Effectiveness of Glutamine Oral Care in Reducing Oral Mucositis and Improving Oral Health After Neurosurgery: A Randomized Controlled Trial with Microbiome Analysis.

BACKGROUND Hospital-acquired infections negatively impact the health of inpatients and are highly costly to treat. Oral care reduces the microorganism number in the mouth and lungs and is essential in preventing postoperative oral inflammation, lung infection, and other complications. This study was designed to determine the effects of oral care with glutamine on oral health, oral flora, and incidence of pneumonia in patients after neurosurgery. MATERIAL AND METHODS This was a parallel, double-blind, randomized trial. Patients admitted to the Neurosurgery Department of the hospital from July to October 2021 were selected. Three hundred patients who met the inclusion criteria were randomized into 3 groups. The control group (n=100) received oral care with routine oral nursing methods with saline, whereas the experimental group (n=100) received oral care with 5% glutamine. A compound chlorhexidine group (n=100) was set as a positive control. All patients, care providers, and investigators were blinded to the group assignment. The incidence of local debris, oral mucositis, halitosis, dryness, oral mucositis disorders, and oral flora types were collected and analyzed in all groups. RESULTS The incidence of local debris, oral mucositis, halitosis, dryness, and other oral mucositis disorders in the glutamine oral care group was significantly decreased, compared with that of the control group. Oral flora types in the glutamine and chlorhexidine groups were significantly reduced. CONCLUSIONS Oral care with 5% glutamine after neurosurgery is associated with a lower incidence of oral disorders and pneumonia, and a significant reduction in oral flora.

Preventing hypothermia in pediatric neurosurgery in Africa-A randomized controlled non-inferiority trial of insulation versus active warming.

PURPOSE: The objective of this study was to compare the efficacy of a low-cost heat-preserving method in preventing intraoperative hypothermia with that of forced-air warming in a resource-limited setting. METHODS: In this randomized controlled non-inferiority trial, we recruited children younger than 12 years scheduled for cranial neurosurgery in a large East-African hospital. Patients were block-randomized by age to intraoperative warming measures using Hibler's method (intervention) or warm air (comparator). Hibler's group patients were circumferentially wrapped in transparent plastic sheeting (providing a vapor-trap) over a layer of cotton blankets, then laid on an insulating foam mattress. Warm air group patients were treated with forced-air convection via an underlying Snuggle Warm™ Pediatric Full Body mattress. Allocated warming measures were initiated in the operating theatre and discontinued upon anesthesia emergence. Perioperative temperatures were measured using noninvasive forehead probes (SpotOn™). The primary outcome was incidence of hypothermia (core temperature < 36.0° for longer than 5 min). Our null hypothesis was that Hibler's method is inferior in efficacy to the warm air method by a margin exceeding 20%. Among secondary outcomes were duration of hypothermia as proportion of surgical duration, incidence of postoperative shivering and rescue measure requirements. RESULTS: We analyzed data for 77 participants (Hibler's = 38; warm air = 39). There was no significant difference between the Hibler's and warm air arms of the study in the primary outcome of incidence of hypothermia (59.0% vs. 60.5% respectively; OR 1.07; 95% CI 0.43-2.65; p = .890). However, the risk difference (1.55%; 95% CI -0.20 to -0.24) exceeded the 0.2 margin and non-inferiority could not be declared. There was considerable need for rescue measures in both groups (71.1 0% vs. 69.2%; OR 1.09; 95% CI 0.41-2.90; p = .861). There was no statistically significant difference between groups for any prespecified secondary outcome. CONCLUSION: Although perioperative core temperatures were not significantly different, we could not declare an inexpensive heat-preserving method non-inferior to warm air convection in preventing intraoperative hypothermia in children undergoing anesthesia for cranial neurosurgery in a resource-limited setting. The extensive need for rescue measures may have masked important differences. TRIAL REGISTRATION: US National Institutes of Health Clinicaltrials.gov database (ID no. NCT02975817).

Strengthening neurosurgical training programs in Sub-saharan Africa: a medical student's perspective.

