Contemporary risk factors for a longer hospital stay following bidirectional cavopulmonary anastomosis.

BACKGROUND: Despite high survival after bidirectional cavopulmonary anastomosis, a considerable number of patients suffer significant post-operative morbidities related to prolonged length of stay. METHODS: A single-center retrospective cohort study of all consecutive patients undergoing a first-time bidirectional cavopulmonary anastomosis from 2006 to 2019. RESULTS: Prolonged length of stay was defined as hospital stay greater than the 75th percentile for our cohort. Of 195 patients who met inclusion criteria, the median post-operative length of stay was 8 days (interquartile range, 4-15 days). Prolonged length of stay was defined as greater than 15 days. In multivariate analysis, greater than mild systemic atrioventricular valve regurgitation (odds ratio 3.7, 95% CI 1.05-13.068, p = 0.04), longer length of stay after the initial palliative procedure (odds ratio 1.028, 95% CI 1.004-1.05, p = 0.02), and pre-operative higher superior vena cava oxygen saturation (odds ratio 0.922, 95% CI 0.85-0.99, p = 0.04) maintained statistical significance as independent risk and protective factors for prolonged length of stay. A one-level increase in the severity of pre-operative systemic atrioventricular valve regurgitation was associated with a multiplicative change in the odds ratio of prolonged length of stay of 5.45 (p = 0.005) independent of the severity of systemic ventricular dysfunction. CONCLUSION: Pre-operative characteristics with greater than mild systemic atrioventricular valve regurgitation, longer length of stay after the initial palliative procedure, and lower superior vena cava oxygen saturation were associated with prolonged length of stay after a first-time bidirectional cavopulmonary anastomosis.

Safety of bloodless open-heart surgery on cardiopulmonary bypass in selected children: A single center experience with minimal invasive extracorporeal circulation.

INTRODUCTION: Bloodless cardiac surgery refers to open-heart surgery without blood or blood products. The cardiopulmonary bypass (CPB) circuits are primed with crystalloid solely, and there is no intraoperative blood transfusion. METHODS: Our program considers bloodless congenital cardiac surgery with a minimal invasive extracorporeal circulation (MiECC) system for patients above 10 kg of weight. We performed a single-center retrospective cohort study of all consecutive patients undergoing bloodless cardiac surgery for congenital heart defects between January 2016 and December 2018. RESULTS: A total of 164 patients were reviewed (86 male and 78 female) at a median age of 9.6 years (interquartile range (IQR), 4.5-15), a weight of 32 kg (IQR, 16-55), preoperative hemoglobin 13.7 g/dl (IQR, 12.6-14.9), and preoperative hematocrit of 40.4% (IQR, 37.2-44.3). Median CPB time was 81.5 min (IQR, 58-125), and median hematocrit coming off CPB was 26% (IQR, 23-29.7). The congenital heart surgery risk (STAT) category was distributed in STAT 1 for 70, STAT 2 for 80, STAT 3 for 9, and STAT 4 for 5 patients. Most patients (95%) were extubated in the operating room with a low complication rate during the hospital stay (14.6%). Only 6 (4%) patients needed a blood transfusion during the postoperative period, with a higher incidence of complications during the hospital course (p < 0.001). CONCLUSIONS: Bloodless congenital heart surgery with MiECC system is safe in low-surgical-risk patients. Our patients had a low rate of complications and short hospital stays.

Development of Novel Octanoyl Chitosan Nanoparticles for Improved Rifampicin Pulmonary Delivery: Optimization by Factorial Design.

