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Background: Statins have been shown to decrease aneurysm progression and rupture in two experimental settings: animals with cerebral aneurysm and humans with abdominal aortic aneurysms., Aims: To investigate statin use and outcomes in humans with unruptured cerebral aneurysms through Medicare administrative data., Methods: We used a 40% random sample Medicare denominator file and corresponding inpatient, outpatient (2003-2011), and prescription (2006-2011) claims to conduct a retrospective cohort study of patients diagnosed with unruptured cerebral aneurysms, between 2003 and 2011. We used propensity score-adjusted models to investigate the association between statin use and risk of subarachnoid hemorrhage. Secondary analyses repeated the main models stratified on tobacco use status and separately assessed other composite outcomes., Results: We identified 28 931 patients with unruptured cerebral aneurysms (average age 72·0 years, 72·6% female); mean follow-up was 30·0 months; 41·3% used statins. Overall, 593 patients developed subarachnoid hemorrhage, and 703 underwent treatment before subarachnoid hemorrhage. Current or recent statin use was not associated with a difference in subarachnoid hemorrhage risk (odds ratio, 1·03; 95% conflict of interest 0·86-1·23); models stratified on tobacco use status were nearly identical. No association was observed between statin use and the composite outcome of subarachnoid hemorrhage or aneurysm treatment (odds ratio, 0·94; 95% conflict of interest, 0·84-1·06). The risk of subarachnoid hemorrhage or out-of-hospital death was lower among statin users (odds ratio, 0·69; 95% conflict of interest, 0·64-0·74)., Conclusions: Statin use by patients with unruptured cerebral aneurysms was not associated with subarachnoid hemorrhage risk. Given the prior animal experimental studies demonstrating a protective effect, further prospective studies are needed to investigate the potential relationship., (© 2015 World Stroke Organization.)

Background: Computed tomographic (CT) scans are central diagnostic tests for ischemic stroke. Their inefficient use is a negative quality measure tracked by the Centers for Medicare and Medicaid Services., Methods and Results: We performed a retrospective analysis of Medicare fee-for-service claims data for adults admitted for ischemic stroke from 2008 to 2009, with 1-year follow-up. The outcome measures were risk-adjusted rates of high-intensity CT use (≥4 head CT scans) and risk- and price-adjusted Medicare expenditures in the year after admission. The average number of head CT scans in the year after admission, for the 327 521 study patients, was 1.94, whereas 11.9% had ≥4. Risk-adjusted rates of high-intensity CT use ranged from 4.6% (Napa, CA) to 20.0% (East Long Island, NY). These rates were 2.6% higher for blacks than for whites (95% confidence interval, 2.1%-3.1%), with considerable regional variation. Higher fragmentation of care (number of different doctors seen) was associated with high-intensity CT use. Patients living in the top quintile regions of fragmentation experienced a 5.9% higher rate of high-intensity CT use, with the lowest quintile as reference; the corresponding odds ratio was 1.77 (95% confidence interval, 1.71-1.83). Similarly, 1-year risk- and price-adjusted expenditures exhibited considerable regional variation, ranging from $31 175 (Salem, MA) to $61 895 (McAllen, TX). Regional rates of high-intensity CT scans were positively associated with 1-year expenditures (r=0.56; P<0.01)., Conclusions: Rates of high-intensity CT use for patients with ischemic stroke reflect wide practice patterns across regions and races. Medicare expenditures parallel these disparities. Fragmentation of care is associated with high-intensity CT use., (© 2014 American Heart Association, Inc.)

