Long-term outcomes of mesial temporal laser interstitial thermal therapy for drug-resistant epilepsy and subsequent surgery for seizure recurrence: a multi-centre cohort study.

BACKGROUND: Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to surgical resection for drug-resistant mesial temporal lobe epilepsy (mTLE). Reported rates of seizure freedom are variable and long-term durability is largely unproven. Anterior temporal lobectomy (ATL) remains an option for patients with MRgLITT treatment failure. However, the safety and efficacy of this staged strategy is unknown. METHODS: This multicentre, retrospective cohort study included 268 patients consecutively treated with mesial temporal MRgLITT at 11 centres between 2012 and 2018. Seizure outcomes and complications of MRgLITT and any subsequent surgery are reported. Predictive value of preoperative variables for seizure outcome was assessed. RESULTS: Engel I seizure freedom was achieved in 55.8% (149/267) at 1 year, 52.5% (126/240) at 2 years and 49.3% (132/268) at the last follow-up ≥1 year (median 47 months). Engel I or II outcomes were achieved in 74.2% (198/267) at 1 year, 75.0% (180/240) at 2 years and 66.0% (177/268) at the last follow-up. Preoperative focal to bilateral tonic-clonic seizures were independently associated with seizure recurrence. Among patients with seizure recurrence, 14/21 (66.7%) became seizure-free after subsequent ATL and 5/10 (50%) after repeat MRgLITT at last follow-up≥1 year. CONCLUSIONS: MRgLITT is a viable treatment with durable outcomes for patients with drug-resistant mTLE evaluated at a comprehensive epilepsy centre. Although seizure freedom rates were lower than reported with ATL, this series represents the early experience of each centre and a heterogeneous cohort. ATL remains a safe and effective treatment for well-selected patients who fail MRgLITT.

Use of a Pericranial Flap Technique for Deep Brain Stimulation Hardware Protection and Improved Cosmesis.

OBJECTIVES: Deep brain stimulation (DBS) has become an established neuromodulation therapy; however, surgical site complications such as hardware skin erosion remain an important risk and can predispose to infection, requiring explantation of the system. Nuances of surgical technique can affect wound healing, cosmetic outcome, comfort, and risk of infection. In this study, we describe our experience with a layered closure technique using a vascularized pericranial flap for improving cosmesis and protection of the implanted hardware against skin erosion and infection. MATERIALS AND METHODS: We retrospectively reviewed 636 individuals (746 lead implantations) who underwent DBS surgery by a single academic neurosurgeon between 2001 and 2020. A layered pericranial flap closure technique for the burr-hole and connector sites was instituted in 2015. We assessed the effects of a multimodal infection prevention approach that included the pericranial flap on hardware complication rates compared with the premultimodality cohort, and we report the nuances of the technique. RESULTS: In our institutional experience, we found that implementation of a pericranial flap closure technique can enhance the subjective cosmetic result at the burr-hole cover site and increase patient comfort and satisfaction. In addition, we found a decrease in hardware infection rates in the current cohort with a multimodal infection prevention regimen that includes the pericranial-flap technique (n = 256, 2015-2020 period) to 1.2% (p = 0.006), from 6.9% in the earlier cohort (n = 490, 2001-2015 period). CONCLUSIONS: The report highlights the potential of a pericranial-flap closure technique as a surgical adjunct to improve DBS surgical site healing and cosmesis and may, as part of a multimodal strategy, contribute to decreased risk of skin breakdown and hardware infection.

Pilot Evaluation of the Online 'Chaplains-CARE' Program: Enhancing Skills for United States Military Suicide Intervention Practices and Care.

