April 2015

Volume 4, Issue 8
 

For some time, the Department of Surgery has been working on a process to assist with late career transitioning amongst surgeons on our faculty. Following a meeting of the Surgeon-in-Chiefs last fall, I appointed Robin Richards, Vice-Chair Clinical, and Ori Rotstein, Associate Chair, to write a draft document to encompass the principles that could be applied to late career surgeons.  After several iterations, and edits, I am pleased to provide you with the wording of the “Guidelines for Late Career Transition”  that has now been approved by the Executive Committee and the Senior Advisory Committee of the Department of Surgery.   Special thanks are given to Robin and to Ori for enabling us to finalize a document which, to my knowledge, is a first of its kind across Canada and perhaps North America on this topic.

 
GUIDELINES FOR LATE CAREER TRANSITION
PREAMBLE
 
In the absence of a defined retirement age, Department members need to develop plans for transition as they approach the end of their academic surgical careers.  The development of a plan for late career transition represents an opportunity for Department members to initiate a constructive process in co-operation with the Department, as represented by their Surgeon-in-Chief, the Hospital Division Head, and the University Division Chair.  The goal of the process is to develop an individual plan for each Department member that is agreeable to the academic surgeon, informs the relevant stakeholders and allows the late career surgeon, the Hospital, the Division and the Department to make plans for the future.  The following guidelines were developed to assist Department members in the development of individual plans for late career transition.
 
GUIDELINES
 

1. All Department members should develop an awareness of and a plan for their late career transition.
2. The development of a constructive plan for late career transition takes several years and discussion of individual plans should be initiated as part of the annual review process by the Surgeon-in-Chief at the Hospital.  
3. University Departmental and Divisional policies and initiatives, such as the annual Assessment of Academic Performance, should be acknowledged and used to inform and guide the annual discussion regarding transition that occurs between the Surgeon-in-Chief and late career transition surgeons.
4. Hospital resource utilization by individual surgeons is linked to on-call responsibilities and both should decrease in a planned and orderly fashion as late career transition occurs.
5. Academic opportunities for surgeons can continue or even increase as reduced hospital resource utilization occurs.  The involvement of late career surgeons, whose careers are transitioning, in mentoring and resource sharing with new recruits initiating their academic surgical practice is encouraged.
6. A marked diminution of surgical activity does not preclude ongoing meaningful participation in Departmental activities, including teaching, research and administration.
7. The Surgeon-in-Chief, Hospital Division Head, and University Division Chair should ensure that the contributions of late career surgeons are recognized at an appropriate point in each Department member’s career.
8. The provision of optimum patient care is of paramount importance to all stakeholders and plans for late career transition need to be developed with this in mind. 

 

Sincerely,  

James T. Rutka, MD, PhD, FRCSC
RS McLaughlin Chair
 

Improving and Driving Excellence Across Sectors (IDEAS).  A partnership of Health Quality Ontario, ICES, IHPME and seven Ontario universities.  Here you will see Reilly Musselman, Timothy Jackson, Najib Safieddine, and Kwaku Gyimah holding their graduation certificates.  For further information on the program, please go to www.ideasontario.ca.
 

Continuing Appointment Reviews (CARs)
The following Continuing Appointment Reviews (CARs) took place in April under the leadership of Ori Rotstein, Associate Chair, Department of Surgery.  
 
Jason Lee is a Lecturer with the Division of Urology, Department of Surgery, University of Toronto and a faculty member at St. Michael’s Hospital.  He completed medical school in 2004 and then urology residency training at the University of Toronto. He passed his Royal College exams and then completed 2 years of fellowship training at the University of California Irvine in Minimally Invasive Urologic Surgery and Surgical Education.  Dr. Lee specializes in the endourologic management of complex stone disease, laparoscopic and robotic management of renal and prostate disease, as well as renal transplantation.  His surgical education research interests include the use of simulation for the instruction and assessment of laparoscopic and robotic skills, as well as curriculum design and program evaluation for the improvement of MIS skills acquisition and OR team crisis management. His work is supported by several research grants, including the Royal College of Physicians and Surgeons of Canada.  From left to right:  K. Pace, J. Lee, N. Fleshner
 
