Parenting and Childbearing in Neurosurgical Residency: Perspectives from the United States and Canada

BACKGROUND

Despite growing interest in family planning alongside surgical training, significant barriers exist including time constraints, stigma, and lack of paid leave and formal policies. We currently lack a deep understanding of the challenges residents face and how practice cultures may prohibit successful policy enactment.

OBJECTIVE

To investigate residents' perspectives surrounding parenting and childbearing during neurosurgical residency in the United States and Canada.

METHODS

A cross-sectional, qualitative study methodology was used, including focus groups with neurosurgical residents. Purposive sampling was employed to capture a broad range of perspectives including stage of training, geographical location, and gender. Data collection and analysis occurred in parallel, using a thematic analysis approach. Data collection continued until no new themes relating to the research questions were identified.

RESULTS

Notable challenges included lack of formal family leave policies, time constraints, insufficient clinical human resources, physical health concerns, lack of lactation accommodations, and lack of mentorship. A subset of barriers were uncovered that stem specifically from workplace cultures, including gender norms, difficulty in asking for help, concerns for inconveniencing others, and pressures to time parental leave during research blocks. Several positive changes were identified including growing awareness and female representation, and benefits of the dual surgeon-parent identity.

CONCLUSION

While parenting during neurosurgery residency is becoming increasingly common, significant practical and cultural barriers persist including a marked absence of formal policies. Culture shifts are essential in ensuring opportunities for life outside of medicine for all residents, irrespective of family status.

Relationship between Anterior Pituitary Volume and IGF-1 Serum Levels in Soldiers with Mild Traumatic Brain Injury History

PURPOSE

A high mild traumatic brain injury (mTBI) incidence rate exists in military and sport. Hypopituitarism is an mTBI sequela; however, few studies have examined this phenomenon in those with an mTBI history. This cross-sectional study of Special Operations Forces combat soldiers aimed 1) to relate anterior pituitary gland volumes (actual and normalized) to insulin-like growth factor 1 (IGF-1) concentrations, 2) to examine the effect of mTBI history on anterior pituitary gland volumes (actual and normalized) and IGF-1 concentrations, and 3) to measure the odds of demonstrating lower anterior pituitary gland volumes (actual and normalized) or IGF-1 concentrations if self-reporting mTBI history.

METHODS

Anterior pituitary gland volumes were manually segmented from T1-weighted 3D brain MRI sequences; IGF-1 serum concentrations were quantified using commercial enzyme-linked immunosorbent assays. Correlations and linear regression were used to determine the association between IGF-1 serum concentration and anterior pituitary gland volume (n = 74). Independent samples t-tests were used to compare outcomes between mTBI groups and logistic regression models were fit to test the odds of demonstrating IGF-1 concentration or anterior pituitary volume less than sample median based on mTBI group (n = 54).

RESULTS

A significant linear relationship between the subjects' anterior pituitary gland volumes and IGF-1 concentrations (r72 = 0.35, P = 0.002) was observed. Soldiers with mTBI history had lower IGF-1 concentrations (P < 0.001) and lower anterior pituitary gland volumes (P = 0.037) and were at greater odds for IGF-1 serum concentrations less than the sample median (odds ratio = 5.73; 95% confidence interval = 1.77-18.55).

CONCLUSIONS

Anterior pituitary gland volume was associated with IGF-1 serum concentrations. Mild TBI history may be adversely associated with anterior pituitary gland volumes and IGF-1 concentrations. Longitudinal IGF-1 and anterior pituitary gland monitoring may be indicated in those who report one or more mTBI.

Sociodemographic disparities as a determinant of fetal versus postnatal surgical myelomeningocele repair

OBJECTIVE

Relatively few women undergo open maternal-fetal surgery (OMFS) for myelomeningocele (MMC) despite the potential to reverse hindbrain herniation, reduce the rate of infant shunt-dependent hydrocephalus, and improve ambulation. These benefits have the potential to significantly reduce morbidity and lifetime medical care. In this study, the authors examined demographics and socioeconomic variables of women who were offered and opted for OMFS for MMC versus postnatal MMC surgery, with the purpose of identifying variables driving the disparity between these two patient populations.

METHODS

This was a retrospective case-control study of patients who underwent evaluation for OMFS for MMC at a single academic hospital from 2015 to 2020. Race/ethnicity, primary insurance type, zip code, and BMI were collected and compared by treatment received and eligibility status for OMFS. Prevalence odds ratios were used to test for associations between each independent variable and the two outcomes. Logistical regression models were utilized to determine significant predictors of undergoing OMFS and being eligible for OMFS.

RESULTS

Of 96 women, 36 underwent OMFS for MMC, 40 received postnatal repair, and 20 either terminated the pregnancy or received care at another institution. Overall, 66 (68.8%) women were White, 14 (14.6%) were Black, 13 (13.5%) were Hispanic/Latinx, 1 (1.0%) was Asian, and 2 (2.1%) identified as other or multiple races. Among women who underwent OMFS for MMC, 27 (75.0%) were White, 2 (5.6%) were Black, 4 (11.1%) were Hispanic/Latinx, 1 (2.8%) was Asian, and 2 (5.6%) identified as other or multiple races. Having private insurance or TRICARE was associated with higher odds of being eligible for OMFS compared with women who were uninsured or had Medicaid when accounting for race and income (OR 3.87, 95% CI 1.51-9.59).

