Exploiting light-based 3D-printing for the fabrication of mechanically enhanced, patient-specific aortic grafts.

Despite polyester vascular grafts being routinely used in life-saving aortic aneurysm surgeries, they are less compliant than the healthy, native human aorta. This mismatch in mechanical behaviour has been associated with disruption of haemodynamics contributing to several long-term cardiovascular complications. Moreover, current fabrication approaches mean that opportunities to personalise grafts to the individual anatomical features are limited. Various modifications to graft design have been investigated to overcome such limitations; yet optimal graft functionality remains to be achieved. This study reports on the development and characterisation of an alternative vascular graft material. An alginate:PEGDA (AL:PE) interpenetrating polymer network (IPN) hydrogel has been produced with uniaxial tensile tests revealing similar strength and stiffness (0.39 ± 0.05 MPa and 1.61 ± 0.19 MPa, respectively) to the human aorta. Moreover, AL:PE tubular conduits of similar geometrical dimensions to segments of the aorta were produced, either via conventional moulding methods or stereolithography (SLA) 3D-printing. While both fabrication methods successfully demonstrated AL:PE hydrogel production, SLA 3D-printing was more easily adaptable to the fabrication of complex structures without the need of specific moulds or further post-processing. Additionally, most 3D-printed AL:PE hydrogel tubular conduits sustained, without failure, compression up to 50% their outer diameter and returned to their original shape upon load removal, thereby exhibiting promising behaviour that could withstand pulsatile pressure in vivo. Overall, these results suggest that this AL:PE IPN hydrogel formulation in combination with 3D-printing, has great potential for accelerating progress towards personalised and mechanically-matched aortic grafts.

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.

Focused selection of open cerebrovascular cases for residents interested in cerebrovascular neurosurgery.

INTRODUCTION: National and international trends continue to show greater emphasis on endovascular techniques for the treatment of cerebrovascular disease. The cerebrovascular neurosurgeon however must be adequately equipped to treat these patients via both open and endovascular techniques. METHODS: The decline in open cerebrovascular cases for aneurysm clipping has forced many trainees to pursue open cerebrovascular fellowships to increase case volume. An alternative strategy has been employed at our institution, which is early identification of subspecialty focus with resident driven self-selection of open cerebrovascular cases. RESULTS: This has allowed recent graduates to obtain enfolded endovascular training and a significant number of open cerebrovascular cases in order to obtain competence and exposure. DISCUSSION: We advocate for further self-selection paradigms supplemented with simulation training in order to obviate the need for extended post-residency fellowships.

A Systematic Review of the Risks of Motor Vehicle Crashes Associated with Psychiatric Disorders.

OBJECTIVE: Psychiatric disorders and their treatments have the potential to adversely impact driving skills. However, it is unclear to what extent this poses a public health risk by increasing the risk of motor vehicle crashes (MVCs). The aim of this systematic review was to synthesize and critically appraise evidence on the risk of MVC for drivers with psychiatric disorders. METHOD: We conducted a systematic review of the MVC risk associated with psychiatric disorders using seven databases in November 2019. Two reviewers examined each study and extracted data. The National Heart, Lung, and Blood Institute Quality Assessment tools were used to assess each study's quality of evidence. RESULTS: We identified 24 studies that met the inclusion criteria, including eight cohort, 10 case-control, and six cross-sectional designs. Quality assessment ratings were "Good" for four studies, "Fair" for 10, and "Poor" for 10. Self-report or questionnaires were used in place of objective measures of either MVC, psychiatric disorder, or both in 12 studies, and only seven adjusted for driving exposure. Fifteen studies reported an increased risk of MVC associated with psychiatric disorders, and nine did not. There was no category of disorder that was consistently associated with increased MVC risk. CONCLUSION: The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder. An individualized approach, as recommended by international guidelines, should continue. Further research should include objective assessments of psychiatric disorders and MVC risk and adjust for driving exposure.

A Systematic Review of the Risk of Motor Vehicle Collision in Patients With Syncope.

