Pseudarthrosis after four-level anterior cervical discectomy and fusion without posterior fixation.

OBJECTIVE: Fusion rates and long-term outcomes are well established for anterior cervical discectomy and fusion (ACDF) of 3 levels or fewer, but there is a paucity of similar data on 4-level fusions. The authors evaluated long-term fusion rates and clinical outcomes after 4-level ACDF without supplemental posterior instrumentation. METHODS: The authors retrospectively reviewed patients who underwent 4-level ACDF at a single institution with at least 1-year of radiological follow-up. Fusion was determined by measuring change in interspinous distance at each segment on dynamic radiographs or by the presence of bridging bone on CT scans at minimum 1-year follow-up. Clinical outcomes were assessed using Neck Disability Index and Short Form-36. RESULTS: A total of 63 patients (252 levels) met the inclusion criteria for the study, with a mean follow-up of 2.6 years. Complete radiographic fusion at all 4 levels was observed in 26 patients (41.3%). Of the 37 patients (58.7%) with radiographic pseudarthrosis, there was a mean of 1.35 nonfused levels. The fusion rate per level, however, was 80.2% (202/252 levels). The most common level demonstrating nonunion was the distal segment (C6-7), showing pseudarthrosis in 29 patients (46.8%), followed by the most proximal segment (C3-4) demonstrating nonunion in 9 patients (14.5%). The mean improvement in Neck Disability Index and Short Form-36 was 15.7 (p < 0.01) and 5.8 (p = 0.14), respectively, with improvement in both scores surpassing the minimum clinically important difference. One patient (1.6%) required revision surgery for symptomatic pseudarthrosis, and 5 patients (7.9%) underwent revision for symptomatic adjacent-segment disease. Patient-reported outcomes results are limited by the low rate of 1-year follow-up (50.8%), whereas reoperation data were available for all 63 patients. CONCLUSIONS: More than half of patients undergoing 4-level ACDF without posterior fixation demonstrated pseudarthrosis of at least 1 level-most commonly the distal C6-7 level. One patient required revision for symptomatic pseudarthrosis. Patient-reported outcomes showed significant improvements at 1-year follow-up, but clinical follow-up was limited. This is the largest series to date to evaluate fusion outcomes in 4-level ACDF.

Leveraging Body-Worn Camera Footage to Better Understand Opioid Overdoses and the Impact of Police-Administered Naloxone.

Objectives. To investigate what transpires at opioid overdoses where police administer naloxone and to identify the frequency with which concerns about police-administered naloxone are observed. Methods. We reviewed body-worn camera (BWC) footage of all incidents where a Tempe, Arizona police officer administered naloxone or was present when the Tempe Fire Medical Rescue (TFMR) administered it, from February 3, 2020 to May 7, 2021 (n = 168). We devised a detailed coding instrument and employed univariate and bivariate analysis to examine the frequency of concerns regarding police-administered naloxone. Results. Police arrived on scene before the TFMR in 73.7% of cases. In 88.6% of calls the individual was unconscious when police arrived, but 94.6% survived the overdose. The primary concerns about police-administered naloxone were rarely observed. There were no cases of improper naloxone administration or accidental opioid exposure to an officer. Aggression toward police from an overdose survivor rarely occurred (3.6%), and arrests of survivors (3.6%) and others on scene (1.2%) were infrequent. Conclusions. BWC footage provides a unique window into opioid overdoses. In Tempe, the concerns over police-administered naloxone are overstated. If results are similar elsewhere, those concerns are barriers that must be removed. (Am J Public Health. 2022;112(9):1326-1332. https://doi.org/10.2105/AJPH.2022.306918).

Can police shootings be reduced by requiring officers to document when they point firearms at citizens?

