Risk factors and outcomes associated with external ventricular drain related hemorrhage.

OBJECTIVE: The objective of this study was to determine risk factors predictive of external ventricular drain (EVD)-related hemorrhage and the association of such hemorrhages with mortality, discharge disposition, length of stay (LOS), and total cost. METHODS: After Institutional Review Board approval, data was collected retrospectively for adult patients requiring EVD placement from 2015 to 2018 at the authors' institution. Collected data included demographic patient information, peri-procedural factors, and relevant post-procedural measures. Computerized tomography (CT) images and associated radiologic reports were independently reviewed, identifying hemorrhages accompanying EVD placement. RESULTS: From this 487-patient sample, 85 (17.5 %) patients had hemorrhages, including asymptomatic hemorrhages identified on imaging alone. A univariable analysis of patient parameters in the overall cohort was performed to identify possible predictors of hemorrhage. Age (p = 0.002), Charlson Comorbidity Index (CCI) (p < 0.001), platelet count (p = 0.002), presence of uremia (p = 0.035), and the number of times the EVD was replaced (p < 0.001) were associated with hemorrhage in univariable models. The experience of the resident surgeon based on post-graduate year (PGY level) and the number of attempts/passes needed for EVD placement were not associated with hemorrhage risk. Significant predictor of hemorrhage confirmed in a multivariable analysis only included the number of times the EVD was replaced (OR = 2.78, adjusted p < 0.001). Outcomes between EVD-related hemorrhage versus no hemorrhage groups, including mortality, discharge disposition, LOS, and cost, were compared. EVD-related hemorrhage was found to be associated with increased mortality (OR = 3.58, adjusted p < 0.001) and decreased likelihood of discharge home (OR = 0.13, adjusted p = 0.030) in the associated multivariable regressions. CONCLUSION: The number of times an EVD was replaced was associated with EVD-related hemorrhage outcome. EVD-related hemorrhage is associated with increased mortality and a decreased likelihood of being discharged home.

Single-center pilot study of remote therapeutic monitoring in patients with operative spinal pathologies.

OBJECTIVES: Spine pathology affects a significant portion of the population, leading to neck and back pain, impacting quality of life, and potentially requiring surgical intervention. Current pre- and postoperative monitoring methods rely on patient reported outcome (PRO) measures and lack continuous objective data on patients' recoveries. Remote therapeutic monitoring (RTM) using wearable devices offers a promising solution to bridge this gap, providing real-time physical function data. This study aims to assess the feasibility and correlation between changes in physical function and daily activity levels using RTM for individuals with operative spinal pathologies. METHODS: A single-center pilot study involving 21 participants with operative spinal pathologies was conducted at an academic hospital. Participants were provided Bluetooth-enabled Fitbit Inspire 2 activity trackers and asked to wear them daily for 100 days. The Healthcare Recovery Solutions (HRS) mobile application facilitated remote administration of the PROMIS - Physical Function Short Form 6b PROs questionnaire at days 1, 30, and 90. Linear regression, Students' paired T tests, and one-way ANOVA were used to analyze collected data. RESULTS: Average compliance with RTM was found to be 82.4% compared to only 48% for PROMs. Changes in daily steps were moderately positively correlated with changes in PROs at both 30 and 90 days. Participant satisfaction with RTM was high, and responses indicated greater satisfaction with RTM compared to PROMs. CONCLUSIONS: RTM offers continuous and objective data collection, presenting a potential solution to the limitations of intermittent clinical assessments and self-reported outcomes. The study demonstrated a moderate correlation between changes in activity levels and changes in PROs, suggesting that RTM data could serve as a surrogate for PROs. Participants' high compliance and satisfaction with RTM underscore its feasibility and potential clinical utility. This study lays the groundwork for larger future investigations into the clinical benefits and broader application of RTM in spine care.

Even one voice: Teaching legislative advocacy as a core competency in family medicine.

Credentialing bodies increasingly focus on advocacy as a competency to be developed by physicians during residency. The skills of advocacy are especially important with the increased attention on social determinants of health and as restrictive state and federal health policy decisions gain widespread attention in the national news media. This movement is reflected in the ACGME's recently revised statement on the training mission of family medicine residencies and with their most recent update of the Milestones which identifies advocacy as a core competency. Additionally, the major family medicine organizations and governing bodies all similarly identify advocacy as an important professional responsibility for family physicians. Advocacy is a broad term that can be applied across a range of settings and scenarios. For the purposes of this paper we focus primarily on legislative advocacy as a specific area for growing curricular experiences in family medicine residency programs.

Mitoepigenetics and gliomas: epigenetic alterations to mitochondrial DNA and nuclear DNA alter mtDNA expression and contribute to glioma pathogenicity.

