Factors affecting operating room scheduling accuracy for primary and revision total hip arthroplasty: a retrospective study.

INTRODUCTION: Optimizing operating room (OR) scheduling accuracy is important for OR efficiency, meeting patient expectations, and maximizing value for health systems. However, limited data exist on factors influencing the precision of Total Hip Arthroplasty (THA) OR scheduling. This study aims to identify the factors influencing the accuracy of OR scheduling for THA. METHODS: A retrospective review of 6,072 THA (5,579 primary THA and 493 revision THA) performed between January 2020 and May 2023 at an urban, academic institution was conducted. We collected baseline patient characteristics, surgeon years of experience, and compared actual wheels in to wheels out (WIWO) OR time against scheduled OR time. Significant scheduling inaccuracies were defined as actual OR times deviating by at least 15% from scheduled OR times. Logistic regression analyses were employed to assess the impact of patient, surgeon, and intraoperative factors on OR scheduling accuracy. RESULTS: Using adjusted odds ratios, primary THA patients who had a lower BMI and surgeons who had less than 10 years of experience were associated with overestimation of OR time. Whereas, higher BMI, younger age, general anesthesia, non-primary osteoarthritis indications, and afternoon procedure start times were linked to underestimation of OR time. For revision THA, lower BMI and fewer components revised correlated with overestimated OR time. Men, higher BMI, more components revised, septic indication for surgery, and morning procedure start times were associated with underestimation of OR time. CONCLUSION: This study highlights several critical patient, surgeon, and intraoperative factors influencing OR scheduling accuracy for THA. OR scheduling models should consider these factors to enhance OR efficiency.

Clinical outcomes of patellofemoral arthroplasty: robotic assistance produces superior short and mid-term outcomes.

INTRODUCTION: Patellofemoral arthroplasty (PFA) has been shown to provide symptomatic improvement for isolated patellofemoral osteoarthritis (PFOA). The efficacy of robotic-assisted PFA and the most suitable PFA implant design, however, remain ongoing matters of debate. This study sought to compare clinical outcomes between patients who underwent robotic-assisted versus conventional PFAs with inlay and onlay prosthetic designs. METHODS: A single-center retrospective review found 237 knees (211 patients) which underwent PFA between 2011 and 2021. One hundred eighty-four knees were included in the final analysis after cases were excluded for having indications other than osteoarthritis or having less than one year of follow-up. There were 90 conventional PFAs and 94 robotic-assisted PFAs performed. Inlay components were implanted in 89 knees and onlay components were implanted in 95 knees. Propensity score matching was utilized to address demographic differences between groups. RESULTS: Overall, there was a revision-free survivorship rate of 89.7% with an average time to follow-up of 4.6 years (range 1.2 to 11.1). Twenty-nine knees (15.8%) required various non-conversion procedures. The conventional matched cohort exhibited a higher all-cause revision rate, accounting for revision PFAs and conversions to TKA, (18.8 vs. 6.4%, p = 0.014) and a shorter mean time to revision than the robotic-assisted cohort (3.1 vs. 5.8 years, p = 0.026). A Kaplan-Meier survivorship curve showed differences between the conventional and robotics cohorts (p = 0.041). All revisions following robotic-assisted PFA were caused by progression of osteoarthritis, whereas conventional PFAs also required revision due to aseptic loosening and patellar maltracking. The rate of infection resulting in irrigation and debridement was higher for conventional cases (4.3 vs. 0%, p = 0.041). No significant differences in clinical outcomes between the inlay and onlay prosthetic design matched cohorts were identified. CONCLUSION: PFA is an effective treatment for addressing advanced patellofemoral arthritis. Robotic-assisted surgery may lead to improved clinical outcomes. LEVEL OF EVIDENCE: III.

Improvement in non-24-h sleep-wake rhythm disorder in a sighted individual treated with a melatonin receptor agonist.

