When peer comparison information harms physician well-being.

Policymakers and business leaders often use peer comparison information-showing people how their behavior compares to that of their peers-to motivate a range of behaviors. Despite their widespread use, the potential impact of peer comparison interventions on recipients' well-being is largely unknown. We conducted a 5-mo field experiment involving 199 primary care physicians and 46,631 patients to examine the impact of a peer comparison intervention on physicians' job performance, job satisfaction, and burnout. We varied whether physicians received information about their preventive care performance compared to that of other physicians in the same health system. Our analyses reveal that our implementation of peer comparison did not significantly improve physicians' preventive care performance, but it did significantly decrease job satisfaction and increase burnout, with the effect on job satisfaction persisting for at least 4 mo after the intervention had been discontinued. Quantitative and qualitative evidence on the mechanisms underlying these unanticipated negative effects suggest that the intervention inadvertently signaled a lack of support from leadership. Consistent with this account, providing leaders with training on how to support physicians mitigated the negative effects on well-being. Our research uncovers a critical potential downside of peer comparison interventions, highlights the importance of evaluating the psychological costs of behavioral interventions, and points to how a complementary intervention-leadership support training-can mitigate these costs.

Development of Low-Toxicity Antimicrobial Polycarbonates Bearing Lysine Residues.

Antibiotic resistance has been threatening public health for a long period, while the COVID pandemic aggravated the scenario. To combat antibiotic resistance strains, host defense peptides (HDPs) mimicking molecules have attracted considerable attention. Herein, we reported a series of polycarbonates bearing cationic lysine amino acid residues that could mimic the mechanism of action of HDPs and possess broad-spectrum antimicrobial activity. Moreover, those polymers had negligible toxicity toward red blood cells and mammalian cells. The membrane-disruption mechanism endows the lysine-containing polycarbonates with low possibility of resistance development and the fast killing kinetics, making them promising candidates for antimicrobial development.

Digital technology integration in business model innovation for carbon neutrality: An evolutionary process model for SMEs.

This study delves into the strategies employed by small and medium-sized enterprises (SMEs) to embed digital technology into their business models, aiming to reach carbon neutrality. We offer a comprehensive analysis of five high technology SMEs, unveiling an evolutionary process model that highlights their journey toward integrating technology. The integration process is delineated into three progressive stages. Initially, digital technology is seen as an 'enabler' that promotes the birth of an innovative business model, essentially transforming the mechanisms of value creation, delivery, and capture. As SMEs evolve to an intermediate stage, digital technology becomes a 'disruptor', reshaping and reinventing the business model in terms of how value is created, delivered, and captured. Entering the maturity stage, digital technology is elevated to the role of 'expertise', leading to a sophisticated business model that refines and optimizes these aspects of value. The influence of these business model innovations on carbon neutrality is complex and varies distinctly with each stage, reflecting the dynamic interplay between digital technology and business model evolution.

Feasibility of postoperative diffusion-weighted imaging to assess representations of spinal cord microstructure in cervical spondylotic myelopathy.