BACKGROUND: Drivers at risk of sudden incapacitation from syncope pose a potential threat to themselves and to society. The purpose of this systematic review is to synthesize the risk of motor vehicle collisions (MVCs) for patients with a history of syncope. METHODS: We systematically searched Medline (1946-2019) as well as Cinahl, Embase, Psychinfo, and the Transportation Research Information Documentation (1806-2017) for articles on MVCs and drivers with vasovagal syncope (VVS), arrhythmic syncope, or syncope not yet diagnosed (NYD). Quality ratings were assigned by team consensus. RESULTS: Eleven studies of moderate quality were included (n = 42,972). Compared with the general populations of Canada, the United States, and the United Kingdom (0.49%-2.29% per driver-year), the prospective MVC risk was lower for VVS (0.0%-0.31% per driver-year; 3 studies; n = 782) and higher for arrhythmic syncope (1.9%-3.4% per driver-year; 2 studies; n = 730). The results were more variable for syncope NYD (0.0%-6.9% per driver-year prospectively; 6 studies; n = 41,460). Patients with syncope NYD had an almost 2-fold increased MVC risk in the largest study, although the smaller studies showed contradictory findings. CONCLUSIONS: VVS patients appear to be at very low risk for MVCs, supporting current guidelines which do not recommend driving suspension for these patients in most cases. Although the data for other forms of syncope are too limited for definitive conclusions and must be improved, arrhythmic syncope appears to be associated with nontrivial risk.

Application of an objective structured clinical examination to evaluate and monitor intern's proficiency of hand hygiene and personal protective equipment use in the United States.

PURPOSE: To determine if an objective structured clinical examination (OSCE) could be used to evaluate and monitor hand hygiene and personal protective equipment (PPE) proficiency for medical interns in the United States. METHODS: Interns in July 2015 (N=123, Cohort 1) without OSCE-based contact precaution evaluation and teaching were evaluated early 2016 by OSCE for hand hygiene and PPE proficiency. They performed poorly. Therefore, the new interns entering July 2016 (N=151, Cohort 2) were immediately tested in the same OSCE station as Cohort 1 and provided feedback and teaching. Cohort 2 was then retested in the OSCE station early 2017. The Mann Whitney U test was used to compare Cohort 1 vs. Cohort 2 performances on checklist items. Cohort 2 performance differences at the beginning and end of the intern year were compared using McNemar's X2 test for paired nominal data. RESULTS: Checklist items were scored, summed and reported as percent correct. In Cohort 2, the mean percent correct was higher in posttest than pretest, 92% vs. 77% )(P <0 .0001). The passing rate (100% correct) was significantly higher, 55% vs. 16%. Comparing Cohort 1 and Cohort 2 at the end of intern year, the mean percent correct was higher for Cohort 2 compared to Cohort 1, 95% vs 90% (P < 0.0001). 55% of the Cohort 2 passed (a perfect score) compared to 24% in Cohort 1 (P < 0.0001). CONCLUSION: An OSCE can be utilized to evaluate and monitor hand hygiene and PPE proficiency for interns in the United States.

A systematic review of the risk of motor vehicle collision after stroke or transient ischemic attack.

BACKGROUND: Returning to driving after stroke is one of the key goals in stroke rehabilitation, and fitness to drive guidelines must be informed by evidence pertaining to risk of motor vehicle collision (MVC) in this population. OBJECTIVES: The purpose of the present study was to determine whether stroke and/or transient ischemic attack (TIA) are associated with an increased MVC risk. METHODS: We searched MEDLINE, CINAHL, EMBASE, PsycINFO, and TRID through December 2016. Pairs of reviewers came to consensus on inclusion, based on an iterative review of abstracts and full-text manuscripts, on data extraction, and on the quality of evidence. RESULTS: Reviewers identified 5,605 citations, and 12 articles met inclusion criteria. Only one of three case-control studies showed an association between stroke and MVC (OR 1.9, 95% CI 1.0-3.9). Of five cohort reports, only one study, limited to self-report, found an increased risk of MVC associated with stroke or TIA (RR 2.71, 95% CI 1.11-6.61). Two of four cross-sectional studies using computerized driving simulators identified a more than two-fold risk of MVCs among participants with stroke compared with controls. The difference in one of the studies was restricted to those with middle cerebral artery stroke. CONCLUSIONS: The evidence does not support a robust increase in risk of MVCs. While stroke clearly prevents some patients from driving at all and impairs driving performance in others, individualized assessment and clinical judgment must continue to be used in assessing and advising those stroke patients who return to driving about their MVC risk.

A Comparison of the Existing Wellness Programs in Neurosurgery and Institution Champion's Perspectives.