Chaplains frequently serve as first responders for United States military personnel experiencing suicidal thoughts and behaviors. The Chaplains-CARE Program, a self-paced, e-learning course grounded in suicide-focused cognitive behavioral therapy principles, was tailored for United States military chaplains to enhance their suicide intervention skills. A pilot program evaluation gathered 76 Department of Defense (DoD), Veterans Affairs (VA), and international military chaplain learners' responses. Most learners indicated that the course was helpful, easy to use, relevant, applicable, and that they were likely to recommend it to other chaplains. Based on open-ended responses, one-quarter (25.0%) of learners indicated that all content was useful, and over one-quarter (26.3%) of learners highlighted the usefulness of the self-care module. One-third (30.3%) of learners reported the usefulness of the interactive e-learning features, while others (26.3%) highlighted the usefulness of chaplains' role play demonstrations, which portrayed counseling scenarios with service members. Suggested areas of improvement include specific course adaptation for VA chaplains and further incorporation of experiential learning and spiritual care principles. The pilot findings suggest that Chaplains-CARE Online was perceived as a useful suicide intervention training for chaplains. Future training can be enhanced by providing experiential, simulation-based practice of suicide intervention skills.

Randomized trial of rTMS in traumatic brain injury: improved subjective neurobehavioral symptoms and increases in EEG delta activity.

PRIMARY OBJECTIVE: While repetitive transcranial magnetic stimulation (rTMS) has shown efficacy for cognitive difficulties accompanying depression, it is unknown if it can improve cognition in persons with traumatic brain injury. RESEARCH DESIGN: Using a sham-controlled crossover design, we tested the capacity of high frequency rTMS of the prefrontal cortex to improve neuropsychological performance in attention, learning and memory, and executive function. METHODS: Twenty-six participants with cognitive complaints and a history of mild-to-moderate traumatic brain injury were randomly assigned to receive first either active or sham 10 Hz stimulation for 20 minutes (1200 pulses) per session for five consecutive days. After a one-week washout, the other condition (active or sham) was applied. Pre- and post-treatment measures included neuropsychological tests, cognitive and emotional symptoms, and EEG. MAIN OUTCOMES AND RESULTS: Results indicated no effect of treatment on cognitive function. Subjective measures of depression, sleep dysfunction, post-concussive symptoms (PCS), and executive function showed significant improvement with stimulation, retaining improved levels at two-week follow-up. EEG delta power exhibited elevation one week after stimulation cessation. CONCLUSIONS: While there is no indication that rTMS is beneficial for neuropsychological performance, it may improve PCS and subjective cognitive dysfunction. Long-term alterations in cortical oscillations may underlie the therapeutic effects of rTMS.

The Poised Cannula Technique Reduces the Stereotactic Error of the Fiducial-Less Frameless DBS Procedure.

BACKGROUND: In this study, we describe a technique of optimizing the accuracy of frameless deep brain stimulation (DBS) lead placement through the use of a cannula poised at the entry to predict the location of the fully inserted device. This allows real-time correction of error prior to violation of the deep gray matter. METHODS: We prospectively gathered data on radial error during the operative placements of 40 leads in 28 patients using frameless fiducial-less DBS surgery. Once the Nexframe had been aligned to target, a cannula was inserted through the center channel of the BenGun until it traversed the pial surface and a low-dose O-arm spin was obtained. Using 2 points along the length of the imaged cannula, a trajectory line was projected to target depth. If lead location could be improved, the cannula was inserted through an alternate track in the BenGun down to target depth. After intraoperative microelectrode recording and clinical assessment, another O-arm spin was obtained to compare the location of the inserted lead with the location predicted by the poised cannula. RESULTS: The poised cannula projection and the actual implant had a mean radial discrepancy of 0.75 ± 0.64 mm. The poised cannula projection identified potentially clinically significant errors (avg 2.07 ± 0.73 mm) in 33% of cases, which were reduced to a radial error of 1.33 ± 0.66 mm (p = 0.02) after correction using an alternative BenGun track. The final target to implant error for all 40 leads was 1.20 ± 0.52 mm with only 2.5% of errors being >2.5 mm. CONCLUSION: The poised cannula technique results in a reduction of large errors (>2.5 mm), resulting in a decline in these errors to 2.5% of implants as compared to 17% in our previous publication using the fiducial-less method and 4% using fiducial-based methods of DBS lead placement.