A novel hydrophobic chitosan derivative, octanoyl chitosan (OC) with improved organic solubility was synthesized, characterized, and employed for the preparation of rifampicin (Rif) encapsulated nanoparticle formulations for pulmonary delivery. OC was characterized to confirm acyl group substitution and cytotoxicity in A549 epithelial lung cells. OC nanoparticles were produced by the double emulsion solvent evaporation technique without cross-linking and characterized for particle size distribution, morphology, crystallinity, thermal stability, aerosol delivery, and drug release rate. OC was successfully synthesized with substitution degree of 44.05 ± 1.75%, and solubility in a range of organic solvents. Preliminary cytotoxicity studies of OC showed no effect on cell viability over a period of 24 h on A549 cell lines. OC nanoparticles were optimized using a 32 full factorial design. An optimized batch of OC nanoparticles, smooth and spherical in morphology, had mean hydrodynamic diameter of 253 ± 19.06 nm (PDI 0.323 ± 0.059) and entrapment efficiency of 64.86 ± 7.73% for rifampicin. Pulmonary deposition studies in a two-stage impinger following aerosolization of nanoparticles from a jet nebulizer gave a fine particle fraction of 43.27 ± 4.24%. In vitro release studies indicated sustained release (73.14 ± 3.17%) of rifampicin from OC nanoparticles over 72 h, with particles demonstrating physical stability over 2 months. In summary, the results confirmed the suitability of the developed systems for pulmonary delivery of drugs with excellent aerosolization properties and sustained-release characteristics.

Candidates' and interviewers' perceptions of multiple-mini interviews for admission to an occupational therapy professional program.

Multiple-Mini Interviews (MMIs) were used to assess professional attributes of candidates seeking admission to an occupational therapy professional entry-level master's program. Candidates and interviewers were invited to complete a questionnaire comprised of quantitative and open-ended questions following the MMIs. The MMIs were perceived to be fair, enjoyable, and capable of capturing professional attributes. Descriptive analysis of candidates' data revealed perceptions regarding logistics, interview station content, process, and interviewers. Interviewers commented on the positive and challenging aspects of the scenarios and the MMI process. Admissions committees need to consider several logistical, content, and process issues when designing and implementing MMIs as a selection tool.

Liposome-based dry powder vaccine immunization targeting the lungs induces broad protection against pneumococcus.

Streptococcus pneumoniae is an important human pathogen. Currently used conjugate vaccines are effective against invasive disease, but protection is restricted to serotypes included in the formulation, leading to serotype replacement. Furthermore, protection against non-invasive disease is reported to be considerably lower. The development of a serotype-independent vaccine is thus important and Pneumococcal surface protein A (PspA) is a promising vaccine candidate. PspA shows some diversity and can be classified in 6 clades and 3 families, with families 1 and 2 being the most frequent in clinical isolates. The ideal vaccine should thus induce protection against the two most common families of PspA. The aim of this work was to develop a liposome-based vaccine containing PspAs from family 1 and 2 and to characterize its immune response. Liposomes (LP) composed of dipalmitoylphosphatidylcholine (DPPC) and 3ß-[N-(N',N'-dimethylaminoethane)-carbamoyl]cholesterol (DC-Chol) with or without α-galactosylceramide (α-GalCer) were produced by microfluidics, encapsulating PspA from clade 1 (PspA1, family 1) and/or clade 4 (PspA4Pro, family 2) followed by spray-drying with trehalose to form nanocomposite microparticles carriers (NCMP). LP/NCMPs showed good stability and preservation of protein activity. LP/NCMPs containing PspA1 and/or PspA4Pro were used for immunization of mice targeting the lungs. High serum IgG antibody titers against both PspA1 and PspA4Pro were detected in animals immunized with LP/NCMPs containing α-GalCer, with a balance of IgG1 and IgG2a titers. IgG in sera from immunized mice bound to pneumococcal strains from different serotypes and expressing different PspA clades, indicating broad recognition. Mucosal IgG and IgA were also detected. Importantly, immunization with LP/NCMPs induced full protection against strains expressing PspAs from family 1 and 2. Furthermore, CD4+ resident memory T cells were detected in the lungs of the immunized animals that survived the challenge.

Optical and electronic properties of MgPc-Ch-diisoQ blend organic thin film as an active layer for photovoltaic cells.

