Automated and Optimized Neurosurgery Scheduling System Improves Resident Satisfaction.

BACKGROUND AND OBJECTIVES: Neurosurgery residency involves a complex structure with multiple hospitals, services, and clinic days, leading to challenges in creating equitable call schedules. Manually prepared scheduling systems are prone to biases, error, and perceived unfairness. To address these issues, we developed an automated scheduling system (Automated Optimization of Neurosurgery Scheduling System [AONSS]) to reduce biases, accommodate resident requests, and optimize call variation, ultimately enhancing the educational experience by promoting diverse junior-senior-attending relationships. METHODS: AONSS was developed and tailored to the University of Florida program, with inaugural use in 2021-2022 and mandatory implementation in the 2022-2023 academic year. 2019-2021 academic years were used as control. Residents were surveyed using Google Forms before and after implementation to assess its impact. Outcome measures included call and pairing variations, duty hours, as well as subjective factors such as satisfaction, fairness, and perceived biases. RESULTS: Twenty-six residents (28%-39% female/year) were included in the study. AONSS was used for 6/13 blocks during the 2021-2022 academic year and 13/13 blocks for the 2022-2023 academic year. Overall call variation reduced by 70%. All other objective secondary measures have improved with AONSS. Weekly and monthly duty hours were reduced and less varied. Satisfaction scores improved from 21% reporting being somewhat satisfied or very satisfied to 90%. Fairness scores improved from 43% reporting being somewhat fair or very fair to 95%. Perception of gender bias decreased from 29% to 0%. No resident felt there was racial bias in either system. CONCLUSION: Our newly developed automated scheduling system effectively reduces variation among calls in a complex neurosurgery residency, which, in return, was found to increase residents' satisfaction with their schedule, improve their perception of fairness with the schedule, and has completely removed the perception of sexual bias in a program that has a large percentage of females. In addition, it was found to be associated with decreased duty hours.

Quasi-dynamic breathing model of the lung incorporating viscoelasticity of the lung tissue.

We advanced a novel model to calculate viscoelastic lung compliance and airflow resistance in presence of mucus, accounting for the quasi-linear viscoelastic stress-strain response of the parenchyma (alveoli) tissue. We adapted a continuum-based numerical modeling approach for the lung, integrating the fluid mechanics of the airflow within individual generations of the bronchi and alveoli. The model accounts for elasticity of the deformable bronchioles, resistance to airflow due to the presence of mucus within the bronchioles, and subsequent mucus flow. Simulated quasi-dynamic inhalation and expiration cycles were used to characterize the net compliance and resistance of the lung, considering the rheology of the mucus and viscoelastic properties of the parenchyma tissue. The structure and material properties of the lung were identified to have an important contribution to the lung compliance and airflow resistance. The secondary objective of this work was to assess whether a higher frequency and smaller volume of harmonic air flow rate compared to a normal ventilator breathing cycle enhanced mucus outflow. Results predict, lower mucus viscosity and higher excitation frequency of breathing are favorable for the flow of mucus up the bronchi tree, towards the trachea.

Inversed probability case-control analysis of operative burr hole evacuation versus subdural evacuating port system for chronic subdural hematomas: Clinical and economic outcomes.

INTRODUCTION: There are multiple treatments for a chronic subdural hematoma, a significant cause of neurosurgical morbidity that cost the healthcare system $5B in 2007, but few generalizable prospective studies. The purpose of this study was to examine outcomes of bedside Subdural Evacuation Port System (SEPS) placement as compared to operating room burr hole evacuation (BHE) to acquire data to support a randomized trial. METHODS: All procedures were performed in a single institution between 2011 and 2019. Patients were included if > 18 years of age, had chronic subdural hematoma, and were treated by SEPS or BHE. Patients with prior neurosurgical history, mass lesions or bilateral hematomas were excluded. Patients who met inclusion for SEPS (n = 55) or BHE (n = 105). Samples were propensity matched to account for variability. Non-inferiority tests compared outcomes. Cost data was obtained through billable charges. RESULTS: Patients with multiple comorbidities were more likely to undergo SEPS drainage. Noninferiority tests reported no statistically significant evidence to suggest SEPS drains were worse in reoperation-rate (18% vs 9%), post-operative seizure, or functional outcome. SEPS drain placement trended towards a faster time to procedure (3 h faster; p = 0.07) but the overall hospital stay was longer (4.23 vs 5.81, p = 0.01). SEPS drain placement costs are less than BHE, but these patients had 25% higher overall hospital costs (p = 0.01) due to comorbidities and increased hospital stay.