Effects of surgical targeting in laser interstitial thermal therapy for mesial temporal lobe epilepsy: A multicenter study of 234 patients.

OBJECTIVE: Laser interstitial thermal therapy (LITT) for mesial temporal lobe epilepsy (mTLE) has reported seizure freedom rates between 36% and 78% with at least 1 year of follow-up. Unfortunately, the lack of robust methods capable of incorporating the inherent variability of patient anatomy, the variability of the ablated volumes, and clinical outcomes have limited three-dimensional quantitative analysis of surgical targeting and its impact on seizure outcomes. We therefore aimed to leverage a novel image-based methodology for normalizing surgical therapies across a large multicenter cohort to quantify the effects of surgical targeting on seizure outcomes in LITT for mTLE. METHODS: This multicenter, retrospective cohort study included 234 patients from 11 centers who underwent LITT for mTLE. To investigate therapy location, all ablation cavities were manually traced on postoperative magnetic resonance imaging (MRI), which were subsequently nonlinearly normalized to a common atlas space. The association of clinical variables and ablation location to seizure outcome was calculated using multivariate regression and Bayesian models, respectively. RESULTS: Ablations including more anterior, medial, and inferior temporal lobe structures, which involved greater amygdalar volume, were more likely to be associated with Engel class I outcomes. At both 1 and 2 years after LITT, 58.0% achieved Engel I outcomes. A history of bilateral tonic-clonic seizures decreased chances of Engel I outcome. Radiographic hippocampal sclerosis was not associated with seizure outcome. SIGNIFICANCE: LITT is a viable treatment for mTLE in patients who have been properly evaluated at a comprehensive epilepsy center. Consideration of surgical factors is imperative to the complete assessment of LITT. Based on our model, ablations must prioritize the amygdala and also include the hippocampal head, parahippocampal gyrus, and rhinal cortices to maximize chances of seizure freedom. Extending the ablation posteriorly has diminishing returns. Further work is necessary to refine this analysis and define the minimal zone of ablation necessary for seizure control.

A Comparative Study of Fiducial-Based and Fiducial-Less Registration Utilizing the O-Arm.

BACKGROUND: Frameless stereotactic surgery utilizing fiducial-based (FB) registration is an established tool in the armamentarium of deep brain stimulation (DBS) surgeons. Fiducial-less (FL) registration via intraoperative CT, such as the O-arm, has been routinely used in spine surgery, but its accuracy for DBS surgery has not been studied in a clinical setting. OBJECTIVE: We undertook a study to analyze the accuracy of the FL technique in DBS surgery and compare it to the FB method. METHODS: In this prospective cohort study, 97 patients underwent DBS surgery using the NexFrame and the O-arm registration stereotactic system. Patients underwent FB (n = 50) registration from 2015 to 2016 and FL (n = 47) O-arm registration from 2016 to 2017. RESULTS: The radial errors (RE) and vector/euclidean errors of FB and FL registration were not significantly different. There was no difference in additional passes between methods, but there was an increase in the number of RE ≥2.5 mm in the FL method. CONCLUSION: Although there was no statistically significant difference in RE or the need for additional passes, the increased number of errors ≥2.5 mm with the FL method (17 vs. 4% in FB) indicates the need for further study. We concluded that O-arm images of the implants should be utilized to assess and correct for this error.

Evaluating the progressive cardiovascular health benefits of short-term high-intensity interval training.

