Surgeons' Responses to a Surgical Mortality Audit: Accepting and Improving: A Cross Sectional Survey.

BACKGROUND: Surgeons strive to provide the best care possible to their patients. The Australian and New Zealand Audit of Surgical Mortality is a process for improving surgical care and outcomes via peer-review assessment of mortality cases. This article examines the acceptability of the assessments to Queensland surgeons, in addition to examining their impact on surgical care. METHODS: This study was a cross-sectional survey. Evaluation forms were sent to all Queensland surgeons who had received a first-line assessment with clinical incidents identified or a second-line assessment (with or without clinical incidents), between April 2018 and January 2020 (n = 484). A total of 102 evaluation forms were returned, giving a response rate of 21%. RESULTS: Most respondents agreed that their assessments were fair (78%) and informative (69%). Almost half (43%) agreed that their assessment improved the subsequent surgical care they provided. Comments supported this, with surgeons describing reflections, meetings and changes that had occurred following their assessments. Despite the strong proportion of positive comments, some surgeons disagreed with the opinions or recommendations of their assessors. A large percentage (41%) was neutral towards the ability of the assessments they had received to improve surgical care at the hospital level. CONCLUSIONS: There was a high degree of acceptance of the QASM peer-review assessment process. The assessments facilitated discussion, reflection and implementation of surgical care improvements in Queensland surgeons. Further research into this topic should involve refinement of the study tool with a larger, and therefore more representative, proportion of the surgical population.

Predictors of an Extended Length of Stay following an Elective Craniotomy in Children and Young Adults.

BACKGROUND: Length of stay (LOS) is now a generally accepted clinical metric within the USA. An extended LOS following an elective craniotomy can significantly impact overall costs. Few studies have evaluated predictors of an extended LOS in pediatric neurosurgical patients. OBJECTIVE: The aim of the study was to determine predictors of an extended hospital LOS following an elective craniotomy in children and young adults. METHODS: All pediatric patients and young adults undergoing an elective craniotomy between January 1, 2010, and April 1, 2019, were retrospectively identified using a prospectively maintained database. Demographic, clinical, radiological, and surgical data were collected. The primary outcome was extended LOS, defined as a postsurgical stay greater than 7 days. Bivariate and multivariable analyses were performed. RESULTS: A total of 1,498 patients underwent 1,720 elective craniotomies during the study period over the course of 1,698 hospitalizations with a median LOS of 4 days (interquartile range 3-6 days). Of these encounters, 218 (12.8%) had a prolonged LOS. Multivariable analysis demonstrated that non-Caucasian race (OR = 1.9 [African American]; OR = 1.6 [other]), the presence of an existing shunt (OR = 1.8), the type of craniotomy (OR = 0.3 [vascular relative to Chiari]), and the presence of a postoperative complication (OR = 14.7) were associated with an extended LOS. CONCLUSIONS: Inherent and modifiable factors predict a hospital stay of more than a week in children and young adults undergoing an elective craniotomy.

Dissecting the Financial Relationship Between Industry and Academic Neurosurgery.

BACKGROUND: Established by the Centers for Medicare and Medicaid Services (CMS), the Open Payments Database (OPD) has reported industry payments to physicians since August 2013. OBJECTIVE: To evaluate the frequency, type, and value of payments received by academic neurosurgeons in the United States over a 5-yr period (2014-2018). METHODS: The OPD was queried for attending neurosurgeons from all neurosurgical training programs in the United States (n = 116). Information from the OPD was analyzed for the entire cohort as well as for comparative subgroup analyses, such as career stage, subspecialty, and geographic location. RESULTS: Of all identified neurosurgeons, 1509 (95.0%) received some payment from industry between 2014 and 2018 for a total of 106 171 payments totaling $266 407 458.33. A bimodal distribution was observed for payment number and total value: 0 to 9 (n = 438) vs > 50 (n = 563) and 0-$1000 (n = 418) vs >$10 000 (n = 653), respectively. Royalty/License was the most common type of payment overall (59.6%; $158 723 550.57). The median number (40) and value ($8958.95) of payments were highest for mid-career surgeons. The South-Central region received the most money ($117 970 036.39) while New England received the greatest number of payments (29 423). Spine surgeons had the greatest median number (60) and dollar value ($20 551.27) of payments, while pediatric neurosurgeons received the least (8; $1108.29). Male neurosurgeons received a greater number (31) and value ($6395.80) of payments than their female counterparts (11, $1643.72). CONCLUSION: From 2014 to 2018, payments to academic neurosurgeons have increased in number and value. Dollars received were dependent on geography, career stage, subspecialty and gender.

