Bi-allelic CAMSAP1 variants cause a clinically recognizable neuronal migration disorder.

Non-centrosomal microtubules are essential cytoskeletal filaments that are important for neurite formation, axonal transport, and neuronal migration. They require stabilization by microtubule minus-end-targeting proteins including the CAMSAP family of molecules. Using exome sequencing on samples from five unrelated families, we show that bi-allelic CAMSAP1 loss-of-function variants cause a clinically recognizable, syndromic neuronal migration disorder. The cardinal clinical features of the syndrome include a characteristic craniofacial appearance, primary microcephaly, severe neurodevelopmental delay, cortical visual impairment, and seizures. The neuroradiological phenotype comprises a highly recognizable combination of classic lissencephaly with a posterior more severe than anterior gradient similar to PAFAH1B1(LIS1)-related lissencephaly and severe hypoplasia or absence of the corpus callosum; dysplasia of the basal ganglia, hippocampus, and midbrain; and cerebellar hypodysplasia, similar to the tubulinopathies, a group of monogenic tubulin-associated disorders of cortical dysgenesis. Neural cell rosette lineages derived from affected individuals displayed findings consistent with these phenotypes, including abnormal morphology, decreased cell proliferation, and neuronal differentiation. Camsap1-null mice displayed increased perinatal mortality, and RNAScope studies identified high expression levels in the brain throughout neurogenesis and in facial structures, consistent with the mouse and human neurodevelopmental and craniofacial phenotypes. Together our findings confirm a fundamental role of CAMSAP1 in neuronal migration and brain development and define bi-allelic variants as a cause of a clinically distinct neurodevelopmental disorder in humans and mice.

Statewide Policy to Increase Provision of Take-Home Naloxone at Emergency Department Visits for Opioid Overdose, Rhode Island, 2018‒2019.

In 2017, Rhode Island responded to rising overdose deaths by establishing statewide emergency department (ED) treatment standards for opioid overdose and opioid use disorder. One requirement of the policy is that providers prescribe or provide take-home naloxone to anyone presenting to EDs with opioid overdose. Among adults presenting to EDs with opioid overdose from 2018 to 2019, approximately half received take-home naloxone. Receipt of naloxone was associated with administration of naloxone before ED presentation, ED policy certification level, and regional overdose frequency. (Am J Public Health. 2023;113(4):372-377. https://doi.org/10.2105/AJPH.2022.307213).

Leader sensemaking style in response to crisis: Consequences and insights from the COVID-19 pandemic.

The international scope of the 2020 COVID-19 crisis compelled a response from world leaders across the globe. However, the nature of these responses was far from universal. These circumstances present a unique opportunity to study how leader style influences, and is influenced by, a common crisis. To explore these relationships, the present effort used a content analysis of weekly COVID-19 statements from world leaders spanning the first 19 weeks of the crisis. Results suggest that leaders shifted toward increasingly pragmatic sensemaking approaches as COVID-19 infections increased and that sustained use of pragmatic leadership styles was associated with fewer infections in the long term. In contrast, sustained use of the charismatic sensemaking style was associated with higher observed infection rates.

Adaptive functioning in children with neurofibromatosis type 1: relationship to cognition, behavior, and magnetic resonance imaging.

AIM: To characterize the adaptive behavior profile of children with neurofibromatosis type 1 (NF1) and determine its relationship to neuropsychological functioning and non-neoplastic T2-weighted hyperintense brain lesions on brain magnetic resonance imaging (MRI). METHOD: In this cross-sectional study, we retrospectively reviewed neuropsychological reports from 104 children with NF1 (56 males, 48 females; mean age 10y 4mo; standard deviation [SD] 3y 4mo; range 3y 5mo-17y 6mo), and extracted data from a range of cognitive and behavioral measures, including the Adaptive Behavior Assessment System (ABAS). Brain MRI was retrospectively reviewed in 42 individuals. RESULTS: Adaptive Behavior Assessment System scores were continuously distributed and pathologically shifted by 0.79 to 1.26SD across Conceptual, Social, and Practical domains, and 46.5% of individuals had a composite score in the borderline or impaired range. Impairment in adaptive functioning was correlated with deficits in executive function (r=-9.543, p<0.001), externalizing problems (r=-0.366, p<0.001), and attention (r=-9.467, p=0.001). Cluster analysis revealed three distinct phenotypic subgroups, one of which exhibited normal cognitive ability, but impaired adaptive functioning, with persistent deficits in executive function, behavioral problems, and attention-deficit/hyperactivity disorder symptomatology. There was no relationship between ABAS scores and the number or location of unidentified bright objects. INTERPRETATION: Adaptive functioning deficits are common among children with NF1 and are associated with impairment in other cognitive/behavioral domains, independent of general cognitive ability. WHAT THIS PAPER ADDS: Deficits in adaptive behavior are common in children with neurofibromatosis type 1 (NF1). Poor adaptive functioning is associated with impairments in executive function, externalizing behaviors, and attention, regardless of cognitive ability. The presence or location of unidentified bright objects do not predict adaptive behavior skills in children with NF1.

