Hello and welcome to the Friday session of the AAMS Pediatric Neurosurgery meeting. I'm Anne Flannery, Pediatric Neurosurgeon in Lafayette, Louisiana. I have been attending this meeting every year since 1984 and have to concede that this meeting is the most exceptional meeting ever. Please remember to visit our exhibitors who support this meeting. Please ask questions, post comments, and join us in the chat lounge for ongoing discussions. And remember to attend the business meeting at the end of the session. Our presentations today include panels, case studies, and the abstracts on the impact of COVID-19, as well as a TED Talk on socioeconomic equity in pediatric neurosurgery. The first two TED Talks will have Q&A immediately following. Today we open with a TED Talk by Pediatric Neurosurgeon Tola Roberts from the Children's Hospital of New Orleans discussing racial equity and pediatric neurosurgery patients. Dr. Roberts. Hello, my name is Tola Roberts. I work in New Orleans at the Children's Hospital. I am on the faculty at the Louisiana State University Health Sciences Center. I am grateful to the section for giving me the opportunity to talk to you today about racial disparities in pediatric neurosurgery. I'm also grateful to my colleagues for their help in making this possible. I have no disclosures. My goals are to review the demographic factors influencing secondary intracranial infections and to use that as a vehicle for considering broader themes of social determinants of health and achieving health equity. The problem of health disparities affecting specific races and pediatric neurosurgical outcomes is not new. A variety of studies in pediatric neurosurgery and in pediatrics in general have documented the problem. We wrestled with the issue after we encountered a series of black males with secondary intracranial infections, thinking this might hint at a disparity that theoretically should be rectifiable. One of our more motivated residents performed the study with the appropriate exclusions, reviewing 14 years of data at our institution. We found what you might expect based on the medical literature. Now patients and patients with public or no insurance were more likely to suffer what were more often synogenic secondary intracranial infections. We also found something that we didn't expect to find, a higher risk among white patients and incongruity. Previous studies have shown evidence of a higher risk among black patients. We attribute the discrepancy to several weaknesses of our article, not least of all the seismic demographic shift that occurred in the city's black population after Hurricane Katrina, a point in time included in the period covered by the study. The population fell by almost 50% and even 10 years after the storm, the black population was still 30% less than before the storm. To be sure, the tragic events of Katrina are themselves an explicit instruction on social determinants in vulnerable populations. Still, the rest of our findings were consistent with what had been shown before, specifically that secondary intracranial infections, primarily the synogenic variety, more often affect males and patients who have public or no insurance. So why are these specific populations at more risk of getting secondary intracranial infections? Chronic rhinosinusitis places patients at higher risk of developing synogenic intracranial absences among the other complications. Black patients and patients with public or no insurance are overrepresented among those with chronic rhinosinusitis presenting to the ER for care, especially at urban hospitals. Their disease is more severe, as reflected in histopathology and synonasal outcome scores. Some reasonably have wondered if this propensity is due to some anatomic, immunologic, or genetic feature. Intriguingly, similar data about synogenic intracranial absences reflected in studies of black patients in South Africa. When we ask why these black patients, poor, uninsured, with chronic rhinosinusitis presenting to urban ERs for care, are at such high risk for secondary intracranial infections, there's another relevant point. A study has shown that they are more likely to delay medical care because of cost. A lot has been said about the opportunity cost decisions that burden poor patients who may have public health insurance or no insurance, who have to choose regularly, too often, between paying for food, electricity, rent, or medicine. This predicament is not apropos of nothing. It has a historical context. And at this point, I would like to take a detour. I hope I'm not being too dramatic, but I would like you to participate in a small thought experiment. Imagine a child born of parents who fled an oppressive land where more than one of their kind is ritually murdered almost every week. That child's parents may struggle to find work in a new hostile place. Perhaps they are scabs at a factory during labor stress. Over the next 30 years, our child grows in a neighborhood segregated by mortgage practices imposed by federal, state, and local law and defended by the judiciary, hindering opportunities for pursuit of education, work, life, liberty, and happiness. Ten years after that, that child, now grown, is able to find residence beyond its previous strict segregated borders, and in so doing, triggers the till-then-settled privileged caste and their accrued economic capital to decamp for greener suburbs and discriminatory covenants. The children of our child, now grown, witness the decay of a city lacking a tax base, beset by a drug epidemic, the plague of HIV, and then the scourge of mass incarceration. The city is bankrupt under emergency management. Austerity measures are enacted. The grandchildren of our child, now gray, have behavioral and learning problems. Is this some cultural thing? Is this genetic? Or is it lead in their blood and in their water? Because this is no fictional dystopian fantasy. This is Flint, Michigan. No doubt this is simplistic, but the story is as foundational as Plymouth Rock. Vulnerable populations are often the first to bear the cost of society's vices, and this country's history has left a large segment of the black population especially vulnerable. Flint, Katrina, COVID, and even the relatively small numbers of cyanogenic intracranial infections bear witness to that fact. There are two works that I would like to draw your attention to. One is the Pulitzer Prize-winning work by Isabel Wilkerson, The Warmth of Other Suns. The other is Richard Rothstein's near epic defining the color of love. Together they offer an informative and often harrowing narrative putting faces to the challenges, failures, successes of black ancestors of the great migration of the Jim Crow South and the federal concerted effort over decades to marginalize them. Perhaps a few definitions are in order. Social determinants refer to conditions defining birth, growth, work, living, and aging in a community and are primarily responsible for health inequities. These are the social forces that govern the distribution of wealth, influence, and opportunity at all levels, not unlike the government practices we just described, and their impact can long outlast the lives of a relevant policy. Health disparities refer to health differences from environmental or socioeconomic disadvantages linked to the identity of the individual, be it race, gender, religion, class, caste, sexual orientation, educational status, employment disability, or incarceration status. Achieving health equity prioritizes overcoming such obstacles so each person has a fair chance to be healthy. Do providers and medical systems contribute to health disparities? Yes, although this is more properly referred to as health care disparities, and in the case of this research population, secondary intracranial infections, it has been shown that during primary care appointments, patients with rhinosinusitis and public or no insurance receive significantly more time with their provider than is their provider of choice or the provider or someone in that provider's practice, suggesting that they're receiving at the very least a proxy of good care. The problem then is getting them into the provider's office. Does the behavior of the individual contribute to health disparities? Certainly. It is not a healthy choice to delay seeking necessary care. However, one cannot simply overlook the impact of a socioeconomic system maintained over decades to the detriment of its inhabitants, its effects so enduring that present-day patterns of racial segregation in major cities still mirror the red line zones of the past. As Faulkner wrote, the past is never dead. It is not even the past. This is an illustration taken from a publication in 2010 by the World Health Organization. I'm grateful to Dr. Ebony Price Abel for showing it to me. It shows that the role of the provider is far downstream of more dominant forces, social determinants defining opportunities in life, predisposing the disadvantaged to health inequities by way of progressively limited education, occupation, income, and then further limited material circumstances, environmental circumstances, behavior, and mindset. It's important to keep this framework in mind when considering our roles as providers to mitigate the impact of social determinants. We can only do so much, but we can certainly be mindful. This is what I have in mind when I read that Black uninsured patients eventually present to urban metropolitan ERs with more severe forms of disease, in part due to the fact they are more likely to delay medical care because of cost. It strikes me as a question of access to health and is influenced by, if not a product of, social determinants, all of which resonates with the fact that research repeatedly shows families without insurance and of lower socioeconomic status have decreased access to primary care and unmet health needs and worse outcomes across different diseases. Increased access can imply inhibitory costs and inflexible work schedule, a lack