PURPOSE: High-intensity training is recognised as a time-efficient way of improving aerobic fitness. However, there is a lack of consensus regarding the temporal nature of adaptation response and which peripheral and cardiac changes occur using the same exercise stimulus and protocol. Therefore, this study aimed to evaluate the progression of vascular and cardiac changes over a 6-week training period. METHODS: Twelve healthy males (age 21 ± 2 years; 42.5 ± 8.3 ml min-1 kg-1) participated in a high-intensity training programme consisting of 1-min sprints, interspersed with 2 min active recovery, 3 days/week for 6 weeks on a cycle ergometer. Cardiac, vascular, blood lipids and VO2max measurements were taken at 0, 3 and 6 weeks and compared against a participant-matched control group (age 21 ± 2 years; 37.7 ± 8.3 ml min-1 kg-1). RESULTS: There was a significant improvement in VO2max (42.5 ± 8.3-47.4 ± 8.5 ml min-1 kg-1; p = 0.009) in the training group and a significant decrease in systolic blood pressure (8%) from 0 to 6 weeks (p = 0.025). There was a small yet significant decrease in ejection fraction and increased end-systolic volume in both groups over time (p = 0.01) with no significant interaction effect (p > 0.05). A between-group difference in peak velocity of early diastolic mitral annular motion was also observed (p = 0.01). No improvements were seen in blood lipid profiles, central arterial stiffness and cardiometabolic risk score. CONCLUSIONS: Six weeks of high-intensity training increases aerobic fitness and is enough to stimulate initial reductions in peripheral pressure, but not sufficient to elicit structural and functional cardiac changes, reduce arterial stiffness or lower CV risk.

Oxygen uptake kinetics in trained adolescent females.

UNLABELLED: Little evidence exists with regard to the effect that exercise training has upon oxygen uptake kinetics in adolescent females. PURPOSE: The aim of the study was to compare [Formula: see text] and muscle deoxygenation kinetics in a group of trained (Tr) and untrained (Utr) female adolescents. METHOD: Twelve trained (6.4 ± 0.9 years training, 10.3 ± 1.4 months per year training, 5.2 ± 2.0 h per week) adolescent female soccer players (age 14.6 ± 0.7 years) were compared to a group (n = 8) of recreationally active adolescent girls (age 15.1 ± 0.6 years) of similar maturity status. Subjects underwent two, 6-min exercise transitions at a workload equivalent to 80 % of lactate threshold from a 3-min baseline of 10 W. All subjects had a passive rest period of 1 h between each square-wave transition. Breath-by-breath oxygen uptake and muscle deoxygenation were measured throughout and were modelled via a mono-exponential decay with a delay relative to the start of exercise. RESULT: Peak [Formula: see text] was significantly (p < 0.05) greater in the Tr compared to the Utr (Tr: 43.2 ± 3.2 mL kg(-1 )min(-1) vs. Utr: 34.6 ± 4.0 mL kg(-1 )min(-1)). The [Formula: see text] time constant was significantly (p < 0.05) faster in the Tr compared to the Utr (Tr: 26.3 ± 6.9 s vs. Utr: 35.1 ± 11.5 s). There was no inter-group difference in the time constant for muscle deoxygenation kinetics (Tr: 8.5 ± 3.0 s vs. Utr: 12.4 ± 8.3 s); a large effect size, however, was demonstrated (-0.804). CONCLUSION: Exercise training and/or genetic self-selection results in faster kinetics in trained adolescent females. The faster [Formula: see text] kinetics seen in the trained group may result from enhanced muscle oxygen utilisation.

Experiences with pregnancy and child-rearing, advice for future mothers, and suggestions for improving the system: a qualitative study of women in neurosurgery.