OBJECTIVE: Diffusion basis spectrum imaging (DBSI) has shown promise in evaluating cervical spinal cord structural changes in patients with cervical spondylotic myelopathy (CSM). DBSI may also be valuable in the postoperative setting by serially tracking spinal cord microstructural changes following decompressive cervical spine surgery. Currently, there is a paucity of studies investigating this topic, likely because of challenges in resolving signal distortions from spinal instrumentation. Therefore, the objective of this study was to assess the feasibility of DBSI metrics extracted from the C3 spinal level to evaluate CSM patients postoperatively. METHODS: Fifty CSM patients and 20 healthy controls were enrolled in a single-center prospective study between 2018 and 2020. All patients and healthy controls underwent preoperative and postoperative diffusion-weighted MRI (dMRI) at a 2-year follow-up. All CSM patients underwent decompressive cervical surgery. The modified Japanese Orthopaedic Association (mJOA) score was used to categorize CSM patients as having mild, moderate, or severe myelopathy. DBSI metrics were extracted from the C3 spinal cord level to minimize image artifact and reduce partial volume effects. DBSI anisotropic tensors evaluated white matter tracts through fractional anisotropy, axial diffusivity, radial diffusivity, and fiber fraction. DBSI isotropic tensors assessed extra-axonal pathology through restricted and nonrestricted fractions. RESULTS: Of the 50 CSM patients, both baseline and postoperative dMR images with sufficient quality for analysis were obtained in 27 patients. These included 15 patients with mild CSM (mJOA scores 15-17), 7 with moderate CSM (scores 12-14), and 5 with severe CSM (scores 0-11), who were followed up for a mean of 23.5 (SD 4.1, range 11-31) months. All preoperative C3-level DBSI measures were significantly different between CSM patients and healthy controls (p < 0.05), except DBSI fractional anisotropy (p = 0.31). At the 2-year follow-up, the same significance pattern was found between CSM patients and healthy controls, except DBSI radial diffusivity was no longer statistically significant (p = 0.75). When assessing change (i.e., postoperative - preoperative values) in C3-level DBSI measures, CSM patients exhibited significant decreases in DBSI radial diffusivity (p = 0.02), suggesting improvement in myelin integrity (i.e., remyelination) at the 2-year follow-up. Among healthy controls, there was no significant difference in DBSI metrics over time. CONCLUSIONS: DBSI metrics derived from dMRI at the C3 spinal level can be used to provide meaningful insights into representations of the spinal cord microstructure of CSM patients at baseline and 2-year follow-up. DBSI may have the potential to characterize white matter tract recovery and inform outcomes following decompressive cervical surgery for CSM.

Treatment of sacroiliac joint laxity-induced coronal imbalance with the kickstand rod technique.

BACKGROUND: Considerations of the sacroiliac joint (SIJ) and its role in causing lower back and limb pain have taken a secondary role ever since Mixter and Barr's hallmark article in 1934 on the herniated nucleus pulposus. However, recent literature has highlighted the contribution of sacroiliac joint degeneration in the development of failed back surgery syndrome (FBSS), especially in patients undergoing lumbar or lumbosacral spinal fusion surgeries. Many reports have studied the anatomy, physiology, and clinical significance of the sacroiliac joint, but none have linked its dysfunction with other spinal deformities. CASE DESCRIPTION: A 63-year-old female with a history of multiple complex instrumented spinal fusions presented to our institution with progressive leftward coronal imbalance despite successful arthrodesis from T3 through S1. She was initially treated with decompression and reimplantation, but adjacent segment disease at the SIJ led to laxity, distal failure, and a worsening coronal deformity. A mechanical fall after her decompression surgery led to a dramatically increased coronal imbalance, which was ultimately treated using Lenke's kickstand rod technique. At 3.5 years follow up, the patient's coronal balance remains stable. CONCLUSION: Few studies have related SIJ degeneration and laxity with spinal deformity. Our case describes SIJ degeneration that evolved to joint laxity, which ultimately produced a leftward coronal imbalance according to the adjacent segment disease mechanism. Additionally, we describe the use of a kickstand rod to effectively correct the coronal imbalance, reduce pain levels, promote SIJ arthrodesis, and prevent further SIJ-related issues without significant complications over 3 years post-operation.

Amino acids and mechanistic target of rapamycin regulate the fate of live engulfed cells.

Metabolic stress contributes to the regulation of cell death in normal and diseased tissues. While different forms of cell death are known to be regulated by metabolic stress, how the cell engulfment and killing mechanism entosis is regulated is not well understood. Here we find that the death of entotic cells is regulated by the presence of amino acids and activity of the mechanistic target of rapamycin (mTOR). Amino acid withdrawal or mTOR inhibition induces apoptosis of engulfed cells and blocks entotic cell death that is associated with the lipidation of the autophagy protein microtubule-associated protein light chain 3 (LC3) to entotic vacuoles. Two other live cell engulfment programs, homotypic cell cannibalism (HoCC) and anti-CD47 antibody-mediated phagocytosis, known as phagoptosis, also undergo a similar vacuole maturation sequence involving LC3 lipidation and lysosome fusion, but only HoCC involves mTOR-dependent regulation of vacuole maturation and engulfed cell death similar to entosis. We further find that the regulation of cell death by mTOR is independent of autophagy activation and instead involves the 4E-BP1/2 proteins that are known regulators of mRNA translation. Depletion of 4E-BP1/2 proteins can restore the mTOR-regulated changes of entotic death and apoptosis rates of engulfed cells. These results identify amino acid signaling and the mTOR-4E-BP1/2 pathway as an upstream regulation mechanism for the fate of live engulfed cells formed by entosis and HoCC.