This article provides a nuanced exploration of the state and exigencies of neurosurgical training in sub-Saharan Africa (SSA), viewed through the discerning lens of a medical student. The region has a pronounced scarcity of neurosurgical services, further compounded by sociocultural intricacies and infrastructural inadequacies, resulting in elevated mortality and morbidity rates. The insufficiency of neurosurgeons, facilities, and training centers, particularly in remote areas, exacerbates this predicament. The imperative to fortify neurosurgical training programs is underscored, necessitating a multifaceted approach inclusive of international collaborations and innovative strategies. The challenges impeding neurosurgical training program implementation range from constrained infrastructure to faculty shortages and financial constraints. Recommendations encompass infrastructural investments, faculty development initiatives, and augmented community engagement. An exploration of neurosurgical training programs across diverse African regions reveals commendable strides and imminent deficits, warranting heightened international collaboration. Furthermore, technological innovations, including virtual reality, robotics, and artificial intelligence, are posited as transformative conduits for augmenting neurosurgical training in SSA. The article concludes with a sagacious compendium of recommendations, encompassing standardized curricula, mentorship paradigms, and stringent evaluation mechanisms, all combining efficaciously fortifying neurosurgical insight in SSA and producing transformative improvements in healthcare outcomes.

Leveraging artificial intelligence in neurosurgery-unveiling ChatGPT for neurosurgical discharge summaries and operative reports.

PURPOSE: Chat generative pre-trained transformer (GPT) is a novel large pre-trained natural language processing software that can enable scientific writing amongst a litany of other features. Given this, there is a growing interest in exploring the use of ChatGPT models as a modality to facilitate/assist in the provision of clinical care. METHODS: We investigated the time taken for the composition of neurosurgical discharge summaries and operative reports at a major University hospital. In so doing, we compared currently employed speech recognition software (i.e., SpeaKING) vs novel ChatGPT for three distinct neurosurgical diseases: chronic subdural hematoma, spinal decompression, and craniotomy. Furthermore, factual correctness was analyzed for the abovementioned diseases. RESULTS: The composition of neurosurgical discharge summaries and operative reports with the assistance of ChatGPT leads to a statistically significant time reduction across all three diseases/report types: p < 0.001 for chronic subdural hematoma, p < 0.001 for decompression of spinal stenosis, and p < 0.001 for craniotomy and tumor resection. However, despite a high degree of factual correctness, the preparation of a surgical report for craniotomy proved to be significantly lower (p = 0.002). CONCLUSION: ChatGPT assisted in the writing of discharge summaries and operative reports as evidenced by an impressive reduction in time spent as compared to standard speech recognition software. While promising, the optimal use cases and ethics of AI-generated medical writing remain to be fully elucidated and must be further explored in future studies.

Gender Bias in Clinical Trial Enrollment: Female Authorship Matters.

BACKGROUND: Despite initiatives to promote equal enrollment of human subjects in clinical trials, females continue to be underrepresented. The goal of this work is to determine if female enrollment in human clinical trials published in 3 high-impact journals from 2015 to 2019 is correlated with gender of first and/or senior authors. METHODS: Clinical trials published in the Journal of the American Medical Association (JAMA), The Lancet, and the New England Journal of Medicine (NEJM) from January 1, 2015, to December 31, 2019, were reviewed. Trials were excluded for ongoing enrollment, sex-specific disease research, or author name without gender assignment. One-sample χ2 pairwise comparisons and two-tailed proportion tests on the proportion of females between gender author pairings were done overall and for each subset analysis. RESULTS: In total, 1,427 articles enrolled a total of 2,104,509 females and 2,616,981 males (44.6% vs. 55.4%, P ≤ 0.0001) in clinical trials. Overall, more females were enrolled if both first and senior authors were female (51.7% vs. 48.3%, P ≤ 0.0001). Proportion of females enrolled decreased with the following first and senior author pairings: female-male (48.9%), male-female (48.6%), and male-male (40.5%, P ≤ 0.0001 compared to female-female authorship). Greater female enrollment in clinical trials with female-female compared to male-male authorship persisted in subset analyses by funding source, phase, randomization for study participants, drug and/or device trial, and geographic location. Female enrollment was higher in 3 surgical specialties: neurosurgery (all authors: 52%, P ≤ 0.01), ophthalmology (all authors: 53.6%, P ≤ 0.0001), and surgery (all authors: 54.4%, P ≤ 0.0001). The majority of surgical specialties did not publish trials with female-female authorship but when stratifying by author gender pairing, surgical oncology had the highest female enrollment with female-female authorship (98.4%, P ≤ 0.0001). CONCLUSIONS: Female authorship of clinical trial publications, specifically having both first and senior authors as female, was correlated with higher female enrollment in clinical trials when compared to male authorship and endured with multiple subset analyses.

