Angulation of the dural venous sinuses of the posterior cranial fossa: Anatomical study with clinical and surgical applications.

Cerebral vein and dural venous sinus thromboses (CVST) account for 0.5%-1% of all strokes. Some structural factors associated with a potentially higher risk for developing CVST have been described. However, angulation of the dural venous sinuses (DVS) has yet to be studied as a structural factor. The current study was performed because this variable could be related to alterations in venous flow, thus predisposing to a greater risk of CVST development. Additionally, such information could help shed light on venous sinus stenosis (VSS) at or near the transverse-sigmoid junction. The angulations formed in the different segments of the grooves of the transverse (TS), sigmoid (SS), and superior sagittal sinuses (SSS) were measured in 52 skulls (104 sides). The overall angulation of the TS groove was measured using two reference points. Other variables were examined, such as the communication pattern at the sinuses' confluence and the sinus grooves' lengths and widths. The patterns of communication between sides were compared statistically. The most typical communication pattern at the sinuses' confluence was a right-dominant TS groove (82.98%). The mean angulations of the entire left TS groove at two different points (A and B) were 46° and 43°. Those of the right TS groove were 44° and 45°. The median angulations of the left and right SSS-transverse sinus junction grooves were 127° and 124°. The mean angulations of the left and right TS-SSJsv grooves were 111° (range 82°-152°) and 103° (range 79°-130°). Differentiating normal and abnormal angulations of the DVSs of the posterior cranial fossa can help to explain why some patients are more susceptible to pathologies affecting the DVSs, such as CVST and VSS. Future application of these findings to patients with such pathologies is now necessary to extrapolate our results.

Psychological impact of lung cancer screening using a novel antibody blood test followed by imaging: the ECLS randomized controlled trial.

BACKGROUND: The Early CDT®-Lung antibody blood test plus serial computed tomography scans for test-positives (TPGs) reduces late-stage lung cancer presentation. This study assessed the psychological outcomes of this approach. METHODS: Randomized controlled trial (n = 12 208) comparing psychological outcomes 1-12 months post-recruitment in a subsample (n = 1032) of TPG, test-negative (TNG) and control groups (CG). RESULTS: Compared to TNG, TPG had lower positive affect (difference between means (DBM), 3 months (3m: -1.49 (-2.65, - 0.33)), greater impact of worries (DBM 1m: 0.26 (0.05, 0.47); 3m: 0.28 (0.07, 0.50)), screening distress (DBM 1m: 3.59 (2.28, 4.90); 3m: 2.29 (0.97, 3.61); 6m: 1.94 (0.61, 3.27)), worry about tests (odds ratio (OR) 1m: 5.79 (2.66, 12.63) and more frequent lung cancer worry (OR 1m: 2.52 (1.31, 4.83); 3m: 2.43 (1.26, 4.68); 6m: 2.87 (1.48, 5.60)). Compared to CG, TPG had greater worry about tests (OR 1m: 3.40 (1.69, 6.84)). TNG had lower negative affect (log-transformed DBM 3m: -0.08 (-0.13, -0.02)), higher positive affect (DBM 1m: 1.52 (0.43, 2.61); 3m: 1.43 (0.33, 2.53); 6m: 1.27 (0.17, 2.37)), less impact of worries (DBM 3m: -0.27 (-0.48, -0.07)) and less-frequent lung cancer worry (OR 3m: 0.49 (0.26, 0.92)). CONCLUSIONS: Negative psychological effects in TPG and positive effects in TNG were short-lived and most differences were small.

Implementation fidelity of the Falls Management Exercise Programme: a mixed methods analysis using a conceptual framework for implementation fidelity.