OBJECTIVE: To examine the impact of a novel firearm 'pointing' policy that requires officers to document when they directly point their guns at citizens. METHODS: Sixteen years (2003-2018) of narrative officer-involved shooting (OIS) reports from the Dallas Police Department were qualitatively coded to explore both the total frequency and specific characteristics of OIS before and after the policy change in 2013. RESULTS: χ2 tests found that the firearm pointing policy was associated with a reduction in the proportion of 'threat perception failure' shootings (ie, those where an officer mistakes an item for a gun). Auto Regressive Integrated Moving Average analysis found that the policy change was associated with a gradual, permanent reduction in total OIS; however, that impact was not immediate. CONCLUSIONS: Firearm pointing policies have the potential to alter organisational behaviour, particularly in highly discretionary shootings. It is unclear whether the specific mechanisms for the changes include more accountability through constrained discretion, reduced options to handle situations once officers' guns are drawn and pointed, or an effect on officers' timing and vision during ambiguous scenarios. POLICY IMPLICATIONS: Although organisational change may be a long and complex process, reductions in OIS can prevent serious injuries and death. The policy change did not lead to an increase in the proportion of officers injured during OIS incidents.

Comparison of Follow-Up Length-Matched Single-Center Myelomeningocele Postnatal Closure Cohort to the Management of Myelomeningocele Study (MOMS) Trial Results.

OBJECTIVE: We sought to compare our large single-institution cohort of postnatal myelomeningocele closure to the 2 arms of the Management of Myelomeningocele Study (MOMS) trial at the designated trial time points, as well as assess outcomes at long-term follow-up among our postnatal cohort. METHODS: A single-institutional retrospective review of myelomeningocele cases presenting from 1995 to 2015 at Children's Hospital of Pittsburgh was performed. We compared outcomes at 12 and 30 months to both arms of the MOMS trial and compared our cohort's outcomes at those designated time points to our long-term outcomes. Univariate statistical analysis was performed as appropriate. RESULTS: One-hundred sixty-three patients were included in this study. All patients had at least 2-year follow-up, with a mean follow-up of 10 years (range 2-20 years). There was no difference in the overall distribution of anatomic level of defect. Compared to our cohort, the prenatal cohort had a higher rate of tethering at 12 months of age, 8 versus 1.8%. Conversely, the Chiari II decompression rate was higher in our cohort (10.4 vs. 1.0%). At 30 months, the prenatal cohort had a higher rate of independent ambulation, but our cohort demonstrated the highest rate of ambulation with or without assistive devices among the 3 groups. When comparing our cohort at these early time points to our long-term follow-up data, our cohort's ambulatory function decreased from 84 to 66%, and the rate of detethering surgery increased almost 10-fold. CONCLUSIONS: This study demonstrated that overall ambulation and anatomic-functional level were significantly better among our large postnatal cohort, as well as having significantly fewer complications to both fetus and mother, when compared to the postnatal cohort of the MOMS trial. Our finding that ambulatory ability declined significantly with age in this patient population is worrisome for the long-term outcomes of the MOMS cohorts, especially given the high rates of cord tethering at early ages within the prenatal cohort. These findings suggest that the perceived benefits of prenatal closure over postnatal closure may not be as substantial as presented in the original trial, with the durability of results still remaining a concern.

Intracranial Myxoid Mesenchymal Tumor with Rare EWSR1-CREM Translocation.

Translocations between EWSR1 and members of the CREB family of transcription factors (CREB1, ATF1, and CREM) are rare genetic findings occurring in various sarcomas. Of these, the EWSR1-CREM translocation is the most rarely reported. We present the case of a 9-year-old boy who presented with a year of fatigue, weight loss, and abulia. A brain MRI revealed a frontal interhemispheric tumor arising from the falx. After resection, pathology demonstrated a myxoid mesenchymal tumor with an EWSR1-CREM translocation. A series of recent reports of similar tumors has generated ongoing debate in the literature over the classification of these tumors either as intracranial angiomatoid fibrous histiocytomas, which also harbor EWSR1-CREB family translocations, or as a novel diagnostic entity. The present case provides another example of the rare EWSR1-CREM fusion in an intracranial myxoid mesenchymal tumor that recurred in just 6 months despite gross total resection. The findings are discussed in the context of the existing literature and the ongoing effort to appropriately classify this type of tumor.

Neurosurgical Resident Exposure to Pediatric Neurosurgery: An Analysis of Resident Case Logs.