Do overlapping neurosurgical procedures affect patient outcomes? A systematic review and meta-analysis.

Overlapping surgery (OS) is a common practice in neurosurgery that has recently come under scrutiny. This study includes a systematic review and meta-analysis on articles evaluating the effects of OS on patient outcomes. PubMed and Scopus were searched for studies that analyzed outcome differences between overlapping and non-overlapping neurosurgical procedures. Study characteristics were extracted, and random-effects meta-analyses were performed to analyze the primary outcome (mortality) and secondary outcomes (complications, 30-day readmissions, 30-day operating room returns, home discharge, blood loss, and length of stay). Mantel-Haenszel tests were completed for binary outcomes, whereas the inverse variance tests were conducted for continuous outcomes. Heterogeneity was measured using the I2 and X2 tests. The Egger's test was conducted to evaluate publication bias. Eight of 61 non-duplicate studies were included. Overall, 21,249 patients underwent non-OS (10,504 female) and 15,863 patients underwent OS (8393 female). OS was associated with decreased mortality (p = 0.002), 30-day returns to OR (p < 0.001), and blood loss (p < 0.001) along with increased home discharges (p < 0.001). High heterogeneity was observed for home discharge (p = 0.002) and length of stay (p < 0.001). No publication bias was observed. OS was not associated with worse patient outcomes compared to non-OS. However, considering multiple sources of limitation in the methodology of the included studies (such as limited number of studies, reports originating from mostly high-volume academic centers, discrepancy in the definition of "critical portion(s)" of the surgery across studies, and selection bias), extra caution is advised in interpretation of our results and further focused studies are warranted.

Cognitive outcomes following functional neurosurgery in refractory OCD patients: a systematic review.

Neurosurgery is a therapeutic option for patients with refractory obsessive-compulsive disorder who do not respond to previous treatments. Although its efficacy in reducing clinical symptomatology has been proven, few studies have analyzed its effects at the cognitive level. The aim of this systematic review was to describe the cognitive outcomes of functional neurosurgery in patients that went through capsulotomies or cingulotomies. PubMed, Medline, Scopus, PsycInfo, PsyArticles, and Web of Knowledge were searched for studies reporting cognitive outcomes in refractory obsessive-compulsive patients after capsulotomies and cingulotomies. The risk of bias was assessed with the Assessment Tool for Before-After (Pre-Post) Studies With No Control Group tool; 13 studies met inclusion criteria, including 205 refractory obsessive-compulsive disorder patients for both surgical procedures. Results showed a substantial number of studies that did report significant cognitive improvement after surgery, being this improvement specially related to memory and executive functions. The second-most frequent finding is the maintenance of cognitive performance (nor improvement or worsening). From a neuropsychological point of view, this outcome might be considered a success, given that it is accompanied by amelioration of obsessive-compulsive symptoms. Subtle cognitive adverse effects have also been reported. Neurosurgery procedures appear to be safe from a cognitive point of view. Methodological issues must be improved to draw clearer conclusions, but capsulotomies and cingulotomies constitute an effective alternative treatment for refractory obsessive-compulsive disorder patients.

Cottonoid Retention After Craniotomy: Causes and Ways to Avoid It.

