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Objective: This study explored the impact of moral distress (MD) and respondent characteristics on intent to leave employment., Background: Managing patient care, within organizational constraints, may create physical discomfort or mental peace disturbances such as MD, negatively impacting RN retention., Methods: Responses from 948 RNs were collected using an anonymous online survey. The impact of MD on intent to leave employment was explored., Results: MD was significantly higher among RNs intending to leave employment. System-level and team-level integrity attributes were significant factors predicting intent to leave, controlling for potential confounders. The odds of intending to leave were 147% higher for new graduate RNs, 124% higher for direct care RNs, and 63% higher for 2nd-career RNs. Gender and race were not significant predictors., Conclusion: Exploring root causes contributing to MD frequency and severity is critical to maintain a healthy work environment. Mitigating MD in the work environment may enhance nursing practice and improve patient care. Support for new graduate and 2nd-career RNs can be realized, further reducing turnover for these vulnerable populations of the nursing workforce., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

On July 1, 2021, cannabis became legal in Virginia for adults 21 years of age and older. Cannabis consumption may have significant implications for outcomes related to medical care, including procedural sedation. The purpose of this study was to determine whether self-reported cannabis consumption has any relationship to sedation medication requirements during endoscopic procedures. A retrospective analysis was conducted to examine two groups of surgical patients (self-reported cannabis use versus self-reported non-cannabis use) at a community hospital in the mid-Atlantic region. Results demonstrate that there were no significant differences between groups for either Time to Aldrete ≥8 (p = .486) or Time to Meet Phase II Criteria (p = .762). Equivalent recovery times for both groups may be an indicator that comparable sedation levels were maintained, despite the increased propofol requirements of the cannabis group. Open conversations to establish patient use of cannabis products prior to procedural sedation is important for determining appropriate plans of care related to risk factors and medication dosage requirements during endoscopic evaluations., Competing Interests: The authors report no conflicts of interest in this work., (Copyright © 2024 Society of Gastroenterology Nurses and Associates.)

Background: Minimizing patient falls and fall-related injuries within organizational constraints is a high priority for nurse leaders. The Centers for Medicare & Medicaid Services do not reimburse hospitals for fall-related expenditures. In-person sitters are used to prevent falls but are resource intensive and costly. Remote patient monitoring (RPM) may offer alternatives to in-person sitters to reduce fall-related harm., Purpose: The efficacy of RPM to reduce patient falls and fall-related injuries was explored., Methods: Electronic health record data were extracted from a 13-hospital integrated health care system. Incidence rate ratios were used to analyze the impact of RPM technology on falls and fall-related injuries., Results: When used in conjunction with standard fall precautions, RPM reduced falls 33.7% and fall-related injuries 47.4%. Fall-related expenditures decreased $304 400 with a combined estimated savings systemwide of $2 089 600 annually., Conclusions: RPM technology minimized falls and associated harm and improved patient safety, positively impacting hospital expenditures., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Abdominal pain is stressful, accounting for a large proportion of emergency and primary care visits. Clinical workups for irritable bowel syndrome (IBS) are often without abnormal findings and symptoms can be severe, diminishing patients' IBS-related quality of life (IBS-QOL)., Purpose: The efficacy of stress-relieving therapies to manage IBS symptoms was explored., Methods: Participants were randomly assigned to standard care or an intervention group (ie, walking, music, and essential oils). The IBS-QOL, gastrointestinal (GI) distress, and general health questionnaires were completed at baseline and 6-week visits., Results: The intervention explained 20% of the variance for IBS-QOL, 19% for GI distress, and 27% for general health, after controlling for baseline scores. IBS-QOL and general health were improved, with GI distress minimized for the walking and essential oils groups., Conclusions: Adding walking and essential oils to an established IBS treatment regimen can positively impact health and well-being., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Patient violence toward others, including doctors and nurses, is a serious concern worldwide. A wealth of literature supports the assertion that violent behavior can be prevented with proper screening and management policies. This project aimed to evaluate the Crisis Triage Rating Scale (CTRS) within a 12-hospital integrated healthcare delivery system located in the southeastern United States. An initial sample of 112,708 unique patient visits between January 2019 and December 2020 was included in this retrospective review of electronic health records. We found that the CTRS harm triage question and risk levels were significant predictors of harm to others. Consistent with previous literature, positive predictive values ranged between 0.025 and 0.070 and negative predictive values ranged between 0.991 and 0.995. Our results support the assertion that clinicians should make balanced judgments about using a positive risk score to allocate safety measures. Variations in practice were evident across our healthcare systems. Improving appropriate assessment procedures may improve the diagnostic tools and risk stratification. When documented correctly, the CTRS performed as expected in an environment where harm to others occurred infrequently., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 National Association for Healthcare Quality.)

Background: Complexity in nursing practice creates an intense and stressful environment that may lead to moral distress (MD) and registered nurses (RNs) seeking other employment., Local Problem: In 2020, the RN turnover rate was 8%, with postpandemic turnover projected to reach 13%., Methods: The Measure of Moral Distress for Health Care Professionals (MMD-HP) was used to measure the frequency and level of RNs' MD., Results: t tests showed significant differences for 16 of 27 MMD-HP items in RN intent to leave. RNs had 2.9 times the odds of intent to leave (P = .019) due to perceived issues with patient quality and safety and 9.1 times the odds of intent to leave (P < .001) due to perceived issues with the work environment. Results explained 40.3% of outcome variance., Conclusions: MD related to work environment or patient quality and safety were significant factors in RN intent to leave their position., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Emergency nurses work in one of the busiest and most stressful departments in a hospital and, as such, may experience burnout more often than nurses working in other nursing units. This study examined the relationship among orientation, burnout (emotional exhaustion, depersonalization, and low sense of personal accomplishment), and intent to leave., Methods: A cross-sectional survey design was used. Emergency nurses who were members of the Emergency Nurses Association were invited to participate in an anonymous survey. The Maslach Burnout Inventory tool was used to explore emotional exhaustion, depersonalization, and sense of personal accomplishment. Emergency nurses' intent to leave was assessed with the Turnover Intention Scale. A logistic regression analysis was used to investigate the odds of intent to leave for those who scored at or above versus below the median on each burnout subscale., Results: The findings revealed that a formal orientation enhanced emergency nurses' sense of personal accomplishment and was associated with lower intent to leave. The odds of intent to leave were almost 9 times greater for participants with 5 or more years of experience, approximately 13 times greater for those with above-median emotional exhaustion, and more than 6 times lower for those with above-median sense of personal accomplishment., Discussion: Emotional exhaustion and low sense of personal accomplishment were key factors influencing emergency nurses' intent to leave. Emergency nurse leaders may find that a formal orientation program enhances sense of personal accomplishment and decreases intent to leave. Creating work environments to help emergency nurses find joy in their work may be critical to work-life balance and staff retention., (Copyright © 2021 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

