Current Trends in Subspecialty Fellowship Training for 1691 Academic Neurological Surgeons.

OBJECTIVE: Neurosurgical subspecialty fellowship training has become increasingly popular in recent decades. However, few studies have evaluated recent trends in postgraduate subspecialty education. This study aims to provide a detailed cross-sectional analysis of subspecialty fellowship training completion trends and demographics among U.S. academic neurosurgeons. METHODS: Academic clinical faculty (M.D. or D.O.) teaching at accredited neurosurgery programs were included. Demographic, career, and fellowship data were collected from departmental physician profiles and the American Association of Neurological Surgeons (AANS) membership database. Relative citation ratio scores were retrieved using the National Institutes of Health iCite tool. RESULTS: This study included 1691 surgeons (1756 fellowships) from 125 institutions. The majority (79.13%) reported fellowship training. Fellowship completion was more common among recent graduates (residency year >2000), as was training in multiple subspecialties (P < 0.0001). Spine was the most popular subspecialty (16.04%), followed by pediatrics (11.18%), and cerebrovascular (9.46%). The least common were trauma/critical care (2.52%) and peripheral nerve (1.26%). Spine, neuroradiology, and endovascular subspecialties grew in popularity over time. Pediatrics and spine were the most popular for females and males, respectively. Epilepsy and cerebrovascular had the most full professors, while endovascular and spine had the most assistant professors. Stereotactic/functional and epilepsy had the most Ph.Ds. Fellowship training correlated with higher weighted, but not mean, relative citation ratio scores among associate (P = 0.002) and full professors (P = 0.005). CONCLUSIONS: There is an emerging proclivity for additional fellowship training among young neurosurgeons, often in multiple subspecialties. These findings are intended to help guide professional decision-making and optimize the delivery of postgraduate education.

Neuropsychological Assessment of Community-Dwelling Older Adults in Almaty, Kazakhstan.

Cognitive impairment in older adults is a major public concern for Kazakhstan's aging population. We aimed to (1) administer a neuropsychological test battery (NTB) in domains relevant to aging-associated cognitive impairment in a sample of adults aged 60+ without dementia in Almaty, Kazakhstan; (2) investigate the associations between demographic factors and test performance; and (3) provide information on the distribution of NTB scores as preliminary local normative data relevant for this population. A cross-sectional evaluation of 276 participants aged 60+ in Almaty, Kazakhstan, was conducted using cognitive instruments including tests of memory, attention, language, executive functions, visuospatial abilities, and processing speed. Multiple linear regression analyses were used to examine the association of demographic factors with neuropsychological test performance. The results from the regression analysis showed that those who are younger, have more years of education, are women, and are of Russian ethnicity had significantly better performance. The current study illustrated (1) the feasibility of administering the NTB to older adults in the general population in Kazakhstan; (2) the preliminary local normative neuropsychological measures; and (3) their independent associations with age, education, gender, and ethnicity. The findings are a platform for future research on dementia and cognitive impairment in older adults in Kazakhstan.

The Cardiovascular Cost of Silence: Relationships Between Self-silencing and Carotid Atherosclerosis in Midlife Women.

BACKGROUND: Individuals engage in a range of behaviors to maintain close relationships. One behavior is self-silencing or inhibiting self-expression to avoid relationship conflict or loss. Self-silencing is related to poor mental health and self-reported physical health in women but has not been examined in relation to cardiovascular health, particularly using direct measures of the vasculature. PURPOSE: To test associations between self-silencing and carotid atherosclerosis in midlife women; secondary analyses examined moderation by race/ethnicity. METHODS: Women (N = 290, ages 40-60) reported on self-silencing in intimate relationships and underwent physical measurements, blood draw, and ultrasound assessment of carotid intima-media thickness (IMT) and plaque. Associations between self-silencing and mean IMT and plaque index (0, 1, ≥2) were tested in linear regression and multinomial logistic regression models, respectively, followed by interaction terms between self-silencing and race, adjusted for demographic factors, CVD risk factors, partner status, depression, physical activity, and diet. RESULTS: Forty-seven percent of women demonstrated carotid plaque. Greater self-silencing was related to increased odds of plaque index ≥2 (e.g., for each additional point, odds ratio [95% confidence interval] = 1.16 [1.03-1.31], p = .012), relative to no plaque). Moderation analyses indicated that self-silencing was related to odds of plaque index ≥2 in non-white women (1.15 [1.05-1.26], p = .004), but there was no significant relationship in white women (1.01 [0.97-1.06], p = .550). No associations emerged for IMT. CONCLUSIONS: Among midlife women, self-silencing was associated with carotid plaque, independent of CVD risk factors, depression, and health behaviors. Emotional expression in relationships may be important for women's cardiovascular health.

