Association of Angiotensin-Converting Enzyme Inhibitors with Increased Mortality Among Patients with Isolated Severe Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is associated with one-third of all deaths from trauma. Preinjury exposure to cardiovascular drugs may affect TBI outcomes. Angiotensin-converting enzyme inhibitors (ACEIs) exacerbate brain cell damage and worsen functional outcomes in the laboratory setting. ß-blockers (BBs), however, appear to be associated with reduced mortality among patients with isolated TBI. OBJECTIVE: Examine the association between preinjury ACEI and BB use and clinical outcome among patients with isolated TBI. METHODS: A retrospective cohort study of patients age ≥ 40 years admitted to an academic level 1 trauma center with isolated TBI between January 2010 and December 2014 was performed. Isolated TBI was defined as a head Abbreviated Injury Scale (AIS) score ≥ 3, with chest, abdomen, and extremity AIS scores ≤ 2. Preinjury medication use was determined through chart review. All patients with concurrent BB use were initially excluded. In-hospital mortality was the primary measured outcome. RESULTS: Over the 5-year study period, 600 patients were identified with isolated TBI who were naive to BB use. There was significantly higher mortality (P = .04) among patients who received ACEI before injury (10 of 96; 10%) than among those who did not (25 of 504; 5%). A multivariate stepwise logistic regression analysis revealed a threefold increased risk of mortality in the ACEI cohort (P < .001), which was even greater than the twofold increased risk of mortality associated with an Injury Severity Score ≥ 16. A second analysis that included patients who received preinjury BBs (n = 98) demonstrated slightly reduced mortality in the ACEI cohort with only a twofold increased risk in multivariate analysis (P = .05). CONCLUSIONS: Preinjury exposure to ACEIs is associated with an increase in mortality among patients with isolated TBI. This effect is ameliorated in patients who receive BBs, which provides evidence that this class of medications may provide a protective benefit.

Intraoperative Intercostal Nerve Block for Pain Management After Retropleural Thoracic Discectomy: Anatomy and Technique.

BACKGROUND: Thoracic discectomy procedures require early and adequate pain control to alleviate patient discomfort after surgery. The intraoperative placement of a nerve block after intercostal nerve violation can offer early pain management after thoracic discectomy. METHODS: The anatomy and technique of placing an intercostal nerve block after retropleural thoracic discectomy are described. Patient data were collected for patients who underwent this technique. RESULTS: This approach is presented with an illustrative figure and a review of relevant anatomical landmarks to describe the technique and ensure its reproducibility. Data for 93 patients (57 [61%] women; 36 [39%] men; mean [SD] age, 54.1 [14.1] years) who underwent the procedure are provided to assess the reliability of this technique. CONCLUSIONS: Intercostal nerve blockage offers a valuable addition to postoperative pain management and may be considered as an available pain relief option for patients undergoing thoracic discectomy.

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.

COVID-19 and Neurosurgery Consultation Call Volume at a Single Large Tertiary Center With a Propensity-Adjusted Analysis.

BACKGROUND: The COVID-19 pandemic has significantly affected patient care across specialties. Ramifications for neurosurgery include substantial disruptions to surgical training and changes in nonurgent patient presentations to the emergency department. This study quantifies the effects of the COVID-19 pandemic on the number of emergency department patients who were referred to the neurosurgery department for further consultation and treatment and identifies and describes trends in the characteristics of these visits. METHODS: A retrospective review was performed of neurosurgical consultations at a single high-volume institution for 28 call-day periods before and after the official announcement of the pandemic. Primary outcomes included consultations per call-day, patient presentation category, and patient admission. RESULTS: The neurosurgical service was consulted regarding 629 patients (367 male patients) during the study period, with 471 (75%) and 158 (25%) patients presenting before and after the announcement of the COVID-19 pandemic, respectively. The mean number of neurosurgical consultations per call-day was significantly lower in the COVID-19 period (5.6 consultations) compared with the pre-COVID-19 period (16.8 consultations) (P < 0.001). After adjusting for patient demographics, the rate of presentation for general nonurgent concerns, such as back pain, headaches, and other general weaknesses, significantly decreased (odds ratio [95% confidence interval], 0.60 [0.47-0.77], P < 0.001). CONCLUSIONS: Neurosurgical consultations significantly decreased after the onset of the COVID-19 pandemic, with a substantially lower overall number of consultations necessitating operative interventions. Furthermore, the relative number of patients with nonemergent neurological conditions significantly decreased during the pandemic.

Correlation of perioperative risk scores with hospital costs in neurosurgical patients.