of child care, extended travel, or lack of transportation, distrust of the medical establishment, lack of specialty care, or some combination thereof. How can we make it better? The pursuit of health equity requires acknowledging that health disparities exist, seeking and identifying disparate outcomes and their probable causes, targeting those causes with research-driven interventions, and assessing the effect of corrective measures. For instance, in the case of cyanogenic intracranial infections, that could mean educating primary and ER providers and the public of the higher risk categories and the severe complications of inadequately treated sinusitis. It could also mean providing more timely monitoring follow-up via labs, imaging, or the gift of 2020 telemedicine. This sort of work is emphasized by national agencies like the Agency for Healthcare Research and Quality, the Department of Health and Human Services, and international organizations such as the WHO, all of whom recognize it, rightly so, as a measure of quality of care. I am encouraged by the contributions of many leaders in the pediatric neurosurgical community in this vein, both in the literature and on the ground, in the United States and around the world, who keep us all in good stead. Thank you for your time, and here's wishing you a peaceful New Year. Be well. Hi, I'm Jeff Blount from UAB. Welcome to our session that's going to talk about racial and socioeconomic equity in pediatric neurosurgery. It doesn't take long in a conversation of this nature before one comes to the concept of disparities. Disparities are a difference in outcome that arises as a result of being a member of a particular group. The COVID-19 pandemic has thrown the curtain back on disparities across our nation. It doesn't take long in a conversation of this nature before one comes to the concept of disparities. Disparities are a difference in outcome that arises as a result of being a member of a particular group. The COVID-19 pandemic has thrown the curtain back on disparities across our nation. In our home state of Alabama, the percent of the population that's African American is about 24-25. The outcomes from COVID reflect outcomes in many other disease processes as well, including the very important chronic diseases. The rates of obesity in African Americans are 38 percent, whereas in Caucasians, 26. Hypertension, 54 percent in African Americans and 46 percent in Caucasians. Diabetes, 16 percent in African Americans and about 11 percent in Caucasians, 5 percent. And health outcomes are just part of the picture. Economic and social features also show significant disparities. In 2020, we were fortunate to match with Lauren Simpson from the Oregon Neurosurgery Program, who's a bright, engaging, thoughtful person, and I want to share with you over about the next 10 minutes a reflection of some of the conversations and discussions that we've enjoyed over the last six months. Lauren will introduce the very fundamental concept in public health of social determinants of health. Social determinants of health are the underlying cause of today's major societal health problems, including obesity, heart disease, diabetes, depression. Data-driven research indicates that resource allegations to social determinants of health have a greater impact on population health than health care medical expenditures. These social circumstances create societal stratification and are responsible for disparities. They include intangible factors such as political, socioeconomic, and cultural constructs, as well as place-based conditions, including accessible health care and education systems, safe environmental conditions, well-designed neighborhoods, and availability of healthful food. And complex interactions and feedback loops exist among the social determinants of health. For example, poor health or lack of education can impact employment opportunities, which can in turn constrain income. Affordable housing limits access to grocery stores and healthy food options. Together, these increase hardship, which cause stress. Stress promotes unhealthy coping mechanisms like cigarette smoking and overeating. So we've learned that in order to achieve large and sustainable improvements in health outcomes, we need to address these. This requires engaging sectors other than health systems and services, including employment, transportation, housing, education, public safety, food access. Of the many social determinants of health, which ones do you think are the most important, perhaps either in COVID or in neurosurgery? 42%. Let's back up for a moment to some definitions that are not necessarily self-evident. So what is equity and how is it different from equality? While equality infers a sameness across groups, equity infers a fairness such that all groups become capable of attaining the same things despite their differences. In order to achieve equity, we must value all individuals and populations equally. We have to recognize and rectify historical and contemporary injustices, and we need to provide needs-specific resources. This pattern is seen in many other states. Inequity is a system of structuring opportunity and assigning value. It unfairly disadvantages some, unfairly advantages others, and saps the strength of society through the waste of human resources. Race is one of many risk factors used to establish inequity. It's in quotations because it's a social construct and not a genetic concept. Sadly, health disparities provide a way for us to measure our progress towards achieving equity, and health disparities just refer to any differences in health between groups. A good example is COVID. Black people or people of African descent have a positive rate 2.4 times that of white people, and together with indigenous people, black people have a death rate of over two times that of white people. We need to address social determinants of equity, namely racism, in order to achieve social justice and eliminate health disparities. Inequities are created when barriers prevent individuals and communities from reaching their full potential. Rule. Inequity is created when barriers obstruct the way and prevent individuals, institutions, communities, and systems from reaching their full potential. Achieving health equity will require optimization of conditions in which people are born, grow, live, work, learn, and age. Public health. Do you have a unique perspective on disparities? And that is the outcome. Do I have a unique perspective on health care disparities? Part of me wants to say, no, I don't have a unique perspective on health care disparities. My experience is unique because it's my own, but I in no way represent the, you know, every woman of color, and there's a lot of variety, and we all have different experiences, and I in no way want to act as a representative. So that's what part of me wants to say, and the other part of me wants to say, of course I have a unique perspective on health care disparities. I'm a woman of color, and being black is bad for your health. I'm not protected by my white coat, by my degrees, by my job. At the end of the day, when I go to the doctor, I face the same outcomes as women who have fewer resources but are white. So now back to the original question of the many social determinants of health, which one do I think is the most important? So this is why I lead explicitly, though not exclusively, with race as the most important social determinant of health, because racial inequities persist in every system across the country without exception. We can't find an example of a system where there are no racial disparities in outcomes. If you look at health, education, criminal justice, employment, and so on, baked into the creation of the ongoing policies of our government, media, and other institutions, unless otherwise countered, racism operates at an individual, institutional, and structural level and is therefore present in every system we examine. Racism must be named as a force in determining how social determinants are distributed. Health equity is a goal that we can achieve. It's within our power to do so. We have the tools, we have the knowledge to make health equity happen, but it's up to all of us to use them. Is race relevant? Yes, of course it is. It's relevant to discuss in academic medicine, but it's because it has profound impacts on health because of social inequality and not because of purely biological differences. Have you seen examples of where a provider said something insensitive without their own awareness? Where are these traps that we can all fall into? When I was doing a rotation during medical school and there was a primary care practitioner who was seeing a patient and said that when he uses the N-word, he uses it just to refer to a lazy person, to refer to a lazy person, not like, you know, to be an offensive term. Just kind of matter of fact. There was the time that an attending who I was working with stopped rounds in the ICU in front of the team to ask what I had done with my hair or what was going on with my hair because I was wearing it natural. So I have two internationally adopted kids and my family's experience is that uniformly the most painful comments don't come from the people that are really ugly. We've only had ugly comments maybe two or three or probably maybe five times across the course of their lives and they're both in their 20s right now. So I won't say it's zero, but it's darn close to zero as far as people really being ugly. Okay, that's happened a time or two. But the painful things that have happened across the course of their lives are well-intended kind of non-thinking people that come up and say things that are kind of in the moment trying to fill in the gap of silence and say something that's really awkward, that's really uncomfortable, that's really, really inappropriate, right? Oh, are they really brothers? Or, oh, what about your real kids? You know, I mean, things like that. It doesn't come from a place of bad