INTRODUCTION: The purpose of this study is to identify the national trends of exposure to pediatric procedures during neurosurgical residency and to subsequently evaluate how neurosurgery residents' experiences correlate with the minimum requirements set forth by the American College of Graduate Medical Education (ACGME). METHODS: ACGME resident case logs from residents graduating between 2013 and 2017 were retrospectively reviewed. These reports were analyzed to determine trends in resident operative experience in pediatric procedures. The number of cases performed by residents was compared to the required minimums set by the ACGME within each pediatric surgical category. A linear regression analysis and t tests were utilized to analyze the change in cases performed over the study period. RESULTS: A mean of 98.8 procedures were performed for each of the 877 residents graduating between 2013 and 2017. The total number of pediatric procedures declined at a rate of 1.7 cases/year (r2 = 0.77, p = 0.05). Spine and cerebrospinal fluid diversion procedures showed decreasing trends at rates of 1.9 (r2 = 0.70, p = 0.08) and 1.2 (r2 = 0.70, p = 0.08) cases/year, respectively. The number of trauma and brain tumor cases were shown to have increasing rates at 1.0 (r2 = 0.86, p = 0.02) and 0.3 (r2 = 0.69, p = 0.08) cases/year, respectively, with trauma cases showing significant increases. There was also a trend of increasing cases logged as the lead resident surgeon by 12.9 cases/year (r2 = 0.99, p < 0.001). The number of cases performed by the average graduating resident was also significantly higher than the minimums required by the ACGME; residents, on average, performed 3 times the required minimum number of pediatric cases. CONCLUSION: Neurosurgical residents graduating from 2013 to 2017 reported significantly higher volumes of pediatric neurosurgery cases than the standards set for by the ACGME. During this time, there was also a significant trend of increasing cases logged as the lead resident surgeon, suggesting more involvement in the critical portions of pediatric cases. There was also a significant, but not clinically impactful, decrease in pediatric case volumes during this time. However, the overall data indicate that residents are continuing to gain valuable pediatric experience during residency training.

Lung Cancer Screening Guidelines: How Readable Are Internet-Based Patient Education Resources?

OBJECTIVE: Following the findings of the National Lung Screening Trial, several national societies from multiple disciplines have endorsed the use of low-dose chest CT to screen for lung cancer. Online patient education materials are an important tool to disseminate information to the general public regarding the proven health benefits of lung cancer screening. This study aims to evaluate the reading level at which these materials related to lung cancer screening are written. MATERIALS AND METHODS: The four terms "pulmonary nodule," "radiation," "low-dose CT," and "lung cancer screening" were searched on Google, and the first 20 online resources for each term were downloaded, converted into plain text, and analyzed using 10 well-established readability scales. If the websites were not written specifically for patients, they were excluded. RESULTS: The 80 articles were written at a 12.6 ± 2.7 (mean ± SD) grade level, with grade levels ranging from 4.0 to 19.0. Of the 80 articles, 62.5% required a high school education to comprehend, and 22.6% required a college degree or higher (≥ 16th grade) to comprehend. Only 2.5% of the analyzed articles adhered to the recommendations of the National Institutes of Health and American Medical Association that patient education materials be written at a 3rd- to 7th-grade reading level. CONCLUSION: Commonly visited online lung cancer screening-related patient education materials are written at a level beyond the general patient population's ability to comprehend and may be contributing to a knowledge gap that is inhibiting patients from improving their health literacy.

Quantitative analysis of the level of readability of online emergency radiology-based patient education resources.