Organic photovoltaic cells are a promising technology for generating renewable energy from sunlight. These cells are made from organic materials, such as polymers or small molecules, and can be lightweight, flexible, and low-cost. Here, we have created a novel mixture of magnesium phthalocyanine (MgPc) and chlorophenyl ethyl diisoquinoline (Ch-diisoQ). A coating unit has been utilized in preparing MgPc, Ch-diisoQ, and MgPc-Ch-diisoQ films onto to FTO substrate. The MgPc-Ch-diisoQ film has a spherical and homogeneous surface morphology with a grain size of 15.9 nm. The optical absorption of the MgPc-Ch-diisoQ film was measured, and three distinct bands were observed at 800-600 nm, 600-400 nm, and 400-250 nm, with a band gap energy of 1.58 eV. The current density-voltage and capacitance-voltage measurements were performed to analyze the photoelectric properties of the three tested cells. The forward current density obtained from our investigated blend cell is more significant than that for each material by about 22%. The photovoltaic parameters (Voc, Isc, and FF) of the MgPc-Ch-diisoQ cell were found to be 0.45 V, 2.12 µA, and 0.4, respectively. We believe that our investigated MgPc-Ch-diisoQ film will be a promising active layer in organic solar cells.

Electromagnetic Source Imaging in Presurgical Evaluation of Children with Drug-Resistant Epilepsy.

For children with drug-resistant epilepsy (DRE), seizure freedom relies on the delineation and resection (or ablation/disconnection) of the epileptogenic zone (EZ) while preserving the eloquent brain areas. The development of a reliable and noninvasive localization method that provides clinically useful information for the localization of the EZ is, therefore, crucial to achieving successful surgical outcomes. Electric and magnetic source imaging (ESI and MSI) have been increasingly utilized in the presurgical evaluation of these patients showing promising findings in the delineation of epileptogenic as well as eloquent brain areas. Moreover, the combination of ESI and MSI into a single solution, namely electromagnetic source imaging (EMSI), performed on simultaneous high-density electroencephalography (HD-EEG) and magnetoencephalography (MEG) recordings has shown higher source localization accuracy than either modality alone. Despite these encouraging findings, such techniques are performed in only a few tertiary epilepsy centers, are rarely recorded simultaneously, and are underutilized in pediatric cohorts. This study illustrates the experimental setup for recording simultaneous MEG and HD-EEG data as well as the methodological framework for analyzing these data aiming to localize the irritative zone, the seizure onset zone, and eloquent brain areas in children with DRE. More specifically, the experimental setups are presented for (i) recording and localizing interictal and ictal epileptiform activity during sleep and (ii) recording visual-, motor-, auditory-, and somatosensory-evoked responses and mapping relevant eloquent brain areas (i.e., visual, motor, auditory, and somatosensory) during visuomotor task, as well as auditory and somatosensory stimulations. Detailed steps of the data analysis pipeline are further presented for performing EMSI as well as individual ESI and MSI using equivalent current dipole (ECD) and dynamic statistical parametric mapping (dSPM).

A preliminary study of the impact of a handover cognitive aid on clinical reasoning and information transfer.

OBJECTIVES: To assess the impact of a written cognitive aid on expressed clinical reasoning and quantity and the accuracy of information transfer during resident doctor handover. METHODS: This study was a randomised controlled trial in an academic paediatric intensive care unit (PICU) of 20 handover events (10 events per group) from residents in their first PICU rotation using a written handover cognitive aid (intervention) or standard practice (control). Before rounds, an investigator generated a reference standard of the handover event by completing a handover aid. Resident handovers were then audio-recorded and transcribed by a blinded research assistant. The content of this transcript was inserted into a blank handover aid. A blinded content expert scored the quantity and accuracy of the information in this aid according to predetermined criteria and these information scores (ISs) were compared with the reference standard. The same expert also blindly scored the transcripts in five domains of clinical reasoning and effectiveness: (i) effective summary of events; (ii) expressed understanding of the care plan; (iii) presentation clarity; (iv) organisation; (v) overall handover effectiveness. Differences between intervention and control groups were assessed using the Mann-Whitney test and multivariate linear regression. RESULTS: The intervention group had total ISs that more closely approximated the reference standard (81% versus 61%; p < 0.01). The intervention group had significantly higher clinical reasoning scores when compared by total score (21.1 versus 15.9 points; p = 0.01) and in each of the five domains. No difference was observed in the duration of handover between groups (7.4 versus 7.7 minutes; p = 0.97). CONCLUSIONS: Using a novel scoring system, our simple handover cognitive aid was shown to improve information transfer and resident expression of clinical reasoning without prolonging the handover duration.