Background: The Women RISE program, educating women and health care providers along with technology support, may reduce opioid use., Local Problem: Opioid use presented health concerns for women in Virginia's Central Shenandoah Valley., Methods: We evaluated the impact of Women RISE on self-management of chronic pain and opioid use, provider prescribing practices, and opioid reduction within our community., Interventions: We implemented the Chronic Pain Self-Management Program (CPSMP), educated women and providers, and streamlined access to the Prescription Management Program. Opioid best practice alerts informed providers about their prescribing practices., Results: The CPSMP was beneficial in improving women's coping skills, knowledge about opioid use, and overall quality of life. Opioid prescriptions were reduced 34%. We also reduced unneeded opioid analgesics within our community., Conclusions: Women were better able to manage chronic pain and stressors impacting opioid misuse. Opioid prescribing practices improved, limiting opioid availability in our community., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Studies have questioned the effectiveness of surgery for the management of unruptured brain arteriovenous malformation (ubAVM). Few studies have examined functional outcomes and quality of life (QOL) prior and 12 months after surgical repair of ubAVM., Objective: This study examined the effectiveness of surgical management of ubAVM by measuring patients' perceived QOL and their ability to perform everyday activities., Methods: Between 2011 and 2016, patients diagnosed with an unbAVM were assessed using the Quality Metric Short Form 36 (SF36), the DriveSafe component of the off-road driver screening tool DriveSafeDriveAware (DSDA), the modified Barthel Index (mBI) and the modified Rankin Scale (mRS). Reassessments were conducted at the 6-week post-operative follow-up for surgical patients and at 12-month follow-up for surgical and conservatively managed patients., Results: Forty-five patients enrolled in the study, of which 35 (78%) had their ubAVM surgically treated. Patients undergoing surgery had a significantly lower ubAVM Spetzler-Ponce Class (SPC). There was no significant difference 12 months after presentation in function or QOL for either the conservative or surgical group. The surgical group had significantly higher QOL of life scores from pre-surgery to 12 months post-surgery (PCS p < 0.01; MCS p = 0.02). Higher SP grade ubAVM was significantly related to poorer function in the surgical group (SP C compared with SP A; p = 0.04, mean difference - 12.4, 95%CI - 24.3 to - 0.4)., Conclusion: Function and QOL are not diminished after surgical treatment of low Spetzler-Ponce Class unruptured brain arteriovenous malformations. QOL is higher 12 months after surgery for ubAVM than for those who do not have treatment for their ubAVM.

Few data exist on bisphenol A (BPA) or triclosan (TCS) residue levels in foods consumed by adults in everyday settings. In a further analysis of study data, the objectives were to determine BPA and TCS residue concentrations in duplicate-single solid food items consumed by adults and to estimate dietary exposure and intake doses per food item. A convenience sample of 50 adults was recruited in North Carolina (2009-2011). Participants completed 24 h food diaries and collected 24 h duplicate-diet solid food samples consumed on days 1 and 2 during sampling weeks 1, 2, and 6. A total of 188 of the collected 776 duplicate-diet solid food samples contained a single, solid food item. BPA and TCS residue levels were quantified in the 188 food items using GC-MS. BPA and TCS were detected in 37% and 58% of these food items, respectively. BPA concentrations were highest in a cheese and tomato sandwich (104 ng/g), whereas the highest TCS concentrations were in a burrito (22.1 ng/g). These chemicals co-occurred in 20% of the samples (maximum = 54.7 ng/g). Maximum dietary intake doses were 429 ng/kg/day for BPA in a vegetable soup with tortilla sample and 72.0 ng/kg/day for TCS in a burrito sample.

Triclosan (TCS) and bisphenol analogues are used in a variety of consumer goods. Few data exist on the temporal exposures of adults to these phenolic compounds in their everyday diets. The objectives were to determine the levels of TCS and five bisphenol analogues (BPB, BPF, BPP, BPS, and BPZ) in duplicate-diet solid food (DDSF) samples of adults and to estimate maximum dietary exposures and intake doses per phenol. Fifty adults collected 776 DDSF samples over a six-week monitoring period in North Carolina in 2009-2011. The levels of the target phenols were concurrently quantified in the DDSF samples using gas chromatography/mass spectrometry. TCS (59%), BPS (32%), and BPZ (28%) were most often detected in the samples. BPB, BPF, and BPP were all detected in <16% of the samples. In addition, 82% of the total samples contained at least one target phenol. The highest measured concentration of 394 ng/g occurred for TCS in the food samples. The adults' maximum 24-h dietary intake doses per phenol ranged from 17.5 ng/kg/day (BPB) to 1600 ng/kg/day (TCS). An oral reference dose (300,000 ng/kg/day) is currently available for only TCS, and the adult's maximum dietary intake dose was well below a level of concern.

Background: Patients in intensive care units are 5 times more likely to have skin integrity issues develop than patients in other units. Identifying the most appropriate assessment tool may be critical to preventing pressure injuries in intensive care patients., Objectives: To validate the Cubbin-Jackson skin risk assessment in the critical care setting and to compare the predictive accuracy of the Cubbin-Jackson and Braden scales for the same patients., Methods: In 5 intensive care units, the Cubbin-Jackson and Braden assessments were completed by different clinicians within 61 minutes of each other for 4137 patients between October 2017 and March 2018. Bivariate correlations and the Fisher exact test were used to check for associations between the scores., Results: The Cubbin-Jackson and Braden scores were significantly and positively correlated (r = 0.80, P < .001). Both tools were significant predictors of skin changes and identified as "at risk" 100% of the patients who had a change in skin integrity occur. The specificity was 18.4% for the Cubbin-Jackson scale and 27.9% for the Braden scale, and the area under the curve was 0.75 (P < .001) for the Cubbin-Jackson scale and 0.76 (P < .001) for the Braden scale. These findings show acceptable construct validity for both scales., Conclusions: The predictive validities of the Cubbin-Jackson and Braden scales are similar, but both are sub-optimal because of poor specificity and positive predictive value. Change in practice may not be warranted, because there are no differences between the 2 scales of practical benefit to bedside nurses., (©2021 American Association of Critical-Care Nurses.)

Background: Telephonic outreach programs (TOPs) can be an effective measure to improve 30-day readmissions and self-management behaviors., Local Problem: Our health care providers identified that patients admitted with heart failure (HF) were among those with the highest readmission rate, so we implemented a TOP specific to HF., Methods: This project evaluated retrospective data from a convenience sample of adult patients admitted to our hospitals between January 2015 and June 2017, with a primary diagnosis of HF, and discharged home (N = 6271). Of those, 1708 patients also had at least partial TOP data, and a subset had timestamped TOP data (n = 1524)., Interventions: The TOP program included patient education and personal follow-up via an automatic voice calling system that employed a series of 4 phone calls over a 27-day period., Results: Results showed that the TOP enhanced our hospital discharge process and contributed to program outcomes when the patients completed all 4 of the calls, with those patients having 11 times lower odds of having a 30-day readmission., Conclusions: The proportion of patients who completed the program reported more use of self-management behaviors compared with those who answered fewer than 4 calls. Our findings related to the lower frequency of self-management behaviors of patients who did not complete all vendor calls stress the important issue of vendor management., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to explore the influence of nurse work characteristics, resiliency, and burnout on retention, and patient quality and safety., Background: With an ongoing nursing shortage, maintaining qualified nursing staff is critical. We explored the direct and indirect effects of practice environment, nurse work characteristics, and burnout on retention, and perceived quality and safety., Methods: Responses from 507 RNs were collected via an anonymous online survey. Theorized relationships were explored via path analysis and invariance testing., Results: Positive practice environment and favorable work characteristics lowered burnout and improved outcomes. The indirect effects of work characteristics and burnout were dependent upon individual level of resilience. Social capital minimized the effects of burnout for participants reporting below-average resilience., Conclusions: Leader support was critical in shaping positive perception of the practice environment. A nurse leader's visibility and actions impact intent to stay. Results of this study may inform healthcare systems struggling to retain a robust, engaged nursing workforce.

Few studies have measured pyrethroid residue concentrations in food items consumed by adults in their daily environments. In a further analysis of study data, the objectives were to determine pyrethroid residue levels in single, solid food items consumed by adults and to estimate dietary pyrethroid exposures and intake doses per food item. A total of 50 adults collected 782 duplicate-diet solid food samples over a six-week monitoring period in North Carolina between 2009 and 2011. Of these samples, 188 contained a single, solid food item (i.e., lasagna). Levels of eight pyrethroids were quantified in the 188 food items using LC-MS/MS. At least one pyrethroid was detected in 39% of these food items. Cis-permethrin (17%), bifenthrin (15%), trans-permethrin (14%), and deltamethrin (14%) were detected the most often. Cyfluthrin, cyhalothrin, cypermethrin, and esfenvalerate were all detected in <6% of the samples. The highest residue level was found in a pizza sample containing both cis-permethrin (96.4 ng/g) and trans-permethrin (73.7 ng/g). For cis-permethrin, median residue levels (>LOQ) were significantly higher (p = 0.001) in foods that contained a fruit/vegetable compared to foods that did not. For individual pyrethroids, the participants' maximum dietary intake doses in the single food items ranged from 38.1 (deltamethrin) to 939 ng/kg/day (cis/trans-permethrin)., Competing Interests: The author declares no conflict of interest.