Epigenetic mechanisms allow cells to fine-tune gene expression in response to environmental stimuli. For decades, it has been known that mitochondria have genetic material. Still, only recently have studies shown that epigenetic factors regulate mitochondrial DNA (mtDNA) gene expression. Mitochondria regulate cellular proliferation, apoptosis, and energy metabolism, all critical areas of dysfunction in gliomas. Methylation of mtDNA, alterations in mtDNA packaging via mitochondrial transcription factor A (TFAM), and regulation of mtDNA transcription via the micro-RNAs (mir 23-b) and long noncoding RNAs [RNA mitochondrial RNA processing (RMRP)] have all been identified as contributing to glioma pathogenicity. Developing new interventions interfering with these pathways may improve glioma therapy.

Inversed probability case-control analysis of operative burr hole evacuation versus subdural evacuating port system for chronic subdural hematomas: Clinical and economic outcomes.

INTRODUCTION: There are multiple treatments for a chronic subdural hematoma, a significant cause of neurosurgical morbidity that cost the healthcare system $5B in 2007, but few generalizable prospective studies. The purpose of this study was to examine outcomes of bedside Subdural Evacuation Port System (SEPS) placement as compared to operating room burr hole evacuation (BHE) to acquire data to support a randomized trial. METHODS: All procedures were performed in a single institution between 2011 and 2019. Patients were included if > 18 years of age, had chronic subdural hematoma, and were treated by SEPS or BHE. Patients with prior neurosurgical history, mass lesions or bilateral hematomas were excluded. Patients who met inclusion for SEPS (n = 55) or BHE (n = 105). Samples were propensity matched to account for variability. Non-inferiority tests compared outcomes. Cost data was obtained through billable charges. RESULTS: Patients with multiple comorbidities were more likely to undergo SEPS drainage. Noninferiority tests reported no statistically significant evidence to suggest SEPS drains were worse in reoperation-rate (18% vs 9%), post-operative seizure, or functional outcome. SEPS drain placement trended towards a faster time to procedure (3 h faster; p = 0.07) but the overall hospital stay was longer (4.23 vs 5.81, p = 0.01). SEPS drain placement costs are less than BHE, but these patients had 25% higher overall hospital costs (p = 0.01) due to comorbidities and increased hospital stay.

Glioma Immunotherapy: Advances and Challenges for Spinal Cord Gliomas.

Spinal cord gliomas are rare entities that often have limited surgical options. Immunotherapy has shown promise in intracranial gliomas with some research suggesting benefit for spinal cord gliomas. A focused review of immunotherapies that have been investigated in spinal cord gliomas was performed. The primary methods of immunotherapy investigated in spinal cord gliomas include immune checkpoint inhibitors, adoptive T-cell therapies, and vaccine strategies. There are innumerable challenges that must be overcome to effectively apply immunotherapeutic strategies to the spinal cord gliomas including low incidence, few antigenic targets, the blood spinal cord barrier, the immunosuppressive tumor microenvironment and neurotoxic treatment effects. Nonetheless, research has suggested ways to overcome these challenges and treatments have been effective in case reports for metastatic non-small cell lung cancer, melanoma, midline glioma and glioblastoma. Current therapies for spinal cord gliomas are markedly limited. Further research is needed to determine if the success of immunotherapy for intracranial gliomas can be effectively applied to these unique tumors.

Academic Accomplishments of Female Neurosurgeons Currently in Practice in the United States.

BACKGROUND: Women have now surpassed men in the number of medical students currently enrolled in the United States. However, in surgical subspecialties including neurosurgery, women continue to be significantly underrepresented. The objective of this study was to investigate the academic accomplishments of women in academic neurosurgery as measured by academic title, publications, and grant funding. METHODS: A list of ACGME (Accreditation Council for Graduate Medical Education) accredited neurosurgery departments was utilized and department websites were reviewed to collect data regarding female and male faculty. Scopus and National Institutes of Health (NIH) RePORTER websites were used to collect other variables. RESULTS: Women comprise 11.0% of all academic neurosurgeons. Of the 116 neurosurgery residency programs in the United States, 77% have at least 1 female faculty member. There are 172 academic female neurosurgeons in practice in the United States currently. Of academic female neurosurgeons, 61% are assistant professors, 21% are associate professors, and 18% are professors. Only 20 women hold leadership positions in their departments. Women have an average of 39.7 49.6 publications. The average h-index of academic female neurosurgeons is 12.0 11.1. Twenty-two women have or have had NIH funding with an average cumulative total grant value of $3,409,919. Having NIH funding and more publications is associated with higher academic rank and holding a leadership position. Women have significantly less funding and publications than men. CONCLUSIONS: Women represent younger faculty with expected publication and grant funding productivity. As women continue to advance into more senior positions, the trends for number of publications and grant funding is expected to increase.