Non-24-hour sleep-wake rhythm disorder (N24SWD) typically presents in patients with visual impairments that disrupt the ability to entrain to the 24 hour solar cycle. We discuss a 43 year old sighted man who presented with periodic daytime hypersomnia and nighttime insomnia, occasionally leading to <3 hours of sleep per day. Previous polysomnography showed an apnea hypopnea index of 6.2 events per hour. A sleep log of 3 months showed irregular time of sleep onset, and an average of 3 hours of sleep per day. Wrist actigraphy confirmed N24SWD. A trial of tasimelteon 20 mg/day resulting in improved daytime hypersomnia (pre-Epworth Sleepiness Scale (ESS) = 21/24, post-ESS = 5/24; a score of > 10/24 is considered sleepy). Follow-up actigraphy showed marked resolution of phase delay with an average of five hours of sleep. The case demonstrates that tasimelteon is a possible treatment for N24SWD in sighted individuals.

Activation of primate frontal eye fields with a CMUT phased array system.

BACKGROUND: There are pushes toward non-invasive stimulation of neural tissues to prevent issues that arise from invasive brain recordings and stimulation. Transcranial Focused Ultrasound (TFUS) has been examined as a way to stimulate non-invasively, but previous studies have limitations in the application of TFUS. As a result, refinement is needed to improve stimulation results. NEW METHOD: We utilized a custom-built capacitive micromachined ultrasonic transducer (CMUT) that would send ultrasonic waves through skin and skull to targets located in the Frontal Eye Fields (FEF) region triangulated from co-registered MRI and CT scans while a non-human primate subject was performing a discrimination behavioral task. RESULTS: We observed that the stimulation immediately caused changes in the local field potential (LFP) signal that continued until stimulation ended, at which point there was higher voltage upon the cue for the animal to saccade. This co-incided with increases in activity in the alpha band during stimulation. The activity rebounded mid-way through our electrode-shank, indicating a specific point of stimulation along the shank. We observed different LFP signals for different stimulation targets, indicating the ability to"steer" the stimulation through the transducer. We also observed a bias in first saccades towards the opposite direction. CONCLUSIONS: In conclusion, we provide a new approach for non-invasive stimulation during performance of a behavioral task. With the ability to steer stimulation patterns and target using a large amount of transducers, the ability to provide non-invasive stimulation will be greatly improved for future clinical and research applications.

Mechanical complications after total knee arthroplasty.

INTRODUCTION: With the increasing demand for total knee arthroplasty (TKA) and the burden of revision TKA on the healthcare system, as well as the quality of life implications for patients, it is extremely important for surgeons to be able to anticipate and prevent TKA mechanical complications. Surgeons must be familiar with the different causes and mechanisms of TKA complications so that they can properly treat patients with failed TKAs and better avoid these complications. AREAS COVERED: This review addresses TKA mechanical complications and provides context for the topic. A detailed review of surgical factors, implant factors, and patient factors that contribute to mechanical complications after TKA is provided. All of the literature cited in this review was gathered from the PubMed online database using different keywords based on the section of the manuscript. EXPERT OPINION: As surgeons and engineers solve certain issues in TKA, new challenges will inevitably arise. We must continue to push forward and innovate from both a surgical technique and implant design perspective.

Sleeping in Airports.

This essay describes the author's experience of sleeping in an airport because of an April blizzard.

Patterns of concomitant injury in thoracic spine fractures.

Background: Thoracic spine fractures (TSFs) are rarely isolated injuries, and they tend to present with a characteristic set of vertebral and non-vertebral injuries based on mechanism of injury. There is limited research on the rates and distribution of injuries that occur concurrently with TSFs. The purpose of this study is to characterize the distributions of these injuries by region of the body and by mechanisms of injury, so that trauma and spine surgeons can efficiently evaluate and treat patients presenting with TSFs. Methods: We retrospectively reviewed the trauma database records of 683 patients presenting with a TSFs at a single institution from 2015 to 2019. We recorded patient demographics, comorbidities, and associated injuries by body region. We characterized the TSFs using the AO classification system, as well as the presenting physical exam and treatment. All associated injuries among the TSF patients were classified into the following categories: head injury (HI), thoracic injury (TI), non-thoracic vertebral injury (NTVI), abdominal injury (AI), upper extremity injury (UEI), lower extremity injury (LEI), and spinal cord injury (SCI). Results: The three leading causes of TSFs were mechanical falls (38.4%), falls from height (24.9%), and motor vehicle crashes (MVCs) (23.4%). Patients with a TSF from MVC were statistically more likely to have concomitant injuries of TI, NTVI, AI, HI, UEI, and LEI. TSFs from fall from height were statistically more likely to have TI, NTVI, and LEI. TSFs from mechanical falls had significantly lower rates of all injury locations, but still presented with high rates of additional injury. TSFs from motorcycle crashes (MCCs) presented with TI, AI, UEI, and LEI. There were high rates of treatment for TSFs, with surgery ranging from 5.3% to 20.0% and bracing from 52.3% to 65.7% depending on mechanism of injury. Conclusions: TSFs after MVCs, mechanical falls, falls from height, and MCCs presented with a predictable pattern of injuries and were rarely an isolated injury. This cross-sectional data may help spine and trauma surgeons better understand patterns of injury associated with TSFs, with the hope of preventing missed injuries and better advising patients with TSFs on severity of injuries.

Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior Outcomes: A Systematic Review and Meta-analysis.

BACKGROUND: In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial. PURPOSE/HYPOTHESIS: We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure. STUDY DESIGN: Meta-analysis and systematic review; Level of evidence, 4. METHODS: A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms "hip,""arthroscopy,""capsule,""capsular,""repair," and "closure" were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living (ADL), and HOS-Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes. RESULTS: Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033). CONCLUSION: This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.

Causation and gravitation in George Cheyne's Newtonian natural philosophy.

This paper analyzes the metaphysical system developed in Cheyne's Philosophical Principles of Religion. Cheyne was an early proponent of Newtonianism and tackled several philosophical questions raised by Newton's work. The most pressing of these concerned the causal origin of gravitational attraction. Cheyne rejected the occasionalist explanations offered by several of his contemporaries in favor of a model on which God delegated special causal powers to bodies. Additionally, he developed an innovative approach to divine conservation. This allowed him to argue that Newton's findings provided evidence for God's existence and providence without the need for continuous divine intervention in the universe.

A comparison of postoperative pain between anterior cruciate ligament reconstruction and repair.

PURPOSE: To determine if patients who underwent ACL repair experienced less short-term postoperative pain versus patients who underwent ACL reconstruction. METHODS: Electronic charts were retrospectively reviewed of patients who underwent ACL surgery from November 2014 through April 2019 by a single surgeon. Patients were divided into two groups based on whether they underwent ACL repair or ACL reconstruction. A two-tailed equal variance t-test was used to evaluate visual analog scale (VAS) pain scores at the first postoperative visit. A chi-squared test of independence was used to evaluate narcotic prescription refills at the first postoperative visit. RESULTS: 36 ACL repair patients and 71 ACL reconstruction patients were included. The mean visual analog scale (VAS) pain score at the first postoperative visit (12.9 ± 3.7 days post-op) for ACL repair patients (2.81 ± 1.79) was significantly lower (p = .004) compared to ACL reconstruction patients (4.07 ± 2.26). The number of narcotic prescription refills at the first postoperative visit was significantly lower (p = .027, ARR = 21.4%, NNT = 4.67) in the ACL repair group (7 of 36, 19.4%) compared to the ACL reconstruction group (29 of 71, 40.8%). CONCLUSION: Patients who underwent ACL repair experienced less short-term postoperative pain and were prescribed fewer narcotics compared to patients who underwent ACL reconstruction.

Posterior Cruciate Ligament Repair With Suture Augmentation: A Report of Two Cases With Two-Year Follow-Up.

We present two cases of posterior cruciate ligament (PCL) repair with suture augmentation (SA) in the setting of multiligamentous knee injury (MLKI). Excellent clinical outcomes were obtained at two-year follow-up with both patients returning to sport following injury. Both patients demonstrated improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) that exceeded the minimal clinically important difference (MCID) as reported in the literature for ligamentous knee injuries. One patient developed arthrofibrosis, which was successfully treated with manipulation under anesthesia and arthroscopic lysis of adhesions two months postoperatively. Both patients had full knee range of motion (ROM) by a one-year follow-up. One patient returned to full preinjury level of sport at six months postoperatively while the other patient returned to 50% of preinjury intensity at two-year follow-up. This series of two cases of PCL repair with SA in MLKIs demonstrates that PCL repair with SA is a viable procedure that can result in excellent short-term outcomes and restore knee stability.