Background: There was an increase in peripheral intravenous catheter (PIVC) complications and adverse patient events after product conversion during the merger between a rural hospital and a larger hospital system. A review of the existing literature identified a gap in evidence evaluating 2 closed PIVC systems compared with an open PIVC system., Purpose: The purpose of the current project was to ascertain whether open or closed PIVCs are best for patients, staff, and the health care system in terms of 3 main criteria: quality, safety, and cost., Methods: A prospective, 2-site randomized controlled trial was used to compare outcomes., Results: There were no differences in the complication rates between catheter types. There was a statistically significant increase in blood leakage and a decrease in clinician satisfaction with the open-system catheter., Conclusions: Our project supports current clinical recommendation that a closed PIVC system, regardless of type, is not only safer and cost-effective but also preferred by patients and clinicians.

Influenza is an acute viral respiratory infection that causes significant morbidity and mortality worldwide. Three types of influenza cause disease in humans. Influenza A is the type most responsible for causing pandemics because of its high susceptibility to antigenic variation. Influenza is highly contagious, and the hallmark of infection is abrupt onset of fever, cough, chills or sweats, myalgias, and malaise. For most patients in the outpatient setting, the diagnosis is made clinically, and laboratory confirmation is not necessary. Laboratory testing may be useful in hospitalized patients with suspected influenza and in patients for whom a confirmed diagnosis will change treatment decisions. Rapid molecular assays are the preferred diagnostic tests because they can be done at the point of care, are highly accurate, and have fast results. Treatment with one of four approved anti-influenza drugs may be considered if the patient presents within 48 hours of symptom onset. The benefit of treatment is greatest when antiviral therapy is started within 24 hours of symptom onset. These drugs decrease the duration of illness by about 24 hours in otherwise healthy patients and may decrease the risk of serious complications. No anti-influenza drug has been proven superior. Annual influenza vaccination is recommended for all people six months and older who do not have contraindications.

Background: Recommendations on the management of brain arteriovenous malformations (bAVM) with respect to pregnancy are based upon conflicting literature., Objective: To systematically review the reported risk and annualized rate of first intracranial hemorrhage (ICH) from bAVM during pregnancy and puerperium., Methods: MEDLINE, EMBASE, and Scopus databases were searched for relevant articles in English published before April 2018. Studies providing a quantitative risk of ICH in bAVM during pregnancy were eligible., Results: From 7 initially eligible studies, 3 studies met the criteria for providing quantitative risk of first ICH bAVM during pregnancy. Data from 47 bAVM ICH during pregnancy across 4 cohorts were extracted for analysis. Due to differences in methodology and definitions of exposure period, it was not appropriate to combine the cases. The annualized risk of first ICH during pregnancy for these 4 cohorts was 3.0% (95% confidence interval [CI]: 1.7-5.2%); 3.5% (95% CI: 2.4-4.5%); 8.6% (95% CI: 1.8-25%); and 30% (95% CI: 18-49%). Only the last result from the last cohort could be considered significantly increased in comparison with the nonpregnant period (relative rate 6.8, 95% CI: 3.6-13). The limited number of eligible studies and variability in results highlighted the need for enhanced rigor of future research., Conclusion: There is no conclusive evidence of an increased risk of first hemorrhage during pregnancy from bAVM. Because advice to women with bAVM may influence the management of pregnancy or bAVM with significant consequences, we believe that a retrospective multicenter, case crossover study is urgently required., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Background: Despite growth in service availability, palliative care (PC) referrals are often underutilized or delayed, which may compromise patient outcomes., Local Problem: Underutilized or delayed PC referrals among hospitalized adults prompted this project aimed at improving PC measures, quality, and utilization outcomes., Methods: Data extracted from the electronic medical record were used to identify needed improvements in PC., Intervention: Interdisciplinary rounds (IDRs) were implemented on the hospitalist service in a nonintensive care setting., Results: Following implementation, median time to PC referral decreased by 2 days. Length of stay (LOS), direct cost, and 30-day mortality also decreased. Postintervention patients were more likely to transition home compared with another facility., Conclusions: Results support IDRs as a mechanism to improve time to PC referral, decrease LOS, direct cost, and 30-day mortality among hospitalized adults. A more objective method of identifying patients with unmet PC needs may be warranted.

Background: Laminar wall sheer stress (LWSS) modulates inflammatory activity of the endothelium and may be a contributing factor in many cerebrovascular pathologies. There is a lack of consensus whether significant differences in LWSS exist between feeding vessels in brain arteriovenous malformation (bAVM) and healthy vessels. A systematic review of LWSS research in bAVM was undertaken, including the methods used and the assumptions made in determining LWSS., Methods: Ovid MEDLINE, EMBASE, and Scopus electronic databases were systematically searched from inception for articles calculating LWSS in bAVM cases. LWSS values were extracted for comparison between ipsilateral bAVM feeding arteries and healthy contralateral vessels or healthy normative data., Results: Three retrospective cohort studies were identified, reporting on 42 adult and pediatric bAVM cases. Mean LWSS (mLWSS) in healthy vessels (contralateral vessels or normative controls) typically ranged from 1.2-2.7 Pa, while mLWSS values in untreated bAVM feeding arteries typically ranged from 1.6-3.6 Pa. All studies had mixed cohorts of ruptured and unruptured cases, obscuring the relationship between LWSS and bAVM history., Conclusions: mLWSS values in healthy arteries and bAVM feeding vessels tend to be low and overlapping. Further research of high scientific and methodologic quality is necessary to improve understanding of how LWSS hemodynamics relate to bAVM formation, rupture, and treatment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Courses in Evidence-Based Medicine (EBM) for doctors have consistently demonstrated short-term improvements in knowledge. However, there is no strong evidence linking EBM training to changes in clinical practice or patient outcomes. This systematic review investigates whether EBM training leads to sustained improvements in doctors' knowledge and practice behaviors that may also facilitate changes in patient outcomes and experiences. A literature search was undertaken in Ovid Medline, Ovid Embase, The Cochrane Library, ERIC and Scopus. Studies published from 1997 to 2016 that assessed outcomes of EBM educational interventions amongst doctors and used measures of knowledge, skills, attitudes, practice or patient outcomes were included. Fifteen studies were included in the analysis: four randomized controlled trials (RCTs), three non-RCTs, and eight before-after (longitudinal cohort) studies. Heterogeneity among studies prevented meaningful comparisons. Varying degrees of bias due to the use of subjective measures were identified, limiting study validity. Results showed that EBM interventions can improve short-term knowledge and skills, but there is little reliable evidence of changes in long-term knowledge, attitudes, and clinical practice. No study measured improvement in patient outcomes or experiences. EBM training for medical practitioners needs to incorporate measures of behavioral changes while incorporating patient outcomes and experience measures.