Object: Precise delineation of individualized risks of morbidity and mortality is crucial in decision making in cerebrovascular neurosurgery. The authors attempted to create a predictive model of complications in patients undergoing cerebral aneurysm clipping (CAC)., Methods: The authors performed a retrospective cohort study of patients who had undergone CAC in the period from 2005 to 2009 and were registered in the Nationwide Inpatient Sample (NIS) database. A model for outcome prediction based on preoperative individual patient characteristics was developed., Results: Of the 7651 patients in the NIS who underwent CAC, 3682 (48.1%) had presented with unruptured aneurysms and 3969 (51.9%) with subarachnoid hemorrhage. The respective inpatient postoperative risks for death, unfavorable discharge, stroke, treated hydrocephalus, cardiac complications, deep vein thrombosis, pulmonary embolism, and acute renal failure were 0.7%, 15.3%, 5.3%, 1.5%, 1.3%, 0.6%, 2.0%, and 0.1% for those with unruptured aneurysms and 11.5%, 52.8%, 5.5%, 39.2%, 1.7%, 2.8%, 2.7%, and 0.8% for those with ruptured aneurysms. Multivariate analysis identified risk factors independently associated with the above outcomes. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated using the area under the receiver operating characteristic curve, and it was found to have good discrimination., Conclusions: The featured model can provide individualized estimates of the risks of postoperative complications based on preoperative conditions and can potentially be used as an adjunct in decision making in cerebrovascular neurosurgery.

Several groups have demonstrated the safety of ambulatory brain biopsies, with no patients experiencing complications related to early discharge. Although they appear to be safe, the reasons factoring into the selection of patients have not been investigated. We performed a cross-sectional study involving 504 patients who underwent outpatient and 10,328 patients who underwent inpatient brain biopsies and were registered in State Ambulatory Surgery Databases and State Inpatient Databases respectively for four US States (New York, California, Florida, North Carolina). In a multivariate analysis private insurance (OR 2.45, 95 % CI, 1.85, 3.24), was significantly associated with outpatient procedures. Higher Charlson Comorbidity Index (OR 0.16, 95 % CI, 0.08, 0.32), high income (OR 0.37, 95 % CI, 0.26, 0.53), and high volume hospitals (OR 0.30, 95 % CI, 0.23, 0.39) were associated with a decreased chance of outpatient procedures. No sex, or racial disparities were observed. Institutional charges were significantly less for outpatient brain biopsies. There was no difference in the rate of 30-day postoperative readmissions among inpatient and outpatient procedures. The median charge for inpatient surgery was 51,316 as compared to 12,266 for the outpatient setting (P < 0.0001, Student's t test). Access to ambulatory brain biopsies appears to be more common for patients with private insurance and less comorbidities, in the setting of lower volume hospitals. Further investigation is needed in the direction of mapping these disparities in resource utilization.

Objective:   To replicate a previously reported association between pollen counts and county suicide rates in the continental United States, across space and time., Method:   The authors evaluated the relationship between airborne pollen counts and suicide rates in 42 counties of the continental United States, containing a pollen-counting station participating in the Aeroallergen Monitoring Network in the United States (N = 120,076 suicides), considering years' quarter, age group, sex, race, rural/urban location, number of local psychiatrists, and median household income, from 1999 to 2002. The county-level effects were broken into between-county and within-county., Results:   No within-county effects were found. Between-county effects for grass and ragweed pollen on suicide rates lost statistical significance after adjustment for median income, number of psychiatrists, and urban vs. rural location., Conclusion:   Future research is necessary to reappraise the previously reported relationship between pollen levels and suicide rates that may have been driven by socioeconomic confounders., (© 2011 John Wiley & Sons A/S.)

