Self-Citation Rates Among Neurosurgery Journals and Authors: Unethical or Misunderstood?

OBJECTIVE: The role of self-citation has not been discussed in the neurosurgery literature, although citations, citation indices, and impact of research may enhance funding opportunities, academic positions, fellowship opportunities, employment, and professional identity development. We sought to assess the magnitude and role of self-citation in academic neurosurgery. METHODS: We performed a retrospective analysis of the citation and self-citation rates of articles published in 2001-2020 in 7 major neurosurgery journals: Acta Neurochirurgica, Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, Neurosurgery, Neurosurgical Review, and World Neurosurgery. RESULTS: The total number of citations was highest for Journal of Neurosurgery and lowest for Neurosurgical Review. Journal of Neurosurgery: Spine had the highest average number of citations per article, followed closely by Journal of Neurosurgery. The self-citation rate increased for all journals over the time period 2001-2020. The highest number of self-citations per article during 2016-2020 was seen in Journal of Neurosurgery: Pediatrics and World Neurosurgery. Neurosurgical Review had the lowest number of self-citations per article. CONCLUSIONS: Academic neurosurgeons must understand the ecosystem around self-citation. In our study, we found overall low levels of self-citations in neurosurgery journals with a few outliers. We have, however, noticed an increasing trend in self-citation rates. Self-citation rates should be considered while evaluating the impact of an author and research productivity. Contrary to popular belief, self-citation is not always unethical and must be understood within its circumstances.

Attitudes Toward Neurosurgery Education for the Nonneurosurgeon: A Survey Study and Critical Analysis of U.S. Military Training Techniques and Future Prospects.

BACKGROUND: The U.S. military requires medical readiness to support forward-deployed combat operations. Because time and distance to neurosurgical capabilities vary within the deployed trauma system, nonneurosurgeons are required to perform emergent cranial procedures in select cases. It is unclear whether these surgeons have sufficient training in these procedures. METHODS: This quality-improvement study involved a voluntary, anonymized specialty-specific survey of active-duty surgeons about their experience and attitudes toward U.S. military emergency neurosurgical training. RESULTS: Survey responses were received from 104 general surgeons and 26 neurosurgeons. Among general surgeons, 81% have deployed and 53% received training in emergency neurosurgical procedures before deployment. Only 16% of general surgeons reported participating in craniotomy/craniectomy procedures in the last year. Nine general surgeons reported performing an emergency neurosurgical procedure while on deployment/humanitarian mission, and 87% of respondents expressed interest in further predeployment emergency neurosurgery training. Among neurosurgeons, 81% had participated in training nonneurosurgeons and 73% believe that more comprehensive training for nonneurosurgeons before deployment is needed. General surgeons proposed lower procedure minimums for competency for external ventricular drain placement and craniotomy/craniectomy than did neurosurgeons. Only 37% of general surgeons had used mixed/augmented reality in any capacity previously; for combat procedures, most (90%) would prefer using synchronous supervision via high-fidelity video teleconferencing over mixed reality. CONCLUSIONS: These survey results show a gap in readiness for neurosurgical procedures for forward-deployed general surgeons. Capitalizing on capabilities such as mixed/augmented reality would be a force multiplier and a potential means of improving neurosurgical capabilities in the forward-deployed environments.

Prediction of Individual Analgesic Response to Intravenous Lidocaine in Painful Diabetic Peripheral Neuropathy: A Randomized, Placebo-controlled, Crossover Trial.

