Remote Assessment of Real-World Surgical Safety Checklist Performance Using the OR Black Box: A Multi-Institutional Evaluation.

BACKGROUND: Large-scale evaluation of surgical safety checklist performance has been limited by the need for direct observation. The operating room (OR) Black Box is a multichannel surgical data capture platform that may allow for the holistic evaluation of checklist performance at scale. STUDY DESIGN: In this retrospective cohort study, data from 7 North American academic medical centers using the OR Black Box were collected between August 2020 and January 2022. All cases captured during this period were analyzed. Measures of checklist compliance, team engagement, and quality of checklist content review were investigated. RESULTS: Data from 7,243 surgical procedures were evaluated. A time-out was performed during most surgical procedures (98.4%, n = 7,127), whereas a debrief was performed during 62.3% (n = 4,510) of procedures. The mean percentage of OR staff who paused and participated during the time-out and debrief was 75.5% (SD 25.1%) and 54.6% (SD 36.4%), respectively. A team introduction (performed 42.6% of the time) was associated with more prompts completed (31.3% vs 18.7%, p < 0.001), a higher engagement score (0.90 vs 0.86, p < 0.001), and a higher percentage of team members who ceased other activities (80.3% vs 72%, p < 0.001) during the time-out. CONCLUSIONS: Remote assessment using OR Black Box data provides useful insight into surgical safety checklist performance. Many items included in the time-out and debrief were not routinely discussed. Completion of a team introduction was associated with improved time-out performance. There is potential to use OR Black Box metrics to improve intraoperative process measures.

Utility of a prognostic assessment tool to predict survival following surgery for brain metastases.

Background: Brain metastases account for more than 50% of all intracranial tumors and are associated with poor outcomes. Treatment decisions in this highly heterogenous cohort remain controversial due to the myriad of treatment options available, and there is no clearly defined standard of care. The prognosis in brain metastasis patients varies widely with tumor type, extracranial disease burden and patient performance status. Decision-making regarding treatment is, therefore, tailored to each patient and their disease. Methods: This is a retrospective cohort study assessing survival outcomes following surgery for brain metastases over a 50-month period (April 1, 2014-June 30, 2018). We compared predicted survival using the diagnosis-specific Graded Prognostic Assessment (ds-GPA) with actual survival. Results: A total of 186 patients were included in our cohort. Regression analysis demonstrated no significant correlation between actual and predicted outcome. The most common reason for exclusion was insufficient information being available to the neuro-oncology multidisciplinary team (MDT) meeting to allow GPA calculation. Conclusions: In this study, we demonstrate that "predicted survival" using the ds-GPA does not correlate with "actual survival" in our operated patient cohort. We also identify a shortcoming in the amount of information available at MDT in order to implement the GPA appropriately. Patient selection for aggressive therapies is crucial, and this study emphasizes the need for treatment decisions to be individualized based on patient and cancer clinical characteristics.

Concussion in facial trauma patients: a retrospective analysis of 100 patients from a UK major trauma centre.

Concussion is a common and potentially debilitating condition. Research has shown that one-third of patients admitted with facial trauma have concurrent concussion. This study aimed to investigate the burden and management of concussion in patients presenting with acute facial trauma, and to identify potential risk factors within this population. A retrospective observational study was conducted at a UK major trauma centre between 1 January 2019 and 1 February2020. One hundred randomly selected patients who attended the acute clinic responsible for managing facial trauma were identified. No parametric data were included. The Mann-Whitney test was used to detect differences for continuous data, the X2 test for categorical data. Clinical significance was defined as p < 0.05. Forty of 100 patients (40%) had evidence of concussion, of which only 4/40 (10%) had evidence that head injury advice had been given. There was no statistically significant difference between the non-concussed and concussed groups for age (p = 0.145), gender (p = 0.921), mechanism of injury (p = 0.158), or location of facial injury (p = 0.451). Clinical features of concussion were found in 40% of patients suffering from facial injury. Despite this, we found that head injury advice was rarely given. In addition, we identified no risk factors for concussion within this population, highlighting the need to screen all patients who present with facial injury. To improve the identification and management of concussion in these patients, future work should focus on the development of simple screening tools for use in clinic, and the signposting of patients to existing written and online concussion resources.