FUNCIONAMIENTO ADAPTATIVO EN NIÑOS CON NEUROFIBROMATOSIS TIPO 1: RELACIÓN ENTRE COGNICIÓN, COMPORTAMIENTO E IMÁGENES DE RESONANCIA MAGNÉTICA: OBJETIVO: Caracterizar el perfil del comportamiento adaptativo de niños con neurofibromatosis tipo 1 (NF1) y determinar la relación entre el funcionamiento neuropsicológico y las lesiones hiperintensas cerebrales no neoplásicas en T2-pesado de la resonancia magnética cerebral (RM). MÉTODO: En este estudio transversal, revisamos de forma retrospectiva reportes neuropsicológicos de 104 niños con NF1 (56 varones, 48 mujeres, media de edad 10 años 4 meses; desviación estándar (DE) 3 años 4 meses; rango 3 años 5 meses a 17 años 6 meses), y se extrajeron datos de una serie de mediciones cognitivas y conductuales, incluyendo el test sistema de evaluación de la conducta adaptativa (Adaptative Behaivor Assesment System ABAS). Se revisaron 42 RM cerebrales de forma retrospectiva. RESULTADOS: Los resultados ABAS fueron continuamente distribuidos y se cambiaron patológicamente entre 0,79 a 1,26 DE en los dominios de lo conceptual, social y práctico, y 46,5 por ciento de los individuos tuvieron un puntaje limítrofe o sin afectación. La afectación en las funciones adaptativas fue correlacionada con los déficits en funciones ejecutivas (r = -9,543, p < 0,001), externalizar problemas (r = -0,366, p < 0,001), y atención (r = -9,467, p = 0,001). El análisis de grupo revelo tres subgrupos fenotípicos distintos, uno de ellos exhibía una habilidad cognitiva tipica, pero afectación en el funcionamiento adaptativo, con déficits persistentes en función ejecutiva, problemas conductuales, y sintomatología de déficit de atención/hiperactividad. No hubo relación entre el puntaje ABAS y el número o localización de imágenes brillantes no identificadas en la RM cerebral. INTERPRETACIÓN: Los déficits de funcionamiento adaptativo son comunes entre niños con NF1 y son asociados con afectación de otros dominios cognitivo/conductual, independiente de la habilidad cognitiva en general.