Background: For sustainability of arteriovenous malformation (AVM) surgery, results from early career cerebrovascular neurosurgeons (ECCNs) must be acceptably safe., Objective: To determine whether ECCNs performance of Spetzler-Ponce Class A AVM (SPC A) resection can be acceptably safe., Methods: ECCNs completing a cerebrovascular fellowship (2004-2015) with the last author were included. Inclusion of the ECCN cases occurred if they: had a prospective database of all AVM cases since commencing independent practice; were the primary surgeon on SPC A; and had made the significant management decisions. All SPC A surgical cases from the beginning of the ECCN's independent surgical practice to a maximum of 8 yr were included. An adverse outcome was considered a complication of surgery leading to a new permanent neurological deficit with a last modified Rankin Scale score >1. A cumulative summation (Cusum) plot examined the performance of each surgery. The highest acceptable level of adverse outcomes for the Cusum was 3.3%, derived from the upper 95% confidence interval of the last author's reported series., Results: Six ECCNs contributed 110 cases for analysis. The median number of SPC A cases operated by each ECCN was 16.5 (range 4-40). Preoperative embolization was performed in 5 (4.5%). The incidence of adverse outcomes was 1.8% (95% confidence interval: <0.01%-6.8%). At no point during the accumulated series did the combined cohort become unacceptable by the Cusum plot., Conclusion: ECCNs with appropriate training appointed to large-volume cerebrovascular centers can achieve results for surgery for SPC A that are not appreciably worse than those published from high-volume neurosurgeons., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Objective: Previous trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, hemodynamic insufficiency may still be a rationale for surgery, provided the bypass can be performed with low morbidity and patency is robust., Methods: Consecutive patients undergoing bypass surgery for symptomatic non-moyamoya intracranial arterial stenosis or occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at 6 weeks, 6 months, and annually thereafter., Results: From 1992 to 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were performed to prevent future stroke (76%) and stroke reversal (24%), with revascularization using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurological deficit) occurred in 8.9% of patients, with arterial pedicle grafts (odds ratio [OR] 0.15), bypass for prophylaxis against future stroke (OR 0.11), or anterior circulation bypass (OR 0.17) identified as protective factors. Over the first 8 years following surgery the 66 cases exhibiting all three of these characteristics had minimal risk of a poor outcome (95% confidence interval 0%-6.6%)., Conclusions: Prophylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subgroup of individuals with hemodynamic insufficiency and ischemic symptoms is likely to benefit from cerebral revascularization surgery.

Background: Avoiding the risk of postoperative hemorrhage after brain arteriovenous malformation (AVM) resection involves aggressive blood pressure control. Remodeling of the feeding arterial system is critical in reducing this risk., Objective: To investigate factors predicting time to return to normal on digital subtraction angiography (DSA) after AVM resection., Methods: For AVM in which the largest feeding artery (FA) on DSA was in the anterior circulation, the preoperative and postoperative diameter of the FA were compared with the diameter of the internal carotid artery (IC) immediately proximal to the posterior communicating artery. The preoperative FA/IC ratio (FA/IC preAVM) was compared with the first postoperative FA/IC ratio (FA/IC postAVM). Normal FA/IC ratio (FA/IC normal) was established from matched arteries in the contralateral hemisphere to the AVM., Results: Eighty-six patients were analyzed for postoperative DSA performed a median 4 d after resection. From the interval-censored proportional hazards regression analysis, FA/IC preAVM (hazard ratio of 0.0006; 95% confidence interval: 0.00-0.21; P = .013) and maximum AVM diameter (hazard ratio of 0.47; 95% confidence interval: 0.23-0.95; P = .036) were significant in time to return to normal. These 2 factors were poorly correlated with each other (r = 0.41). AVMs with FA/IC preAVMs <0.57 combined with a diameter <3.0 cm normalize within 7 d in more than 50% of cases. Any other combination of ratio and size has fewer than 20% normalizing within 7 d (log rank P < .001)., Conclusion: FA/IC preAVM and AVM size are both important in predicting the time taken for return to normal feeding arterial system on DSA after AVM resection.

OBJECTIVE :Few studies have examined patients' ability to drive and quality of life (QOL) after microsurgical repair for unruptured intracranial aneurysms (uIAs). However, without a strong evidentiary basis, jurisdictional road transport authorities have recommended driving restrictions following brain surgery. In the present study, authors examined the outcomes of the microsurgical repair of uIAs by measuring patients' perceived QOL and cognitive abilities related to driving. METHODS: Between January 2011 and January 2016, patients with a new diagnosis of uIA were prospectively enrolled in this study. Assessments were performed at referral, before surgery, and at 6 weeks and 12 months after surgery in those undergoing microsurgical repair and at referral and at 12 months in conservatively managed patients. Assessments included the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36, the off-road driver-screening instrument DriveSafe (DS), the modified Barthel Index (mBI), and the modified Rankin Scale (mRS). RESULTS: One hundred sixty-nine patients were enrolled in and completed the study, and 112 (66%) of them had microsurgical repair of their aneurysm. In the microsurgical group, there was a trend for improved DS scores: from a mean (± standard deviation) score of 108 ± 10.7 before surgery to 111 ± 9.7 at 6 weeks after surgery to 112 ± 10.2 at 12 months after surgery (p = 0.05). Two percent of the microsurgical repair group and 4% of the conservatively managed group whose initial scores indicated competency to drive according to the DS test subsequently had 12-month scores deemed as not competent to drive; the difference between these 2 groups was not statistically significant (p > 0.99). Factors associated with a decline in the DS score among those who had a license at the time of initial assessment were an increasing age (p < 0.01) and mRS score > 0 at one of the assessments (initial, 6 weeks, or 12 months; p < 0.01). Mean PCS scores in the microsurgical repair group were 52 ± 8.1, 46 ± 6.8, and 52 ± 7.1 at the initial, 6-week, and 12-month assessments, respectively (p < 0.01). These values represented a significant decline in the mean PCS score at 6 weeks that recovered by 12 months (p < 0.01). There were no significant changes in the MCS, mBI, or mRS scores in the surgical group. CONCLUSIONS: Overall, QOL at 12 months for the microsurgical repair group had not decreased and was comparable to that in the conservatively managed group. Furthermore, as assessed by the DS test, the majority of patients were not affected in their ability to drive.

Outcomes on the modified Rankin Scale (mRS) are commonly used to guide and evaluate the management of unruptured intracranial aneurysms (uIA). However, the mRS is unlikely to measure all the relevant aspects of the clinical health of a patient. The current study therefore investigated the relationship between the mRS and additional measures of outcome. Between January 2011 and January 2016 patients with a new diagnosis of uIA were prospectively examined at referral and 12-month follow-up. Assessment included the Physical and Mental Component Scores of the Short Form 36 (SF-36), the computerized driver screening instrument DriveSafe (DS), and the mRS. Minimally Important Change (MIC) for each outcome measure was used to identify adverse outcomes for individual patients. A total of 128 patients (98 surgery; 30 untreated) completed the minimal dataset for analysis. In the surgical group, 6% (95% CI 3-14%) experienced morbidity at 12-months, as defined by the MIC for mRS. This risk rate increased to 51% (95% CI 41-61%) when defined as an MIC on any outcome. A combined MIC also identified a downgrade in outcomes, not detectable on the mRS, in 42% (95% CI 26-61%) of untreated patients. Correlation and regression analyses were unable to identify any significant relationships between the different outcomes instruments. In sum, there were considerably more adverse outcomes reported by quality of life (SF-36) and functional (DS) instruments than by the mRS for either treated or untreated uIA. To obtain a more complete representation of patient outcomes requires administration of a multi-dimensional assessment., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The congenital origin of brain arteriovenous malformations (bAVMs) has been increasingly challenged by reports of de novo bAVMs in patients previously confirmed to have no vascular malformation. We describe the oldest patient reported in the English language literature harboring a de novo bAVM. An uneventful frontal convexity meningioma resection was performed for a 60-year-old woman, and at 67 years of age, a bAVM was detected by MRI and confirmed by digital subtraction angiography at the site of the previous meningioma resection. This case adds to the growing literature that the etiology of bAVMs is most likely multifactorial.

