The Use of a Low-Fidelity Simulator to Improve Vascular Anastomosis Skills of Residents during the COVID-19 Pandemic.

BACKGROUND: To evaluate a workshop using a low-fidelity simulator for training vascular surgery residents in vascular anastomosis during the COVID-19 pandemic. DESIGN: Prospective, controlled, single-center. METHODS: Vascular surgery residents at the São Paulo University Medical School were enrolled in the COVID Group (five post graduation year 3 residents) or Control Group (five PGY-4 residents). The COVID Group was trained via a vascular anastomosis workshop. The residents were evaluated using Objective Structured Assessment of Technical Skills (OSATS), Final Product Analysis and time to perform the procedure. The number of anastomoses performed by the residents were calculated. Data were subjected to statistical analysis, and P < 0.05 was considered significant. RESULTS: There was a significant reduction in the number of vascular anastomoses performed by the residents between the COVID group and the control group (mean 22.6 ± 7.76 vs. 35.2 ± 3.9, P = 0.01, Student's t-test). Before the workshop, 80% of the residents from the COVID group failed to perform a vascular anastomosis on the simulator. During the workshop, there was improvement in the Objective Structured Assessment of Technical Skills (OSATS) score (initial: 16.5, interquartile range (IQR) 0, under supervision: 25, IQR 5, and at the end of the workshop: 26.5, IQR 2.5; P = 0.049, Friedman's test) and in the Final Product Analysis (initial: 14.5, IQR 6, under supervision: 26.5, IQR 4.625, end of the workshop: 27, IQR 4, P = 0.049, Friedman's test). Time was not significantly different (initial: 35.6, IQR 2.77; under supervision: 25.8 min, IQR 4.53; P = 0.07, Friedman's test). The residents' technical scores were stable 6 months after the training, and there was no difference between their final scores and those of the control group. The residents from the COVID Group reported an improvement in their knowledge, technical skills and confidence after the workshop. CONCLUSIONS: A workshop using a low-fidelity simulator improved vascular surgery residents' skills and confidence in vascular anastomosis during the pandemic year, when they performed fewer surgical procedures.

Predictive Factors for Muscle Injury After Posterior Lumbar Spinal Surgery.

OBJECTIVE: The aims of this study were to evaluate the risk factors for muscle injury in patients undergoing posterior lumbar spinal surgery and the clearance of postoperative biochemical changes following lumbar fusion and secondarily to evaluate the timing for monitoring postoperative biochemical serum levels and potential clinical correlation. METHODS: The study prospectively enrolled 39 patients with degenerative disease of the lumbar spine. Biochemical markers (creatine phosphokinase [CPK], creatinine, and hemoglobin) were analyzed in 5 predefined stages. All relevant clinical data were collected. Rhabdomyolysis (RML) was defined as a postoperative 5-fold increase of the baseline CPK value. RESULTS: Patients from the lumbar fusion group had the highest postoperative CPK ratio. Overall, the rate of RML was 43.6%. CPK and creatinine activity reached their maximum on the first postoperative day in 69.2% and 87.5% of patients, respectively. Lumbar fusion (P = 0.005), surgical time >270 minutes (P = 0.028), and fall in hemoglobin levels >3 g/dL (P = 0.034) were identified as independent factors associated with higher risk of RML. CONCLUSIONS: The risk of RML increases with prolonged and invasive surgery with higher bleeding potential. Knowing the clearance of postoperative biochemical changes permits a standardized strategy with measurements in precise intervals, thereby avoiding unnecessary costs. The clinical significance is still undetermined.

Universal fluorescence module for intraoperative fluorescein angiography-a technical report.

BACKGROUND: Even in specialized centers, suboptimal aneurysm clipping can be as high as 12%. Intraoperative fluorescence angiography with indocyanine green and, more recently, fluorescein sodium have been shown to be a good method for intraoperative flow assessment. However, the cost with the apparatus it entails limits its widespread use. We have developed a low-cost universal fluorescence module (FM) designed to visualize fluorescein and perform intraoperative angiography. The purpose of this paper is to describe this device as well as to present our early experience with its use in the treatment of cerebral aneurysms. METHOD: A FM was designed and built using a cyan-blue narrow bandpass (460 to 490 nm) excitation filter and a yellow-orange longpass (blocking wavelengths under 520 nm) barrier filter mounted on a 3D-printed holding tray in a specific disposition to perfectly match the light source and the objective lens of the surgical microscope. It allowed switching from white light to fluorescence mode in a simple and sterile fashion. Its perfect attachment to the microscope was possible by reusing the lens fittings extracted from used original drape sets that would otherwise be discarded. Four patients underwent aneurysm clipping using the FM at two institutions from April to September 2018. RESULTS: A bright green fluorescence against a dark background was observed after intravenous bolus of fluorescein. Blood vessels became obviously distinct from non-contrast-filled structures such as clipped aneurysms and the brain. Vascular anatomy could be appreciated without any distortion, including perforating arteries. CONCLUSIONS: Intraoperative fluorescence angiography was successfully performed with the use of this universal FM after intravenous injection of fluorescein sodium. This simple and low-cost device may be useful in resource-limited centers, where other sorts of intraoperative angiography are not available.