Mucosal integrin α4ß7 blockade fails to reduce the seeding and size of viral reservoirs in SIV-infected rhesus macaques.

Cellular viral reservoirs are rapidly established in tissues upon HIV-1/SIV infection, which persist throughout viral infection, even under long-term antiretroviral therapy (ART). Specific integrins are involved in the homing of cells to gut-associated lymphoid tissues (GALT) and inflamed tissues, which may promote the seeding and dissemination of HIV-1/SIV to these tissue sites. In this study, we investigated the efficacy of prophylactic integrin blockade (α4ß7 antibody or α4ß7/α4ß1 dual antagonist TR-14035) on viral infection, as well as dissemination and seeding of viral reservoirs in systemic and lymphoid compartments post-SIV inoculation. The results showed that blockade of α4ß7/α4ß1 did not decrease viral infection, replication, or reduce viral reservoir size in tissues of rhesus macaques after SIV infection, as indicated by equivalent levels of plasma viremia and cell-associated SIV RNA/DNA to controls. Surprisingly, TR-14035 administration in acute SIV infection resulted in consistently higher viremia and more rapid disease progression. These findings suggest that integrin blockade alone fails to effectively control viral infection, replication, dissemination, and reservoir establishment in HIV-1/SIV infection. The use of integrin blockade for prevention or/and therapeutic strategies requires further investigation.

Does the ACS NSQIP Surgical Risk Calculator Accurately Predict Complications Rates After Anterior Lumbar Interbody Fusion Procedures?

STUDY DESIGN: Clinical case series. OBJECTIVE: The aim of this study was to determine the effectiveness of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator in the prediction of complications after anterior lumbar interbody fusion (ALIF). SUMMARY OF BACKGROUND DATA: Identifying at-risk patients may aid in the prevention of complications after spine procedures. The ACS NSQIP surgical risk calculator was developed to predict 30-day postoperative complications for a variety of operative procedures. METHODS: Medical records of patients undergoing ALIF at our institution from 2009 to 2019 were retrospectively reviewed. Demographic and comorbidity variables were entered into the ACS NSQIP surgical risk calculator to generate percentage predictions for complication incidence within 30 days postoperatively. The observed incidences of these complications were also abstracted from the medical record. The predictive ability of the ACS NSQIP surgical risk calculator was assessed in comparison to the observed incidence of complications using area under the curve (AUC) analyses. RESULTS: Two hundred fifty-three (253) patients were analyzed. The ACS NSQIP surgical risk calculator was a fair predictor of discharge to non-home facility (AUC 0.71) and surgical site infection (AUC 0.70). The ACS NSQIP surgical risk calculator was a good predictor of acute kidney injury/progressive renal insufficiency (AUC 0.81). The ACS NSQIP surgical risk calculator was not an adequate predictive tool for any other category, including: pneumonia, urinary tract infections, venous thromboembolism, readmission, reoperations, and aggregate complications (AUC < 0.70). CONCLUSION: The ACS NSQIP surgical risk calculator is an adequate predictive tool for a subset of complications after ALIF including acute kidney injury/progressive renal insufficiency, surgical site infections, and discharge to non-home facilities. However, it is a poor predictor for all other complication groups. The reliability of the ACS NSQIP surgical risk calculator is limited, and further identification of models for risk stratification is necessary for patients undergoing ALIF.Level of Evidence: 3.

Instability and Uncertainty Are Critical for Psychotherapy: How the Therapeutic Alliance Opens Us Up.