Anand Govindarajan is a surgical oncologist in the Division of General Surgery at Mount Sinai Hospital and Princess Margaret Hospital, and Assistant Professor at the University of Toronto.  He completed medical school and a residency in General Surgery at the University of Toronto.  During residency, he completed a Masters of Science through the Department of Health Policy, Management and Evaluation.  Following this, Dr. Govindarajan completed a clinical fellowship in Surgical Oncology at Memorial Sloan-Kettering Cancer Center in New York City.   Dr. Govindarajan’s clinical practice involves the care of patients with gastrointestinal and peritoneal-based malignancies. His primary research focus is to study and narrow the gaps between current practice and best evidence in the treatment of these diseases, through the use of health services research methods and knowledge translation techniques. (PHOTO)  From left to right: R. McLeod, C. Swallow, A. Govindarajan, J. Wonder, A. McCart, N. Baxter.
 
 
RECENT TWEETS
 
Dr. Langer is a pioneer of liver transplant service ‪#cdnmedheroes2015
 
Dr. Bernard Langer is being introduced as an inductee into the ‪@CdnMedHallFame for leadership in medical excellence ‪@uoftmedicine
 
Dr. Bernard Langer-inducted into the Canadian Medical Hall of Fame last night! ‪@UofTSurgery Congratulations.
 
Andy Smith inducted today into membership in the American Surgical Associations! Congratulations Andy!
 
Update in General Surgery 2015 ‪@UofTSurgery ‪#UGS2015
 
At the American Surgical Association Meeting in San Diego with Shaf Keshavjee! @UofTSurgery
 
Congrats ‪@JYLeeUroSMH on passing 3-year review! Well deserved! ‪@UofTSurgery
 
Apr 17
Congratulations to ‪@TGrantcharovMD, newly appointed Canada Research Chair in ‪#Simulation & Surgical Safety! ‪@StMikesHospital ‪@UofTSurgery
 
Apr 17
Only 1 week until ‪@UofTSurgery 41st Gallie Day with Gordon Murray Lecturer, Clifford Ko from ‪@UCLA 
 
Apr 12
Team Urology wins final match of season against team of mixed Surgical Divisions at Varsity Arena. Congrats Urology!
 
Apr 11
See Lucas Murnaghan’s surfing photography at Milk Glass gallery tonite!  1247 Dundas St W.
 
Apr 10
Dr Pawlik presented the Palmer lecture this am, University Rounds, Mt Sinai. "Period blood management .....
 
Apr 9
Palmer Lecture Friday, Apr10@7:30 a.m., Mt. Sinai Aud.Dr.T. Pawlik, John ‪@HopkinsMedicine "Perioperative blood management ...
 
Apr 9
Congrats ‪@TGrantcharovMD, newly appointed Canada Research Chair! ‪http://www.chairs-chaires.gc.ca/media-medias/lists-listes/2015/april-avril-eng.aspx … ‪#simulation ‪#surgery
 
Apr 7
Anand Govindarajan Mt Sinai Gen Surgery successfully completes and passes his continuing appointment review!
 
Apr 3
Surgeons need coaches too. Our recent randomized trial shows that coaching enhances OR performance and safety. ‪http://www.ncbi.nlm.nih.gov/pubmed/25822691 
 
Apr 1
Breakfast with 1st year med students and George Christakis today! 
 
 
HONOURS AND AWARDS
 
Barbara (Dee) Ballyk (Anatomy) has been chosen as the 2015 W.T. Aikins Award recipient in the category of Excellence in Course/Program Development.
 
James Byrne (General Surgery) received a CIHR MSc Scholarship for his work “Impact of Pre-hospital Care and EMS Performance on Trauma Patient Mortality and Trauma Center Outcome Measures”.
 
Karen Devon (General Surgery) received a grant from the Gold Foundation for her work “Transformative Learning Impact of Surgical Ethics Quality of Care Rounds”.
 
Teodor Grantcharov (General Surgery) has been awarded a Tier 2 Canada Research Chair in Simulation and Surgical Safety.  Congratulations Teodor!
 
Shiva Jayaraman (General Surgery, SJHC) received a Special Commendation – Integrated Medical Education Awards for Excellence in Community-Based Teaching.
 
