, Kristy Latour, Martina Giordano, Tavis Taylor and Nitin Agarwal

OBJECTIVE

There is an increasing trend among patients and their families to seek medical knowledge on the internet. Patients undergoing surgical interventions, including lateral lumbar interbody fusion (LLIF), often rely on online videos as a first source of knowledge to familiarize themselves with the procedure. In this study the authors sought to investigate the reliability and quality of LLIF-related online videos.

METHODS

In December 2018, the authors searched the YouTube platform using 3 search terms: lateral lumbar interbody fusion, LLIF surgery, and LLIF. The relevance-based ranking search option was used, and results from the first 3 pages were investigated. Only videos from universities, hospitals, and academic associations were included for final evaluation. By means of the DISCERN instrument, a validated measure of reliability and quality for online patient education resources, 3 authors of the present study independently evaluated the quality of information.

RESULTS

In total, 296 videos were identified by using the 3 search terms. Ten videos met inclusion criteria and were further evaluated. The average (± SD) DISCERN video quality assessment score for these 10 videos was 3.42 ± 0.16. Two videos (20%) had an average score above 4, corresponding to a high-quality source of information. Of the remaining 8 videos, 6 (60%) scored moderately, in the range of 3–4, indicating that the publication is reliable but important information is missing. The final 2 videos (20%) had a low average score (2 or below), indicating that they are unlikely to be of any benefit and should not be used. Videos with intraoperative clips were significantly more popular, as indicated by the numbers of likes and views (p = 0.01). There was no correlation between video popularity and DISCERN score (p = 0.104). In August 2019, the total number of views for the 10 videos in the final analysis was 537,785.

CONCLUSIONS

The findings of this study demonstrate that patients who seek to access information about LLIF by using the YouTube platform will be presented with an overall moderate quality of educational content on this procedure. Moreover, compared with videos that provide patient information on treatments used in other medical fields, videos providing information on LLIF surgery are still exiguous. In view of the increasing trend to seek medical knowledge on the YouTube platform, and in order to support and optimize patient education on LLIF surgery, the authors encourage academic neurosurgery institutions in the United States and worldwide to implement the release of reliable video educational content.

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Alpesh A. Patel, Peter G. Whang, Andrew P. White, Michael G. Fehlings and Alexander R. Vaccaro

The process of publishing scientific research can be hampered by potential pitfalls for journals and researchers alike; the definition and determination of authorship, legal documentation, data accuracy, and disclosure of financial conflicts of interest are all examples. In the current article, the authors discuss the challenges related to scientific medical writing and provide updated recommendations for both the prevention and management of these issues.

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Assessment of level of consciousness following severe neurological insult

A comparison of the psychometric qualities of the Glasgow Coma Scale and the Comprehensive Level of Consciousness Scale

Daniel E. Stanczak, James G. White III, William D. Gouview, Kurt A. Moehle, Michael Daniel, Thomas Novack and Charles J. Long

✓ An alternative method of coma assessment is presented and compared with the Glasgow Coma Scale. The merits of the Comprehensive Level of Consciousness Scale as a research tool are presented. An analysis of 101 consecutive consciousness-impaired patients with their short-term outcome is presented.

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Ryszard M. Pluta, Carla S. Jung, Judith Harvey-White, Anne Whitehead, Sabrina Shilad, Michael G. Espey and Edward H. Oldfield

Object. Increased cerebrospinal fluid (CSF) levels of asymmetric dimethyl l-arginine (ADMA), an endogenous inhibitor of endothelial nitric oxide synthase (eNOS), are associated with delayed vasospasm after subarachnoid hemorrhage (SAH); however, the source, cellular mechanisms, and pharmacological inhibition of ADMA production following SAH are unknown.

Methods. In an in vitro experiment involving human umbilical vein endothelial cells (HUVECs), the authors examined mechanisms potentially responsible for increased ADMA levels during vasospasm and investigated whether this increase can be inhibited pharmacologically. In a second study, an in vivo experiment, the authors used probucol, which effectively inhibited ADMA increase in HUVEC cultures in vitro, in a randomized double-blind placebo-controlled experiment in a primate model of delayed cerebral vasospasm after SAH.