FUNCIONAMENTO ADAPTATIVO EM CRIANÇAS COM NEUROFIBROMATOSE TIPO 1: RELAÇÃO COM COGNIÇÃO, COMPORTAMENTO, E IMAGEM DE RESSONÂNCIA MAGNÉTICA: OBJETIVO: Caracterizar o comportamento adaptativo de crianças com neurofibromatose tipo 1 (NF1) e determinar sua relação com funcionamento neuropsicológico e lesões em T2 hiperintensas não neoplásticas ao exame de ressonância magnética (RM). MÉTODO: Neste estudo transversal, revisamos retrospectivamente os relatórios neuropsicológicos de 104 crianças com NF1 (56 do sexo masculino, 48 do sexo feminino; média de idade 10a 4m; desvio padrão [DP] 3a 4m; variação 3a 5m-17a6m), e extraímos dados de uma variedade de medidas cognitivas e comportamentais, incluindo o Sistema de Avaliação do Comportamento Adaptativo (SACA). Imagens de RM cerebral foram retrospectivamente revisadas em 42 indivíduos. RESULTADOS: Os escores SACA foram distribuídos continuamente, e patologicamente deslocados em 0,79 a 1,26 DP nos domínios Conceitual, Social e Prático, e 46,5 por cento dos indivíduos tiveram escore composto na faixa limítrofe ou deficiente. Deficiências no comportamento adaptativo se correlacionaram com déficits na função executiva (r = −9,543, p < 0,001), problemas externalizantes (r = −0,366, p < 0,001), e atenção (r = −9,467, p = 0,001). Análise agrupada revelou três subgrupos genotípicos distintos, um dos quais exibiu capacidade cognitiva normal, mas funcionamento adaptativo deficiente, e sintomatologia de transtorno de deficit de atenção e hiperatividade. Não houve relação entre escores SACA e o número ou localização de objetos luminosos não identificados. INTERPRETAÇÃO: Déficits no funcionamento adaptativo são comuns entre crianças com NF1 e são associados com deficiência em outros domínios cognitivos/comportamentais, independente da capacidade cognitiva geral.

A public health hazard mitigation planning process.

INTRODUCTION: The Texas A&M Health Science Center School of Rural Public Health, a member of the Training and Education Collaborative System Preparedness and Emergency Response Learning Center (TECS-PERLC), has long-standing partnerships with 2 Health Service Regions (Regions) in Texas. TECS-PERLC was contracted by these Regions to address 2 challenges identified in meeting requirements outlined by the Risk-Based Funding Project. First, within Metropolitan Statistical Areas, there is not a formal authoritative structure. Second, preexisting tools and processes did not adequately satisfy requirements to assess public health, medical, and mental health needs and link mitigation strategies to the Public Health Preparedness Capabilities, which provide guidance to prepare for, respond to, and recover from public health incidents. METHODS: TECS-PERLC, with its partners, developed a framework to interpret and apply results from the Texas Public Health Risk Assessment Tool (TxPHRAT). The 3-phase community engagement-based TxPHRAT Mitigation Planning Process (Mitigation Planning Process) and associated tools facilitated the development of mitigation plans. Tools included (1) profiles interpreting TxPHRAT results and identifying, ranking, and prioritizing hazards and capability gaps; (2) a catalog of intervention strategies and activities linked to hazards and capabilities; and (3) a template to plan, evaluate, and report mitigation planning efforts. OUTCOMES: The Mitigation Planning Process provided a framework for Regions to successfully address all funding requirements. TECS-PERLC developed more than 60 profiles, cataloged and linked 195 intervention strategies, and developed a template resulting in 20 submitted mitigation plans. DISCUSSION: A public health-focused, community engagement-based mitigation planning process was developed by TECS-PERLC and successfully implemented by the Regions. The outcomes met all requirements and reinforce the effectiveness of academic practice partnerships and importance of community engagement in mitigation planning. NEXT STEPS: Additional funding has been approved to expand the Mitigation Planning Process to all counties in Texas with local health departments.

Rapid decrease in tumor perfusion following VEGF blockade predicts long-term tumor growth inhibition in preclinical tumor models.

Vascular endothelial growth factor (VEGF) is a key upstream mediator of tumor angiogenesis, and blockade of VEGF can inhibit tumor angiogenesis and decrease tumor growth. However, not all tumors respond well to anti-VEGF therapy. Despite much effort, identification of early response biomarkers that correlate with long-term efficacy of anti-VEGF therapy has been difficult. These difficulties arise in part because the functional effects of VEGF inhibition on tumor vessels are still unclear. We therefore assessed rapid molecular, morphologic and functional vascular responses following treatment with aflibercept (also known as VEGF Trap or ziv-aflibercept in the United States) in preclinical tumor models with a range of responses to anti-VEGF therapy, including Colo205 human colorectal carcinoma (highly sensitive), C6 rat glioblastoma (moderately sensitive), and HT1080 human fibrosarcoma (resistant), and correlated these changes to long-term tumor growth inhibition. We found that an overall decrease in tumor vessel perfusion, assessed by dynamic contrast-enhanced ultrasound (DCE-US), and increases in tumor hypoxia correlated well with long-term tumor growth inhibition, whereas changes in vascular gene expression and microvessel density did not. Our findings support previous clinical studies showing that decreased tumor perfusion after anti-VEGF therapy (measured by DCE-US) correlated with response. Thus, measuring tumor perfusion changes shortly after treatment with VEGF inhibitors, or possibly other anti-angiogenic therapies, may be useful to predict treatment efficacy.

