Publications by authors named "Debraj Mukherjee"

134 Publications

In Reply: Predictors of Academic Neurosurgical Career Trajectory Among International Medical Graduates Training Within the United States.

Neurosurgery 2021 Aug 25. Epub 2021 Aug 25.

Department of Neurosurgery Johns Hopkins University School of Medicine Baltimore, Maryland, USA.

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http://dx.doi.org/10.1093/neuros/nyab332DOI Listing
August 2021

Adapting the 5-factor modified frailty index for prediction of postprocedural outcome in patients with unruptured aneurysms.

J Neurosurg 2021 Aug 13:1-8. Epub 2021 Aug 13.

Objective: The 5-factor modified frailty index (mFI-5) is a practical tool that can be used to estimate frailty by measuring five accessible factors: functional status, history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. The authors aimed to validate the utility of mFI-5 for predicting endovascular and microsurgical treatment outcomes in patients with unruptured aneurysms.

Methods: A prospectively maintained database of consecutive patients with unruptured aneurysm who were treated with clip placement or endovascular therapy was used. Because patient age is an important predictor of treatment outcomes in patients with unruptured aneurysm, mFI-5 was supplemented with age to create the age-supplemented mFI-5 (AmFI-5). Associations of scores on these indices with major complications (symptomatic ischemic or hemorrhagic stroke, pulmonary embolism, pneumonia, or surgical site infection requiring reoperation) were evaluated. Validation was carried out with the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2006-2017).

Results: The institutional database included 275 patients (88 underwent clip placement, and 187 underwent endovascular treatment). Multivariable analysis of the surgical cohort showed that major complication was significantly associated with mFI-5 (OR 2.0, p = 0.046) and AmFI-5 (OR 1.9, p = 0.028) scores. Significant predictive accuracy for major complications was provided by mFI-5 (c-statistic = 0.709, p = 0.011) and AmFI-5 (c-statistic = 0.720, p = 0.008). The American Society of Anesthesiologists Physical Status Classification System (ASA) provided poor discrimination (area under the curve = 0.541, p = 0.618) that was significantly less than that of mFI-5 (p = 0.023) and AmFI-5 (p = 0.014). Optimal relative fit was achieved with AmFI-5, which had the lowest Akaike information criterion value. Similar results were obtained after equivalent analysis of the endovascular cohort, with additional significant associations between index scores and length of stay (β = 0.6 and p = 0.009 for mFI-5; β = 0.5 and p = 0.003 for AmFI-5). In 1047 patients who underwent clip placement and were included in the NSQIP database, mFI-5 (p = 0.001) and AmFI-5 (p < 0.001) scores were significantly associated with severe postoperative adverse events and provided greater discrimination (c-statistic = 0.600 and p < 0.001 for mFI-5; c-statistic = 0.610 and p < 0.001 for AmFI-5) than ASA score (c-statistic = 0.580 and p = 0.003).

Conclusions: mFI-5 and AmFI-5 represent potential predictors of procedure-related complications in unruptured aneurysm patients. After further validation, integration of these tools into clinical workflows may optimize patients for intervention.
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http://dx.doi.org/10.3171/2021.2.JNS204420DOI Listing
August 2021

Perceptions of the Virtual Neurosurgery Application Cycle During the Coronavirus Disease 2019 (COVID-19) Pandemic: A Program Director Survey.

World Neurosurg 2021 Aug 4. Epub 2021 Aug 4.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Objective: The novel coronavirus disease 2019 (COVID-19) pandemic has led to a shift to virtual residency interviews for the 2020-2021 neurosurgery match, with unknown implications for stakeholders. This study seeks to analyze the perceptions of residency program directors (PDs) and associate program directors (APDs) regarding the current virtual format used for residency selection and interviews.

Methods: An anonymous, 30-question survey was constructed and sent to 115 neurosurgery PDs and 26 APDs to assess respondent demographics, factors used to review applicants, perceptions of applicants and applicant engagement, perceptions of standardized letters and interview questions, the effect of the virtual interview format on various stakeholders, and the future outlook for the virtual residency interview format.

Results: A total of 38 PDs and APDs completed this survey, constituting a response rate of 27.0%. Survey respondents received significantly more Electronic Residency Application Service applications in the 2020-2021 cycle compared with the 2019-2020 cycle (P = 0.0029). Subinternship performance by home-rotators, (26.3%), letters of recommendation (23.7%), and Step 1 score (18.4%) were ranked as the most important factors for evaluating candidates during the current virtual application cycle.

Conclusions: Our study highlights that applicants applied to a greater number of residency programs compared with years prior, that the criteria used by PDs/APDs to evaluate applicants remained largely consistent compared to previous years, and that the virtual residency interview format may disproportionately disadvantage Doctor of Osteopathic medicine and international medical graduate applicants. Further exploring attitudes toward signaling mechanisms and standardized letters may serve to inform changes to future neurosurgery match cycles.
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http://dx.doi.org/10.1016/j.wneu.2021.07.078DOI Listing
August 2021

Launching the Quality Outcomes Database Tumor Registry: rationale, development, and pilot data.

J Neurosurg 2021 Aug 6:1-10. Epub 2021 Aug 6.

4Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.

Objective: Neurosurgeons generate an enormous amount of data daily. Within these data lie rigorous, valid, and reproducible evidence. Such evidence can facilitate healthcare reform and improve quality of care. To measure the quality of care provided objectively, evaluating the safety and efficacy of clinical activities should occur in real time. Registries must be constructed and collected data analyzed with the precision akin to that of randomized clinical trials to accomplish this goal.

Methods: The Quality Outcomes Database (QOD) Tumor Registry was launched in February 2019 with 8 sites in its initial 1-year pilot phase. The Tumor Registry was proposed by the AANS/CNS Tumor Section and approved by the QOD Scientific Committee in the fall of 2018. The initial pilot phase aimed to assess the feasibility of collecting outcomes data from 8 academic practices across the United States; these outcomes included length of stay, discharge disposition, and inpatient complications.

