Standardized Interview Scoring Methodology for Neurosurgical Residency Applicant Selection

Interviews are critical to the neurosurgery resident application process. The COVID-19 pandemic forced residency interview activities are conducted virtually. To maintain a degree of control during a period of uncertainty, our department implemented a standardized survey for interviewers to evaluate the noncognitive attributes and program compatibility of applicants. Our objective was to assess the reliability and biases associated with our standardized interviewer survey implemented in neurosurgical residency interviews. A 5-question interviewer survey to assess applicant interview performance and program compatibility was implemented during the 2020 to 2021 interview season. After the application cycle, survey metrics were retrospectively reviewed. Multiple cohort analyses were performed by dividing interviewers into cohorts based on status (faculty or resident) and sex. Applicant scores were assessed within sex subgroups for each aforementioned interviewer cohort. Intraclass correlation coefficients (ICCs) were calculated to assess survey reliability. Fifteen interviewers (8 faculty and 7 residents) and 35 applicants were included. Female applicants (17%) and interviewers (20%) comprised the minority. There were no differences between resident and faculty reviewer scores; however, female reviewers gave higher overall scores than male reviewers ( P = .003). There was no difference in total scores between female and male applicants when evaluating all reviewers or subgroups of faculty, residents, females, or males. ICC analysis demonstrated good (ICC 0.75-0.90) or excellent (ICC > 0.90) reliability for all questions and overall score. The standardized interviewer survey was a feasible and reliable method for evaluating noncognitive attributes during neurosurgery residency interviews. There was no perceptible evidence of sex bias in our single-program experience.

Seizure Outcomes and Reoperation in Surgical Rasmussen Encephalitis Patients

BACKGROUND

Rasmussen encephalitis (RE) is a rare inflammatory disease affecting one hemisphere, causing progressive neurological deficits and intractable seizures.

OBJECTIVE

To report long-term seizure outcomes, reoperations, and functional outcomes in patients with RE who underwent hemispherectomy at our institution.

METHODS

Retrospective review was performed for all patients with RE who had surgery between 1998 and 2020. We collected seizure history, postoperative outcomes, and functional data. Imaging was independently reviewed in a blinded fashion by 2 neurosurgeons and a neuroradiologist.

RESULTS

We analyzed 30 patients with RE who underwent 35 hemispherectomies (5 reoperations). Using Kaplan-Meier analysis, seizure-freedom rate was 81.5%, 63.6%, and 55.6% at 1, 5, and 10 years after surgery, respectively. Patients with shorter duration of hemiparesis preoperatively were less likely to be seizure-free at follow-up (P = .011) and more likely to undergo reoperation (P = .004). Shorter duration of epilepsy (P = .026) and preoperative bilateral MRI abnormalities (P = .011) were associated with increased risk of reoperation. Complete disconnection of diseased hemisphere on postoperative MRI after the first operation improved seizure-freedom (P = .021) and resulted in fewer reoperations (P = .034), and reoperation resulted in seizure freedom in every case.

CONCLUSION

Obtaining complete disconnection is critical for favorable seizure outcomes from hemispherectomy, and neurosurgeons should have a low threshold to reoperate in patients with RE with recurrent seizures. Rapid progression of motor deficits and bilateral MRI abnormalities may indicate a subpopulation of patients with RE with increased risk of needing reoperation. Overall, we believe that hemispherectomy is a curative surgery for the majority of patients with RE, with excellent long-term seizure outcome.

Assessment of L5-S1 anterior lumbar interbody fusion stability in the setting of lengthening posterior instrumentation constructs: a cadaveric biomechanical study

OBJECTIVE

Excessive stress and motion at the L5-S1 level can lead to degenerative changes, especially in patients with posterior instrumentation suprajacent to L5. Attention has turned to utilization of L5-S1 anterior lumbar interbody fusion (ALIF) to stabilize the lumbosacral junction. However, questions remain regarding the effectiveness of stand-alone ALIF in the setting of prior posterior instrumented fusions terminating at L5. The purpose of this study was to assess the biomechanical stability of an L5-S1 ALIF with increasing lengths of posterior thoracolumbar constructs.

METHODS

Seven human cadaveric spines (T9-sacrum) were instrumented with pedicle screws from T10 to L5 and mounted to a 6 degrees-of-freedom robot. Posterior fusion construct lengths (T10-L5, T12-L5, L2-5, and L4-5) were instrumented to each specimen, and torque-fusion level relationships were determined for each construct in flexion-extension, axial rotation, and lateral bending. A stand-alone L5-S1 ALIF was then instrumented, and L5-S1 motion was measured as increasing pure moments (2 to 12 Nm) were applied. Motion reduction was calculated by comparing L5-S1 motion across the ALIF and non-ALIF states.