Cavernous Sinus Hemangioma: Surgical Aspects.

Resection of lesions in the cavernous sinus remains a challenge to neurosurgeons due to its complex anatomy. This video (Video 1) presents the most relevant landmarks of the cavernous sinus region, helping to understand the surgical anatomy. A 55-year-old female presented with diplopia, partial ptosis, and facial dysesthesia in the left ophthalmic territory. Magnetic resonance imaging revealed a lesion in the left cavernous sinus. Microsurgical resection was performed through an approach that included a fronto-orbital craniotomy, an extradural clinoidectomy, and intradural resection of the lesion through the anteromedial triangle. This maneuver expands the optic-carotid and carotid-oculomotor space, therefore the operative corridor.1,2 Both the carotid and optic nerves are untethering and can be gently and safely mobilized. The result of the histopathologic study was hemangioma. Despite the complex anatomy and surgical challenges, it is possible to treat lesions in the cavernous sinus region without causing major deficits, mainly in the nonmeningioma tumors. This is why it is important to choose a safe route to the sinus, such as the anteromedial or Parkinson triangle.3.

Implementing an epilepsy surgery center. Initial experience at a university hospital in Brazil.

OBJECTIVE: Epilepsy is a serious neurological condition, often without a full and effective treatment. In some cases, surgery is beneficial, despite being underused. Our aim herein is to describe the implementation of an epilepsy surgery center in a federal university hospital, sharing the initial experience gained, as well as describing the main challenges and first results. METHODS: Experience report of an epilepsy surgery center implementation. Retrospective review of 13 drug-resistant patients who underwent surgical treatment. RESULTS: Thirteen patients underwent surgical epilepsy treatment, five patients categorized as the International League Against Epilepsy class 1, two in class 2, three in class 3, zero in class 4, and two in class 5; with a 30.76% complication rate. CONCLUSION: Despite the challenges, it was possible to implement an epilepsy surgery center with favorable results and acceptable incidence of complications, which were not higher than the incidences found in more experienced centers.

Implementing an epilepsy surgery center. Initial experience at a university hospital in Brazil / Implementação de um centro de cirurgia de epilepsia. Experiência inicial em um hospital universitário no Brasil

ABSTRACT Epilepsy is a serious neurological condition, often without a full and effective treatment. In some cases, surgery is beneficial, despite being underused. Our aim herein is to describe the implementation of an epilepsy surgery center in a federal university hospital, sharing the initial experience gained, as well as describing the main challenges and first results. Methods: Experience report of an epilepsy surgery center implementation. Retrospective review of 13 drug-resistant patients who underwent surgical treatment. Results: Thirteen patients underwent surgical epilepsy treatment, five patients categorized as the International League Against Epilepsy class 1, two in class 2, three in class 3, zero in class 4, and two in class 5; with a 30.76% complication rate. Conclusion: Despite the challenges, it was possible to implement an epilepsy surgery center with favorable results and acceptable incidence of complications, which were not higher than the incidences found in more experienced centers.

RESUMO Epilepsia é um problema neurológico sério e para o qual não há um tratamento efetivo e definitivo. Apesar de o tratamento cirúrgico ser bastante benéfico em alguns casos, ainda é subutilizado. O objetivo deste trabalho é descrever a implementação de um Centro de Cirurgia de Epilepsia em um Hospital Universitário Federal, divulgar a experiência inicial obtida, os principais desafios, as dificuldades e os resultados iniciais. Método: Relato da experiência na implementação do Centro de Epilepsia. Análise retrospectiva de série de treze pacientes com epilepsia resistente a medicação e que foram submetidos a tratamento cirúrgico. Resultados: Treze pacientes submetidos a tratamento cirúrgico, 5 com a Liga Internacional Contra Epilepsia classe 1, 2 com classe 3, três com classe 3, zero com classe 4 e 2 com classe 5; com uma taxa de complicação de 30, 76%. Conclusão: Apesar das dificuldades, foi possível a implementação de um Centro de Cirurgia de Epilepsia com resultados favoráveis e taxas de complicação não superiores aos centros de países desenvolvidos.

Emerging Treatments for Neuropathic Pain.

Neuropathic pain is a series of well-known conditions caused by diseases or lesions to the somatosensory system. Due to the better understanding of the pathophysiology of neuropathic pain, previously unexplored therapies have been used with encouraging results. As such, Acetyl-L-carnitine (ALC), Alpha-lipoic-acid (ALA), cannabinoids, Clonidine, EMA401, Botulinum Toxin type A, and new voltage-gated sodium channel blockers, can be cited. Furthermore, new modalities in neuromodulation such as high-frequency spinal cord stimulation, burst stimulation, dorsal root ganglion stimulation, transcranial direct current stimulation, and many others have been showing exciting results. Besides, changing paradigms may occur with the advent of optogenetics and a better understanding of epigenetic regulation. This article reviews the published literature on the treatment of NP. Despite the interesting results, randomized controlled trials are demanded for the majority of the therapies previously mentioned.