PURPOSE: The vast amount of information found on the internet, combined with its accessibility, makes it a widely utilized resource for Americans to find information pertaining to medical information. The field of radiology is no exception. In this paper, we assess the readability level of websites pertaining specifically to emergency radiology. METHODS: Using Google, 23 terms were searched, and the top 10 results were recorded. Each link was evaluated for its readability level using a set of ten reputable readability scales. The search terms included the following: abdominal ultrasound, abdominal aortic aneurysm, aortic dissection, appendicitis, cord compression, CT abdomen, cholecystitis, CT chest, diverticulitis, ectopic pregnancy, epidural hematoma, dural venous thrombosis, head CT, MRI brain, MR angiography, MRI spine, ovarian torsion, pancreatitis, pelvic ultrasound, pneumoperitoneum, pulmonary embolism, subarachnoid hemorrhage, and subdural hematoma. Any content that was not written for patients was excluded. RESULTS: The 230 articles that were assessed were written, on average, at a 12.1 grade level. Only 2 of the 230 articles (1%) were written at the third to seventh grade recommended reading level set forth by the National Institutes of Health (NIH) and American Medical Association (AMA). Fifty-two percent of the 230 articles were written so as to require a minimum of a high school education (at least a 12th grade level). Additionally, 17 of the 230 articles (7.3%) were written at a level that exceeded an undergraduate education (at least a 16th grade level). CONCLUSIONS: The majority of websites with emergency radiology-related patient education materials are not adhering to the NIH and AMA's recommended reading levels, and it is likely that the average reader is not benefiting fully from these information outlets. With the link between health literacy and poor health outcomes, it is important to address the online content in this area of radiology, allowing for patient to more fully benefit from their online searches.

Comparison of percutaneous device closure versus surgical closure of peri-membranous ventricular septal defects: A systematic review and meta-analysis.

BACKGROUND: While percutaneous device closure (PDC) is a first-line therapy for isolated muscular ventricular septal defects (mVSD), surgery is still the preferred approach for peri-membranous ventricular septal defects (pmVSD). OBJECTIVE: We sought to compare the outcomes of percutaneous versus open surgical closure of pmVSDs. METHODS: PubMed, Cochrane Library, and Web of Science databases were searched through October 15, 2014 for English language studies comparing outcomes of PDC with surgical closure of pmVSDs. Study quality, publication bias, and heterogeneity were assessed. A meta-analysis of selected studies was performed using a random effects model. Comparison was done for early (<1 month) safety and efficacy outcomes. RESULTS: Seven studies with a total of 3,134 patients (PDC = 1,312, surgery = 1,822) were identified. Patients in the PDC group were older than those treated surgically (mean age 12.2 vs. 5.5 years, respectively). In six out of seven studies, the mean VSD size was found to be comparable between the treatment arms (PDC 4.9 mm vs. surgery 6.0 mm). Males represented 52% of patients in either group. Follow-up ranged from 5 to 42 months. No significant differences were observed between PDC vs. surgery in terms of procedural success rate [relative risk (RR): 1.00, confidence interval (CI): 0.99-1.00; P = 0.67]. Combined safety end points for major complications (early death/reoperation/permanent pacemaker) were similar in both groups (RR: 0.55, CI: 0.23-1.35; P = 0.19) as were as other outcomes like post-procedure significant residual shunt (RR: 0.69, CI: 0.29-1.68; P = 0.41), significant valvular (aortic/tricuspid) regurgitation (RR: 0.70, CI: 0.26-1.86; P = 0.47), and advanced heart block (RR: 0.99, CI: 0.46-2.14; P = 0.98). The need for blood transfusion (RR: 0.02, CI: 0.00-0.05; P < 0.001) and duration of hospital stay [standard mean difference (SMD) -2.17 days, CI: -3.12 to -1.23; P < 0.001] were significantly reduced in the PDC group. CONCLUSION: Percutaneous closure of pmVSD when performed in a selected subgroup of patients is associated with similar procedural success rate without increased risk of significant valvular regurgitation or heart block when compared with surgical closure.

Efficacy and safety of transulnar coronary angiography and interventions--a single center experience.