Bernard Langer (Surgical Alumni) was inducted into the Canadian Medical Hall of Fame, Thursday, April 23, 2015 in Winnipeg.  An article regarding this appeared in the Canadian Journal of Surgery.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4373986/
The Canadian Medical Hall of Fame contributes to a vibrant health care system by engaging Canada’s health leaders in educational programs that encourage youth to pursue careers in health sciences.  Congratulations Bernie!
 
Frank Mastrogiacomo (Orthopaedics, TEGH) received a Special Commendation for Excellence in Community-Based Teaching (Community Hospital setting).
 
Andy Smith (General Surgery) was inducted into the American Surgical Association, April 23, 2015. 
 
Lloyd Smith (General Surgery, NYGH) received a Special Commendation for Excellence in Community-Based Teaching (Community Hospital setting). 
 
Taufik Valiante (Neurosurgery) is the recipient of a 5 year NSERC Discovery Grant (Natural Sciences and Engineering Research Council of Canada) for his work on “Probabilistic maps of spiking and connectivity in human and mouse cortex”.
 
Toni Zhong (Plastic and Reconstructive Surgery) and co-investigators Nancy Baxter, Brett Beber, Terry Cheng, Jeffrey Hoch, Stefan Hofer, Wanrudee Isaranuwatchai, Jennifer Jones, Kelly Metcalfe, Anne O'Neill, Tony Panzarella, Jennica Platt received a 3 year grant from the Canadian Breast Cancer Foundation for their project “Pre-consultation Educational Group Intervention to Improve Shared Decision Making for Postmastectomy Breast Reconstruction”.
 

 

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Choi WJ, Cleghorn MC, Jiang H, Jackson TD, Okrainec A, Quereshy FA.  Preoperative Neutrophil-to-Lymphocyte Ratio is a Better Prognostic Serum Biomarker than Platelet-to-Lymphocyte Ratio in Patients Undergoing Resection for Nonmetastatic Colorectal Cancer.  Ann Surg Oncol. 2015 Apr 22. 
 
Correia A, Rabeneck L, Baxter NN, Paszat LF, Sutradhar R, Yun L, Tinmouth J.  Lack of follow-up colonoscopy after positive FOBT in an organized colorectal cancer screening program is associated with modifiable health care practices.  Prev Med. 2015 Apr 17.
 
Daniels TR, Younger AS, Penner MJ, Wing KJ, Le IL, Russell IS, Lalonde KA, Evangelista PT, Quiton JD, Glazebrook M, DiGiovanni CW.  Prospective Randomized Controlled Trial of Hindfoot and Ankle Fusions Treated With rhPDGF-BB in Combination With a β-TCP-Collagen Matrix.  Foot Ankle Int. 2015 Apr 6.
 
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Farooq H, Genis H, Alarcon J, Vuong B, Jivraj J, Yang VX, Cohen-Adad J, Fehlings MG, Cadotte DW.  High-resolution imaging of the central nervous system: how novel imaging methods combined with navigation strategies will advance patient care.  Prog Brain Res. 2015;218:55-78.
 
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Haas B, Doumouras AG, Gomez D, de Mestral C, Boyes DM, Morrison L, Nathens AB.  Close to home: An analysis of the relationship between location of residence and location of injury.  J Trauma Acute Care Surg. 2015 Apr;78(4):860-5.
 
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Hallet J, Tsang M, Cheng ES, Habashi R, Kulyk I, Hanna SS, Coburn NG, Lin Y, Law CH, Karanicolas PJ.  The Impact of Perioperative Red Blood Cell Transfusions on Long-Term Outcomes after Hepatectomy for Colorectal Liver Metastases.  Ann Surg Oncol. 2015 Mar 10.
 
Hallet J, Wallace D, El-Sedfy A, Hall TN, Ahmed N, Bridge J, Taggar R, Smith AJ, Nathens AB, Coburn NG, Gotlib-Conn L.  Optimizing inter-professional communications in surgery: protocol for a mixed-methods exploratory study.  JMIR Res Protoc. 2015 Mar 5;4(1):e8. doi: 10.2196/resprot.3623.
 
Hirohashi K, Anayama T, Wada H, Nakajima T, Kato T, Keshavjee S, Orihashi K, Yasufuku K.  Photothermal Ablation of Human Lung Cancer by Low-power Near-Infrared Laser and Topical Injection of Indocyanine Green.  J Bronchology Interv Pulmonol. 2015 Apr;22(2):99-106.
 