OBJECTIVE: Neurosurgery is among the most demanding and time-consuming occupations, and with diversity and inclusion initiatives only recently increasing the number of women in the field, efforts still need to be made to help neurosurgery become more accommodating for pregnancy and child-rearing. Thus, the present study sought to be the first to investigate this issue through in-depth qualitative interviews of women in neurosurgery. METHODS: A total of 33 female neurosurgeons participated in semistructured Zoom interviews. Cocoding and thematic analysis were conducted with interview transcripts to determine themes and corresponding subthemes with regard to these women's experiences with pregnancy and child-rearing, advice for future mothers in neurosurgery, and suggestions for improving the field of neurosurgery for those desiring children. RESULTS: Among the 33 participants, 22 (66.7%) had given birth to or adopted at least one child, had at least one stepchild, or were pregnant at the time of the interview. Three themes emerged regarding these 22 women's experiences with pregnancy and child-rearing: 1) challenges with the physiological changes of pregnancy, 2) feelings of guilt and anxiety, and 3) reliance on loved ones for childcare. Three themes emerged among these 22 women's advice for future mothers in neurosurgery: 1) set realistic expectations, 2) take control of your schedule, and 3) realize that there is no "right" time to start a family. Finally, two themes emerged among all 33 participants' suggestions for making neurosurgery more feasible for pregnancy and child-rearing: 1) revamping of on-site resources, and 2) improved guidance on family planning, childbearing, and maternity leave. The most prominent subtheme in the authors' study was a call for improved on-site daycare under the "revamping of on-site resources" theme, with a particular emphasis on 24/7 operation. CONCLUSIONS: The authors' data have illustrated the themes of the experiences and thoughts of women in a field where pregnancy and child-rearing are arguably the most challenging of any occupation. Resources such as improved on-site daycare and organized, program-specific information sets for future mothers appear to comprise a consensus of suggested solutions by the women directly experiencing these challenges. The authors' results may be useful in guiding system-wide changes that may improve the field of neurosurgery for current and future mothers.

The Spaghetti Sign: Nerve Root Redundancy in Lumbar Spinal Stenosis.

OBJECTIVE: Redundant nerve roots (RNRs) seen in conjunction with lumbar spinal stenosis (LSS) are well-described radiographic findings. Several studies suggest their presence may be a negative prognostic indicator of postoperative outcome. Our hypothesis was that severe RNR (informally known as the spaghetti sign [SS]) can serve as a reliable marker of LSS that would benefit from surgical decompression. We sought to evaluate a grading scale for RNR, characterize the association with stenosis, and investigate the clinical implications of RNR. METHODS: We conducted a retrospective chart review of 72 patients who underwent lumbar spine surgery from 2016 to 2018 at 1 institution. Preoperative T2 magnetic resonance imaging scans were graded by 3 reviewers for severity of stenosis (0-4), severity of RNR (0-3), and rostral versus caudal RNR. SS was defined as RNR score ≥2 (clear-cut or marked nerve root irregularity). Preoperative and postoperative Oswestry Disability Index scores were analyzed by stenosis and RNR severity. RESULTS: Seventy-one (98%) patients had severe stenosis (score ≥3) and 25 (35%) had a SS. SS was 100% specific for high-grade stenosis. If patients had a SS, it was more likely rostral (P=0.02). Postoperative Oswestry Disability Index scores improved significantly, but there were no differences related to RNR score, presence of SS, or stenosis severity. CONCLUSIONS: The study demonstrated that there is a significant association between SS and severe LSS and that presence of RNR is not a negative prognostic indicator for postoperative outcomes.

Precision targeting in the globus pallidus interna: insights from the multicenter, prospective, blinded VA/NINDS CSP 468 study.

