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Visish M. Srinivasan, Caroline C. Hadley, Akash J. Patel, Bruce L. Ehni, Howard L. Weiner, Ganesh Rao, Frederick F. Lang Jr., Raymond E. Sawaya, and Daniel Yoshor

B aylor College of Medicine (BCM) was founded in 1900 in Dallas, Texas, as the University of Dallas Medical Department. The school became affiliated with Baylor University in 1903, changing its name to Baylor University College of Medicine (BUCM). In May 1943, the MD Anderson Foundation invited BUCM to be the first institution in the nascent Texas Medical Center (TMC), a 160-acre area in Houston envisioned to be the country’s largest conglomerate of medical institutions. This move afforded BUCM the opportunity to expand its affiliations to include multiple

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David H. Shin, Kristopher G. Hooten, Brian D. Sindelar, Brian M. Corliss, William R. Y. Carlton Jr., Christopher P. Carroll, Jeffrey M. Tomlin, and W. Christopher Fox

training at the University of Florida (UF), the University of Texas–San Antonio, and Baylor University, as well as the former agreement with the University of Washington. Currently, 3 active-duty neurosurgeons have graduated from UF and 1 has graduated from the University of Texas–San Antonio. Eight residents are currently in training between these 4 programs, with 1 resident at the University of Washington and 1 at Baylor. One qualified active-duty military applicant per year is taken by each program through the military match and the full-time out-service (FTOS

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Visish M. Srinivasan, Gouthami Chintalapani, Edward A. M. Duckworth, and Peter Kan

most neurointerventionalists are familiar and can be performed with ease in both awake and sedated patients with faster acquisition time. While these techniques were developed using a particular C-arm and associated software (Artis zee biplane, Siemens AG), the concept is generalizable to other platforms. Methods After obtaining appropriate consents, we reviewed our institutional endovascular database for patients who underwent advanced venography (3D-RV with or without MPR). All procedures were performed at Baylor St. Luke’s Medical Center in Houston, Texas

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Ian McCarthy, Michael O'Brien, Christopher Ames, Chessie Robinson, Thomas Errico, David W. Polly Jr., and Richard Hostin

-center retrospective study of consecutive ASD patients undergoing primary surgery with ICD-9 (International Classification of Diseases, Ninth Edition) principal diagnosis code 737.0–737.9 from January 2008 through June 2010 at Baylor Scoliosis Center in Plano, Texas. Patients younger than 18 years of age were excluded from the study. All patients underwent spinal fusion with a minimum of 3 levels fused. Our measure of costs was the total costs incurred by the hospital for the episode of surgical care, expressed in 2010 dollars and totaled across the index surgery and any

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Sheila L. Ryan, Anish Sen, Kristen Staggers, Thomas G. Luerssen, and Andrew Jea

Object

Quality improvement methods are being implemented in various areas of medicine. In an effort to reduce the complex (instrumented) spine infection rate in pediatric patients, a standardized protocol was developed and implemented at an institution with a high case volume of instrumented spine fusion procedures in the pediatric age group.

Methods

Members of the Texas Children's Hospital Spine Study Group developed the protocol incrementally by using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied to all children undergoing complex spine surgery starting August 21, 2012. Acute infections were defined as positive wound cultures within 12 weeks of surgery, defined in alignment with current hospital infection control criteria. Procedures and infections were measured before and after protocol implementation. This protocol received full review and approval of the Baylor College of Medicine institutional review board.

Results

Nine spine surgeons performed 267 procedures between August 21, 2012, and September 30, 2013. The minimum follow-up was 12 weeks. The annual institutional infection rate prior to the protocol (2007–2011) ranged from 3.4% to 8.9%, with an average of 5.8%. After introducing the protocol, the infection rate decreased to 2.2% (6 infections of 267 cases) (p = 0.0362; absolute risk reduction 3.6%; relative risk 0.41 [95% CI 0.18–0.94]). Overall compliance with data form completion was 63.7%. In 4 of the 6 cases of infection, noncompliance with completion of the data collection form was documented; moreover, 2 of the 4 spine surgeons whose patients experienced infections had the lowest compliance rates in the study group.

Conclusions

The standardized protocol for complex spine surgery significantly reduced surgical site infection at the authors' institution. The overall compliance with entry into the protocol was good. Identification of factors associated with post–spine surgery wound infection will allow further protocol refinement in the future.

