There Is Wide Variation in Platelet-rich Plasma Injection Pricing: A United States Nationwide Study of Top Orthopaedic Hospitals.

BACKGROUND: Demand for platelet-rich plasma (PRP) injections for osteoarthritis has dramatically increased in recent years despite conflicting evidence regarding its efficacy and highly variable pricing in the top orthopaedic centers in the United States, because PRP is typically not covered by insurance. A previous study investigating the mean price of PRP injections obtained information only from centers advertising online the availability of PRP injections. Thus, there is a need for further clarification of the overall availability and variability in cost of PRP injections in the orthopaedic community as well as an analysis of relevant regional demographic and hospital characteristics that could be associated with PRP pricing. QUESTIONS/PURPOSES: Our study purposes were to (1) report the availability and price variation of knee PRP injections at top-ranked United States orthopaedic centers, (2) characterize the availability of pricing information for a PRP injection over the telephone, (3) determine whether hospital characteristics (Orthopaedic Score [ U . S. News & World Report measure of hospital orthopaedic department performance], size, teaching status, and rural-urban status) were associated with PRP injection availability and pricing, and (4) characterize the price variation, if it exists, of PRP injections in three metropolitan areas and individual institutions. METHODS: In this prospective study, a scripted telephone call to publicly listed clinic telephone numbers was used to determine the availability and price estimate (amount to be paid by the patient) of a PRP injection for knee osteoarthritis from the top 25 hospitals from each United States Census region selected from the U.S. News & World Report ranking of best hospitals for orthopaedics. Univariable analyses examined factors associated with PRP injection availability and willingness to disclose pricing, differences across regions, and the association between hospital characteristics (Orthopaedic Score, size, teaching status, and rural-urban status) and pricing. The Orthopaedic Score is a score assigned to each hospital by U . S. News & World Report as a measure of hospital performance based partly on patient outcomes, with higher scores indicating better outcomes. RESULTS: Overall, 87% (87 of 100) of respondents stated they offered PRP injections. Pricing ranged from USD 350 to USD 2815 (median USD 800) per injection, with the highest prices in the Northeast. The largest price range was in the Midwest, where more than two-thirds of PRP injections given at hospitals that disclosed pricing cost USD 500 to USD 1000. Of the hospitals that offered PRP injections, 68% (59 of 87) were willing to disclose price information over the telephone. PRP injection pricing was inversely correlated with hospital Orthopaedic Score (-3% price change [95% CI -5% to -1%]; p = 0.01) and not associated with any of the other hospital characteristics that were studied, such as patient population median income and total hospital expenses. An intracity analysis revealed wide variations in PRP pricing in all metropolitan areas that were analyzed, ranging from a minimum of USD 300 within 10 miles of metropolitan area B to a maximum of USD 1269 within 20 miles of metropolitan area C. CONCLUSION: We found that although PRP injections are widely available, pricing continues to be a substantial financial burden on patients, with large price variability among institutions. We also found that if patients are willing to shop around in a metropolitan area, there is potential to save a meaningful amount of money. CLINICAL RELEVANCE: As public interest in biologics in orthopaedic surgery increases, knowledge of its pricing should be clarified to consumers. The debated efficacy of PRP injections, combined with our findings that it is an expensive out-of-pocket procedure, suggests that PRP has limited cost-effectiveness, with variable, discrete pricing. As such, the price of PRP injections should be clearly disclosed to patients so they can make informed healthcare decisions.

Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers.

