Background: Our prior six-year review (n=2165) revealed 24% of patients undergoing posterior decompression surgeries (laminectomy or discectomy) sought emergency department (ED) care within three months post-surgery. We established an integrated Spine Assessment Clinic (SAC) to enhance patient outcomes and minimize unnecessary ED visits through pre-operative education, targeted QI interventions, and early post-operative follow-up. Methods: We reviewed 13 months of posterior decompression data (n=205) following SAC implementation. These patients received individualized, comprehensive pre-operative education and follow-up phone calls within 7 days post-surgery. ED visits within 90 days post-surgery were tracked using provincial databases and compared to our pre-SAC implementation data. Results: Out of 205 patients, 24 (11.6%) accounted for 34 ED visits within 90 days post-op, showing a significant reduction in ED visits from 24% to 11.6%, and decreased overall ED utilization from 42.1% to 16.6% (when accounting for multiple visits by the same patient). Early interventions including wound monitoring, outpatient bloodwork, and prescription adjustments for pain management, helped mitigate ED visits. Patient satisfaction surveys (n=62) indicated 92% were “highly satisfied” and 100% would recommend the SAC. Conclusions: The SAC reduced ED visits after posterior decompression surgery by over 50%, with pre-operative education, focused QI initiatives, and its individualized, proactive approach.

Background: Frailty and sarcopenia predict worse surgical outcomes among spinal degenerative and deformity-related populations; this association is less clear in the context of spinal oncology. Here, we identified frailty and sarcopenia tools applied in spinal oncology and appraised their clinimetric properties. Methods: A systematic review was conducted from January 1st, 2000, until June 2022. Study characteristics, frailty tools, measures of sarcopenia, component domains, individual items, cut-off values, and measurement techniques were collected. Clinimetric assessment was performed according to Consensus-based Standards for Health Measurement Instruments. Results: Twenty-two studies were included (42,514 patients). The three most employed frailty tools were the Metastatic Spine tumor Frailty Index (MSTFI), Modified Frailty Index-11 (mFI-11), and the mFI-5. The three most common sarcopenia measures were the L3-Total Psoas Area (TPA)/Vertebral Body Area (VBA), L3-TPA/Height2, and L3-Spinal Muscle Index (L3-Cross-Sectional Muscle Area/Height2). Frailty and sarcopenia measures lacked content and construct validity. Positive predictive validity was observed in select studies employing the HFRS, mFI-5, MSTFI, and L3-TPA/VBA. All frailty tools had floor or ceiling effects. Conclusions: Existing tools for evaluating frailty and sarcopenia in surgical spine oncology have poor clinimetric properties. Here, we provide a pragmatic approach to utilizing existing frailty and sarcopenia tools, until more clinimetrically robust instruments are developed.

Background: Following craniotomy, there is widespread agreement that post-operative neurological impairments require specialized evaluation to evaluate fitness to drive. However, for patients who had a craniotomy and do not have neurological deficits or known seizures, there is less consensus as to when return to driving is safe. In this study, we aim to review existing guidelines regarding driving post-craniotomy and assess the current practices for post-craniotomy recommendations in Canada. Methods: Our study has three components: 1) systematic review of existing guidelines for return to driving after cranial procedure; 2) review of primary evidence (cohort studies) regarding seizure risk following a craniotomy, depending of the underlying pathology; 3) online questionnaire distributed to Canadian neurosurgeons by the Canadian Neurosurgery Collaborative (CNRC) network. Results: Our systematic review unveiled various sets of guidelines for driving after a craniotomy. For instance, UK Driving and Vehicle Licensing Agency writes into law specific guidelines for return to driving varying based on underlying pathology. Their results were drawn from large cohort studies measuring the occurrence of post-operative seizures after craniotomy for a variety of conditions. The questionnaire is currently being distributed to Canadian neurosurgeons. Conclusions: Our study lays the first steps towards the development of Canadian guidelines for return to driving post-craniotomy.

