Practice Patterns in Utilization of Atherectomy and Embolic Protection Devices in Inpatient and Outpatient Treatment Settings.

OBJECTIVES: The frequency of atherectomy in lower extremity arterial disease has increased substantially over the past several years, specifically in the office-based laboratory (OBL) setting, yet the efficacy compared to other interventions and the consequences of distal embolization remain unknown. Embolic Protection Devices (EPD) have been used at varying rates depending on physician and practice setting. Previous studies have described lesion characteristics to consider when weighing the benefits and drawbacks associated with device usage. Our study focuses on the use of atherectomy and EPD in femoropopliteal arterial disease to better characterize resource usage trends and postoperative outcomes in the inpatient and OBL interventional settings. METHODS: We conducted a retrospective analysis on endovascular interventions performed for femoral-popliteal occlusive disease that were entered into the Vascular Quality Initiative (VQI) data registry between 2017-2021. A 1:1 greedy-match, adjusted analysis based on inpatient or OBL location of procedure was utilized to compare the groups. Hierarchical logistical regression with selective use of principal component analysis was utilized to further explore the differences in EPD usage and immediate postoperative outcomes. A proportional hazard model was used to demonstrate differences in reintervention rates up to two years postoperatively between patients who underwent atherectomy in the inpatient vs OBL treatment setting. RESULTS: 2,849 matched pairs were included in the final analysis. In our cohort, there was 22% EPD usage overall, 40% in the hospital setting and 4.4% in the OBL setting (p<0.001). Among the patients with available follow-up information, OBL intervention setting increased probability of reintervention by 18% at 2 years postoperatively compared to the inpatient setting, however there was no difference associated with EPD placement and rate of reintervention. CONCLUSIONS: Use of EPD in the OBL setting compared to the hospital setting is dramatically decreased, however, no increased incidence of postoperative complications was seen compared to procedures performed in the hospital setting when controlling for patient and lesion characteristics. Patients with available follow-up data were more likely to undergo ipsilateral reintervention between 6 months and 2 years postoperatively if atherectomy was done in the OBL setting. Dedicated studies are encouraged to ensure patient safety, effective resource allocation, and long-term efficacy of OBL atherectomy as an ever-growing number of peripheral arterial procedures are transitioned to the OBL setting.

Impact of a Hands-on Pre-Clinical Neurosurgery Elective Course on Second-Year Medical Student Interest and Attitudes.

INTRODUCTION: Medical student involvement opportunities and educational experiences with surgical residents during medical school have been shown to increase the chance of students deciding to specialize in surgical specialties. This study aims to determine the effect of a neurosurgery elective during the second preclinical year on student interest and opinion of neurosurgery. METHODS: Thirty-nine students completed opinion-based surveys and factual knowledge quizzes during a neurosurgical elective course over 3 iterations, which included lecture and skills lab instruction. Pre- and post-course surveys used the Likert scale, with a score of 1 corresponding to the most negative opinion and a score of 10 corresponding to the most positive opinion, in order to measure various aspects including interest in neurological surgery, understanding of the field, and perception of female inclusion in the field. Weekly pre- and post-lecture quizzes assessed practical knowledge of neurosurgical topics. RESULTS: A higher percentage of students rated neurosurgery highly as a career possibility (⩾8/10 interest level) post-course (58.6%) compared to pre-course (45.7%). Post-course, students reported a significantly increased mean understanding of neurosurgery on the Likert scale compared to pre-course (6.1 ± 1.7 vs 4.4 ± 2.0; P = .001). Knowledge based-content assessment revealed a significant increase in overall correct answers after lectures (meanpre = 3.85, meanpost = 5.05, P = .001). Inclusion of female instructors in the second and third iteration of the course resulted in a significant increase in students' perception of female inclusion in the field of neurosurgery (7.6 compared to 5.6, P = .01). CONCLUSIONS: Early exposure to subspecialties may assist in making important career decisions. The implementation of this neurosurgical elective improved medical students' perception of the field and enhanced knowledge of the lectures and procedures. This study can be used as a framework for implementation of this curriculum at other institutions.

Complications After 3- and 4-Level Anterior Cervical Diskectomy and Fusion.

BACKGROUND: Anterior cervical diskectomy and fusion (ACDF) is a standard surgical procedure used widely in the treatment of degenerative cervical spine conditions. Although the safety and effectiveness of single-level ACDF is well supported in the literature, reports of multilevel ACDF are sparse and present mixed results. There is concern for greater complications with increasing levels of fusion given the increased complexity, procedure duration, and invasiveness of multilevel ACDF. METHODS: In this retrospective review, we report complications data for 105 adult neurosurgical patients who underwent elective multilevel ACDF at a single institution by a single surgeon between 2004 and 2016. RESULTS: Fifty-four patients underwent 3-level ACDF and 51 patients underwent 4-level ACDF with a mean follow-up of 2.7 ± 1.9 years. Although patients with 4-level fusion were more likely than those with 3-level fusion to have estimated blood loss ≥100 mL (P = 0.04), we found no significant differences in other peri- and postoperative complications, need for revision, and presence of symptoms at the time of last follow-up between groups. CONCLUSIONS: This study suggests that 4-level ACDF is not necessarily associated with a greater number of or more severe complications than 3-level ACDF.