What Variables Correlate With Different Clinical Outcomes of Abusive Head Injury?

BACKGROUND: The spectrum of injury severity for abusive head trauma (AHT) severity is broad, but outcomes are unequivocally worse than accidental trauma. There are few publications that analyze different outcomes of AHT. OBJECTIVE: To determine variables associated with different outcomes of AHT. METHODS: Patients were identified using our AHT database. Three different, but not mutually exclusive, outcomes of AHT were modeled: (1) death or hemispheric stroke (diffuse loss of grey-white differentiation); (2) stroke(s) of any size; and (3) need for a neurosurgical operation. Demographic and clinical variables were collected and correlations to the 3 outcomes of interest were identified using bivariate and multivariable analysis. RESULTS: From January 2009 to December 2017, 305 children were identified through a prospectively maintained AHT database. These children were typically male (60%), African American (54%), and had public or no insurance (90%). A total of 29 children (9.5%) died or suffered a massive hemispheric stroke, 57 (18.7%) required a neurosurgical operation, and 91 (29.8%) sustained 1 or more stroke. Death or hemispheric stroke was statistically associated with the pupillary exam (odds ratio [OR] = 45.7) and admission international normalized ratio (INR) (OR = 17.3); stroke was associated with the pupillary exam (OR = 13.2), seizures (OR = 14.8), admission hematocrit (OR = 0.92), and INR (9.4), and need for surgery was associated with seizures (OR = 8.6). CONCLUSION: We have identified several demographic and clinical variables that correlate with 3 clinically applicable outcomes of abusive head injury.

Innovation, Royalties, and Introduction of the Patent Hirsch Index within U.S. Academic Neurosurgery.

BACKGROUND: Historically, practicing neurosurgeons have been key drivers of neurosurgical innovation. We sought to describe the patents held by U.S. academic neurosurgeons and to explore the relationship between patents and royalties received. METHODS: The Centers for Medicare and Medicaid CMS Open Payments Data was used to identify academic neurosurgeons who had received royalties and royalty amounts during a 5-year period (2013-2017). Online patent databases were used to gather patent details. Patent citations and 5-year individual and departmental patent Hirsch (h)-indexes were calculated. Royalties were correlated with the number of patents, patent citations, and patent h-index. RESULTS: We found that 119 academic neurosurgeons (7.8%) from 57 U.S. teaching programs (48.3%) had received royalty payments; 72 (60.5%) had published 648 patents. All surgeons were men, with approximately one half in the "late" stages of their career (45.3%) and subspecializing in spinal surgery (50.4%). The patented products or devices were most commonly used for spinal surgery (72.1%), with 2010-2019 the most productive period (n = 455; 70.2%). The median number of citations per patent was 32 (range, 0-620), with 33% having ≥100 citations. The highest individual and institutional patent h-index was 95; 25 (34.7%) neurosurgeons had a patent h-index of ≥5. The median total royalty payment per individual neurosurgeon was $111,011 (range, $58.05-$76,715,750.34). Royalties were correlated with the number of patents (Spearman r = 0.37; P ≤ 0.001), citations (Spearman r, 0.38; P ≤ 0.001), and inventor h-index (Spearman r = 0.38; P ≤ 0.001). CONCLUSIONS: Few U.S. academic neurosurgeons (7.8%) receive royalties and hold patents (4.7%), with an even smaller select group having a patent h-index of ≥5 (1.6%).