OBJECTIVES: To evaluate the efficacy and long-term safety of transulnar approach in complex coronary interventions. BACKGROUND: The success rate of transulnar approach in complex coronary interventions and its long-term safety remains to be proven. METHODS: We conducted a retrospective chart review of patients undergoing transulnar coronary angiography and interventions at our institution from January 2004 through July 2009. Primary endpoint of the study was the success rate of the procedure. Secondary endpoints were major bleeding, local vascular and neurological complications, cerebrovascular accident (CVA)/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE) rate that was a composite of MI, CVA/TIA, and all-cause mortality. RESULTS: Of 81 patients undergoing transulnar approach, 41 (50.6%) patients underwent intervention on 65 lesions. Twelve percent of the interventions were performed on coronary bypass grafts and 9.2% on the left main coronary artery. Success rates for transulnar access, coronary angiography, and coronary/bypass graft interventions were 93.8%, 100%, and 92.6%, respectively. Follow-up data was available on 71 patients at short term (30 days) and 58 patients at long term (1 year). At 30-day follow-up, vascular complication rate was 2.8 %. At 1-year follow-up, there were no residual deficits from vascular or neurological complications associated with the index procedure and the overall MACE rate was 3.4%. CONCLUSION: In this first study evaluating long-term safety and feasibility of transulnar coronary angiography and complex coronary interventions, we conclude that transulnar approach appears to be safe and effective.

Anatomical Reduction of Spondylolisthesis Through Lateral Lumbar Interbody Fusion With Percutaneous Pedicle Screw Fixation: An Intraoperative Technical Note.

BACKGROUND: Surgical management of lumbar spondylolisthesis requires neural decompression, stabilization, and alignment restoration. Minimally invasive spine approaches offer a wide variety of advantages for spondylolisthesis management. This intraoperative note describes the treatment of L4-L5 lumbar spondylolisthesis with lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screw fixation (PSF). METHODS: The surgical technique for treating L4-L5 lumbar spondylolisthesis using a minimally invasive approach with LLIF and percutaneous PSF is described. This operative technique is illustrated with figures, and an intraoperative case example of its application is described. RESULTS: LLIF with percutaneous PSF can be a safe, effective, and reliable option for treating lumbar spondylolisthesis when applied with appropriate surgical technique in a selected patient population. This technique is a valuable addition to the range of available spine surgical options. CONCLUSIONS: LLIF with percutaneous PSF can be an effective technique for treating lumbar L4-L5 spondylolisthesis.

Transpsoas Approaches to the Lumbar Spine: Lateral and Prone.

The lateral transpsoas approach has become fundamental to minimally invasive spine surgery. The large interbody grafts that can be placed through this approach allow for robust arthrodesis of the anterior column, indirect decompression, and restoration of lordosis without disrupting the posterior musculature or ligamentous structures. The lateral decubitus position has traditionally been used for this approach but the prone position has gained popularity because it can reduce operating times for patients who also require posterior pedicle screw fixation. The transpsoas approach can be effectively performed in either position but surgeons should know the nuances that distinguish them.

Long-Term Durability of Stand-Alone Lateral Lumbar Interbody Fusion.

BACKGROUND: The long-term durability of stand-alone lateral lumbar interbody fusion (LLIF) remains unknown. OBJECTIVE: To evaluate whether early patient-reported outcome measures after stand-alone LLIF are sustained on long-term follow-up. METHODS: One hundred and twenty-six patients who underwent stand-alone LLIF between 2009 and 2017 were included in this study. Patient-reported outcome measures included the Oswestry Disability Index (ODI), EuroQOL-5D (EQ-5D), and visual analog score (VAS) scores. Durable outcomes were defined as scores showing a significant improvement between preoperative and 6-week scores without demonstrating any significant decline at future time points. A repeated measures analysis was conducted using generalized estimating equations (model) to assess the outcome across different postoperative time points, including 6 weeks, 1 year, 2 years, and 5 years. RESULTS: ODI scores showed durable improvement at 5-year follow-up, with scores improving from 46.9 to 38.5 ( P = .001). Improvements in EQ-5D showed similar durability up to 5 years, improving from 0.48 to 0.65 ( P = .03). VAS scores also demonstrated significant improvements postoperatively that were durable at 2-year follow-up, improving from 7.0 to 4.6 ( P < .0001). CONCLUSION: Patients undergoing stand-alone LLIF were found to have significant improvements in ODI and EQ-5D at 6-week follow-up that remained durable up to 5 years postoperatively. VAS scores were found to be significantly improved at 6 weeks and up to 2 years postoperatively but failed to reach significance at 5 years. These findings demonstrate that patients undergoing stand-alone LLIF show significant improvement in overall disability after surgery that remains durable at long-term follow-up.