Long-Term Time Series Forecasting and Updates on Survival Analysis of Glioblastoma Multiforme: A 1975-2018 Population-Based Study.

OBJECTIVE: Glioblastomas multiforme (GBMs) are the most common primary CNS tumors. Epidemiologic studies have investigated the effect of demographics on patient survival, but the literature remains inconclusive. METHODS: This study included all adult patients with intracranial GBMs reported in the surveillance epidemiology and end results (SEER)-9 population database (1975-2018). The sample consisted of 32,746 unique entries. We forecast the annual GBM incidence in the US population through the year 2060 using time series analysis with autoregressive moving averages. A survival analysis of the GBM-specific time to death was also performed. Multivariate Cox proportional hazards (PH) regression revealed frank violations of the PH assumption for multiple covariates. Parametric models best described the GBM population's survival pattern; the results were compared to the semi-parametric analysis and the published literature. RESULTS: We predicted an increasing GBM incidence, which demonstrated that by the year 2060, over 1,800 cases will be reported annually in the SEER. All eight demographic variables were significant in the univariable analysis. The calendar year 2005 was the cutoff associated with an increased survival probability. A male survival benefit was eliminated in the year-adjusted Cox. Infratentorial tumors, nonmetropolitan areas, and White patient race were the factors erroneously associated with survival in the multivariate Cox analysis. Accelerated Failure Time (AFT) lognormal regression was the best model to describe the survival pattern in our patient population, identifying age >30 years old as a poor prognostic and patients >70 years old as having the worst survival. Annual income >USD 75,000 and supratentorial tumors had good prognostics, while surgical intervention provided the strongest survival benefit. CONCLUSIONS: Annual GBM incidence rates will continue to increase by almost 50% in the upcoming 30 years. Cox regression analysis should not be utilized for time-to-event predictions in GBM survival statistics. AFT lognormal distribution best describes the GBM-specific survival pattern, and as an inherent population characteristic, it should be implemented by researchers for future studies. Surgical intervention provides the strongest survival benefit, while patient age >70 years old is the worst prognostic. Based on our study, the demographics such as gender, race, and county type should not be considered as meaningful prognostics when designing future trials.

The Role of Exercise in Parkinson's Disease.

Parkinson's disease (PD) is a progressive, neurodegenerative disorder of the central nervous system. While it primarily affects motor function, patients eventually develop non-motor symptoms including depression, anxiety, and eventually dementia. Although there is currently no cure, treatment is aimed largely at improving quality of life though medication or surgical techniques to reduce motor symptoms. However, there is vast evidence of the benefits of physical activity as adjunct therapy for Parkinson's disease. In this review, we analyze 31 studies or reviews and highlight the role of exercise and rehabilitation in PD treatment. This study serves to provide clinicians with a comprehensive resource of the wide variety of exercises with proven benefit for patients affected by Parkinson's disease. Specifically, patients report significant improvements in motor function, cognition, mood and sleep habits.

Discrete Coiled Coil Rotamers Form within the EGFRvIII Juxtamembrane Domain.