Application of the Preventable Shunt Revision Rate to an Adult Population.

BACKGROUND: The preventable shunt revision rate (PSRR) was recently introduced in pediatric hydrocephalus as a quality metric for shunt surgery. We evaluated the PSRR in an adult hydrocephalus population. METHODS: All ventricular shunt operations (January 1, 2013 to March 31, 2018) performed at a university-based teaching hospital were included. For any index surgery (de novo or revision) resulting in reoperation within 90 days, the index surgery details were collected, and a consensus decision was reached regarding whether the failure had been potentially avoidable. Preventable failure was defined as failure due to infection, malposition, disconnection, migration, or kinking. The 90-day shunt failure rate and PSRR were calculated. Bivariate analyses were performed to evaluate the individual effects of each independent variable on preventable shunt failure. RESULTS: A total of 318 shunt operations had been performed in 245 patients. Most patients were women (62%), with a median age of 48.2 years (interquartile range, 31.2-63.2 years). Most had had ventriculoperitoneal shunts placed (86.5%), and just more than one half were new shunts (51.6%). A total of 53 cases (16.7%) in 42 patients experienced shunt failure within 90 days of the index operation. Of these, 27 failures (8.5% of the total cases; 51% of the failures) were considered potentially preventable. The most common reasons were infection (37%; n = 10) and malposition of the proximal and distal catheters (both 25.9%; n = 7). Age was the only statistically significant difference between the 2 groups, with the patients experiencing preventable shunt failure older than those without preventable shunt failure (51.4 vs. 37.1 years; P = 0.017). CONCLUSIONS: The 90-day PSRR can be applied to an adult population and serve as a quality metric.

Postgraduate publishing output in pediatric neurosurgery: correlation with fellowship site and individual scholars.

OBJECTIVE: The objective of this study was to analyze the publication output of postgraduate pediatric neurosurgery fellows for a 10-year period as well as identify 25 individual highly productive pediatric neurosurgeons. The correlation between academic productivity and the site of fellowship training was studied. METHODS: Programs certified by the Accreditation Council for Pediatric Neurosurgery Fellowships that had 5 or more graduating fellows from 2006 to 2015 were included for analysis. Fellows were queried using Scopus for publications during those 10 years with citation data through 2017. Pearson correlation coefficients were calculated, comparing program rankings of faculty against fellows using the revised Hirsch index (r-index; primary) and Hirsch index (h-index; secondary). A list of 25 highly accomplished individual academicians and their fellowship training locations was compiled. RESULTS: Sixteen programs qualified with 152 fellows from 2006 to 2015; 136 of these surgeons published a total of 2009 articles with 23,735 citations. Most publications were pediatric-specific (66.7%) clinical articles (93.1%), with middle authorship (55%). Co-investigators were more likely from residency than fellowship. There was a clustering of the top 7 programs each having total publications of around 120 or greater, publications per fellow greater than 12, more than 1200 citations, and adjusted ir10 (revised 10-year institutional h-index) and ih10 (10-year institutional h-index) values of approximately 2 or higher. Correlating faculty and fellowship program rankings yielded correlation coefficients ranging from 0.53 to 0.80. Fifteen individuals (60%) in the top 25 (by r5 index) list completed their fellowship at 1 of these 7 institutions. CONCLUSIONS: Approximately 90% of fellowship-trained pediatric neurosurgeons have 1 or more publications, but the spectrum of output is broad. There is a strong correlation between where surgeons complete their fellowships and postgraduate publications.

How Does the Media Portray Neurosurgeons?

