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Ambuj Kumar, Amandeep Kumar, Pankaj Kumar Singh, Shashwat Mishra, Kanwaljeet Garg, and Bhawani S. Sharma

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Sanjeev Ariyandath Sreenivasan, Kanwaljeet Garg, Shashwat Mishra, Pankaj Kumar Singh, Manmohan Singh, and Poodipedi Sarat Chandra

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Amol Raheja, Shashwat Mishra, Kanwaljeet Garg, Varidh Katiyar, Ravi Sharma, Vivek Tandon, Revanth Goda, Ashish Suri, and Shashank S. Kale

OBJECTIVE

Extracorporeal telescopes (exoscopes) have been the latest addition to the neurosurgeons’ armamentarium, acting as a bridge between operating microscopes and endoscopes. However, to the authors’ knowledge there are no published preclinical laboratory studies of the accuracy, efficiency, and dexterity of neurosurgical training for the use of 2D or 3D exoscopes compared with microscopes.

METHODS

In a controlled experimental setup, 22 participating neurosurgery residents performed simple (2D) and complex (3D) motor tasks with three visualization tools in alternating sequence: a 2D exoscope, 3D exoscope, and microscope, using a block randomization model based on the neurosurgeons’ prior training experience (novice, intermediate, and senior: n = 6, 12, and 4, respectively). Performance scores (PS; including error and efficiency scores) and dexterity scores (DS) were calculated to objectify the accuracy, efficiency, and finesse of task performance. Repeated measures ANOVA analysis was used to compare the PS, DS, and cumulative scores (CS) of candidates using the three visualization aids. Bland-Altman plots and intraclass correlation coefficients were generated to quantify intraobserver and interobserver agreement for DS. Subgroup analysis was performed to assess the impact of participants’ prior training. A postexercise survey was conducted to assess the comfort level (on a 10-point analog scale) of the participants while using each visualization tool for performing the suturing task.

RESULTS

PS, DS, and CS were significantly impacted by the visualization tool utilized for 2D motor tasks (p < 0.001 for each), with the microscope faring better than the 2D exoscope (p = 0.04) or 3D exoscope (p = 0.008). The PS for the 3D object transfer task was significantly influenced by the visualization aid used (p = 0.007), with the microscope and 3D exoscope faring better than the 2D exoscope (p = 0.04 for both). The visualization instrument used significantly affected the DS and CS for the suturing task (p < 0.001 for both), with the microscope again scoring better than the 2D exoscope (p < 0.001) or 3D exoscope (p = 0.005). The impact of the visualization aid was more apparent in participants with a shorter duration of residency (novice, p = 0.03; intermediate, p = 0.0004). Participants also felt the greatest operational comfort while working with a microscope, 3D exoscope, and 2D exoscope, in that order (p < 0.0001).

CONCLUSIONS

Compared with 3D and 2D exoscopes, an operating microscope provides better dexterity and performance and a greater operational comfort level for neurosurgeons while they are performing 2D or 3D motor tasks. For performing complex 3D motor tasks, 3D exoscopes offer selective advantages in dexterity, performance, and operational comfort level over 2D exoscopes. The relative impact of visualization aids on surgical proficiency gradually weakens as the participants’ residency duration increases.

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Harsh Deora, Kanwaljeet Garg, Manjul Tripathi, Shashwat Mishra, and Bipin Chaurasia

OBJECTIVE

The evolution of the neurosurgical specialty in lower-middle-income countries is uniformly a narrative of continuous struggle for recognition and resource allocation. Therefore, it is not surprising that neurosurgical education and residency training in these countries is relatively nascent. Dr. Harvey Cushing in 1901 declared that he would specialize in neurosurgery and gave his greatest contribution to the advancement of neurosurgical education by laying the foundations of a structured residency training program. Similar efforts in lower-middle-income countries have been impeded by economic instability and the lack of well-established medical education paradigms. The authors sought to evaluate the residency programs in these nations by conducting a survey among the biggest stakeholders in these educational programs: the neurosurgical residents.

METHODS

A questionnaire addressing various aspects of the residency program from a resident’s perspective was prepared with Google Forms and circulated among neurosurgery residents through social media and email groups. Where applicable, a 5-point Likert scale was used to grade the responses to the questions. Responses were collected from May to October 2019 and analyzed using descriptive statistics. Complete anonymity of the respondents was ensured to keep the responses unbiased.