PURPOSE: To categorize and trend annual out-of-pocket expenditures for arthroscopic rotator cuff repair (RCR) patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting. METHODS: Patients who underwent outpatient arthroscopic RCR in the United States from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period. Trends in outcome variables over time and differences across insurance types were analyzed. Multivariable analysis was performed to investigate drivers of POPE. RESULTS: A total of 52,330 arthroscopic RCR patients were identified. Between 2013 and 2018, median POPE increased by 47.5% ($917 to $1,353), and median THU increased by 9.3% ($11,964 to $13,076). Patients with high deductible insurance plans paid $1,910 toward their THU, 52.5% more than patients with preferred provider plans ($1,253, P = .001) and 280.5% more than patients with managed care plans ($502, P = .001). All components of POPE increased over the study period, with the largest observed increase being POPE for the immediate procedure (P = .001). On multivariable analysis, out-of-network facility, out-of-network surgeon, and high-deductible insurance most significantly increased POPE. CONCLUSIONS: POPE for arthroscopic RCR increased at a higher rate than THU over the study period, demonstrating that patients are paying an increasing proportion of RCR costs. A large percentage of this increase comes from increasing POPE for the immediate procedure. Out-of-network facility status increased POPE 3 times more than out-of-network surgeon status, and future cost-optimization strategies should focus on facility-specific reimbursements in particular. Last, ambulatory surgery centers (ASCs) significantly reduced POPE, so performing arthroscopic RCRs at ASCs is beneficial to cost-minimization efforts. CLINICAL RELEVANCE: This study highlights that although payers have increased reimbursement for RCR, patient out-of-pocket expenditures have increased at a much higher rate. Furthermore, this study elucidates trends in and drivers of patient out-of-pocket payments for RCR, providing evidence for development of cost-optimization strategies and counseling of patients undergoing RCR.

A conserved, N-terminal tyrosine signal directs Ras for inhibition by Rabex-5.

Dysregulation of the Ras oncogene in development causes developmental disorders, "Rasopathies," whereas mutational activation or amplification of Ras in differentiated tissues causes cancer. Rabex-5 (also called RabGEF1) inhibits Ras by promoting Ras mono- and di-ubiquitination. We report here that Rabex-5-mediated Ras ubiquitination requires Ras Tyrosine 4 (Y4), a site of known phosphorylation. Ras substitution mutants insensitive to Y4 phosphorylation did not undergo Rabex-5-mediated ubiquitination in cells and exhibited Ras gain-of-function phenotypes in vivo. Ras Y4 phosphomimic substitution increased Rabex-5-mediated ubiquitination in cells. Y4 phosphomimic substitution in oncogenic Ras blocked the morphological phenotypes associated with oncogenic Ras in vivo dependent on the presence of Rabex-5. We developed polyclonal antibodies raised against an N-terminal Ras peptide phosphorylated at Y4. These anti-phospho-Y4 antibodies showed dramatic recognition of recombinant wild-type Ras and RasG12V proteins when incubated with JAK2 or SRC kinases but not of RasY4F or RasY4F,G12V recombinant proteins suggesting that JAK2 and SRC could promote phosphorylation of Ras proteins at Y4 in vitro. Anti-phospho-Y4 antibodies also showed recognition of RasG12V protein, but not wild-type Ras, when incubated with EGFR. A role for JAK2, SRC, and EGFR (kinases with well-known roles to activate signaling through Ras), to promote Ras Y4 phosphorylation could represent a feedback mechanism to limit Ras activation and thus establish Ras homeostasis. Notably, rare variants of Ras at Y4 have been found in cerebellar glioblastomas. Therefore, our work identifies a physiologically relevant Ras ubiquitination signal and highlights a requirement for Y4 for Ras inhibition by Rabex-5 to maintain Ras pathway homeostasis and to prevent tissue transformation.

Hip Arthroscopy Trends: Increasing Patient Out-of-Pocket Costs, Lower Surgeon Reimbursement, and Cost Reduction With Utilization of Ambulatory Surgery Centers.