Background: The presence of intraluminal thrombi (ILT) in acutely symptomatic carotid stenosis (“hot carotid”) represents a therapeutic dilemma for physicians. With little evidence to guide treatment, current ILT management approaches rely on individual or institutional preferences. Methods: This mixed methods study analyzed themes from semi-structured interviews with 22 stroke physicians from 16 centers, paired with a worldwide case-based survey of 628 stroke physicians conducted through the “Practice Current” section of Neurology: Clinical Practice. Results: In the thematic analysis of the interviews and quantitative analysis of the survey, participants favoured using anticoagulation with or without antiplatelet agents in patients with ILT (463/628, 74%). Despite a preference for anticoagulation, uncertainty regarding optimal antithrombotic management was noted in the thematic analysis. Additional themes identified included a preference for re-imaging patients in 3-5 days after initiating treatment to look for complete or partial clot resolution, at which point most experts would then be comfortable proceeding with revascularization if indicated, though uncertainty regarding the optimal timing of revascularization was noted. Conclusions: In cases of ILT in the “hot carotid” practice patterns of global experts show a preference for using anticoagulation and reimaging patients in 3-5 days, though there is considerable equipoise regarding the most appropriate management of these patients.

Background: Frailty is increasingly recognized for an association with adverse events, mortality, and hospital discharge disposition among surgical patients. The purpose of this study was to describe how spinal surgeons conceptualize, define, and assess frailty in the context of spinal metastatic disease (SMD). Methods: We conducted an international, cross-sectional, 33-question survey of the AO Spine community. The survey was developed using a modified Delphi technique and was designed to elucidate preoperative surrogate markers of frailty in the context of SMD. Responses were ranked using weighted averages. Consensus was defined as ≥ 70% agreement among respondents. Results: Results were analyzed for 312 respondents (86% completion rate). Study participants represented 71 countries. Most respondents informally assess frailty in patients with SMD by forming a general perception based on clinical condition and patient history. Consensus was attained regarding the association between 14 clinical variables and frailty. Severe comorbidities, systemic disease burden, and poor performance status were most associated with frailty; severe comorbidities included high-risk cardio-pulmonary disease, renal failure, liver failure, and malnutrition. Conclusions: Surgeons recognized frailty is important but commonly evaluate it based on general clinical impression rather than using existing frailty tools. We identified preoperative surrogate markers of frailty perceived as most relevant in this population.

Background: Little evidence exists to guide the management of symptomatic non-stenotic carotid disease (SyNC). SyNC, which refers to carotid lesions with less than 50% artery stenosis, has been increasingly implicated as a cause of stroke and TIA. Methods: Semi-structured interviews with 22 stroke physicians from 16 centers were conducted as part of the Hot Carotid Qualitative Study. This study explored decision-making approaches, opinions and attitudes regarding the management of symptomatic carotid disease. Presented here are a subset of results related to the decision to revascularize patients with SyNC. Results: Thematic analysis revealed equipoise in the decision to revascularize patients with SyNC. Participants discussed a desire to use imaging features (e.g plaque rupture and plaque morphology) to inform the decision to revascularize, though significant uncertainty remains in appraising the risk conferred by certain features. Experts support further study to better understand the use of these features in risk appraisal for patients with SyNC. Conclusions: The decision to revascularize patients with SyNC is an area with significant equipoise. Experts identify the use of imaging features as an important tool in informing the decision to pursue revascularization in patients with SyNC though more study is required in this area to better inform practice.

Background: Delayed Cerebral Ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. A paucity of high-quality evidence is available to guide the management of DCI. As such, our objective was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI. Methods: The Canadian Neurosurgery Research Collaborative (CNRC) performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. The survey was distributed to members of the Canadian Neurosurgical and Neurocritical Care Societies, respectively. Responses were analyzed using quantitative and qualitative methods. Results: The response rate was 129/340 (38%). Agreement among respondents included the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for prevention of DCI. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients felt to require intravenous milrinone, intra-arterial vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI. Conclusions: DCI is an important clinical entity for which no consensus exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the diagnosis and management of DCI.

