Sleep-disordered breathing in children with Chiari type I malformation.

OBJECTIVE: The objective was to identify clinical and radiological factors associated with sleep-disordered breathing (SDB) in children with Chiari type I malformation (CIM) and to evaluate the efficacy of foramen magnum decompression (FMD) in resolving SDB. METHODS: A retrospective chart review was conducted for all children evaluated for CIM at a single institution from 2002 to 2022, identifying all children who had undergone nocturnal polysomnography (PSG). Apnea-hypopnea index (AHI) score, sleep apnea type (obstructive, central, mixed, and unspecified), clinical manifestations, and radiological measurements were recorded. SDB was considered present when officially diagnosed in the PSG report. Logistic regression was performed to identify factors correlating with the presence of SDB. For children with SDB who underwent FMD, the Wilcoxon signed-rank test was used to assess AHI improvement. RESULTS: Of the 997 children referred for CIM, 310 completed PSG. SDB was diagnosed in 147 patients (overall prevalence 14.7%, 95% CI 12.7%-17.1%; prevalence among children with PSG 47.4%, 95% CI 41.9%-53%). Specific SDB diagnosis consisted of 33% of patients with central sleep apnea, 27% with obstructive sleep apnea, 9% mixed, and 31% unspecified. Lower cranial nerve (CN) dysfunction (OR 3.891, p = 0.009), tonsillar position (OR 1.049, p = 0.017), Chiari type 1.5 malformation (OR 1.862, p = 0.044), and BMI (OR 1.039, p = 0.036) were significantly associated with presence of SDB. Of the 310 patients who underwent PSG, 47 were originally categorized as asymptomatic: 27 (57%) of these asymptomatic patients were diagnosed with SDB on PSG. Of children diagnosed with SDB, 34 completed PSG before and after FMD. Median AHI score decreased from 6.5 preoperatively to 1.8 postoperatively, with a median (IQR) difference of -2.3 (-11.9 to 0.1) (p = 0.001). Twelve (35%) had resolution of SDB. CONCLUSIONS: The authors' findings suggest that the prevalence of SDB in children with CIM is high (15%-47%). Furthermore, lower CN dysfunction, Chiari type 1.5, lower tonsillar position, and higher BMI may be risk factors. Notably, SDB can be present even in the absence of clinical symptoms. This study also demonstrates that surgical intervention has the potential to reduce the severity of SDB. These results could help clinicians identify CIM patients at risk for SDB and those who may benefit from surgical decompression.

Competencies for proficiency in basic point-of-care ultrasound in anesthesiology: national expert recommendations using Delphi methodology.

PURPOSE: Point-of-care ultrasound (POCUS) allows for rapid bedside assessment and guidance of patient care. Recently, POCUS was included as a mandatory component of Canadian anesthesiology training; however, there is no national consensus regarding the competencies to guide curriculum development. We therefore aimed to define national residency competencies for basic perioperative POCUS proficiency. METHODS: We adopted a Delphi process to delineate relevant POCUS competencies whereby we circulated an online survey to academic anesthesiologists identified as POCUS leads/experts (n = 25) at all 17 Canadian anesthesiology residency programs. After reviewing a list of competencies derived from the Royal College of Physicians and Surgeons of Canada's National Curriculum, we asked participants to accept, refine, delete, or add competencies. Three rounds were completed between 2022 and 2023. We discarded items with < 50% agreement, revised those with 50-79% agreement based upon feedback provided, and maintained unrevised those items with ≥ 80% agreement. RESULTS: We initially identified and circulated (Round 1) 74 competencies across 19 clinical domains (e.g., basics of ultrasound [equipment, nomenclature, clinical governance, physics]; cardiac [left ventricle, right ventricle, valve assessment, pericardial effusion, intravascular volume status] and lung ultrasound anatomy, image acquisition, and image interpretation; and clinical applications [monitoring and serial assessments, persistent hypotension, respiratory distress, cardiac arrest]). After three Delphi rounds (and 100% response rate maintained), panellists ultimately agreed upon 75 competencies. CONCLUSION: Through national expert consensus, this study identified POCUS competencies suitable for curriculum development and assessment in perioperative anesthesiology. Next steps include designing and piloting a POCUS curriculum and assessment tool(s) based upon these nationally defined competencies.