Results: As of November 2019, 923 eligible patients have been entered, with the following subsets: intracranial metastasis (17.3%, n = 160), high-grade glioma (18.5%, n = 171), low-grade glioma (6%, n = 55), meningioma (20%, n = 184), pituitary tumor (14.3%, n = 132), and other intracranial tumor (24%, n = 221).

Conclusions: The authors have demonstrated here, as a pilot study, the feasibility of documenting demographic, clinical, operative, and patient-reported outcome characteristics longitudinally for 6 common intracranial tumor types.
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http://dx.doi.org/10.3171/2021.1.JNS201115DOI Listing
August 2021

A Crowdsourced Consensus on Supratotal Resection Versus Gross Total Resection for Anatomically Distinct Primary Glioblastoma.

Neurosurgery 2021 Sep;89(4):712-719

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: Gross total resection (GTR) of contrast-enhancing tumor is associated with increased survival in primary glioblastoma. Recently, there has been increasing interest in performing supratotal resections (SpTRs) for glioblastoma.

Objective: To address the published results, which have varied in part due to lack of consensus on the definition and appropriate use of SpTR.

Methods: A crowdsourcing approach was used to survey 21 neurosurgical oncologists representing 14 health systems nationwide. Participants were presented with 11 definitions of SpTR and asked to rate the appropriateness of each definition. Participants reviewed T1-weighed postcontrast and fluid-attenuated inversion-recovery magnetic resonance imaging for 22 anatomically distinct glioblastomas. Participants were asked to assess the tumor location's eloquence, the perceived equipoise of enrolling patients in a randomized trial comparing gross total to SpTR, and their personal treatment plans.

Results: Most neurosurgeons surveyed (n = 18, 85.7%) agree that GTR plus resection of some noncontrast enhancement is an appropriate definition for SpTR. Overall, moderate inter-rater agreement existed regarding eloquence, equipoise, and personal treatment plans. The 4 neurosurgeons who had performed >10 SpTRs for glioblastomas in the past year were more likely to recommend it as their treatment plan (P < .005). Cases were divided into 3 anatomically distinct groups based upon perceived eloquence. Anterior temporal and right frontal glioblastomas were considered the best randomization candidates.

Conclusion: We established a consensus definition for SpTR of glioblastoma and identified anatomically distinct locations deemed most amenable to SpTR. These results may be used to plan prospective trials investigating the potential clinical utility of SpTR for glioblastoma.
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http://dx.doi.org/10.1093/neuros/nyab257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8440068PMC
September 2021

Impact of international research fellows in neurosurgery: results from a single academic center.

J Neurosurg 2021 Jul 23:1-11. Epub 2021 Jul 23.

Objective: International research fellows have been historically involved in academic neurosurgery in the United States (US). To date, the contribution of international research fellows has been underreported. Herein, the authors aimed to quantify the academic output of international research fellows in the Department of Neurosurgery at The Johns Hopkins University School of Medicine.

Methods: Research fellows with Doctor of Medicine (MD), Doctor of Philosophy (PhD), or MD/PhD degrees from a non-US institution who worked in the Hopkins Department of Neurosurgery for at least 6 months over the past decade (2010-2020) were included in this study. Publications produced during fellowship, number of citations, and journal impact factors (IFs) were analyzed using ANOVA. A survey was sent to collect information on personal background, demographics, and academic activities.

Results: Sixty-four international research fellows were included, with 42 (65.6%) having MD degrees, 17 (26.6%) having PhD degrees, and 5 (7.8%) having MD/PhD degrees. During an average 27.9 months of fellowship, 460 publications were produced in 136 unique journals, with 8628 citations and a cumulative journal IF of 1665.73. There was no significant difference in total number of publications, first-author publications, and total citations per person among the different degree holders. Persons holding MD/PhDs had a higher number of citations per publication per person (p = 0.027), whereas those with MDs had higher total IFs per person (p = 0.048). Among the 43 (67.2%) survey responders, 34 (79.1%) had nonimmigrant visas at the start of the fellowship, 16 (37.2%) were self-paid or funded by their country of origin, and 35 (81.4%) had mentored at least one US medical student, nonmedical graduate student, or undergraduate student.

Conclusions: International research fellows at the authors' institution have contributed significantly to academic neurosurgery. Although they have faced major challenges like maintaining nonimmigrant visas, negotiating cultural/language differences, and managing self-sustainability, their scientific productivity has been substantial. Additionally, the majority of fellows have provided reciprocal mentorship to US students.
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http://dx.doi.org/10.3171/2021.1.JNS203824DOI Listing
July 2021

Patient-Specific Factors Drive Intensive Care Unit and Total Hospital Length of Stay in Operative Patients with Brain Tumor.

World Neurosurg 2021 Sep 2;153:e338-e348. Epub 2021 Jul 2.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Background: Hospital length of stay (LOS) is an important cost driver in neurosurgery. Broader surgical literature has shown that patient-related factors, including comorbidities, and procedure-related factors, such surgeon experience, may be associated with LOS. Because value optimization strategies may be targeted toward either domain, this study investigated the contributions of patient-related and procedure-related factors in predicting prolonged intensive care unit LOS (iLOS) and total hospital LOS (tLOS).

Methods: Data for adult patients undergoing brain tumor surgery (2017-2019) were collected. Bivariate analyses for iLOS and tLOS were performed using the Mann-Whitney U test and Fisher exact test. Variables associated with either outcome with P < 0.10 were included in patient-only, procedure-only, and patient+procedure factor multivariate linear regression models. Model discrimination was quantified using C-statistics.