Concussion in the UK: a contemporary narrative review.

Concussion has been receiving an increasing amount of media exposure following several high-profile professional sports controversies and multimillion-dollar lawsuits. The potential life-changing sequalae of concussion and the rare, but devasting, second impact syndrome have also gained much attention. Despite this, our knowledge of the pathological processes involved is limited and often extrapolated from research into more severe brain injuries. As there is no objective diagnostic test for concussion. Relying on history and examination only, the diagnosis of concussion has become the rate-limiting step in widening research into the disease. Clinical study protocols therefore frequently exclude the most vulnerable groups of patients such as those with existing cognitive impairment, concurrent intoxication, mental health issues or learning difficulties. This up-to-date narrative review aims to summarize our current concussion knowledge and provides an insight into promising avenues for future research.

Concussion in Non-athletes: Assessment of Cognition and Symptomatology (CONTACTS) study protocol - an exploratory cohort study investigating the utility of sports concussion assessment tools and salivary microRNAs to diagnose concussion in NHS patients.

INTRODUCTION: Concussion is a complex pathophysiological process with a wide range of non-specific signs and symptoms. There are currently no objective diagnostic tests to identify concussion, and diagnosis relies solely on history and examination. Recent research has identified a unique panel of microRNAs (miRNAs) that distinguish between concussed and non-concussed rugby players. This study aims to assess the diagnostic utility of salivary miRNAs in concussion for a sample of UK National Health Service patients and whether well-established sports-related concussion (SRC) assessment tools may be translated into the emergency department (ED). METHODS AND ANALYSIS: Concussion in Non-athletes: Assessment of Cognition and Symptomatology is a single-centre, prospective, two-phase cohort study. The concussed cohort will consist of participants with maxillofacial trauma and concurrent concussion. The control cohort will consist of participants with isolated limb trauma and no evidence of concussion. Participants will be recruited in the ED and saliva samples will be taken to identify the presence of miRNAs. The SRC assessments being investigated include the Sports Concussion Assessment Test, Fifth Edition (SCAT5), the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and the ImPACT Quick. Follow-up will be at 24-48 hours in-hospital and remotely via telephone and email at 14 days and 6 months. ETHICS AND DISSEMINATION: Ethical approval was granted in February 2021 by the West Midlands Coventry & Warwickshire Research Ethics Committee (ref 20/WM/0299). The investigators intend to submit their study findings for publication in peer-reviewed journals and to disseminate study findings via presentation at academic meetings. The results will also form part of a doctorate thesis, registered at the University of Birmingham.

Comparison of laser power output from the fiber tip during endovenous laser ablation against displayed power and the "first treatment" effect.

OBJECTIVE: International guidelines recommend endovenous laser ablation as one of the first-line treatments for truncal venous reflux associated with varicose veins. Clinicians use linear endovenous energy density to measure the energy used during treatment. The aim of this study was to investigate the power output from the fiber tip and to see if this changed with use. METHODS: We placed 15 mL of water in a thermally insulated 25-mL beaker. Two thermocouples were placed equidistantly adjacent to the laser fiber tip. A 1470-nm laser was fired at 5W for 2 minutes and the temperature change was measured. Three fibers were used on different days to allow the laser to cool for 24 hours between fibers. Each fiber was tested three times in a row. We also tested the "first treatment" effect by comparing the power output when the fiber was fired immediately after the laser was switched on, compared with treatments when the laser had been switched on for 1 hour. To assess whether this was due to the console being "cold" on the first firing of the day, we repeated the experiment having switched on the laser console 1 hour before firing to "prewarm" the console. However, the diode was not fired during this hour. To measure fiber degradation, three runs of the experiment were performed successively before firing the laser continuously for 20 minutes, then three more runs were conducted, resulting in delivery of approximately 10,000 J. RESULTS: The actual power output seemed to be lower than the console suggested. The power output from the first fiber used in a succession of three with the same laser had a significantly lower power output than the following two runs (P = .0004 and P < .0001, respectively). When the laser was prewarmed for 1 hour without firing, no change in this output pattern was noted (P = .293). Fiber degradation was not found in any of the fibers that were tested within the maximum recommended for the fiber (10,000 J). CONCLUSIONS: The first use of a fiber in a treatment session has a significantly lower power output from the treatment tip than subsequent uses, even if the machine is prewarmed and the console displays the same power for each. The authors believe that this phenomenon is due to the diode being less efficient when first used after switching it on. Clinicians need to be aware that the true power output at the fiber tip may not be as indicated by the console display and may be variable during a treatment session.

