A Decade of Global Skull Base Researchers: Gender Data from over 2,700 Abstract Authors in the Journal of Neurological Surgery Part B: Skull Base.

Objective The North American Skull Base Society (NASBS) annual conference brings together skull base researchers from surgical and nonsurgical fields. Our objective was to quantify the contributions of the authors by gender, who presented their work at NASBS and were subsequently published in the Journal of Neurological Surgery Part B: Skull Base . Methods Oral and poster abstracts presented at the NASBS annual meeting from January 1, 2011 to December 31, 2020 were extracted from the Journal of Neurological Surgery Part B: Skull Base. The genderize.io Web application programming interface was utilized to determine authorship gender. A minority of first and last authors had departmental affiliations listed; a subgroup analysis was performed of these authors. Results Female gender was assigned to 498 (17.8%) of the 2,798 first authors and 269 (9.7%) of the 2,762 last authors. Female authorship has consistently increased over the last decade. Representation was higher in otolaryngology (23.3% of first authors, 12.1% of last authors; p = 0.018) than neurosurgery (13.5% of first authors, 4.3% of last authors; p = 0.004). Female researchers were not less likely than their male counterparts to receive prestigious oral presentations. Of the 52 total countries represented, 20 (38.5%) had at least one female first author. Representation varied dramatically between countries. Conclusion The NASBS' efforts have undoubtedly contributed to these impressive strides toward gender parity. More work is needed to ensure that the best and the brightest, regardless of background, continue to contribute to skull base surgery research.

A Decade of Global Skull Base Researchers: Authorship Trends from 3,295 Abstracts in the Journal of Neurological Surgery Part B: Skull Base.

Objective The North American Skull Base Society (NASBS) multidisciplinary annual conference hosts skull base researchers from across the globe. We hypothesized that the work presented at the NASBS annual conference would reveal diverse authorship teams in terms of specialty and geography. Methods In this retrospective review, abstracts presented at the NASBS annual meeting and subsequently published in the Journal of Neurological Surgery Part B: Skull Base between 01/01/2011 and 12/31/2020 were collected. Variables extracted included year, type of presentation, and author names and affiliations. Statistical analyses were performed with SPSS V23.0 with p -values less than 0.05 considered significant. Geographic heat maps were created to assess author distribution, and a network analysis was performed to display authorship collaboration between geographic regions. Results Of 3,312 published abstracts, 731 (22.1%) had an author with an affiliation outside of the United States. Fifty-seven distinct countries were represented. Three-hundred twenty-four abstracts (9.8%) had authorship teams representing at least 2 different countries. The top five US states by abstract representation were Pennsylvania, California, New York, Ohio, and Minnesota. A majority of authors reported neurosurgery affiliations (56.7% first authors, 53.2% last authors), closely followed by otolaryngology (39.1% first authors, 41.5% last authors). No solo authors and very few (3.3%) of the first authors reported a departmental affiliation outside of otolaryngology or neurosurgery. Conclusions Authors from many countries disseminate their work through poster and oral presentations at the NASBS annual meeting. Ten percent of abstracts were the product of international collaboration. Most authors were affiliated with a neurosurgery or otolaryngology department.

Reasons for use and experiences of using phenibut, a mixed methods analysis of online reports.

Background: Phenibut is a drug similar in structure to gabapentin and pregabalin. It is available online without prescription, often marketed as a dietary supplement or amino acid derivative. Little is known about phenibut use despite its increased popularity in the United States over the last decade.Objective: To clarify reasons for taking phenibut, circumstances, and effects of use.Methods: Reports of phenibut, gabapentin, and pregabalin use were downloaded from a publicly-available database, Erowid.org. A mixed methods approach utilizing qualitative content analysis was used.Results: Of 229 reports, 211 were from male authors. People usually purchased phenibut online and reportedly used it for recreation, to manage a medical or psychiatric problem (primarily insomnia, anxiety), as a substitute for other drugs (especially benzodiazepines), to manage withdrawal from another substance (including benzodiazepines, opioids), and/or for performance enhancement. While it shared many reported effects with pregabalin and gabapentin such as anxiolysis, increased talkativeness, and impaired motor coordination, reports of gastrointestinal distress and sedation were more commonly attributed to phenibut. Several people reported difficulty in restricting their use and managing withdrawal.Conclusions: Phenibut reports suggest that phenibut may have some benefits for some people. Use also, however, carries risks of adverse effects, a potentially dangerous withdrawal syndrome, and addiction. Not dissimilar to unprescribed gabapentin or pregabalin, self-medication is a common motive for phenibut use. Physicians should continue to ask their patients about use of any non-prescribed medications, dietary supplements, or "amino acid derivatives."Abbreviation: PWUPh: people who use phenibut; PWUG: people who use gabapentin; PWUPr: people who use pregabalin.