intent on the person's part, but it's just so painful in the moment because you don't... Someone who's ugly, you can just respond and go, you know, but someone who's trying to be nice, but it's kind of being silly or stupid, you don't want to do that. And so it's always that awkward moment of like, uh, yeah, well, thanks for your comment, but you're so far off base that it's like, we don't even have a place where we can, you know, reach common ground here. Racism occurs on three levels, individual, interpersonal, and institutional. So if we want to combat racism, how do we do it? Step one is combating individual racism, developing your own racial identity. What components of your identity are the most important to you? Where does self stand in relation to the rest of the world? Step two is interpersonal racism. So after you've uncovered your own bias, be self-critical about how your biases affect your behavior. Be actively anti-racist. We know that you're fundamentally a good person, but being racist or anti-racist is not about who you are. It's about what you do. And this requires ongoing self-awareness and self-reflection as you move through life. Step three is a little bit more tricky. How do we combat institutional racism? It's about, it's about reaching out to others, reaching out to your peers, creating educational programs, removing individual discretion from policy and finding objective measures to ensure that we're not reinforcing systematic racism as we go forward. Just some advice. Be sympathetic about how race, gender, the intersectionality of those two, and bias affects people's perceptions and the impact that it can have on an individual over time. Acknowledge that maybe you can be off base sometimes about accusations and that you, maybe you're projecting behavior based on your past experiences that you're not aware of. Good afternoon, I'm Clarence Green. Nine months into this COVID disaster, all of us have been impacted one way or another. We've lost our friends, we've lost loved ones, dear colleagues, and of course patients to this virus. Many of us have experienced significant practice disruptions, revenue hits, and practice integrity problems. Today we're going to hear how the COVID epidemic has influenced our first responders, our neurosurgery residents. Our residents are always in the front line in any emergency or disaster, and this has been no exception. While hospitals were scrambling to find beds to take care of the onslaught of the COVID patients, ORs were closed, routine rounding was disrupted, conferences were either canceled or taken off to be online. The usual pathways in which we interact with our trainees were severely disrupted and perhaps permanently. We invited representatives of programs in the cities around the country, which were hot spots for the COVID epidemic, to share their experiences with dealing with this problem. We wanted to hear about their emotional health and how they coped with their well-being. We want to understand how the interruption of elective surgeries have impacted their education and clinics and so forth and whatnot. We also want to know if they have found in the midst of this chaos any positives in their educational environment. So today we're lucky to have participants from around the country to share their experiences. We're going to have Dr. Jared Robeshaw from New Orleans, Dr. Yosef Dastagirzada from New York, Dr. Konstantin Karas from Chicago, and Dr. Rajeev Desen from Seattle. I think this will be a very interesting discussion, and at the end of their presentations we plan to have that opportunity for questions and answers by way of the Zoom chat function. Thank you again for being here, and we hope you enjoy this panel. Good afternoon. My name is Jared Robeshaw, and I'm a fourth-year resident at the Louisiana State University Department of Neurosurgery in New Orleans. Thank you for letting me take some time to discuss how COVID-19 impacted our pediatric neurosurgery rotation at Children's Hospital of New Orleans. I have no disclosures. Louisiana State University Department of Neurosurgery in New Orleans is located at several hospitals in the New Orleans area. It includes neurosurgical specialists in all areas of the field. In addition, the department is represented by neurointerventionalists, neuro-oncology, and neurocritical care. I was at the beginning of my pediatric rotation when COVID-19 began making an impact in our area. As cases progressed and hospitals became inundated with patients with COVID-19, it became clear that this was something that was going to be dealt with for a while. The impacts to the area were swift and seen early. Local businesses were closed down. Festivals were canceled. In addition, impacts were made on residency and education. The ABNS board exam was postponed and elective cases were canceled. In response to COVID-19, our residency decreased the size of our services. In addition, clinic services were transitioned to telemedicine and conferences were transported to Zoom. During the elective case ban, our service stayed busy with an influx of shunt malfunctions and trauma cases. In contrast, our service prior to the COVID-19 restrictions included a more diverse caseload, including epilepsy surgeries that were delayed during the COVID shutdown. COVID-19 presented our hospital with many challenges. We were able to meet these challenges with improvements. We were able to integrate telemedicine and Zoom to continue patient care and educational activities. Online educational resources were made widely available. This showed the resilience of neurosurgery education and patient care, even in the midst of a pandemic. During this time, there was a loss of case diversity and resident education through direct interaction. However, those can be made up for in the remaining years of residency. As for future considerations, I think it would be interesting to look into the rate of shunt malfunction diagnosis during the lockdowns in other areas. Our service saw an increase in these cases. I think it would be interesting to pull data and show if there's any statistical increase in shunt malfunctions and look into the causation. In addition, it would be interesting to look at rates of pediatric trauma during the lockdown, as our service saw an increase in pediatric trauma related to patients no longer being in school. Thank you for your time and the remainder of my time will be used for further questions. My name is Yosef Dasirzada and I'm a fourth-year neurosurgical resident at NYU Langone Health. Today I'd like to share with you our brief experience from New York City during the peak of the pandemic. March was quite an interesting month as we were starting to hear about the virus more frequently every day. My first memory of this being an issue for us was the policy enacted to start canceling our elective cases. I remember studying from the critical care Bibles the night before my first shift covering the COVID ICU. It was complete chaos when I walked in to pre-round on my patients the following morning. It genuinely felt like a war zone with materials, medications, IV pumps, and crash carts outside of the rooms. The clear doors of our patient rooms were covered in black marker with HPI data, most recent ABGs, goals for the day, ventilator settings, and so much more. Rounds would start with a generous team, each member knowing the specific details of their patient to the T. Soon into rounds we would all run to one patient room as they desatted to the low 80s, refractory to the normal troubleshooting that our amazing neuro ICU nurses had quickly become comfortable with. We would stat page the prone team as it seemed to be the only remedy for a select population to fix the dampened blue curves on their vitals monitor. Soon after we'd hear another alarm from a neighboring room. Hypotension and desaturation this time. Was it a PE? Heart failure? The differential continued to expand, troubleshooting each patient as their alarms called for our team. Eventually we would get through rounds having fought against the pericodes that seemed to be never-ending throughout the day. It was amazing to see the COVID algorithm develop in front of my eyes. Throughout medical school we would hear about how the management of HIV AIDS during the pandemic would transform in real time as those afflicted with opportunistic infections arrived in ICU. From our COVID ICU experience we would catch the patterns of hypercoagulability in our patients and start heparin drips, or the early signs of renal failure that would get us ready to start dialysis when appropriate. We learned alongside the rest of the world as we all tried to figure out this new monster. Out of such horror I can definitely say a lot of positivity was born. There was a new sense of collegial friendships that developed over the week as we rounded together with GI fellows, cardiologists, etc. Our neuro ICU nurses and our staff had never been closer. I had seen my neurosurgical attendings become some of the first quote-unquote non-medical doctors to step up to the plate and volunteer their time in the unit. One of my most cherished memories will forever be the times I would get sign out for my neurosurgery attendings on patient progress on the floor. The delicate surgeon who was teaching me how to slowly peel pituitary macro adenomas off the cavernous sinus weeks prior was now giving me updates and goals for our COVID patients. Every surgeon carries with himself a small cemetery where from time to time he goes to pray. The fragility of life never felt so real and Henry Henry Marsh elegantly describes how impactful our patients are to us and how important reflection is throughout our careers. The COVID pandemic in New York City was a true horror story for many of us and our small cemetery unfortunately grew. That being said the weeks I covered in ICU were life-altering. I became a better doctor as I refined the intricacies of ICU medicine that I fell in love with as a medical student. I was still