Assessment of the NIH-supported relative citation ratio as a measure of research productivity among 1687 academic neurological surgeons.

OBJECTIVE: Publication metrics such as the Hirsch index (h-index) are often used to evaluate and compare research productivity in academia. The h-index is not a field-normalized statistic and can therefore be dependent on overall rates of publication and citation within specific fields. Thus, a metric that adjusts for this while measuring individual contributions would be preferable. The National Institutes of Health (NIH) has developed a new, field-normalized, article-level metric called the "relative citation ratio" (RCR) that can be used to more accurately compare author productivity between fields. The mean RCR is calculated as the total number of citations per year of a publication divided by the average field-specific citations per year, whereas the weighted RCR is the sum of all article-level RCR scores over an author's career. The present study was performed to determine how various factors, such as academic rank, career duration, a Doctor of Philosophy (PhD) degree, and sex, impact the RCR to analyze research productivity among academic neurosurgeons. METHODS: A retrospective data analysis was performed using the iCite database. All physician faculty affiliated with Accreditation Council for Graduate Medical Education (ACGME)-accredited neurological surgery programs were eligible for analysis. Sex, career duration, academic rank, additional degrees, total publications, mean RCR, and weighted RCR were collected for each individual. Mean RCR and weighted RCR were compared between variables to assess patterns of analysis by using SAS software version 9.4. RESULTS: A total of 1687 neurosurgery faculty members from 125 institutions were included in the analysis. Advanced academic rank, longer career duration, and PhD acquisition were all associated with increased mean and weighted RCRs. Male sex was associated with having an increased weighted RCR but not an increased mean RCR score. Overall, neurological surgeons were highly productive, with a median RCR of 1.37 (IQR 0.93-1.97) and a median weighted RCR of 28.56 (IQR 7.99-85.65). CONCLUSIONS: The RCR and its derivatives are new metrics that help fill in the gaps of other indices for research output. Here, the authors found that advanced academic rank, longer career duration, and PhD acquisition were all associated with increased mean and weighted RCRs. Male sex was associated with having an increased weighted, but not mean, RCR score, most likely because of historically unequal opportunities for women within the field. Furthermore, the data showed that current academic neurosurgeons are exceptionally productive compared to both physicians in other specialties and the general scientific community.

Racial/ethnic disparities in women's sleep duration, continuity, and quality, and their statistical mediators: Study of Women's Health Across the Nation.

STUDY OBJECTIVES: To describe racial/ethnic differences in sleep duration, continuity, and perceived sleep quality in postmenopausal women and to identify statistical mediators of differences in sleep characteristics. METHODS: Recruited from the observational Study of Women's Health Across the Nation (SWAN), 1,203 (548 white, 303 black, 147 Chinese, 132 Japanese, and 73 Hispanic; mean age 65 years, 97% postmenopausal) women participated in a week-long actigraphy and daily diary study in 2013-2015. Actigraphic measures of sleep duration and wake after sleep onset (WASO), and diary-rated sleep quality were averaged across the week. Candidate mediators included health-related variables; stress; and emotional well-being assessed up to 13 times across 18 years from baseline to sleep study. RESULTS: Whites slept longer than other groups; the significant mediators were concurrent financial hardship and increasing number of stressors for Hispanics or Japanese versus whites. Whites had less WASO than blacks and Hispanics; significant mediators were concurrent number of health problems, physical inactivity, waist circumference, vasomotor symptoms, number of life stressors, and financial hardship, and increasing number of health problems from baseline to sleep study. Whites reported better sleep quality than blacks, Chinese, and Japanese; significant mediators were concurrent physical inactivity, vasomotor symptoms, positive affect, and depressive symptoms. CONCLUSIONS: Sleep differences between blacks or Hispanics versus whites were mediated by health problems, number of stressors, and financial hardship, whereas sleep differences between Chinese or Japanese versus whites were mediated by emotional well-being. This is the first study using formal mediational approaches.

