"Mini city": a neighborhood in transition: an action-oriented community diagnosis: findings and next steps of action

This document is a description of an Action‐Oriented Community Diagnosis (AOCD) of the Mini City area of Raleigh, Wake County, North Carolina. The community assessment was conducted by a team of five graduate students in the Department of Health Behavior and Health Education at the University of North Carolina at Chapel Hill School of Public Health. The AOCD process took place from September 2007 to April 2008 with the guidance of two preceptors from Wake County Human Services (WCHS). The purpose of this AOCD is to understand community members’ social, economic, cultural, and health experiences from the viewpoint of both community members and service providers in order to assess the strengths and challenges facing the Mini City area. Over the course of the team’s eight months in the Mini City area, team members researched existing information about the Mini City area, interviewed a total of 36 community members and service providers, and attended more than 20 community meetings and events. This process is action‐oriented in that the team actively engages community members and service providers to seek their insight and opinions, as well as to gain entrée into the community. The student team analyzed the information collected and identified three primary strengths of and five challenges facing the Mini City community. A community forum planning committee, composed of service providers and community members, then identified specific issues within the five challenge areas as being most changeable and important to address. These strengths and challenges, along with an explanation of the AOCD process, were presented at a community forum entitled Spring Into Action! on Saturday, April 19, 2008, at the Green Road Community Center in Northeast Raleigh. Approximately 45 community members and service providers attended the forum and participated in small group discussions about the five challenges. Through discussions facilitated by team members, participants identified the causes of and barriers to overcoming the identified challenges, talked about resources available in the community that could be used to improve upon these challenges, and developed specific action steps to help the Mini City community address these challenges. The mission of the forum was to transfer ownership of the information and community change process from the student team to people living and/or working in or near the Mini City area so that desired changes can be made. STRENGTHS & CHALLENGES The following are the three primary strengths of the Mini City community as identified by interviewees: Location: The Mini City area is centrally located in Northeast Raleigh. It is near many residential communities and shopping centers and easily accessed by Capital Boulevard, I‐440, and I‐540. Agencies and Organizations: There are many different businesses and agencies serving the Mini City area. Interviewees commonly noted that there are many nearby organizations that provide religious facilities, child care, recreation, and other services to the Mini City community. People: The friendliness and diversity of the Mini City area residents were identified as major assets to the community. There are persons from many different ethnic and socioeconomic groups living in the Mini City area. The following are the five main challenges facing the Mini City community and the specific action steps that were generated by community forum attendees: HOUSING A high percentage of renters and people who frequently move in and out of the Mini City area directly and indirectly contribute to poor upkeep of property, a lack of connection among residents, and a low level of investment in neighborhoods. Action steps were: Add brief descriptions to an existing list of housing resources so that people know the best number to call for different situations. Restart a Yard‐of‐the‐Month club. Improve communication between the Citizens Advisory Councils (CACs) around Raleigh by having specific group members attend different CAC meetings and then report back to each other. TRANSPORTATION Public transportation options are perceived as inadequate, leading to difficulties commuting to work, accessing services, and traveling around Raleigh. Action steps were: Conduct a survey to find out where additional routes are needed and how the bus system is currently being used. Make the gotriangle.com website available in Spanish. Develop a travel training program to reduce the anxiety of first‐time bus riders. Improve bus signage at the bus stops. CRIME Though not disproportionate for an urban area, crime, including gang activity, drug use, and robbery, is a principal concern among residents of the Mini City area. Build relationships with neighborhood youth. Contact the city about gang‐related resources. Put information about the follow‐up meeting in the Northeast CAC newsletter. Commit to bring at least one young person to the follow‐up meeting. Explore the first steps in developing a community website on gangs. CROSS‐CULTURAL RELATIONS The Mini City area is both economically and racially diverse; however, there are few instances of cross‐cultural mingling and even some reports of anti‐immigrant sentiment. Encourage schools and churches to host “Cultural Days" in which diversity is celebrated and embraced. Speak at the 23rd International Festival of Raleigh in September 2008 about the importance of diversity in the city. Speak with specific influential officials on the Wake County Public School System Board of Education ACCESS TO HEALTH SERVICES Access to health services in the Mini City area is seen as difficult; people feel that the biggest problems are limited local free and urgent care, limited transportation to and from services, a lack of awareness about services, and problems paying for services. Form a coalition made up of discussion group attendees who will act as representatives of local churches, schools, and health care organizations to find out if mobile clinics already exist in the area. RECOMMENDATIONS The following are the student team recommendations for the Mini City community as this AOCD process transfers from the student team to the community: Contact the City of Raleigh and other local service providers about better publicizing of existing gang‐related resources to increase general knowledge about gangs in the Mini City area and throughout Northeast Raleigh. Restart the Yard‐of‐the‐Month program in both Mini City homes and apartment complexes to promote better upkeep of property. Contact and collaborate with the City of Raleigh Community Specialists to make Mini City area residents aware of the free services provided to them by the City of Raleigh. Continue a working relationship with public transportation officials to improve the Capital Area Transit (CAT) system and its service of Mini City area residents. Raise awareness among Mini City residents about existing health services in the Mini City area by distributing information about existing services at health fairs, in local stores, and at community events. CONCLUSION Ultimately, this report is meant to serve as a resource for Mini City area community members and service providers by describing the AOCD process and results. After the completion of the forum, the student team prepared this document and created recommendations for the Mini City community based on interviews, discussions at the community forum, and the team’s observations and experiences throughout the AOCD process. The document is divided into the following six sections: Introduction to AOCD, Community Overview, Methodology, Themes & Findings, Community Forum, and Limitations & Recommendations. The student team truly hopes this report will be valuable in positively shaping the services provided to, and the future quality of life among, Mini City area residents.Master of Public Healt