BACKGROUND: It is not unusual to find neurosurgeons in the news and entertainment. The present study examined the portrayal of neurosurgeons by major print and online media sources. METHODS: Two search strategies identified articles from October 1, 2012 to October 1, 2017 containing the keyword "neurosurgeon." The top 25 newspapers in the United States, determined by their circulation, were searched using the LexisNexis Academic or NewsBank databases; a layman's Google News search was used to collect online stories. Each identified article was evaluated to confirm the relevance and then examined for content. Relevant characteristics for each article and neurosurgeon were determined and analyzed. RESULTS: Our searches returned 1005 articles comprising 561 unique stories about 203 different neurosurgeons. One particular neurosurgeon had 459 reports (45.7%). More articles were reported in 2015 (405; 40.3%) than any other single year. Most articles featured male neurosurgeons (879; 87.1%) and neurosurgeons who had been practicing for >20 years (636; 63.0%), with just 10 institutions accounting for the training of most of them (733; 72.6%). The articles were classified as positive (270; 26.9%), negative (356; 35.4%), or neutral (379; 37.7%) in terms of their reflection on the field of neurosurgery. The odds of a negative story were greater for male neurosurgeons, within 10 years of residency completion, and in a nonacademic position. CONCLUSIONS: Neurosurgeons are naturally subject to media coverage, and we must be cognizant that this predilection can serve as both an occupational advantage and an occupational hazard.

An Analysis of Publication Productivity During Residency for 1506 Neurosurgical Residents and 117 Residency Departments in North America.

BACKGROUND: Bibliometrics is defined as the study of statistical and mathematical methods used to quantitatively analyze scientific literature. The application of bibliometrics in neurosurgery continues to evolve. OBJECTIVE: To calculate a number of publication productivity measures for almost all neurosurgical residents and departments within North America. These measures were correlated with survey results on the educational environment within residency programs. METHODS: During May to June 2017, data were collected from departmental websites and Scopus to compose a bibliometric database of neurosurgical residents and residency programs. Data related to authorship value and study content were collected on all articles published by residents. A survey of residency program research and educational environment was administered to program directors and coordinators; results were compared with resident academic productivity. RESULTS: The median number of publications in residency was 3; median h-index and Resident index were 1 and 0.17 during residency, respectively. There was a statistically significant difference in academic productivity among male neurosurgical residents compared with females. The majority of articles published were tier 1 clinical articles. Residency program research support was significantly associated with increased resident productivity (P < .001). Scholarly activity requirements were not associated with increased resident academic productivity. CONCLUSION: This study represents the most comprehensive bibliometric assessment of neurosurgical resident academic productivity during training to date. New benchmarks for individual and department academic productivity are provided. A supportive research environment for neurosurgical residents is associated with increased academic productivity, but a scholarly activity requirement was, surprisingly, not shown to have a positive effect.

Pediatric Abusive Head Trauma: Return to Hospital System in the First Year Post Injury.

BACKGROUND: Abusive head trauma (AHT) may result in costly, long-term sequelae. OBJECTIVE: To describe the burden of AHT on the hospital system within the first year of injury. METHODS: Single institution retrospective evaluation of AHT cases from January 2009 to August 2016. Demographic, clinical (including injury severity graded I-III), and charge data associated with both initial and return hospital visits within 1 yr of injury were extracted. RESULTS: A total of 278 cases of AHT were identified: 60% male, 76% infant, and 54% African-American. Of these 278 cases, 162 (60%) returned to the hospital within the first year, resulting in 676 total visits (an average of 4.2 returns/patient). Grade I injuries were less likely to return than more serious injuries (II and III). The majority were outpatient services (n = 430, 64%); of the inpatient readmissions, neurosurgery was the most likely service to be involved (44%). Neurosurgical procedures accounted for the majority of surgeries performed during both initial admission and readmission (85% and 68%, respectively). Increasing injury severity positively correlated with charges for both the initial admission and returns (P < .001 for both). Total calculated charges, including initial admission and returns, were over $25 million USD. CONCLUSION: AHT has a high potential for return to the hospital system within the first year. Inpatient charges dominate and account for the vast majority of hospital returns and overall charges. A more severe initial injury correlates with increased charges on initial admission and on subsequent hospital return.