able to form connections with my patients and their families even if it was over a daily update phone call or FaceTime. I'm proud of the few people that I weaned off the ventilator and excavated who soon after would finally be reunited with their loved ones. I'd like to dedicate this short talk about my experience to my Aunt Fatima who succumbed to the virus on my first shift covering the COVID ICU and my two grandparents who so valiantly fought the virus and won. You were my fire throughout this period. Thank you to my amazing co-residents especially those who tirelessly maintain the busy NYU Neurosurgical Service even in the absence of our normal case volume. I'd like to think we lived up to the NYU neurosurgery way with all hands on deck and ready to work. I'm so lucky to work alongside such incredible human beings and to our nurses and staff for fighting on the ground every day. You are the true heroes. Thank you. Hi my name is Constantine Karas and I'm a PGY4 at Northwestern. COVID has had a profound impact on our department and hospital particularly during the months of March through June. At that time nearly all of our ICU beds were filled with COVID patients including our neuro ICU. To accommodate this all elective cases were terminated for several months. During that time we only performed about 5 to 20 urgent to emerging cases per week as a department. You can see here my case log before, during, and after the height of the pandemic. I would estimate that during that time as a PGY3 I missed out on about 50 operative cases. That number is certainly much higher for our more senior residents. Other forms of clinical experience also suffered during that time including seeing and staffing new consoles for the junior residents because we were placed into smaller teams to avoid increased simultaneous exposure. To fill the educational void residents embarked on self-study and board studying, new research projects, skull base and cadaver labs in small groups, and double scrubbing when safe and able to do so. Virtual and remote learning also took off as a new modality for resident education. Some examples are listed below. Our Grand Rounds fully transitioned to virtual on Zoom and Teams. This has been nice for guest speakers from other departments eliminating the need for travel. Our Friday resident didactics have also fully transitioned to virtual. This was especially nice leading up to the May written boards as we were able to virtually host board review sessions every week. It's become clear that other departments also have recognized this need for new educational material during this difficult time. Groups such as Virtual Spine and the University of Miami Lecture Series have been created and they've been a nice collaboration across multiple departments to create new educational material for residents and attendings. Dr. Albright has generously donated his time to meet with our residents once a month and discuss new pediatric neurosurgical cases and management of complex pathology. Other small conferences that take place every week such as our Lurie Indications Conference continue to take place virtually as well. COVID has had a devastating impact on our society and neurosurgical departments across the country this year. In spite of this, I believe that there is a silver lining. It has inspired innovation and creativity to create new forms of education for residency training. In addition, it's demanded flexibility and sacrifice from both residents and attendings alike. I do believe that this has created a sense of camaraderie and a feeling of coming together for the common good of both the department and society as a whole. While we all look forward to one day being able to gather together in large groups with our departments and across other departments and the softball tournament, I do believe that virtual learning has had a profound impact on the resident educational experience and is here to stay. That's the end of my presentation. Please let me know if you have any questions. Good evening everyone. My name is Rajiv Sen. I'm a fourth-year resident at the University of Washington in Seattle. I'm going to give a quick talk on a project that was born during our isolation and quarantine due to the COVID pandemic titled the Home Microsurgery Lab. So COVID in Seattle came early and hit us hard. Basically by March 14th we canceled elective cases and by March 23rd we were in a stay-at-home order and that's when this project was conceived. We designed our Home Microsurgery Lab, the HML, by basically using the internet to put together a list of cost-efficient and commercially available equipment to practice microsurgery at home and then we developed a detailed training program using literature review, reviewing the ACGME competencies and milestones, and consulting with our two senior authors, Dr. Ellen Bogan and Dr. Shaker, who have vast experience in practicing microsurgery and training residents. Here's the list of supplies that constitute our lab. It sums up to about $850. It includes a microscope, camera, instruments, sutures, etc. and the cost can be greatly reduced by residents simply sharing equipment, which is fairly easy. Here is just a picture of our setup and then we spent many hours experimenting with various materials and exercises to come up with our five levels of competency in the Home Microsurgery Lab. Just going into more detail, levels 1 through 3 are designated for interns, juniors, and mid-level residents. The exercises focus mostly on basic micro instrument manipulation and suturing techniques, running sutures, suturing in different patterns and at different depths, and then precision exercises using threads of gauze, and then we even use fruits such as blueberries and grapes to practice arachnoid dissection and tumor capsule dissection by peeling the skin. And then levels 4 and 5 are for more advanced residents, chief residents, fellows, and even attendings. These focus on anastomosis techniques, first using PVA tubing and then advancing towards the well-described turkey wing and turkey leg models. Here we show what we call the U-drill, where we use simply two vessels to practice all anastomosis techniques, end-to-end, end-to-side, and side-to-side. And you can increase difficulty using cardboard tubing to increase your depth and decrease your working space. So basically, in conclusion, this is how we spent our quarantine time. I think it's a great example of how innovations during COVID led to advances in our field and finding new ways to master our crafts and be better even when we're not in the hospital. Here's our work if anyone's interested in learning more about the lab, and I'm happy to take any questions. Hi, good afternoon everybody. I hope you enjoyed those presentations, which were very moving in many regards. I had some questions, but we're going to get first, I want to introduce you to my co-moderator, Lori McBride, who's also going to have some questions for our panelists. I think one of the most interesting or more moving one was from Yosef and his experience in New York City, and it was quite moving. But my question for Yosef is to start out, when somebody came to you and said, okay, forget this neurosurgery business, you're going to become a critical care doctor tomorrow. How did you mentally prepare for such a thing like that? Thank you for your question, Dr. Green. I apologize if it was a little too dramatic. Listening to it now, it seems a little more dramatic than I had attended, but it was a pretty dramatic time. And when they asked us, especially some of the residents who decided to volunteer, I think we were all not excited, but ready to go. I think a lot of us, especially having worked at Bellevue, really enjoy the critical care component of being a neurosurgeon, and we kind of lose that in our junior residency as we start to operate more. So I think we all kind of love the intensive care part of it, and we're ready to take it on. We all really didn't know what to expect, but we were all pretty excited to kind of be part of that. One of our senior residents actually made kind of a cheat sheet about like all the respiratory kind of ventilator settings and things like that that we maybe haven't had so fresh in our minds more recently, and we definitely kind of studied a little bit before it started. But as you all know, nobody was an expert in COVID at that time, and we all kind of learned together as it continued. I was very struck with your comments that in the midst of all this chaos, which people could have just gone bananas, but it seemed to bring your team closer together and better relationships with your nurses and with your attendings. I found that to be quite remarkable, and it sounded like a very positive thing that came out of such a very stressful situation. Yeah, I mean, signing out to our attendings about our patients was the whole experience that I never would have imagined. You know, we obviously talked to our attendings about our neurosurgical patients and kind of the plans for the day, but going systems-based about really critical patients and talking about the day-to-day activities and what our goals are for the day with our own attendings, who obviously have done their ICU rotations much farther back in time, was really, really a moving time to kind of come together as a neurosurgical team. Well, it looks like you've come through the dark spots much with flying colors. I really appreciate it. I had a question for my resident, Jared, who noticed an interesting change in the kinds of cases that came through pre-COVID shutdown and during the shutdown, and there was an increased number of pediatric trauma, and I'm not sure I heard what the etiologies of those traumas were. Was this sort of household injuries, or more ominously, were the number of pediatric trauma cases related to abusive head injury or non-accidental trauma kind of things? As far as the trauma, I think it was a broad variety. Of note, there was several gunshot wounds in the early