RéSUMé: OBJECTIF: L'échographie ciblée (POCUS) permet une évaluation rapide au chevet des patient·es et l'orientation des soins aux patient·es. Récemment, l'échographie ciblée a été incluse en tant que composante obligatoire de la formation en anesthésiologie au Canada; cependant, il n'y a pas de consensus national sur les compétences qui guideront l'élaboration des programmes d'études. Nous avons donc cherché à définir les compétences à inclure dans les programmes de résidence nationaux pour acquérir des compétences de base en échographie ciblée périopératoire. MéTHODE: Nous avons adopté un processus Delphi pour délimiter les compétences pertinentes en échographie ciblée, processus dans le cadre duquel nous avons fait circuler un sondage en ligne auprès d'anesthésiologistes universitaires identifié·es comme des responsables/expert·es en échographie ciblée (n = 25) dans les 17 programmes canadiens de résidence en anesthésiologie. Après avoir examiné une liste de compétences tirées du programme d'études national du Collège royal des médecins et chirurgiens du Canada, nous avons demandé aux participant·es d'accepter, de peaufiner, de supprimer ou d'ajouter des compétences. Trois rondes ont été complétées entre 2022 et 2023. Nous avons écarté les éléments ayant < 50 % d'accord, révisé ceux avec 50 à 79 % d'accord en fonction des commentaires fournis, et maintenu sans révision les éléments obtenant ≥ 80 % d'accord. RéSULTATS: Nous avons d'abord identifié et diffusé (ronde 1) 74 compétences dans 19 domaines cliniques (p. ex., les bases de l'échographie [équipement, nomenclature, gouvernance clinique, physique]; anatomie échographique cardiaque [ventricule gauche, ventricule droit, évaluation valvulaire, épanchement péricardique, état du volume intravasculaire] et pulmonaire [acquisition et interprétation d'images]; et applications cliniques [surveillance et évaluations en série, hypotension persistante, détresse respiratoire, arrêt cardiaque]). Après trois rondes Delphi (et un taux de réponse de 100 % maintenu), les panélistes se sont finalement mis·es d'accord sur 75 compétences. CONCLUSION: Grâce à un consensus d'expert·es au pays, cette étude a permis d'identifier les compétences en échographie ciblée adaptées à l'élaboration et à l'évaluation de programmes d'études en anesthésiologie périopératoire. Les prochaines étapes comprennent la conception et la mise à l'essai d'un programme d'études et d'outils d'évaluation en échographie ciblée basés sur ces compétences définies à l'échelle nationale.

Defining a Framework and Evaluation Metrics for Sustainable Global Surgical Partnerships: A Modified Delphi Study.

OBJECTIVE: The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs). BACKGROUND: Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs. METHODS: A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs. RESULTS: Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds. CONCLUSIONS: We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.

Exploring Patient Advisors' Perceptions of Virtual Care Across Canada: Qualitative Phenomenological Study.