A comparison of modern-era anterior lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion at the lumbosacral junction.

OBJECTIVE: Interbody fusion is the primary method for achieving arthrodesis across the lumbosacral junction in the setting of degenerative pathologies, such as spondylosis and spondylolisthesis. Two common techniques are anterior lumbar interbody fusion (ALIF) and posterior transforaminal lumbar interbody fusion (TLIF). In recent years, interbody design and technology have advanced, and most earlier studies comparing ALIF and TLIF did not specifically assess the lumbosacral junction. This study compared changes in radiographic and clinical parameters between patients undergoing modern-era single-level ALIF and minimally invasive surgery (MIS) TLIF at L5-S1. METHODS: Consecutive patients who underwent single-segment L5-S1 ALIF or MIS TLIF performed by the senior authors over a 6-year interval (January 1, 2016-November 30, 2021) were retrospectively reviewed. Upright radiographs were used to determine pre- and postoperative lumbar lordosis, segmental lordosis, disc angle, and neuroforaminal height. Improvements in patient-reported outcome scores (Oswestry Disability Index and SF-36) were also compared. RESULTS: Overall, 108 patients (58 [54%] men, 50 [46%] women; mean [SD] age 57.6 [13.5] years) were included in the study. ALIF was performed in 49 patients, and TLIF was performed in 59 patients. The most common treatment indications were spondylolisthesis (50%, 54/108) and spondylosis (46%, 50/108). The cohorts did not differ in terms of intraoperative (p > 0.99) or postoperative (p = 0.73) complication rates. The mean (SD) hospital length of stay was significantly shorter for patients undergoing TLIF than ALIF (1.3 [0.6] days vs 2.0 [1.4] days, p < 0.001). Both techniques significantly improved L5-S1 segmental lordosis, disc angle, and neuroforaminal height (p ≤ 0.008). ALIF versus TLIF significantly increased mean [SD] segmental lordosis (12.5° [7.3°] vs 2.0° [5.7°], p < 0.001), disc angle (14.8° [5.5°] vs 3.0° [6.1°], p < 0.001), and neuroforaminal height (4.5 [4.6] mm vs 2.4 [3.0] mm, p = 0.008). Improvements in patient-reported outcome parameters and reoperation rates were similar between cohorts. CONCLUSIONS: When treating patients at a single segment across the lumbosacral junction, ALIF resulted in significantly greater increases in segmental lordosis, L5-S1 disc angle, and neuroforaminal height compared with MIS TLIF. Improvements in clinical parameters and reoperation rates were similar between the 2 techniques.

Patient perception of spinal cord injury through social media: An analysis of 703 Instagram and 117 Twitter posts.

Introduction: Social media has developed exponentially over the last decade as a means for individuals and patients to connect to others and has provided a unique opportunity for physicians to provide broader information to the general public to attempt to positively modify health behavior. The purpose of this study was to assess the patient's perception of spinal cord injury (SCI) on social media. Methods: Instagram and Twitter social media platforms were analyzed to determine posts written by patients with SCI. The initial search for Instagram posts tagged with "#spinalcordinjury" yielded over 270,000 posts in April 2021. Posts pertaining to the patient's experience were retrospectively collected from January 2020 to April 2021. Twitter posts that included "#spinalcordinjury," "@spinalcordinjury," and "spinal cord injury" were retrospectively collected in April 2021. One hundred seventeen tweets were found that were directly from a patient with SCI. Themes associated with patients' experiences living with SCI were coded. Results: The most common theme on Instagram was spreading positivity and on Twitter was the appearance of the wheelchair (75.8% and 37.3%, respectively). Other common themes on Instagram were the appearance of a wheelchair (71.8%), recovery or rehabilitation (29.9%), and life satisfaction (29.0%). Prevalent themes on Twitter included spreading positivity (23.2%) and recovery or rehabilitation (21.3%). Conclusion: The prevalence of themes of positivity and awareness may indicate the utilization of social media as a support mechanism for patients living with SCI. Identification of prevalent themes is important for the holistic treatment of SCI survivors.