Results: Our 654 patients had a mean age of 57.54 years (standard deviation, ± 14.34 years). For iLOS, the patient-only model significantly outperformed the procedure-only model (P < 0.0001) and performed similarly to the patient+procedure model (P = 0.50). Other than tumor diagnosis, 5-Factor Modified Frailty Index score was the only factor associated with iLOS (P < 0.001) and tLOS (P < 0.001) on multivariate analysis. When predicting prolonged tLOS, the patient-only model significantly outperformed the procedure-only model (P < 0.0001), and performed similarly to patient+procedure models (P = 0.49).

Conclusions: Patient-specific factors are the main drivers of prolonged iLOS and tLOS among patients with brain tumor. Frailty was significantly associated with both iLOS and tLOS on multivariate analysis. Efforts to improve care value should focus on strategies to optimize patient status, such as prehabilitation and enhanced recovery after surgery.
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http://dx.doi.org/10.1016/j.wneu.2021.06.114DOI Listing
September 2021

Tranexamic acid for subarachnoid haemorrhage.

Lancet 2021 07;398(10294):25

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(21)00573-0DOI Listing
July 2021

A novel radiographic marker of sarcopenia with prognostic value in glioblastoma.

Clin Neurol Neurosurg 2021 08 24;207:106782. Epub 2021 Jun 24.

Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA. Electronic address:

Objective: Sarcopenia is an important prognostic consideration in surgical oncology that has received relatively little attention in brain tumor patients. Temporal muscle thickness (TMT) has recently been proposed as a novel radiographic marker of sarcopenia that can be efficiently obtained within existing workflows. We investigated the prognostic value of TMT in primary and progressive glioblastoma.

Methods: TMT measurements were performed on magnetic resonance images of 384 patients undergoing 541 surgeries for glioblastoma. Relationships between TMT and clinical characteristics were examined on bivariate analysis. Optimal TMT cutpoints were established using maximally selected rank statistics. Predictive value of TMT upon postoperative survival (PS) was assessed using Cox proportional hazards regression adjusted for age, sex, Karnofsky performance status (KPS), Stupp protocol completion, extent of resection, and tumor molecular markers.

Results: Average TMT for the primary and progressive glioblastoma cohorts was 9.55 mm and 9.40 mm, respectively. TMT was associated with age (r = -0.14, p = 0.0008), BMI (r = 0.29, p < 0.0001), albumin (r = 0.11, p = 0.0239), and KPS (r = 0.11, p = 0.0101). Optimal TMT cutpoints for the primary and progressive cohorts were ≤ 7.15 mm and ≤ 7.10 mm, respectively. High TMT was associated with increased Stupp protocol completion (p = 0.001). On Cox proportional hazards regression, high TMT predicted increased PS in progressive [HR 0.47 (95% confidence interval (CI)) 0.25-0.90), p = 0.023] but not primary [HR 0.99 (95% CI 0.64-1.51), p = 0.949] glioblastoma.

Conclusions: TMT correlates with important prognostic variables in glioblastoma and predicts PS in patients with progressive, but not primary, disease. TMT may represent a pragmatic neurosurgical biomarker in glioblastoma that could inform treatment planning and perioperative optimization.
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http://dx.doi.org/10.1016/j.clineuro.2021.106782DOI Listing
August 2021

Predictors of an academic career among fellowship-trained spinal neurosurgeons.

J Neurosurg Spine 2021 Jun 11:1-8. Epub 2021 Jun 11.

1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: Although fellowship training is becoming increasingly common in neurosurgery, it is unclear which factors predict an academic career trajectory among spinal neurosurgeons. In this study, the authors sought to identify predictors associated with academic career placement among fellowship-trained neurological spinal surgeons.

Methods: Demographic data and bibliometric information on neurosurgeons who completed a residency program accredited by the Accreditation Council for Graduate Medical Education between 1983 and 2019 were gathered, and those who completed a spine fellowship were identified. Employment was denoted as academic if the hospital where a neurosurgeon worked was affiliated with a neurosurgical residency program; all other positions were denoted as nonacademic. A logistic regression model was used for multivariate statistical analysis.

Results: A total of 376 fellowship-trained spinal neurosurgeons were identified, of whom 140 (37.2%) held academic positions. The top 5 programs that graduated the most fellows in the cohort were Cleveland Clinic, The Johns Hopkins Hospital, University of Miami, Barrow Neurological Institute, and Northwestern University. On multivariate analysis, increased protected research time during residency (OR 1.03, p = 0.044), a higher h-index during residency (OR 1.12, p < 0.001), completing more than one clinical fellowship (OR 2.16, p = 0.024), and attending any of the top 5 programs that graduated the most fellows (OR 2.01, p = 0.0069) were independently associated with an academic career trajectory.

Conclusions: Increased protected research time during residency, a higher h-index during residency, completing more than one clinical fellowship, and attending one of the 5 programs graduating the most fellowship-trained neurosurgical spinal surgeons independently predicted an academic career. These results may be useful in identifying and advising trainees interested in academic spine neurosurgery.
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http://dx.doi.org/10.3171/2020.12.SPINE201771DOI Listing
June 2021

Predictors of Academic Neurosurgical Career Trajectory among International Medical Graduates Training Within the United States.

Neurosurgery 2021 Aug;89(3):478-485

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: Within the literature, there has been limited research tracking the career trajectories of international medical graduates (IMGs) following residency training.

Objective: To compare the characteristics of IMG and US medical school graduate (USMG) neurosurgeons holding academic positions in the United States and also analyze factors that influence IMG career trajectories following US-based residency training.

Methods: We collected data on 243 IMGs and 2506 USMGs who graduated from Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery residency programs. We assessed for significant differences between cohorts, and a logistic regression model was used for the outcome of academic career trajectory.