To Treat or Not to Treat: Ethics of Management of Refractory Status Myoclonus Following Pediatric Anoxic Brain Injury.

The development of status myoclonus (SM) in a postcardiac arrest patient has historically been thought of as indicative of not only a poor neurologic outcome but of neurologic devastation. In many instances, this may lead clinicians to initiate conversations about withdrawal of life sustaining therapies (WLST) regardless of the time from return of spontaneous circulation (ROSC). Recent studies showing a percentage of patients may make a good recovery has called into question whether a self-fulfilling prophecy has developed where the concern for a poor neurologic outcome leads clinicians to prematurely discuss WLST. The issue is only further complicated by changing terminology, lack of neuro-axis localization, and limited data regarding association with electroencephalogram (EEG) characteristics, all of which could aid in the understanding of the severity of neurologic injury associated with SM. Here we review the initial literature reporting SM as indicative of poor neurologic outcome, the studies that call this into question, the various definitions of SM and related terms as well as data regarding association with EEG backgrounds. We propose that improved prognostication on outcomes results from combining the presence of SM with other clinical variables (eg EEG patterns, MRI findings, and clinical exam). We discuss the ethical implications of using SM as a prognostic tool and its impact on decisions about life-sustaining care in children following cardiac arrest. We advocate for prognostication efforts to be delayed for at least 72 hours following ROSC and thus to treat SM in those early hours and days.

Peroral Endoscopic Myotomy; Novice Surgeon Learning Curve.

INTRODUCTION: Peroral endoscopic myotomy (POEM) is a novel endoscopic procedure used to treat achalasia and other spastic esophageal disorders that is an alternative to Heller myotomy. We seek to define the learning curve of POEM for a foregut surgeon with no formal endoscopic or POEM training by analyzing different intraoperative factors in a single series. METHODS AND PROCEDURES: The first 38 consecutive patients undergoing POEM by a single foregut surgeon were included in this retrospective study. Inverse curve regression models were used to analyze total operative time (TOT) and total operative time per centimeter of myotomy (TOT-CM), in addition to other intraoperative variables. Clinical outcomes were reported as pre- and post-operative Eckardt Scores. RESULTS: All patients had type II achalasia with no post-operative complications observed. Eckardt scores improved postoperatively (median (range): 1 (0-4)) compared with the preoperative scores (10 (8-12)) (P < .001). The total operative time (median 76 minutes, range 51-129) decreased significantly over the course of the series (R2 = .38, P < .001), with a learning plateau at 70 minutes and a learning rate of 12 cases. Total operative time per centimeter of myotomy (median 7.08 min/cm, range 4.25 to 15.38) decreased over time (R2 = .45, P < .001), with a learning plateau at 7 minutes/cm and a learning rate of 12 cases. CONCLUSION: The number of cases for a foregut surgeon to become proficient in a POEM procedure was found to be 12-14 cases. The learning curve for a POEM in a formally trained foregut surgeon may be comparable to an endoscopically trained interventionist.

Examination of the Accuracy of Existing Overdose Surveillance Systems.

