understanding and managing complications in neurosurgery

It is a well-known surgical maxim that only two types of surgeons do not have surgical complications; those who do not operate, and those who lie. Surgical complications in other words, are unwanted but undeniable part of surgery. There is not one operation with a 0% complication rate and therefore statistically, if a surgeon does not have complications, he probably has not operated enough. Despite their inevitability, complications convey a sense of gravity to the public, health professionals, and the policy makers alike

Current State of Neurosurgery Training in Pakistan, Results of a Nationwide Questionnaire Based Survey: Interdepartmental Variations Preclude Standardization

Objective:  To observe inter departmental variation in the availability of resources and academic activities; within various neurosurgery programs of Pakistan. Material and Methods:  This is a proforma based survey of Neurosurgery trainees and young neurosurgeons of Pakistan looking at the academic infrastructure and output of their programs. The proforma was filled by 36 respondents from 11 neurosurgery centers of the countries. All centers are accredited for neurosurgery training in Pakistan. Results:  Out of 36 respondents, 30 were completing fellowship training (FCPS) and 6 were induced for Master in Surgery (MS) program. About 80% participants used Youman’s text book of neurosurgery as reference book. Only 40% candidates had access to more than one indexed neurosurgery journals. Structured academic sessions (journal clubs, neuroradiology meeting, and neuropathology meeting) were lacking in majority of training institutes. 95% trainees had no microsurgical laboratory. Modern neurosurgical tools (frameless neuronavigation system, neuroendoscopy) were in use at few centers only. Conclusion:  Neurosurgery training in Pakistan is not uniform and wide variations exist between centers. We recommend exchange programs between centers at national and international levels to allow the trainees to gain first hand exposures to facilities not available in their own center

Applying a mixed-method approach to improve on-the-job learning and job satisfaction in a cohort of interns at a university hospital

Introduction: Job satisfaction is vital for the optimal functioning of medical practitioners. Herein, we report our experience of restructuring the internship program by identifying the gaps, developing, implementing strategies to overcome gaps and sharing the results of the pre-implementation and post-implementation audit, as an example for establishing a system for improving intern\u27s work-based learning and satisfaction in a university hospital setting.Methods: Using Kern\u27s six-step instructional model, a prospective mixed-method study was conducted at Aga Khan University Hospital. In phase 1 (2013) gaps were identified by evaluating various aspects of the internship program. Strategies were developed and implemented to overcome the identified gaps. In phase 2 (2014-2016) the impact of these developmental strategies was assessed.Results: A total of 65 interns, 30 residents, and 22 faculty members participated in phase I, while 71 interns participated in phase II. The reformation of orientation sessions, including practical exposure and content of sessions, opportunities to enhance hands-on experience and supervision in inpatient areas, operating rooms, supervision by fellows, supervision for hands-on procedures, career counseling, and mentorship, led to significant improvement in satisfaction. It was identified that the lack of hands-on opportunities can be overcome by surgical skills-based workshops. These reforms led to an overall rise in intern satisfaction (50% vs 75.4%, p=0.02).Conclusion: Periodic restructuring of an existing program helps to improve the work-based learning experience and overall satisfaction among interns. This not only maximizes learning but also eases interns into their postgraduate life and workload subsequently enabling them to become more competent and well-rounded health practitioners

Re-structuring university hospital’s internship program using kern’s six-step model of Instructional design

Abstract Background: Internship is a phase of training wherein a graduate learns in the context of practice, acquiring skills under supervision so that he/she may become capable of functioning independently. We are reporting the process of curriculum restructuring for strengthening the Internship Program at this university hospital. Methodology: We used Kerns’ six-step model to evaluate and restructure the internship curriculum. Step 01: Problem Identification & General need assessment- Thorough literature review revealed Internship as the crucial year of training that needs to be fashioned around the competencies required to make good doctor

Phenytoin versus Leviteracetam for seizure prophylaxis after brain injury - A meta analysis