Results: Among the 2749 neurosurgeons in our study, IMGs were more likely to pursue academic neurosurgery careers relative to USMGs (59.7% vs 51.1%; P = .011) and were also more likely to complete a research fellowship before beginning residency (odds ratio [OR] = 9.19; P < .0001). Among current US academic neurosurgeons, USMGs had significantly higher pre-residency h-indices relative to IMGs (1.23 vs 1.01; P < .0001) with no significant differences between cohorts when comparing h-indices during (USMG = 5.02, IMG = 4.80; P = .67) or after (USMG = 14.05, IMG = 13.90; P = .72) residency. Completion of a post-residency clinical fellowship was the only factor independently associated with an academic career trajectory among IMGs (OR = 1.73, P = .046).

Conclusion: Our study suggests that while IMGs begin their US residency training with different research backgrounds and achievements relative to USMG counterparts, they attain similar levels of academic productivity following residency. Furthermore, IMGs are more likely to pursue academic careers relative to USMGs. Our work may be useful for better understanding IMG career trajectories following US-based neurosurgery residency training.
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http://dx.doi.org/10.1093/neuros/nyab194DOI Listing
August 2021

Can Preoperative Mapping with Functional MRI Reduce Morbidity in Brain Tumor Resection? A Systematic Review and Meta-Analysis of 68 Observational Studies.

Radiology 2021 Aug 1;300(2):338-349. Epub 2021 Jun 1.

From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.).

Background Preoperative functional MRI (fMRI) is one of several techniques developed to localize critical brain structures and brain tumors. However, the usefulness of fMRI for preoperative surgical planning and its potential effect on neurologic outcomes remain unclear. Purpose To assess the overall postoperative morbidity among patients with brain tumors by using preoperative fMRI versus surgery without this tool or with use of standard (nonfunctional) neuronavigation. Materials and Methods A systematic review and meta-analysis of studies across major databases from 1946 to June 20, 2020, were conducted. Inclusion criteria were original studies that included patients with brain tumors, performed preoperative neuroimaging workup with fMRI, investigated the usefulness of a preoperative or intraoperative functional neuroimaging technique and used that technique to resect cerebral tumors, and reported postoperative clinical measures. Pooled estimates for adverse event rate (ER) effect size (log ER, log odds ratio, or Hedges ) with 95% CIs were computed by using a random-effects model. Results Sixty-eight studies met eligibility criteria (3280 participants; 58.9% men [1555 of 2641]; mean age, 46 years ± 8 [standard deviation]). Functional deterioration after surgical procedure was less likely to occur when fMRI mapping was performed before the operation (odds ratio, 0.25; 95% CI: 0.12, 0.53; < .001]), and postsurgical Karnofsky performance status scores were higher in patients who underwent fMRI mapping (Hedges , 0.66; 95% CI: 0.21, 1.11; = .004]). Craniotomies for tumor resection performed with preoperative fMRI were associated with a pooled adverse ER of 11% (95% CI: 8.4, 13.1), compared with a 21.0% ER (95% CI: 12.2, 33.5) in patients who did not undergo fMRI mapping. Conclusion From the currently available data, the benefit of preoperative functional MRI planning for the resection of brain tumors appears to reduce postsurgical morbidity, especially when used with other advanced imaging techniques, such as diffusion-tensor imaging, intraoperative MRI, or cortical stimulation. © RSNA, 2021
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http://dx.doi.org/10.1148/radiol.2021204723DOI Listing
August 2021

Impact of Routine Endoscopic Skull Base Surgery on Subjective Olfaction and Gustation Outcomes.

Oper Neurosurg (Hagerstown) 2021 Aug;21(3):137-142

Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: As endoscopic endonasal skull base surgery (EESBS) for sellar pathology has become routine, there is increasing awareness of quality-of-life (QOL) outcomes related to this approach. Similarly, there is a growing interest in postoperative chemosensory function, with notable emphasis on olfaction and the corresponding psychosocial implications of olfactory dysfunction. Meanwhile, there has been minimal direct investigation into gustatory outcomes, and the association between these 2 chemosensory functions remains poorly understood.

Objective: To investigate patient-reported chemosensory function and rhinologic-specific QOL following EESBS for routine sellar pathologies.

Methods: Comprehensive clinical characteristics and sinonasal QOL assessments, measured using Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12), were collected from 46 patients undergoing EESBS for sellar pathology.

Results: Forty-six patients were included: 65.2% female, average age 52.8 yr (range: 27-89). The most common pathology was nonfunctioning pituitary adenoma (n = 28). Preoperative ASK Nasal-12 scores (mean = 0.81) demonstrated postoperative worsening at 2 wk (mean = 2.52, P < .0001) and 1 mo (mean = 1.33, P = .0031), with no difference at 3 mo postoperatively (mean = 0.89, P = .92). Meanwhile, there was significant worsening of preoperative subjective smell (mean = 0.62) and taste function (mean = 0.42) at 2 wk (mean = 3.48, P < .0001; mean = 2.69, P < .0001) and 1 mo (mean = 2.40, P < .0001; mean = 2.03, P < .0001) postoperatively, which persisted at approximately 3 mo postoperatively (mean = 1.26, P = .04; mean = 1.15, P = .0059).

Conclusion: Patients undergoing EESBS for sellar pathologies experience anticipated, temporary disruptions in sinonasal QOL but may have longer lasting perturbations in subjective olfaction and gustation. Given the increasing use of the endoscopic endonasal corridor, further investigation in postoperative chemosensory function is essential.
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http://dx.doi.org/10.1093/ons/opab137DOI Listing
August 2021

Associations of Baseline Frailty Status and Age With Outcomes in Patients Undergoing Vestibular Schwannoma Resection.

JAMA Otolaryngol Head Neck Surg 2021 Jul;147(7):608-614

Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque.

Importance: Although numerous studies have evaluated the influence of advanced age on surgical outcomes following vestibular schwannoma (VS) resection, few if any large-scale investigations have assessed the comparative prognostic effects of age and frailty. As the population continues to age, it is imperative to further evaluate treatment and management strategies for older patients.