days of the COVID lockdown where kids were no longer in school. I think there was four or five people that came in the first couple of weeks with gunshot wounds to the spine and head. We're in the process of looking at those numbers. We'd like to see and look deeper into them, see what kind of impact that keeping kids out of school and the COVID lockdown with parents, some parents still being at work and kids being at home, unsupervised, could have on the well being and pediatric trauma. Lori, did you have any things at the top of your list that you wanted these doctors to elaborate on? I was sort of wondering maybe just for the whole panel, since you all went through it, in a few years, if you're, when you're an attending, maybe you're the program director at a program, what would you do differently to try and sort of get a program ready for one of these catastrophes? Just from anybody. Nobody knows. Going to have to practice, yeah. It's a good question. I think, especially during residency interviews, a lot of like problem solving and team management kind of comes in, comes up as an interview question. And I think that engages a lot about how ready people are to kind of really just be a team and go solve an issue together. I think that's a good question. I think that's a good question. I think that's a good question. And go solve an issue together. I think as many of our programs have encountered, we kind of had a skeleton crew here at NYU where a few residents were really just the neurosurgical residents 24-7. And the COVID residents were taking care of COVID patients during that time. So nobody would have ever imagined that we would have to break up our residency for that time. And I think just being a great team and kind of looking out for each other and making sure that our attendings that were older and kind of at higher risk weren't in the hospital more and just kind of stratifying like that, I think was a, just comes when things go wrong. Unfortunately, you just have to have a good team that will support that. Constantine, I had a question for you. Your comments, since I'm very much interested in how this impacted your education and you had mentioned that some of the other departments had come together to enhance this virtual learning experience. Could you expand on that a little bit for me and what departments were really instrumental in working with your neurosurgery group? Yeah, I think, well, I mean, the things I described with our program and in terms of a lot of online teaching and grand rounds going virtual, I don't think that was unique. I mean, it's a unique time and I think it's interesting how all these departments adapted and continued educating residents through it. But I think, I noticed also that there were a lot of collaborations between like different departments. I know that one of our attendings, Dr. Doddle, it was part of this like virtual spine group that did weekly presentations and talks. They invited speakers about different spine topics from across the country and then opened it up for discussion panels afterwards. And that was definitely like a multi-departmental collaboration. I think it's still going on. I know our attending Dr. Koski just gave a talk a few weeks ago that we attended. And then there are some other ones too, like lecture series online. I know University of Miami had organized some where they had different panels about different discussions and even like debates and moderators. So I thought it was interesting how, obviously each department did what they had to do for their own residents, but I thought it was interesting how different departments came together and created like educational material that was a collaborative effort. How do you think going forward at the end of the pandemic, these lessons or these different maneuvers will play out in the future? You think that's gonna be there to stay or, and even enhanced upon? What do you think? I think so. I mean, I hope that we go back to, in some ways we go back to the way things were and especially in terms of, for example, this meeting, like I look forward to these meetings being in person other years. But I think that a lot of that is definitely here to stay, especially the collaboration between different departments. I mean, it's so easy to, Grand Rounds there's something nice about having them in person and having invited speakers come and meet with the residents and meet with the department and everything. But I think it enables us to like, kind of do that so much easier now. And you can have an invited speaker from a different department and they can present virtually on Zoom and it can still be like a really educational experience and a nice experience for the, both the speaker and the host department. So I think a lot of that is here to stay and it's hard to obviously travel and go away from your practice for a few days to give a lecture. So I hope we go back to the way things were in some ways, but I also look forward to seeing how people incorporate this. Okay. Thanks. Thanks for that. I have an open question for all the residents in terms of how this epidemic and shutting down of elective surgery has impacted your education or how do you feel it's impacted? And the second part of that is, do you think you've caught up or it will be a problem down the road? Anybody? From my perspective, I think that during the elective ban, one of the areas that was hit hard at our pediatric hospital was epilepsy cases. And I kind of missed out on a large number of those and they were pushed back to after my time on the pediatric service. But I feel like I'll make up over the time with that, get back over here and do the cases and have that experience before I graduate. But definitely something I missed out on. We did have a question from the group. Dr. Drepo was wondering if anyone on any of your services had a pregnant, either resident or attending and how you manage that around COVID? We had one of the chiefs had given birth right before the COVID crisis hit and we were able to accommodate whatever she wanted to do. I think early on in the COVID crisis, people were unsure what the effect it was gonna have on children and babies. So we were able to support her through that. It was an interesting time. Yeah, we didn't have any pregnant residents at the time, but in terms of caseload, you know, we slowed down elective cases for probably three months, but it was, and it remained a little slower than usual through the summer too. I think patients were just hesitant to get completely elective surgery performed. I think it definitely impacted training. I mean, I kind of went through the numbers myself and I probably missed out on like 50 plus cases that I otherwise would have done. We were still doing some cases, obviously. And I think it impacts training, of course. I mean, every missed case is a missed learning opportunity, but I think, you know, people realized that this was an issue for every resident in the country and there are bigger problems at hand and you just have, you do what you have to do for the common good and to get yourself by from an educational perspective. I have a little bit of a different perspective on, yeah, I mean, we had a drop, obviously had a drop in case volume. I was rotating in the beginning of the pandemic. I was at our pediatric hospital and I was doing, you know, every other day, not in the hospital. So my case volume went down, but being, I'm in my fourth year, kind of getting ready for my research year. It was an interesting, somewhat opportune time to have more time on my hands, getting research done, getting grants done. So it was a different, I guess, perspective that many neurosurgery residents have never had, which is having full days to do the dedicated research and academics. So I will say, I hope I took advantage of that positive. Excellent, things quieted down in Seattle now. We're hearing different areas of country that are really on fire, but I haven't heard anything in the news recently about the Northwest. Yeah, well, I mean, it's still, I think we're also in the trend of things are escalating, certainly. I think we, I just got an email this morning, our inpatient numbers are as high as they were back in the spring. So still going up. Seattle itself, just, we're starting to roll back some of the orders on closing restaurants and such. So it's still pretty active here. I think we have under a minute left before the next session. I just wanted to let everybody know that this next session is great. It has sort of a lot of rapid fire presentations and a little bit of something for everybody. If at all possible, I'd like to encourage everyone to stay tuned to the very end. There's a talk from Becker Hall, who's the CEO of Hogs for the Cause. If you're not familiar with them, they're a wonderful foundation with kind of a funny name. They give grants to the families of our patients. So please stay tuned for that. Yeah, that's a very good point. And they're doing great work in not only individual families, but they're developing sort of a Ronald McDonald type prototype home, a Hogs for the Cause home. Hogs Family Center here in New Orleans, and they're getting ready to break ground up where Lori is in Baton Rouge on a similar facility. I think in the interest of time, I would encourage the audience, if they have other questions for our panelists, to go to the conversation lounge and continue this chat and get to know these excellent, fine young neurosurgeons a little better. We do appreciate the fact that you took your time today and listened to our presentation and our discussion, and I hope it was useful to you. So thank you. Lori, was anybody typing anything? Any questions on the chat function? Yeah, the main thing on the chat function was, I had posed a question to the group as to what sorts of changes we saw in case types during COVID. And we saw a lot of gunshot wounds to the head and ATVs. Most everybody else was commenting, they saw gunshot wounds to the head and