PURPOSE: To (1) report on trends in immediate procedure reimbursement, patient out-of-pocket expenditures, and surgeon reimbursement in hip arthroscopy (2) compare trends in ambulatory surgery centers (ASC) versus outpatient hospitals (OH) utilization; (3) quantify the cost differences (if any) associated with ASC versus OH settings; and 4) determine the factors that predict ASC utilization for hip arthroscopy. METHODS: The cohort for this descriptive epidemiology study was any patient over 18 years identified in the IBM MarketScan Commercial Claims Encounter database who underwent an outpatient hip arthroscopy, identified by Current Procedural Terminology codes, in the United States from 2013 to 2017. Immediate procedure reimbursement, patient out-of-pocket expenditure, and surgeon reimbursement were calculated, and a multivariable model was used to determine the influence of specific factors on these outcome variables. Statistically significant P values were less than .05, and significant standardized differences were more than 0.1. RESULTS: The cohort included 20,335 patients. An increasing trend in ASC utilization was observed (P = .001), and ASC utilization for hip arthroscopy was 32.4% in 2017. Patient out-of-pocket expenditures for femoroacetabular impingement surgery increased 24.3% over the study period (P = .003), which was higher than the rate for immediate procedure reimbursement (4.2%; P = .007). ASCs were associated with $3,310 (28.8%; P = .001) reduction in immediate procedure reimbursement and $47 (6.2%; P = .001) reduction in patient out-of-pocket expenditure per hip arthroscopy. CONCLUSIONS: ASCs provide a significant cost difference for hip arthroscopy. Although there is an increasing trend toward ASC utilization, it remains relatively low at 32.4% in 2017. Thus, there are opportunities for expanded ASC utilization, which is associated with significant immediate procedure reimbursement difference of $3,310 and patient out-of-pocket expenditure difference of $47 per hip arthroscopy case, ultimately benefiting healthcare systems, surgeons, and patients alike. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Stimulated Raman histology facilitates accurate diagnosis in neurosurgical patients: a one-to-one noninferiority study.

OBJECTIVE: Stimulated Raman histology (SRH) offers efficient and accurate intraoperative neuropathological tissue analysis without procedural alteration to the diagnostic specimen. However, there are limited data demonstrating one-to-one tissue comparisons between SRH and traditional frozen sectioning. This study explores the non-inferiority of SRH as compared to frozen section on the same piece of tissue in neurosurgical patients. METHODS: Tissue was collected over a 1-month period from 18 patients who underwent resection of central nervous system lesions. SRH and frozen section analyses were compared for diagnostic capabilities as well as assessed for quality and condition of tissue via a survey completed by pathologists. RESULTS: SRH was sufficient for diagnosis in 78% of specimens as compared to 94% of specimens by frozen section of the same specimen. A Fisher's exact test determined there was no significant difference in diagnostic capability between the two groups. Additionally, both quality of SRH and condition of tissue after SRH were deemed to be non-inferior to frozen section. CONCLUSIONS: This study provides further evidence for the non-inferiority of SRH techniques. It is also the first study to demonstrate SRH accuracy using one-to-one tissue analysis in neuropathological specimens.

Global Surgery Opportunities for General Surgery Residents: Are We Making Progress?

INTRODUCTION: Global surgery efforts have significantly expanded in the last decade. While an increasing number of general surgery residents are incorporating global surgery experiences and research into their training, few resources are available for residency applicants to evaluate opportunities at programs to which they are applying. MATERIALS AND METHODS: A 17-question survey of all general surgery residency program directors (PDs) was conducted by the Global Surgery Student Alliance through emails to the Association of Program Directors in Surgery listserv. PDs indicated if they wished to remain anonymous or include program information in an upcoming online database. RESULTS: Two hundred fifty eight general surgery PDs were emailed the survey and 45 (17%) responses were recorded. Twenty eight (62%) programs offered formal global surgery experiences for residents, including clinical rotations, research, and advocacy opportunities. Thirty one (69%) programs were developing a global health center. Forty two (93%) respondents indicated that global surgery education was an important aspect of surgical training. Barriers to global surgery participation included a lack of funding, time constraints, low faculty participation, and minimal institutional interest. CONCLUSIONS: While most respondents felt that global surgery was important, less than two-thirds offered formal experiences. Despite the significant increase in public awareness and participation in global surgery, these numbers remain low. While this study is limited by a 17% response rate, it demonstrates that more efforts are needed to bolster training, research, and advocacy opportunities for surgical trainees and promote a global perspective on healthcare.

Developing Sustainable Prehospital Pediatric Care in Rwanda.

