Predicting over-the-counter antibiotic use in rural Pune, India, using machine learning methods.

Objectives: Over-the-counter (OTC) antibiotic use can cause antibiotic resistance, threatening global public health gains. To counter OTC use, this study used machine learning (ML) methods to identify predictors of OTC antibiotic use in rural Pune, India. Methods: The features of OTC antibiotic use were selected using stepwise logistic, lasso, random forest, XGBoost, and Boruta algorithms. Regression and tree-based models with all confirmed and tentatively important features were built to predict the use of OTC antibiotics. Five-fold cross-validation was used to tune the models' hyperparameters. The final model was selected based on the highest area under the curve (AUROC) with a 95% confidence interval and the lowest log-loss. Results: In rural Pune, the prevalence of OTC antibiotic use was 35.9% (95% CI, 31.56%-40.46%). The perception that buying medicines directly from a medicine shop/pharmacy is useful, using antibiotics for eye-related complaints, more household members consuming antibiotics, and longer duration and higher doses of antibiotic consumption in rural blocks and other social groups were confirmed as important features by the Boruta algorithm. The final model was the XGBoost+Boruta model with 7 predictors (AUROC=0.934; 95% CI, 0.8906-0.9782; log-loss=0.2793) log-loss. Conclusion: XGBoost+Boruta, with 7 predictors, was the most accurate model for predicting OTC antibiotic use in rural Pune. Using OTC antibiotics for eye-related complaints, higher consumption of antibiotics and the perception that buying antibiotics directly from a medicine shop/pharmacy is useful were identified as key factors for planning interventions to improve awareness about proper antibiotic use.

Improved Side-Effect Stimulation Thresholds and Postoperative Transient Confusion With Asleep, Image-Guided Deep Brain Stimulation.

BACKGROUND AND OBJECTIVES: Asleep, image-guided deep brain stimulation (DBS) is a modern alternative to awake, microelectrode recording (MER) guidance. Studies demonstrate comparable efficacy and complications between techniques, although some report lower stimulation thresholds for side effects with image guidance. In addition, few studies directly compare the risk of postoperative transient confusion (pTC) across techniques. The purpose of this study was to compare clinical efficacy, stimulation thresholds for side effects, and rates of pTC with MER-guided DBS vs intraoperative 3D-fluoroscopy (i3D-F) guidance in Parkinson's disease and essential tremor. METHODS: Consecutive patients from 2006 to 2021 were identified from the departmental database and grouped as having either MER-guided DBS or i3D-F-guided DBS insertion. Directional leads were used once commercially available. Changes in Unified Parkinson's Disease Rating Scale (UPDRS)-III scores, levodopa equivalent daily dose, Fahn-Tolosa-Marin scores, and stimulation thresholds were assessed, as were rates of complications including pTC. RESULTS: MER guidance was used to implant 487 electrodes (18 globus pallidus interna, GPi; 171 subthalamic nucleus; 76 ventrointermediate thalamus, VIM) in 265 patients. i3D-F guidance was used in 167 electrodes (19 GPi; 25 subthalamic nucleus; 41 VIM) in 85 patients. There were no significant differences in Unified Parkinson's Disease Rating III Scale, levodopa equivalent daily dose, or Fahn-Tolosa-Marin between groups. Stimulation thresholds for side effects were higher with i3D-F guidance in the subthalamic nucleus (MER, 2.80 mA ± 0.98; i3D-F, 3.46 mA ± 0.92; P = .002) and VIM (MER, 2.81 mA ± 1.00; i3D-F, 3.19 mA ± 1.03; P = .0018). Less pTC with i3D-F guidance (MER, 7.5%; i3D-F, 1.2%; P = .034) was also found. CONCLUSION: Although clinical efficacy between MER-guided and i3D-F-guided DBS was comparable, thresholds for stimulation side effects were higher with i3D-F guidance and the rate of pTC was lower. This suggests that image-guided DBS may affect long-term side effects and pose a decreased risk of pTC.

Indication as a predictor for outcomes in anterior cervical discectomy and fusion: The impact of myelopathy on disposition.