Pattern of thermal damage and tissue carbonisation from endovenous radiofrequency ablation catheter - Using an in vitro porcine liver model.

BACKGROUND: Successful endovenous thermoablation relies on transmural vein wall ablation. We investigated the pattern of thermal spread and tissue carbonisation from RadioFrequency-induced ThermoTherapy (RFiTT) at different powers and pull back methods, using a porcine liver model. METHODS: We used a previously validated in-vitro porcine liver model. Different powers from 5-25 W were used to administer 150 J. We compared continuous and pulsed energy delivery. Length, lateral spread, and total area of thermal damage, together with any tissue carbonisation, was measured using digital analysis software. RESULTS: All experiments used 150 J total energy. Total thermal damage area was smaller with lower power and pulsed energy. Continuous energy caused more tissue carbonisation than pulsed except at 25 W. CONCLUSION: Reduced thermal damage with lower power or pulsed energy results from cooling due to increased time of treatment. Increasing the power increases tissue carbonisation. Optimal treatment is determined by the highest power used continuously that does not cause tissue carbonisation.

Reoperation and complications after anterior cervical discectomy and fusion and cervical disc arthroplasty: a study of 52,395 cases.

PURPOSE: The aim of this study was to analyze rates of perioperative complications and subsequent cervical surgeries in patients treated for cervical degenerative disc disease with anterior cervical discectomy and fusion (ACDF) and those treated with artificial cervical disc arthroplasty (ACDA) for up to 5-year follow-up. METHODS: California's Office of Statewide Health Planning and Development discharge database was analyzed for patients aged 18-65 years undergoing single-level ACDF or ACDA between 2003 and 2010. Medical comorbidities were identified with CMS-Condition Categories. Readmissions for short-term complications of the procedure were identified and rates of subsequent cervical surgeries were calculated at 90-day and 1-, 3-, and 5-year follow-up. Multivariate regression modeling was used to identify associations with complications and subsequent cervical surgeries correcting for patient and provider characteristics. RESULTS: A total of 52,395 eligible cases were identified: 50,926 ACDF and 1469 ACDA. Readmission was less common in the ACDA group (OR: 0.69, 95% CI: 0.48-1.0, p = 0.048). Subsequent cervical spine surgery was more common in the ACDF group in the immediate perioperative period (within 90 days of surgery) (ACDF 3.35% vs. ACDA 2.04%, OR: 0.63, 95% CI: 0.44-0.92, p = 0.015). At 1-, 3-, and 5-year postoperatively, rates of subsequent cervical surgeries were similar between the two cohorts. CONCLUSIONS: We found no protective benefit for ACDA versus ACDF for single-level disease at up to 5-year follow-up in the largest cohort of patients examined to date. Early complications were rare in both cohorts stressing the value of large cohort studies to study risk factors for rare events. These slides can be retrieved under Electronic Supplementary Material.

Clinical and Radiographic Outcomes After Posterior Vertebral Column Resection for Severe Spinal Deformity with Five-Year Follow-up.