Improving Interprofessional Teamwork in Plastic Surgery: A Novel Approach to Microsurgical Skills Training.

Shared mental models between surgeons and nurses allow them to effectively communicate and react to intraoperative complications. Microsurgery poses unique challenges that include the use of an operating microscope, fine instruments, and a restricted view of the operative field. We designed and delivered a microsurgical skills session for surgical nurses consisting of an introduction to the operating microscope and 3 practical stations involving increasingly complex motor tasks designed to highlight the importance of instrument handling and improve awareness of microsurgical challenges. Consultant plastic surgeons acted as scrub persons to add an element of role-reversal. All participants enjoyed the training session and felt that it improved their understanding of microsurgery and was relevant and helpful to their day-to-day role. All attendees reported that they would partake in similar sessions in the future. Our work suggests that role-reversal and skills-based education and training are valuable tools in improving multidisciplinary collaboration during microsurgery. Increasing shared knowledge of complex procedures encourages effective teamwork and communication, which leads to improved efficiency and better patient care. Our study is a first step toward development of a standardized microsurgical skills course for plastic surgical nurses and has broader implications for interprofessional education across all surgical specialties.

Nonepileptic, Stereotypical, and Intermittent Symptoms After Subdural Hematoma Evacuation.

Transient neurological deficits can occur in the setting of subdural hemorrhages with subsequent unremarkable electrodiagnostic and radiological evaluation. This scenario is rare and can be difficult for physicians to interpret. These transient neurological deficits are thought to result from relative ischemia, secondary to a lesser-known concept known as cortical spreading depolarization. These transient neurological deficits are thought to result from relative ischemia, secondary to a lesser-known concept known as cortical spreading depolarization, which may present clinically as nonepileptic, stereotypical, and intermittent symptoms (NESIS). In these instances, patients are often misdiagnosed as epileptics and committed to long-term antiseizure drugs. We present a 51-year-old patient developing acute global aphasia following the evacuation of a subdural hematoma, with no significant findings on laboratory, microbiological, electrodiagnostic, or radiological evaluation. The patient experienced spontaneous improvement and returned to baseline in the subsequent weeks. Increased awareness of NESIS as a cortical spreading depolarization phenomenon can improve patient care and prevent both unnecessary, extended medical evaluations and therapeutic trials.

Music therapy for preterm neonates in the neonatal intensive care unit: An overview of systematic reviews.

AIM: To summarise the quantity and quality of evidence for using music therapy for preterm infants in the neonatal intensive care unit (NICU). METHODS: We performed an overview of evidence for the effectiveness and safety of MT for preterm infants in the NICU. We performed a random-effects meta-analysis of data from studies that fit the definition of MT. RESULTS: We identified 12 eligible systematic reviews and the methodological quality by AMSTAR-2 ranged from moderate to critically low. We identified 14 eligible randomised trials and 7 observational studies where the intervention fits the definition of MT. Meta-analysis of the RCTs showed that MT significantly decreases heart rate, mean difference (MD) (95% CI), -3.21 [-5.22, -1.19], respiratory rate, MD -2.93 [-5.65, -0.22], and maternal anxiety, MD -17.50 [-20.10, -14.90], and increases feeding volume, MD 29.59 [12.79, 46.38]. Long-term neurodevelopmental or safety outcomes were not reported. GRADE assessment of outcomes ranged from low to very low, downgraded for high risk of bias in the included studies, inconsistency and imprecision. CONCLUSION: Low to very low certainty evidence suggests that MT in preterm infants improves short-term physiological parameters, feeding and maternal anxiety but safety and long-term outcomes were not reported.