Tschacher and Haken have recently applied a systems-based approach to modeling psychotherapy process in terms of potentially beneficial tendencies toward deterministic as well as chaotic forms of change in the client's behavioral, cognitive and affective experience during the course of therapy. A chaotic change process refers to a greater exploration of the states that a client can be in, and it may have a potential positive role to play in their development. A distinction is made between on the one hand, specific instances of instability which are due to techniques employed by the therapist, and on the other, a more general instability which is due to the therapeutic relationship, and a key, necessary result of a successful therapeutic alliance. Drawing on Friston's systems-based model of free energy minimization and predictive coding, it is proposed here that the increase in the instability of a client's functioning due to therapy can be conceptualized as a reduction in the precisions (certainty) with which the client's prior beliefs about themselves and their world, are held. It is shown how a good therapeutic alliance (characterized by successful interpersonal synchrony of the sort described by Friston and Frith) results in the emergence of a new hierarchical level in the client's generative model of themselves and their relationship with the world. The emergence of this new level of functioning permits the reduction of the precisions of the client's priors, which allows the client to 'open up': to experience thoughts, emotions and experiences they did not have before. It is proposed that this process is a necessary precursor to change due to psychotherapy. A good consilience can be found between this approach to understanding the role of the therapeutic alliance, and the role of epistemic trust in psychotherapy as described by Fonagy and Allison. It is suggested that beneficial forms of instability in clients are an underappreciated influence on psychotherapy process, and thoughts about the implications, as well as situations in which instability may not be beneficial (or potentially harmful) for therapy, are considered.

Intrathecal 99mTc-DTPA imaging of molecular passage from lumbar cerebrospinal fluid to brain and periphery in humans.

INTRODUCTION: Cerebrospinal fluid (CSF) molecular exchange with brain interstitial fluid (ISF) and periphery is implicated in neurological disorders but needs better quantitative clinical assessment approaches. METHODS: Following intrathecal (ITH) dosing via lumbar puncture, Technetium-99 m (99mTc-) diethylenetriaminepentaacetic acid (DTPA) imaging was used to quantify neuraxial spread, CSF-brain molecular exchange, and CSF-peripheral clearance in 15 normal human volunteers. The effect of experimental convection manipulation on these processes was also assessed. RESULTS: Rostral cranial 99mTc-DTPA exposures were influenced by the volume of artificial CSF in the formulation. Signal translocation to the cranial cisterns and the brain parenchyma was observable by 3 hours. 99mTc-DTPA penetrated cortical ISF but showed lower signal in deeper structures. Urinary 99mTc-DTPA signal elimination was accelerated by higher formulation volumes and mechanical convection. DISCUSSION: Widely used for detecting CSF leaks, ITH 99mTc-DTPA imaging can also become a useful clinical biomarker for measuring molecular exchange physiology between the CSF, brain, and periphery.

Cell-Cycle Cross Talk with Caspases and Their Substrates.

Caspases play central roles in mediating both cell death and inflammation. It has more recently become evident that caspases also drive other biological processes. Most prominently, caspases have been shown to be involved in differentiation. Several stem and progenitor cell types rely on caspases to initiate and execute their differentiation processes. These range from neural and glial cells, to skeletal myoblasts and osteoblasts, and several cell types of the hematopoietic system. Beyond differentiation, caspases have also been shown to play roles in other "noncanonical" processes, including cell proliferation, arrest, and senescence, thereby contributing to the mechanisms that regulate tissue homeostasis at multiple levels. Remarkably, caspases directly influence the course of the cell cycle in both a positive and negative manner. Caspases both cleave elements of the cell-cycle machinery and are themselves substrates of cell-cycle kinases. Here we aim to summarize the breadth of interactions between caspases and cell-cycle regulators. We also highlight recent developments in this area.

The Gravity of Objects: How Affectively Organized Generative Models Influence Perception and Social Behavior.

Friston's (2010) free energy principle (FEP) offers an opportunity to rethink what is meant by the psychoanalytic concept of an object or discrete mental representation (Ogden, 1992). The significance of such objects in psychoanalysis is that they may be superimposed on current experience so that perceptions are partly composed of projected fantasy and partly of more realistic perception. From a free energy perspective, the psychoanalytic (person) object may be understood as a bounded set of prior beliefs about a "platonic" sort of person that provides a free energy minimizing, evidence maximizing, hypothesis to explain inference about - or dyadic interactions with - another. The degree to which realistic perception supervenes - relative to a platonic person object - will depend upon the precision assigned to the sensory evidence (concerning the person) relative to the prior beliefs about a platonic form. This provides a basis for not only explaining projection and transference phenomena but also conceptualizing a central assumption within the object relations psychoanalysis. As an example, the paper examines the Kleinian theory of split good or bad part objects as affectively organized generative models (or platonic part-object models) formed in early infancy. This also provides a basis for building on work by Kernberg (1984, 1996) by conceptualizing the role of the part object(s) in a continuum of reality testing, from mild errors in perception that are relatively easily corrected, through borderline affective instability and frequent shifts between part-object experience, to psychotic failures of reality testing, where Friston et al. (2016) proposed that aberrant precisions bias perception to high precision false beliefs (here cast as platonic part objects), such as stable perceptions of others (and possibly oneself) as persecutory agents of some sort. The paper demonstrates the value that the history of clinical insights into psychoanalysis (including object relations) and a system-based approach to the brain (including the free energy principle) can have for one another. This is offered as a demonstration of the potential value of an "Integrative Clinical Systems Psychology" proposed by Tretter and Lo¨ffler-Stastka (2018), which has the potential to integrate the major theoretical frameworks in the field today.

