Pituitary society expert Delphi consensus: operative workflow in endoscopic transsphenoidal pituitary adenoma resection

Abstract: Purpose: Surgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice. Methods: A mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached. Results: There was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured. Conclusions: Through an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed “core” steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The “optional” steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world

ROOA: CloudIDE framework for extension development

The Program is a mediator as all IDEs are mediator programs, in the sense that IDEs like Eclipse, Eric IDE, and net beans are considered as a mediator between a programmer and Interpreter or the programming language compiler. In fact, in this paper we can say that all things the programs do can be done with a simple text editor and we can see the Program output by direct contact with interpreter or compiler. The only difference between the Program provided by me and other IDEs is that the environment is special for building the extension. It means that instead of being an interface between user and interpreter or compiler, standards provided by other applications are usually different. The program tries to fill in the absence of an Efficient IDE in the field of building an extension. On the other hand, it reduces the cost of extension standard providers for presenting an IDE specific to that standard. In fact, in the second target the program provided will be a platform that has the ability to mount the next standards. Standard providers should only conduct a Part of coding. A constant part is common in all standards. We should find a solution for them in all IDEs, such as file management and information management that have been implemented in constant part of the IDE. The variable and non-similar part is implemented as classes. If needed to implement, it should be inherited from them and some of their functions must be overridden

Explicando el estado de la educación en enfermería clínica: un estudio de análisis de contenido en Irán

Introduction: Challenges and problems of clinical nursing education are the most important factor in determining the quality of nursing students' education. Frequent assessment of the quality of nursing education without considering the existing challenges is an ineffective activity in analyzing the situation of nursing education. Objective This study aimed to explain the status of clinical nursing education at Jahrom University of Medical Sciences in Iran. Methodology: A qualitative design based on the conventional content analysis approach was used. This study was conducted at the X University of Medical Sciences in 2018-2019. Data were drawn from 10 semi-structured focus group interviews with 110 nurses, head nurses, instructors, and students. Purposeful sampling was performed. The time and place of the interviews were chosen according to the participants. The interviews were analyzed by Graneheim and Lundman method by MAXQDA software. Results: 626 in-vivo codes, 46 primary codes, 8 subcategories (lack of attention to the evaluation process, non-participative evaluation, low staff educational cooperation, ineffective instructors, non-educational clinical space, student educational deficits, student drown in the clinic, non-participatory planning), and 3 main categories (planning challenges, implementing challenges and evaluation challenges) were obtained. Conclusion: Educational leaders must shift to three areas; democratic planning, wise implementation with frequent monitoring, and the use of modern clinical evaluation methods (Based on the participation of learners and other stakeholders).Introducción: Los desafíos y problemas de la educación clínica en enfermería son el factor más importante para determinar la calidad de la educación de los estudiantes de enfermería. La evaluación frecuente de la calidad de la educación en enfermería sin considerar los desafíos existentes es una actividad ineficaz en el análisis de la situación de la educación en enfermería. Objetivo Este estudio tuvo como objetivo explicar el estado de la educación en enfermería clínica en la Universidad de Ciencias Médicas Jahrom en Irán. Metodología: Se utilizó un diseño cualitativo basado en el enfoque de análisis de contenido convencional. Este estudio se realizó en la X Universidad de Ciencias Médicas en 2018-2019. Los datos se obtuvieron de 10 entrevistas de grupos focales semiestructurados con 110 enfermeras, enfermeras jefes, instructores y estudiantes. Se realizó un muestreo intencional. La hora y el lugar de las entrevistas se eligieron según los participantes. Las entrevistas fueron analizadas por el método de Graneheim y Lundman por el software MAXQDA. Resultados: 626 códigos in-vivo, 46 ​​códigos primarios, 8 subcategorías (falta de atención al proceso de evaluación, evaluación no participativa, escasa cooperación educativa del personal, instructores ineficaces, espacio clínico no educativo, déficits educativos de los estudiantes, estudiante ahogado en la clínica, planificación no participativa) y 3 categorías principales (desafíos de planificación, desafíos de implementación y desafíos de evaluación). Conclusión: Los líderes educativos deben cambiar a tres áreas; planificación democrática, implementación inteligente con monitoreo frecuente y el uso de métodos modernos de evaluación clínica (basado en la participación de los estudiantes y otras partes interesadas)