BACKGROUND: While virtual care services existed prior to the emergence of COVID-19, the pandemic catalyzed a rapid transition from in-person to virtual care service delivery across the Canadian health care system. Virtual care includes synchronous or asynchronous delivery of health care services through video visits, telephone visits, or secure messaging. Patient advisors are people with patient and caregiving experiences who collaborate within the health care system to share insights and experiences in order to improve health care. OBJECTIVE: This study aimed to understand patient advisors' perceptions related to virtual care and potential impacts on health care quality. METHODS: We adopted a phenomenological approach, whereby we interviewed 20 participants who were patient advisors across Canada using a semistructured interview protocol. The protocol was developed by content experts and medical education researchers. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Data collection stopped once thematic saturation was reached. The study was conducted at Queen's University, Kingston, Ontario. We recruited 20 participants from 5 Canadian provinces (17 female participants and 3 male participants). RESULTS: Six themes were identified: (1) characteristics of effective health care, (2) experiences with virtual care, (3) modality preferences, (4) involvement of others, (5) risks associated with virtual care encounters, and (6) vulnerable populations. Participants reported that high-quality health care included building relationships and treating patients holistically. In general, participants described positive experiences with virtual care during the pandemic, including greater efficiency, increased accessibility, and that virtual care was less stressful and more patient centered. Participants comparing virtual care with in-person care reported that time, scheduling, and content of interactions were similar across modalities. However, participants also shared the perception that certain modalities were more appropriate for specific clinical encounters (eg, prescription renewals and follow-up appointments). Perspectives related to the involvement of family members and medical trainees were positive. Potential risks included miscommunication, privacy concerns, and inaccurate patient assessments. All participants agreed that stakeholders should be proactive in applying strategies to support vulnerable patients. Participants also recommended education for patients and providers to improve virtual care delivery. CONCLUSIONS: Participant-reported experiences of virtual care encounters were relatively positive. Future work could focus on delivering training and resources for providers and patients. While initial experiences are positive, there is a need for ongoing stakeholder engagement and evaluation to improve patient and caregiver experiences with virtual care.

High-fidelity, simulation-based microsurgical training for neurosurgical residents.

OBJECTIVE: Simulation is increasingly recognized as an important supplement to operative training. The live rat femoral artery model is a well-established model for microsurgical skills simulation. In this study, the authors present an 11-year experience incorporating a comprehensive, longitudinal microsurgical training curriculum into a Canadian neurosurgery program. The first goal was to evaluate training effectiveness, using a well-studied rating scale with strong validity. The second goal was to assess the impact of the curriculum on objective measures of subsequent operating room performance during postgraduate year (PGY)-5 and PGY-6 training. METHODS: PGY-2 neurosurgery residents completed a 1-year curriculum spanning 17 training sessions divided into 5 modules of increasing fidelity. Both perfused duck wing and live rat vessel training models were used. Three modules comprised live microvascular anastomosis. Trainee performance was video recorded and blindly graded using the Objective Structured Assessment of Technical Skills Global Rating Scale. Eleven participants who completed the training curriculum and 3 subjects who had not participated had their subsequent operative performances evaluated when they were at the PGY-5 and PGY-6 levels. RESULTS: Eighteen participants completed 106 microvascular anastomoses during the study. There was significant improvement in 6 measurable skills during the curriculum. The mean overall score was significantly higher on the fifth attempt compared with the first attempt for all 3 live anastomotic modules (p < 0.001). Each module had a different improvement profile across the skills assessed. Those who completed the microvascular skills curriculum demonstrated a greater number of independent evaluations during superficial surgical exposure, deep exposure, and primary maneuvers at the PGY-5 and PGY-6 levels. CONCLUSIONS: High-fidelity microsurgical simulation training leads to significant improvement in microneurosurgical skills. Transfer of acquired skills to the operative environment and durability for at least 3 to 4 years show encouraging preliminary results and are subject to ongoing investigation.

Simulation and Active Learning Decreases Training Time of an Emergency Triage Assessment and Treatment Course in Pilot Study in Malawi: Implications for Increasing Efficiency and Workforce Capacity in Low-Resource Settings.