Neuro-oncology authorship trends in gender since 1944: a systematic review of 14,020 articles from five top-tier academic journals.

OBJECTIVE: This study was performed to compare authorship trends, by gender, in the neurosurgical oncology literature. METHODS: Complete author listings for neurosurgical oncology articles published between 1944 and 2021 in five top neuro-oncology journals were extracted from the PubMed database and journal websites on December 2, 2021. Author gender was characterized with the web application programming interface (API) genderize.io. The statistical significance (p < 0.05) of time-, journal-, and gender-based differences was determined by independent-samples t-test, chi-square test, and/or Fisher's exact test. RESULTS: A total of 14,020 articles were written by 67,115 unique authors occupying 97,418 authorship spots. The gender for 80,030 authorship positions (82.2%) was successfully characterized. Male authors were significantly more likely than the female authors to have a first-author publication, have a last-author publication, and have authored multiple articles within the data set. Among authors who published in multiple different years (n = 11,532), women had a shorter time window of publishing (5.46 vs 6.75 years between first and last publication: mean difference [MD] 1.28 [95% CI 1.06-1.50] years, p < 0.001). During this window, however, they were slightly more productive than the men, based on the mean number of publications per year (1.06 vs 1.01 articles: MD 0.05 [95% CI 0.02-0.09] articles, p = 0.002). The percentage of female authors on each neuro-oncology research team has increased by 3.3% (95% CI 2.6%-3.9%) per decade to a mean of 26.5% in the 2020s. Having a female last author was positively associated with having a female first author (OR 2.57 [95% CI 2.29-2.89]) and a higher proportion of women on the research team overall. The percentages of female first and last authors increased at significantly higher rates in medically oriented journals than in surgically oriented journals (first authors: 0.72% [95% CI 0.58%-0.87%] vs 0.36% [95% CI 0.30%-0.42%] per year, p < 0.001; and last authors: 0.50% [95% CI 0.38%-0.62%] vs -0.03% [95% CI -0.10% to 0.05%] per year, p < 0.001). CONCLUSIONS: Female authorship in top neuro-oncology journals has increased since the 1940s, with female-led teams showing greater gender diversity. However, female researchers lag behind their male counterparts in quantity of published research and are less likely to hold first or last authorship positions. This difference is more pronounced in the three neurosurgical oncology journals than in the two medical neuro-oncology journals, which may reflect the relatively low female representation in neurosurgery relative to medical oncology. Collectively, these trends have meaningful implications for career advancement, which is often dependent on academic productivity.

A Novel Interventional Approach to LV Pseudoaneurysm Compressing on LAD by Utilizing LAA Closure Device.

We describe the novel transcatheter approach, with off-label application of LAA closure device, coiling, and concurrent left anterior descending stenting in the setting of left ventricular (LV) pseudoaneurysm. This case underlines collaboration among interventional cardiology, cardiothoracic, and neurosurgery teams in a challenging, nonsurgical candidate with high risk of LV pseudoaneurysm rupture, and death. (Level of Difficulty: Advanced.).

National Rates, Reasons, and Risk Factors for 30- and 90-Day Readmission and Reoperation Among Patients Undergoing Anterior Cervical Discectomy and Fusion: An Analysis Using the Nationwide Readmissions Database.

