Krystal L. Tomei

Comparative analysis of state-level concussion legislation and review of current practices in concussion

OBJECT Forty-two states and the District of Columbia have passed legislation based on the Lystedt law of Washington state, enacted in 2009 to protect young athletes who have sustained a concussion. The aim of this study was to note the several similarities and differences among the various laws. METHODS Concussion legislation was compared for 50 states and the District of Columbia. Evaluation parameters of this study included stipulations of concussion education, criteria for removal from play, requirements for evaluation and return to play after concussion, and individuals required to assess young athletes. Other parameters that were not consistent across states were also noted. RESULTS Forty-three states and the District of Columbia have passed concussion legislation, and an additional 4 states have pending legislation. All states with existing legislation support concussion education for coaches; however, only 48% require coaches to undergo formal education. Athletes must be educated on concussion in 86% of states and parents in 88.7%. Suspicion of concussion is a criterion for removal from play in 75% of states; signs and symptoms of concussion are criteria for removal from play in 16% of states. The individuals allowed to evaluate and clear an athlete for return to play differ greatly among states. CONCLUSIONS Injury prevention legislation holds historical precedent, and given the increasing attention to long-term sequelae of repeated head trauma and concussion, concussion legislation has been rapidly passed in 43 states and the District of Columbia. Although the exact stipulations of these laws vary among states, the overall theme is to increase recognition of concussion in young athletes and ensure that they are appropriately cleared for return to play after concussion.

A Comparative Analysis of the Quality of Patient Education Materials From Medical Specialties

1. Allen LA, Stevenson LW, Grady KL, et al; American Heart Association; Council on Quality of Care and Outcomes Research; Council on Cardiovascular Nursing; Council on Clinical Cardiology; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation. 2012;125(15):1928-1952.

A gender-based comparison of academic rank and scholarly productivity in academic neurological surgery

The number of women pursuing training opportunities in neurological surgery has increased, although they are still underrepresented at senior positions relative to junior academic ranks. Research productivity is an important component of the academic advancement process. We sought to use the h-index, a bibliometric previously analyzed among neurological surgeons, to evaluate whether there are gender differences in academic rank and research productivity among academic neurological surgeons. The h-index was calculated for 1052 academic neurological surgeons from 84 institutions, and organized by gender and academic rank. Overall men had statistically higher research productivity (mean 13.3) than their female colleagues (mean 9.5), as measured by the h-index, in the overall sample (p<0.0007). When separating by academic rank, there were no statistical differences (p>0.05) in h-index at the assistant professor (mean 7.2 male, 6.3 female), associate professor (11.2 male, 10.8 female), and professor (20.0 male, 18.0 female) levels based on gender. There was insufficient data to determine significance at the chairperson rank, as there was only one female chairperson. Although overall gender differences in scholarly productivity were detected, these differences did not reach statistical significance upon controlling for academic rank. Women were grossly underrepresented at the level of chairpersons in this sample of 1052 academic neurological surgeons, likely a result of the low proportion of females in this specialty. Future studies may be needed to investigate gender-specific research trends for neurosurgical residents, a cohort that in recent years has seen increased representation by women.

A comparative analysis of neurosurgical online education materials to assess patient comprehension

Americans have increasingly utilized the internet as a first-line resource for a variety of information, including healthcare-oriented materials. Therefore, these online resources should be written at a level the average American can understand. Patient education resources specifically written for and available to the public were downloaded from the American Association of Neurological Surgeons website and assessed for their level of readability using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook Grading, Coleman-Liau Index, and Gunning-Fog Index. A total of 71 subsections from different neurosurgical specialties were reviewed, including Cerebrovascular, Spine and Peripheral Nerves, Neurotrauma and Critical Care, Pain, Pediatric, Stereotactic and Functional, and Tumor material. All neurosurgical subspecialty education material provided on the American Association of Neurological Surgeons website was uniformly written at a level that was too high, as assessed by all modalities. In order to reach a larger patient population, patient education materials on the American Association of Neurological Surgeons website should be revised with the goal of simplifying readability.

Lipomyelomeningocele: pathology, treatment, and outcomes.

Lipomyelomeningocele represents a rare but complex neurological disorder that may present with neurological deterioration secondary to an inherent tethered spinal cord. Radiological testing is beneficial in determining the morphology of the malformation. Specialized testing such as urodynamic studies and neurophysiological testing may be beneficial in assessing for neurological dysfunction secondary to the lipomyelomeningocele. Early surgical intervention may be beneficial in preventing further neurological decline.