Pediatric abusive head trauma and stroke.

OBJECTIVE Despite established risk factors, abusive head trauma (AHT) continues to plague our communities. Cerebrovascular accident (CVA), depicted as areas of hypodensity on CT scans or diffusion restriction on MR images, is a well-known consequence of AHT, but its etiology remains elusive. The authors hypothesize that a CVA, in isolation or in conjunction with other intracranial injuries, compounds the severity of a child's injury, which in turn leads to greater health care utilization, including surgical services, and an increased risk of death. METHODS The authors conducted a retrospective observational study to evaluate data obtained in all children with AHT who presented to Le Bonheur Children's Hospital (LBCH) from January 2009 through August 2016. Demographic, hospital course, radiological, cost, and readmission information was collected. Children with one or more CVA were compared with those without a CVA. RESULTS The authors identified 282 children with AHT, of whom 79 (28%) had one or more CVA. Compared with individuals without a CVA, children with a stroke were of similar overall age (6 months), sex (61% male), and race (56% African-American) and had similar insurance status (81% public). Just under half of all children with a stroke (38/79, 48%) were between 1-6 months of age. Thirty-five stroke patients (44%) had a Grade II injury, and 44 (56%) had a Grade III injury. The majority of stroke cases were bilateral (78%), multifocal (85%), associated with an overlying subdural hematoma (86%), and were watershed/hypoperfusion in morphology (73%). Thirty-six children (46%) had a hemispheric stroke. There were a total of 48 neurosurgical procedures performed on 28 stroke patients. Overall median hospital length of stay (11 vs 3 days), total hospital charges ($13.8 vs $6.6 million), and mean charges per patient ($174,700 vs $32,500) were significantly higher in the stroke cohort as a whole, as well as by injury grade (II and III). Twenty children in the stroke cohort (25%) died as a direct result of their AHT, whereas only 2 children in the nonstroke cohort died (1%). There was a 30% readmission rate within the first 180-day postinjury period for patients in the stroke cohort, and of these, approximately 50% required additional neurosurgical intervention(s). CONCLUSIONS One or more strokes in a child with AHT indicate a particularly severe injury. These children have longer hospital stays, greater hospital charges, and a greater likelihood of needing a neurosurgical intervention (i.e., bedside procedure or surgery). Stroke is such an important predictor of health care utilization and outcome that it warrants a subcategory for both Grade II and Grade III injuries. It should be noted that the word "stroke" or "CVA" should not automatically imply arterial compromise in this population.

Independent Proteolytic Activities Control the Stability and Size of Drosophila Inhibitor of Apoptosis 2 Protein.

The Drosophila immune deficiency pathway defends many bacterial pathogens and bears striking molecular similarities to the mammalian tumor necrosis factor signal transduction pathway. Orthologous inhibitors of apoptosis ubiquitin ligases act at a proximal stage of both responses to coordinate the assembly of signal transduction platforms that shape host immune responses. Despite the importance of inhibitor of apoptosis proteins within evolutionarily conserved innate immune responses, we know relatively little about the cellular machinery that controls inhibitor of apoptosis activity. In this study, we examined the molecular basis for inhibitor of apoptosis 2 protein regulation in the immune deficiency pathway. Our studies identified two distinct proteolytic events that determine the stability and composition of cellular inhibitor of apoptosis 2 protein pools. We found that apoptotic caspase activity cleaves inhibitor of apoptosis 2 at an N-terminal aspartate to generate a truncated protein that retains the ability to interact with immune deficiency pathway members. We also showed that a C-terminal ubiquitin ligase activity within inhibitor of apoptosis 2 directs the proteasomal destruction of full-length and truncated inhibitor of apoptosis 2 isoforms. These studies add to our appreciation of the regulation of innate immunity and suggest potential links between apoptotic caspases and innate defenses.