Objective: To conduct a population-based evaluation of the independent associations of chronological age and frailty (physiological age) with outcomes following VS resection.

Design, Setting, And Participants: In this large-scale, multicenter, cross-sectional analysis, weighted discharge data from the National Inpatient Sample were searched to identify adult patients (≥18 years old) who underwent VS resection from 2002 through 2017 using International Classification of Diseases, Ninth Revision, Clinical Modification and Tenth Revision, Clinical Modification codes. Data collection and analysis took place September to December 2020.

Main Outcomes And Measures: Complex samples regression models and receiver operating characteristic curve analysis were used to evaluate the independent associations of frailty and age (along with demographic confounders) with complications and discharge disposition. Frailty was evaluated using the previously validated 11-point modified frailty index (mFI).

Results: Among the 27 313 patients identified for VS resection, the mean (SEM) age was 50.4 (0.2) years, 15 031 (55.0%) were women, and 4720 (21.0%) were of non-White race/ethnicity, as determined by the National Inpatient Sample data source. Of the included patients, 15 090 (55.2%) were considered robust (mFI score = 0), 8204 (30.0%) were prefrail (mFI score = 1), 3022 (11.1%) were frail (mFI score = 2), and 996 (3.6%) were severely frail (mFI score ≥3). On univariable analysis, increasing frailty was associated with development of postoperative hemorrhagic or ischemic stroke (odds ratio [OR], 2.44 [95% CI, 2.07-2.87]; area under the curve, 0.73), while increasing age was not. Following multivariable analysis, increasing frailty and non-White race/ethnicity were independently associated with both mortality (adjusted OR [aOR], 2.32 [95% CI, 1.70-3.17], and aOR, 3.05 [95% CI, 1.02-9.12], respectively) and extended hospital stays (aOR, 1.54 [95% CI, 1.41-1.67], and aOR, 1.71 [95% CI, 1.42-2.05], respectively), while increasing age was not. Increasing frailty (aOR, 0.61 [95% CI, 0.56-0.67]), age (aOR, 0.98 [95% CI, 0.97-0.99]), and non-White race/ethnicity (aOR, 0.62 [95% CI 0.51-0.75]) were all independently associated with routine discharge.

Conclusions And Relevance: In this cross-sectional study, findings suggest that frailty may be more accurate for predicting outcomes and guiding treatment decisions than advanced patient age alone following VS resection.
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http://dx.doi.org/10.1001/jamaoto.2021.0670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085763PMC
July 2021

Quality-of-life instruments in endoscopic endonasal skull base surgery-A practical systematic review.

Int Forum Allergy Rhinol 2021 08 21;11(8):1264-1268. Epub 2021 Feb 21.

Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1002/alr.22783DOI Listing
August 2021

In Reply to the Letter to the Editor Regarding "Predictors of Nonroutine Discharge Disposition Among Parasagittal/Parafalcine Meningioma Patients".

World Neurosurg 2021 02;146:429

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2020.08.132DOI Listing
February 2021

Predicting High-Value Care Outcomes After Surgery for Skull Base Meningiomas.

World Neurosurg 2021 05 7;149:e427-e436. Epub 2021 Feb 7.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Background: Although various predictors of adverse postoperative outcomes among patients with meningioma have been established, research has yet to develop a method for consolidating these findings to allow for predictions of adverse health care outcomes for patients diagnosed with skull base meningiomas. The objective of the present study was to develop 3 predictive algorithms that can be used to estimate an individual patient's probability of extended length of stay (LOS) in hospital, experiencing a nonroutine discharge disposition, or incurring high hospital charges after surgical resection of a skull base meningioma.

Methods: The present study used data from patients who underwent surgical resection for skull base meningiomas at a single academic institution between 2017 and 2019. Multivariate logistic regression analysis was used to predict extended LOS, nonroutine discharge, and high hospital charges, and 2000 bootstrapped samples were used to calculate an optimism-corrected C-statistic. The Hosmer-Lemeshow test was used to assess model calibration, and P < 0.05 was considered statistically significant.

Results: A total of 245 patients were included in our analysis. Our cohort was mostly female (77.6%) and white (62.4%). Our models predicting extended LOS, nonroutine discharge, and high hospital charges had optimism-corrected C-statistics of 0.768, 0.784, and 0.783, respectively. All models showed adequate calibration (P>0.05), and were deployed via an open-access, online calculator: https://neurooncsurgery3.shinyapps.io/high_value_skull_base_calc/.

Conclusions: After external validation, our predictive models have the potential to aid clinicians in providing patients with individualized risk estimation for health care outcomes after meningioma surgery.
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http://dx.doi.org/10.1016/j.wneu.2021.02.007DOI Listing
May 2021

Development of new brain metastases in triple negative breast cancer.

J Neurooncol 2021 Apr 29;152(2):333-338. Epub 2021 Jan 29.

Department of Neurosurgery, Neurosurgery Oncology, Radiation Oncology, Otolaryngology, Institute of NanoBiotechnology, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 123, Baltimore, MD, 21287, USA.

Background: Brain metastases are common in patients with breast cancer, and those with triple negative status have an even higher risk. Triple negative status is currently not considered when managing brain metastases.

Objective: To determine whether triple negative breast cancer (TNBC) patients with brain metastases have a higher burden of intracranial disease and whether WBRT has a survival benefit in this cohort of patients.

Methods: We conducted a retrospective cohort study with 85 patients meeting the inclusion criteria.

Results: 25% of patients had TNBC. 95% of the patients in this study received SRS and 48% received WBRT. The average number of new brain metastases from time of initial brain imaging to radiation therapy was 0.67 ± 1.1 in the non-TNBC status patients and 2.6 ± 3.7 in the triple negative status patients (p = 0.001). A cox proportional hazards model showed that WBRT does not significantly affect overall survival in patients with TNBC (HR 1.48; 95% CI 0.47-4.67; p = 0.50).