Background: Extracranial traumatic vertebral artery injury (eTVAI) is common following non-penetrating head and neck trauma. Most cases are initially asymptomatic with an increased risk for stroke. Consensus is lacking regarding screening, treatment, and follow-up of asymptomatic patients with eTVAI. Our objective was to investigate national practice patterns reflecting these domains. Methods: An electronic survey was distributed via the Canadian Neurological Sciences Federation and Canadian Spine Society. Two case-based scenarios featured asymptomatic patients with eTVAI. Case 1: non-displaced cervical lateral mass fracture; angiography stratified by luminal diameter reduction. Case 2: complex C2 fracture; angiography featuring pseudoaneurysm dissection. Analysis: descriptive statistics. Results: Response Rate: 108 of 182 participants (59%), representing 20 academic institutions.

Case 1: 78% of respondents would screen using CTA (97%), immediately (88%). Most respondents (97%) would initiate treatment, using aspirin (89%) for 3-6 months (46%).

Case 2: 73% of respondents would screen using CTA (96%), immediately (88%). The majority of respondents (94%) would initiate treatment, using aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy.

In both cases, the majority of respondents would follow-up clinically or radiographically every 1-3 months, respectively. Conclusions: This study highlights consensus in Canadian practice patterns for the workup and management of asymptomatic eTVAI.

Background: Competitive flow diversion (CFD) is a novel application of flow diversion stenting (FDS), redirecting flow into a normal artery proximal or distal to the aneurysmal parent artery. A classification system for CFD has not been previously reported. Methods: Report of operative technique and novel classification system for CFD. Results: A patient with subarachnoid haemorrhage and three aneurysms arising from the Pcomm-P1 complex, was treated with endovascular coiling and CFD. The PCOM aneurysm was coiled. Two aneurysms arose from the distal right P1- PCA. After a failed attempt to treat with FDS across the P1-PCA, the P1-aneurysms were successfully treated with CFD distal to the P1-PCA, from Pcomm to P2. Over 12 months, CFD redirected flow via ICA-Pcomm-P2, reducing the size of the P1-PCA, obliterating the P1-aneurysms. Herein, we classify competitive flow diversion into two types. Type I CFD is when the parent artery harbouring the aneurysm is “jailed” proximally. Type II CFD occurs when flow is diverted from the parent artery distal to the aneurysm origin. Conclusions: Herein, we propose a novel classification for CFD. We describe the first case of aneurysm occlusion in the circle of Willis with Type II CFD, and use of CFD for the treatment of multiple adjacent aneurysms.

In recent years, a variety of efforts have been made in political science to enable, encourage, or require scholars to be more open and explicit about the bases of their empirical claims and, in turn, make those claims more readily evaluable by others. While qualitative scholars have long taken an interest in making their research open, reflexive, and systematic, the recent push for overarching transparency norms and requirements has provoked serious concern within qualitative research communities and raised fundamental questions about the meaning, value, costs, and intellectual relevance of transparency for qualitative inquiry. In this Perspectives Reflection, we crystallize the central findings of a three-year deliberative process—the Qualitative Transparency Deliberations (QTD)—involving hundreds of political scientists in a broad discussion of these issues. Following an overview of the process and the key insights that emerged, we present summaries of the QTD Working Groups’ final reports. Drawing on a series of public, online conversations that unfolded at www.qualtd.net, the reports unpack transparency’s promise, practicalities, risks, and limitations in relation to different qualitative methodologies, forms of evidence, and research contexts. Taken as a whole, these reports—the full versions of which can be found in the Supplementary Materials—offer practical guidance to scholars designing and implementing qualitative research, and to editors, reviewers, and funders seeking to develop criteria of evaluation that are appropriate—as understood by relevant research communities—to the forms of inquiry being assessed. We dedicate this Reflection to the memory of our coauthor and QTD working group leader Kendra Koivu.1

Multiple sclerosis (MS) is a chronic, progressive, autoimmune, neurodegenerative disorder that can interfere with physical and psychological functioning, negatively affecting health-related quality of life (HRQoL). Fostering mindfulness may mitigate the negative consequences of MS on HRQoL. The relationship between mindfulness, mood and MS-related quality of life was investigated. In total, 52 individuals with MS completed questionnaires to examine the relationship between trait mindfulness and wellness. Higher levels of trait mindfulness were associated with better HRQoL, lower depression and anxiety, lower fatigue impact and fewer perceived cognitive deficits. Mindfulness interventions have the potential to enhance wellness in those living with MS.