Seizures following surgery for supratentorial extratemporal low-grade tumors in children: a multicenter retrospective study.

OBJECTIVE: Resection of brain tumors may lead to new-onset seizures but may also reduce seizure rates in patients presenting with seizures. Seizures are seen at presentation in about 24% of patients with brain tumors. For lesional epilepsy in general, early resection is associated with improved seizure control. However, the literature is limited regarding the occurrence of new-onset postoperative seizures, or rates of seizure control in those presenting with seizures, following resections of extratemporal low-grade gliomas (LGGs) in children. METHODS: Data were collected retrospectively from 4 large tertiary centers for children (< 18 years of age) who underwent resection of a supratentorial extratemporal (STET) LGG. The patients were divided into 4 groups based on preoperative seizure history: no seizures, up to 2 seizures, more than 2 seizures, and uncontrolled or refractory epilepsy. The authors analyzed the postoperative occurrence of seizures and the need for antiepileptic drugs (AEDs) over time for the various subgroups. RESULTS: The study included 98 children. Thirty patients had no preoperative seizures, 18 had up to 2, 16 had more than 2, and 34 had refractory or uncontrolled epilepsy. The risk for future seizures was higher if the patient had seizures within 1 month of surgery. The risk for new-onset seizures among patients with no seizures prior to surgery was low. The rate of seizures decreased over time for children with uncontrolled or refractory seizures. The need for AEDs was higher in the more active preoperative seizure groups; however, it decreased with time. CONCLUSIONS: The resection of STET LGGs in children is associated with a low rate of postoperative new-onset epilepsy. For children with preoperative seizures, even with uncontrolled epilepsy, most have a significant improvement in the seizure activity, and many may be weaned off their AEDs.

Radiographic and Computed Tomography Correlation of Kienböck's Disease: Is There a Need to Revisit Staging with Improved Imaging?

Carpal height ratio and ulnar variance on plain X-ray were measured and compared to the width/height ratio of the lunate as measured on a computed tomography (CT) scan in 50 patients with Kienböck's disease. Width/height ratio of the lunate was also measured in a series of 50 controls. No correlation between ulnar variance and fractures was found. Conversely, the correlation between carpal height ratio on X-ray and width/height ratio on a CT scan was statistically significant. Similarly, the correlation between ulnar variance and width/height ratio was statistically significant. We have concluded that width/height ratio while correlating with carpal height is a better measure of lunate collapse. It also appeared that lunate collapse precedes carpal collapse, specifically most if not all lunates have collapsed prior to reduction in carpal height ratio. Finally, while we are unable to conclude the level at which the width/height ratio of lunate becomes unreconstructable, it does appear that in all Litchman stage 3b and most if not all of 3a the shape of the lunate has altered significantly.

Firework-related blast injury to the hand and treatment algorithm.

Firework injuries, which most commonly affect hands, are increasing in frequency and severity. We present a pictorial case of a devastating hand injury following a firework explosion in a young male patient. The blast resulted in splaying of the hand with multiple fractures, neurovascular compromise and soft tissue loss. Reconstruction involved a third-ray amputation, fracture fixation, nerve and soft tissue repair resulting in an adequate hand with near-normal appearance. Firework-related hand injuries pose a significant surgical challenge due to the combination of burn and blast forces that can compromise the function of intact vessels and nerves making salvage and reconstruction particularly difficult. Here, we propose a treatment algorithm based on current literature. Our case demonstrates, what initially appeared to be an unsalvageable injury can be reconstructed to produce a functional hand if appropriate surgical measures are taken.

A standardized protocol to reduce pediatric baclofen pump infections: a quality improvement initiative.