Mutations in the epidermal growth factor receptor (EGFR) extracellular domain (ECD) are implicated in the development of glioblastoma multiforme (GBM), which is a highly aggressive form of brain cancer. Of particular interest to GBM is the EGFR variant known as EGFRvIII, which is distinguished by an in-frame deletion of exons 2-7, which encode ECD residues 6-273. Included within the deleted region is an autoinhibitory tether, whose absence, alongside unique disulfide interactions within the truncated ECD, supports assembly of a constitutively active asymmetric kinase dimer. Previous studies have shown that the binding of growth factors to the ECD of wild-type EGFR leads to the formation of two distinct coiled coil dimers in the cytoplasmic juxtamembrane (JM) segment, whose identities correlate with the downstream phenotype. One coiled coil contains leucine residues at the interhelix interface (EGF-type), whereas the other contains charged and polar side chains (TGF-α-type). It has been proposed that growth-factor-dependent structural changes in the ECD and adjacent transmembrane helix are transduced into distinct JM coiled coils. Here, we show that, in the absence of this growth-factor-induced signal, the JM of EGFRvIII adopts both EGF-type and TGF-α-type structures, providing direct evidence for this hypothesis. These studies confirm that the signals that define JM coiled coil identity begin within the ECD, and support a model in which growth-factor-induced conformational changes are transmitted from the ECD through the transmembrane helix to favor different coiled coil isomers within the JM.

Discovery of FAHFA-Containing Triacylglycerols and Their Metabolic Regulation.

FAHFAs are a class of bioactive lipids, which show great promise for treating diabetes and inflammatory diseases. Deciphering the metabolic pathways that regulate endogenous FAHFA levels is critical for developing diagnostic and therapeutic strategies. However, it remains unclear how FAHFAs are metabolized in cells or tissues. Here, we investigate whether FAHFAs can be incorporated into other lipid classes and identify a novel class of endogenous lipids, FAHFA-containing triacylglycerols (FAHFA-TGs), which contain a FAHFA group esterified to the glycerol backbone. Isotope-labeled FAHFAs are incorporated into FAHFA-TGs when added to differentiated adipocytes, which implies the existence of enzymes and metabolic pathways capable of synthesizing these lipids. Induction of lipolysis (i.e., triacylglycerol hydrolysis) in adipocytes is associated with marked increases in nonesterified FAHFA levels, demonstrating that FAHFA-TGs breakdown is a regulator of cellular FAHFA levels. To quantify FAHFA levels in FAHFA-TGs and determine their regioisomeric distributions, we developed a mild alkaline hydrolysis method that liberates FAHFAs from triacylglycerols for easier detection. FAHFA-TG concentrations are greater than 100-fold than that of nonesterified FAHFAs, indicating that FAHFA-TGs are a major reservoir of FAHFAs in cells and tissues. The discovery of FAHFA-TGs reveals a new branch of TG and FAHFA metabolism with potential roles in metabolic health and regulation of inflammation.

Long- and Short-Term Memory Model of Cotton Price Index Volatility Risk Based on Explainable Artificial Intelligence.

Market uncertainty greatly interferes with the decisions and plans of market participants, thus increasing the risk of decision-making, leading to compromised interests of decision-makers. Cotton price index (hereinafter referred to as cotton price) volatility is highly noisy, nonlinear, and stochastic and is susceptible to supply and demand, climate, substitutes, and other policy factors, which are subject to large uncertainties. To reduce decision risk and provide decision support for policymakers, this article integrates 13 factors affecting cotton price index volatility based on existing research and further divides them into transaction data and interaction data. A long- and short-term memory (LSTM) model is constructed, and a comparison experiment is implemented to analyze the cotton price index volatility. To make the constructed model explainable, we use explainable artificial intelligence (XAI) techniques to perform statistical analysis of the input features. The experimental results show that the LSTM model can accurately analyze the cotton price index fluctuation trend but cannot accurately predict the actual price of cotton; the transaction data plus interaction data are more sensitive than the transaction data in analyzing the cotton price fluctuation trend and can have a positive effect on the cotton price fluctuation analysis. This study can accurately reflect the fluctuation trend of the cotton market, provide reference to the state, enterprises, and cotton farmers for decision-making, and reduce the risk caused by frequent fluctuation of cotton prices. The analysis of the model using XAI techniques builds the confidence of decision-makers in the model.

Spontaneous and asymptomatic rupture of an RCC with resolution of symptoms.