OBJECTIVE: Deep brain stimulation (DBS) targeting the globus pallidus interna (GPi) has been shown to significantly improve motor symptoms for the treatment of medication-refractory Parkinson's disease. Yet, heterogeneity in clinical outcomes persists, possibly due to suboptimal target identification within the GPi. By leveraging robust sampling of the GPi and 6-month postsurgical outcomes, this study aims to determine optimal symptom-specific GPi DBS targets. METHODS: In this study, the authors analyzed the anatomical lead location and 6-month postsurgical, double-blinded outcome measures of 86 patients who underwent bilateral GPi DBS. These patients were selected from the multicenter Veterans Affairs (VA)/National Institutes of Neurological Disorders and Stroke (NINDS) Cooperative Studies Program (CSP) 468 study to identify the optimal target zones ("sweet spots") for the control of overall motor (United Parkinson's Disease Rating Scale [UPDRS]-III), axial, tremor, rigidity, and bradykinesia symptoms. Lead coordinates were normalized to Montreal Neurological Institute space and the optimal target zones were identified and validated using a leave-one-patient-out approach. RESULTS: The authors' findings revealed statistically significant optimal target zones for UPDRS-III (R = 0.37, p < 0.001), axial (R = 0.22, p = 0.042), rigidity (R = 0.20, p = 0.021), and bradykinesia (R = 0.23, p = 0.004) symptoms. These zones were localized within the primary motor and premotor subdivisions of the GPi. Interestingly, these zones extended beyond the GPi lateral border into the GPi-globus pallidus externa (GPe) lamina and into the GPe, but they did not reach the GPi ventral border, challenging traditional surgical approaches based on pallidotomies. CONCLUSIONS: Drawing upon a robust dataset, this research effectively delineates specific optimal target zones for not only overall motor improvement but also symptom subscores. These insights hold the potential to enhance the precision of targeting in subsequent bilateral GPi DBS surgical procedures.

Deep Brain Stimulation of Nucleus Basalis of Meynert improves learning in rat model of dementia.

Background: Deep brain stimulation (DBS) of the nucleus basalis of Meynert (NBM) has been preliminarily investigated as a potential treatment for dementia. The degeneration of NBM cholinergic neurons is a pathological feature of many forms of dementia. Although stimulation of the NBM has been demonstrated to improve learning, the ideal parameters for NBM stimulation have not been elucidated. This study assesses the differential effects of varying stimulation patterns and duration on learning in a dementia rat model. Methods: 192-IgG-saporin (or vehicle) was injected into the NBM to produce dementia in rats. Next, all rats underwent unilateral implantation of a DBS electrode in the NBM. The experimental groups consisted of i-normal, ii-untreated demented, and iii-demented rats receiving NBM DBS. The stimulation paradigms included testing different modes (tonic and burst) and durations (1-hr, 5-hrs, and 24-hrs/day) over 10 daily sessions. Memory was assessed pre- and post-stimulation using two established learning paradigms: novel object recognition (NOR) and auditory operant chamber learning. Results: Both normal and stimulated rats demonstrated improved performance in NOR and auditory learning as compared to the unstimulated demented group. The burst stimulation groups performed better than the tonic stimulated group. Increasing the daily stimulation duration to 24-hr did not further improve cognitive performance in an auditory recognition task and degraded the results on a NOR task as compared with 5-hr. Conclusion: The present findings suggest that naturalistic NBM burst DBS may offer a potential effective therapy for treating dementia and suggests potential strategies for the reevaluation of current human NBM stimulation paradigms.

Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease.

BACKGROUND: Deep-brain stimulation is the surgical procedure of choice for patients with advanced Parkinson's disease. The globus pallidus interna and the subthalamic nucleus are accepted targets for this procedure. We compared 24-month outcomes for patients who had undergone bilateral stimulation of the globus pallidus interna (pallidal stimulation) or subthalamic nucleus (subthalamic stimulation). METHODS: At seven Veterans Affairs and six university hospitals, we randomly assigned 299 patients with idiopathic Parkinson's disease to undergo either pallidal stimulation (152 patients) or subthalamic stimulation (147 patients). The primary outcome was the change in motor function, as blindly assessed on the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III), while patients were receiving stimulation but not receiving antiparkinsonian medication. Secondary outcomes included self-reported function, quality of life, neurocognitive function, and adverse events. RESULTS: Mean changes in the primary outcome did not differ significantly between the two study groups (P=0.50). There was also no significant difference in self-reported function. Patients undergoing subthalamic stimulation required a lower dose of dopaminergic agents than did those undergoing pallidal stimulation (P=0.02). One component of processing speed (visuomotor) declined more after subthalamic stimulation than after pallidal stimulation (P=0.03). The level of depression worsened after subthalamic stimulation and improved after pallidal stimulation (P=0.02). Serious adverse events occurred in 51% of patients undergoing pallidal stimulation and in 56% of those undergoing subthalamic stimulation, with no significant between-group differences at 24 months. CONCLUSIONS: Patients with Parkinson's disease had similar improvement in motor function after either pallidal or subthalamic stimulation. Nonmotor factors may reasonably be included in the selection of surgical target for deep-brain stimulation. (ClinicalTrials.gov numbers, NCT00056563 and NCT01076452.)