OBJECTIVES: The aim of the Emergency Triage Assessment and Treatment (ETAT) plus trauma course is to improve the quality of care provided to infants and children younger than 5 years. The curriculum was revised and shortened from 5 to 2.5 days by enhancing simulation and active learning opportunities. The aim of this study was to examine the feasibility and value of the new short-form ETAT course by assessing postcourse knowledge and satisfaction. METHODS: We delivered the short-form ETAT course to a group of interdisciplinary health workers in Malawi. Precourse and postcourse knowledge was assessed using a standardized 20 questions short answer test used previously in the 5-day courses. A 13-statement survey with 2 open-ended questions was used to examine participant satisfaction. RESULTS: Participants' postcourse knowledge improved significantly (P < 0.001) after the shorter ETAT course. Participants reported high levels of satisfaction with the short-form ETAT. CONCLUSIONS: Simulation and other active learning strategies reduced training time by 50% in the short-form ETAT course. Participants with and without previous ETAT training improved their knowledge after participating in the short-form ETAT course. Reduced training time is beneficial in settings already burdened by scarce human resources, may facilitate better access to in-service training, and build capacity while conserving resources in low-resource settings.

A model for global surgical training and capacity development: the Children's of Alabama-Viet Nam pediatric neurosurgery partnership.

INTRODUCTION: Training capable and competent neurosurgeons to work in underserved regions of the world is an essential component of building global neurosurgical capacity. One strategy for achieving this goal is establishing longitudinal partnerships between institutions in low- and middle-income countries (LMICs) and their counterparts in high-income countries (HICs) utilizing a multi-component model. We describe the initial experience of the Children's of Alabama (COA) Global Surgery Program partnership with multiple Vietnamese neurosurgical centers. METHODS: The training model developed by the COA Global Surgery Program utilizes three complementary and interdependent methods to expand neurosurgical capacity: in-country training, out-of-country training, and ongoing support and mentorship. Multiple Vietnamese hospital systems have participated in the partnership, including three hospitals in Hanoi and one hospital in Ho Chi Minh City. RESULTS: During the 7 years of the partnership, the COA and Viet Nam teams have collaborated on expanding pediatric neurosurgical care in numerous areas of clinical need including five subspecialized areas of pediatric neurosurgery: cerebrovascular, epilepsy, neuroendoscopy for hydrocephalus management, craniofacial, and neuro-oncology. CONCLUSION: Long-term partnerships between academic departments in LMICs and HICs focused on education and training are playing an increasingly important role in scaling up global surgical capacity. We believe that our multi-faceted approach consisting of in-country targeted hands-on training, out-of-country fellowship training at the mentor institution, and ongoing mentorship using telecollaboration and Internet-based tools is a viable and generalizable model for enhancing surgical capacity globally.

The initial experience of InterSurgeon: an online platform to facilitate global neurosurgical partnerships.

OBJECTIVE: Despite general enthusiasm for international collaboration within the organized neurosurgical community, establishing international partnerships remains challenging. The current study analyzes the initial experience of the InterSurgeon website in partnering surgeons from across the world to increase surgical collaboration. METHODS: One year after the launch of the InterSurgeon website, data were collected to quantify the number of website visits, average session duration, total numbers of matches, and number of offers and requests added to the website each month. Additionally, a 15-question survey was designed and distributed to all registered members of the website. RESULTS: There are currently 321 surgeon and institutional members of InterSurgeon representing 69 different countries and all global regions. At the time of the survey there were 277 members, of whom 76 responded to the survey, yielding a response rate of 27.4% (76/277). Twenty-five participants (32.9%) confirmed having either received a match email (12/76, 15.8%) or initiated contact with another user via the website (13/76, 17.1%). As expected, the majority of the collaborations were either between a high-income country (HIC) and a low-income country (LIC) (5/18, 27.8%) or between an HIC and a middle-income country (MIC) (9/18, 50%). Interestingly, there were 2 MIC-to-MIC collaborations (2/18, 11.1%) as well as 1 MIC-to-LIC (1/18, 5.6%) and 1 LIC-to-LIC partnership. At the time of response, 6 (33.3%) of the matches had at least resulted in initial contact via email or telephone. One of the partnerships had involved face-to-face interaction via video conference. A total of 4 respondents had traveled internationally to visit their partner's institution. CONCLUSIONS: Within its first year of launch, the InterSurgeon membership has grown significantly. The partnerships that have already been formed involve not only international visits between HICs and low- to middle-income countries (LMICs), but also telecollaboration and inter-LMIC connections that allow for greater exchange of knowledge and expertise. As membership and site features grow to include other surgical and anesthesia specialties, membership growth and utilization is expected to increase rapidly over time according to social network dynamics.