CONCLUSIONS

The population evaluated and treated for MMC was homogeneous and insufficiently representative of the population affected by the disease. This finding raises concern, as it suggests underlying barriers to formal evaluation for OMFS for MMC. Insurance status and BMI have a significant association between the access to and election of OMFS, revealing socioeconomic disparities. This was the first study to explore sociodemographic characteristics of patient populations who may be at risk for limited access to highly specialized fetal surgical care.

Postoperative seizures following endoscopic third ventriculostomy and choroid plexus cauterization: a case series

OBJECTIVE

In this study, the authors sought to investigate variables associated with postoperative seizures following endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) for treatment of pediatric hydrocephalus.

METHODS

A retrospective analysis of 37 patients who underwent ETV/CPC for treatment of hydrocephalus at an academic medical center from September 2016 to March 2021 was conducted. Demographics, etiology of hydrocephalus, operative details, electroencephalography (EEG) data, MRI findings, need for subsequent procedures, perioperative laboratory tests, medical history, and presence of clinical postoperative seizures were collected. Postoperative seizures were defined as clinical seizures within 24 hours of surgery. Eighteen patients received levetiracetam intraoperatively as well as over the next 7 days postoperatively for seizure prophylaxis.

RESULTS

Of 37 included patients, 9 (24%) developed clinical seizures within 24 hours after surgery, 5 of whom subsequently had electroclinical seizures captured on video-EEG. The clinical seizures in 4 of those 5 patients (80%) may have been associated with the hemisphere of the brain through which the endoscope was introduced. The median corrected age of the cohort was 3.4 months. The median corrected age of patients who did not develop postoperative seizures was 2.3 months compared with 0.7 months for patients who did develop postoperative seizures (p > 0.99). Postoperative seizures occurred in 43% (3/7) of prenatally repaired myelomeningocele patients versus 29% (2/7) of postnatally repaired myelomeningocele patients. Of the 18 patients who received prophylactic levetiracetam, none (0%) developed postoperative seizures compared with 9 of the 19 patients (47%) who did not receive prophylactic levetiracetam (p = 0.014).

CONCLUSIONS

Postoperative seizures were recorded in 24% of the pediatric patients who underwent ETV/CPC for hydrocephalus, which is higher than previously reported rates in the literature of 5%. Since 80% of the postoperative electrographic seizures may have been associated with the hemisphere through which the endoscope was introduced, the surgical entry site may contribute to postoperative seizure development. In patients who received prophylactic perioperative levetiracetam, the postoperative seizure incidence dropped to 0% compared with 47% in those who did not receive prophylactic perioperative levetiracetam. This finding indicates that the use of prophylactic perioperative levetiracetam may be efficacious in the prevention of clinical seizures in this patient population.

Adherence to Guidelines for Managing Severe Traumatic Brain Injury in Children

Pediatric traumatic brain injury (TBI) protocols vary widely among institutions, despite the existence of published guidelines. This study seeks to identify significant differences in management of pediatric TBI across several institutions. Severe pediatric TBI protocols were collected from major US pediatric hospitals through direct communication with trauma staff. Of 24 institutions identified and contacted, 10 did not respond and 5 did not have a pediatric TBI protocol. Pediatric TBI protocols were successfully collected from 9 institutions. These 9 protocols were separated into treatment tiers analogous to those in the 2019 Society of Critical Care Medicine and World Federation of Pediatric Intensive and Critical Care Societies guidelines, and the intervention variables were identified and compared across the 9 institutions. First-line therapies were similar between institutions, including seizure prophylaxis, maintenance of normoglycemia and normothermia, and avoidance of hypoxia, hyponatremia, and hypotension. However, significant variation across institutions was found regarding timing of cerebrospinal fluid drainage, hyperventilation, and neuromuscular blockade. When included in institutional protocols, most therapies are in line with the 2019 guidelines, except for diversion of cerebrospinal fluid, hyperventilation, maintenance of cerebral perfusion pressure, and use of neuromuscular blocking agents. Although these variations may represent differences in style or preference, the optimal timing of these specific treatment variations should be studied to determine the impact of each protocol on clinical outcomes.

Pediatric Neurosurgery in Primary Care: Masses of the Scalp and Skull in Children

There are a wide variety of scalp and skull lesions that can affect the pediatric population, many of which are first encountered by primary care physicians. The differential consists of a broad range of more common congenital lesions, sequelae of trauma, and vascular anomalies, to very rare neoplastic processes. It is important to understand signs and symptoms that may indicate whether a lesion may be benign versus life threatening, what imaging studies are appropriate and how to interpret them, and when to seek referrals to specialists.

Local Authority Expenditure Reactions to Losses in Grant Aid: The Case of the Metropolitan District Councils

This paper presents the results of an initial investigation into the expenditure responses of a group of local authorities in England to a loss in grant income. The Government has restricted grant aid to local authorities in an attempt to secure restraint in the expenditure of these authorities, but (until recently) local authorities have had the opportunity to make good any loss in grant income by increasing local taxes. A central issue is, then, how much restraint in local authority expenditure is secured by a given reduction in grant aid. Reduction in grant aid is measured in this paper in terms of its impact on the local tax rate (and the average local domestic tax bill) if a local authority is to maintain the real value of its spending. An incremental budgeting type model is developed and the empirical work is concerned with the financial years 1982–1983 and 1984–1985. It is found that in the later year local authorities have been less willing to reduce their expenditure in the face of loss of grant aid. It is also found that the response of the local authorities has become more political in the sense that a statistically significant difference has developed between the responses of Labour and those of non-Labour controlled councils.