Surgical Outcome Measures Research Articles

NCOG-17. THE COMBAT PROJECT - CORE POST OPERATIVE MORBIDITY SET FOR PAEDIATRIC BRAIN TUMOURS

Abstract BACKGROUND Brain tumours are associated with high morbidity both from the tumour and the medical and surgical interventions used to treat them. Post operative morbidity reporting following surgery for paediatric brain tumours is poor due to the lack of a common language when reporting harms. One solution is to develop a core outcome set to stipulate the minimum post operative adverse outcomes that should be reported. The COMBAT (Core Post Operative Morbidity Set for Paediatric Brain Tumours) Project will develop a core outcome set that can be applied to post operative paediatric brain tumour patients to harmonise how adverse outcomes are measured and reported, enabling comparison between different trials, studies and clinical services. We aim to generate interest in The COMBAT Project and invite participation in the project from healthcare professionals and researchers experienced in paediatric neuro-oncology for the consensus process. METHODS AND ANALYSIS We will engage with national and international stakeholders including patients and their carers, healthcare professionals and researchers. A systematic review will identify harms reported in post operative paediatric brain tumour patients and how they are measured. Qualitative interviews with patients and carers will identify any harms of importance to them. A Delphi survey will be created from the harms identified. A consensus meeting will be held to finalise the core outcome set. The final core outcome set will be published and disseminated to encourage uptake. DISCUSSION There is a clear need for a common language to harmonise measurement and reporting of harms following surgery for paediatric brain tumour patients. This project will define post operative adverse outcomes that are of critical importance to key stakeholders. It will be used to standardise surgical morbidity outcome measurement and reporting in trials, studies and clinical practice and will inform future research in this field.

Higher rates of recurrence and worse quality of life in obese patients undergoing inguinal hernia repair.

Prior investigations regarding the effect of obesity on inguinal hernia repair have been mixed. The aim of our study was to retrospectively compare perioperative outcomes, recurrence rate, and quality of life between obese and non-obese patients undergoing inguinal hernia repair. Patients who underwent inguinal hernia repair by any approach at a single institution were identified from a prospectively maintained quality database. Patients with a body mass index (BMI) greater than or equal to 30kg/m2 were considered obese. Quality of life was measured with the Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale (CSS) surveys. Differences between obese and non-obese patients were assessed using independent samples t-tests, Wilcoxon rank-sum, and chi-square tests. Between 2010 and 2021, a total of 5575 patients underwent inguinal hernia repair. Fifteen percent of patients were identified as obese (835 patients, mean BMI 33.2 ± 3.3kg/m2). A significantly higher percentage of obese patients were diabetic, and operative time and estimated blood loss were higher in the obese group (all p < 0.001). Rates of hernia recurrence in obese patients was significantly more likely than in non-obese patients (4.2% vs 2.0%, p < 0.001). Up to 2 years postoperatively, a greater percentage of obese patients reported worse quality of life on the SOMS and more bothersome symptoms on the CCS. Inguinal hernia repair in obese patients is a more technically challenging operation. Long-term follow-up revealed a greater risk of hernia recurrence and worse quality of life up to 2 years postoperatively in this patient population.

Transvaginal uterine niche repair: surgical technique and outcome.

A uterine niche after caesarean section may play a role in secondary infertility. The transvaginal approach is a newly developed minimally invasive surgical technique for repairing a uterine isthmocele. To report on the feasibility, effectiveness, and safety of the transvaginal uterine niche repair. The technique is demonstrated in a live-surgery video. A retrospective chart review involving all patients with secondary infertility who underwent a transvaginal uterine niche repair in Ziekenhuis Oost-Limburg between August 2019 and July 2022 was conducted. We compared the pre- and postoperative residual myometrial thickness as a primary surgical outcome measurement. The pregnancy ratio and the peri- and postoperative complications were also reported. A total of 26 patients underwent a transvaginal uterine niche repair with an average operation time of 44 minutes. No major surgical complications were reported. 23 patients (88%) had good postoperative myometrial integrity, while 3 patients had a partial or complete postoperative recurrence of the uterine niche. The average pre- and postoperative myometrial thicknesses were 1.6 mm and 6.4 mm respectively. 64% of patients desiring pregnancy became pregnant after the transvaginal niche repair. There were no obstetric complications reported. A transvaginal approach is a safe and effective technique for uterine niche repair. It offers good results in re-establishing myometrial integrity and may favour fertility outcomes. It represents a valid minimal invasive procedure for patients with a very thin residual myometrial thickness and secondary infertility without leaving a visual scar.