OBJECTIVES: Intravenous lidocaine can alleviate painful diabetic peripheral neuropathy (DPN) in some patients. Whether quantitative sensory testing (QST) can identify treatment responders has not been prospectively tested. MATERIALS AND METHODS: This was a prospective, randomized, double-blind, crossover, placebo-controlled trial comparing intravenous lidocaine to normal saline (placebo) for painful DPN. Thirty-four participants with painful DPN were enrolled and administered intravenous lidocaine (5 mg/kg ideal body weight) or placebo as a 40-minute infusion, after a battery of QST parameters were tested on the dorsal foot, with a 3-week washout period between infusions. RESULTS: Thirty-one participants completed both study sessions and were included in the final analysis. Lidocaine resulted in a 51% pain reduction 60 to 120 minutes after infusion initiation, as assessed on a 0 to 10 numerical rating scale, while placebo resulted in a 33.5% pain reduction (difference=17.6%, 95% confidence interval [CI], 1.9%-33.3%, P=0.03). Neither mechanical pain threshold, heat pain threshold, or any of the other measured QST parameters predicted the response to treatment. Lidocaine administration reduced mean Neuropathic Pain Symptom Inventory paresthesia/dysesthesia scores when compared with placebo by 1.29 points (95% CI, -2.03 to -0.55, P=0.001), and paroxysmal pain scores by 0.84 points (95% CI, -1.62 to -0.56, P=0.04), without significant changes in burning, pressing or evoked pain subscores. DISCUSSION: While some participants reported therapeutic benefit from lidocaine administration, QST measures alone were not predictive of response to treatment. Further studies, powered to test more complex phenotypic interactions, are required to identify reliable predictors of response to pharmacotherapy in patients with DPN.

Clinical Effectiveness of S2-Alar Iliac Screws in Spinopelvic Fixation in Pediatric Neuromuscular Scoliosis: Systematic Literature Review.

STUDY DESIGN: Systematic literature review. OBJECTIVES: To comprehensively review the S2-alar iliac (S2-AI) screw technique for pelvic fixation in pediatric neuromuscular scoliosis. METHODS: Articles identified from the PubMed and EMBASE databases were reviewed for relevance and applicability, and the studies were summarized. RESULTS: Eight articles met the inclusion criteria. A total of 277 pediatric patients underwent spinopelvic fixation using S2-AI fixation for neuromuscular scoliosis; the mean follow-up was 3 years (range = 0.75-6 years). Six articles had level III evidence (5 retrospective cohort studies, 1 observational study), and 2 articles had level IV evidence (case series). Wound complications occurred in 34 (12.2%) patients. Instrumentation complications occurred in 36 patients (13.0%), including lucency around the screw (6.5%), screw fracture (3.6%), disengaging of the set/screw or rod from the tulip head (2.8%), and screw displacement (0.7%). Three patients (1.1%) required reoperation for instrumentation failures. The overall reoperation rate-including 3 hardware replacements and 3 cases of L5-S1 pseudarthrosis-was 2.1%. The mean Cobb angle correction was 51.4°, and the mean pelvic obliquity correction was 14.8°; deformity correction was maintained at 3- and 5-year follow-ups. There were 10 (3.6%) cases of implant prominence/implant-related pain, 1 case of sacroiliac joint pain (resolved with longer screw placement), and no major neurological or vascular complications secondary to S2-AI screw placement. CONCLUSIONS: This review suggests that the use of S2-AI screws in pediatric neuromuscular scoliosis is efficacious with a reasonable safety profile and provides a useful technique for pelvic fixation in children with scoliosis.

Stereoselective Steady-State Disposition and Bioequivalence of Brand and Generic Bupropion in Adults.