OBJECTIVE Although intracranial vessel remodeling has been observed in moyamoya disease, concerns remain regarding the effect of bypass surgery on hemodynamic changes within the internal carotid artery (ICA). The authors aimed to quantify the surgical effect of bypass surgery on bilateral ICAs in moyamoya disease and to estimate pressure drop (PD) along the length of the ICA to predict surgical outcomes. METHODS Records of patients who underwent bypass surgery for treatment of moyamoya disease and in whom flow rates were obtained pre- and postsurgery by quantitative MR angiography were retrospectively reviewed. Quantitative MR angiography and computational fluid dynamics were applied to measure morphological and hemodynamic changes during pre- and postbypass procedures. The results for vessel diameter, volumetric flow, PD, and mean wall shear stress along the length of the ICA were analyzed. Subgroup analysis was performed for the circle of Willis (CoW) configurations. RESULTS Twenty-three patients were included. The PD in ICAs on the surgical side (surgical ICAs) decreased by 21.18% (SD ± 30.1%) and increased by 11.75% (SD ± 28.6%) in ICAs on the nonsurgical side (contralateral ICAs) (p = 0.001). When the PD in contralateral ICAs was compared between patients with a complete or incomplete CoW, the authors found that the PDI in the former group decreased by 2.45% and increased by 20.88% in the latter (p = 0.05). Regression tests revealed that a greater postoperative decrease in PD corresponded to shrinking of ICAs (R 2 = 0.22, p = 0.02). CONCLUSIONS PD may be used as a reliable biomechanical indicator for the assessment of surgical treatment outcomes. The vessel remodeling characteristics of contralateral ICA were related to CoW configurations.

Introduction: There is uncertainty as to the best management of arteriovenous malformations of the brain (bAVM). However, the Spetzler-Martin grade (SMG) has been validated as an effective determinant of surgical risks. We performed a systematic review for the best evidence regarding the management of bAVM for series that incorporate an analysis based upon SMG., Evidence Acquisition: Medline, Embase, Scopus and Cochrane databases were searched for series between January 2000 and January 2018, with a minimum of 100 cases and that incorporated SMG stratification. From this primary search, series were selected for analysis that dichotomized outcomes at modified Rankin Scale (mRS) scores between 1 and 2 due to complications of treatment or reported favorable outcome (FO) (i.e. complete occlusion, no neurological deterioration and no post treatment hemorrhage). Case series that used a subset of the population other than SMG or had a prior history of hemorrhage were excluded. The series finally analyzed were explored for outcomes that reported: complications of treatment that led to a new permanent neurological deficit with mRS score >1 (adverse outcome); post treatment hemorrhage; occlusion rate; and FO. A comparison of treatment outcomes was made when more than one modality of treatment (surgery, radiosurgery, embolization or multiple treatment modalities) could be examined with results for specific Spetzler-Ponce class (SPC) A (i.e. SMG I and II), B (i.e. SMG III) or C (i.e. SMG IV and V)., Evidence Synthesis: The primary search produced 116 papers. After reviewing each publication and eliminating papers that had patient outcomes duplicated, 11 publications met the criteria for analysis (including: 5 exclusively surgery; 4 exclusively radiosurgery; 1 exclusively endovascular; and, 1 multi-modality). The following outcome comparisons analyzed were significant. For SPC A and B bAVM, there was a significantly higher rate of FO following treatment by surgery (98.6%; 95% CI: 97.5-99.2% and 76.4%; 95% CI: 70.0-81.7%, respectively) than radiosurgery (70.8%; 95% CI: 66.8-74.6% and 61.0%; 95% CI: 56.0-65.8%, respectively)(P<0.01). For SPC A and B bAVM, there were significantly fewer unobliterated bAVM following treatment by surgery (0.5%; 95% CI: 0.2-1.4% and 3.0%; 95% CI: 1.4-5.8%, respectively) than radiosurgery (23.9%; 95% CI: 20.4-27.8% and 30.9%; 95% CI: 27.9-34.0%, respectively) or embolization (7.6%; 95% CI: 4.3-12.9% SPC A) (P<0.01). Adverse outcomes from treatment were significantly higher for surgery (15.6%; 95% CI: 11.8-20.0%) than radiosurgery (3.3%; 95% CI: 2.3-4.8%) for SPC B (P<0.01) but not SPC A bAVM. No analysis of SPC C was possible., Conclusions: Surgery remains, in general, the best choice for treating SPC A bAVM. For SPC B bAVM the decision as to best treatment should hinge on the likelihood of obliteration by radiosurgery. In cases where obliteration rate is expected to be high, radiosurgery should be the preferred treatment. There is insufficient information to make a recommendation from this analysis with regards the role of embolization for cure. There is no satisfactory standardized treatment for SPC C bAVM and treatment must remain individualized.

Background: There is uncertainty of the benefit of preoperative embolization for Spetzler-Ponce Class (SPC) B and C arteriovenous malformations of the brain (bAVM). We examined whether or not preoperative embolization reduces the risk of permanent neurological deficits in SPC B and C bAVM surgery., Methods: A prospective bAVM database (between1989 and 2015) was analyzed by regression for factors associated with a new permanent neurological deficit arising as a consequence of surgery or preoperative embolization with a modified Rankin Scale (mRS) score >1 at 12 months after surgery (adverse outcome)., Results: From a cohort of 785 patients with bAVM, 277 patients with SPC B or C bAVM were planned for treatment by surgery with (N.=67) or without (N.=210) preoperative embolization. There were significant differences (embolization versus no embolization) in: permanent neurological deficits leading to a mRS>1 (45% versus 20%, P<0.01); permanent neurological deficits leading to a mRS>2 (22% versus 8.1%, P=0.04); perioperative transfusion of 2.5 liters of blood or more (31% versus 16%, P<0.01); and, delayed postoperative hemorrhage (19% versus 8.1%, P=0.01). Regression analysis identified the following factors to be associated with increased likelihood of an adverse outcome: infratentorial location (odds ratio 0.441, P=0.045); SPC C bAVM (OR=0.501, P=0.034); earlier rank order of surgery (OR=0.994, P<0.01); and, preoperative embolization (OR=0.313, P<0.01)., Conclusions: The use of preoperative embolization does not reduce adverse outcomes in SPC B and C bAVM. The role of embolization in the preoperative management of complex bAVM by surgery deserves further study.

Active shooter events occur frequently across the United States in a variety of locations, including health care facilities. Hospital health care worker response to an active shooter event may mean the difference in life or death for self or others. There is little research on how hospitals prepare nonmanagers to respond to active shooter events. We conducted a study to explore differences in knowledge, perceived organizational preparedness, and program utility following participation in an active shooter response program. Self-efficacy, personal characteristics, and professional characteristics were also explored. Program evaluation was conducted via a one-group pretest/posttest design. There was a significant increase in knowledge and perceived organizational preparedness postintervention. Trait-level self-efficacy did not have a significant effect on retained knowledge and perceived organizational preparedness. The current study is the first known to evaluate the efficacy of an active shooter response program for nonmanagers within an inpatient health care facility. Findings from this study may inform risk managers on how to educate employees on what to expect and how to react should an active shooter event occur., (© 2018 American Society for Health Care Risk Management of the American Hospital Association.)

Pyrethroids are a class of neurotoxic insecticides, and some studies have used single-time wiping of hard surface flooring to estimate indoor pyrethroid concentrations. Considering that human activities may affect concentrations, knowledge of temporal variability is needed to reduce the uncertainty of exposure estimates that are calculated using wipe sampling of pyrethroids in occupied housing. During weeks one, two, and six of a 6-week study, two wipe samples of hard surface kitchen flooring were collected in each of 50 occupied residences and used to estimate the temporal variability of eight pyrethroids and six pyrethroid degradation products. Beginning 1 month prior to sample collection, the participants kept pesticide use diaries. All pyrethroids were widely distributed among the houses, and co-occurrence of multiple pyrethroids was common structured. Application diaries and detection frequencies appeared unconnected, but the applications were correlated with measurable changes in pyrethroid concentrations. In general, degradation products were detected less frequently and at lower concentrations than their parent pyrethroids. Estimates of the intraclass correlation coefficient (ICC) for individual pyrethroids ranged from 0.55 (bifenthrin) to 0.80 (deltamethrin), and two sampling events at each residence would have been sufficient to estimate the mean concentration of most pyrethroids with an ICC of 0.80., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA.)