Exploring Health Inequalities and Presurgical Attitudes on Postsurgical Outcomes in Spine Surgery

The influence of social determinants of health on health disparities is substantial. However, their impact on postsurgical outcomes in spine can be challenging to ascertain at the community level. This study aims to explore the interplay between presurgical attitudes, area deprivation index (ADI), income, employment status, and body mass index (BMI) on postsurgical outcomes at 3, 6, 9, and 12 months after elective spine surgery. The study involved 127 patients who underwent elective spine surgery between August 2021 and August 2022 at a large academic institution. The main objective involved a prospective analysis of presurgical attitudes, coupled with a retrospective assessment of ADI, income, employment status, and BMI over 3, 6, 9, and 12 months following elective spine surgery using a univariate analysis. Utilizing the univariate analyses, ADI displayed a significant correlation with increased Patient-Reported Outcomes Measurement Information System and Visual Analog Scale scores both before surgery and at the 3-, 6-, and 9-month postsurgical intervals (P < 0.05). One year after surgery, patients in the lowest income group (annual income under $25,000) consistently demonstrated the highest Patient-Reported Outcomes Measurement Information System pain (8.00, P= 0.022). Patients who were not employed had significantly lower levels of social support (P= 0.042) and confidence in the health care system (P= 0.009). Individuals who were unemployed were most likely to be readmitted six weeks after surgery (P < 0.001). Presurgical attitudes, ADI, income, employment status, and BMI were important factors associated with improved surgical outcome measurements, indicating potential focal points for combating health disparities in spinal surgery patients.

Surgical Handover Core Outcome Measures (SH-CORE): a protocol for the development of a core outcome set for trials in surgical handover

BackgroundSurgical handover is associated with a significant risk of care failures. Existing research displays methodological deficiencies and little consensus on the outcomes that should be used to evaluate interventions in this area. This paper reports a protocol to develop a core outcome set (COS) to support standardisation, comparability, and evidence synthesis in future studies of surgical handover between doctors.MethodsThis study adheres to the Core Outcome Measures in Effectiveness Trials (COMET) initiative guidance for COS development, including the COS-Standards for Development (COS-STAD) and Reporting (COS-STAR) recommendations. It has been registered prospectively on the COMET database and will be led by an international steering group that includes surgical healthcare professionals, researchers, and patient and public partners. An initial list of reported outcomes was generated through a systematic review of interventions to improve surgical handover (PROSPERO: CRD42022363198). Findings of a qualitative evidence synthesis of patient and public perspectives on handover will augment this list, followed by a real-time Delphi survey involving all stakeholder groups. Each Delphi participant will then be invited to take part in at least one online consensus meeting to finalise the COS.Ethics and disseminationThis study was approved by the Royal College of Surgeons in Ireland (RCSI) Research Ethics Committee (202309015, 7th November 2023). Results will be presented at surgical scientific meetings and submitted to a peer-reviewed journal. A plain English summary will be disseminated through national websites and social media. The authors aim to integrate the COS into the handover curriculum of the Irish national surgical training body and ensure it is shared internationally with other postgraduate surgical training programmes. Collaborators will be encouraged to share the findings with relevant national health service functions and national bodies.DiscussionThis study will represent the first published COS for interventions to improve surgical handover, the first use of a real-time Delphi survey in a surgical context, and will support the generation of better-quality evidence to inform best practice.Trial registrationCore Outcome Measures in Effectiveness Trials (COMET) initiative 2675. http://www.comet-initiative.org/Studies/Details/2675.