non-accidental trauma looked like the top. Is that what y'all saw as well? Anybody? Yeah, similar case mix from us. Now outdoor sports are big around here. So as kids weren't in school, we saw them, ATV accidents very frequently. And then ATVs definitely help. We didn't see many gunshot wounds, but we did see more just like NATV patients coming. For sure. Okay, very good. How much time do we have left, Lori? I mean, time for any more questions? Okay, well, thanks everybody. We appreciate all your attention and your cooperation in this project. Thank you. Thank you. Good afternoon. Thank you to this section for giving me the opportunity to discuss the clinical outcomes of the Spoken Sickle Cell Devascularization Study. Stroke is one of the most devastating complications in sickle cell disease and has a high incidence in childhood. It's estimated that about 11% of children before the age of 21 develop strokes if left untreated. The current standard of care is regular blood transfusions to keep hemoglobin S less than 30%. This results in 92% reduction in risk of stroke. However, it can still occur in about 13% of children. It appears that children, it appears that children with Moynih-Moynih Syndrome in sickle cell disease have a higher risk of stroke. In one study, it was almost double. In our study, we sought to determine if revascularization surgery decreases stroke rates in children with sickle cell disease and children with Moynih-Moynih Syndrome. We required that participating centers have an active sickle cell program practicing best medical treatment and have the additional capability to treat patients with revascularization surgery. Outcomes were cerebrovascular events comprised of stroke and TIA, death and treatment-related complications. These were the collaborating centers along with their principal investigators. We are very grateful to all the centers and their research staff for putting in all the work to enter the data. We were able to collect 121 patients, 69 in the surgical group, 52 in the conservative group. Both groups were similar in demographics and in different aspects of medical treatment, including chronic transfusion treatment, hydroxyurea intake, antiplatelet intake, and chelation treatment. The follow-up time mean was about eight to nine years. Surgery-related complications included subdural collections, wound problems, and seizures, comprising about 60% of total surgeries. Complications from medical treatment included vaso-occlusive crises, acute chest syndrome, spenic sequestration, and dactylitis. There were no differences in medical complications between the two groups. We found that the mean number of cerebrovascular events and cerebrovascular events per 100 patient years were significantly decreased in the surgical group. This finding was reflected in the Kaplan-Meier survival curve. This curve shows the furthest follow-up of almost 20 years, showing a significant difference between the two groups. If we truncate this to 10 years, there was still a significant finding, and 90% of surgical patients did not experience CDEs versus 48% of medical patients up to 10 years or on last follow-up. Next, we looked at antiplatelet intake. Again, there was no difference in intake between the two groups. However, we found that there were less CVEs seen in those taking antiplatelets than those that were not. We performed a multivariate analysis of the factors that can affect CVEs, including gender, age, antiplatelet intake, and surgical treatment. We found that both antiplatelet intake and revascularization surgery showed significant reduction in risk for CVEs. For antiplatelet intake, it was about 52% compared to those who did not take antiplatelet treatment. And for revascularization surgery, this is larger, 80% versus those that were treated only medically. Age also increases the risk, but to a lesser degree. So in conclusion, children with sickle cell disease and Moyamoya syndrome who underwent revascularization surgery have substantially less cerebrovascular events occur than those undergoing medical treatment alone. This surgery is safe. Also, we found that antiplatelet intake has a protective effect when compared to those not taking antiplatelets. So next steps, some centers are still entering data. Once this is done, we can analyze further the CVEs and break them down, hopefully, into stroke and TIA rates. For future studies, we are conducting a radiation study and a radiology study, and a survey of surgical practices. And we'll be engaging in the design of a prospective study and considering randomization. Thank you to our research center staff, our collaborators, the pediatric section, and the SOX Center at Vanderbilt. I hope this message finds you well. It's a privilege to present this work highlighting the progress and impact of the Hydrocephalus Clinical Research Network on quality improvement in clinical research in pediatric hydrocephalus. The objectives of this talk are shown here. The purpose is to highlight the collaborative multi-center model that the HCRN has implemented and to contextualize its bibliometric impact. Of note, this work is not affiliated with the HCRN itself. The HCRN was formalized in 2006 by the National Center for Clinical Research in the United States by Dr. John Kessel at the University of Utah. Over the next 12 years, a steady rate of growth eventually yielded a total of 14 HCRN centers across North America. In 2019, the HCRN initiated an implementation arm known as the HCRN-Q, comprised of 26 centers across North America. The goal of this arm was to facilitate expanded quality improvement activities by enabling real-world benchmarking of proposed initiatives. Such an expansion highlights a network's foresight in overcoming key hurdles in robust clinical research, particularly within pediatric neurosurgery, where the small pool of patients and necessity for multi-center generalizability can be limiting. Over the period from 2008 to 2019, the HCRN has published 23 articles with a steady output of approximately two articles per year. These articles have also accrued citations at an appreciable rate. The citation network of the HCRN publications reveals clustering of citations with particular HCRN publications, highlighting the highly focused research questions within each study. In order to further contextualize the bibliometric characteristics of the HCRN, we assembled a manually curated set of non-HCRN publications over the same time period from JNS Pediatrics and Neurosurgery. Primary clinical research articles focusing on pediatric hydrocephalus were included, yielding a total of 296 non-HCRN publications. Using either PubMed or Scopus citation counts, we identified a higher citation rate for HCRN publications as well as a greater number of prospective studies. Additionally, the time to first citation was shorter for HCRN articles, and the number of patients in HCRN studies was also higher. Given the emphasis on quality improvement protocols in pediatric hydrocephalus, HCRN articles were more likely to be focused on shut infection. Note that these results are not intended to provide a comprehensive benchmarking of the HCRN versus all other publications in pediatric hydrocephalus. Rather, we chose JNS Peds and Neurosurgery given their direct relevance for neurosurgeons managing pediatric hydrocephalus. While citation counts and rates represent one of many surrogates for bibliometric impact, we're also interested in understanding the global influence of the HCRN. The map above depicts the distribution of author affiliations and papers citing the HCRN. With over 40 countries represented, it is encouraging to note that the findings of this North American multi-center collaboration are being considered across the globe. Additionally, the HCRN has two ongoing randomized controlled trials, a gold standard in clinical research. With the imminent completion of the CSF-SHUNT entry site trial, the results in future publications from the HCRN are eagerly anticipated. In summary, the HCRN has made key strides in multi-center collaboration within pediatric neurosurgery. With a highly cited body of collaborative work, two randomized controlled trials on the horizon with the conclusion of one anticipated by the end of this year, and the expansion of a targeted implementation arm, the HCRN represents a model of fruitful and translatable collaboration. We eagerly anticipate the future contributions of this network. My name is Randalynn Barnett, and I'm a PGY-5 neurosurgery resident at the University of North Carolina in Chapel Hill. Today, I'll be discussing how the increasing utilization of telemedicine may contribute to worsening healthcare disparities. Like most institutions across the nation, we rapidly implemented virtual care options for patients to be evaluated via video or phone visits when the pandemic started. A few weeks into conducting our telemedicine visits, we realized that some populations of patients were experiencing more technological difficulties than others, making it hard to care for them without interruptions. This sometimes resulted in difficulty conveying all necessary information regarding their diagnosis and management plan, as well as delays in care as we had to schedule them for in-person visits at later dates. We decided to look into this to explore what populations were particularly vulnerable. We conducted a retrospective analysis of 202 pediatric neurosurgery virtual visits, in which we collected data on age, sex, race, location, preferred language, insurance type, diagnosis, type of visit, visit attendance, presence and type of technical barrier, and software platform utilized. Technical barriers were defined as inability to access the video visit, inability to turn on video and or audio services within the platform, and or loss of internet connectivity. We found that patients who were primarily Spanish-speaking were 6.75 times more likely to experience a technical barrier compared to patients who primarily speak English. 