Retrograde Pulmonary Vein Recanalization Using Transcatheter Electrosurgery.

Transcatheter electrosurgery is a wire-based technique used to traverse or cut tissue within blood-filled spaces using alternating current delivered by guidewires or catheters. The use of transcatheter electrosurgical techniques in the pediatric population has been limited. We are reporting the first case of retrograde pulmonary vein recanalization using transcatheter electrosurgery. (Level of Difficulty: Advanced.).

Gender Differences in Perceptions and Attitudes of Medical Students Toward Neurosurgery: A German Nationwide Survey.

BACKGROUND: Despite advances in gender equity, the paucity of women neurosurgeons remains. In Germany, women accounted for only 24% of the specialists who completed their neurosurgical training in 2019. We sought to explore the perceptions of medical students in Germany toward a neurosurgical career, focusing on gender-specific differences. METHODS: A digital 26-item questionnaire with a Likert 4-point scale and open-ended questions was distributed to the German medical school student bodies. Data were analyzed to determine statistically significant intragroup variability between women and men. RESULTS: Two hundred ten medical students participated in the survey. Women and men were equally interested in brain pathologies (38% vs. 47%, strongly agreed), whereas interest in neurosurgery was significantly greater in men (12% vs. 26%, strongly agreed). Men were less likely to believe that women neurosurgery residents would face inequality at work. They were also less likely to support a gender quota in neurosurgery. Yet, both women and men were convinced that a rise in the number of women would positively impact the field. No gender dependency was seen in students' strive for success and prestige. Men felt discouraged from pursuing neurosurgery because they feared an unpleasant work environment, whereas women were concerned about neurosurgery not being family-friendly. Regardless of gender, the greatest factor deterring students from neurosurgery was poor work-life balance. CONCLUSIONS: Awareness must be raised concerning gender inequity and discrimination in our specialty. A multifaceted approach is imperative to develop neurosurgery into a profession where gender no longer hinders access to training and success in the field.

Comparative Analysis of the Efficacies of the GeneXpert and Solid Culture Media Techniques in the Diagnosis of Mycobacterium Tuberculosis.

Tuberculosis is one of the predominant infectious diseases causing significant deaths worldwide. Detection of Mycobacterium tuberculosis bacilli (MTB) using culture media was officially recognized by World Health Organization. However, there is a significant limitation in the authenticity of evaluation for its effectiveness on clinically important attributes. GeneXpert detects the presence of Mycobacterium tuberculosis (M. tuberculosis) based on the detection of nucleic acid and is able to identify the resistance of both isoniazid (INH) and Rifampicin (RIF) drugs. In this technique, DNA amplification is done using the GeneXpert instrument in the suspected sample with a specific reagent cartridge. Although GeneXpert is a rapid technique compared to other diagnostic tools for MTB identification due to false-negative results, the culture media technique is still considered the gold standard in detecting M. tuberculosis. The current study was designed to evaluate the comparative efficacies of GeneXpert and the solid culture media technique in identifying MTB. Sputum samples of 250 (n=250) suspected tuberculosis (TB) patients were investigated using both diagnostic techniques. The results revealed that out of the 250 suspected patients, 30 (12%) samples were positive with the culture media technique, while only 17 (6.8%) samples showed positive results with GeneXpert. Culture tests and GeneXpert are not equally efficient in detecting M. tuberculosis. The current study's findings showed that the culture-based detection method for M. tuberculosis is more efficient and reliable than GeneXpert.

Temporal lobe pleomorphic xanthoastrocytoma and acquired BRAF mutation in an adolescent with the constitutional 22q11.2 deletion syndrome.