Uncertainty-based modulation for lifelong learning.

The creation of machine learning algorithms for intelligent agents capable of continuous, lifelong learning is a critical objective for algorithms being deployed on real-life systems in dynamic environments. Here we present an algorithm inspired by neuromodulatory mechanisms in the human brain that integrates and expands upon Stephen Grossberg's ground-breaking Adaptive Resonance Theory proposals. Specifically, it builds on the concept of uncertainty, and employs a series of "neuromodulatory" mechanisms to enable continuous learning, including self-supervised and one-shot learning. Algorithm components were evaluated in a series of benchmark experiments that demonstrate stable learning without catastrophic forgetting. We also demonstrate the critical role of developing these systems in a closed-loop manner where the environment and the agent's behaviors constrain and guide the learning process. To this end, we integrated the algorithm into an embodied simulated drone agent. The experiments show that the algorithm is capable of continuous learning of new tasks and under changed conditions with high classification accuracy (>94%) in a virtual environment, without catastrophic forgetting. The algorithm accepts high dimensional inputs from any state-of-the-art detection and feature extraction algorithms, making it a flexible addition to existing systems. We also describe future development efforts focused on imbuing the algorithm with mechanisms to seek out new knowledge as well as employ a broader range of neuromodulatory processes.

Assessing variability in surgical decision making among attending neurosurgeons at an academic center.

OBJECTIVE: Although it is known that intersurgeon variability in offering elective surgery can have major consequences for patient morbidity and healthcare spending, data addressing variability within neurosurgery are scarce. The authors performed a prospective peer review study of randomly selected neurosurgery cases in order to assess the extent of consensus regarding the decision to offer elective surgery among attending neurosurgeons across one large academic institution. METHODS: All consecutive patients who had undergone standard inpatient surgical interventions of 1 of 4 types (craniotomy for tumor [CFT], nonacute redo CFT, first-time spine surgery with/without instrumentation, and nonacute redo spine surgery with/without instrumentation) during the period 2015-2017 were retrospectively enrolled (n = 9156 patient surgeries, n = 80 randomly selected individual cases, n = 20 index cases of each type randomly selected for review). The selected cases were scored by attending neurosurgeons using a need for surgery (NFS) score based on clinical data (patient demographics, preoperative notes, radiology reports, and operative notes; n = 616 independent case reviews). Attending neurosurgeon reviewers were blinded as to performing provider and surgical outcome. Aggregate NFS scores across various categories were measured. The authors employed a repeated-measures mixed ANOVA model with autoregressive variance structure to compute omnibus statistical tests across the various surgery types. Interrater reliability (IRR) was measured using Cohen's kappa based on binary NFS scores. RESULTS: Overall, the authors found that most of the neurosurgical procedures studied were rated as "indicated" by blinded attending neurosurgeons (mean NFS = 88.3, all p values < 0.001) with greater agreement among neurosurgeon raters than expected by chance (IRR = 81.78%, p = 0.016). Redo surgery had lower NFS scores and IRR scores than first-time surgery, both for craniotomy and spine surgery (ANOVA, all p values < 0.01). Spine surgeries with fusion had lower NFS scores than spine surgeries without fusion procedures (p < 0.01). CONCLUSIONS: There was general agreement among neurosurgeons in terms of indication for surgery; however, revision surgery of all types and spine surgery with fusion procedures had the lowest amount of decision consensus. These results should guide efforts aimed at reducing unnecessary variability in surgical practice with the goal of effective allocation of healthcare resources to advance the value paradigm in neurosurgery.