OBJECTIVES: Falls in older adults cause significant morbidity and mortality and incur cost to health and care services. The Falls Management Exercise (FaME) programme is a 24-week intervention for older adults that, in clinical trials, improves balance and functional strength and leads to fewer falls. Similar but more modest outcomes have been found when FaME is delivered in routine practice. Understanding the degree to which the programme is delivered with fidelity is important if 'real-world' delivery of FaME is to achieve the same magnitude of outcome as in clinical trials. The objective of this study was to examine the implementation fidelity of FaME when delivered in the community to inform quality improvement strategies that maximise programme effectiveness. STUDY DESIGN: A mixed methods implementation study of FaME programme delivery. METHODS: Data from programme registers, expert observations of FaME classes, and semistructured interviews with FaME instructors were triangulated using a conceptual framework for implementation fidelity. Quantitative data were analysed using descriptive statistics. Interviews were transcribed verbatim and analysed using thematic analysis. RESULTS: In total, 356 participants enrolled on 29 FaME programmes, and 143 (40%) participants completed at least 75% of the classes within a programme. Observations showed that 72%-78% of programme content was delivered, and 80%-84% quality criteria were met. Important content that was most often left out included home exercises, Tai Chi moves, and floor work, whereas quality items most frequently missed out included asking about falls in the previous week, following up attendance absence and explaining the purpose of exercises. Only 24% of class participants made the expected strength training progression. Interviews with FaME instructors helped explain why elements of programme content and quality were not delivered. Strategies for improving FaME delivery were established and helped to maintain quality and fidelity. CONCLUSIONS: FaME programmes delivered in the 'real world' can be implemented with a high degree of fidelity, although important deviations were found. Facilitation strategies could be used to further improve programme fidelity and maximise participant outcomes.

Educational weight loss interventions in obese and overweight adults with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials.

AIM: The worldwide prevalence of type 2 diabetes mellitus is increasing, with most individuals with the disease being overweight or obese. Weight loss can reduce disease-related morbidity and mortality and weight losses of 10-15 kg have been shown to reverse type 2 diabetes. This review aimed to determine the effectiveness of community-based educational interventions for weight loss in type 2 diabetes. METHODS: This is a systematic review and meta-analysis of randomized controlled trials (RCT) in obese or overweight adults, aged 18-75 years, with a diagnosis of type 2 diabetes. Primary outcomes were weight and/or BMI. CINAHL, MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to June 2019. Trials were classified into specified a priori comparisons according to intervention type. A pooled standardized mean difference (SMD) (from baseline to follow-up) and 95% confidence intervals (95% CI) between trial groups (difference-in-difference) were estimated through random-effects meta-analyses using the inverse variance method. Heterogeneity was quantified using I2 and publication bias was explored visually using funnel plots. RESULTS: Some 7383 records were screened; 228 full-text articles were assessed and 49 RCTs (n = 12 461 participants) were included in this review, with 44 being suitable for inclusion into the meta-analysis. Pooled estimates of education combined with low-calorie, low-carbohydrate meal replacements (SMD = -2.48, 95% CI -3.59, -1.49, I2  = 98%) or diets (SMD = -1.25, 95% CI -2.11, -0.39, I2  = 95%) or low-fat meal replacements (SMD = -1.15, 95%CI -2.05, -1.09, I2  = 85%) appeared most effective. CONCLUSION: Low-calorie, low-carbohydrate meal replacements or diets combined with education appear the most promising interventions to achieve the largest weight and BMI reductions in people with type 2 diabetes.

Understanding pathways to social inequalities in childhood unintentional injuries: findings from the UK millennium cohort study.