BACKGROUND: While the indication for Anterior Cervical Discectomy and Fusion (ACDF) may influence the expected postoperative course, there is limited data comparing how length of stay (LOS) and disposition for patients with myelopathy differ from those with radiculopathy. This study aimed to compare LOS and discharge disposition, in patients undergoing ACDF for cervical radiculopathy versus those for myelopathy. METHODS: A retrospective review of all adult ACDF cases between 2013 and 2019 was conducted analyzing sex, age, race, comorbidities, level of surgery, myelopathy measures when applicable, complications, dysphagia, hospital LOS, and discharge disposition. RESULTS: A total of 157 patients were included in the study with 73 patients undergoing an ACDF for radiculopathy and 84 for myelopathy. Univariate analysis determined older age (p < 0.01), male sex (p = 0.03), presence of CKD (p < 0.01) or COPD (p = 0.01), surgery at C3/4 level (p = 0.01), and indication (p < 0.01) as predictors for a discharge to either acute rehabilitation or a skilled nursing facility rather than to home. Multivariate logistic regression demonstrated age and indication as the only independent predictors of disposition, with home disposition being more likely with decreased age (OR 0.92, 95 % CI 0.86-0.98) and radiculopathy as the diagnosis (OR 6.72, 95 % CI 1.22- 37.02). CONCLUSIONS: Myelopathic patients, as compared to those with radiculopathy at presentation, had significantly longer LOS, increased dysphagia, and were more often discharged to a facility. Understanding these two distinct populations as separate entities will streamline the pre and post-surgical care as the current DRG codes and ICD 10 PCS do not differentiate the expected post-operative course in patients undergoing ACDF for myelopathy versus radiculopathy.

The World Neurosurgery Global Champions Program: First-Year Experience of a Model Initiative for Reducing Disparities in Global Neurosurgical Literature.

OBJECTIVE: Most surgical journals are published in English, representing a challenge for researchers from non-Anglophone countries. We describe the implementation, workflow, outcomes, and lessons learned from the WORLD NEUROSURGERY Global Champions Program (GCP), a novel journal-specific English language editing program for articles rejected because of poor English grammar or usage. METHODS: The GCP was advertised via the journal website and social media. Applicants were selected to be a reviewer for the GCP if they demonstrated English proficiency on writing samples supplied in their application. The demographics of GCP members and characteristics and outcomes of articles edited by the GCP during its first year were reviewed. Surveys of GCP members and authors who used the service were conducted. RESULTS: Twenty-one individuals became part of the GCP, representing 8 countries and 16 languages apart from English. A total of 380 manuscripts were peer reviewed by the editor-in-chief, who determined these manuscripts to have potentially worthwhile content but needed to be rejected due to poor language. The authors of these manuscripts were informed of the existence of this language assistance program. Forty-nine articles (12.9%) were edited by the GCP in 41.6 ± 22.8 days. Of 40 articles resubmitted to WORLD NEUROSURGERY, 24 (60.0%) were accepted. GCP members and authors understood the purpose and workflow of the program and recognized improvements in article quality and the probability of acceptance through their participation. CONCLUSIONS: The WORLD NEUROSURGERY Global Champions Program mitigated a critical barrier to publication in an English language journal for authors from non-Anglophone countries. This program promotes research equity by providing a free, largely medical student and trainee operated, English language editing service. This model or a similar service can be replicated by other journals.

Racial differences in time to blood pressure control of aneurysmal subarachnoid hemorrhage patients: A single-institution study.

BACKGROUND AND PURPOSE: Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 patients annually in the United States. Uncontrolled blood pressure is a major risk factor for aneurysmal subarachnoid hemorrhage. Clinical guidelines recommend maintaining blood pressure control until definitive aneurysm securement occurs. It is unknown whether racial differences exist regarding blood pressure control and outcomes (HLOS, discharge disposition) in aneurysmal subarachnoid hemorrhage. Here, we aim to assess whether racial differences exist in 1) presentation, 2) clinical course, and 3) outcomes, including time to blood pressure stabilization, for aSAH patients at a large tertiary care medical center. METHODS: We conducted a retrospective review of adult aneurysmal subarachnoid hemorrhage cases from 2013 to 2019 at a single large tertiary medical center. Data extracted from the medical record included sex, age, race, insurance status, aneurysm location, aneurysm treatment, initial systolic and diastolic blood pressure, Hunt Hess grade, modified Fisher score, time to blood pressure control (defined as time in minutes from first blood pressure measurement to the first of three consecutive systolic blood pressure measurements under 140mmHg), hospital length of stay, and final discharge disposition. RESULTS: 194 patients met inclusion criteria; 140 (72%) White and 54 (28%) Black. While White patients were more likely than Black patients to be privately insured (62.1% versus 33.3%, p < 0.001), Black patients were more likely than White patients to have Medicaid (55.6% versus 15.0%, p < 0.001). Compared to White patients, Black patients presented with a higher median systolic (165 mmHg versus 148 mmHg, p = 0.004) and diastolic (93 mmHg versus 84 mmHg, p = 0.02) blood pressure. Black patients had a longer median time to blood pressure control than White patients (200 minutes versus 90 minutes, p = 0.001). Black patients had a shorter median hospital length of stay than White patients (15 days versus 18 days, p < 0.031). There was a small but statistically significant difference in modified Fisher score between black and white patients (3.48 versus 3.17, p = 0.04).There were no significant racial differences present in sex, Hunt Hess grade, discharge disposition, complications, or need for further interventions. CONCLUSION: Black race was associated with higher blood pressure at presentation, longer time to blood pressure control, but shorter hospital length of stay. No racial differences were present in aneurysmal subarachnoid hemorrhage associated complications or interventions.