Development and evaluation of a patient-specific surgical simulator for endoscopic colloid cyst resection.

OBJECTIVE: Endoscopic resection of third-ventricle colloid cysts is technically challenging due to the limited dexterity and visualization provided by neuroendoscopic instruments. Extensive training and experience are required to master the learning curve. To improve the education of neurosurgical trainees in this procedure, a synthetic surgical simulator was developed and its realism, procedural content, and utility as a training instrument were evaluated. METHODS: The simulator was developed based on the neuroimaging (axial noncontrast CT and T1-weighted gadolinium-enhanced MRI) of an 8-year-old patient with a colloid cyst and hydrocephalus. Image segmentation, computer-aided design, rapid prototyping (3D printing), and silicone molding techniques were used to produce models of the skull, brain, ventricles, and colloid cyst. The cyst was filled with a viscous fluid and secured to the roof of the third ventricle. The choroid plexus and intraventricular veins were also included. Twenty-four neurosurgical trainees performed a simulated colloid cyst resection using a 30° angled endoscope, neuroendoscopic instruments, and image guidance. Using a 19-item feedback survey (5-point Likert scales), participants evaluated the simulator across 5 domains: anatomy, instrument handling, procedural content, perceived realism, and confidence and comfort level. RESULTS: Participants found the simulator's anatomy to be highly realistic (mean 4.34 ± 0.63 [SD]) and appreciated the use of actual instruments (mean 4.38 ± 0.58). The procedural content was also rated highly (mean 4.28 ± 0.77); however, the perceived realism was rated slightly lower (mean 4.08 ± 0.63). Participants reported greater confidence in their ability to perform an endoscopic colloid cyst resection after using the simulator (mean 4.45 ± 0.68). Twenty-three participants (95.8%) indicated that they would use the simulator for additional training. Recommendations were made to develop complex case scenarios for experienced trainees (normal-sized ventricles, choroid plexus adherent to cyst wall, bleeding scenarios) and incorporate advanced instrumentation such as side-cutting aspiration devices. CONCLUSIONS: A patient-specific synthetic surgical simulator for training residents and fellows in endoscopic colloid cyst resection was successfully developed. The simulator's anatomy, instrument handling, and procedural content were found to be realistic. The simulator may serve as a valuable educational tool to learn the critical steps of endoscopic colloid cyst resection, develop a detailed understanding of intraventricular anatomy, and gain proficiency with bimanual neuroendoscopic techniques.

Predictors of endoscopic third ventriculostomy ostomy status in patients who experience failure of endoscopic third ventriculostomy with choroid plexus cauterization.