BACKGROUND: Childhood unintentional injuries (UI) are common but continue to happen more often to children living in less advantaged socioeconomic circumstances (SEC). Our aim was to explore how early life factors mediate the association between SEC and UIs, using the UK Millennium Cohort Study. METHODS: We calculated risk ratios (RR) and 95% confidence intervals (95%CI) for parental report of UI occurring between age 3 and 5 years, using Poisson regression according to family income as a measure of SEC. We explored potentially mediating pathways by controlling associations between SEC and UI for groups of early life risks in three domains: factors that may influence environmental safety, supervision and the MCS child's abilities and behaviours. RESULTS: Twenty eight percent of children had a UI from 3 to 5 years old. Children from the lowest income quintile were more likely to be injured compared to those from the highest (RR 1.20 95%CI 1.05, 1.37). Sequentially controlling for early life factors that may influence environmental safety (RR 1.19 95%CI 1.02, 1.38), then supervision (RR 1.18, 95%CI 1.02, 1.36), and finally adding child's behaviour and abilities (RR 1.15, 95%CI 1.00, 1.34) into the model reduced the RR by 5, 10 and 25% respectively. CONCLUSIONS: Addressing factors that may influence environmental safety and supervision, and the child's abilities and behaviours only partly explains the increased UI risk between the highest and lowest income quintiles. Further research is required to explore factors mediating associations between SEC and specific mechanisms and types of injuries.

Factors influencing the decision to attend screening for cancer in the UK: a meta-ethnography of qualitative research.

Background: This review aimed to better understand experiences of being invited to cancer screening and associated decision-making. Methods: Qualitative evidence explaining UK cancer screening attendance decisions was systematically identified. Data were extracted and meta-ethnography used to identify shared themes, synthesize findings and generate higher level interpretations. Results: Thirty-four studies met inclusion criteria. They related to uptake of breast, cervical, colorectal, prostate, ovarian and lung cancer screening. Three primary themes emerged from the synthesis. 'Relationships with the health service' shaped decisions, influenced by trust, compliance with power, resistance to control or surveillance and perceived failures to meet cultural, religious and language needs. 'Fear of cancer screening' was both a motivator and barrier in different ways and to varying degrees. Strategies to negotiate moderate fear levels were evident. 'Experiences of risk' included the creation of alternative personal risk discourses and the use of screening as a coping strategy, influenced by disease beliefs and feelings of health and wellness. Conclusions: The findings highlight the importance of the provider-patient relationship in screening uptake and enrich our understanding of how fear and risk are experienced and negotiated. This knowledge can help promote uptake and improve the effectiveness of cancer screening.

Keeping active: maintenance of physical activity after exercise programmes for older adults.

OBJECTIVES: To explore factors associated with maintenance of moderate-to-vigorous physical activity (MVPA) in community-dwelling adults aged ≥65 years after completing a 24-week exercise programme. STUDY DESIGN: This is a cohort study nested within a randomised controlled trial evaluating group- and home-based exercise programmes for older people in England. METHODS: MVPA levels and factors potentially associated with physical activity (PA) were self-reported at recruitment, 6, 12, 18 and 24 months after exercise programme. Multilevel logistic regression estimated odds ratios (ORs) for achieving target MVPA level (150 min/week) 6-24 months after exercise programmes ended. RESULTS: Older people (OR per year increase: 0.89, 95% confidence interval [CI] 0.86, 0.93) and women (OR 0.47, 95% CI 0.33, 0.67) were less likely to achieve target MVPA. Those physically active at recruitment (OR 11.28, 95% CI 7.95, 16.01), with wider social networks (OR per unit increase in Lubben Social Network Scale: 1.06, 95% CI 1.03, 1.10) and performing more sit-to-stands in 30 s (OR for quartile 3 compared with quartile 1: 1.87, 95% CI 1.12, 3.10), were more likely to achieve target MVPA. Negative exercise expectations increased the odds of achieving target MVPA but only among the less active at recruitment (OR per unit increase in Outcome and Expectation for Exercise negative subscale: 1.90, 95% CI 1.39, 2.60). Associations did not differ significantly across the follow-up period. CONCLUSION: A range of factors are associated with maintenance of PA 6-24 months after exercise programmes. Factors are not more strongly associated with shorter vs longer term PA maintenance. Commissioners and providers should consider targeting maintenance interventions to those least likely to maintain PA.

Psychological morbidity and health-related quality of life after injury: multicentre cohort study.