Once the accepted norm during Harvey Cushing's time, the mantra of work to the exclusion of family and lifestyle is now recognized as deleterious to overall well-being. A number of neurosurgical residency training programs have implemented wellness programs to enhance the physical, mental, and emotional well-being of trainees and faculty. This manuscript highlights existing organized wellness education within neurosurgery residency programs in order to describe the motivations behind development, structure, and potential implementation strategies, cost of implementation, and identify successes and barriers in the integration process. This manuscript is designed to serve as a "how-to" guide for other programs who may identify a need in their own trainees and begins the discussion of how to develop wellness, leadership, grit, and resiliency within our future generation of neurosurgeons.

An International Approach to Enhancing a National Guideline on Driving and Dementia.

PURPOSE OF REVIEW: The purpose of this study was to update a national guideline on assessing drivers with dementia, addressing limitations of previous versions which included a lack of developmental rigor and stakeholder involvement. METHODS: An international multidisciplinary team reviewed 104 different recommendations from 12 previous guidelines on assessing drivers with dementia in light of a recent review of the literature. Revised guideline recommendations were drafted by consensus. A preliminary draft was sent to specialist physician and occupational therapy groups for feedback, using an a priori definition of 90% agreement as consensus. RECENT FINDINGS: The research team drafted 23 guideline recommendations, and responses were received from 145 stakeholders. No recommendation was endorsed by less than 80% of respondents, and 14 (61%) of the recommendations were endorsed by more than 90%.The recommendations are presented in the manuscript. The revised guideline incorporates the perspectives of consensus of an expert group as well as front-line clinicians who regularly assess drivers with dementia. The majority of the recommendations were based on evidence at the level of expert opinion, revealing gaps in the evidence and future directions for research.

Update on the Risk of Motor Vehicle Collision or Driving Impairment with Dementia: A Collaborative International Systematic Review and Meta-Analysis.

Guidelines that physicians use to assess fitness to drive for dementia are limited in their currency, applicability, and rigor of development. Therefore, we performed a systematic review to determine the risk of motor vehicle collisions (MVCs) or driving impairment caused by dementia, in order to update international guidelines on driving with dementia. Seven literature databases (MEDLINE, CINAHL, Embase, etc.) were searched for all research studies published after 2004 containing participants with mild, moderate, or severe dementia. From the retrieved 12,860 search results, we included nine studies in this analysis, involving 378 participants with dementia and 416 healthy controls. Two studies reported on self-/informant-reported MVC risk, one revealing a four-fold increase in MVCs per 1,000 miles driven per week in 3 years prior, and the other showing no statistically significant increase over the same time span. We found medium to large effects of dementia on driving abilities in six of the seven recent studies that examined driving impairment. We also found that persons with dementia were much more likely to fail a road test than healthy controls (RR: 10.77, 95% CI: 3.00-38.62, z = 3.65, p < 0.001), with no significant heterogeneity (χ2 = 1.50, p = 0.68, I2 = 0%) in a pooled analysis of four studies. Although the limited data regarding MVCs are equivocal, even mild stages of dementia place patients at a substantially higher risk of failing a performance-based road test and of demonstrating impaired driving abilities on the road.

Development of a decision-making tool for reporting drivers with mild dementia and mild cognitive impairment to transportation administrators.

BACKGROUND: Driving in persons with dementia poses risks that must be counterbalanced with the importance of the care for autonomy and mobility. Physicians often find substantial challenges in the assessment and reporting of driving safety for persons with dementia. This paper describes a driving in dementia decision tool (DD-DT) developed to aid physicians in deciding when to report older drivers with either mild dementia or mild cognitive impairment to local transportation administrators. METHODS: A multi-faceted, computerized decision support tool was developed, using a systematic literature and guideline review, expert opinion from an earlier Delphi study, as well as qualitative interviews and focus groups with physicians, caregivers of former drivers with dementia, and transportation administrators. The tool integrates inputs from the physician-user about the patient's clinical and driving history as well as cognitive findings, and it produces a recommendation for reporting to transportation administrators. This recommendation is translated into a customized reporting form for the transportation authority, if applicable, and additional resources are provided for the patient and caregiver. CONCLUSIONS: An innovative approach was needed to develop the DD-DT. The literature and guideline review confirmed the algorithm derived from the earlier Delphi study, and barriers identified in the qualitative research were incorporated into the design of the tool.

Publication misrepresentation among neurosurgery residency applicants: an increasing problem.