OBJECTIVE: At failure of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC), the ETV ostomy may be found to be closed or open. Failure with a closed ostomy may indicate a population that could benefit from evolving techniques to keep the ostomy open and may be candidates for repeat ETV, whereas failure with an open ostomy may be due to persistently abnormal CSF dynamics. This study seeks to identify clinical and radiographic predictors of ostomy status at the time of ETV/CPC failure. METHODS: The authors conducted a multicenter, retrospective cohort study on all pediatric patients with hydrocephalus who failed initial ETV/CPC treatment between January 2013 and October 2016. Failure was defined as the need for repeat ETV or ventriculoperitoneal (VP) shunt placement. Clinical and radiographic data were collected, and ETV ostomy status was determined endoscopically at the subsequent hydrocephalus procedure. Statistical analysis included the Mann-Whitney U-test, Wilcoxon rank-sum test, t-test, and Pearson chi-square test where appropriate, as well as multivariate logistic regression. RESULTS: Of 72 ETV/CPC failures, 28 patients (39%) had open-ostomy failure and 44 (61%) had closed-ostomy failure. Patients with open-ostomy failure were older (median 5.1 weeks corrected age for gestation [interquartile range (IQR) 0.9-15.9 weeks]) than patients with closed-ostomy failure (median 0.2 weeks [IQR -1.3 to 4.5 weeks]), a significant difference by univariate and multivariate regression. Etiologies of hydrocephalus included intraventricular hemorrhage of prematurity (32%), myelomeningocele (29%), congenital communicating (11%), aqueductal stenosis (11%), cyst/tumor (4%), and other causes (12%). A wider baseline third ventricle was associated with open-ostomy failure (median 15.0 mm [IQR 10.3-18.5 mm]) compared to closed-ostomy failure (median 11.7 mm [IQR 8.9-16.5 mm], p = 0.048). Finally, at the time of failure, patients with closed-ostomy failure had enlargement of their ventricles (frontal and occipital horn ratio [FOHR], failure vs baseline, median 0.06 [IQR 0.00-0.11]), while patients with open-ostomy failure had no change in ventricle size (median 0.01 [IQR -0.04 to 0.05], p = 0.018). Previous CSF temporizing procedures, intraoperative bleeding, and time to failure were not associated with ostomy status at ETV/CPC failure. CONCLUSIONS: Older corrected age for gestation, larger baseline third ventricle width, and no change in FOHR were associated with open-ostomy ETV/CPC failure. Future studies are warranted to further define and confirm features that may be predictive of ostomy status at the time of ETV/CPC failure.

A mixed methods study of challenges in the implementation and use of the surgical safety checklist.

BACKGROUND: The surgical safety checklist is an evidence-based global initiative designed to reduce perioperative morbidity and mortality. However, the expounded benefits of the surgical safety checklist have not been realized in naturalistic settings. This may be related to the quality of surgical safety checklists being performed in operating rooms. METHODS: In this explanatory, sequential, mixed-methods study, 2 trained observers used a standardized tool to record the compliance and quality of the surgical safety checklist completed during 51 surgeries performed at a pediatric academic hospital. We compared compliance with each phase of the surgical safety checklist, the number of checklist items completed, and professionals initiating the surgical safety checklist across surgical specialties and case urgency levels. Interviews with nurses, anesthesiologists, and surgeons (n = 18) were subsequently conducted to explore and contextualize the findings. RESULTS: Hospital-recorded surgical safety checklist compliance (94%, 100%, and 100% on briefing, time out, and debriefing) was higher than the proportion of checklist items completed in matched cases (26%, 59%, and 42%, respectively). Thematic analysis of the interview data suggests this may result from limited staff "buy in," arising from the "top-down" mandated nature of the surgical safety checklist, the perceived lack of benefit in surgical safety checklist completion, and redundancies with other operating room processes. This has led to the surgical safety checklist becoming "an exercise in box ticking" (ie, compliance is recorded without ensuring quality), thereby obfuscating potential safety benefits. CONCLUSION: These results highlight that compliance data are insufficient for monitoring surgical safety checklist quality. Our study suggests that surgical safety checklist quality may be enhanced through better calibration of the surgical safety checklist with existing procedures and staff expectations through a bottom-up implementation strategy.

Engagement: what is it good for? The role of learner engagement in healthcare simulation contexts.

Learner engagement matters, particularly in simulation-based education. Indeed, it has been argued that instructional design only matters in the service of engaging learners in a simulation encounter. Yet despite its purported importance, our understanding of what engagement is, how to define it, how to measure it, and how to assess it is limited. The current study presents the results of a critical narrative review of literature outside of health sciences education, with the aim of summarizing existing knowledge in these areas and providing a research agenda to guide future scholarship on learner engagement in healthcare simulation. Building on this existing knowledge base, we provide a working definition for engagement and provide an outline for future research programs that will help us better understand how health professions' learners experience engagement in the simulated setting. With this in hand, additional research questions can be addressed including: how do simulation instructional design features (fidelity, range of task difficulty, feedback, etc.) affect engagement? What is the relationship between engagement and simulation learning outcomes? And how is engagement related to or distinct from related variables like cognitive load, motivation, and self-regulated learning?