Impact of anemia on acute ischemic stroke outcomes: A systematic review of the literature.

INTRODUCTION: Anemia has been reported in nearly 40% of acute ischemic stroke (AIS) patients and is linked to significant morbidity and disability. The presence of anemia is associated with worse outcomes in AIS, specifically in the presence of large vessel occlusion (LVO). An optimal hemoglobin (Hb) target specific to this pathology has not yet been established. The goal of this review is to systematically review literature that observes the association that exists between AIS outcomes and hemoglobin (Hb) levels. METHODS: A systematic review was performed in accordance with guidelines for the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to identify studies from 2008-2022. The following inclusion and exclusion criteria were used: studies of adult patients with AIS; must describe outcomes with regard to Hb levels in AIS (not limited to LVO); must be written in English. The clinical variables extracted included Length of Stay (LOS), modified rankin score (mRS), Hb levels, and mortality. RESULTS: A total of 1,154 studies were gathered, with 116 undergoing full text review. 31 studies were included in this review. The age of patients ranged from 61.4 to 77.8. The presence of anemia in AIS increased LOS by 1.7 days on average and these patients also have a 15.2% higher rate of mortality at one year, on average. DISCUSSION: This data suggests that the contemporary thresholds for treating anemia in AIS patients may be inadequate because anemia is strongly associated with poor outcomes (e.g., mRS>2 or mortality) and increased LOS in AIS patients. The current generalized Hb threshold for transfusion (7 g/dL) is also used in AIS patients, however, a more aggressive transfusion parameter should be further explored based on these findings. Further studies are required to confirm these findings and to determine if a more liberal RBCT threshold will result in clinical benefits.

Predictors of In-Hospital Mortality and Home Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A 4-Year Retrospective Analysis.

BACKGROUND: Factors associated with discharge disposition and mortality following aneurysmal subarachnoid hemorrhage (aSAH) are not well-characterized. We used a national all-payer database to identify factors associated with home discharge and in-hospital mortality. METHODS: The National Inpatient Sample was queried for patients with aSAH within a 4-year range. Weighted multivariable logistic regression models were constructed and adjusted for age, sex, race, household income, insurance status, comorbidity burden, National Inpatient Sample SAH Severity Score, disease severity, treatment modality, in-hospital complications, and hospital characteristics (size, teaching status, and region). RESULTS: Our sample included 37,965 patients: 33,605 were discharged alive and 14,350 were discharged home. Black patients had lower odds of in-hospital mortality compared with White patients (adjusted odds ratio [aOR] = 0.67, 95% confidence interval [CI] 0.52-0.86, p = 0.002). Compared with patients with private insurance, those with Medicare were less likely to have a home discharge (aOR = 0.58, 95% CI 0.46-0.74, p < 0.001), whereas those with self-pay (aOR = 2.97, 95% CI 2.29-3.86, p < 0.001) and no charge (aOR = 3.21, 95% CI 1.57-6.55, p = 0.001) were more likely to have a home discharge. Household income percentile was not associated with discharge disposition or in-hospital mortality. Paradoxically, increased number of Elixhauser comorbidities was associated with significantly lower odds of in-hospital mortality. CONCLUSIONS: We demonstrate independent associations with hospital characteristics, patient characteristics, and treatment characteristics as related to discharge disposition and in-hospital mortality following aSAH, adjusted for disease severity.

Stereotactic radiosurgery and resection for treatment of multiple brain metastases: a systematic review and analysis.