OBJECTIVE: Unintentional injury is the leading cause of death in children older than 1 year and disproportionately affects pediatric patients in low- and middle-income countries.Improved prehospital care capacity has demonstrated the ability to improve care and save lives. Our collaboration developed and implemented a sustainable prehospital emergency pediatrics care course (EPCC) for Service d'Aide Medicale Urgente, the public emergency medical service in Rwanda. METHODS: A 1-day context-specific EPCC was developed based on international best practices and local feedback. Two cohorts were created to participate in the course. The first group, EPCC 1, was made of 22 Service d'Aide Medicale Urgente providers with preexisting knowledge on the topic who participated in the course and received training to lead future sessions. After completion of the EPCC1, this group led the second cohort, EPCC 2, which was composed of 26 healthcare providers from around Rwanda. Each group completed a 50 question assessment before and after the course. RESULTS: Emergency pediatrics care course 1 mean scores were 58% vs 98% (pre vs post), EPCC 2 mean scores were 49% vs 98% (pre vs post), using matched-pair analysis of 22 and 32 participants, respectively. When comparing unequal variances across the groups with a 2-tailed paired t test, EPCC 1 and EPCC 2 had a statistically significant mean change in pretest and posttest assessment test scores of 40% compared with 46%, P < 0.0001, with 95% confidence interval. A 1-way analysis of variance mean square analysis for the change in scores showed that regardless of the baseline level of training for each participant, all trainees reached similar postassessment scores (F(1) = 1.45, P = 0.2357). CONCLUSIONS: This study demonstrates effective implementation of a context-appropriate prehospital pediatric training program in Kigali, Rwanda. This program may be effective to support capacity development for prehospital care in Rwanda using a qualified local source of instructors.

HIV-Associated Aortitis Causing Rapid Development of an Abdominal Aortic Aneurysm.

Vasculitides are rare manifestations of human immunodeficiency virus (HIV) infection. They encompass a wide range of different pathologies, both infectious and noninfectious. We present the case of a 68-year-old female with HIV, being treated with antiretrovirals, who presented with a symptomatic abdominal aortic aneurysm. The aneurysm developed within one week. The patient underwent endovascular aneurysm repair, and her aneurysm completely resolved on follow-up computed tomography imaging 16 months later. We also present a review of HIV-associated vascular pathologies.

Prehospital epidemiology and management of injured children in Kigali, Rwanda.

INTRODUCTION: Paediatric injuries are a major cause of mortality and disability worldwide, yet little information exists regarding its epidemiology or prehospital management in low-income and middle-income countries. We aimed to describe the paediatric injuries seen and managed by the prehospital ambulance service, Service d'Aide Medicale d'Urgence (SAMU), in Kigali, Rwanda over more than 3 years. METHODS: A retrospective, descriptive analysis was conducted of all injured children managed by SAMU in the prehospital setting between December 2012 and April 2016. RESULTS: SAMU responded to a total of 636 injured children, 10% of all patients seen. The incidence of paediatric injury in Kigali, Rwanda was 140 injuries per 100 000 children. 65% were male and the average age 13.5 (±5.3). Most patients were between 15 and 19 years old (56%). The most common causes of injuries were road traffic incidents (RTIs) (447, 72%), falls (70, 11%) and assaults (50, 8%). Most RTIs involved pedestrians (251, 56%), while 15% (65) involved a bicycle. Anatomical injuries included trauma to the head (330, 52%), lower limb (280, 44%) and upper limb (179, 28%). Common interventions included provision of pain medications (445, 70%), intravenous fluids (217, 34%) and stabilisation with cervical collar (190, 30%). CONCLUSION: In Kigali, RTIs were the most frequent cause of injuries to children requiring prehospital response with most RTIs involving pedestrians. Rwanda has recently instituted several programmes to reduce the impact of paediatric injuries especially with regard to RTIs. These include changes in traffic laws and increased road safety initiatives.

Increased rate of out-of-network surgeon selection for hip arthroscopy compared to more common orthopedic sports procedures.