The antidepressant bupropion is stereoselectively metabolized and metabolite enantiomers have differential pharmacologic effects, but steady-state enantiomeric disposition is unknown. Controversy persists about bupropion XL 300 mg generic equivalence to brand product, and whether generics might have different stereoselective disposition leading to enantiomeric non-bioequivalence and, thus, clinical nonequivalence. This preplanned follow-on analysis of a prospective, randomized, double-blinded, crossover study of brand and 3 generic bupropion XL 300 mg products measured steady-state enantiomeric plasma and urine parent bupropion and primary and secondary metabolite concentrations and evaluated bioequivalence and pharmacokinetics. Steady-state plasma and urine bupropion disposition was markedly stereoselective, with up to 40-fold differences in plasma concentrations of the active metabolite S,S-hydroxybupropion vs. R,R,-hydroxybupropion. Urine metabolite glucuronides were prominent, but glucuronidation was metabolite-specific and enantioselective. There were no differences between any generic and brand, or between generics, in plasma enantiomer concentrations of bupropion or the major metabolites. All generic products satisfied formal bioequivalence criteria (peak plasma concentration (Cmax ) and area under the plasma concentration-time curve over 24 hours (AUC0-24 )) using enantiomers for bupropion as well as for metabolites, and generics were comparable to each other, and were considered bioequivalent, based on enantiomeric analysis. Enantiomeric bioequivalence explains the previously observed therapeutic equivalence of bupropion generics and brand in treating major depression. These results have important implications for understanding the clinical therapeutic effects of bupropion based on complex and stereoselective metabolism.

Bioequivalence and Therapeutic Equivalence of Generic and Brand Bupropion in Adults With Major Depression: A Randomized Clinical Trial.

Controversy persists about bupropion XL 300 mg generic equivalence to brand product. A prospective, randomized, double-blinded crossover in 70 adults with major depression in stable remission taking any bupropion XL 300 mg tested bioequivalence and therapeutic equivalence of available XL 300 mg products. After a 4-week lead-in on patients' existing bupropion, four 6-week phases evaluated brand and three generics. Patients were uninformed of switching. Drug overencapsulation ensured blinding. There were no differences between any generic and brand, or between generics, in peak plasma concentration (Cmax ) and area under the plasma concentration-time curve over the 24-hour dosing interval (AUC0-24 ) for racemic bupropion or major metabolites. All generics met formal bioequivalence criteria for bupropion and metabolites. There were no differences between generics and brand, or between generics, in depression symptoms or side effects, assessed by every 3-week in-person interview and daily smartphone-based self-report. There were no differences in patients' perceptions of bupropion products. Results show three bupropion XL 300 mg generic products are both bioequivalent and not therapeutically different from brand drug and each other.

The Need for Cost-Effective Neurosurgical Innovation--A Global Surgery Initiative.

The authors discuss the unmet needs for neurosurgical care around the world and some of the innovative work being done to address this need. The growing demonstration of surgical innovation and cost-effective technology represents an opportunity within neurosurgery to achieve the goal of making surgical care more accessible to the global population.

Expanding neurosurgery.

The history of medicine is replete with innovations in neurosurgery that have spurred further developments across the medical spectrum. Surgeons treating pathologies in the head and spine have broken ground with new approaches, techniques, and technologies since ancient times. Neurosurgeons occupy a vital nexus in patient care, interfacing with the clinical symptoms and signs afflicting patients, the pathology at surgery, and imaging studies. No other physicians occupy this role within the nervous system. This power of observation and the ability to intercede place neurosurgeons in a unique position for impacting disease. Yet despite these pioneering achievements, more recently, forces in the workplace may be challenging neurosurgery's opportunities to contribute to the future growth of the neurosciences and medicine. The authors posit that, in the current health care climate, revenue generation by neurosurgical clinical activity is valued by the system more than neurosurgical research and academic output. Without providing the talented stream of new neurosurgeons with the opportunities and, in fact, the directive to achieve beyond simple financial success, the specialty is missing the opportunity to optimize its progress. The authors contend that the key to remaining relevant with the incorporation of new technologies to the treatment of neurosurgical patients will be to be flexible, open-minded, and nimble with the adaptation of new procedures by training and encouraging neurosurgical residents to pursue new or neglected areas of the specialty. Only by doing so can neurosurgery continue to expand.

Regression of cerebral arteriovenous malformation in the puerperium.

Spontaneous regression of a cerebral arteriovenous malformation (AVM) is a rare occurrence. The authors describe a patient presenting with a ruptured AVM with a feeding artery aneurysm during second trimester of pregnancy. The feeding artery with aneurysm was clipped and the hematoma removed. The AVM subsequently spontaneously regressed by serial angiography during the postpartum period. The authors believe this is the first reported case of spontaneous regression of cerebral AVM early after pregnancy. The dramatic regression noted in the postpartum period in this case suggests the particular significance of hormonal factors in the dynamics of growth and rupture of an AVM.

