The Western giants of the neuroanatomical past: an ode to yesterday. Part II.

"The history of the world is the biography of the great man. And I said: the great man always acts like a thunder. He storms the skies, while others are waiting to be stormed," said Thomas Carlyle. In this historical vignette, we study the contribution to neuroanatomy, of greats from the past. What led them to find the basis of topography and anatomical localization? How did they unravel the pathways of cerebrospinal fluid and cortical structure of the human brain? To understand this, we study the paths of Pierre Paul Broca, Richard L. Heschl, Hubert von Luschka, Carl Wernicke, Hans Chiari, Ludwig Edinger, and Carl Westphal, Korbinian Brodmann, and Walter Dandy.

State-to-State Variation in Medicaid Reimbursement for Neurosurgical Procedures: Implications for Healthcare Access in Vulnerable Populations.

BACKGROUND AND OBJECTIVES: Medicaid payment for healthcare services traditionally reimburses less than Medicare and commercial insurance. This disparity in reimbursement seems to be an important driver of limited access to care among Medicaid beneficiaries. This study seeks to examine the degree of variation in Medicaid and Medicare reimbursement for the most common neurosurgical current procedural terminology codes and determine its potential impact on provider accessibility. METHODS: In this cross-sectional study, maximum allowed physician reimbursement fees for 20 common neurosurgical codes reported in the literature were obtained from the 2022 Medicare Physician Fee Schedule and individual state Medicaid Fee-for-Service Schedules. The Medicaid-Medicare Index (MMI), which measures Medicaid reimbursement as a fraction of Medicare allowed amounts, was calculated for each procedure across 49 states and the District of Columbia. Lower MMI indicates a greater disparity, or "discount," between Medicaid and Medicare reimbursement. The proportion of providers accepting new Medicaid patients and total Medicaid enrollment were compared across states as a function of MMI. RESULTS: The average national MMI was 0.79, with a range of 0.37 in NY/NJ to 1.43 in NE. Maximum allowed amounts for Medicare reimbursement (coefficient of variation = 0.09) were less variable than those for Medicaid (coefficient of variation = 0.26, P < .01). The largest absolute disparity was observed for intracranial aneurysm clipping in NY, where the maximum Medicaid reimbursement is $3496.52 less than that of Medicare. Higher MMI was associated with a significantly larger proportion of providers accepting new Medicaid patients (R2 = 0.43, P < .01). Moreover, MMI varied inversely with the number of Medicaid beneficiaries (R2 = 0.12, P = .01). CONCLUSION: Medicaid reimbursement varies between states reflecting the disparate methods of fee schedule calculation. Lower reimbursement is associated with more limited provider enrollment, especially in states with a greater number of beneficiaries.

The western giants of neuroanatomical past: an ode to yesterday - Part I.

"The only history is a mere question of one's struggle inside oneself. But that is the joy of it. One need neither discover Americas nor conquer nations, and yet one has as great a work as Columbus or Alexander to do," said David H. Lawrence. In this historical vignette, we look at the lives of certain western giants of neuroanatomy from the past. To understand the origin of today's advancements and successes in neurosurgery, a strong foothold on the path taken by anatomical greats is necessary. What curiosity inspired them to search the meaning of the human nervous system? Learning this from the paths of Herophilus, Galen, Franciscus Sylvius, Thomas Willis, Alexander Monro secundus, Luigi Rolando, François Magendie, and Martin Rathke, will propel us to create a better future for our successors.

Evaluating academic productivity and match outcomes in neurosurgery residents from medical schools without a neurosurgery residency program: a 2016-2022 bibliometric analysis.

OBJECTIVE: Transition of the United States Medical Licensing Examination Step 1 to a pass/fail structure has focused attention on medical student research in residency application. Previous studies have explored how various factors affect the neurosurgery match success, but none have focused on applicants from schools without a neurosurgery residency program. METHODS: The authors compiled a list of neurosurgery residents matched from 2016 to 2022 from schools lacking a neurosurgery program. They gathered demographic and bibliometric data, focusing on academic productivity before residency. The distinction between the top 40 and non-top 40 programs used the 5-year institutional h-index (ih[5]-index) of departments. RESULTS: Between 2016 and 2022, the gross number of students entering neurosurgery from schools without a home program rose from 15 to 26 in 2021, declining to 23 in 2022. The range of matched applicants per school was 0 to 10. The median number of publications per resident increased from 2 in 2016 to 5 in 2022 (p < 0.001). The lowest and highest numbers of publications by applicants were 0 and 40, respectively, with 22.5% reporting no publications. The lowest and highest h-indices by applicants were 0 and 11, respectively, with nearly one-third (31.2%) possessing an h-index of 0. Applicants from schools lacking a neurosurgery residency program who matched into top 40 programs had a publication range of 0-11, with a higher median of 3 compared with those who did not (median 2, range 0-8). While no significant differences were found in publication numbers (p = 0.084), a difference in h-index was observed (p = 0.024) between the two groups. Publications significantly correlated with the h-index, with each additional publication increasing the h-index by 0.19 (p < 0.001, adjusted R2 = 0.3348). CONCLUSIONS: Median publication counts have increased in this cohort, but they do not distinguish top 40 program matches. Conversely, the h-index, correlating with publication quantity and journal impact factor, does.

The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial.

BACKGROUND: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(ß -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE: IV.