STUDY DESIGN: Retrospective cohort study of the Nationwide Readmissions Database (NRD). OBJECTIVE: To determine causes of and independent risk factors for 30- and 90-day readmission in a cohort of anterior cervical discectomy and fusion (ACDF) patients. SUMMARY OF BACKGROUND DATA: Identifying populations at high-risk of 30-day readmission is a priority in healthcare reform so as to reduce cost and patient morbidity. However, among patients undergoing ACDF, nationally-representative data have been limited, and have seldom described 90-day readmissions, early reoperation, or socioeconomic influences. METHODS: We queried the NRD, which longitudinally tracks 49.3% of hospitalizations, for all adult patients undergoing ACDF. We calculated the rates of, and determined reasons for, readmission and reoperation at 30 and 90 days, and determined risk factors for readmission at each timepoint. RESULTS: We identified 50,126 patients between January and September 2014. Of these, 2294 (4.6%) and 4152 (8.3%) were readmitted within 30 and 90 days of discharge, respectively, and were most commonly readmitted for infections, medical complications, and dysphagia. The characteristics most strongly associated with readmission were Medicare or Medicaid insurance, length of stay greater than or equal to 4 days, three or more comorbidities, and non-routine discharge, whereas surgical factors (e.g., greater number of vertebrae fused) were more modest. By 30 and 90 days, 8.2% and 11.7% of readmitted patients underwent an additional spinal procedure, respectively. CONCLUSION: Our analysis uses the NRD to thoroughly characterize readmission in the general ACDF population. Readmissions are often delayed (after 30 days), strongly associated with insurance status, and many result in reoperation. Our results are crucial for risk-stratifying future ACDF patients and developing interventions to reduce readmission.Level of Evidence: 3.

Obstetrician-Gynecologists' Practices in Postpartum Sterilization Without a Valid Medicaid Consent Form.

OBJECTIVE: To explore the practices of obstetrician-gynecologists (ob-gyns) in the United States surrounding postpartum sterilization when the Medicaid consent form was not valid. METHODS: Using the American College of Obstetricians and Gynecologists' online directory, we conducted a qualitative study where we recruited ob-gyns practicing in 10 geographically diverse U.S. states for a qualitative study using semi-structured interviews conducted by telephone. We analyzed interview transcripts using the constant comparative method and principles of grounded theory. RESULTS: Thirty ob-gyns (63% women, 77% nonsubspecialized, and 53% academic setting) were interviewed. Although most physicians stated that they did not perform sterilizations without a valid Medicaid sterilization form, others noted that they sometimes did due to a sense of ethical obligation toward their patient's health, being in a role with more authority or seniority, interpreting the emergency justification section of the form more broadly, or backdating the form. The physicians who said that they never went ahead without a signed form tended to work at large institutions and were concerned with losing funding and engaging in potentially illegal or fraudulent behavior. CONCLUSION: Physicians' varied behaviors related to providing postpartum sterilization without a valid Medicaid consent form demonstrate that the policy is in need of revision. Unclear terminology and ramifications of the Medicaid sterilization policy need to be addressed to ensure equitable care.

Women neurosurgeons around the world: a systematic review.

OBJECTIVE: Gender disparities in neurosurgery have persisted even as the number of female medical students in many countries has risen. An understanding of the current gender distribution of neurosurgeons around the world and the possible factors contributing to country-specific gender disparities is an important step in improving gender equity in the field. METHODS: The authors performed a systematic review of studies pertaining to women in neurosurgery. Papers listed in PubMed in the English language were collected. A modified grounded theory approach was utilized to systematically identify and code factors noted to contribute to gender disparities in neurosurgery. Statistical analysis was performed with IBM SPSS Statistics for Windows. RESULTS: The authors identified 39 studies describing the density of women neurosurgeons in particular regions, 18 of which documented the proportion of practicing female neurosurgeons in a single or in multiple countries. The majority of these studies were published within the last 5 years. Eight factors contributing to gender disparity were identified, including conference representation, the proverbial glass ceiling, lifestyle, mentoring, discrimination, interest, salary, and physical burden. CONCLUSIONS: The topic of women in neurosurgery has received considerable global scholarly attention. The worldwide proportion of female neurosurgeons varies by region and country. Mentorship was the most frequently cited factor contributing to noted gender differences, with lifestyle, the glass ceiling, and discrimination also frequently mentioned. Future studies are necessary to assess the influence of country-specific sociopolitical factors that push and pull individuals of all backgrounds to enter this field.

Update on the global neurosurgery movement: A systematic review of international vernacular, research trends, and authorship.