OBJECTIVE: Stereotactic radiosurgery (SRS) has recently emerged as a minimally invasive alternative to resection for treating multiple brain metastases. Given the lack of consensus regarding the application of SRS versus resection for multiple brain metastases, the authors aimed to conduct a systematic literature review of all published work on the topic. METHODS: The PubMed, OVID, Cochrane, Web of Science, and Scopus databases were used to identify studies that examined clinical outcomes after resection or SRS was performed in patients with multiple brain metastases. Radiological studies, case series with fewer than 3 patients, pediatric studies, or national database studies were excluded. Data extracted included patient demographics and mean overall survival (OS). Weighted t-tests and ANOVA were performed. RESULTS: A total of 1300 abstracts were screened, 450 articles underwent full-text review, and 129 studies met inclusion criteria, encompassing 20,177 patients (18,852 treated with SRS and 1325 who underwent resection). The OS for the SRS group was 10.2 ± 6 months, and for the resection group it was 6.5 ± 3.8 months. A weighted ANOVA test comparing OS with covariates of age, sex, and publication year revealed that the treatment group (p = 0.045), age (p = 0.034), and publication year (0.0078) were all independently associated with OS (with SRS, younger age, and later publication year being associated with longer survival), whereas sex (p = 0.95) was not. CONCLUSIONS: For patients with multiple brain metastases, SRS and resection are effective treatments to prolong OS, with published data suggesting that SRS may have a trend toward lengthened survival outcomes. The authors encourage additional work examining outcomes of treatments for multiple brain metastases.

Presentation and management of nervous system cavernous malformations in children: A systematic review and case report.

Cerebral cavernous malformations (CMs) are slow-flow vascular lesions that affect up to 0.5% of the pediatric population. These lesions are at risk for hemorrhage, causing seizures, and leading to neurological deficits. Here, we conduct a literature review and then present a report of a supratentorial CM in a 2-year-old patient with no significant past medical history who presented at our institution with 1 month of eye twitching. We performed a literature search of five databases of all articles published before 2020. Our inclusion criteria included cohort and case series of children with mean age under 12 years. Our search yielded 497 unique articles, of which 16 met our inclusion criteria. In our pooled literature analysis, a total of 558 children were included, 8.3% of which had a positive family history and 15.9% had multiple CMs. About 46.1% of the children had seizures, and 88.4% of those who underwent surgery had a total resection. About 85.1% of those with epilepsy were Engel Class 1 postsurgery. Over a mean follow-up of 4.1 years, 3.4% of patients had additional neurological deficits, including paresis and speech deficits. Our analysis of published literature shows surgical intervention should be considered first-line therapy for patients who are symptomatic from CM, present with seizure, and have surgically accessible lesions. Additional work is needed on outcomes and long-term effects of minimally invasive treatments, including radiosurgery and laser ablation, in pediatric populations.

Physician empathy during crisis: A survey of doctors in COVID-19 pandemic (COPE study).

Background: There is a lack of research studies on physician empathy levels towards patients, which is a critical component of providing high-quality patient-care and satisfaction. Our study aimed at assessing the physician-reported empathy levels towards patients during a crisis like the ongoing COVID-19 pandemic. Methods: Cross-sectional online-based survey was conducted among 409 practicing doctors from varied healthcare levels during the pandemic. We used a validated Jefferson Physician's Empathy (JPE) - Health Professional (HP) version questionnaire. Empathy score was expressed as a median and interquartile range, and the analysis was done in STATA 12.1 (StataCorp LP, Texas, USA). Results: Among the survey respondents, 55% were between 26-35 years, 56% were from the government health sector, and 57% were male doctors. Overall physicians' empathy score was 100 (89, 113). The empathy score among physicians engaged in OPD duty was significantly higher (p = 0.022). A total of 70.0% of physicians consulting more than 50 patients/day reported a score ≤105 (p = 0.035). Physicians aged more than 40 years (AOR = 2.545, 95% CI = 1.1133, 5.8184) and those working in government healthcare centers (AOR = 2.711, 95% CI = 1.1372, 6.4616) were about three times more likely to have a score >105 compared to younger physicians (p = 0.027) and private practitioners (p = 0.024). Conclusion: Physician-reported empathy scores during the COVID pandemic were high. Middle-aged physicians involved in OPD consultation and those working in government healthcare recorded good scores. However, reporting lower empathy scores when the patient load increases highlights the need for administrative and medical education interventions.