Capturing longer term surgical outcome measures as part of routine care of breast cancer patients

IntroductionThe transition away from routine clinical follow up after breast cancer towards imaging surveillance and patient-initiated contact limits opportunities for patients and doctors to communicate about the long-term effects of treatment. The ABS oncoplastic guidelines (2021) recommend that post-operative 2D images and patient-reported outcomes (PROMs) are routinely collected but give no guidance as to how best to implement this. MethodsFrom December 2019 until March 2024, women due for their year 3 or 5 surveillance mammogram at The Royal Marsden Sutton site were invited to complete a BREAST-Q questionnaire and attend medical photography. Panel assessment of photographs was undertaken. Results were presented to the oncoplastic MDT, including summary PROMs and illustrative case presentations. Free-text comments were shared with the relevant teams. Associations between demographic or clinic-pathological factors and uptake were investigated. ResultsOf the 1211 women invited, 246 patients (20.3 %) completed BREAST-Q questionnaires, 182 (15.0 %) attended for medical photography and 114 (9.4 %) completed both. Uptake was not associated with age, ethnicity or surgical factors but patients with higher BMI were less likely to respond to the questionnaire. Patients who had undergone complex oncoplastic procedures were more likely to respond than those who had simple procedures. Patient-reported outcome results were in line with the published literature. ConclusionReviewing images with their paired PROMs and discussing free-text feedback was instructive for the team. Work is needed to identify barriers to patient participation and improve uptake to be representative of the overall patient population. Quantifying appearance in photographs would help summarise aesthetic outcome data.

Capturing longer term surgical outcome measures as part of routine care of breast cancer patients

Capturing longer term surgical outcome measures as part of routine care of breast cancer patients

The impact of intranasal corticosteroids in a prospective cohort of children with sleep disordered breathing

IntroductionSleep disordered breathing (SDB) is common in children and the most common reason for adenotonsillectomy. This large observational cohort study from a specialist outpatient clinic describes the impact of intranasal steroids (INS) on symptom improvement and the need for surgery. MethodObservational cohort study of 568 children assessing the impact of INS using the OSA-5 questionnaire with clinical and surgical outcome measures. ResultsThe mean OSA-5 score at first visit was 7.78. Symptoms were persistent for a median 9 months (range 2–72). 51% underwent a trial of INS with 56% reporting symptomatic improvement. The mean score decreased from 8.2 to 5.5 (p < 0.0001) in those prescribed INS. They had a significantly higher symptom load (p < 0.01), turbinate size (p < 0.005) and history of atopy (p < 0.01) than the non-trial group. The rate of surgery in the non-trial group was 56% compared with 38% in those who had INS (p < 0.001). With increasing symptom burden, the reported improvement with INS and comparative reduction in surgery increased. Baseline OSA-5 scores were predictive of rates of surgery. Atopic status or age did not influence response to INS. ConclusionThe mean score at first visit and the median duration of symptoms indicated significant persistent symptoms in this cohort. The use of INS improved symptoms of SDB in 56%. The need for surgery in the group that received INS was 38% compared with 56% in those not trialling INS, despite the non-trial group having significantly less symptoms and signs. Symptomatic improvement was not influenced by age or atopic status.

Efficacy and safety of management of placenta accreta spectrum by transverse uterine fundal incision in a single tertiary care centre: A retrospective study.