Hughes J, Wang P, Alusi G, Shi H, Chu Y, Wang J, Bhakta V, McNeish I, McCart A, Lemoine NR, Wang Y.  Lister strain vaccinia virus with thymidine kinase gene deletion is a tractable platform for development of a new generation of oncolytic virus.  Gene Ther. 2015 Apr 16. doi: 10.1038/gt.2015.13.
 
Ibrahim GM, Cadotte DW, Bernstein M.  A framework for the monitoring and evaluation of international surgical initiatives in low- and middle-income countries.  PLoS One. 2015 Mar 30;10(3):e0120368.
 
Ibrahim GM, Morgan BR, Doesburg SM, Taylor MJ, Pang EW, Donner E, Go CY, Rutka JT, Snead OC 3rd.  Atypical language laterality is associated with large-scale disruption of network integration in children with intractable focal epilepsy.  Cortex. 2015 Apr;65:83-8.
 
Insel N, Pilkiw M, Nobrega JN, Hutchison WD, Takehara-Nishiuchi K, Hamani C.  Chronic deep brain stimulation of the rat ventral medial prefrontal cortex disrupts hippocampal-prefrontal coherence.  Exp Neurol. 2015 Apr 1;269:1-7.
 
Kalaniti K, Lo Rito M, Hickey EJ, Sivarajan VB.  Successful Pulmonary Embolectomy of a Saddle Pulmonary Thromboembolism in a Preterm Neonate.  Pediatrics. 2015 Apr 20.
 
Kassam I, Gagnon F, Cusimano MD.  Association of the APOE-ε4 allele with outcome of traumatic brain injury in children and youth: a meta-analysis and meta-regression.  J Neurol Neurosurg Psychiatry. 2015 Apr 22.
 
Kayssi A, Pope M, Vucemilo I, Werneck C.  Endovenous radiofrequency ablation for the treatment of varicose veins.  Can J Surg. 2015 Apr;58(2):85-6.
 
Keshavjee S.  50th Anniversary Landmark Commentary on Pearson FG, Andrews MJ. Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg 1971;12:359-74.  Ann Thorac Surg. 2015 Apr;99(4):1119-20.
 
Klotz L.  Active surveillance for low-risk prostate cancer.  Curr Urol Rep. 2015 Apr;16(4):24.
 
Kruser JM, Pecanac KE, Brasel KJ, Cooper Z, Steffens NM, McKneally MF, Schwarze ML.  "And I think that we can fix it": mental models used in high-risk surgical decision making.  Ann Surg. 2015 Apr;261(4):678-84.
 
Kwan BY, Krings T, Bernstein M, Mandell DM.  A novel mechanism of toxic injury to the Papez circuit from chemotherapy.  J Clin Neurosci. 2015 Apr;22(4):760-2.
 
Liang S, Jayaraman S.  Starting a new laparoscopic liver surgery program: initial experience and improved efficiency.  Can J Surg. 2015 Apr 1;58(2):012514-12514.
 
Lau K, Tao H, Liu H, Wen J, Sturgeon K, Sorfazlian N, Lazic S, Burrows JT, Wong MD, Li D, Deimling S, Ciruna B, Scott I, Simmons C, Henkelman RM, Williams T, Hadjantonakis AK, Fernandez-Gonzalez R, Sun Y, Hopyan S.  Anisotropic stress orients remodelling of mammalian limb bud ectoderm.  Nat Cell Biol. 2015 Apr 20.
 
Law N, Greenberg M, Bouffet E, Laughlin S, Taylor MD, Malkin D, Liu F, Moxon-Emre I, Scantlebury N, Skocic J, Mabbott D.  Visualization and segmentation of reciprocal cerebrocerebellar pathways in the healthy and injured brain.  Hum Brain Mapp. 2015 Apr 14.
 
Mäkinen TJ, Dhotar HS, Fichman SG, Gunton MJ, Woodside M, Safir O, Backstein D, Willett TL, Kuzyk PR.  Periprosthetic supracondylar femoral fractures following knee arthroplasty: a biomechanical comparison of four methods of fixation.  Int Orthop. 2015 Apr 16.
 