Conclusion: Our findings highlight the highly aggressive intracranial nature of TNBC. The rate of new brain metastasis formation is higher in TNBC patients compared to non-TNBC patients. Furthermore, there is no survival benefit for WBRT in TNBC patients. These findings are relevant for clinicians planning brain radiation for TNBC patients as they may find more brain metastases at the time of brain radiation than they anticipated based on initial brain imaging.
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http://dx.doi.org/10.1007/s11060-021-03702-0DOI Listing
April 2021

Predictors of Postoperative Visual Outcome After Surgical Intervention for Craniopharyngiomas.

World Neurosurg 2021 04 20;148:e589-e599. Epub 2021 Jan 20.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Background: Because of involvement of the optic apparatus, craniopharyngiomas frequently present with visual deterioration. Although visual improvement is a primary goal of surgical intervention, prediction models are lacking.

Methods: We retrospectively reviewed all patients undergoing craniopharyngioma surgery at a single institution (2014-2019). Preoperative, intraoperative, and postoperative variables of interest were collected. Visual acuity and visual fields (VFs) were standardized into Visual Impairment Scores (VISs), defined by the German Ophthalmological Society. VIS ranged from 0 (normal vision) to 100 (complete bilateral blindness). Visual improvement/deterioration was defined as a postsurgical decrease/increase of ≥5 VIS points, respectively.

Results: Complete ophthalmologic assessments were available for 61 operations, corresponding to 41 patients (age, 4-73 years). Vision improved after 28 operations (46%), remained stable after 27 (44%), and deteriorated after 6 (10%). In bivariate analysis, significant predictors of visual improvement included worse preoperative VIS (odds ratio [OR], 1.058; P < 0.001), worse preoperative VF mean deviation (OR, 1.107; P = 0.032), preoperative vision deficits presenting for longer than 1 month (OR, 6.050; P = 0.010), radiographic involvement of the anterior cerebral arteries (OR, 3.555; P = 0.019), and gross total resection (OR, 4.529; P = 0.022). The translaminar surgical approach was associated with visual deterioration (OR, 6.857; P = 0.035). In multivariate analysis, worse preoperative VIS remained significantly associated with postoperative visual improvement (OR, 1.060; P = 0.011). Simple linear correlation (R=0.398; P < 0.001) suggests prediction of postoperative VIS improvement via preoperative VIS.

Conclusions: Patients with reduced preoperative vision, specific radiographic vascular involvement, and gross total resection showed increased odds of visual improvement, whereas the translaminar approach was associated with visual deterioration. Such characteristics may facilitate patient-surgeon counseling and surgical decision making.
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http://dx.doi.org/10.1016/j.wneu.2021.01.044DOI Listing
April 2021

Pitfalls in Performing and Interpreting Inferior Petrosal Sinus Sampling: Personal Experience and Literature Review.

J Clin Endocrinol Metab 2021 04;106(5):e1953-e1967

Johns Hopkins University, Division of Endocrinology, Diabetes and Metabolism, Baltimore, MD, USA.

Context: Inferior petrosal sinus sampling (IPSS) helps differentiate the source of ACTH-dependent hypercortisolism in patients with inconclusive biochemical testing and imaging, and is considered the gold standard for distinguishing Cushing disease (CD) from ectopic ACTH syndrome. We present a comprehensive approach to interpreting IPSS results by examining several real cases.

Evidence Acquisition: We performed a comprehensive review of the IPSS literature using PubMed since IPSS was first described in 1977.

Evidence Synthesis: IPSS cannot be used to confirm the diagnosis of ACTH-dependent Cushing syndrome (CS). It is essential to establish ACTH-dependent hypercortisolism before the procedure. IPSS must be performed by an experienced interventional or neuroradiologist because successful sinus cannulation relies on operator experience. In patients with suspected cyclical CS, it is important to demonstrate the presence of hypercortisolism before IPSS. Concurrent measurement of IPS prolactin levels is useful to confirm adequate IPS venous efflux. This is essential in patients who lack an IPS-to-peripheral (IPS:P) ACTH gradient, suggesting an ectopic source. The prolactin-adjusted IPS:P ACTH ratio can improve differentiation between CD and ectopic ACTH syndrome when there is a lack of proper IPS venous efflux. In patients who have unilateral successful IPS cannulation, a contralateral source cannot be excluded. The value of the intersinus ACTH ratio to predict tumor lateralization may be improved using a prolactin-adjusted ACTH ratio, but this requires further evaluation.

Conclusion: A stepwise approach in performing and interpreting IPSS will provide clinicians with the best information from this important but delicate procedure.
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http://dx.doi.org/10.1210/clinem/dgab012DOI Listing
April 2021

Preoperative BMI Predicts Postoperative Weight Gain in Adult-onset Craniopharyngioma.

J Clin Endocrinol Metab 2021 03;106(4):e1603-e1617

Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Context: Craniopharyngiomas, while benign, have the highest morbidity of all nonmalignant sellar tumors. Studies on weight and metabolic outcomes in adult-onset craniopharyngioma (AOCP) remain sparse.

Objective: To examine postsurgical weight and metabolic outcomes in AOCP and to identify any clinical predictors of weight gain.

Methods: Retrospective chart review of patients with AOCP who underwent surgery between January 2014 and May 2019 in a single pituitary center. The study included 45 patients with AOCP with a minimum follow-up of 3 months. Median follow-up time was 26 months (interquartile range [IQR] 10-44). Main outcome measures were the changes in weight/body mass index (BMI), metabolic comorbidities, and pituitary deficiencies between preoperative and last follow-up.

