Surgical cytoreduction of deep-seated high-grade glioma through tubular retractor.

OBJECTIVE: Maximal safe resection is the goal of surgical treatment for high-grade glioma (HGG). Deep-seated hemispheric gliomas present a surgical challenge due to safety concerns and previously were often considered inoperable. The authors hypothesized that use of tubular retractors would allow resection of deep-seated gliomas with an acceptable safety profile. The purpose of this study was to describe surgical outcomes and survival data after resection of deep-seated HGG with stereotactically placed tubular retractors, as well as to discuss the technical advances that enable such procedures. METHODS: This is a retrospective review of 20 consecutive patients who underwent 22 resections of deep-seated hemispheric HGG with the Viewsite Brain Access System by a single surgeon. Patient demographics, survival, tumor characteristics, extent of resection (EOR), and neurological outcomes were recorded. Cannulation trajectories and planned resection volumes depended on the relative location of white matter tracts extracted from diffusion tractography. The surgical plans were designed on the Brainlab system and preoperatively visualized on the Surgical Theater virtual reality SNAP platform. Volumetric assessment of EOR was obtained on the Brainlab platform and confirmed by a board-certified neuroradiologist. RESULTS: Twenty adult patients (18 with IDH-wild-type glioblastomas and 2 with IDH-mutant grade IV astrocytomas) and 22 surgeries were included in the study. The cohort included both newly diagnosed (n = 17; 77%) and recurrent (n = 5; 23%) tumors. Most tumors (64%) abutted the ventricular system. The average preoperative and postoperative tumor volumes measured 33.1 ± 5.3 cm3 and 15.2 ± 5.1 cm3, respectively. The median EOR was 93%. Surgical complications included 2 patients (10%) who developed entrapment of the temporal horn, necessitating placement of a ventriculoperitoneal shunt; 1 patient (5%) who suffered a wound infection and pulmonary embolus; and 1 patient (5%) who developed pneumonia. In 2 cases (9%) patients developed new permanent visual field deficits, and in 5 cases (23%) patients experienced worsening of preoperative deficits. Preoperative neurological or cognitive deficits remained the same in 9 cases (41%) and improved in 7 (32%). The median overall survival was 14.4 months in all patients (n = 20) and in the newly diagnosed IDH-wild-type glioblastoma group (n = 16). CONCLUSIONS: Deep-seated HGGs, which are surgically challenging and frequently considered inoperable, are amenable to resection through tubular retractors, with an acceptable safety profile. Such cytoreductive surgery may allow these patients to experience an overall survival comparable to those with more superficial tumors.

A Scoping Review of the Evidence About the Nurses Improving Care for Healthsystem Elders (NICHE) Program.

BACKGROUND AND OBJECTIVES: The Nurses Improving Care for Healthsystem Elders (NICHE) is a nurse-led education and consultation program designed to help health care organizations improve the quality of care for older adults. To conduct a scoping review of the evidence associated with the NICHE program to (a) understand how it influences patient outcomes through specialized care of the older adult and (b) provide an overview of implementation of the NICHE program across organizations as well as its impact on nursing professionals and the work environment. RESEARCH DESIGN AND METHODS: Six databases were searched to identify NICHE-related articles between January 1992 and April 2019. After critical appraisal, 43 articles were included. RESULTS: Four thematic categories were identified including specialized older adult care, geriatric resource nurse (GRN) model, work environment, and NICHE program adoption and refinement. Specialized older adult care, a key feature of NICHE programs, resulted in improved quality of care, patient safety, lower complications, and decreased length of stay. The GRN model emphasizes specialized geriatric care education and consultation. Improvements in the geriatric nurse work environment as measured by perceptions of the practice environment, quality of care, and aging-sensitive care delivery have been reported. NICHE program adoption and refinement focuses on the methods used to improve care, implementation and adoption of the NICHE program, and measuring its impact. DISCUSSION AND IMPLICATIONS: The evidence about the NICHE program in caring for older adults is promising but more studies examining patient outcomes and the impact on health care professionals are needed.

Home health care services to persons with dementia and language preference.

Despite the rapid increase in the number of persons with dementia (PWD) receiving home health care (HHC), little is known of HHC services patterns to PWD of varied backgrounds, including language preference other than English. Analyzing data of 12,043 PWD from an urban home health agency, we found on average PWD received 2.48 skilled visits or 1.88-hour skilled care and 5.81 aide visits or 24.13-hour aide care weekly. Approximately 63% of the skilled visits were from nurses. More non-English preferred PWD received aide visits, compared to English preferred PWD (44% vs. 36%). The type and intensity of HHC services were associated with language preference; when stratified by insurance, non-English preference was still significantly associated with more HHC aide care. Our study indicated that HHC services (both type and amount) varied by language preference and insurance type as an indicator of access disparities was a significant contributor to the observed differences.

Experiences and Perceptions of Hospitalization and Recovery of Older Adults and Their Caregivers Following Traumatic Brain Injury: "Not Knowing".

The purpose of the current study is to describe the experience and perceptions of older adults and their caregivers following hospitalization for mild or moderate traumatic brain injury (TBI). Qualitative analysis of data obtained in individual semi-structured interviews with older adults and their caregivers (N = 11, five dyads and one individual) was performed to capture the perceptions and experiences of the survivor and their caregivers about the acute injury, hospitalization, and recovery. Data were collected over a 2-month period following discharge from the hospital. Open coding and constant comparative analysis generated codes that were revised throughout the analysis and reformulated into thematic descriptions. As a result, seven interrelated themes were identified. These findings can be used to implement interventions focused on recovery, communication, teaching, patient outcomes, and satisfaction. [Res Gerontol Nurs. 2019; 12(5):227-238].