Oxidized low-density lipids (OxLDLs; positive control; p < 0.02) and bilirubin oxidation products (BOXes; p < 0.01), but not oxyhemoglobin (p = 0.74), increased ADMA levels in HUVECs. Probucol inhibited changes in ADMA levels evoked by either OxLDLs (p < 0.001) or BOXes (p < 0.01). Comparable changes were observed in cell lysates. In vivo probucol (100 mg/kg by mouth daily) did not alter serum ADMA levels on Days 7, 14, and 21 after SAH compared with levels before SAH, and these levels were not different from those observed in the placebo group (p = 0.3). Despite achieving therapeutic levels in plasma and measurable levels in CSF, probucol neither prevented increased CSF ADMA levels nor the development of vasospasm after SAH. Increased CSF ADMA and decreased nitrite levels in both groups were strongly associated with the degree of delayed vasospasm after SAH (correlation coefficient [CC] 0.5, 95% confidence interval [CI] 0.19–0.72, p < 0.002 and CC −0.43, 95% CI −0.7 to < 0.05, p < 0.03, respectively).

Conclusions. Bilirubin oxidation products, but not oxyhemoglobin, increased ADMA levels in the HUVEC. Despite its in vitro ability to lower ADMA levels, probucol failed to inhibit increased CSF ADMA and decreased nitrite levels, and it did not prevent delayed vasospasm in a primate SAH model.

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Carla S. Jung, Brian A. Iuliano, Judith Harvey-White, Michael G. Espey, Edward H. Oldfield and Ryszard M. Pluta

Object. Decreased availability of nitric oxide (NO) has been proposed to evoke delayed cerebral vasospasm after subarachnoid hemorrhage (SAH). Asymmetric dimethyl-l-arginine (ADMA) inhibits endothelial NO synthase (eNOS) and, therefore, may be responsible for decreased NO availability in cases of cerebral vasospasm. The goal of this study was to determine whether ADMA levels are associated with cerebral vasospasm in a primate model of SAH.

Methods. Twenty-two cynomolgus monkeys (six control animals and 16 with SAH) were used in this study. The levels of ADMA, l-arginine, l-citrulline, nitrites, and nitrates in cerebrospinal fluid (CSF) and serum were determined on Days 0, 7, 14, and 21 following onset of SAH. Cerebral arteriography was performed to assess the degree of vasospasm. Western blot analyses of the right and left middle cerebral arteries (MCAs) were performed to assess the expression of eNOS, type I protein—arginine methyl transferase (PRMT1) and dimethylarginine dimethylaminohydrolase (DDAH2).

Cerebrospinal fluid levels of ADMA remained unchanged in the control group (six animals) and in animals with SAH that did not have vasospasm (five animals; p = 0.17), but the levels increased in animals with vasospasm (11 animals) on Day 7 post-SAH (p < 0.01) and decreased on Days 14 through 21 (p < 0.05). Cerebrospinal fluid levels of ADMA correlated directly with the degree of vasospasm (correlation coefficient = 0.7, p = 0.0001; 95% confidence interval: 0.43–0.83). Levels of nitrite and nitrate as well as those of l-citrulline in CSF were decreased in animals with vasospasm. Furthermore, DDAH2 expression was attenuated in the right spastic MCA on Day 7 post-SAH, whereas eNOS and PRMT1 expression remained unchanged.

Conclusions. Changes in the CSF levels of ADMA are associated with the development and resolution of vasospasm found on arteriograms after SAH. The results indicate that endogenous inhibition of eNOS by ADMA may be involved in the development of delayed cerebral vasospasm. Inhibition of ADMA production may provide a new therapeutic approach for cerebral vasospasm after SAH.

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Stephen L. Atkin, Victoria L. Green, Leslie J. Hipkin, Alex M. Landolt, Patrick M. Foy, Richard V. Jeffreys and Michael C. White

✓ The authors compared detection methods for cell proliferation in human anterior pituitary adenomas using histological sections and dispersed cell culture. After tumor cells had been grown for 4 days in dispersed culture, bromodeoxyuridine (BUdR), proliferating cell nuclear antigen (PCNA), and Ki-67 were compared by double immunostaining and contrasted with single staining of PCNA and Ki-67 indices in the corresponding histological sections from 12 human pituitary adenomas. In vitro, the BUdR labeling index was positive in six of 12 tumors (range < 0.1–5.1%), 10 of 12 tumors were PCNA-positive (range < 0.1–100%), and Ki-67 was positive in 10 of 12 adenomas (range < 0.1–8%). In vitro, BUdR and Ki-67 gave similar proliferative indices for 10 of 12 adenomas. In vivo, the PCNA labeling index was positive in 12 of 12 adenomas (range 0.9–95%) and Ki-67 was positive in 11 of 12 adenomas (range < 0.1–2%). Tumors with a labeling index less than 0.1% were considered to be negative for proliferation. High PCNA values were found in vitro and in vivo, whereas Ki-67 labeling indices were similar in vitro and in vivo for nine of 12 adenomas. It is concluded that Ki-67 proliferative indices in vivo reflect those found in vitro, at least after 4 days in dispersed culture, but that PCNA overestimates pituitary adenoma proliferation in histological sections as well as in dispersed culture.