PURPOSE: To demonstrate the impact of psychological morbidity 1 month post-injury on subsequent post-injury quality of life (HRQoL) in a general injury population in the UK to inform development of trauma care and rehabilitation services. METHODS: Multicentre cohort study of 16-70-year-olds admitted to 4 UK hospitals following injury. Psychological morbidity and HRQoL (EQ-5D-3L) were measured at recruitment and 1, 2, 4 and 12 months post-injury. A reduction in EQ-5D compared to retrospectively assessed pre-injury levels of at least 0.074 was taken as the minimal important difference (MID). Multilevel logistic regression explored relationships between psychological morbidity 1 month post-injury and MID in HRQoL over the 12 months after injury. RESULTS: A total of 668 adults participated. Follow-up rates were 77% (1 month) and 63% (12 months). Substantial reductions in HRQoL were seen; 93% reported a MID at 1 month and 58% at 12 months. Problems with pain, mobility and usual activities were commonly reported at each time point. Depression and anxiety scores 1 month post-injury were independently associated with subsequent MID in HRQoL. The relationship between depression and HRQoL was partly explained by anxiety and to a lesser extent by pain and social functioning. The relationship between anxiety and HRQoL was not explained by factors measured in our study. CONCLUSIONS: Hospitalised injuries result in substantial reductions in HRQoL up to 12 months later. Depression and anxiety early in the recovery period are independently associated with lower HRQoL. Identifying and managing these problems, ensuring adequate pain control and facilitating social functioning are key elements in improving HRQoL post-injury.

The impact of psychological factors on recovery from injury: a multicentre cohort study.

PURPOSE: Unintentional injuries have a significant long-term health impact in working age adults. Depression, anxiety and post-traumatic stress disorder are common post-injury, but their impact on self-reported recovery has not been investigated in general injury populations. This study investigated the role of psychological predictors 1 month post-injury in subsequent self-reported recovery from injury in working-aged adults. METHODS: A multicentre cohort study was conducted of 668 unintentionally injured adults admitted to five UK hospitals followed up at 1, 2, 4 and 12 months post-injury. Logistic regression explored relationships between psychological morbidity 1 month post-injury and self-reported recovery 12 months post-injury, adjusting for health, demographic, injury and socio-legal factors. Multiple imputations were used to impute missing values. RESULTS: A total of 668 adults participated at baseline, 77% followed up at 1 month and 63% at 12 months, of whom 383 (57%) were included in the main analysis. Multiple imputation analysis included all 668 participants. Increasing levels of depression scores and increasing levels of pain at 1 month and an increasing number of nights in hospital were associated with significantly reduced odds of recovery at 12 months, adjusting for age, sex, centre, employment and deprivation. The findings were similar in the multiple imputation analysis, except that pain had borderline statistical significance. CONCLUSIONS: Depression 1 month post-injury is an important predictor of recovery, but other factors, especially pain and nights spent in hospital, also predict recovery. Identifying and managing depression and providing adequate pain control are essential in clinical care post-injury.

The short-term cost of falls, poisonings and scalds occurring at home in children under 5†years old in England: multicentre longitudinal study.

BACKGROUND: Childhood falls, poisonings and scalds, occurring predominantly in the home, are an important public health problem, yet there is limited evidence on the costs of these injuries to individuals and society. OBJECTIVES: To estimate National Health Service (NHS) and child and family costs of falls, poisonings and scalds. METHODS: We undertook a multicentre longitudinal study of falls, poisonings and scalds in children under 5 years old, set in acute NHS Trusts across four UK study centres. Data from parental self-reported questionnaires on health service resource use, family costs and expenditure were combined with unit cost data from published sources to calculate average cost for participants and injury mechanism. RESULTS: 344 parents completed resource use questionnaires until their child recovered from their injury or until 12 months, whichever came soonest. Most injuries were minor, with >95% recovering within 2 weeks, and 99% within 1 month of the injury. 61% emergency department (ED) attendees were not admitted, 35% admitted for ≤1 day and 4% admitted for ≥2 days. The typical healthcare cost of an admission for ≥2 days was estimated at £2000-3000, for an admission for ≤1 day was £700-1000 and for an ED attendance without admission was £100-180. Family costs were considerable and varied across injury mechanisms. Of all injuries, scalds accrued highest healthcare and family costs. CONCLUSIONS: Falls, poisonings and scalds incur considerable short-term healthcare and family costs. These data can inform injury prevention policy and commissioning of preventive services.