OBJECTIVE Intrathecal baclofen pumps are generally placed in children for the treatment of spasticity and dystonia. Use of implants in this pediatric population with comorbidities is reported to have a high risk of complications and infections. With the aim of reducing baclofen pump-related infections, a quality improvement project was instituted at the authors' institution. METHODS A workflow paradigm unique to baclofen pump implantation aimed at decreasing implant-related infections was implemented. All baclofen pump operations performed at the authors' institution between August 2012 and June 2016 were reviewed. An infection prevention protocol was created and implemented in August 2014 based on a literature review and the consensus opinion of the pediatric neurosurgeons in the group. Compliance with the prevention bundle was tracked. Case outcomes before and after implementation of the protocol with a minimum of 3 months of follow-up were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the association of the steps in the prevention bundle with infection and complication outcomes. RESULTS A total of 128 baclofen pump surgeries were performed (64 preprotocol and 64 postprotocol). The patient age range was 3 to 27 years. The overall compliance rate with the infection prevention bundle was 82%. The pre- and postimplementation infection rates were 12.5% and 6.3%, respectively (p = 0.225). The total pre- and postimplementation complication rates were 23.4% and 9.4%, respectively (p = 0.032). The absolute and relative risk reductions for infections were 6.3% (95% CI 3.8%-16.3%) and 50%, respectively; for complications, the absolute and relative risk reductions were 14.1% (95% CI 1.5%-26.7%) and 60%, respectively. CONCLUSIONS The total complication rate following intrathecal baclofen pump surgery was significantly lower after implementation of the quality improvement protocol. This study is an example of using checklist standardization to diminish special cause variability.

Local therapy to distant metastatic sites in stage IV rhabdomyosarcoma.

PURPOSE: To determine the impact of surgery and/or radiation therapy on distant metastatic sites (DMS) in children with stage IV rhabdomyosarcoma (RMS). METHODS: A retrospective chart review was conducted on all patients with stage IV RMS at Texas Children's Hospital from 1992 to 2012. Data analyzed included age, gender, primary site, histologic subtype, number and sites of metastases, treatment including local therapy to DMS, and Oberlin score. RESULTS: The 5-year progression-free survival (PFS) and overall survival (OS) rates were 20% and 25%. The 5-year PFS in patients receiving local therapy to all DMS (n = 16) and to less than all DMS (n = 19) was 31.3% versus 0% (P = 0.002), whereas the 5-year OS was 37.3% versus 0% (P < 0.001), respectively. The 5-year PFS in patients with isolated lung metastasis versus other types of metastasis was 29% versus 7% (P = n.s.), whereas the 5-year OS was 43% versus 10% (P = 0.01). The 5-year pulmonary local control was improved by the use of whole lung irradiation (WLI; 56% vs. 10%, P = 0.03). CONCLUSIONS: Local treatment to all metastatic sites was associated with improved PFS and OS at 5 years. The use of WLI improved pulmonary control in patients with lung metastasis. We recommend an aggressive approach including local therapy to DMS in children with stage IV RMS.

Operating efficiency of an emergency Burns theatre: An eight month analysis.

BACKGROUND: The efficient use of operating theatres is important to insure optimum cost-benefit for the hospital. We used the emergency Burns theatre as a model to assess theatre efficiency at our institution. METHODS: Data was collected retrospectively on every operation performed in the Burns theatre between 01/04/15 and 30/11/15. Each component of the operating theatre process was considered and integrated to calculate values for surgical/anaesthetic time, changeover time and ultimately theatre efficiency. RESULTS: A total of 426 operations were carried out over 887h of allocated theatre time (ATT). Actual operating time represented 67.7%, anaesthetic time 8.8% and changeover time 14.2% of ATT. The average changeover time between patients was 30.1min. Lists started on average 27.7min late each day. There were a total of 5.8h of overruns and 9.6h of no useful activity. Operating theatre efficiency was 69.3% for the 8 month period. CONCLUSION: Our study highlights areas where theatre efficiency can be improved. We suggest various strategies to improve this that may be applied universally.