There is no standard of care for management of Rathke cleft cysts (RCCs), and protocol for spontaneous rupture or residual capsule fragments is not well documented.Our case involves a Caucasian man in his 80s who presented with muscle weakness, fatigue, bitemporal hemianopia and pain. Further examination demonstrated decreased thyroid and cortisol levels. MRI revealed a 1.6×1.5×1.3 cm sellar homogenous mass with extension into the suprasellar cistern. While the size of the cyst was rather large, a decision was made to follow conservatively with serial MRI. At 3 years, the mass had spontaneously regressed. The patient was asymptomatic without imaging evidence of RCC recurrence at 4-year follow-up.Classic indications for surgical intervention in suprasellar cysts were subtle in our patient and his advanced age made us take a conservative approach. Current data are lacking regarding management of RCCs presenting with endocrine dysfunction. Our case suggests that RCCs presenting with endocrine dysfunction may be managed conservatively with serial imaging-based monitoring.

Helical sulfonyl-γ-AApeptides for the inhibition of HIV-1 fusion and HIF-1α signaling.

Synthetic helical peptidic foldamers show promising applications in chemical biology and biomedical sciences by mimicking protein helical segments. Sulfonyl-γ-AApeptide helices developed by our group exhibit good chemodiversity, predictable folding structures, proteolytic resistance, favorable cell permeability, and enhanced bioavailability. Herein, in this minireview, we highlight two recent examples of homogeneous left-handed sulfonyl-γ-AApeptide helices to modulate protein-protein interactions (PPIs). One is sulfonyl-γ-AApeptides as anti-HIV-1 fusion inhibitors mimicking the helical C-terminal heptad repeat (CHR), which show excellent anti-HIV-1 activities through tight binding with the N-terminal heptad repeat (NHR) and inhibiting the formation of the 6-helical bundle (HB) structure. Another example is helical sulfonyl-γ-AApeptides disrupting hypoxia-inducible factor 1α (HIF-1α) and p300 PPI, thus selectively inhibiting the relevant signaling cascade. We hope these findings could help to elucidate the principles of the structural design of sulfonyl-γ-AApeptides and inspire their future applications in PPI modulations.

Copper-Catalyzed 1,3-Aminocyclization of Cyclopropanes as a Rapid Entry to γ-Amino Heterocycles.

We herein report a copper-catalyzed 1,3-aminocyclization of cyclopropanes as a direct and versatile entry into important heterocycles. This reaction was initiated by a copper-catalyzed, NFSI-promoted ring opening of cyclopropanes, followed by nucleophilic cyclization. A variety of nucleophiles successfully participate in this transformation, including alcohols, carboxylic acids, sulfonamides, and amides, for the construction of diverse cyclic ethers, pyrrolidines, lactones, and iminolactones.

Prediction of pediatric peanut oral food challenge outcomes using machine learning.

Background: Clinical testing, including food-specific skin and serum IgE level tests, provides limited accuracy to predict food allergy. Confirmatory oral food challenges (OFCs) are often required, but the associated risks, cost, and logistic difficulties comprise a barrier to proper diagnosis. Objective: We sought to utilize advanced machine learning methodologies to integrate clinical variables associated with peanut allergy to create a predictive model for OFCs to improve predictive performance over that of purely statistical methods. Methods: Machine learning was applied to the Learning Early about Peanut Allergy (LEAP) study of 463 peanut OFCs and associated clinical variables. Patient-wise cross-validation was used to create ensemble models that were evaluated on holdout test sets. These models were further evaluated by using 2 additional peanut allergy OFC cohorts: the IMPACT study cohort and a local University of Michigan cohort. Results: In the LEAP data set, the ensemble models achieved a maximum mean area under the curve of 0.997, with a sensitivity and specificity of 0.994 and 1.00, respectively. In the combined validation data sets, the top ensemble model achieved a maximum area under the curve of 0.871, with a sensitivity and specificity of 0.763 and 0.980, respectively. Conclusions: Machine learning models for predicting peanut OFC results have the potential to accurately predict OFC outcomes, potentially minimizing the need for OFCs while increasing confidence in food allergy diagnoses.

Top 50 Spine Surgery Publications Most Cited by Patents: A Bibliometric Analysis Focused on Research Driving Innovation.

