Letter to Our Colleagues Family Practitioners, Geriatricians, and Radiologists to Increase Awareness Regarding Idiopathic Normal Pressure Hydrocephalus.

OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) affects elderly individuals and is characterized by a progressive deterioration of gait, urinary continence, and cognition. In most cases, it is reversible with treatment. INPH is not uncommonly an unrecognized cause of dementia. We wish to raise awareness of iNPH among primary care providers who are seeing these patients first. METHODS: We reviewed the current epidemiological data regarding iNPH as well as epidemiological data regarding Alzheimer disease. We searched for the most sensitive radiological screening test for iNPH. RESULTS: Alzheimer disease comprises 60%-70% of all dementia cases, in 2023 is affecting 6.7 million Americans, about 10.7% of people 65 and older. Epidemiological data from the Scandinavian countries confirmed that 3.7% of people older than 65 have iNPH. Surgical studies confirmed the presence of early Alzheimer's pathology in about 25% of operated patients with iNPH. Useful radiological findings of iNPH include an Evans Index greater than 0.30, and a disproportionally enlarged subarachnoid space hydrocephalus (DESH). However, the callosal angle is thought to represent the best tool to discriminate iNPH from its mimics. CONCLUSIONS: According to the available epidemiological data iNPH is underdiagnosed. We strongly encourage the primary care physicians and geriatricians to ask the radiologist to measure the callosal angle on the initial brain computed tomography (or magnetic resonance) image. If the callosal angle is ≤71°, it is appropriate to refer the patient to neurosurgery for further diagnostic work-up.

Management of hemorrhage from cavernous malformations.

Cavernous Malformations (CMs) are immature vessels consisting of endothelium-lined sinusoids. Often diagnosed incidentally, they remain clinically silent in the vast majority of patients. Their natural history is now largely believed to follow a benign course that should be conservatively managed in the majority of cases. The exception is the treatment of deep lesions. Here there is not a consensus but the general inclination is towards radiosurgical treatment of inaccessible lesions. However, the results of radiosurgical or gross surgical resection have not been shown to be significantly better than many patients who were managed conservatively. In view of this, an understanding of the natural history of CM and the various outcomes from surgery, radiosurgery and conservative management are essential to define the goals for patients and to individualize treatment strategy.

Achieving and Maintaining Safety in Healthcare Requires Unwavering Institutional and Individual Commitments.

In 2000, "To Err Is Human" brought to light the fact that the estimated number of people dying from medical errors occurring in hospitals exceeded those that die from motor vehicle accidents (MVAs), breast cancer, or acquired immunodeficiency syndrome (AIDS) - three causes receiving far more public attention. The report prompted the gradual adoption of safety processes developed in the nuclear and aviation industries. However, sophisticated engineering solutions to operations are not enough. High and low mortality hospitals have similar processes and procedures, but low-mortality hospitals are more proficient at recognizing and managing serious complications as they unfold. This ability to rescue a deteriorating situation (resilience) reflects a healthier safety culture. Organizations move within the safety space in the direction of either more or less resilience depending on the fluctuation of their safety culture. Improving resilience requires transforming learned safety practices into a "habit" in conjunction with accepting accountability. Personal accountability means commitment to safe practices along with effective and transparent reporting of near misses/close calls and adverse events (AEs). Institutional accountability means putting safety first by ensuring the availability of appropriate resources, role leadership modeling, and effective management of sentinel events (SEs) to reduce harm occurrence and re-occurrence. This requires a more robust root cause analysis (RCA) process to guarantee that action plans produce strong and effective corrective measures. Synergistic coaching interventions include instilling the awareness that failure can and will happen, mapping team talents, and assessing gaps. These interventions will optimize group expertise, reaffirming the concept of institutional and personal accountability. The unending performance of drills will sustain the group resilience under both expected and unexpected conditions. Given the strong correlation between practice environment and outcomes, sustained improvement of the safety climate will produce more robust safety behaviors and ultimately better outcomes.