Multidisciplinary approaches to gliosarcoma: A case report and review of the literature.

A 58-year-old right-handed man presented to our tertiary care center with gliosarcoma (GS) infiltration through the dura, skull, and soft tissue. Patient had a previous history of right temporal GS, with four intracranial surgeries prior to presentation. A multidisciplinary approach was used to treat the lesion and perform reconstruction.

Pudendal tumor mimicking cauda equina syndrome and acute radiculopathy: case report.

INTRODUCTION: Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts. CLINICAL PRESENTATION: A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved. CONCLUSION: CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc.

Inpatient virtual shared medical appointments to improve health literacy, increase patient self-efficacy, and reduce provider burnout in acute cerebrovascular pathology patients and their caregivers: a pilot study.

OBJECTIVE: Admission to the hospital for an acute cerebrovascular condition such as stroke or brain hemorrhage can be a traumatic and disorienting experience for patients and their family members. The COVID-19 pandemic has further intensified this experience in addition to exacerbating clinician and resident burnout. To ameliorate some of these concerns, a team of resident and medical student trainees implemented a virtual shared medical appointment (vSMA) program for inpatients with acute cerebrovascular disorders and their caregivers. The authors hypothesized that an early intervention in the form of a vSMA improves patient and caregiver health literacy and preparedness while simultaneously educating clinical trainees on effective communication skills and reducing clinician burnout. METHODS: Patients and caregivers of admitted patients were identified through a census of neurosurgery, neurocritical care, and neurology electronic medical records. A weekly 60-minute secure virtual session consisted of introductions and a 10-minute standardized presentation on cerebrovascular disease management, followed by participant-guided discussion. Participants completed presession and postsession surveys. Through this small feasibility study data were obtained regarding present challenges, both expected and unforeseen. RESULTS: A total of 170 patients were screened, and 13 patients and 26 caregivers participated in at least 1 vSMA session. A total of 6 different healthcare providers facilitated sessions. The vSMA program received overwhelmingly positive feedback from caregivers. Survey responses demonstrated that 96.4% of caregivers and 75% of patients were satisfied with the session, 96.4% of caregivers and 87.5% of patients would recommend this type of appointment to a friend or family member, and 88.8% of providers reported feeling validated by conducting the session. The participant group had a 20% greater percentage of patients discharged home without home needs compared to the nonparticipant group. The primary obstacles encountered included technological frustrations with the consent process and the sessions themselves. CONCLUSIONS: Implementation of a vSMA program at a tertiary care center during a pandemic was feasible. Themes caregivers expressed on the postsession survey included better understanding of caring for a stroke patient and coping with the unpredictability of a patient's prognosis. The pandemic has precipitated shifts toward telehealth, but this study highlights the importance of avoiding marginalization of elderly and less technologically inclined populations.

Use of Patients' Protected Health Information to Solicit Hospital Funds: How did This Practice Come About?

Modifications to Health Insurance Portability and Accountability Act (HIPAA) have allowed for the disclosure of patient protected health information (PHI) for the purpose of hospital fundraising. The public has recently raised ethical concerns regarding these practices. We examined the forces that brought about these HIPAA modifications. We first examined 304 comments submitted to the proposed rule for the HIPPA regulation modifications. We additionally queried the OpenSecrets repository for lobbying activity by these commenters. We found that 57 out of the 304 comments pertained specifically to fundraising practices. The majority of comments were from hospital developmental (fundraising) offices (51%, 29 of 57 comments), and the majority (96%, 24 of 25 hospital comments; 83%, 34 of 41 total comments discussing PHI disclosure) supported additional PHI disclosure. There was a paucity of comments from physician organizations (1 of 57) and patient advocates (2 of 57). The majority of lobbying dollars (95% of over $81 million) were from commenters who favored the modifications. The lack of physician and patient representation in the rule-making process likely contributed to the creation of regulations that elicit ethical concerns in physicians, and potential harm for patients.

Spine centers of excellence: a systematic review and single-institution description of a spine center of excellence.