Background We assessed the efficacy and safety of management of morbidly adherent placenta by the transfundal uterine incision approach. As a secondary outcome measure, we compared ultrasound and magnetic resonance imaging (MRI) for the diagnosis of adherent placenta. Methods We retrospectively analysed the records of 5 years of women with adherent placenta. Twenty-five women with an antenatal diagnosis of placenta increta and percreta operated by transfundal uterine incision were included. Blood loss, transfusion requirements, operative injuries, and maternal and neonatal intensive care unit (ICU) stay were compared among three different types of adherent placenta. Surgical and other outcome measures were also analysed. Results On antenatal screening with ultrasound, an accurate diagnosis could be achieved in all cases of increta and two-thirds of percreta. Antenatal diagnosis by MRI detected 93.3% of increta and all percreta cases. The mean (SD) gestation at delivery was 34 (4.9) weeks in accreta, 34.9 (2.7) weeks in increta and 31 (4.8) weeks in percreta patients. The mean blood loss encountered intraoperatively was 1012.5 (193.1) ml, 1566.67 (566.52) ml and 1591.67 (629.61) ml in accreta, increta and percreta patients, respectively. Inadvertent bladder injury occurred in 3 women who had placenta percreta invading the bladder. There was no long-term morbidity and no mortality. Conclusion Transfundal incision for delivery of baby is associated with the advantage of avoiding the placenta thereby minimizing blood loss.

Surgical Sabermetrics: A Scoping Review of Technology-enhanced Assessment of Nontechnical Skills in the Operating Room.

To evaluate the current evidence for surgical sabermetrics: digital methods of assessing surgical nontechnical skills and investigate the implications for enhancing surgical performance. Surgeons need high-quality, objective, and timely feedback to optimize performance and patient safety. Digital tools to assess nontechnical skills have the potential to reduce human bias and aid scalability. However, we do not fully understand which of the myriad of digital metrics of performance assessment have efficacy for surgeons. A systematic review was conducted by searching PubMed, EMBASE, CINAHL, and PSYCINFO databases following PRISMA-ScR guidelines. MeSH terms and keywords included "Assessment," "Surgeons," and "Technology". Eligible studies included a digital assessment of nontechnical skills for surgeons, residents, and/or medical students within an operative context. From 19,229 articles screened, 81 articles met the inclusion criteria. The studies varied in surgical specialties, settings, and outcome measurements. A total of 122 distinct objective, digital metrics were utilized. Studies digitally measured at least 1 category of surgical nontechnical skill using a single (n=54) or multiple objective measures (n=27). The majority of studies utilized simulation (n=48) over live operative settings (n=32). Surgical Sabermetrics has been demonstrated to be beneficial in measuring cognitive load (n=57), situation awareness (n=24), communication (n=3), teamwork (n=13), and leadership (n=2). No studies measured intraoperative decision-making. The literature detailing the intersection between surgical data science and operative nontechnical skills is diverse and growing rapidly. Surgical Sabermetrics may provide a promising modifiable technique to achieve desirable outcomes for both the surgeon and the patient. This study identifies a diverse array of measurements possible with sensor devices and highlights research gaps, including the need for objective assessment of decision-making. Future studies may advance the integration of physiological sensors to provide a holistic assessment of surgical performance.

Timing of Outcomes and Expectations After Knee Surgery in the US Military: A Systematic Review.

Knee injury and subsequent surgery are widespread in the military setting. Associations between knee surgery and expected outcomes over time have not been consolidated and characterized systematically by procedure type across the body of literature, and the temporal expectations of these outcomes remain unclear. To summarize common postoperative follow-up times and associated outcomes that determine clinical or surgical failure in US service members after elective knee surgery. A systematic search was conducted with 3 bibliographic databases of published research reports from 2010 through 2021. Studies in US military service members undergoing elective knee surgery, with a minimum of 1-year follow-up, and reporting on a functional/occupational outcome were included. Three reviewers screened all abstracts and full-text articles to determine eligibility. Systematic review of longitudinal cohort studies. Level 2a. Extracted data included military demographics, surgical procedure variables, surveillance period, and outcome measures. The Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development, and Evaluation approach were used to determine study quality and risk of bias. A total of 22 studies (mean follow-up time of 40.7 months) met the inclusion criteria. For cruciate ligament repair, approximately one-third of patients required a second surgery or were medically separated from military service by 2 years from surgery; 100% were reinjured by 4 years, and 85% sustained a new injury within 5 years of surgery. For meniscal repair, nearly one-third of patients were medically separated, and half were placed on activity restrictions within 3 years of surgery. For articular cartilage repair, within 5 years, 39% of patients required a second surgery, 30% were placed on activity restrictions, and 36% were medically separated. For patellar repair, 37% of patients were medically separated and over half were placed on activity restrictions within 5 years. Common knee surgeries can have long-term implications for military careers that may not become apparent with shorter follow-up periods (<2 years). When longer surveillance periods are used (eg, up to 5 years), additional surgical procedures are more common and the likelihood of being injured or medically separated from military service is higher.