BACKGROUND: The use of bibliometric analysis studies allows for the precise assessment of high impact contributions to various fields of study. A bibliometric assessment of academic works cited in filed patents enables tracking the academic studies which have been most influential in the development of new technologies in spine surgery. METHODS: The Lens database was utilized to retrieve scholarly articles related to the field of spine surgery, with special focus on spinal fusion and biologics. Scholarly works cited in patents were organized by publishing journal, article topic, study type, publishing institution, and authors information. Such publications were also categorized by country of origin and, for U.S. patents, region of origin. RESULTS: The employed search criteria yielded 37,005 scholarly works related to spine surgery published between 1889 and 2022 and a total of 947 scholarly works cited in patents from 1968 to 2022. Many of the top contributing authors were orthopedic surgeons while the top 3 authors were biomedical engineers. The region in the U.S. with the most citations in patents and the most scholarly work overall was the middle-Atlantic region. CONCLUSIONS: This patent bibliometric analysis provides a general overview of trends in publications impacting spine surgery innovation over time. Our results highlight top instutions and regional contributions to spine surgery innovation within the United States and worldwide. As the first patent bibliometric study providing data on the most technologically impactful scholarly work in spine surgery, this study has not only historical value in terms of documenting the scientific and intellectual property developments in spine surgery in the past 50 years, but also practical relevance insofar as the identified trends and research hotspots that may provide researchers valuable insights regarding future decisions involving research efforts and resources allocation.

Health Care Fraud and Abuse: Lessons From One of the Largest Scandals of the 21st Century in the Field of Spine Surgery.

Up to hundreds of billions of dollars are annually lost to fraud and abuse in the US health care, making it a significant burden on the system. This study investigates a specific instance of health care fraud in spine surgery, in which a medical device company ended up paying $75 million to settle violations of the False Claims Act. We review the surgical background regarding the kyphoplasty procedure, as well as its billing and reimbursement details. We also explore the official legal complaint brought by the US Department of Justice to tell the story of how one of the most significant medical innovations in spine surgery in the 21st century turned into a widespread fraudulent marketing scheme. In the sequence, we provide a detailed root cause analysis of this scandal and propose some proactive measures that can be taken to avoid such type of unfortunate events. Ultimately, this historical health care scandal constitutes a valuable lesson to surgeons, health care administrators, medical device companies, and policymakers on how misaligned incentives and subsequent unscrupulous practices can transform a medical innovation into an unfortunate tale of fraud and deceit.

The Message of the Glasgow Coma Scale: A Comprehensive Bibliometric Analysis and Systematic Review of Clinical Practice Guidelines Spanning the Past 50 years.

BACKGROUND: Despite the ubiquitous use of the Glasgow Coma Scale (GCS) worldwide, no study to date has objectively and quantitatively assessed its impact on the scientific literature and clinical practice. Therefore, we comprehensively analyzed scientific publications and clinical practice guidelines employing the GCS to gauge its clinical and academic impact, identify research hotspots, and inform future research on the topic. METHODS: A cross-sectional bibliometric analysis was performed on Scopus to obtain relevant publications incorporating the GCS from 1974 to 2022. In addition, a systematic review of existing clinical practice guidelines in PubMed, Scopus, Web of Science, and Trip Database was performed. Validated bibliometric parameters including article title, journal, publication year, authors, citation count, country, institution, keywords, impact factor, and references were assessed. When evaluating clinical practice guidelines, the sponsoring organization, country of origin, specialty, and publication year were assessed. RESULTS: A total of 37,633 articles originating from 3924 different scientific journals spanning 1974-2022 were included in the final analysis. The compound annual growth rate of publications referencing the GCS was 16.7%. Of 104 countries, the United States had the highest total number of publications employing the GCS (n = 8517). World Neurosurgery was the scientific periodical with the highest number of publications on the GCS (n = 798). The top trending author-supplied keyword was "traumatic brain injury" (n = 3408). The 97 included clinical practice guidelines most commonly employed the GCS in the fields of internal medicine (n = 22, 23%), critical care (n = 21, 22%), and neurotrauma (n = 19, 20%). CONCLUSIONS: At the turn of the 50th anniversary of the GCS, we provided a unique and detailed description of the "path to success" of the GCS both in terms of its scientific and clinical impact. These results have not only a historical but also an important didactic value. Ultimately our detailed analysis, which revealed some of the factors that led the GCS to become such a widespread and highly influential score, may assist future researchers in their development of new outcome measures and clinical scores, especially as such tools become increasingly relevant in an evidence-based data-driven age.