Background: Demand for hip arthroscopy (HA) has increased, but shortfalls in HA training may create disparities in care access. This analysis aimed to (1) compare out-of-network (OON) surgeon utilization for HA with that of more common orthopedics sports procedures, including rotator cuff repair (RCR), partial meniscectomy (PM), and anterior cruciate ligament reconstruction (ACLR), (2) compare the HA OON surgeon rate with another less commonly performed procedure, meniscus allograft transplant (MAT), and (3) analyze trends and predictors of OON surgeon utilization. Methods: The 2013-2017 IBM MarketScan database identified patients under 65 who underwent HA, RCR, PM, ACLR, or MAT. Demographic differences were determined using standardized differences. Cochran-Armitage tests analyzed trends in OON surgeon utilization. Multivariable logistic regression identified predictors of OON surgeon utilization. Statistical significance was set to p < 0.05 and significant standardized differences were >0.1. Results: 410,487 patients were identified, of which 12,636 patients underwent HA, 87,607 RCR, 233,241 PM, 76,700 ACLR, and 303 MAT. OON surgeon utilization increased for HA, rising from 7.98 % in 2013 to 9.37 % in 2017 (p = 0.026). Compared to RCR, PM, and ACLR, HA was associated with higher likelihood of OON surgeon utilization. Usage of ambulatory surgery centers (ASCs) was predictive of higher OON surgeon rates along with procedure year, insurance plan type, and geographic region. HA performed in an ASC was 13 % less likely to have an OON surgeon (p = 0.047). Conclusion: OON surgeon utilization generally declined but increased for HA. HA was a predictor of OON surgeon status, possibly because HA is a technically complicated procedure with fewer trained in-network providers. Other predictors of OON surgeon status included ASC usage, PPO/EPO plan type, and Northeast geographic region. There is a need to improve access to experienced HA providers-perhaps with prioritization of HA training in residency and fellowship programs-in order to address rising OON surgeon utilization.

Does Medicare Insurance Mitigate Racial/Ethnic Disparities in Access to Lumbar Spinal Surgery When Compared to Commercial Insurance?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Compare disparities in lumbar surgical care utilization in Commercially insured versus Medicare patients. SUMMARY OF BACKGROUND DATA: While disparities in spinal surgery have been previously described, less evidence exists on effective strategies to mitigate them. Theoretically, universal health care coverage under Medicare should improve health care access. MATERIALS AND METHODS: Utilizing National Inpatient Sample data (2003-2018), we included inpatient lumbar discectomy or laminectomy/fusion cases in black, white, or Hispanic patients aged 18-74 years, with Commercial or Medicare insurance. A multivariable Poisson distribution model determined race/ethnicity subgroup-specific rate ratios (RRs) of patients undergoing lumbar surgery compared to their respective population distribution (using US Census data) based on race/ethnicity, region, gender, primary payor, and age (Commercially insured age subgroups: 18-39, 40-54, and 55-64 y; Medicare age subgroup: 65-74 y). RESULTS: Of the 2,310,956 lumbar spine procedures included, 88.9%, 6.1%, and 5.0% represented white, black, and Hispanic patients, respectively. Among Commercially insured patients, black and Hispanic (compared to white) patients had lower rates of surgical care utilization; however, these disparities decreased with increasing age: black (RR=0.37, 95% CI: 0.37-0.38) and Hispanic patients (RR=0.53, 95% CI: 0.52-0.54) aged 18-39 years versus black (RR=0.72, 95% CI: 0.71-0.73) and Hispanic patients (RR=0.64, 95% CI: 0.63-0.65) aged 55-64 years. Racial/ethnic disparities persisted in Medicare patients, especially when compared to the neighboring age subgroup that was Commercially insured: black (RR=0.61, 95% CI: 0.60-0.62) and Hispanic patients (RR=0.61, 95% CI: 0.60-0.61) under Medicare. CONCLUSIONS: Disparities in surgical care utilization among black and Hispanic patients persist regardless of health care coverage, and an expansion of Medicare eligibility alone may not comprehensively address health care disparities. LEVEL OF EVIDENCE: Level III.

An analysis of ChatGPT recommendations for the diagnosis and treatment of cervical radiculopathy.