Importance: Health departments have used a variety of methods for overdose surveillance, and the Centers for Disease Control and Prevention (CDC) is implementing a standardized case definition to improve overdose surveillance nationally. The comparative accuracy of the CDC opioid overdose case definition vs existing state opioid overdose surveillance systems is unknown. Objective: To evaluate the accuracy of the CDC opioid overdose case definition and existing Rhode Island Department of Health (RIDOH) state opioid overdose surveillance system. Design, Setting, and Participants: This cross-sectional study of ED opioid overdose visits was conducted at 2 EDs in Providence, Rhode Island, at the state's largest health system from January to May 2021. Electronic health records (EHRs) were reviewed for opioid overdoses identified by the CDC case definition and opioid overdoses reported to the RIDOH state surveillance system. Included patients were those at study EDs whose visit met the CDC case definition, was reported to the state surveillance system, or both. True overdose cases were confirmed by EHR review using a standard case definition; 61 of 460 EHRs (13.3%) were double reviewed to estimate classification accuracy. Data were analyzed from January through May 2021. Main Outcome and Measure: Accurate identification of an opioid overdose was assessed by estimating the positive predictive value of the CDC case definition and state surveillance system using results from the EHR review. Results: Among 460 ED visits that met the CDC opioid overdose case definition, were reported to the RIDOH opioid overdose surveillance system, or both (mean [SD] age, 39.7 [13.5] years; 313 males [68.0%]; 61 Black [13.3%], 308 White [67.0%], and 91 other race [19.8%]; and 97 Hispanic or Latinx [21.1%] among each patient visit), 359 visits (78.0%) were true opioid overdoses. For these visits, the CDC case definition and RIDOH surveillance system agreed that 169 visits (36.7%) were opioid overdoses. Of 318 visits meeting the CDC opioid overdose case definition, 289 visits (90.8%; 95% CI, 87.2%-93.8%) were true opioid overdoses. Of 311 visits reported to the RIDOH surveillance system, 235 visits (75.6%; 95% CI, 70.4%-80.2%) were true opioid overdoses. Conclusions and Relevance: This cross-sectional study found that the CDC opioid overdose case definition more often identified true opioid overdoses compared with the Rhode Island overdose surveillance system. This finding suggests that using the CDC case definition for opioid overdose surveillance may be associated with improved data efficiency and uniformity.

Histopathologic correlation with diffusion tensor imaging after chronic hypoxia in the immature ferret.

INTRODUCTION: Chronic hypoxia in rodents induces white matter (WM) injury similar to that in human preterm infants. We used diffusion tensor imaging (DTI) and immunohistochemistry to study the impact of hypoxia in the immature ferret at two developmental time points relevant to the preterm and term brain. RESULTS: On ex vivo imaging, the apparent diffusion coefficient (ADC) was decreased throughout the WM after 10 days of hypoxia (hypoxia from postnatal day 10 (P10) to P20 and killed at P20 (early hypoxia P20)), corresponding to increased astrocytosis and decreased myelination. Diffusion values normalized after 10 days of normoxia (hypoxia from P10 to P20 and killed at P30 (early hypoxia P30)), but immunohistochemistry revealed significant astrocytosis and hypomyelination. In contrast, ADC and anisotropy were increased after 10 days of hypoxia at a later developmental time point (hypoxia from P20 to P30 and killed at P30 (late hypoxia P30)), with less astrocytosis and more prominent myelination. DISCUSSION: The patterns of alteration in imaging and histology varied in relation to the developmental time at which hypoxia occurred. Normalization of diffusion measures did not correspond to the normalization of underlying histopathology. METHODS: Ferrets were subjected to 10% hypoxia and divided into three groups: early hypoxia P20, early hypoxia P30, and late hypoxia P30.

MR imaging correlates of white-matter pathology in a preterm baboon model.

INTRODUCTION: Cerebral white-matter (WM) abnormalities on magnetic resonance imaging (MRI) correlate with neurodevelopmental disability in infants born prematurely. RESULTS: Quantitative histological measures of WM and ventricular volumes correlated with qualitative MRI scores of WM volume loss and ventriculomegaly. Diffuse astrocytosis was associated with signal abnormality on T(2)-weighted imaging and higher apparent diffusion coefficient in WM. Loss of oligodendrocytes was associated with lower relative anisotropy characterized by higher radial diffusivity values. The relationship between histopathology and MRI abnormalities was more pronounced in animals in the 28 d model, equivalent to the term human infant. DISCUSSION: MRI reflects microstructural and anatomical abnormalities that are characteristic of WM injury in the preterm brain, and these changes are more evident on MRI at term-equivalent postmenstrual age. METHODS: We assessed the histopathological correlates of MRI abnormalities in a baboon model of premature birth. Baboons were delivered at 125 d of gestation (dg, term ~185 dg) and maintained in an animal intensive care unit for 14 (n = 26) or 28 d (n = 17). Gestational control animals were delivered at 140 dg (n = 9) or 153 dg (n = 4). Cerebral WM in fixed brains was evaluated using MRI, diffusion tensor imaging (DTI), and histopathology.