Expanding the Role of the Surgical Preoperative Evaluation Clinic: Impact on Risk and Quality Outcome Measures

ObjectiveTo prove that inpatient-adjusted surgical risk and quality outcome measures can be considerably impacted by interventions to improve documentation in the preoperative evaluation (POE) clinic. Patients and MethodsWe designed a quality improvement project with a multidisciplinary team in our POE clinic to more accurately reflect surgical risk and impact expected surgical quality outcomes through improved documentation. Interventions included an improved patient record acquisition process and extensive POE provider education regarding patient comorbidities’ documentation. For patients admitted after their planned operations, POE clinic comprehensive evaluation notes were linked to inpatient History and Physical notes. High complexity patients seen from October 1, 2018 to December 31, 2018 were the preintervention cohort, and the patients seen from January 1, 2019 to December 31, 2019 were the postintervention cohort. ResultsThe primary outcome measures included the total number of coded diagnoses per encounter and the number of coded hierarchical condition categories per encounter. The secondary outcomes included the calculated severity of illness, risk of mortality, case-mix index, and risk-adjustment factor. Postintervention results show statistically significant increases in all primary outcomes with a P<.05. All secondary outcome measures reported positive change. ConclusionOur interventions confirm that a comprehensive POE and thorough documentation provide a more accurate clinical depiction of the preoperative patient, which in turn impacts quality outcomes in inpatient surgical settings. These results are impactful for direct and indirect patient care and publicly reported hospital and provider level performance data.

Factors Associated with Treatment Outcome Satisfaction Six Months after Upper Blepharoplasty: A Large Cohort Study.

Upper blepharoplasty is the most popular facial cosmetic surgery. Although there are a variety of reasons to undergo this procedure, all patients expect an optimal cosmetic result. However, little is known about the factors that influence satisfaction with treatment outcome. We assessed to what extent patient characteristics, clinician-rated and postsurgical outcome measures, and patient-reported satisfaction with facial appearance and quality-of-life are associated with patient-reported satisfaction with treatment outcome after a primary upper blepharoplasty. This study was performed in 583 patients with an upper blepharoplasty between 2016 and 2021. The primary outcome was satisfaction with treatment outcome 6 months postoperatively using the FACE-Q. Determinants were baseline patient characteristics (demographics), preoperative and postoperative clinician-rated and surgical outcome measures, and preoperative and postoperative FACE-Q appearance and quality-of-life scales. Hierarchical linear regression analysis was used to determine how much of the variance in satisfaction with outcome could be explained by these groups of determinants. A total of 63% of the variance could be explained by the five groups of determinants of which 8% was explained by the baseline patient characteristics and clinician-rated and patient-reported outcomes together, another 8% by the postoperative clinician-rated outcomes, and the remaining 47% by the postoperative patient-reported outcomes. Patient characteristics, clinician-rated outcome measures, and baseline FACE-Q appearance and quality-of-life scores were of limited value in explaining satisfaction with treatment outcome. However, the postoperative FACE-Q appearance scale and the decision to undergo a blepharoplasty were strongly associated with satisfaction with treatment outcome.

