High rate of isolated teratospermia in a population of fertile men and the questionable clinical utility of sperm morphology.

Objective: To better understand the impact of sperm morphology on fertility by assessing sperm morphology in a population of known fertile men. Design: A prospective cohort study. Setting: Fertility center associated with the university. Patients: Healthy men >18 years of age were recruited to provide one semen sample before a vasectomy appointment scheduled between March 2020 and November 2022. Patients were included in the study when they had at least one biologic child and no history of difficulty achieving pregnancy or fertility procedures. Interventions: None. Main Outcome Measures: Sperm morphology. Results: A total of 68 patients (mean age 36.7 years) were included. Thirty-eight (55.9%) patients had 3% or lower normal sperm morphology, including two patients who had 0 normal morphology. The most common morphologic abnormalities were head-shaped defects (n = 59, 84.3%), followed by coiled tails (n = 14, 20.3%). Count, concentration, motility, and progressive motility were normal in >90% of patients. Conclusions: More than half (55.9%) of fertile male patients had lower than normal sperm morphology in our study. The results of our study further question the clinical relevance of sperm morphology on fertility outcomes and when the current approach in assessing morphology is too strict.

Mixed Reality in the Operating Room: An Initial Use in Frontal Sinus Setback in Gender-affirming Facial Surgery.

Demand for gender-affirming facial surgery is growing rapidly. Frontal sinus setback, one of the key procedures used in gender-affirming facial surgery, has a particularly high impact on gender perception. Mixed reality (MR) allows a user to view and virtually overlay three-dimensional imaging on the patient and interact with it in real time. We used the Medivis's SurgicalAR system in conjunction with the Microsoft HoloLens Lucille2 (Microsoft). Computed tomography imaging was uploaded to SurgicalAR, and a three-dimensional (3D) hologram was projected onto the display of the HoloLens. The hologram was registered and matched to the patient, allowing the surgeon to view bony anatomy and underlying structures in real time on the patient. The surgeon was able to outline the patient's frontal sinuses using the hologram as guidance. A 3D printed cutting guide was used for comparison. Negligible difference between the mixed reality-based outline and 3D-printed outline was seen. The process of loading the hologram and marking the frontal sinus outline lasted less than 10 minutes. The workflow and usage described here demonstrate significant promise for the use of mixed reality as imaging and surgical guidance technology in gender-affirming facial surgery.

Single institution series describing external ventricular drain (EVD) placement and short- and long-term complications related to placement accuracy.

Background: The placement of an external ventricular drain (EVD) for the treatment of acute hydrocephalus is one of the most common life-saving procedures that neurosurgeons perform worldwide. There are many well-known complications associated with EVD placement, including tract hemorrhages, intra-parenchymal and subdural hemorrhages, infection, and catheter misplacement. Given the variety of complications associated with EVD placement and the inconsistent findings on the relationship of accuracy to complications, the present study reviewed short- and long-term complications related to EVD placement at our institution. Methods: A retrospective review was conducted for all consecutive patients who underwent bedside EVD placement for any indication between December 2020 and December 2021. Collected variables included demographic information, etiology of disease state, pre-and post-operative head computed tomography measurements, and post-procedural metrics (immediate and delayed complications). Results: A total of 124 patients qualified for inclusion in our study. EVDs that were non-functioning/exchanged were not significantly related to age, accuracy, ventriculomegaly, sex, disposition, laterality, type of EVD used, intraventricular hemorrhage (IVH), etiology, or Kakarla Grade (KG) (all P > 0.17). The need for a second EVD was similarly not related to age, accuracy, ventriculomegaly, sex, disposition, location, laterality, type of EVD used, IVH, etiology, or KG (all P > 0.130). Patients who died, however, were significantly more likely to have a second contralateral EVD placed (18.2% vs. 4.9% P = 0.029). We also found that left-sided EVDs were significantly more likely to fail within seven days of placement (29.4% vs 13.3%, P = 0.037; relative risk (RR) 1.93, 95% confidence interval: 1.09-3.43), unrelated to age, sex, etiology, type of EVD, IVH, location of the procedure, or accuracy (all P > 0.07). This remained significant when using a binary logistic regression to control for ventriculomegaly, accuracy, mortality, age, sex, and etiology (P = 0.021, B = 3.43). Conclusion: In our cohort, although a clear relationship between inaccuracy and complication rates was not found, our data did demonstrate that left-sided EVDs were more likely to fail within the immediate postoperative time point, and patients who died were more likely to have a second, contralateral EVD placed.