Two controlled trials to determine the effectiveness of a mailed intervention to increase colon cancer screening.

OBJECTIVE: Colorectal cancer (CRC) screening is underutilized. Effective and efficient interventions are needed to increase its utilization in primary care. METHODS: We used UNC Internal Medicine electronic medical records to perform 2 effectiveness trials. Eligible patients had no documentation of recent CRC screening and were aged 50-75 years. The mailed intervention contained a letter documenting the need for screening signed by the attending physician in wave A and the practice director in wave B, a postcard to request a decision aid about CRC screening options, and information about how to obtain screening. RESULT: Three-hundred and forty patients of attending physicians in wave A, 944 patients of resident physicians in wave B, and 214 patients of attending physicians in wave B were included. The intervention increased screening compared with controls for attending physicians' patients in wave A (13.1% vs. 4.1%, 95% CI, 3.1%-14.9%) but not for resident physicians' patients in wave B (1.3% vs. 1.9%, 95% CI, -2.2% to 1.0%). A small increase in screening with the intervention was seen in attending physicians' patients in wave B (6.9% vs. 2.4%, 95% CI, -1.4% to 10.5%). Requests for decision aids were uncommon in both waves (12.5% wave A and 7.8% wave B). LIMITATIONS: The group assignments were not individually randomized, and covariate information to explain the differences in effect was limited. CONCLUSIONS: The intervention increased CRC screening in attending physicians' patients who received a letter from their physicians, but not resident physicians' patients who received a letter signed by the practice director.

Macroperiodic Oscillations Are Associated With Seizures Following Acquired Brain Injury in Young Children.

PURPOSE: Seizures occur in 10% to 40% of critically ill children. We describe a phenomenon seen on color density spectral array but not raw EEG associated with seizures and acquired brain injury in pediatric patients. METHODS: We reviewed EEGs of 541 children admitted to an intensive care unit between October 2015 and August 2018. We identified 38 children (7%) with a periodic pattern on color density spectral array that oscillates every 2 to 5 minutes and was not apparent on the raw EEG tracing, termed macroperiodic oscillations (MOs). Internal validity measures and interrater agreement were assessed. We compared demographic and clinical data between those with and without MOs. RESULTS: Interrater reliability yielded a strong agreement for MOs identification (kappa: 0.778 [0.542-1.000]; P < 0.0001). There was a 76% overlap in the start and stop times of MOs among reviewers. All patients with MOs had seizures as opposed to 22.5% of the general intensive care unit monitoring population ( P < 0.0001). Macroperiodic oscillations occurred before or in the midst of recurrent seizures. Patients with MOs were younger (median of 8 vs. 208 days; P < 0.001), with indications for EEG monitoring more likely to be clinical seizures (42 vs. 16%; P < 0.001) or traumatic brain injury (16 vs. 5%, P < 0.01) and had fewer premorbid neurologic conditions (10.5 vs. 33%; P < 0.01). CONCLUSIONS: Macroperiodic oscillations are a slow periodic pattern occurring over a longer time scale than periodic discharges in pediatric intensive care unit patients. This pattern is associated with seizures in young patients with acquired brain injuries.

A Virtual Community of Practice: An International Educational Series in Pediatric Neurocritical Care.

Pediatric neurocritical care (PNCC) is a rapidly growing field. Challenges posed by the COVID-19 pandemic on trainee exposure to educational opportunities involving direct patient care led to the creative solutions for virtual education supported by guiding organizations such as the Pediatric Neurocritical Care Research Group (PNCRG). Our objective is to describe the creation of an international, peer-reviewed, online PNCC educational series targeting medical trainees and faculty. More than 1600 members of departments such as pediatrics, pediatric critical care, and child neurology hailing from 75 countries across six continents have participated in this series over a 10-month period. We created an online educational channel in PNCC with over 2500 views to date and over 130 followers. This framework could serve as a roadmap for other institutions and specialties seeking to address the ongoing problems of textbook obsolescence relating to the rapid acceleration in knowledge acquisition, as well as those seeking to create new educational content that offers opportunities for an interactive, global audience. Through the creation of a virtual community of practice, we have created an international forum for pediatric healthcare providers to share and learn specialized expertise and best practices to advance global pediatric health.