Follow-Up on a National Survey: American Neurosurgery Resident Opinions on the 2011 Accreditation Council for Graduate Medical Education-Implemented Duty Hours

OBJECTIVE We previously performed a nationwide survey of American neurosurgical residents before the initiation of the 2011 Accreditation Council for Graduate Medical Education regulations, in which more than 70% indicated the proposed changes would negatively impact residency training. We sought to resurvey the resident population as to the actual changes that occurred to their programs after the 2011 standards went into effect. METHODS Surveys were mailed to every neurosurgery training program in the United States and Puerto Rico. Program directors and coordinators were asked to distribute surveys to their residents. RESULTS A total of 253 neurosurgery residents responded. Reported duty-hour violations were largely unchanged after the 2011 duty-hour changes. Sixty-percent of residents reported that they had underreported duty hours, with nearly 25% of respondents doing so on a weekly or daily basis. Most reported that the 2011 changes had not affected operative caseload, academic productivity, quality of life, or resident fatigue. The majority of residents disagreed or strongly disagreed that the PGY-1 16-hour limitation had a positive impact on first-year resident training (69%) or had improved patient safety (62%). Overall, the majority of respondents reported that the 2011 changes had a negative (35%) or negligible (33%) effect on residency training at their institution. CONCLUSION Respondents indicated that the 2011 Accreditation Council for Graduate Medical Education regulations have had a smaller perceived effect on neurosurgical training programs than previously predicted. However, the majority of residents admitted to underreporting duty hours, with a quarter doing so on a regular basis. The 16-hour rule for interns remains unpopular.

Optimal Timing of Whole-Brain Radiation Therapy Following Craniotomy for Cerebral Malignancies.

BACKGROUND For patients with cerebral metastases that are limited in number, surgical resection followed by whole-brain radiation therapy is the standard of care. In addition, for high-grade gliomas, maximal surgical resection followed by local radiotherapy is considered the optimal treatment. Radiation is known to impair wound healing, including healing of surgical incisions. Radiotherapy shortly after surgical resection would be expected to minimize the opportunity for tumor regrowth or progression. Owing to these competing interests, the purpose of this study was to shed light on the optimal timing of radiotherapy after surgical resection of brain metastasis or high-grade gliomas. METHODS A review of the literature was conducted on the following topics: radiation and wound healing, corticosteroid use and wound healing, radiotherapy for tumor control for cerebral metastases and high-grade gliomas, and whole-brain radiation therapy or focal radiotherapy after craniotomy with focus on the timing of radiotherapy after surgery. RESULTS In animal models, wound integrity and healing was less impaired by radiotherapy administered 1 week after surgery. In humans, this timing would be expected to be significantly longer, on the order of several weeks. CONCLUSIONS Given the limited literature, insufficient conclusions can be drawn. However, animal data suggest a period of at least 1 week (but it is likely several weeks in humans) is necessary for reconstitution of wound strength before initiation of radiation therapy. A randomized prospective study is recommended to understand better the effect of the timing of radiation therapy following surgical intervention for brain metastasis or high-grade gliomas.

Posterior reversible encephalopathy syndrome in a patient with a Chiari I malformation.

Background: The authors describe a unique case of a patient who developed posterior reversible encephalopathy syndrome (PRES) following postoperative treatment of a Chiari I malformation. Case Decsription: A 25-year-old female presented with complaints of left upper and lower extremity paresthesias and gait disturbances. A magnetic resonance imaging (MRI) of the brain and cervical spine showed a Chiari I malformation with tonsillar descent beyond the level of the C1 lamina. She underwent a suboccipital craniectomy and C1 laminectomy with cerebellar tonsillar cauterization and duraplasty. Postoperatively, an MRI showed bilateral acute infarcts of the cerebellar vermis. She was initially treated for cerebellar ischemia with hypertensive therapy with a subsequent decline in her neurologic status and generalized tonic–clonic seizure. Further workup showed evidence of PRES. After weaning pressors, the patient had a significant progressive improvement in her mental status. Conclusion: Although the mechanism of PRES remains controversial given its diverse clinical presentation, several theories implicate hypertension and steroid use as causative agents.

Spontaneous Hemorrhage of a Facial Neurofibroma: Endovascular Embolization Before Surgical Intervention

Abstract A 50-year-old man with neurofibromatosis type 1 presented to the emergency department after a spontaneous hemorrhage into a facial plexiform neurofibroma. An emergent selective angiography of the external carotid artery was performed with Onyx embolization of the origin of the internal maxillary artery as well as the superficial temporal artery to minimize arterial bleeding during the subsequent operative hematoma evacuation. This technique was aimed to control blood loss during the surgical procedure and reduce the amount of transfusion product required for resuscitation. This technique provides a viable option to control potentially life-threatening arterial bleeding in emergent settings.