Results: Both weight and BMI were higher at last follow-up, with a mean increase of 3.4 kg for weight (P = .015) and 1.15 kg/m2 for BMI (P = .0095). Median % weight change was 2.7% (IQR -1.1%, 8.8%). Obesity rate increased from 37.8% at baseline to 55.6% at last follow-up. One-third of patients had ~15% median weight gain. The prevalence of metabolic comorbidities at last follow-up was not different from baseline. Pituitary deficiencies increased postoperatively, with 58% of patients having ≥3 hormonal deficiencies. Preoperative BMI was inversely associated with postoperative weight gain, which remained significant after adjusting for age, sex, race, tumor, and treatment characteristics. Patients with ≥3 hormonal deficiencies at last follow-up also had higher postoperative weight gain.

Conclusion: In this AOCP cohort, those with a lower BMI at the preoperative visit had higher postoperative weight gain. Our finding may help physicians better counsel patients and provide anticipatory guidance on postoperative expectations and management.
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http://dx.doi.org/10.1210/clinem/dgaa985DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993568PMC
March 2021

Evaluation and Management of Symptomatic Vasospasm following Endoscopic Endonasal Resection of Pediatric Adamantinomatous Craniopharyngioma.

Case Rep Pediatr 2020 20;2020:8822874. Epub 2020 Nov 20.

Department of Anesthesiology & Critical Care Medicine, Division of Pediatric Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Cerebral vasospasm is a well-described pathology following subarachnoid hemorrhage and trauma in children; however, very few cases have been published following craniopharyngioma resection in children. Those that were published were associated with significant morbidity or mortality at hospital discharge. . Here, we report the challenging clinical course of a pediatric patient who developed delayed cerebral vasospasm following craniopharyngioma resection. It was first noted on postoperative day 13. The patient was managed with induced hypertension, hypervolemia, and intra-arterial vasodilator therapy (nicardipine). This patient made a full recovery without new focal deficits at hospital discharge.

Conclusion: In contrast to previously reported similar pediatric cases, this patient with cerebral vasospasm after craniopharyngioma resection made a full recovery without new focal neurologic deficits. To our knowledge, this is the first occurrence of a patient with this clinical course.
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http://dx.doi.org/10.1155/2020/8822874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700025PMC
November 2020

Effect of radiation therapy on overall survival following subtotal resection of adult pilocytic astrocytoma.

J Clin Neurosci 2020 Nov 21;81:340-345. Epub 2020 Oct 21.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States. Electronic address:

Objective: Pilocytic astrocytoma (PCA) is a low-grade glioma that primarily presents in children, but can also present in adulthood. Ideal primary treatment for PCA is gross total resection. However, for patients who are only able to undergo subtotal resection, the optimal course of post-operative therapy remains unclear. We investigated the association of patient characteristics and radiation therapy (RT) with overall survival specifically for adult PCA patients who underwent subtotal tumor resection.

Methods: Information on adult patients (age ≥18 years old) who underwent subtotal PCA resection between 2004 and 2016 was collected from the National Cancer Database (NCDB). A multivariate Cox proportional hazards model was utilized to determine factors associated with overall survival.

Results: A total of 451 patients were identified. The mean age of our patient cohort was 36.8 years old, and the majority of patients (83.4%) did not receive RT following subtotal PCA resection. Overall median survival was >93.8 months. On multivariate analysis, patients who were older at diagnosis (hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 1.02-1.06, p < 0.01), black (HR = 2.35, CI = 1.05-5.23, p = 0.037), had a Charlson/Deyo comorbidity score ≥ 1 (HR = 2.27, CI = 1.00-5.14, p = 0.049), or received RT during their initial treatment (HR = 3.77, CI = 1.77-8.03, p < 0.01) had a significantly higher risk of death following subtotal PCA resection.

Conclusion: Post-operative RT was associated with a significantly higher risk of death among adults who underwent subtotal PCA resection. Our findings provide support for further inquiry into the efficacy of RT within this patient population.
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http://dx.doi.org/10.1016/j.jocn.2020.10.020DOI Listing
November 2020

Predictive factors for overall survival in surgical cases of gliomatosis cerebri from the National Cancer Database.

J Clin Neurosci 2020 Nov 13;81:186-191. Epub 2020 Oct 13.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, United States. Electronic address:

Gliomatosis Cerebri (GC) is a rare, aggressive, diffusely infiltrating cerebral tumor. Prognostic indicators and management strategies are currently poorly characterized. The National Cancer Database was queried for patients with histologically confirmed GC between 2004 and 2016. Demographic, tumor, and treatment characteristics were collected, including the Charlson/Deyo score, a comorbidity index adapted from the Charleston Comorbidity Index. Allowable values for the Charlson/Deyo score are 0 (no recorded comorbidities), 1, 2, and 3+ (most severe). Factors associated with overall survival were identified via bivariate log-rank tests and multivariate stepwise Cox proportional hazards models. The query returned 108 GC patients. The median age was 60.0 years, males were predominantly affected (63%), and most patients were white (86%). While 12% of cases achieved near/gross total resection and 27% of cases achieved partial resection, most surgeries were for biopsy (61%). Treatments included radiation therapy in 64% and chemotherapy in 63% of patients. The median overall survival was 15.1 (95% confidence interval [CI] = 11.1-24.8) months. On bivariate analysis, chemotherapy improved overall survival (p = 0.01) while radiation therapy (p = 0.07) and extent of resection (p = 0.48) did not. On multivariate analysis, older patients (hazard ratio [HR] = 1.07, CI = 1.03-1.11, p < 0.01) and Charlson/Deyo scores of ≥1 versus 0 (HR = 3.47, CI = 1.40-8.60, p < 0.01) had significantly increased mortality risk following surgery. In particular, the Charlson/Deyo score is a novel prognostic factor for GC that may guide clinical and surgical decision-making for this rare, rapidly fatal tumor. Further prospective studies are warranted to clarify the effects of chemotherapy versus radiation as treatment modalities for GC.
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http://dx.doi.org/10.1016/j.jocn.2020.09.056DOI Listing
November 2020

The Prognostic Impact of Nutritional Status on Postoperative Outcomes in Glioblastoma.