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Guillermo Aldave, Daniel Hansen, Valentina Briceño, Thomas G. Luerssen, and Andrew Jea

OBJECTIVE

The authors previously demonstrated the use of a validated Objective Structured Assessment of Technical Skills (OSATS) tool for evaluating residents' operative skills in pediatric neurosurgery. However, no benchmarks have been established for specific pediatric procedures despite an increased need for meaningful assessments that can either allow for early intervention for underperforming trainees or allow for proficient residents to progress to conducting operations independently with more passive supervision. This validated methodology and tool for assessment of operative skills for common pediatric neurosurgical procedures—external ventricular drain (EVD) placement and shunt surgery— was applied to establish its procedure-based feasibility and reliability, and to document the effect of repetition on achieving surgical skill proficiency in pediatric EVD placement and shunt surgery.

METHODS

A procedure-based technical skills assessment for EVD placements and shunt surgeries in pediatric neurosurgery was established through the use of task analysis. The authors enrolled all residents from 3 training programs (Baylor College of Medicine, Houston Methodist Hospital, and University of Texas–Medical Branch) who rotated through pediatric neurosurgery at Texas Children's Hospital over a 26-month period. For each EVD placement or shunt procedure performed with a resident, the faculty and resident (for self-assessment) completed an evaluation form (OSATS) based on a 5-point Likert scale with 7 categories. Data forms were then grouped according to faculty versus resident (self) assessment, length of pediatric neurosurgery rotation, postgraduate year level, and date of evaluation (“beginning of rotation,” within 1 month of start date; “end of rotation,” within 1 month of completion date; or “middle of rotation”). Descriptive statistical analyses were performed with the commercially available SPSS statistical software package. A p value < 0.05 was considered statistically significant.

RESULTS

Five attending evaluators (including 2 fellows who acted as attending surgeons) completed 260 evaluations. Twenty house staff completed 269 evaluations for self-assessment. Evaluations were completed in 562 EVD and shunt procedures before the surgeons left the operating room. There were statistically significant differences (p < 0.05) between overall attending (mean 4.3) and junior resident (self; mean 3.6) assessments, and between overall attending (mean 4.8) and senior resident (self; mean 4.6) assessment scores on general performance and technical skills. The learning curves produced for the residents demonstrate a stereotypical U- or V-shaped curve for acquiring skills, with a significant improvement in overall scores at the end of the rotation compared with the beginning. The improvement for junior residents (Δ score = 0.5; p = 0.002) was larger than for senior residents (Δ score = 0.2; p = 0.018).

CONCLUSIONS

The OSATS is an effective assessment tool as part of a comprehensive evaluation of neurosurgery residents' performance for specific pediatric procedures. The authors observed a U-shaped learning curve, contradicting the idea that developing one's surgical technique and learning a procedure represents a monotonic, cumulative process of repetitions and improvement.

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David L. Kelly

Sadly, we lost a truly esteemed member of our neurological surgery profession when Dr. Byron Cone Pevehouse died April 16, 2010. His contributions to the speciality have been numerous, important, and long lasting. Byron Cone Pevehouse ( Fig. 1 ) was born in Lubbock, Texas, on April 5, 1927. He attended Baylor University, but his education was interrupted by service for 22 months in the Naval Hospital Corps in the Pacific. He received his B.A. and M.D. degrees at Baylor, finishing in 1952. Following an internship at the University of Colorado, he entered the

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described approximately 20 years ago by Nicholls and Baylor 1 in studies of the central nervous system of the leech. References 1. Nicholls JG , Baylor DA : Specific modalities and receptor fields of sensory neurons in CNS of the leech. J Neurophysiol 31 : 740 – 756 , 1968 Nicholls JG, Baylor DA: Specific modalities and receptor fields of sensory neurons in CNS of the leech. J Neurophysiol 31: 740–756, 1968 2. Smith FP : Pathological studies of spinal nerve ganglia in relation to intractable intercostal

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Neurosurgical Forum: Letters to the editor To The Editor Shankar P. Gopinath , M.D. Baylor College of Medicine Houston, Texas 596 597 In an interesting article, Matsuoka, et al. , give an excellent description of selective disorganization of sleep and associated pathological laughter due to compression of the pons by clival chordoma (Matsuoka S, Yokota A, Yasukouchi H, et al: Clival chordoma associated with pathological laughter. Case report. J Neurosurg 79: 428–433, September, 1993). Their description is fully

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Neurosurgical Forum: Letters to the Editor To The Editor Mary K. Gummerlock , M.D. University of Missouri Columbia, Missouri Howard H. Kaufman , M.D. West Virginia University Morgantown, West Virginia Raj K. Narayan , M.D. Baylor College of Medicine Houston, Texas 310 310 The Neurological Devices Panel of the Food and Drug Administration (FDA), which includes the three undersigned neurosurgeons, met in Rockville, Maryland, on February 2, 1990. One of the issues