Nonabsorbable surgical material left in an surgical wound may cause early postoperative infections and specific types of granulomas; thus, it represents a dangerous complication in neurosurgery. The authors have analyzed their experience and present four cases of cottonoid retention after intracranial tumor resection. During 5-year period (from 2013 until 2017), the incidence of such an undesirable event after craniotomy for various indications was 0.07%. It was not related to the professional experience of the operating neurosurgeon, but cases of deep-seated lesions, the presence of brain edema or excessive bleeding of neoplastic or peritumoral tissue, prolonged surgeries, use of cottonoids without marking thread, and inadequate counting of disposable surgical materials at the end of the procedure may increase the risk of this complication. In all of the presented cases, the retained cottonoids were clearly seen on postoperative computed tomography because of the presence of radiopaque identifiers. All of the patients underwent an urgent reoperation for removal of the foreign body within 24 h after completion of the primary surgery, and they subsequently experienced an uneventful postoperative course without any complications. Well-coordinated work of the surgical team-in particular, appropriate communication between the surgeon and the circulating nurse during counting of surgical materials at the end of the procedure-is absolutely necessary for prevention of cottonoid retention after brain surgery.

Gender diversity in neurosurgical training: an analysis of trends and resident program characteristics.

OBJECTIVE: Recent trends have shown more women entering neurosurgery, but large gender gaps in the number of female trainees continue to persist. A previous study on the gender diversity of residents and faculty in neurosurgery training programs found that only 18.2% of residents and 8.7% of faculty at neurosurgical training programs were female. The goal of this study was to better understand program characteristics that may affect the recruitment of female residents and the gender composition of neurosurgery residency programs. METHODS: The authors assessed publicly available information on websites and social media from 116 Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery residency programs from the 2022-2023 academic year. Data collected on residents included gender and postgraduate year (PGY), geographic region, accreditation year, and complement size for programs. The authors analyzed the distribution of female residents at each program and compared accreditation year, program size, program geographics, PGY, and acceptance rates. RESULTS: There were 1602 residents across the 116 programs included in this study: 1223 (76.3%) male and 379 (23.7%) female residents. The gender distribution of female residents showed 29 programs had 30% or more female residents, 50 programs had between 16% and 30%, and 37 had fewer than 16%, including 8 with none. There were significantly more PGY-1 than PGY-7 female residents (28.9% vs 16.4%, p < 0.01). Programs with ACGME accreditation before 1970 had significantly higher percentages of female residents (26.0%) compared with those accredited after 1970 (18.2%, p < 0.01). Program size was associated with a higher percentage of female residents (large = 25.2%, medium = 24.9%, and small = 19.6%), although the results were not significant. The distribution of female trainees across five geographic regions of the United States was fairly even: Northeast (24.5%), West (25.2%), South Atlantic (23.1%), South Central (21.8%), and North Central (21.2%). Residency acceptance rates were similar between genders. CONCLUSIONS: The underrepresentation of women in neurosurgery residency programs remains a significant issue. While some programs have achieved higher female representation than the overall average proportion of female neurosurgery residents, many still fall short. There are twice as many female PGY-1 compared with PGY-7 residents, suggesting increased recruitment over the past few years. Programs with longer accreditation histories have significantly higher proportions of female residents. Larger program size can also play a role in attracting more female residents, but geographic location did not impact gender composition of resident cohorts in this study.

Implementation of the Enhanced Recovery After Surgery (ERAS®) program in neurosurgery.

BACKGROUND: Over the past decade, Enhanced Recovery After Surgery (ERAS®) guidelines have been proven to simplify postoperative care and improve recovery in several surgical disciplines. The authors set out to create and launch an ERAS® program for cranial neurosurgery that meets official ERAS® Society standards. The authors summarize the successive steps taken to achieve this goal in two specific neurosurgical conditions and describe the challenges they faced. METHODS: Pituitary neuroendocrine tumors (Pit-NET) resected by a transsphenoidal approach and craniosynostosis (Cs) repair were selected as appropriate targets for the implementation of ERAS® program in the Department of Neurosurgery. A multidisciplinary team with experience in managing these pathologies was created. A specialized ERAS® nurse coordinator was hired. An ERAS® certification process was performed involving 4 seminars separated by 3 active phases under the supervision of an ERAS® coach. RESULTS: The ERAS® Pit-NET team included 8 active members. The ERAS® Cs team included 12 active members. Through the ERAS® certification process, areas for improvement were identified, local protocols were written, and the ERAS® program was implemented. Patient-centered strategies were developed to increase compliance with the ERAS® protocols. A prospective database was designed for ongoing program evaluation. Certification was achieved in 18 months. Direct costs and time requirements are reported. CONCLUSION: Successful ERAS® certification requires a committed multidisciplinary team, an ERAS® coach, and a dedicated nurse coordinator.