BACKGROUND: Short-term studies have shown improved outcomes and alignment after posterior vertebral column resection for severe spinal deformity. Our goal was to report long-term changes in radiographic and health-related quality-of-life measures in a consecutive series of pediatric and adult patients undergoing posterior vertebral column resection with a minimum follow-up of 5 years. METHODS: We reviewed all patients undergoing posterior vertebral column resection by a single surgeon prior to January 1, 2010, at a single institution. Standard preoperative and perioperative data were collected, including the Scoliosis Research Society (SRS)-22/24 instrument. Radiographic and health-related quality-of-life measures changes were evaluated at a minimum follow-up of 5 years. RESULTS: One hundred and nine patients underwent posterior vertebral column resection prior to January 2010, and 54 patients (49.5%) were available for analysis: 31 (57.4%) were pediatric patients, and 23 (42.6%) were adult patients. The mean age (and standard deviation) was 12.5 ± 3 years for the pediatric cohort and 39.3 ± 20 years for the adult cohort. Improvements in the mean major Cobb angle at a minimum follow-up of 5 years were seen: 61.6% correction for the pediatric cohort and 53.9% correction for the adult cohort. The rates of proximal junctional kyphosis, defined as proximal junctional kyphosis of >10°, were 16.1% for the pediatric cohort and 34.8% for the adult cohort, but none underwent a revision surgical procedure for symptomatic proximal junctional kyphosis. Of the 54 patients, 30 (55.6%) sustained complications, 5 (9.3%) experienced postoperative neurological deficits, and 7 (13.0%) required a revision by 5 years postoperatively. Significant improvements were observed in the SRS-Self Image with regard to the pediatric cohort at 0.9 (p = 0.017) and the adult cohort at 1.3 (p = 0.002) and in the SRS-Satisfaction with regard to the pediatric cohort at 1.8 (p = 0.008) and the adult cohort at 1.3 (p = 0.005). CONCLUSIONS: Posterior vertebral column resection offers substantial, sustained improvements in global radiographic alignment and patient outcome scores at 5 years. The major radiographic deformity was reduced by 61.6% in the pediatric cohort and by 53.9% in the adult cohort. Despite the high rate of complications, patients experienced significant improvement in the SRS-Self Image and SRS-Satisfaction domains. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Health-related quality of life outcomes in complex adult spinal deformity surgery.

OBJECTIVE Significant health-related quality of life (HRQOL) benefits have been observed for patients undergoing primary and revision adult spinal deformity (ASD) surgery. The purpose of this study was to report changes in HRQOL measures in a consecutive series of patients undergoing complex spinal reconstructive surgery, using Scoli-RISK-1 (SR-1) inclusion criteria. METHODS This was a single-center, retrospective cohort study. The SR-1 inclusion criteria were used to define patients with complex ASD treated between June 1, 2009, and June 1, 2011. Standard preoperative and perioperative data were collected, including the Scoliosis Research Society (SRS)-22r instrument. The HRQOL changes were evaluated at a minimum 2-year follow-up. Standardized forms were used to collect surgery-related complications data for all patients. Complications were defined as minor, transient major, or permanent major. Patients who achieved a minimum 2-year follow-up were included in the analysis. RESULTS Eighty-four patients meeting SR-1 criteria were identified. Baseline demographic and surgical data were available for 74/84 (88%) patients. Forty-seven of 74 (64%) patients met the additional HRQOL criteria with a minimum 2-year follow-up (mean follow-up 3.4 years, range 2-6.5 years). Twenty-one percent of patients underwent posterior fusion only, 40% of patients had a posterior column osteotomy, and 38% had a 3-column osteotomy. Seventy-five percent of patients underwent a revision procedure. Significant improvements were observed in all SRS-22r domains: Pain: +0.8 (p < 0.001); Self-Image: +1.4 (p < 0.001); Function: +0.46 (p < 0.001); Satisfaction: +1.6 (p < 0.001); and Mental Health: +0.28 (p = 0.04). With the exception of Mental Health, more than 50% of patients achieved a minimum clinically important difference (MCID) in SRS-22r domain scores (Mental Health: 20/47, 42.6%). A total of 65 complications occurred in 31 patients. This includes 29.8% (14/47) of patients who suffered a major complication and 17% (8/47) who suffered a postoperative neurological deficit, most commonly at the root level (10.6%, 5/47). Of the 8 patients who suffered a neurological deficit, 1 (13%) was able to achieve MCID in the SRS Function domain. CONCLUSIONS The majority of patients experienced clinically relevant improvement in SRS-22r HRQOL scores after complex ASD surgery. The greatest improvements were seen in the SRS Pain and SRS Self-Image domains. Although 30% of patients suffered a major or permanent complication, benefits from surgery were still attained. Patients sustaining a neurological deficit or major complication were unlikely to achieve HRQOL improvements meeting or exceeding MCID for the SRS Function domain.