Understanding Effects of Visual Feedback Delay in AR on Fine Motor Surgical Tasks.

Latency is a pervasive issue in various systems that can significantly impact motor performance and user perception. In medical settings, latency can hinder surgeons' ability to quickly correct movements, resulting in an experience that doesn't align with user expectations and standards of care. Despite numerous studies reporting on the negative effects of latency, there is still a gap in understanding how it impacts the use of augmented reality (AR) in medical settings. This study aims to address this gap by examining how latency impacts motor task performance and subjective perceptions, such as cognitive load, on two display types: a monitor display, traditionally used inside an operating room (OR), and a Microsoft HoloLens 2 display. Our findings indicate that both level of latency and display type impact motor performance, and higher latencies on the HoloLens result in relatively poor performance. However, cognitive load was found to be unrelated to display type or latency, but was dependent on the surgeon's training level. Surgeons did not compromise accuracy to gain more speed and were generally well aware of the latency in the system irrespective of their performance on task. Our study provides valuable insights into acceptable thresholds of latency for AR displays and proposes design implications for the successful implementation and use of AR in surgical settings.

Fracture patterns, associated injuries, management, and treatment outcomes of 530 pediatric mandibular fractures.

BACKGROUND: Mandibular fractures account for up to 48.8% of pediatric facial fractures; however, there are a wide range of available treatment modalities, and few studies describe trends in adverse outcomes of these injuries. This study describes fracture etiology, pattern, management, and treatment outcomes in pediatric mandibular fracture patients. METHODS: A retrospective review was performed of patients under 18 years of age who were evaluated for mandibular fractures at a pediatric level I trauma center between 2006 and 2021. Variables studied included demographics, etiology, medical history, associated facial fractures, other associated injuries, treatments, and outcomes. RESULTS: A total of 530 pediatric patients with 829 mandibular fractures were included in the analysis. Most isolated mandibular fractures were treated with physical therapy (PT) and rest (n=253, 47.7%). Patients with combination fractures, specifically those involving the parasymphysis and angle, were 2.63 times more likely to undergo surgical management compared to patients with a single facial fracture (p<0.0001). Older age (p<0.001), gender (p=0.042), mechanism (p=0.008) and cause of injury (p=0.002), as well as specific fractures (e.g., isolated angle (p=0.001)) were more associated with adverse outcomes. The odds of adverse outcomes were higher for patients treated with CREF or ORIF compared to conservative management (OR=1.8; 95% Cl 1.0-3.2 and OR=2.1; 95% Cl 1.2-3.5, respectively). CONCLUSION: Fracture type, mechanism of injury, and treatment modality in pediatric mandibular fractures are associated with distinct rates and types of adverse outcomes. Large scale studies characterizing these injuries are critical for guiding physicians in the management of these patients.

Pediatric Nasoorbitoethmoid Fractures: A Single Institution's 15-Year Experience.