Exploring Novel Innovation Strategies to Close a Technology Gap in Neurosurgery: HORAO Crowdsourcing Campaign.

BACKGROUND: Scientific research is typically performed by expert individuals or groups who investigate potential solutions in a sequential manner. Given the current worldwide exponential increase in technical innovations, potential solutions for any new problem might already exist, even though they were developed to solve a different problem. Therefore, in crowdsourcing ideation, a research question is explained to a much larger group of individuals beyond the specialist community to obtain a multitude of diverse, outside-the-box solutions. These are then assessed in parallel by a group of experts for their capacity to solve the new problem. The 2 key problems in brain tumor surgery are the difficulty of discerning the exact border between a tumor and the surrounding brain, and the difficulty of identifying the function of a specific area of the brain. Both problems could be solved by a method that visualizes the highly organized fiber tracts within the brain; the absence of fibers would reveal the tumor, whereas the spatial orientation of the tracts would reveal the area's function. To raise awareness about our challenge of developing a means of intraoperative, real-time, noninvasive identification of fiber tracts and tumor borders to improve neurosurgical oncology, we turned to the crowd with a crowdsourcing ideation challenge. OBJECTIVE: Our objective was to evaluate the feasibility of a crowdsourcing ideation campaign for finding novel solutions to challenges in neuroscience. The purpose of this paper is to introduce our chosen crowdsourcing method and discuss it in the context of the current literature. METHODS: We ran a prize-based crowdsourcing ideation competition called HORAO on the commercial platform HeroX. Prize money previously collected through a crowdfunding campaign was offered as an incentive. Using a multistage approach, an expert jury first selected promising technical solutions based on broad, predefined criteria, coached the respective solvers in the second stage, and finally selected the winners in a conference setting. We performed a postchallenge web-based survey among the solvers crowd to find out about their backgrounds and demographics. RESULTS: Our web-based campaign reached more than 20,000 people (views). We received 45 proposals from 32 individuals and 7 teams, working in 26 countries on 4 continents. The postchallenge survey revealed that most of the submissions came from single solvers or teams working in engineering or the natural sciences, with additional submissions from other nonmedical fields. We engaged in further exchanges with 3 out of the 5 finalists and finally initiated a successful scientific collaboration with the winner of the challenge. CONCLUSIONS: This open innovation competition is the first of its kind in medical technology research. A prize-based crowdsourcing ideation campaign is a promising strategy for raising awareness about a specific problem, finding innovative solutions, and establishing new scientific collaborations beyond strictly disciplinary domains.

Effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery: A meta-analysis.

We performed a meta-analysis to evaluate the effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery. A systematic literature search up to July 2022 was performed and 24 137 subjects with neurosurgery at the baseline of the studies; 10 496 of them were using the powdered vancomycin, and 13 641 were not using the powdered vancomycin as a control. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery using dichotomous methods with a random or fixed-effect model. The powdered vancomycin had significantly lower surgical site wound infections after spinal surgery (OR, 0.53; 95% CI, 0.41-0.70, P < .001), deep surgical site wound infections after spinal surgery (OR, 0.45; 95% CI, 0.35-0.57, P < .001), superficial surgical site wound infections after spinal surgery (OR, 0.60; 95% CI, 0.43-0.83, P = .002), and surgical site wound infections after cranial surgery (OR, 0.37; 95% CI, 0.22-0.61, P < .001) compared to control in subjects with neurosurgery. The powdered vancomycin had significantly lower surgical site wound infections after spinal surgery, deep surgical site wound infections after spinal surgery, superficial surgical site wound infections after spinal surgery, and surgical site wound infections after cranial surgery compared to control in subjects with neurosurgery. The analysis of outcomes should be done with caution even though the low number of studies with low sample size, 3 out of the 42 studies, in the meta-analysis, and a low number of studies in certain comparisons.

Relationship between nosocomial infections and coronavirus disease 2019 in the neurosurgery unit: clinical characteristics and outcomes from a Chinese Tertiary-Care Hospital.