DiGeorge syndrome, or velocardiofacial syndrome (DGS/VCFS), is a rare and usually sporadic congenital genetic disorder resulting from a constitutional microdeletion at chromosome 22q11.2. While rare cases of malignancy have been described, likely due to underlying immunodeficiency, central nervous system tumors have not yet been reported. We describe an adolescent boy with DGS/VCFS who developed a temporal lobe pleomorphic xanthoastrocytoma. High-resolution single nucleotide polymorphism array studies of the tumor confirmed a constitutional 22q11.21 deletion, and revealed acquired gains, losses and copy number neutral loss of heterozygosity of several chromosomal regions, including a homozygous deletion of the CDKN2A/B locus. The tumor also demonstrated a common V600E mutation in the BRAF oncogene. This is the first reported case of a patient with DiGeorge syndrome developing a CNS tumor of any histology and expands our knowledge about low-grade CNS tumor molecular genetics.

Handover after pediatric heart surgery: a simple tool improves information exchange.

OBJECTIVE: To improve the quality of handover of complex patients after pediatric cardiac surgery through the use of a simple handover tool. DESIGN: Prospective, pre-/postinterventional. SETTING: A tertiary care, pediatric intensive care unit in North America. SUBJECTS: Thirty-three consenting healthcare providers from pediatric cardiac anesthesia, critical care, and cardiothoracic surgery participating in 31 handovers. INTERVENTION: A fill-in-the-blank, one-page tool was developed to guide the information transmitted by the surgeon and anesthesiologist to the pediatric intensive care unit team during handover of postcardiac surgery patients. MEASUREMENTS AND MAIN RESULTS: Total handover score, four subscores, handover duration, and postoperative high-risk events were measured before and after introducing the tool into clinical practice. The patients in both the pre- and postintervention groups were similar at baseline. The total handover score (maximum 43 points) improved significantly after the implementation of the handover tool (28.2 of 43 ± 4.6 points vs. 33.5 of 43 ± 3.7 points, p = .002). There was also a significant improvement in the medical (8.3 ± 2.6 vs. 10.3 ± 2.1 points, p = .024) and surgical (7.5 ± 1.4 vs. 9.3 ± 1.6 points, p = .002) intraoperative information subscores. Use of the tool did not prolong handover duration (8.3 ± 4.6 vs. 11.1 ± 3.9 mins, p = .1). There was a trend toward more patients being free from high-risk events in the postintervention group (31.2% vs. 6.7%), but this did not reach statistical significance (p = .1). CONCLUSIONS: Use of a simple tool during handover of pediatric postcardiac surgery patients resulted in a more complete exchange of critical information with no significant prolongation of the handover duration.

The interaction between the oropharyngeal geometry and aerosols via pressurised metered dose inhalers.

PURPOSE: This study investigated the effect of oropharyngeal geometry on inhaled aerosol characteristics via pressurised metered dose inhalers (pMDIs), both with or without spacers. METHODS: Seven adult oropharyngeal models with different centreline lengths, total volumes, and degrees of constriction were employed as induction ports for a laser diffraction particle size analyser and cascade impactor. Particle size change over time, mass median aerodynamic diameter (MMAD), average median volume diameter (D(V)50), inhaled doses, and oropharyngeal depositions (percentage of the nominal dose) for aerosols via suspension and ultrafine pMDIs with or without spacers at 30 l/min airflow were determined. RESULTS: Variations in oropharyngeal geometry caused significant variations in inhaled particle size distributions, doses, oropharyngeal drug depositions, and particle size change over time when pMDIs were used without spacers. However, inhaled aerosol characteristics had marginal variations for the ultrafine pMDI plus large volume spacer (MMAD range: 0.69-0.78 microm, D(V)50 range: 1.27-1.36 microm, inhaled dose range: 46.46-52.92%). It was found that the amounts of inhaled aerosol particles with aerodynamic size of less than 0.83 microm via pMDIs plus large volume spacer were slightly affected by the oropharyngeal geometry. CONCLUSION: Inhaling ultrafine aerosols via spacers may reduce the effect of oropharyngeal geometry on inhaled aerosol properties.

Randomised controlled trial of the effect of standard and detailed risk disclosure prior to bronchoscopy on peri-procedure anxiety and satisfaction.

