From Athlete to Surgeon: Examining Sports and Grit Among General Surgery Residents.

OBJECTIVE: The transition of Step 1 to pass/fail has generated concerns over selecting promising candidates. Holistic reviews integrate other proficiencies, including extracurriculars such as sports. Grit - defined as perseverance and passion for long-term goals - has been positively associated with competitive activities and is predictive of academic success. The prevalence and impact of sports participation and its relationship to grit in the general surgery resident population has not been described and was investigated in this study. DESIGN: Surveys measuring sports participation and grit were distributed after the 2021 ABSITE. Grit was assessed through the short grit scale. Inferential statistics were performed. SETTING/PARTICIPANTS: General surgery residents in all US training programs who completed the 2021 ABSITE. RESULTS: Of 5468 respondents (response rate 59.6%), 2,548 (46.7%) were female, 917 (17.4%) URiM, 2171 (39.8%) married, and 1,069 (19.6%) parents. About 4284 (83.8%) residents reported being involved in competitive sports. Grit was higher in residents with a competitive sports history (3.67 ± 0.58 versus 3.60 ± 0.61, p = 0.0022). Greater time commitment and being part of a team was positively correlated to grit (both p < 0.0001). Individuals that self-identified as underrepresented in medicine (URiM) had higher grit (3.71 ± 0.59 versus 3.65 ± 0.58 for non-URiM, p < 0.0001) as did female (p = 0.0016), married residents (p < 0.0001), and parents (p < 0.0001). Being an athlete was associated with significantly higher grit for nearly all demographic subgroups, including URiM (p = 0.0068), married (p = 0.0175), and parents (p = 0.0487). CONCLUSIONS: Higher grit was found in athletes and marginalized groups including females, URiM, and residents that were married or parents. Our data suggests that recruiting applicants of diverse backgrounds and experiences will result in a grittier cohort; a group potentially equipped to weather the arduous surgical residency training path. Recruiting residents with characteristics associated with higher grit can potentially impact diversity of the surgical workforce.

Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty.

BACKGROUND: With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care. METHODS: A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service. RESULTS: From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans. CONCLUSION: From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Investigating the Association of Patient Body Mass Index With Posterior Subcutaneous Fat Thickness in the Cervical Spine: A Retrospective Radiographic Study.

INTRODUCTION: Although BMI is often used as a surrogate for posterior cervical subcutaneous fat thickness (SFT), the association of BMI with cervical SFT is unknown. We performed a retrospective radiographic study to analyze the relationship between BMI and cervical SFT. METHODS: This was a retrospective cohort study of patients with cervical CT scans. SFT was assessed by measuring the distance (mm) from the spinous processes of C2-C7 to the skin edge. Pearson correlations and linear regression were used to analyze the relationship between BMI and SFT. One-way ANOVA was used to analyze differences in C2-C7 distances while stratifying by BMI. RESULTS: A total of 96 patients were included. BMI had a moderate correlation with average C2-C7 (r=0.546, p < 0.05) SFT, and a weak to moderate correlation with each individual C2-C7 distance. The strongest correlation was at the C7 level (r= 0.583, p < 0.05). These analyses remained significant controlling for potential confounders of patient age, sex, and diabetes. No difference was found in the average C2-C7 distance in patients with BMIs of 25-30 compared to those with BMIs of 30-40 (p=0.996), whereas in patients with BMI <25 and BMI >40, differences were significant (p < 0.05). CONCLUSIONS: BMI is not strongly correlated with SFT in the cervical spine. Although BMI less than 25 or greater than 40 is correlated with respectively decreased or increased cervical SFT, BMI of 25-40 is not correlated with cervical SFT. This is clinically important information for surgeons counseling patients on perioperative risk before undergoing cervical spine procedures, namely infection. Further research delineating the relationship between posterior SFT and surgical site infection in the cervical spine is warranted.

Conservative management of intraventricular migration of a gelatin sponge: illustrative case.

BACKGROUND: Gelatin sponges, such as Gelfoam, are used as hemostatic agents during surgery and are generally absorbed over the course of 4-6 weeks in most body cavities. The time course of the dissolution of Gelfoam sponges within the cerebral ventricles has not been described. OBSERVATIONS: The authors present a case of intraventricular migration of Gelfoam after ventriculoperitoneal shunt placement in a 6-week-old infant. The infant was imaged regularly after ventriculoperitoneal shunt placement, and the Gelfoam sponge persisted within the ventricles on all images until 11 months after surgery. At no time during follow-up did the patient have any symptoms of hydrocephalus requiring retrieval of the sponge or shunt revision. LESSONS: This is the first case describing time until absorption of a gelatin sponge within the ventricle and successful conservative management.

Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience.

BACKGROUND: Cephalohematoma of infancy is the result of a subperiosteal blood collection that usually forms during birth-related trauma. A small proportion of cephalohematomas can calcify over time, causing a permanent calvarial deformity that is only correctable with surgery. The authors present a technique for the excision and reconstruction of calcified cephalohematoma and their management experience over the past 25 years. METHODS: All patients with a diagnosis of calcified cephalohematoma between 1994 and 2019 were identified. Patients were included if the diagnosis was confirmed by a pediatric plastic surgeon or a neurosurgeon. All patients underwent surgical evaluation followed by surgical intervention or observation. Patient demographics and potential risk factors for both surgical and nonsurgical groups were compared using chi-square or Fisher's exact test. Additional data were collected for the surgical cohort. RESULTS: Of 160 infants diagnosed with cephalohematoma, 72 met inclusion criteria. Thirty patients underwent surgical treatment. There was no significant difference in demographics, baseline characteristics, or potential risk factors between the operative and nonoperative groups. Mean age at the time of surgery was 8.6 months. Twenty-one surgical patients (70 percent) required inlay bone grafting. All surgery patients had improvement in calvarial shape. The main risk of surgery was blood loss requiring transfusion [eight patients (26.7 percent)]. Thirteen percent of patients experienced minor complications. CONCLUSIONS: This series of 72 children with calcified cephalohematomas, 30 of whom required surgical intervention, is one of the largest to date. The technique presented herein demonstrated excellent surgical outcomes by restoring normal cranial contours and was associated with a low complication profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Smartphone Use and Interest in a Spine Surgery Recovery Mobile Application Among Patients in a US Academic Neurosurgery Practice.

BACKGROUND: Mobile applications (apps) are serving an increasingly important role in healthcare for patients and providers alike. In addition to streamlining active communication of patient-reported outcomes regarding quality of life, pain, and opioid consumption, smartphones equipped with activity tracking afford the opportunity to passively and objectively measure mobility, a key metric of recovery in spine surgery. However, app development is a resource-intensive process. OBJECTIVE: To survey adult neurosurgery patients regarding access to and interest in this platform. METHODS: In June and July 2017, a paper-based anonymous survey was distributed to patients in the waiting room of the adult neurosurgery clinic of a large US academic medical center. Patients' smartphone use and interest in using a mobile app following spine surgery were the primary and secondary outcomes, respectively. RESULTS: Of 146 included responses, 102 patients (70%) regularly used a smartphone, and this number increased to 77% among patients with a history of spine surgery (n = 66, 45% of respondents). Seventy-one percent of patients with previous spine surgery expressed an interest in using a postoperative monitoring and communication app, compared to 81% of patients without prior spine operations (n = 80, 55%). CONCLUSION: Among neurosurgery patients, there is a high level of access to and interest in smartphone apps to aid postoperative recovery. These results are useful for other neurosurgeons considering mobile app development for this purpose.

Effect of Muscle Quality on Operative and Nonoperative Treatment of Rotator Cuff Tears.

BACKGROUND: Rotator cuff muscle atrophy and fatty infiltration are predictors of negative outcomes after rotator cuff repair. However, the impact of muscle degeneration on nonsurgical treatment is unknown. HYPOTHESIS: Rotator cuff muscle atrophy and fatty infiltration will reduce the outcomes of operative repair while having a minimal effect on nonsurgical treatment. Additionally, in the setting of atrophy and fatty infiltration, surgical and nonsurgical treatment will produce equivalent outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing operative and nonoperative treatment of full-thickness rotator cuff tears were prospectively enrolled into a nonrandomized cohort study. Muscle quality was assessed on magnetic resonance imaging by use of the supraspinatus tangent sign, Warner atrophy, and Goutallier fatty infiltration classifications. Grading was performed by 2 independent observers who were blinded to patient treatment and outcomes. Normalized Western Ontario Rotator Cuff (WORC) index was the primary patient-reported outcome. Multivariate linear regression analysis was used to determine the impact of muscle quality on treatment outcomes. RESULTS: The cohort consisted of 157 patients, 89 (57%) surgical and 68 (43%) nonsurgical, with a mean follow-up of 2.4 years (range, 1-5 years). Tangent sign had the best inter- and intrarater reliability, with kappa statistics of 0.81 and 0.86, respectively. Reliability for Warner atrophy was 0.69 to 0.76 and for Goutallier classification was 0.54 to 0.64. Overall, improvement in WORC scores was higher in the surgical group than the nonsurgical group (39.3 vs 21.2; P < .001). A positive tangent sign was the only independent predictor (P < .01) of worse outcomes in the surgical group, accounting for an estimated 22-point lower improvement in WORC scores. CONCLUSION: A positive tangent sign was predictive of worse operative outcomes, resulting in equivalent improvements between surgical and nonsurgical treatment. The tangent sign is a reliable, prognostic indicator that clinicians can use when counseling patients on the optimal treatment of rotator cuff tears.