BACKGROUND: The COVID-19 pandemic has raised awareness of infection prevention and control. We found that the incidence of nosocomial infection in neurosurgery has changed. This study aimed to evaluate the impact of "coronavirus disease 2019 (COVID-19) prevention and control measures" on nosocomial infections in neurosurgery. METHODS: To explore changes in nosocomial infections in neurosurgery during the COVID-19 pandemic, the clinical data of inpatients undergoing neurosurgery at Taizhou Hospital of Zhejiang Province between January 1 and April 30, 2020 (COVID-19 era) were first analyzed and then compared with those from same period in 2019 (first pre-COVID-19 era). We also analyzed data between May 1 and December 31, 2020 (post-COVID-19 era) at the same time in 2019 (second pre-COVID-19 era). RESULTS: The nosocomial infection rate was 7.85% (54/688) in the first pre-COVID-19 era and 4.30% (26/605) in the COVID-19 era (P = 0.01). The respiratory system infection rate between the first pre-COVID-19 and COVID-19 eras was 6.1% vs. 2.0% (P < 0.01), while the urinary system infection rate was 1.7% vs. 2.0% (P = 0.84). Between the first pre-COVID-19 and COVID-19 eras, respiratory system and urinary infections accounted for 77.78% (42/54) vs. 46.15% (12/26) and 22.22% (12/54) vs. 46.15% (12/26) of the total nosocomial infections, respectively (P < 0.01). Between the second pre-COVID-19 and post-COVID-19 eras, respiratory system and urinary accounted for 53.66% (44/82) vs. 40.63% (39/96) and 24.39% (20/82) vs. 40.63% (39/96) of the total nosocomial infections, respectively (P = 0.02). CONCLUSIONS: The incidence of nosocomial infections in neurosurgery reduced during the COVID-19 pandemic. The reduction was primarily observed in respiratory infections, while the proportion of urinary infections increased significantly.

Topical hemostatic agents in neurosurgery, a comprehensive review: 15 years update.

Hemostasis in neurosurgery is of utmost importance. Bleeding management is one of the crucial steps of each neurosurgical procedure. Several strategies, namely thermal, mechanical, electric, and chemical, have been advocated to face blood loss within the surgical field. Over time, countless hemostatic agents and devices have been proposed. Furthermore, the ever-growing recent technological innovation has made available several novel and interesting tools. Pursuant to their impact on surgical practice, we perceived the imperative to update our previous disclosure paper. Therefore, we reviewed the literature and analyzed technical data sheets of each product in order to provide an updated and comprehensive overview in regard to chemical properties, mechanisms of action, use, complications, tricks, and pitfalls of topical hemostatic agents.

Prognostic significance of competition ratios in surgical specialty training selection.

BACKGROUND: A competition ratio (CR) indicates the ratio of total applications for a training post when compared with numbers of specialty posts available. This study aimed to evaluate CRs' influence on National Training Number (NTN) selection in a single UK Statutory Education Body. METHODS: Consecutive core surgical trainees numbering 154 (105 men, 49 women; median years since graduation: four) were studied over a 6-year period. Annual specialty specific CRs were obtained from Health Education England's website, and primary outcome measure was UK NTN appointment. RESULTS: Overall NTN appointment was 45.5%. Median CR was 2.36; range Oral & Maxillofacial Surgery 0.70 (2020) to Neurosurgery 22.0 (2020). Multivariable analysis revealed that NTN success was associated with: CR (OR 0.46, p=0.003), a single scientific publication (OR 6.25, p=0.001), cohort year (2019, OR 12.65, p=0.003) and Universal Annual Review of Competence Progression Outcome 1 (OR 45.24, p<0.001). CRs predicted NTN appointment with a Youden index defined critical ratio of 4.42; 28.6% (n=8) versus 49.2% (n=62), p=0.018. CONCLUSION: CRs displayed 30-fold variation, with CRs below 4.42 associated with twofold better NTN promotion, but strong clinical competence and academic reach again emerged as the principal drivers of career advancement.

Trends of core versus subspecialty operative procedures completed in general surgery residency training programs.