OBJECTIVES/SPECIFIC AIMS: Obesity is a rapidly growing epidemic and long-term interventions aimed to reduce body weight are largely unsuccessful due to an increased drive to eat and a reduced metabolic rate established during weight loss. Previously, our lab demonstrated that exercise has beneficial effects on weight loss maintenance by increasing total energy expenditure above and beyond the cost of an exercise bout and reducing the drive to eat when allowed to eat ad libitum (relapse). We hypothesized that exercise’s ability to counter these obesogenic-impetuses are mediated via improvements in skeletal muscle oxidative capacity, and tested this using a mouse model with augmented oxidative capacity in skeletal muscle. METHODS/STUDY POPULATION: We recapitulated the exercise-induced improvements in oxidative capacity using FVB mice that overexpress lipoprotein lipase in skeletal muscle (mLPL). mLPL and wild type (WT) mice were put through a weight-loss-weight-regain paradigm consisting of a high fat diet challenge for 13 weeks, with a subsequent 1-week calorie-restricted medium fat diet to induce a ~15% weight loss. This newly established weight was maintained for 2 weeks and followed with a 24-hour relapse. Metabolic phenotype was characterized by indirect calorimetry during each phase. At the conclusion of the relapse day, mice were sacrificed and tissues were harvested for molecular analysis. RESULTS/ANTICIPATED RESULTS: During weight loss maintenance, mLPL mice had a higher metabolic rate (p=0.0256) that was predominantly evident in the dark cycle (p=0.0015). Furthermore, this increased metabolic rate was not due to differences in activity (p=0.2877) or resting metabolic rate (p=0.4881). During relapse, mLPL mice ingested less calories and were protected from rapid weight regain (p=0.0235), despite WT mice exhibiting higher metabolic rates during the light cycle (p=0.0421). DISCUSSION/SIGNIFICANCE OF IMPACT: These results highlight the importance of muscular oxidative capacity in preventing a depression in total energy expenditure during weight loss maintenance, and in curbing overfeeding and weight regain during a relapse. Moreover, our data suggest that the thermic effect of food is responsible for the differences in metabolic rate, because no differences were found in activity or resting metabolic rate. Additional studies are warranted to determine the molecular mechanisms driving the ability of oxidative capacity to assist with weight loss maintenance.

This article presents the results of a program of radiocarbon dating and Bayesian modeling from the precontact Yup'ik site of Nunalleq (GDN-248) in subarctic southwestern Alaska. Nunalleq is deeply stratified, presenting a robust relative chronological framework of well-defined individual house floors abundant in ecofacts suitable for radiocarbon dating. Capitalizing on this potential, we present the results of one of the first applications of Bayesian statistical modeling of radiocarbon data from an archaeological site in the North American Arctic. Using these methods, we demonstrate that it is possible to generate robust, high-resolution chronological models from Arctic archaeology. Radiocarbon dates, procured prior to the program of dating and modeling presented here, suggested an approximately three-century duration of occupation at the site. The results of Bayesian modeling nuance this interpretation. While it is possible that there may have been activity for almost three centuries (beginning in the late fourteenth century), occupation of the dwelling complex, which dominates the site, was more likely to have endured for no more than a century. The results presented here suggest that the occupation of Nunalleq likely encompassed three generations beginning cal AD 1570–1630 before being curtailed by conflict around cal AD 1645–1675.

Native Americans have been structurally excluded from the discipline of political science in the continental United States, as has Native epistemology and political issues. I analyze the reasons for these erasures and elisions, noting the combined effects of rejecting Native scholars, political issues, analysis, and texts. I describe how these arise from presumptions inherent to the disciplinary practices of U.S. political science, and suggest a set of alternative formulations that could expand our understanding of politics, including attention to other forms of law, constitutions, relationships to the environment, sovereignty, collective decision-making, U.S. history, and majoritarianism.