BACKGROUND: Deciding what risks to disclose before a procedure is often challenging for clinicians. Consecutive patients undergoing elective fibreoptic bronchoscopy were randomised to receive simple or more detailed written information about the risks of the procedure and the effects on anxiety and satisfaction levels were compared. METHODS: A 100 mm anxiety visual analogue scale (VAS) and a modified Amsterdam preoperative anxiety (scored 4-20) scale (APAIS) were completed before and after reading the designated information leaflet. Following bronchoscopy, subjects completed a satisfaction questionnaire. RESULTS: Of 142 consecutive patients, 122 (86%) (mean age 57.8 years, 53% male) completed the study. Baseline demographic, clinical and anxiety measures were similar in the two groups. Those who received more detailed risk information had significantly greater increase in anxiety levels than those who received simple information on both the VAS (mean 14.0 (95% CI 10.1 to 17.9) vs 2.5 (95% CI -1.4 to 6.4), p<0.001) and the APAIS (1.73 (95% CI 1.19 to 2.26) vs 0.57 (95% CI 0.05 to 1.10), p<0.001). Almost twice as many of those receiving detailed risk information reported that they felt they had received too much information about complications or that the information they had received about bronchoscopy had been worrying. CONCLUSIONS: Provision of more detailed risk information before bronchoscopy may come at the cost of a small but significant increase in anxiety.

Liposome-based dry powder vaccine immunization targeting the lungs induces broad protection against pneumococcus

Streptococcus pneumoniae is an important human pathogen. Currently used conjugate vaccines are effective against invasive disease, but protection is restricted to serotypes included in the formulation, leading to serotype replacement. Furthermore, protection against non-invasive disease is reported to be considerably lower. The development of a serotype-independent vaccine is thus important and Pneumococcal surface protein A (PspA) is a promising vaccine candidate. PspA shows some diversity and can be classified in 6 clades and 3 families, with families 1 and 2 being the most frequent in clinical isolates. The ideal vaccine should thus induce protection against the two most common families of PspA. The aim of this work was to develop a liposome-based vaccine containing PspAs from family 1 and 2 and to characterize its immune response. Liposomes (LP) composed of dipalmitoylphosphatidylcholine (DPPC) and 3β-[N-(N′,N′-dimethylaminoethane)-carbamoyl]cholesterol (DC-Chol) with or without α-galactosylceramide (α-GalCer) were produced by microfluidics, encapsulating PspA from clade 1 (PspA1, family 1) and/or clade 4 (PspA4Pro, family 2) followed by spray-drying with trehalose to form nanocomposite microparticles carriers (NCMP). LP/NCMPs showed good stability and preservation of protein activity. LP/NCMPs containing PspA1 and/or PspA4Pro were used for immunization of mice targeting the lungs. High serum IgG antibody titers against both PspA1 and PspA4Pro were detected in animals immunized with LP/NCMPs containing α-GalCer, with a balance of IgG1 and IgG2a titers. IgG in sera from immunized mice bound to pneumococcal strains from different serotypes and expressing different PspA clades, indicating broad recognition. Mucosal IgG and IgA were also detected. Importantly, immunization with LP/NCMPs induced full protection against strains expressing PspAs from family 1 and 2. Furthermore, CD4+ resident memory T cells were detected in the lungs of the immunized animals that survived the challenge.

"Crimes against the Nervous System": Neurological References During the Nuremberg Doctors' Trials.

The Nuremberg Trials were a sequence of tribunal sessions held by the Allied Forces between November 1945 and October 1946 with the intent of prosecuting prominent representatives of the Nazi Party for crimes committed before and during the war. Because medical experiments in human prisoners were among the most heinous offenses, a specific series of court cases, known as the Doctor's Trials (the USA vs. Karl Brandt et al), was carried out. A considerable part of the official documents of the Nuremberg Trials has been recently made publicly available through the Nuremberg Trials Project, an initiative of the Harvard Law School Library. We performed a comprehensive analysis of the Doctors' Trials original documents (NMT 1: Medical Case) as well as other available academic and historical sources focusing on references to the nervous system, neurosurgical, and neurologic diseases. Besides providing a brief glance of a unique source of original historical documents, this historical vignette also attempts to fulfill, at least in some limited sense, the moral duty toward the Holocaust victims laid on our generation by remembering their fate.

Minimally invasive superficial temporal artery to middle cerebral artery bypass through an enlarged bur hole: the use of computed tomography angiography neuronavigation in surgical planning.