How to grow our own: an evaluation of preceptorship in New Zealand graduate nurse programmes.

Effective preceptorship has consistently been identified as an essential support process for graduate nurses in their first year of practice. Quality preceptorship supports a new graduate to develop confidence and competence and is seen as a critical component of any new graduate programme. This paper provides an overview of nurse entry to practice (NETP) programmes within New Zealand, along with key findings from a commissioned evaluation study during 2007-2009 that focused on preceptorship support for new graduate nurses. Findings from the evaluation identified access to preceptors, the importance of the preceptor/new graduate relationship, preceptor preparation for their role and the overall culture of support as important. Nursing leadership is additionally identified as a critical component to support effective preceptorship in any new graduate nursing programme.

Cochlear implants and deep brain stimulators.

OBJECTIVE AND IMPORTANCE: With an aging population and increasing utilization of both cochlear implants (CI) to treat hearing loss and deep brain stimulation (DBS) to treat neurodegenerative movement disorders, more patients will be sequentially implanted with the two devices. As such, understanding both presurgical evaluations and surgical procedures will be of great importance to the treating cochlear implant surgeon and neurosurgeon in optimizing outcomes for both conditions. CLINICAL PRESENTATION: Two illustrative cases of sequential CI followed by DBS are reviewed. Relevant pre-, intra-, and postoperative issues are discussed for both DBS following CI surgery and CI following DBS surgery. CONCLUSION: Despite the potential for challenges, sequential CI and DBS (and vice versa) can provide substantial benefit to those individuals with severe hearing loss and movement disorders. A thorough understanding of both devices is critical to ensuring optimal outcomes.

Firearm Suicide Prevention in the U.S. Military: Recommendations From a National Summit.

The U.S. DoD has identified firearm suicide prevention as a key operational priority. One vital approach to addressing firearm suicides is through promoting lethal means safety, which involves the voluntary use of secure storage for personally owned firearms and/or temporarily moving firearms out of the home during risk periods. Despite promising approaches to lethal means safety, critical gaps remain in research, programming, and communication among and across scientists, DoD programmatic leaders, front-line commanders, and service members. To address these gaps, the first-ever national "Firearm Suicide Prevention in the Military: Messaging and Interventions Summit" was convened in June 2022, bringing together DoD personnel and researchers with expertise in firearm suicide prevention and lethal means safety. The Summit identified 10 recommendations to enhance firearm suicide prevention messaging and interventions in the U.S. military, including (1) repeal or amend prohibitions on questioning service members about personal firearms; (2) develop, examine, and use common language for firearm injury prevention; (3) implement a universal approach to training on comprehensive firearm injury prevention; (4) encourage leadership across disciplines and levels; (5) aim for broad culture change; (6) support innovative research; (7) consider various outcome measures; (8) promote "cultural competence" for better communication; (9) reduce territorialism; and (10) develop creative partnerships. Ultimately, these recommendations can facilitate productive partnerships with a shared goal: to develop, test, and implement strategies that standardize lethal means safety and reduce firearm suicides and other firearm injuries or harm among service members.

The New Zealand nurse specialist framework: clarifying the contribution of the nurse specialist.