Development of synthetic simulators for endoscope-assisted repair of metopic and sagittal craniosynostosis.

OBJECTIVE Endoscope-assisted repair of craniosynostosis is a safe and efficacious alternative to open techniques. However, this procedure is challenging to learn, and there is significant variation in both its execution and outcomes. Surgical simulators may allow trainees to learn and practice this procedure prior to operating on an actual patient. The purpose of this study was to develop a realistic, relatively inexpensive simulator for endoscope-assisted repair of metopic and sagittal craniosynostosis and to evaluate the models' fidelity and teaching content. METHODS Two separate, 3D-printed, plastic powder-based replica skulls exhibiting metopic (age 1 month) and sagittal (age 2 months) craniosynostosis were developed. These models were made into consumable skull "cartridges" that insert into a reusable base resembling an infant's head. Each cartridge consists of a multilayer scalp (skin, subcutaneous fat, galea, and periosteum); cranial bones with accurate landmarks; and the dura mater. Data related to model construction, use, and cost were collected. Eleven novice surgeons (residents), 9 experienced surgeons (fellows), and 5 expert surgeons (attendings) performed a simulated metopic and sagittal craniosynostosis repair using a neuroendoscope, high-speed drill, rongeurs, lighted retractors, and suction/irrigation. All participants completed a 13-item questionnaire (using 5-point Likert scales) to rate the realism and utility of the models for teaching endoscope-assisted strip suturectomy. RESULTS The simulators are compact, robust, and relatively inexpensive. They can be rapidly reset for repeated use and contain a minimal amount of consumable material while providing a realistic simulation experience. More than 80% of participants agreed or strongly agreed that the models' anatomical features, including surface anatomy, subgaleal and subperiosteal tissue planes, anterior fontanelle, and epidural spaces, were realistic and contained appropriate detail. More than 90% of participants indicated that handling the endoscope and the instruments was realistic, and also that the steps required to perform the procedure were representative of the steps required in real life. CONCLUSIONS Both the metopic and sagittal craniosynostosis simulators were developed using low-cost methods and were successfully designed to be reusable. The simulators were found to realistically represent the surgical procedure and can be used to develop the technical skills required for performing an endoscope-assisted craniosynostosis repair.

Validity Evidence for the Neuro-Endoscopic Ventriculostomy Assessment Tool (NEVAT).

BACKGROUND: Growing demand for transparent and standardized methods for evaluating surgical competence prompted the construction of the Neuro-Endoscopic Ventriculostomy Assessment Tool (NEVAT). OBJECTIVE: To provide validity evidence of the NEVAT by reporting on the tool's internal structure and its relationship with surgical expertise during simulation-based training. METHODS: The NEVAT was used to assess performance of trainees and faculty at an international neuroendoscopy workshop. All participants performed an endoscopic third ventriculostomy (ETV) on a synthetic simulator. Participants were simultaneously scored by 2 raters using the NEVAT procedural checklist and global rating scale (GRS). Evidence of internal structure was collected by calculating interrater reliability and internal consistency of raters' scores. Evidence of relationships with other variables was collected by comparing the ETV performance of experts, experienced trainees, and novices using Jonckheere's test (evidence of construct validity). RESULTS: Thirteen experts, 11 experienced trainees, and 10 novices participated. The interrater reliability by the intraclass correlation coefficient for the checklist and GRS was 0.82 and 0.94, respectively. Internal consistency (Cronbach's α) for the checklist and the GRS was 0.74 and 0.97, respectively. Median scores with interquartile range on the checklist and GRS for novices, experienced trainees, and experts were 0.69 (0.58-0.86), 0.85 (0.63-0.89), and 0.85 (0.81-0.91) and 3.1 (2.5-3.8), 3.7 (2.2-4.3) and 4.6 (4.4-4.9), respectively. Jonckheere's test showed that the median checklist and GRS score increased with performer expertise ( P = .04 and .002, respectively). CONCLUSION: This study provides validity evidence for the NEVAT to support its use as a standardized method of evaluating neuroendoscopic competence during simulation-based training.