Arthroscopic Treatment of Shoulder Stiffness With Rotator Cuff Repair Yields Similar Outcomes to Isolated Rotator Cuff Repair

To compare patient-reported and surgical outcome measures in patients with and without secondary shoulder stiffness (SSS) undergoing rotator cuff repair (RCR). Patients undergoing rotator cuff repair from 2014 to 2020 with complete patient-reported outcome measures (PROMs) by the short-form 12 survey (SF-12) were retrospectively reviewed to identify if operative intervention for SSS was performed alongside the RCR. Those patients with operative intervention for SSS were propensity matched to a group without prior intervention for stiffness by age, sex, laterality, body mass index, diabetes mellitus status, and the presence of a thyroid disorder. The groups were compared by rotator cuff tear (RCT) size, surgical outcomes, further surgical intervention, rotator cuff retear rate, postoperative range of motion (ROM), and SF-12 results at 1 year after surgery. Delta values were calculated for component scores of the SF-12 and ROM values by subtracting the preoperative result from the postoperative result. A total of 89 patients with SSS were compared to 156 patients in the control group at final analysis. The patients in the SSS group experienced a significant improvement in the delta mental health component score (MCS-12) of the SF-12 survey that was not seen in the control group (P= .005 to P= .539). Both groups experienced significant improvement by the delta physical health component score (PCS-12) of the SF-12 survey (SSS: 7.68; P < .001; control: 6.95; P < .001). The SSS group also experienced greater improvement of their forward flexion (25.8° vs 12.9°; P= .005) and external rotation (7.13° vs 1.65°; P= .031) ROM than the control group. Operative intervention of SSS at the time of RCR has equivalent postoperative SF-12 survey outcome scores when compared to patients undergoing RCR without preoperative stiffness despite those patients having lower preoperative scores. Level III retrospective comparative study.

Tibial Bone Transport with a Single Implant All-Internal Bone Transport Nail.

A single implant all-internal magnet-driven bone transport (BT) intramedullary nail (BTN - NuVasive Specialized Orthopaedics, Inc.) has recently been introduced as a treatment method for segmental tibial bone defects. This innovation provides promise in the management of segmental bone defects as it negates numerous complications associated with circular external fixation and the need for multiple implants when considering hybrid plate assisted bone segment transport (PABST) constructs. Given the novelty of the BTN, description of the surgical application and patient outcome measures are scarce in the current literature. To date, we have treated four patients with an average age of 27 years (range: 19-44 years) using the BTN for segmental tibial defects ranging from 50-128 mm. We have accumulated data over an average follow up of 18.07 months (range: 12.96-25.13 months) demonstrating good patient tolerance of the device. Three patients successfully completed their treatment course with a calculated average bone healing index of 41.4 days/cm (range: 31.41-54.82 days/cm). One patient was noted to experience an asymptomatic docking site nonunion requiring subsequent surgery for nonunion repair. Implant-associated complications included symptomatic implant, axial malalignment, docking site nonunion, and External Remote Control technical malfunction. Injury-related complications were encountered and noted to include: superficial infection, wound dehiscence, peroneal tendonitis, and joint rigidity. In this study, the authors present a case series utilizing this implant to date and discuss our experiences with the BTN with reference to clinical indications, tibial bone preparation, BTN implantation, transport protocol, docking site procedure, and clinical/radiographic outcomes.

Virtual Surgical Planning for Patients with Skeletal-Dental and Obstructive Sleep Apnea Syndrome.

The integration of virtual surgical planning (VSP) for the treatment of skeletal, dental, and facial abnormalities and obstructive sleep apnea (OSA) with maxillofacial surgery has catapulted surgical planning. Although reported for treating skeletal dental abnormalities and dental implant surgery, a paucity of knowledge existed reporting the feasibility and resultant outcome measures when virtual surgical planning was employed for planning maxillary and mandibular surgery for OSA patients. The surgery first approach is at the forefront of advancing maxillofacial surgery. Case series reporting success with the surgery first approach for patients with skeletal-dental and sleep apnea patients have been reported. In sleep apnea patients, clinically significant reductions in AHI (apnea hypopnea index) and improvement of low oxyhemoglobin saturation have been achieved. More so, significant improvement in the posterior airway space at the occlusal and mandibular planes were achieved, while preserving aesthetic norms as measured by tooth to lip measurements. VSP is a feasible tool used for predicting surgical outcome measures in maxillomandibular advancement surgery for patients with skeletal, dental, facial and OSA derangements.