Predictive factors for pre-intervention rebleeding in aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis

Rebleeding before intervention is a devastating complication of aneurysmal subarachnoid haemorrhage (aSAH). It often occurs early and is associated with poor outcomes. We present a systematic review and meta-analysis to identify potential predictors of rebleeding in aSAH. A database search identified studies detailing the occurrence of pre-intervention rebleeding in aSAH, and 809 studies were screened. The association between rebleeding and a variety of demographic, clinical, and radiological factors was examined using random effects meta-analyses. Fifty-six studies totalling 33,268 patients were included. Rebleeding occurred in 3,223/33,268 patients (11.1%, 95%CI 9.4-13), with risk decreasing by approximately 0.2% per year since 1981. Systolic blood pressure (SBP) during admission was higher in patients who rebled compared with those who did not (MD 7.4 mmHg, 95%CI 2.2 - 12.7), with increased risk in cohorts with SBP > 160 mmHg (RR 2.12, 95%CI 1.35-3.34), but not SBP > 140 mmHg. WFNS Grades IV-V (RR 2.05, 95%CI 1.13-3.74) and Hunt-Hess grades III-V (RR 2.12, 95%CI 1.38-3.28) were strongly associated with rebleeding. Fisher grades IV (RR 2.24, 95%CI 1.45-3.49) and III-IV (RR 2.05, 95%CI 1.17-3.6) were also associated with an increased risk. Awareness of potential risk factors for rebleeding is important when assessing patients with aSAH to ensure timely management in high-risk cases. Increased SBP during admission, especially > 160 mmHg, poorer clinical grades, and higher radiological grades are associated with an increased risk. These results may also aid in designing future studies assessing interventions aimed at reducing the risk of rebleeding. </p

Multi-layered repair of high-flow CSF fistulae following endoscopic skull base surgery without nasal packing or lumbar drains: technical refinements to optimise outcome

Aims: Post-operative CSF leak remains a significant problem following endoscopic skull base surgery, particularly when there is a high-flow intra-operative CSF leak. Most skull base repair techniques are accompanied by the insertion of a lumbar drain and/or the use of nasal packing which have significant shortcomings. Our aim was to review the results of a large series of endoscopic skull base cases where a high-flow intra-operative CSF leak rate was encountered and repaired to assess if modifications in technique could reduce the post-operative CSF leak rate. Methods: A retrospective review of a prospectively maintained database of skull base cases performed by a single surgeon over a 10-year period was performed. Data regarding patient demographics, underlying pathology, skull base repair techniques and post-operative complications were analysed. Results: One hundred forty-two cases with high-flow intra-operative CSF leak were included in the study. The most common pathologies were craniopharyngiomas (55/142, 39%), pituitary adenomas (34/142, 24%) and meningiomas (24/142, 17%). The CSF leak rate was 7/36 (19%) when a non-standardised skull base repair technique was used. However, with the adoption of a standardised, multi-layer repair technique, the post-operative CSF leak rate decreased significantly (4/106, 4% vs. 7/36, 19%, p = 0.006). This improvement in the rate of post-operative CSF leak was achieved without nasal packing or lumbar drains. Conclusion: With iterative modifications to a multi-layered closure technique for high-flow intra-operative CSF leaks, it is possible to obtain a very low rate of post-operative CSF leak, without lumbar drains or nasal packing.</p

Atypical meningoma: current management dilemmas and prospective clinical trials

Atypical meningioma is an intermediate grade tumour with a greater risk of recurrence following surgical resection. Changes to the WHO classification have resulted in an increased reporting of these tumours. The role of early adjuvant radiotherapy after gross total resection has not been clearly defined and the literature evidence is of poor quality providing conflicting information. This review assesses the evidence for current clinical practice, management dilemmas and the need for prospective clinical trials for atypical meningioma