Bisphenol A (BPA) is commonly manufactured to make polycarbonate plastics and epoxy resins for use in consumer products and packaged goods. BPA has been found in several different types of environmental media (e.g., food, dust, and air). Many cross-sectional studies have frequently detected BPA concentrations in adult urine samples. However, limited data are available on the temporal variability and important predictors of urinary BPA concentrations in adults. In this work, the major objectives were to: 1) quantify BPA levels in duplicate-diet solid food, drinking water, hard floor surface wipe, and urine samples (first-morning void [FMV], bedtime, and 24-h) collected from adults over a six-week monitoring period; 2) determine the temporal variability of urinary BPA levels using concentration, specific gravity (SG) adjusted, creatinine (CR) adjusted, and excretion rate values, and; 3) examine associations between available study factors and urinary BPA concentrations. In 2009-2011, a convenience sample of 50 adults was recruited from residential settings in North Carolina. The participants completed diaries and collected samples during weeks 1, 2, and/or 6 of a six-week monitoring period. BPA was detected in 38%, 4%, and 99% of the solid food (n=775), drinking water (n=50), and surface wipe samples (n=138), respectively. Total BPA (free plus conjugated) was detected in 98% of the 2477 urine samples. Median urinary BPA levels were 2.07ng/mL, 2.20ng/mL-SG, 2.29ng/mg, and 2.31ng/min for concentration, SG-adjusted, CR-adjusted, and excretion rate values, respectively. The intraclass correlation coefficient (ICC) estimates for BPA showed poor reproducibility (≤0.35) for all urine sample types and methods over a day, week, and six weeks. CR-adjusted bedtime voids collected over six-weeks required the fewest, realistic number of samples (n=11) to obtain a reliable biomarker estimate (ICC=0.80). Results of linear mixed-effects models showed that sex, race, season, and CR-level were all significant predictors (p<0.05) of the adults' urinary BPA concentrations. BPA levels in the solid food and surface wipe samples did not contribute significantly to the participants' urinary BPA concentrations. However, a significant positive relationship was observed between solid food intake and urine-based estimates of BPA dose, when aggregated over 24-h periods. Ingestion of BPA via solid food explained only about 20% of the total dose (at the median of the dose distribution), suggesting that these adults were likely exposed to other major unknown (non-dietary) sources of BPA in their everyday environments., (Published by Elsevier Ltd.)

Background: Few data are available on disability and quality of life (QOL) after surgery versus conservative management for unruptured brain arteriovenous malformations (uAVMs)., Objective: The aim of this study was to test the hypothesis that QOL and disability are worse after surgery ± preoperative embolisation for uAVM compared with conservative management., Methods: We included consecutive patients diagnosed with uAVM from a prospective population-based study in Scotland (1999-2003; 2006-2010) and a prospective hospital-based series in Australia (2011-2015). We assessed outcomes on the modified Rankin Scale (mRS) and the Short Form (SF)-36 at ~ 12 months after surgery or conservative treatment and compared these groups using continuous ordinal regression in the two cohorts separately., Results: Surgery was performed for 29% of all uAVM cases diagnosed in Scotland and 84% of all uAVM referred in Australia. There was no statistically significant difference between surgery and conservative management at 12 months among 79 patients in Scotland (mean SF-36 Physical Component Score (PCS) 39 [SD 14] vs. 39 [SD 13]; mean SF-36 Mental Component Score (MCS) 38 [SD 14] vs. 39 [SD 14]; mRS > 1, 24 vs. 9%), nor among 37 patients in Australia (PCS 51 [SD 10] vs. 49 [SD 6]; MCS 48 [SD 12] vs. 49 [SD 10]; mRS > 1, 19 vs. 30%). In the Australian series, there was no statistically significant change in the MCS and PCS between baseline before surgery or conservative management and 12 months., Conclusions: We did not find a statistically significant difference between surgery ± preoperative embolisation and conservative management in disability or QOL at 12 months.

Previous research has reported concurrent levels of pyrethroid insecticides and their environmental degradates in foods. These data raise concerns about using these same pyrethroid degradates found in the diet as urinary biomarkers of exposures in humans. The primary objective was to quantify levels of selected pyrethroids and their environmental degradates in duplicate-diet solid food samples of 50 adults over a six-week monitoring period. The study was conducted at the US EPA's Human Studies Facility in North Carolina and at participants' residences in 2009-2011. Participants collected duplicate-diet solid food samples on days 1 and 2 during weeks 1, 2, and 6 of the monitoring period. These samples were collected over three consecutive time periods each sampling day. A total of 782 food samples were homogenized and analyzed by LC/MS/MS for seven pyrethroids (bifenthrin, λ-cyhalothrin, cyfluthrin, cypermethrin, cis-deltamethrin, esfenvalerate, and cis/trans-permethrin) and six pyrethroid degradates. Results showed that 49% and 2% of all the samples contained at least one target pyrethroid or pyrethroid degradate, respectively. Cis/trans-permethrin (20%) and bifenthrin (20%) were the most frequently detected pyrethroids. The results suggest that the pyrethroid degradates were likely not present in sufficient levels in the diet to substantially impact the adults' urinary biomarker concentrations.

Background: The evidence for the risk of seizures following surgery for brain arteriovenous malformations (bAVM) is limited., Objective: To determine the risk of seizures after discharge from surgery for supratentorial bAVM., Methods: A prospectively collected cohort database of 559 supratentorial bAVM patients (excluding patients where surgery was not performed with the primary intention of treating the bAVM) was analyzed. Cox proportional hazards regression models (Cox regression) were generated assessing risk factors, a Receiver Operator Characteristic curve was generated to identify a cut-point for size and Kaplan-Meier life table curves created to identify the cumulative freedom from postoperative seizure., Results: Preoperative histories of more than 2 seizures and increasing maximum diameter (size, cm) of bAVM were found to be significantly (P < .01) associated with the development of postoperative seizures and remained significant in the Cox regression (size as continuous variable: P = .01; hazard ratio: 1.2; 95% confidence interval: 1.0-1.3; more than 2 seizures: P = .02; hazard ratio: 2.1; 95% confidence interval: 1.1-3.8). The cumulative risk of first seizure after discharge from hospital following resection surgery for all patients with bAVM was 5.8% and 18% at 12 mo and 7 yr, respectively. The 7-yr risk of developing postoperative seizures ranged from 11% for patients with bAVM ≤4 cm and with 0 to 2 preoperative seizures, to 59% for patients with bAVM >4 cm and with >2 preoperative., Conclusion: The risk of seizures after discharge from hospital following surgery for bAVM increases with the maximum diameter of the bAVM and a patient history of more than 2 preoperative seizures., (Copyright © 2017 by the Congress of Neurological Surgeons)