A High-Content RNAi Screen Identifies Ubiquitin Modifiers That Regulate TNF-Dependent Nuclear Accumulation of NF-κB.

The mammalian tumor necrosis factor (TNF) cytokine is a central mediator of inflammatory events. Recent studies revealed a number of complex and sophisticated interactions between the TNF pathway and the enzymatic activities encoded by ubiquitin ligases and deubiquitylation enzymes. However, very little is known about the identity of the ubiquitin pathway members that control the extent of ubiquitylation in TNF responses. To address this deficit, we conducted an unbiased, high-content screen of the human ubiquitin pathway for gene products that control defining features of the cellular response to TNF. In particular, we sought to identify ubiquitin modifying enzymes that alter the ability of TNF to regulate the nuclear accumulation of nuclear factor kappa B. In this screen, we identified and validated several novel regulators of the TNF pathway. We believe these regulators constitute potential targets for pharmacological interventions that manipulate TNF-dependent inflammation.

Regeneration of cone photoreceptors when cell ablation is primarily restricted to a particular cone subtype.

We sought to characterize the regenerated cells, if any, when photoreceptor ablation was mostly limited to a particular cone subtype. This allowed us to uniquely assess whether the remaining cells influence specification of regenerating photoreceptors. The ability to replace lost photoreceptors via stem cell therapy holds promise for treating many retinal degenerative diseases. Zebrafish are potent for modelling this because they have robust regenerative capacity emanating from endogenous stem cells, and abundant cone photoreceptors including multiple spectral subtypes similar to human fovea. We ablated the homolog of the human S-cones, the ultraviolet-sensitive (UV) cones, and tested the hypothesis that the photoreceptors regenerating in their place take on identities matching those expected from normal cone mosaic development. We created transgenic fish wherein UV cones can be ablated by addition of a prodrug. Thus photoreceptors developed normally and only the UV cones expressed nitroreductase; the latter converts the prodrug metronidazole to a cell-autonomous neurotoxin. A significant increase in proliferation of progenitor cell populations (p<0.01) was observed when cell ablation was primarily limited to UV cones. In control fish, we found that BrdU primarily incorporated into rod photoreceptors, as expected. However the majority of regenerating photoreceptors became cones when retinal cell ablation was predominantly restricted to UV cones: a 2-fold increase in the relative abundance of cones (p = 0.008) was mirrored by a 35% decrease in rods. By primarily ablating only a single photoreceptor type, we show that the subsequent regeneration is biased towards restoring the cognate photoreceptor type. We discuss the hypothesis that, after cone death, the microenvironment formed by the remaining retinal cells may be influential in determining the identity of regenerating photoreceptors, though other interpretations are plausible. Our novel animal model provides control of ablation that will assist in identifying mechanisms required to replace cone photoreceptors clinically to restore daytime vision.

Investigating regeneration and functional integration of CNS neurons: lessons from zebrafish genetics and other fish species.

Zebrafish possess a robust, innate CNS regenerative ability. Combined with their genetic tractability and vertebrate CNS architecture, this ability makes zebrafish an attractive model to gain requisite knowledge for clinical CNS regeneration. In treatment of neurological disorders, one can envisage replacing lost neurons through stem cell therapy or through activation of latent stem cells in the CNS. Here we review the evidence that radial glia are a major source of CNS stem cells in zebrafish and thus activation of radial glia is an attractive therapeutic target. We discuss the regenerative potential and the molecular mechanisms thereof, in the zebrafish spinal cord, retina, optic nerve and higher brain centres. We evaluate various cell ablation paradigms developed to induce regeneration, with particular emphasis on the need for (high throughput) indicators that neuronal regeneration has restored sensory or motor function. We also examine the potential confound that regeneration imposes as the community develops zebrafish models of neurodegeneration. We conclude that zebrafish combine several characters that make them a potent resource for testing hypotheses and discovering therapeutic targets in functional CNS regeneration. This article is part of a Special Issue entitled Zebrafish Models of Neurological Diseases.