An aPKC-exocyst complex controls paxillin phosphorylation and migration through localised JNK1 activation.

Atypical protein kinase C (aPKC) isoforms have been implicated in cell polarisation and migration through association with Cdc42 and Par6. In distinct migratory models, the Exocyst complex has been shown to be involved in secretory events and migration. By RNA interference (RNAi) we show that the polarised delivery of the Exocyst to the leading edge of migrating NRK cells is dependent upon aPKCs. Reciprocally we demonstrate that aPKC localisation at the leading edge is dependent upon the Exocyst. The basis of this inter-dependence derives from two-hybrid, mass spectrometry, and co-immunoprecipitation studies, which demonstrate the existence of an aPKC-Exocyst interaction mediated by Kibra. Using RNAi and small molecule inhibitors, the aPKCs, Kibra, and the Exocyst are shown to be required for NRK cell migration and it is further demonstrated that they are necessary for the localized activation of JNK at the leading edge. The migration associated control of JNK by aPKCs determines JNK phosphorylation of the plasma membrane substrate Paxillin, but not the phosphorylation of the nuclear JNK substrate, c-jun. This plasma membrane localized JNK cascade serves to control the stability of focal adhesion complexes, regulating migration. The study integrates the polarising behaviour of aPKCs with the pro-migratory properties of the Exocyst complex, defining a higher order complex associated with the localised activation of JNK at the leading edge of migrating cells that determines migration rate.

Patient satisfaction reviews for 967 spine neurosurgeons on Healthgrades.

OBJECTIVE: Patients are increasingly relying on independent physician rating websites (PRWs) to obtain information about healthcare providers. Healthgrades.com is a widely used PRW that allows patients to rate physicians on various metrics of performance and quality of care. This study categorically investigated the correlations between demographics of spine neurosurgeons and online ratings on Healthgrades to better understand the factors driving patient satisfaction in spine surgery in the United States. METHODS: In August-December 2019, the authors performed a retrospective data analysis using Healthgrades. The American Association of Neurological Surgeons (AANS) membership database was used to identify spine neurosurgeons in the United States and extract biographical and career data. Individuals with an academic practice were further investigated for academic rank, leadership, and fellowship training. Scores from eight patient satisfaction metrics (PSMs) were collected for each surgeon from Healthgrades. RESULTS: A total of 967 spine neurosurgeons were included in the study cohort. Patient satisfaction did not correlate with sex, PhD acquisition, academic status, or academic rank. Among those who were academic surgeons, completion of fellowship training was associated with higher ratings. Geographical location of practice did not influence patient satisfaction. Prolonged wait time was an independent predictor of decreased patient satisfaction and was a key confounding variable underlying trends seen with advanced career duration and age. CONCLUSIONS: Overall, patients rated spine neurosurgeons highly favorably on the Healthgrades website. Due to the emerging role of PRWs in locating and assessing providers, it is important for both patients and clinicians to understand the factors that impact patient experience.

Neurosurgery Subspecialty Practice During a Pandemic: A Multicenter Analysis of Operative Practice in 7 U.S. Neurosurgery Departments During Coronavirus Disease 2019.