In 2015, key global and neurosurgical organizations increased collaboration to improve neurosurgical care access, delivery, and outcomes, particularly in low- to middle-income countries (LMICs); sparking what has been termed the global neurosurgery movement. The authors sought to assess trends in usage of the term 'global neurosurgery' in academic literature with particular focus on author affiliations, world regions most frequently discussed, and topics of research performed. A PubMed search for articles indexed as 'global neurosurgery' was completed yielding 277 articles which met inclusion criteria. It was found that over time, use of the term 'global neurosurgery' has increased, with increasing growth notable starting in the year 2008 and continuing into October 2019. Statistical comparisons showed authors with affiliated global neurosurgery centers were more likely to publish studies related to the continent of Africa (47.4% vs 15.9%, p < 0.001), and less likely to focus on countries in Asia (2.6% vs 20.9%, p = 0.023). Use of the term 'global neurosurgery' in the article abstract/title/keywords was associated with focus on LMICs (18.6% vs. 5.1%, p = 0.006). Use of the term 'global neurosurgery' was associated with workforce and capacity as research topics (41.9% vs 22.6%, p = 0.036). While fairly new, the global neurosurgery movement has seen a rapid increase in publications utilizing the term 'global neurosurgery.' Articles frequently have focused on collaborative, targeted workforce capacity building in LMICs. We encourage the development of more global neurosurgery academic centers, especially in non-USA countries, to continue this momentum.

Attitudes and beliefs of obstetricians-gynecologists regarding Medicaid postpartum sterilization - A qualitative study.

OBJECTIVE: To explore the attitudes and beliefs of obstetrician-gynecologists in the United States (US) regarding the Medicaid postpartum sterilization policy. STUDY DESIGN: We recruited obstetrician-gynecologists practicing in ten geographically diverse US states for a qualitative study using the American College of Obstetricians and Gynecologists directory. We conducted semi-structured interviews via telephone, professionally transcribed, and analyzed using the constant comparative method and principles of grounded theory. RESULTS: We interviewed thirty obstetrician-gynecologists (63.3% women, 76.7% non-subspecialized, and 53.3% academic setting). Participants largely described the consent form as unnecessary, paternalistic, an administrative hassle, a barrier to desired patient care, and associated with worse health outcomes. Views on the waiting period's utility and impact were mixed. Many participants felt the sterilization policy was discriminatory. However, some participants noted the policy's importance in terms of the historical basis, used the form as a counseling tool to remind patients of the permanence of sterilization, felt the policy prompted them to counsel regarding sterilization, and protected patients in contemporary medical practice. CONCLUSION: Many physicians shared concerns about the ethics and clinical impact of the Medicaid sterilization policy. Future revisions to the Medicaid sterilization policy must balance prevention of coercion with reduction in barriers to those desiring sterilization in order to maximize reproductive autonomy. IMPLICATIONS: Obstetrician-gynecologists are key stakeholders of the Medicaid sterilization policy. Obstetrician-gynecologists largely believe that revision to the Medicaid sterilization policy is warranted to balance reduction of external barriers to desired care with a process that enforces the need for counseling regarding contraception and reviewing patient preference for sterilization throughout pregnancy in order to minimize regret.

Fellowship, gender, and scholarly productivity: trends among academic neurosurgeons in the US.

OBJECTIVE: Current data on fellowship choice and completion by neurosurgical residents are limited, especially in relation to gender, scholarly productivity, and career progression. The objective of this study was to determine gender differences in the selection of fellowship training and subsequent scholarly productivity and career progression. METHODS: The authors conducted a quantitative analysis of the fellowship training information of practicing US academic neurosurgeons. Information was extracted from publicly available websites, the Scopus database, and the Centers for Medicare and Medicaid Services Open Payments website. RESULTS: Of 1641 total academic neurosurgeons, 1403 (85.5%) were fellowship trained. There were disproportionately more men (89.9%) compared to women (10.1%). A higher proportion of women completed fellowships than men (p = 0.004). Proportionally, significantly more women completed fellowships in pediatrics (p < 0.0001), neurooncology (p = 0.012), and critical care/trauma (p = 0.001), while significantly more men completed a spine fellowship (p = 0.012). Within those who were fellowship trained, the academic rank of professor was significantly more commonly held by men (p = 0.001), but assistant professor was held significantly more often by women (p = 0.017). The fellowships with the largest mean h-indices were functional/stereotactic, pediatrics, and critical care/trauma. Despite more women completing neurooncology and pediatric fellowships, men had significantly greater h-indices in these subspecialties compared to women. Women had more industry funding awards than men in pediatrics (p < 0.0001), while men had more in spine (p = 0.023). CONCLUSIONS: Women were found to have higher rates for fellowship completion compared with their male counterparts, yet had lower scholarly productivity in every subspecialty. Fellowship choice remains unequally distributed between genders, and scholarly productivity and career progression varies between fellowship choice.