OBJECT Misrepresentation of scholarly achievements is a recognized phenomenon, well documented in numerous fields, yet the accuracy of reporting remains dependent on the honor principle. Therefore, honest self-reporting is of paramount importance to maintain scientific integrity in neurosurgery. The authors had observed a trend toward increasing numbers of publications among applicants for neurosurgery residency at Vanderbilt University and undertook this study to determine whether this change was a result of increased academic productivity, inflated reporting, or both. They also aimed to identify application variables associated with inaccurate citations. METHODS The authors retrospectively reviewed the residency applications submitted to their neurosurgery department in 2006 (n = 148) and 2012 (n = 194). The applications from 2006 were made via SF Match and those from 2012 were made using the Electronic Residency Application Service. Publications reported as "accepted" or "in press" were verified via online search of Google Scholar, PubMed, journal websites, and direct journal contact. Works were considered misrepresented if they did not exist, incorrectly listed the applicant as first author, or were incorrectly listed as peer reviewed or published in a printed journal rather than an online only or non-peer-reviewed publication. Demographic data were collected, including applicant sex, medical school ranking and country, advanced degrees, Alpha Omega Alpha membership, and USMLE Step 1 score. Zero-inflated negative binomial regression was used to identify predictors of misrepresentation. RESULTS Using univariate analysis, between 2006 and 2012 the percentage of applicants reporting published works increased significantly (47% vs 97%, p < 0.001). However, the percentage of applicants with misrepresentations (33% vs 45%) also increased. In 2012, applicants with a greater total of reported works (p < 0.001) and applicants from unranked US medical schools (those not ranked by US News & World Report) were more likely to have erroneous citations (p = 0.038). CONCLUSIONS The incidence of legitimate and misrepresented scholarly works reported by applicants to the authors' neurosurgery residency program increased during the past 6 years. Misrepresentation is more common in applicants from unranked US medical schools and those with a greater number of reported works on their application. This trend is concerning in a profession where trustworthiness is vital. To preserve integrity in the field, programs should consider verifying citations prior to submitting their rank lists.

Follow-up on a national survey: american neurosurgery resident opinions on the 2011 accreditation council for graduate medical education-implemented duty hours.

OBJECTIVE: We previously performed a nationwide survey of American neurosurgical residents before the initiation of the 2011 Accreditation Council for Graduate Medical Education regulations, in which more than 70% indicated the proposed changes would negatively impact residency training. We sought to resurvey the resident population as to the actual changes that occurred to their programs after the 2011 standards went into effect. METHODS: Surveys were mailed to every neurosurgery training program in the United States and Puerto Rico. Program directors and coordinators were asked to distribute surveys to their residents. RESULTS: A total of 253 neurosurgery residents responded. Reported duty-hour violations were largely unchanged after the 2011 duty-hour changes. Sixty-percent of residents reported that they had underreported duty hours, with nearly 25% of respondents doing so on a weekly or daily basis. Most reported that the 2011 changes had not affected operative caseload, academic productivity, quality of life, or resident fatigue. The majority of residents disagreed or strongly disagreed that the PGY-1 16-hour limitation had a positive impact on first-year resident training (69%) or had improved patient safety (62%). Overall, the majority of respondents reported that the 2011 changes had a negative (35%) or negligible (33%) effect on residency training at their institution. CONCLUSION: Respondents indicated that the 2011 Accreditation Council for Graduate Medical Education regulations have had a smaller perceived effect on neurosurgical training programs than previously predicted. However, the majority of residents admitted to underreporting duty hours, with a quarter doing so on a regular basis. The 16-hour rule for interns remains unpopular.

Crash rates of quebec drivers with medical conditions.

Using a databank that combines comprehensive medical data with the driving records of 96% of the drivers in Quebec, odds ratios were calculated for crash risk involving death or serious injury according to the diagnosis of medical conditions traditionally associated with increased crash risk. Results were controlled for age, sex, residence (rural/urban), possession of a professional licence (classes 1 - 4), previous involvement in a crash with injury or death and for the presence of other medical conditions. In addition, crash risk was calculated for drivers with multiple conditions. There was a slight to moderate increase in crash risk for most of the conditions and an incremental increase in crash risk as the number of conditions increased.

Educating doctors on evaluation of fitness to drive: impact of a case-based workshop.