Meta-Synthesis on Migraine Management.

BACKGROUND: Migraine is one of the top 10 most disabling conditions among adults worldwide. Most migraine research is quantitative and indicates concerns about medication adherence, stigma, and more. Qualitative studies might reveal an improved understanding of migraine patients' perspectives regarding migraine treatment. OBJECTIVE: The aim of this study was to synthesize the qualitative research on migraine patients' perspectives regarding migraine treatment to (a) identify common patterns across various types of migraine treatment studies and (b) inform future research. METHODS: A systematic search for qualitative studies in the HA (HA) literature was conducted in Medline (PubMed), PsycINFO, EMBASE, CINAHL, Web of Science, Joanna Briggs Institute EBP Database, and The Cochrane Library. Search terms (subject headings and keywords) were HA, HA disorders, migraine, qualitative studies, and qualitative research. Qualitative studies were systematically identified by using published qualitative search filters recommended by The InterTASC Information Specialists' Sub-Group (ISSG). The search was limited to English only, peer reviewed publications, and studies published between 1996 and 2016. For screening, additional inclusion criteria were (1) adult migraine patients; (2) must mention treatment in the title or study design of the abstract. Ten studies met the inclusion criteria. The Critical Appraisal Skills Program tool was applied to appraise study quality. Thematic analysis produced the codes and themes. Two authors read articles separately and individually created codes. Code lists were synthesized and themes emerged iteratively from the process. RESULTS: Study sample sizes ranged from 10 to 33 participants, with our findings representing 161 participants. Data were collected either using interviews or focus groups. The more common methodologies were grounded theory and phenomenology. Few (3) studies described the number of headache (HA) days for inclusion in the study. Eight out of 10 used International Classification of Headache Disorders (ICHD) criteria. Our synthesis produced five major themes. The first theme was "Migraine patients' difficulties with health care utilization," and it included issues surrounding the cost of migraine treatment (seeing providers and prescription medications). The second theme was "Migraine patients' perceived relationships with their providers," which included the role and relationship with the provider, as well as trust in the provider and the providers' knowledge in managing HAs. The third theme was "Thoughts about the various migraine treatments." It was based on patients' comments indicating an aversion to prescription medications, the use of non-pharmacological interventions for treatment, behavioral modification as a form of treatment, and the need for additional treatment options. The fourth and fifth themes were "Understanding diagnosis/triggers" and "Societal implications," respectively. The latter theme included feelings of not being taken seriously and issues surrounding quality of life. DISCUSSION: The metasynthesis revealed several key commonalities regarding patients' perspectives on migraine treatment and identified new areas for research using a qualitative approach. Researchers conducting qualitative research with patients experiencing migraines might consider using and reporting more of the inclusion and exclusion criteria commonly used in migraine research, for example, reporting whether the ICHD criteria were used and the number of HA days for patients to be in a study. Future studies might be done to determine how the role of allied health care providers, for example, pharmacists, physical therapists, and psychologists, might be expanded to help with migraine treatment and ultimately to improve patient outcomes.

Nonaneurysmal subarachnoid hemorrhage: a review of clinical course and outcome in two hemorrhage patterns.

Patients who experience a nonaneurysmal subarachnoid hemorrhage differ from patients who suffer an aneurysmal subarachnoid hemorrhage in initial presentation (including neurological examination and computed tomography [CT] scans), clinical course, and outcome. A perimesencephalic distribution of nonaneurysmal subarachnoid blood on CT imaging has been described as a distinct clinical entity with a benign course and an excellent prognosis; research suggests that the majority of these patients have excellent outcomes. In most cases, these patients return to their previous level of functioning. Surviving a subarachnoid hemorrhage can be emotionally devastating to patients and their families and can threaten employment and health insurance eligibility. Using evidence-based practice, neuroscience nurses can reassure and educate patients, staff members, and the public and facilitate their understanding of the clinical course and outcome.

Tandem practice model: a model for physician-nurse practitioner collaboration in a specialty practice, neurosurgery.

PURPOSE: To describe the benefits of a physician-nurse practitioner (NP) collaborative practice model, specifically that of a tandem practice model, using a neurosurgeon and a primary care NP in the clinic and inpatient setting. DATA SOURCES: Selected journal articles from Medline and CINAHL, and anecdotal clinical experience. CONCLUSIONS: This collaborative practice model, in which the physician and NP deliver patient care in tandem, is beneficial to patients and their families because they receive comprehensive care that is patient oriented and holistic. Further, the model benefits multiple disciplines across the healthcare continuum by providing efficient communication of patient needs, accessibility of the specialty team, and timely implementation of patient interventions. The collaboration of the physician specialist and primary care NP provides a holistic approach to the care of diverse and challenging patient populations. IMPLICATIONS FOR PRACTICE: Patients seen in a specialty practice, particularly that of neurosurgery, often have little understanding of their problem and may be frightened or confused because of their perceptions of the unknown. Providing care to such specialized patient populations in a constantly changing healthcare environment may prove demanding to the specialist. The introduction of a primary care NP into such specialty settings offers patients, their families, consultants, and staff members an additional resource for evaluation, intervention, education, and communication, improving the continuity and comprehensiveness of care to challenging patient populations. This model is an option for physician specialists interested in augmenting their practice and provides further resources for meeting the holistic needs of selected patient populations regardless of the setting.