Health literacy among neurosurgery and other surgical subspecialties: Readability of online patient materials found with Google.

OBJECTIVE: To both determine whether the most high-yield online patient materials for surgical specialties meet the 6th grade readability level recommended by the National Institutes of Health (NIH) and American Medical Association (AMA), and to discover differences in readability across specialties. We hypothesize average readability scores will exceed an 11th grade level. METHODS: The top five most common procedures for each of seven surgical specialties (neurological, orthopedic, plastic, general, thoracic, pediatric, and vascular) were searched using an incognito Google query to minimize location bias. The text from the top five patient-relevant links per procedure, excluding Wikipedia, journal articles, and videos, was extracted and inserted into Readability Studio Software for analysis. RESULTS: The combined average grade level of materials (± standard deviation) was: 10.47 ±â€¯2.51 Flesh-Kincaid Grade Level (FKGL), 11-12 New Dale-Chall (NDC), 10.09 ±â€¯1.97 Simple Measure of Gobbledygook (SMOG), 12 Fry Graph (FG). Thoracic, neurologic, vascular, plastic, and orthopedic were least readable (grade level 10+ by all metrics). CONCLUSIONS: High readability of procedure materials for patients is not unique to neurosurgery: all specialties exceeded the recommended 6th grade level by three or more grades. Online patient education materials related to surgical subspecialties must be written more comprehensibly.

Paediatric deep brain stimulation: ethical considerations in malignant Tourette syndrome.

Gilles de la Tourette syndrome (TS) is a childhood neuropsychiatric disorder characterised by the presence of motor and vocal tics. Patients with malignant TS experience severe disease sequelae; risking morbidity and mortality due to tics, self-harm, psychiatric comorbidities and suicide. By definition, those cases termed 'malignant' are refractory to all conventional psychiatric and pharmacological regimens. In these instances, deep brain stimulation (DBS) may be efficacious. Current 2015 guidelines recommend a 6-month period absent of suicidal ideation before DBS is offered to patients with TS. We therefore wondered whether it may be ethically justifiable to offer DBS to a minor with malignant TS. We begin with a discussion of non-maleficence and beneficence. New evidence suggests that suicide risk in young patients with TS has been underestimated. In turn, DBS may represent an invaluable opportunity for children with malignant TS to secure future safety, independence and fulfilment. Postponing treatment is associated with additional risks. Ultimately, we assert this unique risk-benefit calculus justifies offering DBS to paediatric patients with malignant TS. A multidisciplinary team of clinicians must determine whether DBS is in the best interest of their individual patients. We conclude with a suggestion for future TS-DBS guidelines regarding suicidal ideation. The importance of informed consent and assent is underscored.

Encephalopathy of Unknown Origin in a Baclofen Patient: Case Report and Review of the Literature.

BACKGROUND: Encephalopathy is reported to have affected 250,000 people in the United States over the last decade, with considerable morbidity and mortality. Baclofen, a gamma-aminobutyric acid-B agonist that acts on the central nervous system, is the drug most widely used to treat spasticity. Baclofen overdose is a potentially deadly condition that can cause encephalopathy and can result from multiple etiologies. Renal disease can contribute to baclofen overdose and encephalopathy, and there are currently no dosing recommendations for patient's on baclofen with renal impairment. CASE DESCRIPTION: We report an unusual case of a man aged 35 years who presented with persistent fevers, seizures, and normal mentation. The patient presented with intrathecal baclofen use and prior exposure to West Nile Virus. He developed acute kidney injury at hospital secondary to vancomycin use, and mental status declined. CONCLUSIONS: This case highlights that patients with baclofen overdose can initially appear to have serious brain injury, however, full patient recovery can occur in <72 hours. This case provides additional insight into the guidelines for the treatment and management for unknown cause encephalopathy. This case also highlights the link between renal disease, baclofen, and encephalopathy through a review of the literature.