OBJECTIVE: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) online surgical risk calculator uses inherent patient characteristics to provide predictive risk scores for adverse postoperative events. The purpose of this study was to determine if predicted perioperative risk scores correlate with actual hospital costs. METHODS: A single-center retrospective review of 1005 neurosurgical patients treated between September 1, 2011, and December 31, 2014, was performed. Individual patient characteristics were entered into the NSQIP calculator. Predicted risk scores were compared with actual in-hospital costs obtained from a billing database. Correlational statistics were used to determine if patients with higher risk scores were associated with increased in-hospital costs. RESULTS: The Pearson correlation coefficient (R) was used to assess the correlation between 11 types of predicted complication risk scores and 5 types of encounter costs from 1005 health encounters involving neurosurgical procedures. Risk scores in categories such as any complication, serious complication, pneumonia, cardiac complication, surgical site infection, urinary tract infection, venous thromboembolism, renal failure, return to operating room, death, and discharge to nursing home or rehabilitation facility were obtained. Patients with higher predicted risk scores in all measures except surgical site infection were found to have a statistically significant association with increased actual in-hospital costs (p < 0.0005). CONCLUSIONS: Previous work has demonstrated that the ACS NSQIP surgical risk calculator can accurately predict mortality after neurosurgery but is poorly predictive of other potential adverse events and clinical outcomes. However, this study demonstrates that predicted high-risk patients identified by the ACS NSQIP surgical risk calculator have a statistically significant moderate correlation to increased actual in-hospital costs. The NSQIP calculator may not accurately predict the occurrence of surgical complications (as demonstrated previously), but future iterations of the ACS universal risk calculator may be effective in predicting actual in-hospital costs, which could be advantageous in the current value-based healthcare environment.

Human Factors Associated with Continuous Glucose Monitor Use in Patients with Diabetes: A Systematic Review.

Consistent continuous glucose monitor (CGM) use is associated with substantial improvements in glycemic control, yet the uptake and continued use of these technologies remains low. This systematic review aims to identify and summarize the state of science on human factors and their association with CGM use to inform training methods and best practices that support adherence to CGM use and automated insulin delivery systems. A literature search was conducted in PubMed, CINAHL, The Cochrane Library, and PsychInfo databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify studies that reported psychological human factors related to CGM or sensor-augmented pump use in patients with type 1 diabetes. In total, 389 records were identified through our database search and 26 studies published between 2010 and 2017 were included. Articles underwent quality appraisal using the Effective Public Health Practice Project Quality Assessment Tool and were categorized according to study outcomes. Identified human factors with a potential association with CGM use were treatment satisfaction, quality of life, emotional distress, and self-efficacy. Eight patient-reported barriers to CGM use were identified as a subcomponent of satisfaction. To date, studies of human factors associated with CGM use generally lack standardized measures and sufficient methodological rigor necessary to establish causation. A more robust understanding of how identified human factors influence CGM use is necessary. Future studies should test interventions that target human factors to improve consistency of use and establish best practices for enhancing patients' experience and acceptance of these technologies, especially within adolescents and young adults.

Trends and Predictors of National Institutes of Health Funding to Plastic Surgery Residency Programs.

BACKGROUND: Recent studies have demonstrated low levels of National Institutes of Health funding for surgical research. The authors compared the funding in plastic surgery with the funding for other surgical specialties. METHODS: A query of National Institutes of Health grants awarded to departments of surgical specialties was performed using the National Institutes of Health RePORTER database (2008 to 2016). Trends in funding were compared by specialty and adjusted for the number of active physicians in each specialty. Plastic surgery residency program characteristics were correlated with funding procurement. RESULTS: Eight hundred eighty-nine faculty at 94 plastic surgery residency programs were queried. Forty-eight investigators (5.4 percent) at 23 programs (24.4 percent) had National Institutes of Health funding. From 2008 to 2016, a total of $84,142,138 was awarded through 81 grants. Funding supported translational (44.6 percent), clinical (26.4 percent), basic science (27.2 percent), and educational (1.7 percent) research. In 2016, plastic surgery received the least amount of National Institutes of Health funding per active physician ($1,530) relative to orthopedic surgery ($3124), obstetrics and gynecology ($3885), urology ($5943), otolaryngology ($9999), general surgery ($11,649), ophthalmology ($11,933), and neurologic surgery ($20,874). Plastic surgery residency program characteristics associated with National Institutes of Health funding were high ranking and had more than 10 clinical faculty (p < 0.05). CONCLUSIONS: Plastic surgery receives the least National Institutes of Health funding among the surgical specialties. Departments and divisions of plastic surgery should support investigators applying for research grants to increase future National Institutes of Health funding.

National Institutes of Health Funding in Plastic Surgery: A Crisis?

BACKGROUND: Decreasing funding rates and increasing competition for National Institutes of Health research grants have prompted diverse interventions in various fields of biomedicine. Currently, the state of National Institutes of Health funding for plastic surgery research is poorly understood. The purpose of this study was to describe the portfolio of National Institutes of Health grants in academic plastic surgery. METHODS: Plastic surgery faculty at integrated and independent programs were queried individually in the National Institutes of Health RePORTER database for grants awarded in 2014. Funding totals, mechanisms, and institutes were calculated. Abstracts were categorized by research type and field of interest. Characteristics of National Institutes of Health-funded principal investigators were elucidated. RESULTS: Eight hundred sixty-one academic plastic surgeons at 94 programs were queried, and only 18 investigators (2.1 percent) were funded at 12 programs (12.8 percent). National Institutes of Health-funded investigators were predominately male (72 percent), fellowship-trained (61 percent), and aged 49.3 ± 7.8 years. A total of 20 awards amounted to $6,916,886, with an average award of $345,844 ± $222,909. Costs were primarily awarded through the R01 mechanism (77.2 percent). The top three National Institutes of Health institutes awarded 72.9 percent of the entire portfolio. Funding supported clinical (41.1 percent), translational (36.9 percent), and basic science (22.0 percent) research. Craniofacial (20.5 percent), hand (18.7 percent), and breast (16.2 percent) had the greatest funding. CONCLUSIONS: Few programs and faculty drive the National Institutes of Health portfolio of plastic surgery research. These data suggest a tenuous funding situation that may be susceptible to future spending cuts. Future research is needed to identify barriers to National Institutes of Health funding procurement in academic plastic surgery.