A Cost-Effectiveness Comparison Between Open Transforaminal and Minimally Invasive Lateral Lumbar Interbody Fusions Using the Incremental Cost-Effectiveness Ratio at 2-Year Follow-up.

BACKGROUND: Direct cost comparisons between minimally invasive spine surgeries and the open options are rare. OBJECTIVE: To compare healthcare costs associated with open transforaminal lumbar interbody fusion (TLIF) and minimally invasive lateral lumbar interbody fusion (LLIF) by calculating the incremental cost-effectiveness ratio (ICER) and to calculate the thresholds for minimum clinically important difference and minimum cost-effective difference for patient-reported outcome measures at the 2-year follow-up. METHODS: Forty-five patients who underwent single-level TLIF and 29 patients who underwent single-level stand-alone LLIF were included in the comparison. All costs from diagnosis through the 2-year follow-up were available from a comprehensive single-center data bank within a unified hospital system. Payment provided for all spine-related medical resource use from the time of diagnosis through 2 years was recorded. A 0% discount rate was applied. Quality-adjusted life-years (QALYs) were calculated from the EuroQol-5D collected in an unbiased manner. Difference in total cost per QALY gained for LLIF minus that for TLIF was assessed as the estimate of the ICER from a US perspective. RESULTS: Significant improvements were observed at the 2-year follow-up for both TLIF and LLIF with the Short Form-36 physical component summary, Oswestry Disability Index, visual analog scale back pain and leg pain scores, and EuroQol-5D. ICER calculations revealed similar mean cumulative QALYs gained at the 2-year interval (0.67 for TLIF and 0.60 for LLIF; P = .33). Median total costs of care after TLIF and LLIF were $44 068 and $45 574, respectively (P = .96). Minimum cost-effective difference thresholds with an anchor of <$50 000 per QALY were higher than minimum clinically important difference thresholds for all patient-reported outcome measures. Total mean cost and EuroQol-5D were statistically equivalent between the 2 treatment groups. CONCLUSION: TLIF and LLIF produced equivalent 2-year patient outcomes at an equivalent cost-effectiveness profile.

Childhood Socioeconomic Circumstances, Inflammation, and Hemostasis Among Midlife Women: Study of Women's Health Across the Nation.

BACKGROUND: Childhood socioeconomic status (SES) is related to risk for cardiovascular disease in adulthood, perhaps, in part, due to associations with inflammatory and hemostasis processes. We tested the hypotheses that childhood SES is related to C-reactive protein (CRP), fibrinogen, factor VIIc, and plasminogen activator inhibitor-1 (PAI-1) in midlife women and that the associations are mediated by adult SES and/or adult body mass index (BMI). METHODS: Using data from the prospective Study of Women's Health Across the Nation, we classified 1067 black and white women into 3 multidimensional childhood SES groups based on latent class analysis. Biological measures were assessed across 7 years along with covariates and mediators and analyzed by mixed regression models, followed by tests for mediation. RESULTS: Compared with women raised in high SES families, those from the lowest SES families had higher levels of CRP (b [standard error] = 0.37 [0.11]), PAI-1 (b = 0.23 [0.07]) factor VIIc (b = 0.05 [0.02]), and fibrinogen (b = 11.06 [4.89]), after adjustment for ethnicity, site, age, ratings of health between ages 11 and 18 years, visit, smoking status, menopausal status, stroke or heart attack, medications, and hormone use. Introduction of adult SES and BMI into the models reduced the childhood SES associations to nonsignificance for all four measures. Indirect mediation was apparent for adult education and BMI for CRP, and BMI for PAI-1. CONCLUSIONS: Women raised in lower SES families had elevated markers of inflammation and hemostasis, in part, due to elevated BMI and education in adulthood.

Intermittent versus continuous cerebrospinal fluid drainage management in adult severe traumatic brain injury: assessment of intracranial pressure burden.