Risk and protective factors for falls on one level in young children: multicentre case-control study.

BACKGROUND: Childhood falls are an important global public health problem, but there is lack of evidence about their prevention. Falls on one level result in considerable morbidity and they are costly to health services. OBJECTIVE: To estimate ORs for falls on one level in children aged 0-4 years for a range of safety behaviours, safety equipment use and home hazards. DESIGN, SETTING AND PARTICIPANTS: Multicentre case-control study at hospitals, minor injury units and general practices in and around four UK study centres. Participants included 582 children less than 5 years of age with a medically attended fall injury occurring at home and 2460 controls matched on age, sex, calendar time and study centre. MAIN OUTCOME MEASURE: Fall on one level. RESULTS: Cases' most common injuries were bangs on the head (52%), cuts or grazes not needing stitches (29%) or cuts or grazes needing stitches (17%). Comparing cases to community controls in the adjusted analyses, significant findings were observed for only two exposures. Injured children were significantly less likely to live in a household without furniture corner covers (adjusted OR (AOR) 0.72, 95% CI 0.55 to 0.95), or without rugs and carpets firmly fixed to the floor (AOR 0.76, 95% CI 0.59 to 0.98). CONCLUSIONS: We did not find any safety practices, use of safety equipment or home hazards associated with a reduced risk of fall on one level. Our findings do not provide evidence to support changes to current injury prevention practice.

The other side of the story - maternal perceptions of safety advice and information: a qualitative approach.

BACKGROUND: A qualitative study of maternal perceptions of home safety advice. The aim was to gain an understanding of maternal perceptions of and possible barriers to the implementation of home safety advice. METHODS: Semi-structured interviews with 37 mothers with a child aged less than 5 years of age; 16 were mothers living in an area of socio-economic disadvantage (with a high rate of childhood unintentional injury), 21 were mothers living in an area of relative affluence (with a low rate of childhood unintentional injury). Thematic analysis was used to analyse the data. RESULTS: Although some mothers living in both areas found talking to a health professional about child home safety was helpful, mothers in both areas tended to find talking to other mothers as being more helpful and they preferred this to talking to a professional. Barriers to obtaining safety advice from professionals exist for mothers living in both areas. Mothers living in the advantaged area describe 'feeling silly' and that they should 'know it already' when talking to professionals. Mothers living in the disadvantaged area are less likely to access home safety advice due to fear of being perceived as an incompetent mother and the fear of social service involvement. CONCLUSIONS: Mothers find home safety advice from other parents more useful and prefer this to advice from professionals. This suggests greater use could be made of appropriately trained parents to deliver safety advice and education. Fear and mistrust can limit access to child safety advice in parents living in disadvantaged areas and this may be a potential explanation for differential unintentional injury rates as those who need the advice and support most may be least likely to access it. Further research should explore how professionals can build trust, gain parents' confidence and provide child safety advice and education that is targeted appropriately to parents living circumstances and their child safety needs.

Keeping children safe at home: protocol for a case-control study of modifiable risk factors for scalds.