Maximizing the contribution that nurses can make to the health care outcomes is the focus of health workforce planners and funders worldwide. New Zealand, along with many other countries, faces significant taxonomical challenges in developing specialist nursing workforce as nurse specialists and specialty areas of practice are inconsistently defined. Clearly defining and capturing data on current workforces is a challenge shared by many countries impacting on the ability to understand current supply and plan for anticipated increased demand. This article presents an overview of the New Zealand Nurse Specialist Framework (NZNSF) developed through a consensus approach as part of a doctoral study. The NZSNF has already been adopted by some national nursing groups in New Zealand and provides an overarching structure to support coherence, clarity and consistency for nurse specialists. The framework aims to support workforce policy makers in planning effective utilization of the nurse specialist in health care delivery.

Entry to nursing practice preceptor education and support: could we do it better?

High quality preceptorship during their first year of practice is seen as critical for new graduate nurses' development of competence and confidence. Quality preceptorship is dependent upon skilled and knowledgeable preceptors who are committed to this role. A recent longitudinal evaluation of 21 Nursing Entry to Practice (NETP) programmes in New Zealand identified that preceptorship selection, education and support do not always receive the attention they warrant. Failure to plan preceptor selection leads to ad hoc selection and consequent allocations of many preceptors who may not have attended appropriate education, or have a desire to undertake this role. Such a situation is detrimental to the job satisfaction of both preceptors and new graduate nurses. High workloads, rostering difficulties and increased acuity in many clinical areas often prevent preceptors from attending appropriate education and that, in turn, impacts negatively on the preceptor's expectations and clarity with respect to the role. To offset this effect the authors recommend development of a clearly defined preceptor selection process, along with flexible preceptor education programmes that provide a good foundation for support of new graduates in their first year of practice; but do not increase preceptor workloads.

Utility of GPI+VIM dual-lead deep brain stimulation for Parkinson's disease patients with significant residual tremor on medication.

OBJECTIVE: Randomized controlled trials have demonstrated that deep brain stimulation (DBS) of both the globus pallidus internus (GPI) and subthalamic nucleus (STN) for Parkinson's disease (PD) is superior to the best medical therapy. Tremor is particularly responsive to DBS, with reports of 70%-80% improvement. However, a small number of patients do not obtain the expected response with both STN and GPI targets. Indeed, the authors' patient population had a similar 81.2% tremor reduction with a 9.6% failure rate. In an analysis of these failures, they identified patients with preoperative on-medication tremor who subsequently received a GPI lead as a subpopulation at higher risk for inadequate tremor control. Thereafter, STN DBS was recommended for patients with on-medication tremor. However, for the patients with symptoms and comorbidities that favored GPI as the target, dual GPI and ventral intermediate nucleus of the thalamus (VIM) leads were proposed. This report details outcomes for those patients. METHODS: This is a retrospective review of patients with PD who met the criteria for and underwent simultaneous GPI+VIM DBS surgery from 2015 to 2020 and had available follow-up data. The preoperative Unified Parkinson's Disease Rating Scale scores were obtained with the study participants on and off their medication. Postoperatively, the GPI lead was kept on at baseline and scores were obtained with and without VIM stimulation. RESULTS: Thirteen PD patients with significant residual preoperative tremor on medication underwent simultaneous GPI+VIM DBS surgery (11 unilateral, 2 bilateral). A mean 90.6% (SD 15.0%) reduction in tremor scores was achieved with dual GPI+VIM stimulation compared to a 21.8% (SD 71.9%) reduction with GPI stimulation alone and a 30.9% (SD 37.8%) reduction with medication. Although rigidity and bradykinesia reductions were accomplished with just GPI stimulation, 13 of the 15 hemispheres required VIM stimulation to achieve excellent tremor control. CONCLUSIONS: GPI+VIM stimulation was required to adequately control tremor in all but 2 patients in this series, substantiating the authors' hypothesis that, in their population, medication-resistant tremor does not completely respond to GPI stimulation. Dual stimulation of the GPI and VIM proved to be an effective option for the patients who had symptoms and comorbidities that favored GPI as a target and had medication-resistant tremor.