Simulation-based Education for Endoscopic Third Ventriculostomy: A Comparison Between Virtual and Physical Training Models.

BACKGROUND: The relative educational benefits of virtual reality (VR) and physical simulation models for endoscopic third ventriculostomy (ETV) have not been evaluated "head to head." OBJECTIVE: To compare and identify the relative utility of a physical and VR ETV simulation model for use in neurosurgical training. METHODS: Twenty-three neurosurgical residents and 3 fellows performed an ETV on both a physical and VR simulation model. Trainees rated the models using 5-point Likert scales evaluating the domains of anatomy, instrument handling, procedural content, and the overall fidelity of the simulation. Paired t tests were performed for each domain's mean overall score and individual items. RESULTS: The VR model has relative benefits compared with the physical model with respect to realistic representation of intraventricular anatomy at the foramen of Monro (4.5, standard deviation [SD] = 0.7 vs 4.1, SD = 0.6; P = .04) and the third ventricle floor (4.4, SD = 0.6 vs 4.0, SD = 0.9; P = .03), although the overall anatomy score was similar (4.2, SD = 0.6 vs 4.0, SD = 0.6; P = .11). For overall instrument handling and procedural content, the physical simulator outperformed the VR model (3.7, SD = 0.8 vs 4.5; SD = 0.5, P < .001 and 3.9; SD = 0.8 vs 4.2, SD = 0.6; P = .02, respectively). Overall task fidelity across the 2 simulators was not perceived as significantly different. CONCLUSION: Simulation model selection should be based on educational objectives. Training focused on learning anatomy or decision-making for anatomic cues may be aided with the VR simulation model. A focus on developing manual dexterity and technical skills using endoscopic equipment in the operating room may be better learned on the physical simulation model.

The "Empty Chairs" Approach to Learning: Simulation-Based Train the Trainer Program in Mzuzu, Malawi.

Together, a group of Canadian colleagues from St. John's, Newfoundland, Calgary, Alberta (some via Doha) and London, Ontario introduced the first Train the Trainer in Simulation-Based Learning (TTT-SBL) program in Mzuzu Central Hospital and Mzuzu University in Malawi. The team led by Elaine Sigalet (Doha) and consisting of Ian Wishart (Calgary), Faizal Haji (London) and Adam Dubrowski (St. John's) was invited to Malawi by Norman Lufesi to conduct a two-day TTT-SBL course for facilitators who teach an Emergency Triage, Assessment and Treatment (ETAT) plus Trauma course. The following technical report describes this course.  All trainees-facilitators who took part in the first iteration of the TTT-SBL course were asked to participate in teaching an ETAT course and modify it to include elements of simulation. The new format of ETAT resulted in a reduction of time necessary to conduct the course from four days (based on historical data) to 2.5 days.

Rapid Recovery from Paraplegia in a Patient with Foix-Alajouanine Syndrome.

BACKGROUND: Foix-Alajouanine syndrome is defined as acute neurologic deterioration in the setting of a spinal dural arteriovenous fistula. CASE DESCRIPTION: This case report on a young patient with an unusual clinical onset of Foix-Alajouanine syndrome coincidentally occurring after his outpatient clinic appointment illustrates how prompt surgical treatment can result in rapid recovery of neurologic function despite preoperative paraplegia. CONCLUSIONS: Venous hypertension with subsequent rapid resolution after surgical treatment is the pathophysiological mechanism underlying a dural arteriovenous fistula, in contrast to historical views suggesting that these lesions result from irreversible venous thrombosis, resulting in necrotic myelopathy.