INTRODUCTION: General surgery residency involves performing subspecialty procedures in addition to the core general procedures. However, the proportion of core general surgery versus subspecialty procedures during training is variable and its temporal changes are unknown. The goal of our study was to assess the current trends in core general surgery and subspecialty procedure distributions during general surgery residency training. METHODS: Data were collected from the ACGME core general surgery national resident available report case logs from 2007 to 2019. Descriptive and time series analyses were used to compare proportions of average procedures performed per resident in the core general surgery category versus the subspecialty category. F-tests were conducted to show whether the slopes of the trend lines were significantly non-zero. RESULTS: The mean of total procedures completed for major credit by the average general surgery resident increased from 910.1 (SD=30.31) in 2007 to 1070.5 (SD=37.59) in 2019. Over that same period, the number of general, cardiothoracic, plastic and urology surgery procedures increased by 24.9%, 9.8%, 76.6% and 19.3%, respectively. Conversely, vascular and paediatric surgery procedures decreased by 7.6% and 30.7%, respectively. The neurological surgery procedures remain stable at 1.1 procedures per resident per year. A significant positive correlation in the trend reflecting total (p<0.0001), general (p<0.0001) and plastic (p<0.0016) surgery procedures and the negative correlation in the trend lines for vascular (p<0.0006) and paediatric (p<0.0001) surgery procedures were also noted. CONCLUSIONS: Trends in overall surgical case volume performed by general surgery residents over the last 12 years have shown a steady increase in operative training opportunity despite the increasing number of subspecialty training programmes and fellowships. Further research to identify areas for improvement and to study the diversity of operative procedures, and their outcomes is warranted in the years to come.

Construct validity of the Surgical Autonomy Program for the training of neurosurgical residents.

OBJECTIVE: There is no standard way in which physicians teach or evaluate surgical residents intraoperatively, and residents are proving to not be fully competent at core surgical procedures upon graduating. The Surgical Autonomy Program (SAP) is a novel educational model that combines a modified version of the Zwisch scale with Vygotsky's social learning theory. The objective of this study was to establish preliminary validity evidence that SAP is a reliable measure of autonomy and a useful tool for tracking competency over time. METHODS: The SAP breaks each surgical case into 4 parts, or zones of proximal development (ZPDs). Residents are evaluated on a 4-tier autonomy scale (TAGS scale) for each ZPD in every surgical case. Attendings were provided with a teaching session about SAP and identified appropriate ZPDs for surgical cases under their area of expertise. All neurosurgery residents at Duke University Hospital from July 2017 to July 2021 participated in this study. Chi-square tests and ordinal logistic regression were used for the analyses. RESULTS: Between 2017 and 2021, there were 4885 cases logged by 27 residents. There were 30 attendings who evaluated residents using SAP. Faculty completed evaluations on 91% of cases. The ZPD of focus directly correlated with year of residency (postgraduate year) (χ2 = 1221.1, df = 15, p < 0.001). The autonomy level increased with year of residency (χ2 = 3553.5, df = 15, p < 0.001). An ordinal regression analysis showed that for every year increase in postgraduate year, the odds of operating at a higher level of independence was 2.16 times greater (95% CI 2.11-2.21, p < 0.001). The odds of residents performing with greater autonomy was lowest for the most complex portion of the case (ZPD3) (OR 0.18, 95% CI 0.17-0.20, p < 0.001). Residents have less autonomy with increased case complexity (χ2 = 160.28, df = 6, p < 0.001). Compared with average cases, residents were more likely to operate with greater autonomy on easy cases (OR 1.44, 95% CI 1.29-1.61, p < 0.001) and less likely to do so on difficult cases (OR 0.72, 95% CI 0.67-0.77, p < 0.001). CONCLUSIONS: This study demonstrates preliminary evidence supporting the construct validity of the SAP. This tool successfully tracks resident autonomy and progress over time. The authors' smartphone application was widely used among surgical faculty and residents, supporting integration into the perioperative workflow. Wide implementation of SAP across multiple surgical centers will aid in the movement toward a competency-based residency education system.