Study Design: Longitudinal cohort study., Objective: To compare functional outcomes between male and female patients before and after surgery for adolescent idiopathic scoliosis (AIS)., Summary of Background Data: There is no clear consensus in the existing literature with respect to sex differences in functional outcomes in the surgical treatment of AIS., Methods: A prospective, consecutive, multicenter database of patients who underwent surgical correction for adolescent idiopathic scoliosis was analyzed retrospectively. All patients completed Scoliosis Research Society-30 (SRS-30) questionnaires before and 2 years after surgery. Patients with previous spine surgery were excluded. Data were collected for sex, age, Risser grade, previous bracing history, maximum preoperative Cobb angle, curve correction at 2 years, and SRS-30 domain scores. Paired sample t tests were used to compare preoperative and postoperative scores within each sex. Independent sample t tests were used to compare scores between sexes. A P value of <0.05 was considered statistically significant., Results: Seven hundred forty-four patients (621 females and 123 males) were included. On average, males were 1 year older than females. There were no differences between sexes in Risser grade, bracing history, maximum curve magnitude, or correction after surgery. Both males and females had similar improvement in all SRS-30 domains after surgery. Self-image/appearance had the greatest relative improvement. Males had better self-image/appearance scores preoperatively, better pain scores at 2 years, and better mental health and total scores both preoperatively and at 2 years. Both males and females were similarly satisfied with surgery., Conclusions: Males treated with surgery for AIS report better preoperative self-image, less postoperative pain, and better mental health than females. These differences may be clinically significant. For both males and females, the most beneficial effect of surgery is improved self-image/appearance. Overall, the benefits of surgery for AIS are similar for both sexes.

Object: The authors sought to determine a cause-specific mortality profile for US neurosurgeons during the period 1979-2005., Methods: Neurosurgeons who died during the study period were identified from the Physician Master File database. Using the National Death Index, the reported cause of death was identified for 93.7% of decedents. Standardized mortality ratios were used to compare mortality risk in the study cohort to that of the US population., Results: There was a marked reduction in mortality from virtually all causes in comparison with the control population. This finding is consistent with prior studies of mortality in physicians. The small number of deaths among female neurosurgeons precluded meaningful analysis for this group. Increased mortality risk for male neurosurgeons was seen from leukemia, nervous system disease (particularly Alzheimer disease), and aircraft accidents. Deaths from viral hepatitis and HIV infection, considered to be occupational hazards for surgeons, were less frequent than in the general population. Suicide, drug-related deaths, and alcohol-related deaths were less frequent than in the general population., Conclusions: Neurosurgeons may be at higher risk for death from leukemia, aircraft accidents, and diseases of the nervous system, particularly Alzheimer disease; however, the mortality profile of neurosurgeons is favorable when compared with the general population.

Aims: The genetic diversity of Beauveria bassiana was investigated by comparing isolates of this species to each other (49 from different geographical regions of Brazil and 4 from USA) and to other Beauveria spp., Methods and Results: The isolates were examined by multilocus enzyme electrophoresis (MLEE), amplified fragment length polymorphism (AFLP), and rDNA sequencing. MLEE and AFLP revealed considerable genetic variability among B. bassiana isolates. Several isolates from South and Southeast Brazil had high similarity coefficients, providing evidence of at least one population with clonal structure. There were clear genomic differences between most Brazilian and USA B. bassiana isolates. A Mantel test using data generated by AFLP provided evidence that greater geographical distances were associated with higher genetic distances. AFLP and rDNA sequencing demonstrated notable genotypic variation between B. bassiana and other Beauveria spp., Conclusion: Geographical distance between populations apparently is an important factor influencing genotypic variability among B. bassiana populations in Brazil., Significance and Impact of the Study: This study characterized many B. bassiana isolates. The results indicate that certain Brazilian isolates are considerably different from others and possibly should be regarded as separate species from B. bassiana sensu latu. The information on genetic variation among the Brazilian isolates, therefore, will be important to comprehending the population structure of B. bassiana in Brazil.

Nurses are responsible to protect the confidentiality and security of patients' health information. In the critical care setting, these privacy and confidentiality issues may be even more poignant. If able to carry on with their normal lives after discharge, many of the patients that nurses treat will have some sequelae from their illnesses that could affect their careers, finances, and personal lives. This article reviews the current literature, presents a discussion of confidentiality and security as it applies to uniquely identifiable health information, and offers some "best practices" that can be used in daily practice. Furthermore, the author discusses the Health Insurance Portability and Accountability Act of 1996 and details some reasons why the act is not fully implemented a full 6 years after it was signed into law.