BACKGROUND: Scalds are one of the most common forms of thermal injury in young children worldwide. Childhood scald injuries, which mostly occur in the home, result in substantial health service use and considerable morbidity and mortality. There is little research on effective interventions to prevent scald injuries in young children. OBJECTIVES: To determine the relationship between a range of modifiable risk factors for medically attended scalds in children under the age of 5 years. DESIGN: A multicentre case-control study in UK hospitals and minor injury units with parallel home observation to validate parental reported exposures. Cases will be 0-4 years old with a medically attended scald injury which occurred in their home or garden, matched on gender and age with community controls. An additional control group will comprise unmatched hospital controls drawn from children aged 0-4 years attending the same hospitals and minor injury units for other types of injury. Conditional logistic regression will be used for the analysis of cases and matched controls, and unconditional logistic regression for the analysis of cases and unmatched controls to estimate ORs and 95% CI, adjusted and unadjusted for confounding variables. MAIN EXPOSURE MEASURES: Use of safety equipment and safety practices for scald prevention and scald hazards. DISCUSSION: This large case-control study will investigate modifiable risk factors for scalds injuries, adjust for potential confounders and validate measures of exposure. Its findings will enhance the evidence base for prevention of scalds injuries in young children.

Evaluating the effect of child home safety training upon three family support practitioner groups: a mixed-methods study.

AIMS: Unintentional injuries in the home contribute substantially to preschool child morbidity and mortality. Practitioners such as health visitors, family mentors and children's centre staff are well-positioned to facilitate child injury prevention by providing home safety advice to families, and training may enhance their ability to do so. We aimed to assess the impact of child home safety training for these practitioners. METHODS: An explanatory mixed-methods design was used. Practitioners completed questionnaires before, and up to 7 months after, receiving child home safety training and took part in interviews. Seventy-eight health visitors, 72 family mentors and 11 children's centre staff members completed questionnaires. Items were used to calculate scores on home safety knowledge, confidence to provide home safety advice and belief that child home safety promotion is important. Thematic analysis of interviews with seven health visitors and nine family mentors, open-ended responses to the questionnaires and an additional evaluation form was conducted to explore attendees' perceptions of the training and its impact. In addition, seven health visitors and six children's centre staff who had received no training were interviewed. RESULTS: Knowledge was greater post-training than pre-training across all participants (p < .001). When practitioner groups were analysed separately, there were significant increases in family mentors' knowledge (p < .001) and belief (p = .016), and health visitors' confidence (p = .0036). Qualitative findings indicated that most training session attendees valued the training, believed their practice relating to child home safety had improved as a result, and felt further similar training sessions would be beneficial. Those who had not attended the sessions described a need for more child home safety training. CONCLUSIONS: Delivering training to practitioners providing child home safety promotion to families with preschool children can enhance injury prevention knowledge, beliefs and confidence and positively impact on home safety promotion by practitioners.

Dural sinus septum as an underlying cause of intrinsic venous sinus stenosis: Anatomical, clinical, and stent placement considerations.

Recently, an interesting study regarding "Dural sinus septum: an underlying cause of cerebral venous sinus stenting failure and complications." was published, to our knowledge, being the launching point of the clinical/interventional applications of this intraluminal variation. Herein, we wish to highlight paramount anatomical, clinical, and stent placement considerations related to DSS located in the dural venous sinus at the posterior cranial fossa and the interventional complications caused by the presence of this variation during stenting procedures.

Sequential Flow Diversion After Nitinol Stent Placement for a Large, Matricidal Cavernous Internal Carotid Artery Aneurysm: Technical Video.

The Surpass Evolve flow diverter is a novel 64-wire braided intravascular stent approved to treat unruptured large or giant saccular wide-neck or fusiform intracranial aneurysms of the intracranial internal carotid artery.1-3 Flow diverting stents have been used for the treatment of previously stented aneurysms, including residual aneurysms following prior flow diversion.5-8 This patient initially presented with a large symptomatic matricidal cavernous ICA aneurysm4 that was treated with stand-alone Neuroform Atlas stenting at an outside hospital. Here we present a video demonstrating the placement of sequential Surpass Evolve flow diverter stents within a Neuroform Atlas nitinol stent.

An exploratory survey on the awareness and usage of clinical practice guidelines among clinical pharmacists.