Background: Centers of excellence (COEs) are interdisciplinary healthcare organizations created with the goal of improving health/economic outcomes in medical treatment for both individuals and health systems, compared to traditionally structured counterparts. Multiple studies have highlighted both societal/individual burdens associated with back pain, underscoring the importance of identifying new avenues for improving both cost/clinical outcomes for this patient population. Here, we utilize available literature to better characterize the features of a spine COE at a tertiary care center and determine the impact of COEs on patient satisfaction and outcomes. Methods: A systematic review describing spine COEs was performed. PubMed, OVID, Cochrane, Web of Science, and Scopus were utilized for electronic literature search. Data including institution, department, pathologies treated, patient satisfaction scores, patient outcomes, and descriptions of the COE, were extracted and analyzed by two reviewers per full-text article. Inclusion criteria consisted of literature describing the organization, purpose, or outcomes of a spine COE, all publication types (except technical/operative report), adult or pediatric patients, publication from inception through September 2021. Exclusion criteria consisted of articles that do not discuss spinal COEs, technical/operative reports, studies unavailable in English language, unavailable full text, or non-human subjects. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of the included studies. Results: Five hundred and sixty-seven unique publications were obtained from the literature search. Of these articles, 20 were included and 547 were excluded based on inclusion and exclusion criteria. Following full-text review of the 20 publications, 6 contained pertinent data. Quantitative data comparing COE versus non-COE was contradictory in comparing complication rates and episodic costs. Qualitative data included descriptions of spine COE features and cited improved patient care, technical advancements, and individualized care paths as positive aspects of the COE model. Mean risk of bias assessment was 3.67. Discussion: There is little evidence regarding if spine COEs provide an advantage over traditionally organized facilities. The current number and heterogeneity of publications, and lack of standardized metrics used to define a spinal COE are limiting factors. Spinal COE may offer higher value care, reduced complication rates and advancements in knowledge and technical skill.

Epidemiology, clinical presentation and management of COVID-19 associated mucormycosis: A single centre experience from Pune, Western India.

BACKGROUND: The second COVID-19 wave in India has been associated with an unprecedented increase in cases of COVID-19 associated mucormycosis (CAM), mainly Rhino-orbito-cerebral mucormycosis (ROCM). METHODS: This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India, between 1 April, 2020, and 1 August, 2021, to identify CAM patients and assess their management outcomes. The primary endpoint was incidence of all-cause mortality due to CAM. RESULTS: 59 patients were diagnosed with CAM. Median duration from the first positive COVID-19 RT PCR test to diagnosis of CAM was 17 (IQR: 12,22) days. 90% patients were diabetic with 89% having uncontrolled sugar level (HbA1c >7%). All patients were prescribed steroids during treatment for COVID-19. 56% patients were prescribed steroids for non-hypoxemic, mild COVID-19 (irrational steroid therapy), while in 9%, steroids were prescribed in inappropriately high dose. Patients were treated with a combination of surgical debridement (94%), intravenous liposomal Amphotericin B (91%) and concomitant oral Posaconazole (95.4%). 74.6% patients were discharged after clinical and radiologic recovery while 25.4% died. On relative risk analysis, COVID-19 CT severity index ≥18 (p = .017), presence of orbital symptoms (p = .002), presence of diabetic ketoacidosis (p = .011) and cerebral involvement (p = .0004) were associated with increased risk of death. CONCLUSIONS: CAM is a rapidly progressive, angio-invasive, opportunistic fungal infection, which is fatal if left untreated. Combination of surgical debridement and antifungal therapy leads to clinical and radiologic improvement in majority of cases.

Evaluating diversity in neurosurgery through the use of a multidimensional statistical model: a pilot study.

