Snapshot: Socioeconomic Competence in US Neurosurgery Residents.

INTRODUCTION: Socioeconomic topics such as federal mandates/regulations, conflict of interest, and practice management have become increasingly important for all neurosurgeons. Graduating residents immediately need a host of skills to successfully navigate neurosurgical practice. Surgical and medical skills are closely evaluated through the American Board of Neurological Surgery, and a formal socioeconomic curriculum has been developed with defined milestones. Nevertheless, little has been done to evaluate neurosurgery resident competence in socioeconomic and medicolegal principles. The purpose of this study was to assess the competence of Accreditation Council for Graduate Medical Education neurosurgical residents in socioeconomic knowledge. METHODS: Neurosurgery resident members of the American Association of Neurological Surgeons (N = 1385) were sent a Survey Monkey of 10 questions. The survey covered the most basic of socioeconomic principles. Initial survey responses were collected across a 1-month period from April to May 2018. RESULTS: The response rate was 14% (194/1385). Overall, neurosurgery residents would have received a grade of D, with an average score of 67% on the survey. For 7 of the 10 questions, the majority (>50%) of neurosurgery residents answered correctly. Furthermore, for 3 questions, more than 90% of residents selected the correct answer. However, for one-half of all questions, residents averaged a score of less than 65%. Residents tended to answer questions correctly for physician compensation and compensation models, but incorrectly for topics of informed consent, Controlled Substances Act, and conflicts of interest. CONCLUSION: With the increasing complexity of neurosurgery practice, solid knowledge of socioeconomic topics is essential. The study confirms suspected deficiencies in socioeconomic proficiency among neurosurgery residents, despite the availability of a validated curriculum. This knowledge gap will likely affect career success and satisfaction. Nevertheless, this survey had a significantly low response rate, and it may be an incomplete representation of the neurosurgical resident mind. Focused educational initiatives through the neurosurgical Residency Review Committee and individual training programs must facilitate an action plan that ensures the effective implementation of socioeconomic curricula.

Preoperative and Histological Predictors of Recurrence and Survival in Atypical Meningioma After Initial Gross Total Resection.

OBJECTIVE: Atypical (World Health Organization grade II) meningiomas (AMs) have been associated with a substantial risk of recurrence even after complete, gross total resection (GTR). The present study evaluated the clinical and AM tumor histopathological features that might predict for the risk of recurrence and survival within this patient population. METHODS: The data from 72 consecutive patients who had undergone primary GTR for AM from 2007 to 2016 and corresponding tumor specimens at a single institution were reviewed. The preoperative patient and tumor characteristics were correlated with the postresection outcomes, including recurrence and 1-year survival. Cox regression models on recurrence-free survival (RFS) and Kaplan-Meier survival estimates were performed. RESULTS: The overall 1-, 3-, and 5-year RFS estimates for the AM cohort were 100.0%, 82.4%, and 78.1% after resection, respectively. A high mitotic index was an independent predictor of RFS on Cox regression analysis (hazard ratio, 1.26; P = 0.008), and the tumor volume showed a trend toward a significant association (hazard ratio, 0.93; P = 0.079). Patient age and the mitotic index were significantly associated with 1-year mortality (odds ratio, 1.11 and 1.36, respectively; P = 0.028 and P = 0.045, respectively). CONCLUSIONS: AM tumors with a high proliferative index showed an increased likelihood of recurrence and short-term survival even after complete GTR. A smaller tumor volume might also have contributed to an increased risk of recurrence for patients with AM. Although other histopathological features were not linked to recurrence or mortality for patients with AM, the biopsy findings can indicate key predictive information, and further molecular analysis might reveal additional prognostic markers.

Malpractice Litigation in Brain Tumor Surgery: A 31-Year Analysis of Causative Factors in the United States from the Westlaw Database.

BACKGROUND: Medical malpractice litigation is an issue of major concern in neurosurgery, with 19.1% of neurosurgeons facing a claim annually. Neurosurgery possesses the greatest risk of malpractice of any specialty, likely owing to the complex clinical environment and disease severity. In the present study, we have characterized such litigation to determine the common factors that compel plaintiffs to file these claims. METHODS: WestLawNext, a prominent legal database, was used to identify all cases from 1985 to 2016 related to brain tumors. A total of 225 cases were identified, and each was analyzed for the cause of litigation (multiple causes were permitted). Because many had >1 ground for litigation, the reported percentages were based on the total counts of litigation rather than the number of cases. Additional information was collected from each case, including location, tumor type, and physician specialty. RESULTS: The cases were distributed across 36 states and U.S. territories: California (n = 42; 20%) and New York (n = 28; 13%) had the greatest number of cases. The top reasons for litigation were failure to diagnose (n = 109; 28%), failure to treat (n = 72; 18%), procedural error (n = 63; 16%), and failure to refer for diagnostic tests (n = 55; 14%). The most common diagnoses included pituitary adenoma (n = 26; 12%), acoustic neuroma (n = 27; 12%), and meningioma (n = 23; 10%). CONCLUSIONS: Malpractice litigation contributes to high overhead and physician burnout and escalates the cost of patient care. We found that benign brain tumors were the most common in litigation and that surgical issues accounted for only a small percentage.

Antidepressant use in patients with meningioma: is there an association with tumor recurrence?

OBJECTIVE With increasing general use of antidepressants (ADs), multiple studies have noted a small protective effect of ADs for patients with glioma, but their impact on meningioma has not been established. This study aims to evaluate the role of ADs in the context of additional clinical factors in relation to long-term risk of meningioma recurrence. METHODS One hundred five patients with an intracranial meningioma presenting from 2011-2014 with at least 3 years of follow-up (median 4.2 years) after resection were reviewed. AD use along with demographics, tumor characteristics, and outcomes were recorded. Multivariate logistic regression was used to analyze the association of AD use with tumor recurrence, including other clinical measures significantly associated with recurrence as covariates. RESULTS Twenty-nine patients (27.4%) were taking ADs (27 selective serotonin reuptake inhibitors, 2 norepinephrine-dopamine reuptake inhibitors) prior to tumor recurrence. Their tumors largely affected the frontal (31.0%) or parietal lobe (17.2%) and were located in convexity, parasagittal, or falcine (CPF) areas more frequently than skull base areas relative to the tumors of non-AD users (p = 0.035). AD use was found to be an independent predictor of recurrence, in addition to subtotal resection and WHO grade II/III classification (p values < 0.05). The median time from AD prescription to tumor recurrence was 36.6 months (interquartile range [IQR] = 20.9-62.9 months) and median length of AD use was 41.4 months (IQR = 24.7-62.8 months). CONCLUSIONS AD use was an independent predictor of meningioma recurrence. This association may be due to mood or affective changes caused by tumor location in CPF regions that may be a sign of early recurrence. The finding calls attention to AD use in the management of patients with meningioma, and warrants further exploration of an underlying relationship.