OBJECTIVE: Changes to neurosurgical practices during the coronavirus disease 2019 (COVID-19) pandemic have not been thoroughly analyzed. We report the effects of operative restrictions imposed under variable local COVID-19 infection rates and health care policies using a retrospective multicenter cohort study and highlight shifts in operative volumes and subspecialty practice. METHODS: Seven academic neurosurgery departments' neurosurgical case logs were collected; procedures in April 2020 (COVID-19 surge) and April 2019 (historical control) were analyzed overall and by 6 subspecialties. Patient acuity, surgical scheduling policies, and local surge levels were assessed. RESULTS: Operative volume during the COVID-19 surge decreased 58.5% from the previous year (602 vs. 1449, P = 0.001). COVID-19 infection rates within departments' counties correlated with decreased operative volume (r = 0.695, P = 0.04) and increased patient categorical acuity (P = 0.001). Spine procedure volume decreased by 63.9% (220 vs. 609, P = 0.002), for a significantly smaller proportion of overall practice during the COVID-19 surge (36.5%) versus the control period (42.0%) (P = 0.02). Vascular volume decreased by 39.5% (72 vs. 119, P = 0.01) but increased as a percentage of caseload (8.2% in 2019 vs. 12.0% in 2020, P = 0.04). Neuro-oncology procedure volume decreased by 45.5% (174 vs. 318, P = 0.04) but maintained a consistent proportion of all neurosurgeries (28.9% in 2020 vs. 21.9% in 2019, P = 0.09). Functional neurosurgery volume, which declined by 81.4% (41 vs. 220, P = 0.008), represented only 6.8% of cases during the pandemic versus 15.2% in 2019 (P = 0.02). CONCLUSIONS: Operative restrictions during the COVID-19 surge led to distinct shifts in neurosurgical practice, and local infective burden played a significant role in operative volume and patient acuity.

Longitudinal Survey of Trainee Case Log Entry for Carotid Endarterectomy: Trends in Neurologic, General, and Vascular Surgery.

BACKGROUND: Multiple surgical specialties perform carotid endarterectomy (CEA). As indications for CEA narrows, neurosurgery residents are less exposed to this procedure. This study aims to determine trends in CEA training among graduating trainees in neurosurgery and compare these to general and vascular surgery. METHODS: ACGME case log reports were retrospectively reviewed from 2013 to 2019 for neurologic, general, and vascular surgery residencies and vascular surgery fellowship. These annual reports contain the mean number of logged cases for graduating trainees and their level of participation. We analyzed trends in logged cases over the study period and compared mean number of logged cases between specialties and their respective required minimum numbers. RESULTS: Neurosurgery residents (13.5 ± 0.76) performed significantly more CEAs than their counterparts in general surgery (9.4 ± 0.34, P < 0.01) but less in integrated vascular surgery (57.7 ± 0.88) and vascular surgery fellowship (47.9 ± 0.79, both P < 0.001). The only statistically significant change over the study period was a decline in mean number of cases logged by general surgery residents at -0.4 cases/year (P < 0.001). Trainees in all specialties reported around twice as many cases as the respective Accreditation Council for Graduate Medical Education required minimum numbers. Neurosurgery residents demonstrated increasing participation as lead surgeons by 0.7 cases/year (P = 0.04) and a concurrent decline as senior surgeons by 1.4 cases/year (P < 0.01). CONCLUSIONS: Neurosurgery residents exceeded their minimum requirements for CEA, with increasing trend in higher level of participation. But neurosurgery residents' exposure to this procedure was far less significant than their colleagues in vascular surgery, a gap that may widen over time and should be addressed proactively.

Moving Beyond Narcan: A Police, Social Service, and Researcher Collaborative Response to the Opioid Crisis.

The opioid crisis is the most persistent, long-term public health emergency facing the United States, and available evidence suggests the crisis has worsened during the COVID-19 global pandemic. Naloxone is an effective overdose response that saves lives, but the drug does not address problematic drug use, addiction, or the underlying conditions that lead to overdoses. The opioid crisis is at its core a multidisciplinary, multisystem problem, and an effective response to the crisis requires collaboration across those various systems. This paper describes such a collaborative effort. The Tempe First-Responder Opioid Recovery Project is a multidisciplinary partnership that includes police officers, social workers, substance use peer counselors, public health professionals, police researchers, and drug policy/harm reduction researchers. The project, 10 months underway, trained and equipped Tempe (AZ) police officers to administer Narcan. In addition, a 24/7 in-person "Crisis Outreach Response Team" rapidly responds to any suspected overdose and offers follow-up support, referrals, and services to the individual (and loved ones) for up to 45 days after the overdose. We present preliminary project data including interviews with project managers, counselors, and police officers, descriptions of Narcan administrations in the field, and aggregate data on client service engagement. These data highlight the complexity of the opioid crisis, the collaborative nature of the Tempe project, and the importance of initiating a multidisciplinary, comprehensive response to effectively deal with the opioid problem.