67% of Spanish-speaking patients experienced technical issues compared to only 23% of English-speaking patients. When we looked at health insurance as a factor, we found that patients with public health insurance were 3.37 times more likely to experience a technical issue compared to those with private insurance. 36% of publicly insured patients had this problem compared to only 14% of privately insured patients. The no-show rate out of all the visits was 7%. We found an association between insurance type and attending a visit. 11% of patients with public health insurance were no-shows compared to 2% of patients with private health insurance. Publicly insured patients were 5.87 times more likely to no-show than privately insured patients. With regards to limitations, our study results represent the experience of a single institution and our study was conducted over a short timeframe of 60 days so that we can analyze short-term health disparities to quickly implement changes to improve our quality of care. Another limitation of our study is that only 6% of our patients had Spanish as their preferred language, so our results may not be representative of the Spanish-speaking population across the United States, which is roughly 18.3% of the population. In order to conduct successful telemedicine visits, it is necessary to have reliable technology with internet, video, and audio capability, as well as being able to understand how to effectively utilize these resources. By understanding the challenges that at-risk populations face and the effects that this may impose on their care, we can devise ways to help improve deliverance of virtual care, such as scheduling a virtual appointment during a visit with a primary care physician or establishing designated virtual care sites. We can help develop virtual care platforms that are more user-friendly and specific to a particular patient's needs. By recognizing these potential barriers to care, we can work to implement strategies in order to improve access to care, health literacy, patient satisfaction, and overall outcomes in care for all patient populations. I would like to thank Dr. Carolyn Quincy for her valuable mentorship throughout my residency training. I would also like to thank Kristen Weiss, a second-year medical student who is interested in neurosurgery, and Gammy Pager, a fourth-year medical student who is applying to neurosurgery residency this cycle, for all their hard work and significant contributions to this study. Hello, all. I'm Eric Metzman, and I will be presenting our team's abstract today. As we've come to learn today and over the past several years, the U.S. healthcare system is laced with racial and socioeconomic disparities. These effects have been sparsely studied in our field. We found studies done in neuro-oncology, CSF shunting, and craniosynostosis, but none have been done on the pediatric spasticity population. We chose to look at the impact of race and socioeconomic status on accessibility to and post-operative outcomes of neurosurgical care for these patients. Using Riley Hospital for Children's electronic database, we were able to gather information on their pediatric spasticity patients. We identified the patient's race and their payer status as public versus private slash self-pay, and then compared it to a slew of other variables. These variables included age, time to surgery from first encounter, distance traveled to care, type of referring physician, the household income, the surgery type. We looked at baclofen pump placements versus selective dorsal rhizotomy, and then surgical outcomes we identified, including modified ASHRAE score at latest follow-up, baclofen pump infections, pump malfunctions, and unplanned readmissions. From these, we calculated mean standard deviation in p-values using appropriate tests. We set our statistical significance to a p-value of less than or equal to 0.05. And in our study, we originally had 151 unique patients, and exclude 69 for various reasons, and ended up with 82 in the final study population. Table one highlights some of our findings. Here you can see our patient population. We had 11 non-white patients, and our insurance split was 5725. We compared each of these to surgery type, the selective dorsal rhizotomy versus baclofen pump placement, and referring physician type, PCP versus specialist. When race was compared to surgery type, we had no significant findings there. And when race was compared to referring physician type, we had no significant findings. When insurance type was compared to surgery type, we found the value trending towards significance, trending towards public payers undergoing more selective dorsal rhizotomies. We compared insurance type to referring physician type, and had no significant findings there. We estimated the income for each of our patients' households, and we had no patients with an estimated income under $20,000 a year. In table two, we looked at race and insurance type compared to age at consult and time to surgery. We had no statistically significant findings, but when race was compared to time to surgery, it was trending in that direction with a p-value of 0.12. Table three compares race and insurance type to distance traveled, and there were no statistically significant differences. We compared race to modified Ashford score at latest follow-up, and non-whites has statistically higher score than whites. Insurance type was also compared with modified Ashford score, and we found public insurance was associated with higher scores. Race and insurance type were compared with our other surgical outcomes, and we had no statistically significant findings. Where do we take this? Our study suggests there may be difference in surgical outcomes based on race and based on insurance type. Future studies with larger sample sizes could explore why these disparities exist and hone in on some of the causative factors. Thank you all for listening. Hi, my presentation is titled Medical Malpractice Litigation Arising from Cerebrospinal Fluid Diversion. My co-authors are Ranjit Ganguly, John McGregor, Karen Powers, and Jeffrey Leonard. Introduction. Medical malpractice litigation is common in neurosurgery. Among physicians, neurosurgeons are the most likely to be sued on a yearly basis. And although the neurosurgical literature has many different ways of doing it, the medical literature has numerous publications involving medical malpractice arising from spinal procedures and cranial procedures in general. Medical malpractice arising from reshunts and CSF diversion has not been analyzed. Our methods. We queried the Westlaw Legal Research Database for medical malpractice cases related to CSF diversion. Of these, we recorded demographic information about both the plaintiffs and defendants and case outcomes. And comparisons were then made between adult and minor patients using t-tests and chi-square tests where appropriate. Results are case demographics. We were able to find 114 cases of medical malpractice arising from CSF diversion. These range from 1987 to 2016. 92% of cases involved obstructed hydrocephalus and 79% of cases involved BP shunting. Plaintiff injury was death in 40% of cases and neurologic injury in 42% of cases. Regarding the allegation of negligence, negligent surgery was alleged in 35%, failures of diagnosis in 60% and delays in treatment in 57% of cases. Case outcomes. We found defense verdicts in 41% of cases, plaintiff's verdicts were found in 28% of cases and settlements in 31% of cases. Mean damage awards for plaintiff verdicts was $4.6 million and for settlements was $1.9 million. In our comparative study between the patients, the adult patients and the minor patients, we found that cases involving adults were more likely to involve a first shunt placement and more likely to allege negligent surgery. Whereas cases involving minors were less likely to result in an offense verdict and more likely to result in a settlement. Overall, mean damage awards were higher in cases involving minors, $1.9 million versus $950,000. Limitations. Our data was obtained from a single legal research database and due to limited amount of data that is available on these jury verdict briefs, a detailed analysis is not possible. Conclusion, treatment of patients requiring CSF diversion can result in substantial medical malpractice liability for practicing neurosurgeons, especially for surgeons involved in pediatric neurosurgery. And further studies are needed to quantify the risks of medical malpractice litigation. I hope this message finds you well. My name is Rahul Kumar and it's a privilege to share our work on describing resident operative experience in pediatric neurosurgery across US training programs. For this study, we requested resident case logs for recent graduates or residents who had completed their primary pediatric exposure in neurosurgery training programs across the United States. At least one resident case log was received from 86 of 113 programs. A median of three resident case logs were received per program, yielding a total of 316 resident level data points. Procedural subcategories were defined as outlined in the schematic on the right. Overall, residents reported a median of 109 pediatric specific cases, well above the ACGME defined minimum. When looking at case volumes within procedural subcategories CSF diversion was the highest with the median of 34 cases per resident. Resident level responses shown as dots were then aggregated by individual programs designated by bars, revealing appreciable heterogeneity in case volumes between individual residents at certain programs. The dashed line represents the median case volume per program. Additionally, ACPNF designated programs appear to have higher median resident case volumes compared to non-ACPNF programs. In order to further explore the association between program level characteristics and operative experience, we compared resident and program level case volumes according to ACPNF designation and whether the pediatric