Aortic Paravalvular Leak Repair: Can TAVR Be the Answer?

A 71-year-old male with endocarditis mediated severe paravalvular leak and nonischemic cardiomyopathy underwent percutaneous repair attempts with a closure device followed by valve-in-valve transcatheter aortic replacement procedure. The case was complicated by cardiac arrest requiring hemodynamic support with Impella placement and secondary iatrogenic central aortic insufficiency requiring further intervention. (Level of Difficulty: Beginner.).

Quality of life outcomes in transcatheter aortic valve replacement patients requiring pacemaker implantation.

BACKGROUND: Permanent pacemaker implantation is the most common complication after Transcatheter aortic valve replacement (TAVR) and is associated with worse outcomes and mortality. However, its impact on quality-of-life (QoL) outcomes remains unknown. METHODS: We included 383 consecutive patients undergoing TAVR from January 2012 to 2016 who completed a baseline Kansas City Cardiomyopathy Questionnaire (KCCQ-12) health survey. The clinical, laboratory, angiographic, QoL, mortality, and occurrence of poor outcomes (KCCQ-12 score < 45 or KCCQ decrease of ≥10 points) were obtained. RESULTS: The mean age was 83 ± 8 years, 51% were men, and majority were Caucasians (n = 364, 95%). Permanent pacemaker (PPM) was implanted in 11.5% of patients post-TAVR. PPM patients were more likely to have prior conduction disease including RBBB (25% vs 12%, P = .02) and PQ interval >250 ms (11% vs 5%, P = .07). One-month median KCCQ-12 scores were significantly lower among PPM patients (84.7 vs 68.8, P = .04), but did not differ significantly at 1-year (86.5 vs 90.6, P = .5) post-TAVR. Occurrence of poor outcomes did not differ significantly among those with or without PPM at 1 month (11% vs 7%, P = .39) and 1 year (13% vs 9%, P = .45), respectively. However, patients with poor QoL outcomes at 1 month post-TAVR also had significantly worse mortality during follow-up in unadjusted (31.3% vs 4.5%, P < .001) and adjusted (HR = 5.30, 95% [CI: 1.85-15.22, P = .002])analyses, respectively. CONCLUSION: Permanent pacemaker implantation is associated with short-term reduction in QoL without long-term implications post-TAVR. Patients with poor QoL post-TAVR also have significantly higher mortality.

Consenting to invasive contraceptives: an ethical analysis of adolescent decision-making authority for long-acting reversible contraception.

Since USA constitutional precedent established in 1976, adolescents have increasingly been afforded the right to access contraception without first obtaining parental consent or authorisation. There is general agreement this ethically permissible. However, long-acting reversible contraception (LARC) methods have only recently been prescribed to the adolescent population. They are currently the most effective forms of contraception available and have high compliance and satisfaction rates. Yet unlike other contraceptives, LARCs are associated with special procedural risks because they must be inserted and removed by trained healthcare providers. It is unclear whether the unique invasive nature of LARC changes the traditional ethical calculus of permitting adolescent decision-making in the realm of contraception. To answer this question, we review the risk-benefit profile of adolescent LARC use. Traditional justifications for permitting adolescent contraception decision-making authority are then considered in the context of LARCs. Finally, analogous reasoning is used to evaluate potential differences between permitting adolescents to consent for LARC procedures versus for emergency and pregnancy termination procedures. Ultimately, we argue that the invasive nature of LARCs does not override adolescents' unique and compelling need for safe and effective forms of contraception. In fact, LARCs may oftentimes be in the best interest of adolescent patients who wish to prevent unintended pregnancy. We advocate for the specific enumeration of adolescents' ability to consent to both LARC insertion and removal procedures within state policies. Given the provider-dependent nature of LARCs and the stigma regarding adolescent sexuality, special political and procedural safeguards to protect adolescent autonomy are warranted.