RESULTS

The average motion at L5-S1 in axial rotation, flexion-extension, and lateral bending was assessed for each fusion construct with and without ALIF. After adding ALIF to a posterior fusion, L5-S1 motion was significantly reduced relative to the non-ALIF state in all but one fused surgical condition (p < 0.05). Longer fusions with ALIF produced larger L5-S1 motions, and in some cases resulted in motions higher than native state motion.

CONCLUSIONS

Posterior fusion constructs up to L4-5 could be appropriately stabilized by a stand-alone L5-S1 ALIF when using a nominal threshold of 80% reduction in native motion as a potential positive indicator of fusion. The results of this study allow conclusions to be drawn from a biomechanical standpoint; however, the clinical implications of these data are not well defined. These findings, when taken in appropriate clinical context, can be used to better guide clinicians seeking to treat L5-S1 pathology in patients with prior posterior thoracolumbar constructs.

Fluorinated N,N'-diarylureas as AMPK activators

Adenosine monophosphate-activated kinase (AMPK) plays a central role in regulating energy homeostasis in eukaryotic cells. AMPK also regulates lipid synthesis by inhibiting acetyl-CoA carboxylase (ACC) and regulates mTOR signaling by activating TSC2. Due to its important roles in cell metabolism, AMPK is an attractive target for metabolic diseases, such as type II diabetes and obesity. AMPK activators, such as metformin, that are used for diabetes treatment are also effective anticancer agents. However, the efficacies of many known AMPK activators are relatively low. For example, metformin activates AMPK at millimolar levels. In this study, we identified a novel family of AMPK activators, namely fluorinated N,N'-diarylureas, that activate AMPK at 1-3μM concentrations. These novel agents strongly inhibit the proliferation of colon cancer cells. We studied the potential mechanisms of these agents, performed a structure-activity relationship (SAR) study and identified several fluorinated N,N'-diarylureas as potent AMPK activators.

Arthroscopic debridement of the arthritic knee

Arthroscopic debridement was carried out in 49 knees of 44 patients. These patients, who had a primary diagnosis of arthritis, were older than 50 years of age. Two-thirds had roentgenographic evidence of severe arthritis. Age, weight, compartment location of arthritis, and presurgical range of motion did not affect surgical results. Symptoms of long duration, arthritic severity as evidenced by roentgenograms, and malalignment predicted poor results. Conversely, shorter duration of symptoms, mechanical symptoms, mild to moderate roentgenographic changes, and crystal deposition correlated with improved results. Surgery offered no benefit for 39% of the patients. Another 9% had temporary improvement, averaging 15 months, but were judged failures at the final follow-up examination. Good or excellent results were achieved in 52% of the patients and maintained through the final follow-up examination in 40% of the patients. Of these, two-thirds had no visible deterioration within a 33-month average follow-up period.

Glutamate dehydrogenase: biochemical and clinical aspects of an interesting enzyme

The molecular properties and possible metabolic functions of glutamate dehydrogenase (GLDH-EC 1.4.1.3) are described. The distribution of this enzyme in the body and particularly in the liver are outlined. The significance of these properties for GLDH release into the extracellular space, for the distribution and elimination of the enzyme and, foremost, for the assay of GLDH as a diagnostic indicator of hepatic and biliary disease are shown. Analytical methods are reviewed.

Standardization by reference methods: a German viewpoint

The problems of applying optimized as well as standardized methods to the determination of enzyme activities in modern clinical laboratories are described. The failure of the so-called 'New Concept of Reference Method Values' in the quality assessment of enzyme assays is evidenced, and the advantages of standardized methods rather than only standard materials is demonstrated. Finally, the great similarities among European national recommended methods for enzyme assay is emphasized by a comparison of results obtained in estimating 5 enzymes.

Amygdalin toxicity studies in rats predict chronic cyanide poisoning in humans

Significant amounts of cyanide are released when amygdalin (Laetrile), a cyanogenic glycoside, is given orally or intravenously to rats. The amount of cyanide liberated following oral administration is dependent in part on the bacterial flora of the gut and can be suppressed by antibiotic pretreatment of the animals. Bacteria from human feces likewise hydrolyze amygdalin with release of cyanide. Humans taking amygdalin orally in the hope of preventing cancer are likely to be exposed to levels of cyanide in excess of that associated with the development of tropical ataxic neuropathy in people of underdeveloped countries where food containing cyanogenic glycosides is a staple part of the diet.

Laetrile toxicity studies in dogs

Dogs were fed laetrile and fresh, sweet almonds under various conditions. The doses of laetrile were similar to those prescribed for patients with cancer and ranged on a basis of gram to square meter from an equivalent of the oral dose for man to five times this dose. Six of the ten dogs died of cyanide poisoning. One dog recovered, and three dogs, at the time of sacrifice, demonstrated various levels of neurologic impairment, ranging from difficulty in walking to coma. These studies demonstrate that oral laetrile is highly toxic when taken with some common table foods. We predict that there will be an increased incidence of cyanide poisoning in man as laetrile becomes more readily available.