The Impact of National Institutes of Health Funding on Scholarly Productivity in Academic Plastic Surgery.

BACKGROUND: The h-index is an objective measure of an investigator's scholarly impact. The purpose of this investigation was to determine the association between scholarly impact, as measured by the h-index, and the procurement of National Institutes of Health (NIH) grant funding among academic plastic surgeons. METHODS: This was a case-control study of NIH-funded plastic surgery faculty identified on the RePORTER database. Non-NIH-funded faculty from the top 10 NIH-funded programs served as a control group. The mean h-index was calculated from Scopus (Elsevier, London, United Kingdom) and compared by funding status, academic rank, and terminal degree(s). The relationship between h-index and career NIH funding was elucidated via Spearman's correlation coefficient. RESULTS: NIH-funded faculty had higher h-indices than nonNIH-funded faculty (23.9 versus 9.9, p < 0.001), an effect that persisted when controlling for academic rank. Higher rank correlated with higher h-indices and predicted greater NIH funding (p < 0.05). The h-index did not vary by terminal degree (p > 0.05), but investigators with a master's degree exhibited a trend toward greater NIH funding. Higher h-indices correlated with greater NIH funding (r = 0.481, p < 0.001). CONCLUSIONS: A strong relationship exists between scholarly impact and the procurement of NIH funding. Faculty with greater funding had greater scholarly impact, as measured by the h-index, which suggests that this tool may have utility during the NIH grant application process.

Neurosurgery Residency Websites: A Critical Evaluation.

OBJECTIVE: To evaluate the accessibility of educational and recruitment content of Neurosurgery Residency Websites (NRWs). METHODS: Program lists from the Fellowship and Residency Electronic Interactive Database (FREIDA), Electronic Residency Application Service (ERAS), and the American Association of Neurological Surgeons (AANS) were accessed for the 2015 Match. These databases were assessed for accessibility of information and responsive program contacts. Presence of online recruitment and education variables was assessed, and correlations between program characteristics and website comprehensiveness were made. RESULTS: All 103 neurosurgery residency programs had an NRW. The AANS database provided the most number of viable website links with 65 (63%). No links existed for 5 (5%) programs. A minority of programs contacts responded via e-mail (46%). A minority of recruitment (46%) and educational (49%) variables were available on the NRWs. Larger programs, as defined by the number of yearly residency spots and clinical faculty, maintained greater online content than smaller programs. Similar trends were seen with programs affiliated with a ranked medical school and hospital. CONCLUSIONS: Multiple prior studies have demonstrated that medical students applying to neurosurgery rely heavily on residency program websites. As such, the paucity of content on NRWs allows for future opportunity to optimize online resources for neurosurgery training. Making sure that individual programs provide relevant content, make the content easier to find and adhere to established web design principles could increase the usability of NRWs.

Evaluation of content and accessibility of hand fellowship websites.

BACKGROUND: Graduates of general, orthopedic, and plastic surgery residencies utilize web-based resources when applying for hand fellowship training. The purpose of this study was to evaluate the accessibility and content of hand fellowship websites (HFWs). METHODS: Websites of accredited hand surgery fellowships were eligible for study inclusion. HFWs were evaluated for comprehensiveness in the domains of education and recruitment. Website content was correlated with program characteristics via Fisher exact tests. RESULTS: Fifteen plastic, 65 orthopedic, and 1 general surgery hand fellowships were analyzed. Seventy-four hand fellowships maintained an HFW (91 %). HFWs were not found for 3 plastic and 4 orthopedic hand programs (20 versus 6 %, p = 0.118). HFWs provided only half of all analyzed content (54 %-education and 49 %-recruitment). Orthopedic programs had more education content than plastic surgery programs (55 versus 44 %, p = 0.030). Programs in the South had more education content than programs in the Northeast (63 versus 47 %, p = 0.001), but not more than programs in the West (54 %) or Midwest (55 %). Larger programs with more fellows had greater education content than those with only one fellow (57 versus 49 %, p = 0.042). Programs affiliated with top-ranked medical schools had less education content than lower-ranked schools (48 versus 56 %, p = 0.045). No differences existed in recruitment content between programs. CONCLUSIONS: Most hand surgery fellowships lack readily accessible and comprehensive websites. The paucity of online content suggests HFWs are underutilized as educational resources and future opportunity may exist to optimize these tools.