OBJECTIVE: There is a growing body of evidence demonstrating the benefits of diversity across many domains. However, neurosurgery consistently lags most of medicine in many aspects of diversity. Any inability to make progress in this arena is likely due to the multifactorial and complex nature of the issue, which makes it difficult to meaningfully measure and track diversity within the workforce. The goal of this pilot study was to assess the utilization of a multidimensional statistical model to quantify and assess diversity within neurosurgery. The authors sought to 1) assess the diversity of neurosurgery residents using Simpson's Diversity Index and Sullivan's Composite Diversity Index (CDI) and 2) determine if a medical school's intrinsic academic opportunities and resources, indicated by US News & World Report's (USNWR's) best research medical schools ranking, are related to the number of neurosurgery residents produced per medical school. METHODS: A cross-sectional study of all neurosurgery residents (projected graduation years 2020-2026) and 1st-year medical students (matriculating years 2016-2019) was undertaken. Biographical diversity data (gender and matriculation data) were collected from institutional websites between December 2019 and June 2020. The CDI expresses the diversity of a given population by representing the effective proportion of categories present across all diversity attributes and was calculated for neurosurgery residents and medical students. Statistical results are reported as the median and interquartile range. RESULTS: Neurosurgery residency program CDI (0.21, IQR 0.16-0.25) was significantly less (p < 0.001) than medical school CDI (0.42, 0.37-0.48). There was no significant difference in CDI between top-40 and non-top 40 Doximity ranked research output neurosurgery residency programs (p = 0.35) or between top-40 and non-top 40 USNWR ranked research medical schools (p = 0.11). Over a 7-year period, top-40 ranked research medical schools produced significantly more (p < 0.001) neurosurgery residents (11.9, IQR 7.1-18.9) than the non-top 40 ranked research medical schools (5.6, IQR 2.6-8.5). CONCLUSIONS: The authors demonstrated the feasibility of using a multidimensional statistical model as a measure to understand the complex issues of diversity. Their preliminary data suggested that neurosurgery's challenge in achieving the desired diversity relates to uneven attraction and/or recruitment across an increasingly diverse medical student body. In recent years, neurosurgery has made great progress in the arena of diversity and has shown a strong desire to do more. Utilization of these diversity measures will help the neurosurgery field to monitor progress along this valuable journey.

Deep Brain Stimulation Compared With Contingency Management for the Treatment of Cocaine Use Disorders: A Threshold and Cost-Effectiveness Analysis.

OBJECTIVES: Cocaine is the second most frequently used illicit drug worldwide (after cannabis), and cocaine use disorder (CUD)-related deaths increased globally by 80% from 1990 to 2013. There is yet to be a regulatory-approved treatment. Emerging preclinical evidence indicates that deep brain stimulation (DBS) of the nucleus accumbens may be a therapeutic option. Prior to expanding the costly investigation of DBS for treatment of CUD, it is important to ensure societal cost-effectiveness. AIMS: We conducted a threshold and cost-effectiveness analysis to determine the success rate at which DBS would be equivalent to contingency management (CM), recently identified as the most efficacious therapy for treatments of CUDs. MATERIALS AND METHODS: Quality of life, efficacy, and safety parameters for CM were obtained from previous literature. Costs were calculated from a societal perspective. Our model predicted the utility benefit based on quality-adjusted life-years (QALYs) and incremental-cost-effectiveness ratio resulting from two treatments on a one-, two-, and five-year timeline. RESULTS: On a one-year timeline, DBS would need to impart a success rate (ie, cocaine free) of 70% for it to yield the same utility benefit (0.492 QALYs per year) as CM. At no success rate would DBS be more cost-effective (incremental-cost-effectiveness ratio <$50,000) than CM during the first year. Nevertheless, as DBS costs are front loaded, DBS would need to achieve success rates of 74% and 51% for its cost-effectiveness to exceed that of CM over a two- and five-year period, respectively. CONCLUSIONS: We find DBS would not be cost-effective in the short term (one year) but may be cost-effective in longer timelines. Since DBS holds promise to potentially be a cost-effective treatment for CUDs, future randomized controlled trials should be performed to assess its efficacy.

Can responsive deep brain stimulation be a cost-effective treatment for severe obesity?

OBJECTIVE: A first-in-human responsive deep brain stimulation (rDBS) trial (NCT03868670) for obesity is under way, which is based on promising preclinical evidence. Given the upfront costs of rDBS, it is prudent to examine the success threshold for cost-effectiveness compared with laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Efficacy and safety data on LRYGB and safety data on rDBS were collected for established indications through a literature search. The success threshold was defined as minimum BMI reduction. Treatment costs were calculated via Medicare national reimbursement data. RESULTS: LRYGB had a mean BMI reduction of 13.75 kg/m2 . Based on adverse events, LRYGB was a less-preferred health state (overall adverse event utility of 0.96 [0.02]) than rDBS (0.98 [0.01]), but LRYGB ($14,366 [$6,410]) had a significantly lower treatment cost than rDBS ($29,951 [$4,490]; p < 0.0001). Therefore, for rDBS to be cost-effective compared with LRYGB, the multiple models yielded a success threshold range of 13.7 to 15.2 kg/m2 . CONCLUSIONS: This study established a preliminary efficacy success threshold for rDBS to be cost-effective for severe obesity, and results from randomized controlled trials are needed. This analysis allows for interpretation of the economic impact of advancing rDBS for obesity in light of ongoing trial results and suggests an attainable threshold is needed for cost-effectiveness.