RESULTS

A total of 195 responses were received, with 189 of them from lower-middle-income countries (LMICs). The majority of these were from India (75%), followed by Brazil and Pakistan. An abiding concern among residents was lack of work hour regulations, inadequate exposure to emerging subspecialties, and the need for better hands-on training (> 60% each). Of the training institutions represented, 89% were offering more than 500 major neurosurgical surgeries per year, and 40% of the respondents never got exposure to any subspecialty. The popularity of electronic learning resources was discernible and most residents seemed to be satisfied with the existent system of evaluation. Significant differences (p < 0.05) among responses from India compared with those from other countries were found in terms of work hour regulations and subspecialty exposure.

CONCLUSIONS

It is prudent that concerned authorities in LMICs recognize and address the deficiencies perceived by neurosurgery residents in their training programs. A determined effort in this direction would be endorsed and assisted by a host of international neurosurgical societies when it is felt that domestic resources may not be adequate. Quality control and close scrutiny of training programs should ensure that the interests of neurosurgical trainees are best served.

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Renu Saini, Bhavya Pahwa, Deepak Agrawal, Pankaj Singh, Hitesh Gurjar, Shashwat Mishra, Aman Jagdevan, and Mahesh Chandra Misra

OBJECTIVE

The intramedullary route holds the potential to provide the most concentration of stem cells in cases of spinal cord injury (SCI). However, the safety and feasibility of this route need to be studied in human subjects. The aim of this study was to evaluate the safety and feasibility of intramedullary injected bone marrow–derived mesenchymal stem cells (BM-MSCs) in acute complete SCI.

METHODS

In this prospective study conducted over a 2-year period, 27 patients with acute (defined as within 1 week of injury) and complete SCI were randomized to receive BM-MSC or placebo through an intramedullary route intraoperatively at the time of spinal decompression and fusion. Institutional ethics approval was obtained, and informed consent was obtained from all patients. Safety was assessed using laboratory and clinicoradiological parameters preoperatively and 3 and 6 months after surgery.

RESULTS

A total of 180 patients were screened during the study period. Of these, 27 were enrolled in the study. Three patients withdrew, 3 patients were lost to follow-up, and 8 patients died, leaving a total of 13 patients for final analysis. Seven of these patients were in the stem cell group, and 6 were in the control group. Both groups were well matched in terms of sex, age, and weight. No adverse events related to stem cell injection were noted for laboratory and radiological parameters. Five patients in the control group and 3 patients in the stem cell group died during the follow-up period.

CONCLUSIONS

Intramedullary injection of BM-MSCs was found to be safe and feasible for use in patients with acute complete SCI.

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Raman A. Mahalangikar, Pankaj Kumar Singh, Shashwat Mishra, and Bhawani Shanker Sharma

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Narendra Kumar, Varidh Katiyar, Kokkula Praneeth, Ravi Sharma, Priya Narwal, Amol Raheja, Vivek Tandon, Shashwat Mishra, Kanwaljeet Garg, Ashish Suri, P. Sarat Chandra, and Shashank S. Kale

OBJECTIVE

The adoption of telemedicine became a necessity during the COVID-19 pandemic because patients found commuting to be difficult owing to travel restrictions. Initially, audio-based teleconsultations were provided. Later, on the basis of the feedback of patients and caregivers, the authors started to provide video-based teleconsultations via WhatsApp. The authors subsequently surveyed the patients and caregivers to determine their satisfaction levels with telemedicine services.

METHODS

An anonymized telephone survey of patients who had participated in teleconsultation was conducted with a structured questionnaire. The responses were analyzed and their correlations with the perceived benefits and limitations of audio and video teleconsultation were determined.

RESULTS

Three hundred respondents were included in the first round of surveys, of whom 250 (83.3%) consented to video teleconsultation. Among the respondents who participated in both audio and video teleconsultations (n = 250), paired analysis showed that video teleconsultation was perceived as better in terms of providing easier access to healthcare services (p < 0.001), saving time (p < 0.001), and satisfaction with the way patient needs were conveyed to healthcare providers (p = 0.023), as well as in terms of adequacy of addressing healthcare needs (p < 0.001) and consequently providing a higher rate of overall satisfaction (p < 0.001). For both audio and video teleconsultation, overall patient satisfaction was significantly related to only previous exposure to WhatsApp. However, for video consultation, longer call duration (p = 0.023) was an important independent factor. Video teleconsultation was preferable to face-to-face consultation irrespective of educational status, but higher education was associated with preference for video teleconsultation.

CONCLUSIONS

Both audio and video teleconsultation are viable cost-effective surrogates for in-person physical neurosurgical consultation. Although audio teleconsultation is more user-friendly and is not restricted by educational status, video teleconsultation trumps the former owing to a more efficient and satisfactory doctor-to-patient interface.