Perioperative antibiotic use in vagus nerve stimulator implantation: a clinical series.

PURPOSE: Preoperative antibiosis contributes up to one third of total antibiotic use in major hospitals. Choice of antibiotic is not uniformly standardized, and polypharmacy regimens may be used without knowing the effect on rates of surgical site infection, nonsurgical infections, or antibiotic resistance. Careful examination of trends in surgical prophylaxis is warranted. In this study, we aimed to examine our institution's experience with vagus nerve stimulator (VNS) implantation, focusing on association between perioperative antibiotic practices and postoperative infectious outcomes. METHODS: We conducted a single-center case-control study using a retrospective chart review of 50 consecutively operated patients undergoing VNS implantation over 24 months by two experienced surgeons at our institution from April 2014 to March 2016. In each surgery, the technical procedure, operating room, and surgical team were the same, while surgeon's preference in antibiotic prophylaxis differed. Group 1 received a single dose of intravenous (IV) cefazolin (n = 26), and Group 2 received IV cefazolin, paired with one or both of gentamicin/vancomycin, in addition to a 10-day outpatient oral course of clindamycin (n = 24). Patient demographics, perioperative details, and minimum 3-month follow-up for infection and healthcare utilization were recorded. Student t tests were computed for significance. RESULTS: Group 1 patients on average were older than group 2 patients (10.2, 7.1 years, p = 0.01), and length of surgery was longer (115.5, 91.9 min, p = 0.007). There were no differences in number of surgeons gowned (p = 0.11), presence of tracheostomy (p = 0.43) or gastrostomy (p = 0.20) tube, nonsurgical infections (p = 0.32), and number of postoperative emergency department (ED) visits (p = 0.22) or readmissions (p = 0.23). Neither group had VNS infections in the follow-up period. CONCLUSION: Single preoperative dosing of one antibiotic appropriately chosen to cover typical skin flora conferred equal benefit to perioperative prophylactic polypharmacy in this study. There were no differences in postoperative infection events or ED visits/readmissions. Restraint with preoperative antibiosis shows equipoise in postoperative infection and overall resource utilization.

Patient functional outcomes with trapeziectomy alone versus trapeziectomy with TightRope(®).

PURPOSE OF THE STUDY: We assess whether patient functional outcomes with the use of a tightrope in conjunction with trapeziectomy are better than traditional trapeziectomy alone. METHODS: Retrospective study of 56 trapeziectomies in 53 patients; 26 trapeziectomies alone without additional procedures, and 30 trapeziectomies performed in conjunction with tightrope suspensionplasty. All patients were scored using Quick DASH, Patient-Rated Wrist Evaluation and Nelson base of thumb arthritis scores pre- and post-operatively. RESULTS: Significant improvements were seen with both operations using all three scoring systems. However, there was no statistically significant difference in post-operative scores between the two operations. STUDY DESIGN: Retrospective comparative study. LEVEL OF EVIDENCE: III.

The functional potential of microbial communities in hydraulic fracturing source water and produced water from natural gas extraction characterized by metagenomic sequencing.

Microbial activity in produced water from hydraulic fracturing operations can lead to undesired environmental impacts and increase gas production costs. However, the metabolic profile of these microbial communities is not well understood. Here, for the first time, we present results from a shotgun metagenome of microbial communities in both hydraulic fracturing source water and wastewater produced by hydraulic fracturing. Taxonomic analyses showed an increase in anaerobic/facultative anaerobic classes related to Clostridia, Gammaproteobacteria, Bacteroidia and Epsilonproteobacteria in produced water as compared to predominantly aerobic Alphaproteobacteria in the fracturing source water. The metabolic profile revealed a relative increase in genes responsible for carbohydrate metabolism, respiration, sporulation and dormancy, iron acquisition and metabolism, stress response and sulfur metabolism in the produced water samples. These results suggest that microbial communities in produced water have an increased genetic ability to handle stress, which has significant implications for produced water management, such as disinfection.