Geriatrics educational outreach: A tale of three GRECCS.

Current geriatrics workforce projections indicate that clinicians who care for adults will need basic geriatrics knowledge and skills to address the geriatric syndromes and issues that limit functional independence and complicate medical management. This is most evident for the clinicians caring for veterans in the Department of Veterans Affairs hospitals and clinics nationwide. Geriatric Research, Education and Clinical Centers (GRECCs), whose staff are geriatric-content experts, have developed a number of programs to tackle this daunting educational task. This article introduces three different programs designed and implemented by GRECCs to train currently practicing health care providers in the Veterans Health Administration medical clinics. It also describes the successes and lessons learned from these three programs.

Renal schwannoma: A case report and literature review of a rare and benign entity mimicking an invasive renal neoplasm.

Schwannomas of the kidney are rare with only a handful of cases reported in literature. We present a case of a large Schwannoma of the right kidney causing mass effect with imaging characteristics thought to represent renal cell carcinoma. On imaging, these masses present similarly to solid renal masses and are therefore indistinguishable without tissue diagnosis. Thus, surgical resection is the definitive treatment for renal schwannomas.

A targeted decision aid for the elderly to decide whether to undergo colorectal cancer screening: development and results of an uncontrolled trial.

BACKGROUND: Competing causes of mortality in the elderly decrease the potential net benefit from colorectal cancer screening and increase the likelihood of potential harms. Individualized decision making has been recommended, so that the elderly can decide whether or not to undergo colorectal cancer (CRC) screening. The objective is to develop and test a decision aid designed to promote individualized colorectal cancer screening decision making for adults age 75 and over. METHODS: We used formative research and cognitive testing to develop and refine the decision aid. We then tested the decision aid in an uncontrolled trial. The primary outcome was the proportion of patients who were prepared to make an individualized decision, defined a priori as having adequate knowledge (10/15 questions correct) and clear values (25 or less on values clarity subscale of decisional conflict scale). Secondary outcomes included overall score on the decisional conflict scale, and preferences for undergoing screening. RESULTS: We enrolled 46 adults in the trial. The decision aid increased the proportion of participants with adequate knowledge from 4% to 52% (p < 0.01) and the proportion prepared to make an individualized decision from 4% to 41% (p < 0.01). The proportion that preferred to undergo CRC screening decreased from 67% to 61% (p = 0. 76); 7 participants (15%) changed screening preference (5 against screening, 2 in favor of screening) CONCLUSION: In an uncontrolled trial, the elderly participants appeared better prepared to make an individualized decision about whether or not to undergo CRC screening after using the decision aid.

Studer unplugged: identifying underlying managerial concepts.

There is evidence that the application of Quint Studer's Hardwiring Excellence approach to organizational change is associated with significant accomplishments in hospitals. The authors' review finds the Studer approach to be closely aligned with management-related concepts of motivation and feedback, social networks, human capital, social capital, management by objectives, evidence based management, and organizational learning. The article is intended to familiarize more managers and management researchers with the content of the Studer approach, demonstrate its grounding in management concepts and principles, and stimulate additional discussion around the utility of such human resources-focused interventions in significant organizational change.

Continuous Electroencephalography Monitoring in Critically Ill Infants and Children.

Continuous video electroencephalography (CEEG) monitoring of critically ill infants and children has expanded rapidly in recent years. Indications for CEEG include evaluation of patients with altered mental status, characterization of paroxysmal events, and detection of electrographic seizures, including monitoring of patients with limited neurological examination or conditions that put them at high risk for electrographic seizures (e.g., cardiac arrest or extracorporeal membrane oxygenation cannulation). Depending on the inclusion criteria and clinical characteristics of the population studied, the percentage of pediatric patients with electrographic seizures varies from 7% to 46% and with electrographic status epilepticus from 1% to 23%. There is also evidence that epileptiform and background CEEG patterns may provide important information about prognosis in certain clinical populations. Quantitative EEG techniques are emerging as a tool to enhance the value of CEEG to provide real-time bedside data for management and prognosis. Continued research is needed to understand the clinical value of seizure detection and identification of other CEEG patterns on the outcomes of critically ill infants and children.