BACKGROUND: Nasoorbitoethmoid (NOE) fractures impact growth of the craniofacial skeleton in children, which may necessitate differentiated management from adult injuries. This study describes characteristics, management, and outcomes of NOE fractures in children seen at a single institution. METHODS: A retrospective review of patients under 18 years who presented to our institution from 2006 to 2021 with facial fractures was conducted; patients with NOE fractures were included. Data collected included demographics, mechanism of injury, fracture type, management, and outcomes. RESULTS: Fifty-eight patients met inclusion criteria; 77.6% presented with Manson-Marcowitz Type I fractures, 17.2% with Type II, and 5.2% with Type III. The most common cause of injury was motor vehicle accidents (MVAs, 39.7%) and sports (31%). Glasgow Coma Scale and injury mechanism were not predictive of injury severity in the pediatric population ( P =0.353, P =0.493). Orbital fractures were the most common associated fractures (n=55, 94.8%); parietal bone fractures were more likely in Type III fractures ( P =0.047). LeFort III fractures were more likely in type II fractures ( P =0.011). Soft tissue and neurological injuries were the most common associated injuries regardless of NOE fracture type (81% and 58.6%, respectively). There was no significant difference in type of operative management or in the rates of adverse outcomes between types of NOE fractures. CONCLUSIONS: These findings suggest that pediatric NOE fractures, although rare, present differently from adult NOE fractures and that revisiting predictive heuristics and treatment strategies is warranted in this population.

Using Clinical Data Visualizations in Electronic Health Record User Interfaces to Enhance Medical Student Diagnostic Reasoning: Randomized Experiment.

BACKGROUND: In medicine, the clinical decision-making process can be described using the dual-process theory consisting of the fast, intuitive "System 1," commonly seen in seasoned physicians, and the slow, deliberative "System 2," associated with medical students. System-1-type diagnostic reasoning is thought to be less cognitively burdensome, thereby reducing physician error. To date, limited literature exists on inducing System-1-type diagnosis in medical students through cognitive heuristics, particularly while using modern electronic health record (EHR) interfaces. OBJECTIVE: In this experimental pilot study, we aimed to (1) attempt to induce System-1-type diagnostic reasoning in inexperienced medical students through the acquisition of cognitive user interface heuristics and (2) understand the impact of clinical patient data visualizations on students' cognitive load and medical education. METHODS: The participants were third- and fourth-year medical students recruited from the University of Pittsburgh School of Medicine who had completed 1+ clinical rotations. The students were presented 8 patient cases on a novel EHR, featuring a prominent data visualization designed to foster at-a-glance rapid case assessment, and asked to diagnose the patient. Half of the participants were shown 4 of the 8 cases repeatedly, up to 4 times with 30 seconds per case (Group A), and the other half of the participants were shown cases twice with 2 minutes per case (Group B). All participants were then asked to provide full diagnoses of all 8 cases. Finally, the participants were asked to evaluate and elaborate on their experience with the system; content analysis was subsequently performed on these user experience interviews. RESULTS: A total of 15 students participated. The participants in Group A scored slightly higher on average than those in Group B, with a mean percentage correct of 76% (95% CI 0.68-0.84) versus 69% (95% CI 0.58-0.80), and spent on average 50% less time per question than Group B diagnosing patients (13.98 seconds vs 19.13 seconds, P=.03, respectively). When comparing the novel EHR design to previously used EHRs, 73% (n=11) of participants rated the new version on par or higher (3+/5). Ease of use and intuitiveness of this new system rated similarly high (mean score 3.73/5 and 4.2/5, respectively). In qualitative thematic analysis of poststudy interviews, most participants (n=11, 73%) spoke to "pattern-recognition" cognitive heuristic strategies consistent with System 1 decision-making. CONCLUSIONS: These results support the possibility of inducing type-1 diagnostics in learners and the potential for data visualization and user design heuristics to reduce cognitive burden in clinical settings. Clinical data presentation in the diagnostic reasoning process is ripe for innovation, and further research is needed to explore the benefit of using such visualizations in medical education.

Testing Medical Student Diagnostic Reasoning Using Clinical Data Visualizations.

This experiment aimed to (1) induce System-1-type diagnostic reasoning in medical students through the acquisition of cognitive user interface (UI) heuristics and (2) understand qualitatively how clinical data visualizations could enhance medical education. Third- and fourth-year medical students were presented patient cases through a novel electronic health record (EHR) design then asked to diagnose patients after being shown the cases either briefly and repeatedly (Group A) or twice over a longer period (Group B). Group A had higher accuracy than Group B. Findings support the possibility of inducing System-1 reasoning via UI heuristics and potential of integrating data visualizations in medical education.