OBJECTIVE The aim of this study was to examine the impact of deliberate employment of postoperative hypotension on delayed postoperative hemorrhage (DPH) for all Spetzler-Ponce Class (SPC) C brain arteriovenous malformations (bAVMs) and SPC B bAVMs ≥ 3.5 cm in diameter (SPC B 3.5+). METHODS A protocol of deliberate employment of postoperative hypotension was introduced in June 1997 for all SPC C and SPC B 3.5+ bAVMs. The aim was to achieve a maximum mean arterial blood pressure (BP) ≤ 70 mm Hg (with cerebral perfusion pressure > 50 mm Hg) for a minimum of 7 days after resection of bAVMs (BP protocol). The authors compared patients who experienced DPH (defined as brain hemorrhage into the resection bed that resulted in a new neurological deficit or that resulted in reoperation during the hospitalization for microsurgical bAVM resection) between 2 periods (prior to adopting the BP protocol and after introduction of the BP protocol) and 4 bAVM categories (SPC A, SPC B 3.5- [that is, SPC B < 3.5 cm maximum diameter], SPC B 3.5+, and SPC C). Patients excluded from treatment by the BP protocol were managed in the intensive care unit to avoid moderate hypertensive episodes. The pooled cases of all bAVM treated by surgery were analyzed to identify characteristics associated with the risk of DPH. These identified characteristics were then examined by multiple logistic regression analysis in both SPC B 3.5+ and SPC C cases. RESULTS From a cohort of 641 bAVMs treated by microsurgery, 32 patients with DPH were identified. Of those, 66% (95% CI 48-80) had a permanent new neurological deficit with a modified Rankin Scale score of 2-6. This included a mortality rate of 13% (95% CI 4.4-29). The BP protocol was used to treat 162 patients with either SPC B 3.5+ or SPC C. For SPC B 3.5+, there was no significant reduction in DPH with the introduction of the BP protocol (p = 0.77). For SPC C, there was a significant (p = 0.035) reduction of DPH from 29% (95% CI 13%-53%) to 8.2% (95% CI 3.2%-18%) associated with the introduction of the BP protocol. Multiple logistic regression analysis found that the absence of the BP protocol (p = 0.011, odds ratio 7.5, 95% CI 1.6-36) remained significant for the development of DPH in patients with SPC C bAVMs. CONCLUSIONS Treating patients with SPC C bAVMs with a protocol that lowers BP immediately after resection seems to reduce the risk of DPH. For SPC A and SPC B 3.5- bAVMs, there is unlikely to be a need to do more than avoid postoperative hypertension. For SPC B 3.5+ bAVMs, a larger number of patients would be required to test the absence of benefit of the BP protocol.

OBJECTIVE The purpose of this study was to adapt and apply the extended definition of favorable outcome established for Gamma Knife radiosurgery (GKRS) to surgery for brain arteriovenous malformations (bAVMs). The aim was to derive both an error around the point estimate and a model incorporating angioarchitectural features in order to facilitate comparison among different treatments. METHODS A prospective microsurgical cohort was analyzed. This cohort included patients undergoing embolization who did not proceed to microsurgery and patients denied surgery because of perceived risk of treatment. Data on bAVM residual and recurrence during long-term follow-up as well as complications of surgery and preoperative embolization were analyzed. Patients with Spetzler-Ponce Class C bAVMs were excluded because of extreme selection bias. First, patients with a favorable outcome were identified for both Class A and Class B lesions. Patients were considered to have a favorable outcome if they were free of bAVM recurrence or residual at last follow-up, with no complication of surgery or preoperative embolization, and a modified Rankin Scale score of more than 1 at 12 months after treatment. Patients who were denied surgery because of perceived risk, but would otherwise have been candidates for surgery, were included as not having a favorable outcome. Second, the authors analyzed favorable outcome from microsurgery by means of regression analysis, using as predictors characteristics previously identified to be associated with complications. Third, they created a prediction model of favorable outcome for microsurgery dependent upon angioarchitectural variables derived from the regression analysis. RESULTS From a cohort of 675 patients who were either treated or denied surgery because of perceived risk of surgery, 562 had Spetzler-Ponce Class A or B bAVMs and were included in the analysis. Logistic regression for favorable outcome found decreasing maximum diameter (continuous, OR 0.62, 95% CI 0.51-0.76), the absence of eloquent location (OR 0.23, 95% CI 0.12-0.43), and the absence of deep venous drainage (OR 0.19, 95% CI 0.10-0.36) to be significant predictors of favorable outcome. These variables are in agreement with previous analyses of microsurgery leading to complications, and the findings support the use of favorable outcome for microsurgery. The model developed for angioarchitectural features predicts a range of favorable outcome at 8 years following microsurgery for Class A bAVMs to be 88%-99%. The same model for Class B bAVMs predicts a range of favorable outcome of 62%-90%. CONCLUSIONS Favorable outcome, derived from GKRS, can be successfully used for microsurgical cohort series to assist in treatment recommendations. A favorable outcome can be achieved by microsurgery in at least 90% of cases at 8 years following microsurgery for patients with bAVMs smaller than 2.5 cm in maximum diameter and, in the absence of either deep venous drainage or eloquent location, patients with Spetzler-Ponce Class A bAVMs of all diameters. For patients with Class B bAVMs, this rate of favorable outcome can only be approached for lesions with a maximum diameter just above 6 cm or smaller and without deep venous drainage or eloquent location.

Background: An understanding of the present standing of surgery, surgical results and the role in altering the future morbidity and mortality of untreated brain arteriovenous malformations (bAVMs) is appropriate considering the myriad alternative management pathways (including radiosurgery, embolization or some combination of treatments), varying risks and selection biases that have contributed to confusion regarding management. The purpose of this review is to clarify the link between the incidence of adverse outcomes that are reported from a management pathway of either surgery or no intervention with the projected risks of surgery or no intervention., Methods: A critical review of the literature was performed on the outcomes of surgery and non-intervention for bAVM. An analysis of the biases and how these may have influenced the outcomes was included to attempt to identify reasonable estimates of risks., Results: In the absence of treatment, the cumulative risk of future hemorrhage is approximately 16% and 29% at 10 and 20 years after diagnosis of bAVM without hemorrhage and 35% and 45% at 10 and 20 years when presenting with hemorrhage (annualized, this risk would be approximately 1.8% for unruptured bAVMs and 4.7% for 8 years for bAVMs presenting with hemorrhage followed by the unruptured bAVM rate). The cumulative outcome of these hemorrhages depends upon whether the patient remains untreated and is allowed to have a further hemorrhage or is treated at this time. Overall, approximately 42% will develop a new permanent neurological deficit or death from a hemorrhagic event. The presence of an associated proximal intracranial aneurysm (APIA) and restriction of venous outflow may increase the risk for subsequent hemorrhage. Other risks for increased risk of hemorrhage (age, pregnancy, female) were examined, and their purported association with hemorrhage is difficult to support. Both the Spetzler-Martin grading system (and its compaction into the Spetzler-Ponce tiers) and Lawton-Young supplementary grading system are excellent in predicting the risk of surgery. The 8-year risk of unfavorable outcome from surgery (complication leading to a permanent new neurological deficit with a modified Rankin Scale score of greater than one, residual bAVM or recurrence) is dependent on bAVM size, the presence of deep venous drainage (DVD) and location in critical brain (eloquent location). For patients with bAVMs who have neither a DVD nor eloquent location, the 8-year risk for an unfavorable outcome increases with size (increasing from 1 cm to 6 cm) from 1% to 9%. For patients with bAVM who have either a DVD or eloquent location (but not both), the 8-year risk for an unfavorable outcome increases with the size (increasing from 1 cm to 6 cm) from 4% to 35%. For patients with bAVM who have both a DVD and eloquent location, the 8-year risk for unfavorable outcome increases with size (increasing from 1 cm to 3 cm) from 12% to 38%., Conclusion: Patients with a Spetzler-Ponce A bAVM expecting a good quality of life for the next 8 years are likely to do better with surgery in expert centers than remaining untreated. Ongoing research is urgently required on the outcome of management pathways for bAVM.