OBJECTIVE: The objective of this study was to assess the safety and accuracy of ChatGPT recommendations in comparison to the evidence-based guidelines from the North American Spine Society (NASS) for the diagnosis and treatment of cervical radiculopathy. METHODS: ChatGPT was prompted with questions from the 2011 NASS clinical guidelines for cervical radiculopathy and evaluated for concordance. Selected key phrases within the NASS guidelines were identified. Completeness was measured as the number of overlapping key phrases between ChatGPT responses and NASS guidelines divided by the total number of key phrases. A senior spine surgeon evaluated the ChatGPT responses for safety and accuracy. ChatGPT responses were further evaluated on their readability, similarity, and consistency. Flesch Reading Ease scores and Flesch-Kincaid reading levels were measured to assess readability. The Jaccard Similarity Index was used to assess agreement between ChatGPT responses and NASS clinical guidelines. RESULTS: A total of 100 key phrases were identified across 14 NASS clinical guidelines. The mean completeness of ChatGPT-4 was 46%. ChatGPT-3.5 yielded a completeness of 34%. ChatGPT-4 outperformed ChatGPT-3.5 by a margin of 12%. ChatGPT-4.0 outputs had a mean Flesch reading score of 15.24, which is very difficult to read, requiring a college graduate education to understand. ChatGPT-3.5 outputs had a lower mean Flesch reading score of 8.73, indicating that they are even more difficult to read and require a professional education level to do so. However, both versions of ChatGPT were more accessible than NASS guidelines, which had a mean Flesch reading score of 4.58. Furthermore, with NASS guidelines as a reference, ChatGPT-3.5 registered a mean ± SD Jaccard Similarity Index score of 0.20 ± 0.078 while ChatGPT-4 had a mean of 0.18 ± 0.068. Based on physician evaluation, outputs from ChatGPT-3.5 and ChatGPT-4.0 were safe 100% of the time. Thirteen of 14 (92.8%) ChatGPT-3.5 responses and 14 of 14 (100%) ChatGPT-4.0 responses were in agreement with current best clinical practices for cervical radiculopathy according to a senior spine surgeon. CONCLUSIONS: ChatGPT models were able to provide safe and accurate but incomplete responses to NASS clinical guideline questions about cervical radiculopathy. Although the authors' results suggest that improvements are required before ChatGPT can be reliably deployed in a clinical setting, future versions of the LLM hold promise as an updated reference for guidelines on cervical radiculopathy. Future versions must prioritize accessibility and comprehensibility for a diverse audience.

Assessment of Risk Factors and Rate of Conversion to Total Hip Arthroplasty Within 2 Years After Hip Arthroscopy Utilizing a Large Database of Commercially Insured Patients in the United States.

Background: The conversion rate of hip arthroscopy (HA) to total hip arthroplasty (THA) has been reported to be as high as 10%. Despite identifying factors that increase the risk of conversion, current studies do not stratify patients by type of arthroscopic procedure. Purpose/Hypothesis: To analyze the rate and predictors of conversion to THA within 2 years after HA. It was hypothesized that osteoarthritis (OA) and increased patient age would negatively affect the survivorship of HA. Study Design: Cohort study; Evidence level, 3. Methods: The IBM MarketScan database was utilized to identify patients who underwent HA and converted to THA within 2 years at inpatient and outpatient facilities between 2013 and 2017. Patients were split into 3 procedure cohorts as follows: (1) femoroacetabular osteoplasty (FAO), which included treatment for femoroacetabular impingement; (2) isolated debridement; and (3) isolated labral repair. Cohort characteristics were compared using standardized differences. Conversion rates between the 3 cohorts were compared using chi-square tests. The relationship between age and conversion was assessed using linear regression. Predictors of conversion were analyzed using multivariable logistic regression. The median time to conversion was estimated using Kaplan-Meier tests. Results: A total of 5048 patients were identified, and the rates of conversion to THA were 12.86% for isolated debridement, 8.67% for isolated labral repair, and 6.76% for FAO (standardized difference, 0.138). The isolated labral repair cohort had the shortest median time to conversion (isolated labral repair, 10.88 months; isolated debridement, 10.98 months; and FAO, 11.9 months [P = .034). For patients >50 years, isolated debridement had the highest rate of conversion at 18.8%. The conversion rate increased linearly with age. Factors that increased the odds of conversion to THA were OA, having an isolated debridement procedure, and older patient age (P < .05). Conclusion: Older patients and those with preexisting OA of the hip were at a significantly increased risk of failing HA and requiring a total hip replacement within 2 years of the index procedure. Younger patients were at low risk of requiring a conversion procedure no matter which arthroscopic procedure was performed.

Performance of a Large Language Model in the Generation of Clinical Guidelines for Antibiotic Prophylaxis in Spine Surgery.