experience site was in-house or outsourced to another academic center. We noted higher case volumes at both resident and program levels with ACPNF designation. Higher volumes were noted for in-house versus outsourced pediatric experience site using resident level but not program level data. Notably, all ACPNF programs had in-house training experience. In addition to case volumes, case diversity represents an important indicator of operative experience. Using resident reports aggregated at the program level, we calculated programs case diversity index, which represents the probability that two selected cases originated from different procedural subcategories. Given that CSF diversion cases comprise the largest proportion of case volume, we observe a rough anti-correlation between case diversity and proportion of CSF diversion cases as shown in the pink bars. Finally, we explored additional program level characteristics as shown in the right panel to determine associations with resident operative volumes calculated from the current study. We utilize backward selection to develop a predictive model for operative case volumes at the program level based on these characteristics. Interestingly, a program's estimated annual pediatric case volume and the duration of a resident's pediatric experience were significantly associated with predicting the reported resident case volumes identified in the current study. Call covering the pediatric service also appears to be an important factor while ACPNF designation was insignificant, likely due to strong auto-correlations with other co-variants. Future studies using longitudinal resident level data would be extremely beneficial for a more comprehensive assessment of resident operative experience and would provide a tremendous resource for defining the landscape of operative experience in pediatric neurosurgery during resident training. Hi, my name is Becker Hall. I am the co-founder and CEO of Hogs for the Cause here in New Orleans, Louisiana. Hogs for the Cause is a 501c3 nonprofit that provides outreach services to families who have children with pediatric brain cancer. We currently are the leading provider of these services, these outreach services in the United States of America. We were founded in 2009. On my left, you'll see, or in the picture left, that is Renee Louat, my co-founder, and I am there on the right. And in the middle there is Ben Surratt Jr. Hogs was founded for little Ben. He was a six-year-old who had an inoperable brain tumor, as you probably well know as DIPG. We had the opportunity to meet Ben after our first event, which was a barbecue event that had one pig and about 200 of our friends, and we were able to raise $10,000 for the Surratt family. In that meeting with little Ben, he spent the whole, probably two hours that we were with him trying to make us laugh and tell us jokes. So it was an extremely cathartic experience for Renee and myself. Neither of us had children at the time, and we walked out of that meeting so inspired that we said we're going to build the biggest and greatest fundraiser for pediatric brain cancer in this country, and that's what we think we may have done. So what went from one day, one pig, and one grant in 12 years has grown to a three-day festival here in New Orleans that has over 30,000 patrons, 25 bands on three stages, and 100 barbecue teams that sells out in one day. It is a barbecue competition that actually sells food, each team, to all the patrons that come to our festival, and these 100 teams are also fundraising for Hogsworth of Cause over the whole year. We have teams that raise as much as $500,000 down to a minimum of $4,000 to be able to stay in the event each year. So it is our primary funding vehicle, and sadly it was canceled in 2020 due to COVID, but we are hopeful that we'll be able to have it again in 2021. It's become the springboard for a lot of national acts and just has become one of the biggest barbecue competitions in the country as well as one of the biggest music festivals as well, all for the amazing benefit of our families and their wonderful children. As you can see on this slide, Hogs currently grants in 48 out of 50 states in the United States. We're pretty proud of that in only 12 years. Being that most of our funds are raised here in Louisiana, you will see that we've given back over $500,000 close to 2 million in 12 years in Louisiana, but have done a lot of incredible things throughout the South and are really growing throughout the rest of the country. So I do invite you to take a look at that map and you can also see a bit of a deeper dive on our website at www.hogsforthecause.org. As you well know, pediatric brain cancer demand for outreach services is massive. And we've been fortunate enough that we have not had to turn down a grant yet since we were founded 12 years ago. That's a little bit more challenging now that we have been canceled by COVID, but our teams really stepped up last year and we still were able to raise about a million dollars even though we didn't even have the festival. So I do encourage you if you have relationships at these hospitals in your states and in the other states, what we do is we work very closely with social workers at hospitals and they are the ones typically that will fill out the grant applications on our website, which saves us a lot of time in the vetting process being that there's really only 1.5 employees that make all the POGs happen. Outside of the giving that we do for pediatric brain cancer families, we also took on a secondary mission of building housing hospital family residents on campus. So you'll see in this picture, it's our first Hogs House on the Children's Hospital of New Orleans campus. This was a $2.5 million raise and we were able to preserve a historic property on the Children's Hospital of New Orleans campus. It is a wonderful amenity and we couldn't be more proud of it. We did a lot of research into St. Jude's model with their target houses and found just the immense benefits of the emotional and mental healing that can take place outside of the hospital and the opportunity to get back with your family. So this is our first house in New Orleans. It has 12 individual family suites. Each suite has its own bathroom and families are able to come together and not be separated and neither do they have to spend the night in hospital beds and really just get them in a more positive environment, which we all know is more beneficial for healing overall. And it's also another financial burden that we happen to relieve for families and it allows us to expand that relief outside of pediatric brain cancer into all families in any condition. So it's just been a wonderful, wonderful, tangible asset that we have in place. And we're happy to announce that we are now building our second family residence in Baton Rouge at Our Lady of the Lake Children's Hospital. And we are currently fundraising under that, which obviously has been a little bit difficult given the headwinds, whether it be COVID here in Louisiana, hurricanes, and then, of course, different political climates. So we're hoping to break ground on this property in August. And once again, it's another vehicle that allows us to help all families in all conditions. But we're still chugging along with our outreach services for pediatric brain cancer families and are looking for any kind of support we can get right now in these tumultuous times. So that kind of brings us to some other alternative strategies that we look for to be able to help our families. My co-founder, Renee Luop, and I are also the founders of Buccaneer Wine. And this wine, which is made in the Willamette Valley, our red blend with an esteemed winemaker by the name of Lynn Penner Ash, is just a wonderful product that we launched about a year ago. And 50 cents of every bottle goes back to Hogs for the Cause. And just three months alone last year, we were able to raise $5,000 to give back to Hogs. And we are now the fastest growing brand in Louisiana, which is gonna allow us to write a much bigger check to Hogs this year. So if you are a wine drinker and we'd love to get Buccaneer in your state, every single bottle that is purchased stays, the 50 cents goes back to a children's hospital within that state. We're in Alabama and Louisiana right now, but looking to grow it and looking for this wine to be a great benefactor for Hogs for the Cause as well. So I do appreciate telling you the story about Hogs. It's now been 12 years. And like I said, we're granting in 48 states. We've given over grants to over a thousand families, closer to about 1,500 now. The grant totals have been around $2 million at this point. So we don't have any plans of slowing down. Cancer obviously still is going to thrive in a COVID environment. We're just looking for different ways and pivoting our model at the festival is not gonna continue to find ways to keep helping our families. Because we all know that the demand once again is immense and there's not enough organizations out there like us. I invite you to email me and get in touch with me. You can email me at becker at hogsforthecause.org. And again, I do invite y'all to peruse our website and look at some of the great things we're doing to help your patients around the country. Appreciate your time today. Thank you. If you believe in me. I'll be the first one in our family to graduate college. I'll be the one to change our history of diabetes. I'll live a healthy life. If you believe in me. I'll know my worth is more than face value. I'll be stronger than a weak heart. I'll know 68 pounds carries weight in this world. If you believe in me. I'll believe in myself. Belief in our children can change their future. Our Lady of the Lake Children's Health.

pediatric trauma

neurosurgery

COVID-19 pandemic

gunshot wounds

teamwork

cerebral spinal fluid diversion

telemedicine

healthcare disparities

CSF diversion

resident operative experience

Hogs for the Cause

pediatric brain cancer