The authors describe their minimally invasive technique for performing a superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, which relies on an enlarged bur hole (2-2.5 cm) rather than the standard craniotomy. They perform this procedure in a minimally invasive fashion, using CT angiography for intraoperative neuronavigation as well as for preoperative identification of the donor and recipient vessels and planning of bur hole location. They present 2 cases in which this procedure was used, including one involving a patient with multivessel occlusive disease and significant cerebrovascular hemodynamic compromise in whom they performed the procedure using only local anesthetic and propofol sedation in order to minimize the risk of hypotension associated with the use of general anesthetic agents. A comprehensive literature search revealed no previously published case of an extracranial-intracranial arterial bypass procedure performed in an awake patient. The authors have adopted the described minimally invasive method for all STA-MCA bypass procedures. The awake setting, however, is reserved for specific indications, primarily patients with severe moyamoya disease, in whom ventilator-related hypocarbia can result in intraoperative ischemia, or patients with multivessel occlusive disease and significant cerebral hemodynamic compromise, in whom general anesthesia-related hypotension can lead to intraoperative ischemia.

Awake Microvascular Decompression for Trigeminal Neuralgia: Concept and Initial Results.

BACKGROUND: In this initial series, we evaluated the use of microvascular decompression (MVD) under an awake anesthesia protocol ("awake" MVD) to assess whether intraoperative pain evaluation can identify and mitigate insufficient decompression of the trigeminal nerve, improving surgical outcomes, and possibly expand the indications of MVD in patients with comorbidities that would preclude the use of general endotracheal anesthesia (GEA). METHODS: An Institutional Review Board-approved prospective study of 10 consecutive adults who underwent MVD for trigeminal neuralgia (TN) was conducted. The primary outcome measure was postoperative TN pain quantified on the Barrow Neurological Institute (BNI) Pain Severity Scale. RESULTS: The median patient age was 65.5 years, with a female:male ratio of 6:4. All 10 patients tolerated the procedure well and did not require GEA intraoperatively or postoperatively. Nine patients had a successful surgical outcome (BNI score I, n = 5; BNI score II, n = 4). One patient did not have pain relief (BNI score IV). This same patient also developed a pseudomeningocele, which was the sole surgical complication observed in this series. One patient experienced recurrence of pain at 11 months, with BNI score increasing from I to II. The median duration of follow-up was 16.5 months. Two patients did not experienced resolution of evoked pain during intraoperative awake testing following decompression. Further intraoperative exploration revealed secondary offending vessels that were subsequently decompressed, leading to resolution of pain. CONCLUSIONS: Intraoperative awake testing for treatment efficacy may increase the success rate of MVD by rapidly identifying and mitigating insufficient cranial nerve V decompression.

Facilitating admissions of diverse students: A six-point, evidence-informed framework for pipeline and program development.

INTRODUCTION: Several national level calls have encouraged reconsideration of diversity issues in medical education. Particular interest has been placed on admissions, as decisions made here shape the nature of the future physician workforce. Critical analysis of current practices paired with evidence-informed policies may counter some of the barriers impeding access for underrepresented groups. METHODS: We present a framework for diversity-related program development and evaluation grounded within a knowledge translation framework, and supported by the initiation of longitudinal collection of diversity-related data. We provide an illustrative case study for each component of the framework. Descriptive analyses are presented of pre/post intervention diversity metrics if applicable and available. RESULTS: The framework's focal points are: 1) data-driven identification of underrepresented groups, 2) pipeline development and targeted recruitment, 3) ensuring an inclusive process, 4) ensuring inclusive assessment, 5) ensuring inclusive selection, and 6) iterative use of diversity-related data. Case studies ranged from wording changes on admissions websites to the establishment of educational and administrative offices addressing needs of underrepresented populations. CONCLUSIONS: We propose that diversity-related data must be collected on a variety of markers, developed in partnership with stakeholders who are most likely to facilitate implementation of best practices and new policies. These data can facilitate the design, implementation, and evaluation of evidence-informed diversity initiatives and provide a structure for continued investigation into 'interventions' supporting diversity-related initiatives.