OBJECTIVE: Large language models, such as chat generative pre-trained transformer (ChatGPT), have great potential for streamlining medical processes and assisting physicians in clinical decision-making. This study aimed to assess the potential of ChatGPT's 2 models (GPT-3.5 and GPT-4.0) to support clinical decision-making by comparing its responses for antibiotic prophylaxis in spine surgery to accepted clinical guidelines. METHODS: ChatGPT models were prompted with questions from the North American Spine Society (NASS) Evidence-based Clinical Guidelines for Multidisciplinary Spine Care for Antibiotic Prophylaxis in Spine Surgery (2013). Its responses were then compared and assessed for accuracy. RESULTS: Of the 16 NASS guideline questions concerning antibiotic prophylaxis, 10 responses (62.5%) were accurate in ChatGPT's GPT-3.5 model and 13 (81%) were accurate in GPT-4.0. Twenty-five percent of GPT-3.5 answers were deemed as overly confident while 62.5% of GPT-4.0 answers directly used the NASS guideline as evidence for its response. CONCLUSION: ChatGPT demonstrated an impressive ability to accurately answer clinical questions. GPT-3.5 model's performance was limited by its tendency to give overly confident responses and its inability to identify the most significant elements in its responses. GPT-4.0 model's responses had higher accuracy and cited the NASS guideline as direct evidence many times. While GPT-4.0 is still far from perfect, it has shown an exceptional ability to extract the most relevant research available compared to GPT-3.5. Thus, while ChatGPT has shown far-reaching potential, scrutiny should still be exercised regarding its clinical use at this time.

The Effect of Intraoperative Overdistraction on Subsidence Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The purpose of this study was to evaluate the effect of overdistraction on interbody cage subsidence. BACKGROUND: Vertebral overdistraction due to the use of large intervertebral cage sizes may increase the risk of postoperative subsidence. METHODS: Patients who underwent anterior cervical discectomy and fusion between 2016 and 2021 were included. All measurements were performed using lateral cervical radiographs at 3 time points - preoperative, immediate postoperative, and final follow-up >6 months postoperatively. Anterior and posterior distraction were calculated by subtracting the preoperative disc height from the immediate postoperative disc height. Cage subsidence was calculated by subtracting the final follow-up postoperative disc height from the immediate postoperative disc height. Associations between anterior and posterior subsidence and distraction were determined using multivariable linear regression models. The analyses controlled for cage type, cervical level, sex, age, smoking status, and osteopenia. RESULTS: Sixty-eight patients and 125 fused levels were included in the study. Of the 68 fusions, 22 were single-level fusions, 35 were 2-level, and 11 were 3-level. The median final follow-up interval was 368 days (range: 181-1257 d). Anterior disc space subsidence was positively associated with anterior distraction (beta = 0.23; 95% CI: 0.08, 0.38; P = 0.004), and posterior disc space subsidence was positively associated with posterior distraction (beta = 0.29; 95% CI: 0.13, 0.45; P < 0.001). No significant associations between anterior distraction and posterior subsidence (beta = 0.07; 95% CI: -0.06, 0.20; P = 0.270) or posterior distraction and anterior subsidence (beta = 0.06; 95% CI: -0.14, 0.27; P = 0.541) were observed. CONCLUSIONS: We found that overdistraction of the disc space was associated with increased postoperative subsidence after anterior cervical discectomy and fusion. Surgeons should consider choosing a smaller cage size to avoid overdistraction and minimize postoperative subsidence.

Isolating the Superficial Peroneal Nerve Motor Branch to the Peroneus Longus Muscle with Concentric Stimulation during Diagnostic Motor Nerve Biopsy.

Motor nerve biopsies are performed in the workup of neuropathies of unknown origin when motor neuron disease is suspected. Biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle has been described as a convenient alternative to other commonly biopsied motor nerves. To date, neuromonitoring techniques have not been described for this procedure. We describe the surgical neurophysiology techniques necessary for preservation of motor function and associated data during muscle biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle. We present a case of a patient who underwent uncomplicated biopsy of the motor branch of the superficial peroneal nerve innervating the peroneus longus muscle during workup for suspected motor neuropathy. The surgical neurophysiology techniques and data are presented in detail. No postsurgical sensory or motor deficit was related to the procedure. Surgical neurophysiology is critical to confirm the appropriate motor branch to the peroneus longus muscle and facilitates safe and accurate motor nerve biopsy.