Early Palliative Care for Patients With Brain Metastases Decreases Inpatient Admissions and Need for Imaging Studies.

BACKGROUND: Early encounters with palliative care (PC) can influence health-care utilization, clinical outcome, and cost. AIM: To study the effect of timing of PC encounters on brain metastasis patients at an academic medical center. SETTING/PARTICIPANTS: All patients diagnosed with brain metastases from January 2013 to August 2015 at a single institution with inpatient and/or outpatient PC records available for review (N = 145). DESIGN: Early PC was defined as having a PC encounter within 8 weeks of diagnosis with brain metastases; late PC was defined as having PC after 8 weeks of diagnosis. Propensity score matched cohorts of early (n = 46) and late (n = 46) PC patients were compared to control for differences in age, gender, and Karnofsky Performance Status (KPS) at diagnosis. Details of the palliative encounter, patient outcomes, and health-care utilization were collected. RESULTS: Early PC versus late PC patients had no differences in baseline KPS, age, or gender. Early PC patients had significantly fewer number of inpatient visits per patient (1.5 vs 2.9; P = .004), emergency department visits (1.2 vs 2.1; P = .006), positron emission tomography/computed tomography studies (1.2 vs 2.7, P = .005), magnetic resonance imaging scans (5.8 vs 8.1; P = .03), and radiosurgery procedures (0.6 vs 1.3; P < .001). There were no differences in overall survival (median 8.2 vs 11.2 months; P = .2). Following inpatient admissions, early PC patients were more likely to be discharged home (59% vs 35%; P = .04). CONCLUSIONS: Timely PC consultations are advisable in this patient population and can reduce health-care utilization.

Fostering Student Interest in Neurologic Surgery: The University of Pittsburgh Experience.

INTRODUCTION: Early involvement and research in neurosurgery can increase chances for medical students to matriculate successfully into residency. This study reports the creation of a Neurological Surgery Interest Group (NSIG) at the University of Pittsburgh School of Medicine and shares its activities over 2 academic years. METHODS: In October 2014, the University of Pittsburgh School of Medicine's NSIG was created to augment medical student interest in neurosurgery. The group consisted of 4 appointed officers for a membership base of 100 students. In June 2015, a neurosurgery resident and faculty member joined as mentors. A research committee of 14 medical students was created to conduct collaborative research projects with the department. In August of 2015 and 2016, surveys were sent out to the research committee regarding research productivity. RESULTS: The NSIG hosted 17 medical student-oriented events over 2 years, including didactic and suturing workshops, senior faculty panels, postmatch talks, and a neurosurgery networking dinner. A survey of students about scholarly achievement in neurosurgery reported 17 accepted publications in peer-reviewed journals with a mean impact factor of 3.5 ± 2.5. Ten abstracts were submitted to the 2015 and 2016 American Association of Neurological Surgeons Scientific Meetings, with a 100% acceptance rate. An increase in the number of students matching from our institution into neurosurgery residencies was observed following the group's inception. CONCLUSIONS: An NSIG can be mutually beneficial to both medical students and an institution's neurosurgical department. This study's findings may be applied to numerous specialties and across various academic institutions.

Differential patterns of amygdala and ventral striatum activation predict gender-specific changes in sexual risk behavior.

Although the initiation of sexual behavior is common among adolescents and young adults, some individuals express this behavior in a manner that significantly increases their risk for negative outcomes including sexually transmitted infections. Based on accumulating evidence, we have hypothesized that increased sexual risk behavior reflects, in part, an imbalance between neural circuits mediating approach and avoidance in particular as manifest by relatively increased ventral striatum (VS) activity and relatively decreased amygdala activity. Here, we test our hypothesis using data from seventy 18- to 22-year-old university students participating in the Duke Neurogenetics Study. We found a significant three-way interaction between amygdala activation, VS activation, and gender predicting changes in the number of sexual partners over time. Although relatively increased VS activation predicted greater increases in sexual partners for both men and women, the effect in men was contingent on the presence of relatively decreased amygdala activation and the effect in women was contingent on the presence of relatively increased amygdala activation. These findings suggest unique gender differences in how complex interactions between neural circuit function contributing to approach and avoidance may be expressed as sexual risk behavior in young adults. As such, our findings have the potential to inform the development of novel, gender-specific strategies that may be more effective at curtailing sexual risk behavior.