Background: Current standard therapy for seizure prophylaxis in Neuro-surgical patients involves the use of Phenytoin (PHY). However, a new drug Levetiracetam (LEV) is emerging as an alternate treatment choice. We aimed to conduct a meta-analysis to compare these two drugs in patients with brain injury.Methods: An electronic search was performed in using Pubmed, Embase, and CENTRAL. We included studies that compared the use of LEV vs. PHY for seizure prophylaxis for brain injured patients (Traumatic brain injury, intracranial hemorrhage, intracranial neoplasms, and craniotomy). Data of all eligible studies was extracted on to a standardized abstraction sheet. Data about baseline population characteristics, type of intervention, study design and outcome was extracted. Our primary outcome was seizures.Results: The literature search identified 2489 unduplicated papers. Of these 2456 papers were excluded by reading the abstracts and titles. Another 25 papers were excluded after reading their complete text. We selected 8 papers which comprised of 2 RCTs and 6 observational studies. The pooled estimate\u27s Odds Ratio 1.12 (95% CI = 0.34, 3.64) demonstrated no superiority of either drug at preventing the occurrence of early seizures. In a subset analysis of studies in which follow up for seizures lasted either 3 or 7 days, the effect estimate remained insignificant with an odds ratio of 0.96 (95% CI = 0.34, 2.76). Similarly, 2 trials reporting seizure incidence at 6 months also had insignificant pooled results while comparing drug efficacy. The pooled odds ratio was 0.96 (95% CI = 0.24, 3.79).Conclusions: Levetiracetam and Phenytoin demonstrate equal efficacy in seizure prevention after brain injury. However, very few randomized controlled trials (RCTs) on the subject were found. Further evidence through a high quality RCT is highly recommended

Pediatric colloid cysts: a multinational, multicenter study. An IFNE-ISPN-ESPN collaboration

OBJECTIVE Colloid cysts (CCs) are rare at all ages, and particularly among children. The current literature on pediatric CC is limited, and often included in mixed adult/pediatric series. The goal of this multinational, multicenter study was to combine forces among centers and investigate the clinical course of pediatric CCs. METHODS A multinational, multicenter retrospective study was performed to attain a large sample size, focusing on CC diagnosis in patients younger than 18 years of age. Collected data included clinical presentation, radiological characteristics, treatment, and outcome. RESULTS One hundred thirty-four children with CCs were included. Patient age at diagnosis ranged from 2.4 to 18 years (mean 12.8 ± 3.4 years, median 13.2 years, interquartile range 10.3–15.4 years; 22% were \u3c 10 years of age). Twenty-two cases (16%) were diagnosed incidentally, including 48% of those younger than 10 years of age. Most of the other patients had symptoms related to increased intracranial pressure and hydrocephalus. The average follow-up duration for the entire group was 49.5 ± 45.8 months. Fifty-nine patients were initially followed, of whom 28 were eventually operated on at a mean of 19 ± 32 months later due to cyst growth, increasing hydrocephalus, and/or new symptoms. There was a clear correlation between larger cysts and symptomatology, acuteness of symptoms, hydrocephalus, and need for surgery. Older age was also associated with the need for surgery. One hundred three children (77%) underwent cyst resection, 60% using a purely endoscopic approach. There was 1 death related to acute hydrocephalus at presentation. Ten percent of operated patients had some form of complication, and 7.7% of operated cases required a shunt at some point during follow-up. Functional outcome was good; however, the need for immediate surgery was associated with educational limitations. Twenty operated cases (20%) experienced a recurrence of their CC at a mean of 38 ± 46 months after the primary surgery. The CC recurrence rate was 24% following endoscopic resection and 15% following open resections (p = 0.28). CONCLUSIONS CCs may present in all pediatric age groups, although most that are symptomatic present after the age of 10 years. Incidentally discovered cysts should be closely followed, as many may grow, leading to hydrocephalus and other new symptoms. Presentation of CC may be acute and may cause life-threatening conditions related to hydrocephalus, necessitating urgent treatment. The outcome of treated children with CCs is favorable