Species-typical group size differentially influences social reward neural circuitry during nonreproductive social interactions.

We investigated whether nonreproductive social interactions may be rewarding for colonial but not non-colonial species. We found that the colonial spiny mouse (Acomys cahirinus) is significantly more gregarious, more prosocial, and less aggressive than its non-colonial relative, the Mongolian gerbil (Meriones unguiculatus). In an immediate-early gene study, we examined oxytocin (OT) and tyrosine hydroxylase (TH) neural responses to interactions with a novel, same-sex conspecific or a novel object. The paraventricular nucleus of the hypothalamus (PVN) OT cell group was more responsive to interactions with a conspecific compared to a novel object in both species. However, the ventral tegmental area (VTA) TH cell group showed differential responses only in spiny mice. Further, PVN OT and VTA TH neural responses positively correlated in spiny mice, suggesting functional connectivity. These results suggest that colonial species may have evolved neural mechanisms associated with reward in novel, nonreproductive social contexts to promote large group-living.

BRAINterns 2.0: Durability of Webinar-Based Education and Social Media Beyond the Coronavirus Disease 2019 Pandemic.

BACKGROUND: Webinars offer novel educational opportunities beyond those of traditional, in-person experiences. BRAINterns is an open-access webinar-based education platform created to replace opportunities lost during the coronavirus disease 2019 pandemic. This program previously showed the efficacy of webinars to expand access to careers in medicine, and in particular, neurosurgery. BRAINterns 2.0 was established to assess the durability of Web-based learning. METHODS: A modified 4-week webinar series was held during July 2021. A retrospective exit survey was distributed to participants and responses analyzed. RESULTS: A total of 16,045 people registered for BRAINterns 2.0, representing 103 countries. Survey responses were received from 3765 participants (23% response rate). New, first-time registrants comprised 66% of participants, with the rest being returning participants. A total of 342 students participated in a dedicated module delivered entirely in Spanish. Females represented 81% of respondents. Participants identified that desirable elements of the program were opportunities to hear from women (53%) and people of color (44%) in health care. Participants heard about the series through TikTok (n = 1251; 33%), Instagram (n = 1109; 29%), Facebook (n = 637; 17%), and word of mouth (n = 708; 19%) with assistance from an ambassador program. CONCLUSIONS: Webinar-based education programs continue to be of interest to students in an increasingly digital world. Social media, and specifically the use of educational ambassadors, are effective to improve visibility of educational programs across a diverse population of students. Understanding the desires of participants is critical to building a successful online education platform.

Weekend Admission Increases Risk of Readmissions Following Elective Thoracolumbar Spinal Fusion.

STUDY DESIGN: Retrospective database study. OBJECTIVES: The goal of this study was to assess the influence of weekend admission on patients undergoing elective thoracolumbar spinal fusion by investigating hospital readmission outcomes and analyzing differences in demographics, comorbidities, and postoperative factors. METHODS: The 2016-2018 Nationwide Readmission Database was used to identify adult patients who underwent elective thoracolumbar spinal fusion. The sample was divided into weekday and weekend admission patients. Demographics, comorbidities, complications, and discharge status data were compiled. The primary outcomes were 30-day and 90-day readmission. Univariate logistic regression analyzed the relationship between weekday or weekend admission and 30- or 90-day readmission, and multivariate regression determined the impact of covariates. RESULTS: 177,847 patients were identified in total, with 176,842 in the weekday cohort and 1005 in the weekend cohort. Multivariate regression analysis found that 30-day readmissions were significantly greater for the weekend cohort after adjusting for sex, age, Medicare or Medicaid status, and comorbidity status (OR 2.00, 95% CI: 1.60-2.48; P < .001), and 90-day readmissions were also greater for the weekend cohort after adjustment (OR 2.01, 95% CI: 1.68-2.40, P < .001). CONCLUSIONS: Patients undergoing elective thoracolumbar spinal fusion surgery who are initially admitted on weekends are more likely to experience hospital readmission. These patients have increased incidence of deep vein thrombosis, postoperative infection, and non-routine discharge status. These factors are potential areas of focus for reducing the impact of the "weekend effect" and improving outcomes for elective thoracolumbar spinal fusion.