Restoration of respiration in high cervical spinal cord injury via phrenic nerve reinnervation: illustrative case.

BACKGROUND: Traumatic high cervical spinal cord injury (SCI) can result in a devastating loss of functional respiration, leaving patients permanently dependent on mechanical ventilation. Nerve transfer is a promising reinnervation strategy that has the potential to restore connectivity in paralyzed distal muscles. The spinal accessory nerve (SAN) remains functional in most cases after high cervical SCI and can serve as a donor to reinnervate the phrenic nerve (PN), thereby improving diaphragmatic function. OBSERVATIONS: Information regarding thorough physical, electrodiagnostic, and pulmonary assessments to establish candidacy for nerve transfer, as well as the surgical procedure, was summarized with an illustrative case. The patient demonstrated improvement in pulmonary function testing but did not achieve independent respiration. A systematic literature review identified 3 studies with 9 additional patients who had undergone SAN-to-PN transfer. The nerve transfer meaningfully restored diaphragmatic function, improving pulmonary function tests and reducing ventilator dependency. LESSONS: Respiratory dependency significantly impacts the quality of life of patients with a high cervical SCI. The use of the lower SAN motor branch for PN transfer is safe and does not result in a meaningful downgrade in trapezius function. Outcomes following this procedure are promising but heterogeneous, indicating a need for significant innovation and improvement for future therapies. https://thejns.org/doi/10.3171/CASE24236.

Using Multimodal Assessments to Reevaluate Depression Designations for Spine Surgery Candidates.

BACKGROUND: Depression is common in spine surgery candidates and may influence postoperative outcomes. Ecological momentary assessments (EMAs) can overcome limitations of existing depression screening methods (e.g., recall bias, inaccuracy of historical diagnoses) by longitudinally monitoring depression symptoms in daily life. In this study, we compared EMA-based depression assessment with retrospective self-report (a 9-item Patient Health Questionnaire [PHQ-9]) and chart-based depression diagnosis in lumbar spine surgery candidates. We further examined the associations of each depression assessment method with surgical outcomes. METHODS: Adult patients undergoing lumbar spine surgery (n = 122) completed EMAs quantifying depressive symptoms up to 5 times daily for 3 weeks preoperatively. Correlations (rank-biserial or Spearman) among EMA means, a chart-based depression history, and 1-time preoperative depression surveys (PHQ-9 and Psychache Scale) were analyzed. Confirmatory factor analysis was used to categorize PHQ-9 questions as somatic or non-somatic; subscores were compared with a propensity score-matched general population cohort. The associations of each screening modality with 6-month surgical outcomes (pain, disability, physical function, pain interference) were analyzed with multivariable regression. RESULTS: The association between EMA Depression scores and a depression history was weak (r rb = 0.34 [95% confidence interval (CI), 0.14 to 0.52]). Moderate correlations with EMA-measured depression symptoms were observed for the PHQ-9 (r s = 0.51 [95% CI, 0.37 to 0.63]) and the Psychache Scale (r s = 0.68 [95% CI, 0.57 to 0.76]). Compared with the matched general population cohort, spine surgery candidates endorsed similar non-somatic symptoms but significantly greater somatic symptoms on the PHQ-9. EMA Depression scores had a stronger association with 6-month surgical outcomes than the other depression screening modalities did. CONCLUSIONS: A history of depression in the medical record is not a reliable indication of preoperative depression symptom severity. Cross-sectional depression assessments such as PHQ-9 have stronger associations with daily depression symptoms but may conflate somatic depression symptoms with spine-related disability. As an alternative to these methods, mobile health technology and EMAs provide an opportunity to collect real-time, longitudinal data on depression symptom severity, potentially improving prognostic accuracy. LEVEL OF EVIDENCE: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.