Spontaneous obliteration of brain arteriovenous malformations: illustrative cases

Background: Spontaneous angiographic obliteration of a brain arteriovenous malformation (AVM) is considered a rare outcome, with most cases in the literature related to prior hemorrhage in small brain AVMs. The authors present a prospective, single center, consecutive case series. The clinical course and radiographic features of four cases with spontaneous obliteration of brain AVM were analyzed. Observations: The median age of patients in this series was 47.6 years, with an equal gender split. The median maximum brain AVM diameter was 2 cm. The median time to spontaneous obliteration was 26 months, with hemorrhage preceding this in three out of four cases and a prolonged latency in the only case with a nidus size larger than 3 cm and no hemorrhage. Lessons: The present study provides additional information to allow clinicians to counsel patients about the rare outcomes of conservative management. This work extends our understanding of when this phenomenon can occur by reporting on the differences associated with spontaneous obliteration of larger AVMs

Neurosurgery in octogenarians during the COVID-19 pandemic: results from a tertiary care trauma centre

Background: In 2020, 6% of Scotland's adult population was ≥80 years. Advancements in care mean improved chances of survival at 6-months for older adults following injury to the brain or spine. The Covid-19 pandemic also resulted in local and national policies aimed at protecting the elderly. We sought to evaluate referral patterns and outcomes for patients ≥80 years referred to our institution during this period. Objective: To evaluate referral patterns and outcomes for patients ≥80 years referred to our institution both before and during the coronavirus pandemic. Design: Retrospective observational cohort study. Setting: Tertiary care in a developing major trauma centre (Queen Elizabeth University Hospital, Glasgow). Participants: All patients ≥80 years referred to the on-call neurosurgical service over two four-month periods before (2016–17; n = 1573) and after the onset of Covid-19 (2020; n = 2014). Methods: Data on demographics, ASA, diagnosis and referral decision were collected. 30-day and 6-month mortality and functional independence were assessed. Results: 246 (before) and 335 (during Covid-19) referred patients were ≥80 years. No gender bias. A significant increase (17%) in acute trauma was seen during the pandemic months. Fewer older adults were transferred (6% to 2% Covid-19) for specialist care, most commonly for chronic subdural haematoma. Most were alive, home and independent at 6 months (47% pre and 63% during Covid-19). Conclusions: Octogenarians feature disproportionately in acute adult neurosurgical referrals. In our department, local and national responses to the Covid-19 pandemic did not appear to influence this. Robust evidence of neurosurgical outcomes in the older adult is required to fairly distribute resources for our ageing population, but decisions must not be based on age alone

Two cases of SMA syndrome after neurosurgical injury to the frontal aslant tract

Supplementary motor area (SMA) syndrome is characterised by transient disturbance in volitional movement and speech production which classically occurs after injury to the medial premotor area. We present two cases of SMA syndrome following isolated surgical injury to the frontal aslant tract (FAT) with the SMA intact. The first case occurred after resection of a left frontal operculum tumour. The second case occurred after a transcortical approach to a ventricular neurocytoma. The clinical picture and fMRI activation patterns during recovery were typical for SMA syndrome and support the theory that the FAT is a critical bundle in the SMA complex function

Case report: delayed outflow obstruction of a DVA: a rare complication of brainstem cavernoma surgery

Introduction: Developmental venous anomalies (DVAs) are considered variants of normal transmedullary veins. Their association with cavernous malformations is reported to increase the risk of hemorrhage. Expert consensus recommends meticulous planning with MR imaging, use of anatomical “safe zones”, intraoperative monitoring of long tracts and cranial nerve nuclei, and preservation of the DVA as key to avoiding complications in brainstem cavernoma microsurgery. Symptomatic outflow restriction of DVA is rare, with the few reported cases in the literature restricted to DVAs in the supratentorial compartment. Case: We present a case report of the resection of a pontine cavernoma complicated by delayed outflow obstruction of the associated DVA. A female patient in her 20's presented with progressive left-sided hemisensory disturbance and mild hemiparesis. MRI revealed two pontine cavernomas associated with interconnected DVA and hematoma. The symptomatic cavernoma was resected via the infrafacial corridor. Despite the preservation of the DVA, the patient developed delayed deterioration secondary to venous hemorrhagic infarction. We discuss the imaging and surgical anatomy pertinent to brainstem cavernoma surgery, as well as the literature exploring the management of symptomatic infratentorial DVA occlusion. Conclusion: Delayed symptomatic pontine venous congestive edema is extremely rare following cavernoma surgery. DVA outflow restriction from a post-operative cavity, intraoperative manipulation, and intrinsic hypercoagulability from COVID-10 infection are potential pathophysiological factors. Improved knowledge of DVAs, brainstem venous anatomy, and “safe entry zones” will further elucidate the etiology of and the efficacious treatment for this complication