Mariappan R, Mehta J, Massicotte E, Nagappa M, Manninen P, Venkatraghavan L.  Effect of superficial cervical plexus block on postoperative quality of recovery after anterior cervical discectomy and fusion: a randomized controlled trial.  Can J Anaesth. 2015 Apr 14.
 
Mutabdzic D, Mylopoulos M, Murnaghan ML, Patel P, Zilbert N, Seemann N, Regehr G, Moulton CA.  Coaching Surgeons: Is Culture Limiting Our Ability to Improve?  Ann Surg. 2015 Apr 17.
 
Narayanan UG.  Should children with cerebral palsy exercise?  Dev Med Child Neurol. 2015 Apr 16.
 
Nayan M, Jewett MA, Sweet J, Anson-Cartwright L, Bedard PL, Moore M, Chung P, Warde P, Hamilton RJ.  Lymph Node Yield in Primary Retroperitoneal Lymph Node Dissection for Nonseminoma Germ Cell Tumours.  J Urol. 2015 Mar 27.
 
Nouri A, Tetreault L, Côté P, Zamorano JJ, Dalzell K, Fehlings MG.  Does Magnetic Resonance Imaging Improve the Predictive Performance of a Validated Clinical Prediction Rule Developed to Evaluate Surgical Outcome in Patients with Cervical Spondylotic Myelopathy?  Spine (Phila Pa 1976). 2015 Apr 14.
 
Nouri A, Tetreault L, Singh A, Karadimas SK, Fehlings MG.  Degenerative Cervical Myelopathy: Epidemiology, Genetics and Pathogenesis.  Spine (Phila Pa 1976). 2015 Apr 2.
 
Platt J, Zhong T, Moineddin R, Booth GL, Easson AM, Fernandes K, Gozdyra P, Baxter NN.  Geographic Variation Immediate and Delayed Breast Reconstruction Utilization in Ontario, Canada and Plastic Surgeon Availability: A Population-Based Observational Study.  World J Surg. 2015 Apr 21.
 
Plant MA, Fish JS.  Resident use of the internet, e-mail, and personal electronics in the care of surgical patients.  Teach Learn Med. 2015 Apr-Jun;27(2):215-23.
 
Polisena J, Gagliardi A, Urbach D, Clifford T, Fiander M.  Factors that influence the recognition, reporting and resolution of incidents related to medical devices and other healthcare technologies: a systematic review.  Syst Rev. 2015 Mar 29;4(1):37.
 
Rahman F, Cotterchio M, Cleary SP, Gallinger S.  Association between Alcohol Consumption and Pancreatic Cancer Risk: A Case-Control Study.  PLoS One. 2015 Apr 9;10(4):e0124489.
 
Richard PO, Jewett MA, Bhatt JR, Kachura JR, Evans AJ, Zlotta AR, Hermanns T, Juvet T, Finelli A.  Renal Tumor Biopsy for Small Renal Masses: A Single-center 13-year Experience.  Eur Urol. 2015 Apr 18.
 
Rolston JD, Bernstein M.  Errors in Neurosurgery.  Neurosurg Clin N Am. 2015 Apr;26(2):149-155.
 
Schroeder GD, Vaccaro AR, Kepler CK, Koerner JD, Oner FC, Dvorak MF, Vialle LR, Aarabi B, Bellabarba C, Fehlings MG, Schnake KJ, Kandziora F.  Establishing the Injury Severity of Thoracolumbar Trauma: Confirmation of the Hierarchical Structure of the AOSpine Thoracolumbar Spine Injury Classification System.  Spine (Phila Pa 1976). 2015 Apr 15;40(8):E498-503.
 
Schuh S, Chan K, Langer JC, Kulik D, Preto-Zamperlini M, Aswad NA, Man C, Mohanta A, Stephens D, Doria AS.  Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use.  Acad Emerg Med. 2015 Apr;22(4):406-14.
 
Sermer C, Devitt B, Chahal J, Kandel R, Theodoropoulos J.  The Addition of Platelet-Rich Plasma to Scaffolds Used for Cartilage Repair: A Review of Human and Animal Studies.  Arthroscopy. 2015 Mar 27.
 
Siddiqui AM, Khazaei M, Fehlings MG.  Translating mechanisms of neuroprotection, regeneration, and repair to treatment of spinal cord injury.  Prog Brain Res. 2015;218:15-54.
 