The development of neurosurgery at the University of Utah, 1955-2009.

Located in the geographic Intermountain West, the Department of Neurosurgery at the University of Utah has undergone remarkable growth and transformation since the appointment of the first full-time clinical faculty member in 1955. The Department has provided broad neurosurgical services to an expanding community while fulfilling its academic mission of pushing the frontiers within neurosurgical subspecialties. The history of neurosurgery in the Salt Lake Valley and the achievements of the Department of Neurosurgery, including the seminal development of early cranial stereotactic devices, are reviewed in this article.

Use of the h index in neurosurgery. Clinical article.

OBJECT: Assessing academic productivity through simple quantification may overlook key information, and the use of statistical enumeration of academic output is growing. The h index, which incorporates both the total number of publications and the citations of those publications, has been recently proposed as an objective measure of academic productivity. The authors used several tools to calculate the h index for academic neurosurgeons to provide a basis for evaluating publishing by physicians. METHODS: The h index of randomly selected academic neurosurgeons from a sample of one-third of the academic programs in the US was calculated using data from Google Scholar and from the Scopus database. The mean h index for each academic rank was determined. The h indices were also correlated with various other factors (such as time spent practicing neurosurgery, authorship position) to identify how these factors influenced the h index. The h indices were then compared with other citation statistics to evaluate the robustness of this metric. Finally, h indices were also calculated for a sampling of physicians in other medical specialties for comparison. RESULTS: As expected, the h index increased with academic rank and there was a statistically significant difference between each rank. A weighting based on position of authorship did not affect h indices. The h index was positively correlated with time since American Board of Neurological Surgery certification, and it was also correlated with other citation metrics. A comparison among medical specialties supports the assertion that h index values may not be comparable between fields, even closely related specialties. CONCLUSIONS: The h index appears to be a robust statistic for comparing academic output of neurosurgeons. Within the field of academic neurosurgery, clear differences of h indices between academic ranks exist. On average, an increase of the h index by 5 appears to correspond to the next highest academic rank, with the exception of chairperson. The h index can be used as a tool, along with other evaluations, to evaluate an individual's productivity in the academic advancement process within the field of neurosurgery but should not be used for comparisons across medical specialties.

Neurosurgical workforce trends in the United States.

OBJECT: The purpose of this study was to evaluate the US neurosurgery workforce by reviewing journal recruitment advertisements published during the past 10 years. METHODS: The number of available academic and private neurosurgical staff positions was determined based on recruitment advertisements in the Journal of Neurosurgery and Neurosurgery for the 10-year period from 1994 to 2003. Advertisements were evaluated for practice venue, subspecialization, and location. The numbers of active neurosurgeons and graduating residents also were reviewed. The number of advertised neurosurgical positions increased from 141.6 +/- 38.2 per year from 1994 through 1998 to 282.4 +/- 13.6 per year from 1999 through 2003 (mean +/- standard deviation, p < 0.05). The mean number of academic positions increased from 50.6 +/- 11.1 to 95 +/- 17.5 (p < 0.05), and the mean number of private positions rose from 91 +/- 30.4 to 187.4 +/- 6.8 (p < 0.05). Subspecialty positions represented a mean of only 15.6 +/- 5% per year during the first time period and 18.8 +/- 3% per year in the second period (p = 0.22), and therefore the majority of positions advertised continued to be those for generalists. The number of practicing neurosurgeons declined after 1998, and by 2002 it was less than it had been in 1991. The numbers of incoming and matriculating residents during the study period were static. CONCLUSIONS: The number of recruitment advertisements for neurosurgeons during the last 5 years has increased significantly, concomitant with a severe decline in the number of active neurosurgeons and a static supply of residents.