INTRODUCTION: In 2004, faced with demographic data predicting large increases in the number of older drivers within a relatively short period combined with the realization that screening for driver fitness was largely dependent on health professionals, principally physicians, the Société de l'assurance automobile du Québec (SAAQ) initiated measures to achieve better cooperation with the health professionals performing the screening. A continuing medical education (CME) program was initiated to improve the health professionals' understanding of road safety considerations. This article describes the program and its impact. METHODS: A 90-minute workshop combining presentation and discussion methods and centering on five case studies was developed and delivered to 824 participants. Outcomes were evaluated at the levels of satisfaction and performance. RESULTS: Participants reported a high level of satisfaction with the workshop. Data suggest that there was an increase in the number of reports submitted by physicians. The quality of physician reports also improved. DISCUSSION: SAAQ statistics show the benefit of its CME program. Informed physicians appear more willing to report drivers with medical problems affecting driver fitness, especially when they are asked to provide functional evaluations and not make decisions about fitness to drive. We believe that the success of this program was due to several factors: (1) its clinical rather than administrative orientation, (2) the use of physicians to deliver the workshop, and (3) formal recognition of the program by the authority responsible for licensing physicians.

Visual field defects may not affect safe driving.

OBJECTIVE: In Quebec a driver whose acquired visual field defect renders them ineligible for a driver's permit renewal may request an exemption from the visual field standard by demonstrating safe driving despite the defect. For safety reasons it was decided to attempt to identify predictors of failure on the road test in order to avoid placing driving evaluators in potentially dangerous situations when evaluating drivers with visual field defects. METHODS: During a 4-month period in 2009 all requests for exemptions from the visual field standard were collected and analyzed. All available medical and visual field data were collated for 103 individuals, of whom 91 successfully completed the evaluation process and obtained a waiver. RESULTS: The collated data included age, sex, type of visual field defect, visual field characteristics, and concomitant medical problems. No single factor, or combination of factors, could predict failure of the road test. All 5 failures of the road test had cognitive problems but 6 of the successful drivers also had known cognitive problems. Thus, cognitive problems influence the risk of failure but do not predict certain failure. CONCLUSION: Most of the applicants for an exemption were able to complete the evaluation process successfully, thereby demonstrating safe driving despite their handicap. Consequently, jurisdictions that have visual field standards for their driving permit should implement procedures to evaluate drivers with visual field defects that render them unable to meet the standard but who wish to continue driving.

Evaluation of a transition to practice program for neurosurgery residents: creating a safe transition from resident to independent practitioner.

BACKGROUND: In 2004, the Department of Neurosurgery at the University of Florida implemented a major curriculum innovation called the Transition to Practice program. This program was established to prepare residents to more safely transition to the role of independent practitioner. METHODS: A qualitative and quantitative evaluation of the program was conducted after its fifth year using online surveys and interviews. Study participants included Transition to Practice graduates, faculty, and current residents. RESULTS: Of the 26 respondents, 89% of faculty and all graduates were very satisfied with the program. Strengths identified included an independent yet mentored broad operative experience, the development of self-confidence, and a real sense of responsibility for patients. Medical billing and coding instruction and career mentoring were areas of the program that required additional attention. CONCLUSION: Overall, this program is meeting the stated objectives and is well received by the graduates and faculty. Based on the results of this evaluation, curricular changes such as instructions in practice management and implementation of a career-mentoring program have occurred. The Transition to Practice program is a unique curricular response to change that other surgical specialties may find useful in addressing the current-day stresses on graduate medical education.

Commentary: evaluation of driver fitness--the role of continuing medical education.

Faced with demographic trends that predicted large increases of older drivers within a relatively short period combined with the realization that screening for driver fitness was largely dependent upon health professionals, principally physicians, in 2004 the Société de l'assurance automobile du Québec (SAAQ) initiated measures that sought to achieve better cooperation with the health professionals performing the screening. A program was initiated that sought to improve the health professionals' understanding of road safety considerations. This article examines the measures included in this program and their results. SAAQ statistics show the benefit of the SAAQ's continuing medical education (CME) program. Since the initiation of the program the number of reports submitted by physicians has increased exponentially, whereas police reports have remained constant. Informed physicians report drivers with medical problems that may affect driver fitness when they are aware that the licensing agency's decisions are based principally upon valid functional evaluations. Discretionary reporting may be as effective as mandatory reporting when physicians are knowledgeable about the road safety implications of medical conditions.