Citations

New coils have been designed to preserve the safety of coil embolization while improving on long-term efficacy. There is currently no scientific evidence that one type of coil material is better than another. The recurrence problem may be more pressing in certain types of patients, such as patients with large aneurysms or those already presenting with angiographic recurrences.

The proliferation of new endovascular devices and therapeutic strategies calls for a prudent and rational evaluation of their clinical benefit. This evaluation must be done in an effective manner and in collaboration with industry. Such research initiative requires organisational and methodological support to survive and thrive in a competitive environment. We propose the formation of an international consortium, an academic alliance committed to the pursuit of effective neurovascular therapies. Such a consortium would be dedicated to the design and execution of basic science, device development and clinical trials. The Consortium is owned and operated by its members. Members are international leaders in neurointerventional research and clinical practice. The Consortium brings competency, knowledge, and expertise to industry as well as to its membership across a spectrum of research initiatives such as: expedited review of clinical trials, protocol development, surveys and systematic reviews; laboratory expertise and support for research design and grant applications to public agencies. Once objectives and protocols are approved, the Consortium provides a stable network of centers capable of timely realization of clinical trials or preclinical investigations in an optimal environment. The Consortium is a non-profit organization. The potential revenue generated from client-sponsored financial agreements will be re-directed to the academic and research objectives of the organization. The Consortium wishes to work in concert with industry, to support emerging trends in neurovascular therapeutic development. The Consortium is a realistic endeavour optimally structured to promote excellence through scientific appraisal of our treatments, and to accelerate technical progress while maximizing patients' safety and welfare.

Headache is one of the most frequently reported symptoms following traumatic brain injury (TBI). Little is known about how these headaches change over time. We describe the natural history of headache in individuals with moderate to severe TBI over 5 years after injury. A total of 316 patients were prospectively enrolled and followed at 3, 6, 12, and 60 months after injury. Individuals were 72% male, 73% white, and 55% injured in motor vehicle crashes, with an average age of 42. Pre-injury headache was reported in 17% of individuals. New or worse headache prevalence remained consistent with at least 33% at all time points. Incidence was >17% at all time points with first report of new or worse headache in 20% of participants at 60 months. Disability related to headache was high, with average headache pain (on 0–10 scale) ranging from 5.5 at baseline to 5.7 at 60 months post-injury, and reports of substantial impact on daily life across all time points. More than half of classifiable headaches matched the profile of migraine or probable migraine. Headache is a substantial problem after TBI. Results suggest that ongoing assessment and treatment of headache after TBI is needed, as this symptom may be a problem up to 5 years post-injury.

Purpose In-training evaluation reports (ITERs) constitute an integral component of medical student and postgraduate physician trainee (resident) assessment. ITER narrative comments have received less attention than the numeric scores. The authors sought both to determine what validity evidence informs the use of narrative comments from ITERs for assessing medical students and residents and to identify evidence gaps. Method Reviewers searched for relevant English-language studies in MEDLINE, EMBASE, Scopus, and ERIC (last search June 5, 2015), and in reference lists and author files. They included all original studies that evaluated ITERs for qualitative assessment of medical students and residents. Working in duplicate, they selected articles for inclusion, evaluated quality, and abstracted information on validity evidence using Kane’s framework (inferences of scoring, generalization, extrapolation, and implications). Results Of 777 potential articles, 22 met inclusion criteria. The scoring inference is supported by studies showing that rich narratives are possible, that changing the prompt can stimulate more robust narratives, and that comments vary by context. Generalization is supported by studies showing that narratives reach thematic saturation and that analysts make consistent judgments. Extrapolation is supported by favorable relationships between ITER narratives and numeric scores from ITERs and non-ITER performance measures, and by studies confirming that narratives reflect constructs deemed important in clinical work. Evidence supporting implications is scant. Conclusions The use of ITER narratives for trainee assessment is generally supported, except that evidence is lacking for implications and decisions. Future research should seek to confirm implicit assumptions and evaluate the impact of decisions.

Aromatherapy is an integrative intervention that uses essential oils to address symptom management, potentially as a first-line intervention or as a complement to other medical treatments. Aromatherapy is gaining widespread acceptance and increased scientific evidence of efficacy. Integrative and holistic nursing care uses integrative therapies such as aromatherapy and the principle of moving from a less invasive intervention to a more invasive intervention according to patient needs, symptoms, and preferences. Aromatherapy is often provided as a minimally invasive, independent, and integrative nursing intervention. This article describes the process used to introduce essential oils into practices at a large Midwestern academic medical center.