Background: The NHLBI has not developed clinical practice guidelines since 2007. As a result, multiple organizations have released competing guidelines. This has created confusion and debate among clinicians as to which recommendations are most applicable for practice. Objectives: To explore preliminary attitudes, awareness, and usage of clinical practice guidelines in practice and teaching for hypertension, dyslipidemia and asthma among clinical pharmacists. Methods: Clinical pharmacists across the US were surveyed electronically over a two week period in Spring 2019 regarding utilization and knowledge of practice guidelines for hypertension, dyslipidemia, and asthma. Clinical cases were included to evaluate application of guidelines. Descriptive statistics, Chi-square analysis, and Wilcoxon signed-rank test were conducted. Statistical significance level was set to 0.01 to account for multiple tests conducted on the same survey participants. Results: Forty-eight, 34, and 28 pharmacists voluntarily completed hypertension, dyslipidemia, and asthma survey questions, respectively. Interactions by disease state (p < 0.001) revealed more pharmacists (93%) reporting to have ≤50% patient load in managing asthma and more pharmacists (95%) had read the full summary/report of the most recent hypertension guideline. Primary reasons why the most recent guideline was not selected were also significantly different by disease state (interaction; p < 0.001). For dyslipidemia and asthma, pharmacists had a higher mean rating of agreement (p < 0.007) in having the most confidence in the most recent as compared to older guidelines. Proportionally more clinical cases were answered correctly (interaction; p < 0.001) when pharmacists applied the most recent guideline for hypertension (84%), while the opposite outcome was found for asthma (27%). Conclusion: While more pharmacists selected the most recent guideline for practice and teaching, there was inconsistent application of guidelines to clinical cases. Further studies with a larger representation of pharmacists are warranted to more definitively determine factors influencing guideline preference and usage.

Woven EndoBridge Embolized Aneurysm Clippings: 2-Dimensional Operative Video.

The Woven EndoBridge (WEB) device (MicroVention, Aliso Viejo, California) is an intrasaccular flow disruptor used for the treatment of both unruptured and ruptured intracranial aneurysms. WEB has been shown to have 54% complete and 85% adequate aneurysm occlusion rates at 1-yr follow-up.1 Residual and recurrent ruptured aneurysms have been shown to have a higher risk of re-rupture than completely occluded aneurysms.2 With increased utilization of WEB in the United States, optimizing treatment strategies of residual aneurysms previously treated with the WEB device is essential, including surgical clipping.3,4 Here, we present an operative video demonstrating the surgical clip occlusion of previously ruptured middle cerebral artery and anterior communicating artery aneurysms that had been treated with the WEB device and had sizable recurrence on follow-up angiography. Informed consent was obtained from both patients. Lessons learned include the following: (1) the WEB device is highly compressible, unlike coils; (2) proximal WEB marker may interfere with clip closure; (3) no evidence of WEB extrusion into the subarachnoid space; (4) no more scarring than expected in ruptured cases; and (5) clipping is a feasible option for treating WEB recurrent or residual aneurysms.

What can trauma patients' experiences and perspectives tell us about the perceived quality of trauma care? a qualitative study set within the UK National Health Service.

The global drive for improvements in the efficiency and quality of healthcare has led to the development of frameworks to assist in defining and measuring 'good quality care'. However, such frameworks lack a systematic or meaningful definition of what 'good quality care' means from the patients' perspective. The present research provides an in-depth analysis of patients' experiences in a hospital setting from a quality of care perspective. Forty-five adults (aged 16-70) hospitalised in one of four UK NHS trusts following an unintentional injury were interviewed about their experiences of care. The findings show variability in perceived quality of care within the same hospital episode which cannot be meaningfully captured by existing frameworks. The context of trauma care (e.g. distressing nature of injury, patient vulnerability, expectations of hospitalisation and participants' interaction with different service providers) defined the care experience and the value of being 'cared for'. Participants identified some aspects of good and care which related to holistic, person-centred and personalised care beyond the medical needs. Participants discussed the value of being understood, staff thinking of their needs beyond hospitalisation, staff trying 'their best' despite constrains of current care, having their emotional needs recognised and addressed and staff competence. Patients reported also poor quality of care and 'not being cared for' by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults' psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care.