OBJECTIVE The occurrence of transdural arterial recruitment (TDAR) in association with brain arteriovenous malformation (bAVM) is uncommon, and the reason for TDAR is not understood. The aim of this cohort study was to examine patient and bAVM characteristics associated with TDAR and the implications of TDAR on management. METHODS A prospective surgical database of bAVMs was examined. Cases previously treated elsewhere or incompletely examined by digital subtraction angiography (DSA) assessment were excluded. Three studies of this cohort were performed, as follows: characteristics associated with TDAR, the relationship between TDAR and neurological deficits unassociated with hemorrhage (NDUH), and the impact of TDAR on outcome from surgery. Regression models were performed. RESULTS Of 769 patients with complete DSA who had no previous treatment, 51 (6.6%) were found to have TDAR. The presence of TDAR was associated with increasing age (p < 0.01; OR 1.05; 95% CI 1.02-1.07); presentation with NDUH (p < 0.01; OR 2.71; 95% CI 1.29-5.71); increasing size of the bAVM (p < 0.01; OR 1.57; 95% CI 1.29-1.91); and combined supply from both anterior and posterior circulations (p = 0.02; OR 2.37; 95% CI 1.17-4.78). Further analysis of TDAR cases comparing those with and without NDUH found an association of larger size (6.6 cm [2.9 SD] compared with 4.7 cm [1.8 SD]; p < 0.01) and combined supply from both anterior and posterior circulations (relative risk 2.5; 95% CI 1.0-6.2; p = 0.04) to be associated with an NDUH presentation. For the 632 patients undergoing surgery there was an increased risk of complications (where this produced a new permanent neurological deficit at 12 months represented by a modified Rankin Scale score of > 1) with the following variables: size; location in eloquent brain; deep venous drainage; increasing age; and no presentation with hemorrhage. The presence of TDAR was not associated with an increased risk of complications from surgery. CONCLUSIONS The authors found that TDAR occurs in older patients with larger bAVMs, and that TDAR is also more likely to be associated with bAVMs presenting with NDUH. The likely explanation for the presence of TDAR is a secondary recruitment arising as a consequence of shear stress, rather than a primary vascular supply present from the earliest development of the bAVM.

In December of 2016, a Consensus Conference on unruptured AVM treatment, involving 24 members of the three European societies dealing with the treatment of cerebral AVMs (EANS, ESMINT, and EGKS) was held in Milan, Italy. The panel made the following statements and general recommendations: (1) Brain arteriovenous malformation (AVM) is a complex disease associated with potentially severe natural history; (2) The results of a randomized trial (ARUBA) cannot be applied equally for all unruptured brain arteriovenous malformation (uBAVM) and for all treatment modalities; (3) Considering the multiple treatment modalities available, patients with uBAVMs should be evaluated by an interdisciplinary neurovascular team consisting of neurosurgeons, neurointerventionalists, radiosurgeons, and neurologists experienced in the diagnosis and treatment of brain AVM; (4) Balancing the risk of hemorrhage and the associated restrictions of everyday activities related to untreated unruptured AVMs against the risk of treatment, there are sufficient indications to treat unruptured AVMs grade 1 and 2 (Spetzler-Martin); (5) There may be indications for treating patients with higher grades, based on a case-to-case consensus decision of the experienced team; (6) If treatment is indicated, the primary strategy should be defined by the multidisciplinary team prior to the beginning of the treatment and should aim at complete eradication of the uBAVM; (7) After having considered the pros and cons of a randomized trial vs. a registry, the panel proposed a prospective European Multidisciplinary Registry.

A 22-year-old human immunodeficiency virus-infected male presented with fever, rash, hypotension, and renal insufficiency 18 days following initiation of therapy with an efavirenz-based antiretroviral regimen. Although rash is a common side effect of efavirenz, severe hypersensitivity reactions are rare. Systemic symptoms can include hepatic toxicity and pneumonitis, and in one instance death. Corticosteroids are the mainstay of treatment., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Surgical management includes selection of patients for surgery, performing the technical procedure of brain arteriovenous malformation (bAVM) resection and perioperative management that maximize the chance for the best outcome. In general the Spetzler-Ponce class (SPC) can divide patients into those with good evidence that surgery is appropriate in most cases (SPC A), those in whom surgery should only be considered occasionally with highly nuanced indications (SPC C), and surgery may be appropriate having made a detailed analysis of patient (including age), clinical (including mode of presentation), and AVM characteristics (including diffuseness), and a comparative analysis of outcomes with alternate management pathways for SPC B cases. The underlying competent performance of surgery must successfully achieve: consideration of the physiology; correct identification of vessel; protection of the arterial supply to normal brain; understanding of the expected anatomic relationship between feeding arteries and draining veins; and recognition and management of complex arterial feeding patterns from transdural and transosseous sources. Aggressive blood pressure management is required for bAVM with significant changes to brain vascular physiology as a consequence of surgery. For such cases, brain vascular remodeling will take approximately 1 week after surgery. During this period, protection against elevation of blood pressure must be strictly achieved., (© 2017 Elsevier B.V. All rights reserved.)

Dramatic hemodynamic changes occur following resection of brain arteriovenous malformations (AVM). Transcranial Doppler (TCD) records non-invasive velocity and pulsatility parameters. We undertook a systematic review to assess AVM hemodynamics including the time course of changes in velocity and pulsatility in patients undergoing AVM resection. The review employed the Embase and Medline databases. A search strategy was designed. An initial title search for clinical series on AVM and TCD was performed followed by a search for reports on AVM and TCD. A total of 283 publications were selected. Full text analysis produced 54 studies with extractable data regarding AVM, velocity and pulsatility. Two TCD techniques were utilized: conventional "blind" TCD (blind TCD); and transcranial color duplex Doppler (TCCD). Of these, 23 publications reported on blind TCD and seven on TCCD. The presence of high velocity and low pulsatility within AVM feeding arteries preoperatively followed by a postoperative decrease in velocity and subsequent increase in pulsatility of feeding arteries is established. The time sequence of hemodynamic changes following AVM resection using TCD remains uncertain, confounded by variations in methodology and timing of perioperative measurements. Of the two techniques, TCCD reported qualitative aspects including improved differentiation of feeding arteries from draining veins. However, there are a limited number of studies supporting this conclusion. Furthermore, none report reproducible changes with time from treatment. TCCD appears to be a useful technique to analyze the hemodynamic changes occurring following treatment of AVM, however little data is available. This is a field of research that is appropriate to pursue., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: We aimed to identify a group of patients with a low risk of seizure after surgery for unruptured intracranial aneurysms (UIA)., Objective: To determine the risk of seizure after discharge from surgery for UIA., Methods: A consecutive prospectively collected cohort database was interrogated for all surgical UIA cases. There were 726 cases of UIA (excluding cases proximal to the superior cerebellar artery on the vertebrobasilar system) identified and analyzed. Cox proportional hazards regression models and Kaplan-Meier life table analyses were generated assessing risk factors., Results: Preoperative seizure history and complication of aneurysm repair were the only risk factors found to be significant. The risk of first seizure after discharge from hospital following surgery for patients with neither preoperative seizure, treated middle cerebral artery aneurysm, nor postoperative complications (leading to a modified Rankin Scale score >1) was <0.1% and 1.1% at 12 months and 7 years, respectively. The risk for those with preoperative seizures was 17.3% and 66% at 12 months and 7 years, respectively. The risk for seizures with either complications (leading to a modified Rankin Scale score >1) from surgery or treated middle cerebral artery aneurysm was 1.4% and 6.8% at 12 months and 7 years, respectively. These differences in the 3 Kaplan-Meier curves were significant (log-rank P < .001)., Conclusion: The risk of seizures after discharge from hospital following surgery for UIA is very low when there is no preexisting history of seizures. If this result can be supported by other series, guidelines that restrict returning to driving because of the risk of postoperative seizures should be reconsidered., Abbreviations: MCA, middle cerebral arterymRS, modified Rankin ScaleUIA, unruptured intracranial aneurysms.