World Neurosurg 2021 02 13;146:e865-e875. Epub 2020 Nov 13.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Objective: The clinical impact and optimal method of assessing nutritional status (NS) have not been rigorously examined in glioblastoma. We investigated the relationship between NS and postoperative survival (PS) in glioblastoma using 4 nutritional indices and identified which index best modeled PS.

Methods: NS was retrospectively assessed for patients with glioblastoma undergoing surgery at our institution from 2007 to 2019 using the albumin level, albumin/globulin ratio (AGR), nutritional risk index (NRI), and prognostic nutritional index (PNI). Optimal cut points for each index were identified using maximally selected rank statistics and previously established criteria. The predictive value of each index on PS was determined using Cox proportional hazards models adjusted for prognostic variables. The best-performing model was identified using the Akaike Information Criterion.

Results: Our analysis included 242 patients (64% male) with a mean age of 57.6 years, Karnofsky Performance Status of 77.6, 5-factor modified frailty index of 0.59, albumin level of 4.2 g/dL, AGR of 1.9, NRI of 105.6, and PNI of 47.4. Median PS after index and repeat surgery was 12.7 and 7.8 months, respectively. On multivariable analysis, low albumin level (hazard ratio [HR], 2.09; 95% confidence interval [CI], 1.52-2.89; P < 0.001), mild NRI (HR, 1.61; 95% CI, 1.04-2.49; P = 0.032), moderate/severe NRI (HR, 2.51; 95% CI, 1.64-3.85; P < 0.001), and low PNI (HR, 2.51; 95% CI, 1.78-3.53; P < 0.001), but not low AGR (HR, 1.17; 95% CI, 0.89-1.54; P = 0.270), predicted decreased PS. PNI had the lowest Akaike Information Criterion.

Conclusions: NS predicts PS in glioblastoma. PNI may provide the best model for assessing NS. NS is an important modifiable aspect of brain tumor management that warrants increased attention.
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http://dx.doi.org/10.1016/j.wneu.2020.11.033DOI Listing
February 2021

Predictive Model and Online Calculator for Discharge Disposition in Brain Tumor Patients.

World Neurosurg 2021 02 10;146:e786-e798. Epub 2020 Nov 10.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Background: In the era of value-based payment models, it is imperative for neurosurgeons to eliminate inefficiencies and provide high-quality care. Discharge disposition is a relevant consideration with clinical and economic ramifications in brain tumor patients. We developed a predictive model and online calculator for postoperative non-home discharge disposition in brain tumor patients that can be incorporated into preoperative workflows.

Methods: We reviewed all brain tumor patients at our institution from 2017 to 2019. A predictive model of discharge disposition containing preoperatively available variables was developed using stepwise multivariable logistic regression. Model performance was assessed using receiver operating characteristic curves and calibration curves. Internal validation was performed using bootstrapping with 2000 samples.

Results: Our cohort included 2335 patients who underwent 2586 surgeries with a 16% non-home discharge rate. Significant predictors of non-home discharge were age >60 years (odds ratio [OR], 2.02), African American (OR, 1.73) or Asian (OR, 2.05) race, unmarried status (OR, 1.48), Medicaid insurance (OR, 1.90), admission from another health care facility (OR, 2.30), higher 5-factor modified frailty index (OR, 1.61 for 5-factor modified frailty index ≥2), and lower Karnofsky Performance Status (increasing OR with each 10-point decrease in Karnofsky Performance Status). The model was well calibrated and had excellent discrimination (optimism-corrected C-statistic, 0.82). An open-access calculator was deployed (https://neurooncsurgery.shinyapps.io/discharge_calc/).

Conclusions: A strongly performing predictive model and online calculator for non-home discharge disposition in brain tumor patients was developed. With further validation, this tool may facilitate more efficient discharge planning, with consequent improvements in quality and value of care for brain tumor patients.
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http://dx.doi.org/10.1016/j.wneu.2020.11.018DOI Listing
February 2021

A national survey on the impact of the COVID-19 pandemic upon burnout and career satisfaction among neurosurgery residents.

J Clin Neurosci 2020 Oct 19;80:137-142. Epub 2020 Aug 19.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address:

The coronavirus disease 2019 (COVID-19) pandemic has posed significant changes to resident education and workflow. However, the impact of the pandemic on U.S. neurosurgery residents has not been well characterized. We investigated the impact of the COVID-19 pandemic on U.S. neurosurgery resident workflow, burnout, and career satisfaction. In 2020, a survey evaluating factors related to career satisfaction and burnout was emailed to 1,374 American Association of Neurological Surgeons (AANS) residents. Bivariate and multivariate (logistic) analyses were performed to characterize predictors of burnout and career satisfaction. 167 survey responses were received, with a response rate (12.2%) comparable to that of similar studies. Exclusion of incomplete responses yielded 111complete responses. Most respondents were male (65.8%) and White (75.7%). Residents reported fewer work hours (67.6%) and concern that COVID-19 would impair theirachievement of surgical milestones (65.8%). Burnout was identified in 29 (26.1%) respondents and career satisfaction in 82 (73.9%) respondents. In multivariate analysis, burnout was significantly associated with alterations in elective rotation/vacation schedules (p = .013) and the decision to not pursue neurosurgery again if given the choice (p < .001). Higher post-graduate year was associated with less burnout (p = .011). Residents displayed greater career satisfaction when focusing their clinical work upon neurosurgical care (p = .065). Factors related to COVID-19 have contributed to workflow changes among U.S. neurosurgery residents. We report a moderate burnout rate and a paradoxically high career satisfaction rate among neurosurgery residents. Understanding modifiable stressors during the COVID-19pandemic may help to formulate interventions to mitigate burnout and improve career satisfaction among residents.
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http://dx.doi.org/10.1016/j.jocn.2020.08.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438065PMC
October 2020
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