ABSTRACTBackgroundMutations in the leucine‐rich repeat kinase 2 gene (LRRK2) are the most common genetic cause of Parkinson's disease (PD). Unexpectedly, tau pathology has been reported in a subset of LRRK2 mutation carriers.MethodsTo estimate the frequency of pathogenic LRRK2 mutations and to evaluate the association of common LRRK2 variants with risk of primary tauopathies, we studied 1039 progressive supranuclear palsy (PSP) and 145 corticobasal degeneration patients from the Mayo Clinic Florida brain bank and 1790 controls ascertained at Mayo Clinic. Sanger sequencing of LRRK2 exons 30, 31, 35, and 41 was performed in all patients, and genotyping of all 17 known exonic variants with minor allele frequency >0.5% was performed in patients and controls.ResultsLRRK2 mutational screening identified 2 known pathogenic mutations (p.G2019S and p.R1441C), each in 1 PSP patient, the novel p.A1413T mutation in a PSP patient and the rare p.R1707K mutation in a corticobasal degeneration patient. Both p.A1413T and p.R1707K mutations were predicted damaging by at least 2 of 3 prediction programs and affect evolutionary conserved sites of LRRK2. Association analysis using common LRRK2 variants only showed nominal association of the p.L153L variant with PSP.ConclusionsOur study confirms the presence of pathogenic and potentially pathogenic LRRK2 mutations in pathologically confirmed primary tauopathies, albeit with low frequency. In contrast to PD, common LRRK2 variants do not appear to play a major role in determining PSP and corticobasal degeneration risk. © 2016 International Parkinson and Movement Disorder Society.

ABSTRACT The immunocompromised host is at increased risk of Mycobacterium tuberculosis complex and nontuberculous mycobacteria infection. Although Mycobacterium tuberculosis complex is a significant mycobacterial pathogen, nontuberculous mycobacteria causes substantial disease in those with suppressed immune responses. Mycobacterial infections can cause significant morbidity and mortality in this patient population, and rapid identification and susceptibility testing of the mycobacterial species is paramount to patient management and outcomes. Mycobacterial diagnostics has undergone some significant advances in the last two decades with immunodiagnostics (interferon gamma release assay), microscopy (light-emitting diode), culture (automated broth-based systems), identification (direct PCR, sequencing and matrix-assisted laser-desorption ionization–time of flight mass spectrometry) and susceptibility testing (molecular detection of drug resistance from direct specimens or positive cultures). Employing the most rapid and sensitive methods in the mycobacterial laboratory will have a tremendous impact on patient care and, in the case of Mycobacterium tuberculosis complex, in the control of tuberculosis.

AbstractRationale, aims and objectivesHospital readmission within 30 days of discharge occurs in almost 20% of US Medicare patients and may be a marker of poor quality inpatient care, ineffective hospital to home transitions, or disease severity. Within a patient centered medical home, care transition interventions may only be practical from cost and staffing perspectives if targeted at patients with the greatest risk of readmission. Various scoring algorithms attempt to predict patients at risk for 30‐day readmission, but head‐to‐head comparison of performance is lacking. Compare published scoring algorithms which use generally available electronic medical record data on the same set of hospitalized primary care patients.MethodsThe LACE index, the LACE+ index, the HOSPITAL score, and the readmission risk score were computed on a consecutive cohort of 26,278 hospital admissions. Classifier performance was assessed by plotting receiver operating characteristic curves comparing the computed score with the actual outcome of death or readmission within 30 days. Statistical significance of differences in performance was assessed using bootstrapping techniques.ResultsCorrect readmission classification on this cohort was moderate with the following c‐statistics: Readmission risk score 0.666; LACE 0.680; LACE+ 0.662; and HOSPITAL 0.675. There was no statistically significant difference in performance between classifiers.ConclusionsLogistic regression based classifiers yield only moderate performance when utilized to predict 30‐day readmissions. The task is difficult due to the variety of underlying causes for readmission, nonlinearity, and the arbitrary time period of concern. More sophisticated classification techniques may be necessary to increase performance and allow patient centered medical homes to effectively focus efforts to reduce readmissions.

Hematopoietic cell transplantation (HCT) is an important and complex treatment modality for a variety of hematologic malignancies and some solid tumors. Although outcomes of patients who have undergone HCT and require care in intensive care units (ICUs) have improved over time, mortality rates remain high and there are significant associated costs. Lack of a team-based approach to care, especially during critical illness, is detrimental to patient autonomy and satisfaction, and to team morale, ultimately leading to poor quality of care. In this manuscript, we describe the case of a patient who had undergone HCT and was in the ICU setting, where inconsistent team interaction among the various stakeholders delivering care resulted in a lack of shared goals and poor outcomes. Team cognition is cognitive processing at the team level through interactions among team members and is reflected in dynamic communication and coordination behaviors. Although the patient received multidisciplinary care as needed in a medically complicated case, a lack of team cognition and, particularly, inconsistent communication among the dynamic teams caring for the patient, led to mixed messages being delivered with high-cost implications for the health-care system and the family. This article highlights concepts and recommendations that begin a necessary in-depth assessment of implications for clinical care and initiate a research agenda that examines the effects of team cognition on HCT teams, and, more generally, critical care of the patient with cancer.