Trial of Dexamethasone for Chronic Subdural Hematoma

BACKGROUND: Chronic subdural hematoma is a common neurologic disorder that is especially prevalent among older people. The effect of dexamethasone on outcomes in patients with chronic subdural hematoma has not been well studied. METHODS: We conducted a multicenter, randomized trial in the United Kingdom that enrolled adult patients with symptomatic chronic subdural hematoma. The patients were assigned in a 1:1 ratio to receive a 2-week tapering course of oral dexamethasone, starting at 8 mg twice daily, or placebo. The decision to surgically evacuate the hematoma was made by the treating clinician. The primary outcome was a score of 0 to 3, representing a favorable outcome, on the modified Rankin scale at 6 months after randomization; scores range from 0 (no symptoms) to 6 (death). RESULTS: From August 2015 through November 2019, a total of 748 patients were included in the trial after randomization - 375 were assigned to the dexamethasone group and 373 to the placebo group. The mean age of the patients was 74 years, and 94% underwent surgery to evacuate their hematomas during the index admission; 60% in both groups had a score of 1 to 3 on the modified Rankin scale at admission. In a modified intention-to-treat analysis that excluded the patients who withdrew consent for participation in the trial or who were lost to follow-up, leaving a total of 680 patients, a favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group (difference, -6.4 percentage points [95% confidence interval, -11.4 to -1.4] in favor of the placebo group; P = 0.01). Among the patients with available data, repeat surgery for recurrence of the hematoma was performed in 6 of 349 patients (1.7%) in the dexamethasone group and in 25 of 350 patients (7.1%) in the placebo group. More adverse events occurred in the dexamethasone group than in the placebo group. CONCLUSIONS: Among adults with symptomatic chronic subdural hematoma, most of whom had undergone surgery to remove their hematomas during the index admission, treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Dex-CSDH ISRCTN number, ISRCTN80782810.)

Dex-CSDH randomised, placebo-controlled trial of dexamethasone for chronic subdural haematoma: report of the internal pilot phase.

The Dex-CSDH trial is a randomised, double-blind, placebo-controlled trial of dexamethasone for patients with a symptomatic chronic subdural haematoma. The trial commenced with an internal pilot, whose primary objective was to assess the feasibility of multi-centre recruitment. Primary outcome data collection and safety were also assessed, whilst maintaining blinding. We aimed to recruit 100 patients from United Kingdom Neurosurgical Units within 12 months. Trial participants were randomised to a 2-week course of dexamethasone or placebo in addition to receiving standard care (which could include surgery). The primary outcome measure of the trial is the modified Rankin Scale at 6 months. This pilot recruited ahead of target; 100 patients were recruited within nine months of commencement. 47% of screened patients consented to recruitment. The primary outcome measure was collected in 98% of patients. No safety concerns were raised by the independent data monitoring and ethics committee and only five patients were withdrawn from drug treatment. Pilot trial data can inform on the design and resource provision for substantive trials. This internal pilot was successful in determining recruitment feasibility. Excellent follow-up rates were achieved and exploratory outcome measures were added to increase the scientific value of the trial.NIHR HT

A randomised, double blind, placebo-controlled trial of a two-week course of dexamethasone for adult patients with a symptomatic Chronic Subdural Haematoma (Dex-CSDH trial)

Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/15/02) and is published in full in Health Technology Assessment; Vol. 28, No. 12. See the NIHR Funding and Awards website for further award information.Peer reviewe

Trial of Dexamethasone for Chronic Subdural Hematoma

(Trial funded by NIHR, Dex-CSDH Current Controlled Trials number ISRCTN80782810). ACKNOWLEDGEMENTS In memory of Mrs. Kate Massey, who was the patient representative involved in study design. Peter Hutchinson is supported by a Research Professorship and Senior Investigator Award from the NIHR, the NIHR Cambridge Biomedical Research Centre, and the Royal College of Surgeons of England. Ellie Edlmann is supported by the Royal College of Surgeons of England. Angelos Kolias is supported by a Lectureship, School of Clinical Medicine, University of Cambridge and the Royal College of Surgeons of England. SUPPORT This paper presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.Peer reviewedPublisher PD