Capturing longer term surgical outcome measures as part of routine care of breast cancer patients

Capturing longer term surgical outcome measures as part of routine care of breast cancer patients

Applications of machine learning for nursing monitoring of electroencephalography

The nursing monitoring of electroencephalography (EEG) during neurosurgery includes verifying the proper placement of electrodes on the patient's scalp and ensuring the accurate display of EEG readings on the monitoring apparatus. This study aims to examine the use of machine learning (ML) in EEG monitoring by analyzing the R programming language. The results will provide insights into surgical nursing care by evaluating EEG patterns. The preceding evidence was collected following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines in the present study. The logical analysis of the data was conducted using the R programming language. ML algorithms based on usage rate included logistic regression (LR), support vector machine (SVM), random forest (RF), artificial neural networks (ANN), and convolutional neural network (CNN). Also, the use of ML in nursing monitoring of EEG is categorized into three indications rehabilitation measurement (post-operation), delayed cerebral ischemia (DCI) detection (pre-operation), hypotension identification (intra-operation), surgical outcomes measurement(post-operation), and seizure prediction. In sum, the algorithm, including LR and SVM, have been frequently utilized in the realm of EEG evaluation, as indicated by the results obtained.

The Hawthorne Effect: Quality and Outcomes in Neurosurgery.

Measure something, and it gets better-this is what is called as the Hawthorne effect (also known as the observer effect). The Hawthorne factory experiments in 1920s were remarkable industrial data collection and analysis exercises that lead to Edwards Deming's quality revolution. The Harvard Medical Practice Study (1991), Leape's "Error in Medicine" (1994), and the Bristol pediatric cardiac report (2001) are among many documents that have revealed the huge gap between best practices and actual medical practice. Alarmed by the poor standards of quality at the most respected institutions, the medical fraternity therefore began visiting facilities in different fields and observing their quality assessment processes. The next leap for neurosurgery is to realize that it is unacceptable to treat patients with no regard for the standard of clinical outcomes. The traditional neurosurgery residency training has long ignored the most important issues of self-assessment, reappraisal, relearning, and measurement of skill and surgical outcomes. However, the experience taken from disparate fields, especially cardiac surgery, may encourage research and progress in measurement and improvement of quality in neurosurgery. Like cardiac surgeons, neurosurgeons must examine and analyze the results of their interventions. The concept of quality measurement is the most important single advance we can make in neurosurgery practice. Meticulous and precise measurement of outcomes will allow future progress of our specialty.

Using Digital Biomarkers for Objective Assessment of Perfusionists' Workload and Acute Stress During Cardiac Surgery.

The cardiac operating room (OR) is a high-risk, high-stakes environment inserted into a complex socio-technical healthcare system. During cardiopulmonary bypass (CPB), the most critical phase of cardiac surgery, the perfusionist has a crucial role within the interprofessional OR team, being responsible for optimizing patient perfusion while coordinating other tasks with the surgeon, anesthesiologist, and nurses. The aim of this study was to investigate objective digital biomarkers of perfusionists' workload and stress derived from heart rate variability (HRV) metrics captured via a wearable physiological sensor in a real cardiac OR. We explored the relationships between several HRV parameters and validated self-report measures of surgical task workload (SURG-TLX) and acute stress (STAI-SF), as well as surgical processes and outcome measures. We found that the frequency-domain HRV parameter HF relative power - FFT (%) presented the strongest association with task workload (correlation coefficient: -0.491, p-value: 0.003). We also found that the time-domain HRV parameter RMSSD (ms) presented the strongest correlation with perfusionists' acute stress (correlation coefficient: -0.489, p-value: 0.005). A few workload and stress biomarkers were also associated with bypass time and patient length of stay in the hospital. The findings from this study will inform future research regarding which HRV-based biomarkers are best suited for the development of cognitive support systems capable of monitoring surgical workload and stress in real time.