INTRODUCTION: There is clinical equipoise regarding whether neurointensive care unit management of external ventricular drains (EVD) in severe traumatic brain injury (TBI) should involve an open EVD, with continuous drainage of cerebrospinal fluid (CSF), versus a closed EVD, with intermittent opening as necessary to drain CSF. In a matched cohort design, we assessed the relative impact of continuous versus intermittent CSF drainage on intracranial pressure in the management of adult severe TBI. METHODS: Sixty-two severe TBI patients were assessed. Thirty-one patients managed by open EVD drainage were matched by age, sex, and injury severity (initial Glasgow Coma Scale (GCS) score) to 31 patients treated with a closed EVD drainage. Patients in the open EVD group also had a parenchymal intracranial pressure (ICP) monitor placed through an adjacent burr hole, allowing real-time recording of ICP. Hourly ICP and other pertinent data, such as length of stay in intensive care unit (LOS-ICU), Injury Severity Score, and survival status, were extracted from our prospective database. RESULTS: With age, injury severity (initial GCS score), and neurosurgical intervention adjusted for, there was a statistically significant difference of 5.66 mmHg in mean ICP (p < 0.0001) between the open and the closed EVD groups, with the closed EVD group exhibiting greater mean ICP. ICP burden (ICP ≥ 20 mmHg) was shown to be significantly higher in the intermittent EVD group (p = 0.0002) in comparison with the continuous EVD group. CONCLUSION: Continuous CSF drainage via an open EVD seemed to be associated with more effective ICP control in the management of adult severe TBI.

Predictive value of autoantibody testing for validating self-reported diagnoses of rheumatoid arthritis in the Women's Health Initiative.

Rheumatoid arthritis (RA) research using large databases is limited by insufficient case validity. Of 161,808 postmenopausal women in the Women's Health Initiative, 15,691 (10.2%) reported having RA, far higher than the expected 1% population prevalence. Since chart review for confirmation of an RA diagnosis is impractical in large cohort studies, the current study (2009-2011) tested the ability of baseline serum measurements of rheumatoid factor and anti-cyclic citrullinated peptide antibodies, second-generation assay (anti-CCP2), to identify physician-validated RA among the chart-review study participants with self-reported RA (n = 286). Anti-CCP2 positivity had the highest positive predictive value (PPV) (80.0%), and rheumatoid factor positivity the lowest (44.6%). Together, use of disease-modifying antirheumatic drugs and anti-CCP2 positivity increased PPV to 100% but excluded all seronegative cases (approximately 15% of all RA cases). Case definitions inclusive of seronegative cases had PPVs between 59.6% and 63.6%. False-negative results were minimized in these test definitions, as evidenced by negative predictive values of approximately 90%. Serological measurements, particularly measurement of anti-CCP2, improved the test characteristics of RA case definitions in the Women's Health Initiative.

Efficacy and cost-effectiveness analysis of external beam and stereotactic body radiation therapy in the treatment of spine metastases: a matched-pair analysis.

OBJECT: The objective of this study was to compare the palliative efficacy and cost effectiveness of external beam radiation therapy (EBRT) to stereotactic body radiation therapy (SBRT) as primary treatment for bone metastatic disease of the spinal column. METHODS: Forty-four patients were matched based on age, primary tumor site, year of treatment, and location of metastasis. Outcomes of interest were pain relief, cost-effectiveness, toxicities, and need for further intervention. Pain relief was rated as excellent, good, fair, or poor, using a radiosurgical pain scale to combine visual analog scale and verbal descriptor ordinal scale scores. Medicare fee schedules were used to compute the charges for both the technical and professional components of care. Patients in the EBRT group were treated using a linear accelerator while patients in the SBRT group were treated with the CyberKnife robotic radiosurgery system. Patients received regular follow-up evaluations by a radiation oncologist and neurosurgeon. RESULTS: Forty-four patients (22 pairs) were analyzed. At a follow-up of 1 month, there was no statistically significant difference in pain between the 2 groups (p = 0.11). Patients who underwent SBRT had the highest total gross charge; depending on technique, EBRT treatments ranged from 29% to 71% of the SBRT charge. Patients treated using EBRT had more acute toxicities, and more of these patients underwent further intervention at the treated spinal level. There were no late complications attributed to either treatment modality. CONCLUSIONS: External beam radiation therapy remains an efficacious and cost-effective method of palliation of spine metastases. In this study, patients treated with EBRT had more acute toxicities and were more likely to require additional interventions at the treated sites. Stereotactic body radiation therapy, although more costly, resulted in comparable rates of pain relief and late treatment-related toxicity, and continues to show promise as an emerging modality for selected patients with spine metastases.