Clinical Level of Evidence Presented at the Lumbar Spine Research Society (LSRS) Annual Meeting Over 10 Years (2008-2017): A Systematic Review.

STUDY DESIGN: A systematic review. OBJECTIVE: The Lumbar Spine Research Society (LSRS) is dedicated to advancing knowledge of the lumbar spine to promote evidence-based care. We sought to systematically review the level of clinical evidence presented at LSRS annual meetings from 2008 through 2017. SUMMARY OF BACKGROUND DATA: Improvements in clinical evidence have been reported at similar bone and joint scientific meetings. METHODS: A total of 458 paper abstracts presented at LSRS annual meetings were independently assessed by two reviewers. Only clinical studies being included for analysis. Reviewers designated a clinical level of evidence (LOE) to each included abstract from level I to level IV based on criteria set forth by the Oxford Centre for Evidence-Based Medicine. Reviewer agreement was assessed using Cohens Kappa coefficient (k). Student t test was used to assess for differences in mean LOE grades. Chi-squared testing was used to assess nonrandom changes in LOE. RESULTS: A total of 299 abstracts met inclusion criteria. Over the last 10 LSRS meetings, 2.68% of the presentations were level I, 22.4% were level II, 37.1% were level III, and 37.8% were level IV. We found the average LOE from 2008 to 2017 to be 3.10 (median = 3). In addition, 63.9% presentations were Therapeutic Studies, 30.1% were Prognostic Studies, and 6.02% were Diagnostic studies. When comparing the first 5 years (2008-2012) to the last 5 years (2013-2017), we observed a significant increase in Level II (P < 0.05) and Level III (P < 0.05) evidence along with a corresponding decrease in level IV evidence (P < 0.01). The average LOE improved significantly from 3.28 (2008-2012) to 2.88 (2013-2017) (P < 0.001). CONCLUSION: Emphasis on evidence-based medicine within spine surgery, specifically pertaining to the lumbar spine, has positively influenced the clinical LOE disseminated at LSRS annual meetings between 2008 and 2017. LEVEL OF EVIDENCE: 4.

Preliminary evidence that age and sex affect exercise-induced hTERT expression.

The ability to repair cellular damage is reduced with aging, resulting in cellular senescence. Telomeres shorten as cells divide but the rate of telomere attrition is modulated by telomerase, an enzyme that adds nucleotides to the chromosome. Shelterin is a protein complex that acts as a negative regulator of telomerase. The aim of the present study was to investigate age-related differences in telomerase and shelterin responses to acute exercise. We hypothesized that acute exercise would stimulate an increased activity of telomerase (measured by telomerase reverse transcriptase, hTERT) without an increase in activity of shelterin (measured by telomeric repeat binding factor 2, TRF2) in both young and older individuals and that hTERT response would be attenuated in older individuals. Young (22±2y, n=11) and older (60±2y, n=8) men and women performed 30min of cycling. Blood was collected pre-exercise and 30, 60, and 90-min post-exercise. The trial induced a significant hTERT response in the cohort as a whole (p<0.05) with greater increases in the young as compared to the older group (time-by-group interaction p<0.05). As expected, TRF2 did not change in response to the trial, however older individuals had a higher TRF2 response at 60min (p<0.05). There was an unexpected sex difference, regardless of age, where men had significantly greater hTERT and TRF2 responses to the acute exercise as compared to women (p<0.05). These data support the hypothesis that aging is associated with attenuated telomerase activation in response to high-intensity exercise; however, this was only evident in men.