Sidler-Maier CC, Waddell JP.  Incidence and predisposing factors of periprosthetic proximal femoral fractures: a literature review.  Int Orthop. 2015 Mar 27.
 
Tajdaran K, Shoichet MS, Gordon T, Borschel GH.  A novel polymeric drug delivery system for localized and sustained release of tacrolimus (FK506).  Biotechnol Bioeng. 2015 Apr 7.
 
Torchia J, Picard D, Lafay-Cousin L, Hawkins CE, Kim SK, Letourneau L, Ra YS, Ho KC, Chan TS, Sin-Chan P, Dunham CP, Yip S, Ng HK, Lu JQ, Albrecht S, Pimentel J, Chan JA, Somers GR, Zielenska M, Faria CC, Roque L, Baskin B, Birks D, Foreman N, Strother D, Klekner A, Garami M, Hauser P, Hortobágyi T, Bognár L, Wilson B, Hukin J, Carret AS, Van Meter TE, Nakamura H, Toledano H, Fried I, Fults D, Wataya T, Fryer C, Eisenstat DD, Scheineman K, Johnston D, Michaud J, Zelcer S, Hammond R, Ramsay DA, Fleming AJ, Lulla RR, Fangusaro JR, Sirachainan N, Larbcharoensub N, Hongeng S, Barakzai MA, Montpetit A, Stephens D, Grundy RG, Schüller U, Nicolaides T, Tihan T, Phillips J, Taylor MD, Rutka JT, Dirks P, Bader GD, Warmuth-Metz M, Rutkowski S, Pietsch T, Judkins AR, Jabado N, Bouffet E, Huang A.  Molecular subgroups of atypical teratoid rhabdoid tumours in children: an integrated genomic and clinicopathological analysis.  Lancet Oncol. 2015 Apr 13.
 
Tseng CL, Sussman MS, Atenafu EG, Letourneau D, Ma L, Soliman H, Thibault I, Cho BC, Simeonov A, Yu E, Fehlings MG, Sahgal A.  Magnetic resonance imaging assessment of spinal cord and cauda equina motion in supine patients with spinal metastases planned for spine stereotactic body radiation therapy.  Int J Radiat Oncol Biol Phys. 2015 Apr 1;91(5):995-1002.
 
Turner JM, Josephson J, Field CJ, Wizzard PR, Ball RO, Pencharz PB, Wales PW. Liver Disease, Systemic Inflammation, and Growth Using a Mixed Parenteral Lipid Emulsion, Containing Soybean Oil, Fish Oil, and Medium Chain Triglycerides, Compared With Soybean Oil in Parenteral Nutrition-Fed Neonatal Piglets.  JPEN J Parenter Enteral Nutr. 2015 Apr 2.
 
Wada H, Anayama T, Hirohashi K, Nakajima T, Kato T, Waddell TK, Keshavjee S, Yoshino I, Yasufuku K.  Thoracoscopic ultrasonography for localization of subcentimetre lung nodules†.  Eur J Cardiothorac Surg. 2015 Apr 7.
 
Weber-Adrian D, Thévenot E, O'Reilly MA, Oakden W, Akens MK, Ellens N, Markham-Coultes K, Burgess A, Finkelstein J, Yee AJ, Whyne CM, Foust KD, Kaspar BK, Stanisz GJ, Chopra R, Hynynen K, Aubert I.  Gene delivery to the spinal cord using MRI-guided focused ultrasound.  Gene Ther. 2015 Apr 23.
 
Willett TL, Burton B, Woodside M, Wang Z, Gaspar A, Attia T.  γ-Irradiation sterilized bone strengthened and toughened by ribose pre-treatment.  J Mech Behav Biomed Mater. 2015 Apr;44:147-55.
 
Witiw CD, Nathan V, Bernstein M.  Economics, Innovation, and Quality Improvement in Neurosurgery.  Neurosurg Clin N Am. 2015 Apr;26(2):197-205.
 
Zarnett OJ, Sahgal A, Gosio J, Perry J, Berger MS, Chang S, Das S.  Treatment of Elderly Patients With Glioblastoma: A Systematic Evidence-Based Analysis.  JAMA Neurol. 2015 Mar 30. 
 

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