Teaching through the screen: a toolbox for creating a virtual neurosurgical subinternship program.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic disrupted the landscape of traditional neurosurgical subinternships, ramifications of which persist to this day. The outright cancellation of in-person subinternships in 2020 presented not only a challenge to both applicants and programs, but also an opportunity to establish an effective and efficient platform for virtual neurosurgical training. To address this need, the authors designed and trialed a novel virtual neurosurgical subinternship (Virtual Sub-I). METHODS: The weeklong, case-based Virtual Sub-I program combined flipped-classroom and active learning approaches. Students worked in small groups to discuss neurosurgical cases. Faculty and residents offered personalized mentorship sessions to participants. Surveys were used to assess students' experience with the authors' subinternship program, consistent with level 1 of the Kirkpatrick model. RESULTS: A total of 132 students applied from both international and American medical schools. The final cohort comprised 27 students, of whom 8 (30%) were female and 19 (70%) were male. Students characterized the subinternship as "interactive," "educational," and "engaging." One hundred percent of survey respondents were "very likely" to recommend the Virtual Sub-I to their peers. Faculty involved in the Virtual Sub-I stated that the program allowed them to determine the fit of participating medical students for their neurosurgery residency program, and that information gathered from the Virtual Sub-I had the potential to influence their ranking decisions. CONCLUSIONS: The Virtual Sub-I recapitulates the educational and interpersonal benefits of the traditional subinternship experience and can serve as a prototype for future virtual surgical education endeavors. Furthermore, the Virtual Sub-I presents a more equitable platform for introducing medical students across the undergraduate medical education spectrum to neurosurgical education and mentorship.

The benefits of perioperative music interventions for patients undergoing neurosurgery: a mixed-methods systematic review.

BACKGROUND: Several studies have demonstrated music intervention as a safe and inexpensive option for reducing anxiety and pain perioperatively. We performed a systematic review to evaluate its possible benefit in perioperative neurosurgical management. METHODS: The following databases were searched with no restrictions on publication date: PubMed, Embase, CINAHL, PsycINFO, CENTRAL and ClinicalTrials.gov. All studies that quantitatively or qualitatively assessed the effects of any music-based intervention administered within one week of cranial or spinal neurosurgery were eligible. Meta-analysis could not be performed, and quantitative findings were instead summarised narratively. We then synthesised qualitative observations through thematic analysis before conducting an integrative review. PROSPERO registration: CRD42019152626. RESULTS: Seven studies, of sample sizes ranging from 8 to 60, were included, with the timing, duration, frequency and type of music intervention varying considerably across studies. Quantitative analysis involving five studies showed a significant decrease in anxiety following music intervention in four studies (p < 0.05), and reduced pain perception in three studies (p < 0.05). Mixed evidence was obtained for physiological outcomes including heart rate and blood pressure. Risk of bias was moderate to high. Quantitative findings were generally supported by qualitative analysis which provided additional insight into the factors influencing music intervention's effectiveness. CONCLUSION: Despite the heterogeneity in study characteristics, this review, which is the first mixed-methods systematic review assessing the effects of perioperative music intervention, not only reveals a potential role for music intervention in neurosurgery, but also highlights the possible importance of considering qualitative evidence in future studies to better characterise its effectiveness.

The impact of coronavirus 2019 (COVID-19) on neurosurgical practice and training: a review article.

The 2019 coronavirus pandemic (COVID-19) has affected all of society at different levels. Similarly, COVID-19 has significantly impacted every medical field, including neurosurgery. By exposing scarcities in the healthcare industry and requiring the reallocation of available resources towards the priority setting and away from elective surgeries and outpatient visits, the pandemic posed new, unprecedented challenges to the medical community. Despite the redistribution of resources towards COVID-19 patients and away from elective surgeries, urgent and emergent surgeries for life-threatening conditions needed to be continued. The neurosurgical community, like other specialties not directly involved in the care of COVID-19 patients, initially struggled to balance the needs of COVID-19 patients with those of neurosurgical patients, residents, and researchers. Several articles describing the effect of COVID-19 on neurosurgical practice and training have been published throughout the COVID-19 pandemic. This article aims to provide a focused review of the impact COVID-19 has had on neurosurgical practice and training as well as describe neurological manifestations of the disease.