Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: A quality improvement project.

BACKGROUND: Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia. AIMS: We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram-guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations. METHODS: The project key drivers were education, equipment, and electronic health record modifications. Plan-Do-Study-Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram-guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case-based knowledge; (3) adding age-based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram-guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart. RESULTS: After the four Plan-Do-Study-Act cycles, electroencephalogram-guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram-guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001). CONCLUSION: Quality improvement methods may be deployed to adopt electroencephalogram-guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.

Implementation of an electroencephalogram-guided propofol anesthesia education program in an academic pediatric anesthesia practice.

BACKGROUND: Propofol total intravenous anesthesia (TIVA) is increasingly popular in pediatric anesthesia, but education on its use is variable and over-dosage adverse events are not uncommon. Recent work suggests that electroencephalogram (EEG) parameters can guide propofol dosing in the pediatric population. This education quality improvement project aimed to implement a standardized EEG TIVA training program over 12 months in a large pediatric anesthesia division. METHODS: The division consisted of 63 faculty, 11 clinical fellows, 32 residents, and 28 nurse anesthetists at the Children's Hospital of Philadelphia. The program was assessed for effectiveness (a significant improvement in EEG knowledge scores), scalability (training 50% of fellows and staff), and sustainability (recurring EEG lectures for 80% of rotating residents and 100% of new fellows and staff). The key drivers included educational content development (lectures, articles, and hand-outs), training a cohort of EEG TIVA trainers, intraoperative teaching (teaching points and dosing tables), decision support tools (algorithms and anesthesia electronic record pop-ups), and knowledge tests (written exam and verbal quiz during cases). RESULTS: Over 12 months, 78.5% of the division (62/79) completed EEG training and test scores improved (mean score 38% before training vs 59% after training, p < .001). Didactic lectures were given to 100% of the fellows, 100% (11/11) of new staff, and 80% (4/5 blocks) of rotating residents. CONCLUSION: This quality improvement education project successfully trained pediatric anesthesia faculty, staff, residents, and fellows in EEG-guided TIVA. The training program was effective, scalable, and sustainable over time for newly hired faculty staff and rotating fellows and residents.

Dynamic Tracheobronchial Compression in Steep Trendelenburg Position With Pneumoperitoneum for Robotic-Assisted Cystectomy: A Case Report.

Tracheobronchomalacia is a weakness of the trachea and bronchi due to abnormal cartilage and muscular support leading to airway obstruction. We report a case of an adult former smoker without pulmonary symptoms who underwent robotic-assisted laparoscopic cystectomy in the steep Trendelenburg position. After repeated episodes of hypoxemia, bronchoscopic examination revealed collapse of the distal trachea and bronchi, supporting a diagnosis of tracheobronchomalacia. Tracheomalacia is an underdiagnosed condition in patients with a smoking history and may mimic other obstructive diseases. The anesthesiologist should remain vigilant to the possibility of airway collapse in former smokers, specifically in cases of increased intrathoracic pressure.

Brief report #3: building a rural community caregiver network: student learning in small town America.

The Rural Caregiver Network Project in Eastern Maine is a prime example of indigenous coalition-building in a region struggling to ensure that vulnerable older adults can age-in-place and manage with scarce resources. Through this innovative initiative, a range of elder caregiver interventions were mobilized, coordinated, and sustained in a rural two-county region in Maine, including navigator services, adult day care, information and referral, caregiver support groups, a caregiver resource center, and caregiver skills-building workshops. The endorsement of participatory research, evaluation, and programming principles enabled undergraduate and graduate social work students to assume major roles in all aspects of project planning, implementation, and assessment while remaining grounded in the realities of rural life. Competence in such a generalist gerontological social work practice perspective is critical in small towns and nonmetropolitan communities.

Engaging students in gerontological work through innovative caregiving programming: introduction to three brief reports.

The number of Americans aged 65 and older is projected to increase from 35 million to 88.5 million in the first half of the 21st century. However, there is a serious gap between the number of health care and social service practitioners needed to work with the aging and the number available and trained to do so. The authors review current research on what works in engaging students in geriatric and gerontological work. The authors then present three projects from the Weinberg Caregiver Initiative as illustrations of innovative caregiver programming building on community-based partnerships which successfully incorporate aspects of best practices in gerontological education to increase student interest in work with the aging populations, while serving older adults and their caregivers.

Decreased dendritic spine density and abnormal spine morphology in Fyn knockout mice.

Fyn is a Src-family tyrosine kinase that affects long term potentiation (LTP), synapse formation, and learning and memory. Fyn is also implicated in dendritic spine formation both in vitro and in vivo. However, whether Fyn's regulation of dendritic spine formation is brain-region specific and age-dependent is unknown. In the present study, we systematically examined whether Fyn altered dendritic spine density and morphology in the cortex and hippocampus and if these effects were age-dependent. We found that Fyn knockout mice trended toward a decrease in dendritic spine density in cortical layers II/III, but not in the hippocampus, at 1 month of age. Additionally, Fyn knockout mice had significantly decreased dendritic spine density in both the cortex and hippocampus at 3 months and 1 year, and Fyn's effect on dendritic spine density was age-dependent in the hippocampus. Moreover, Fyn knockout mice had wider spines at the three time points (1 month, 3 months, 1 year) in the cortex. These findings suggest that Fyn regulates dendritic spine number and morphology over time and provide further support for Fyn's role in maintaining proper synaptic function in vivo.

Reelin supplementation enhances cognitive ability, synaptic plasticity, and dendritic spine density.

Apolipoprotein receptors belong to an evolutionarily conserved surface receptor family that has intimate roles in the modulation of synaptic plasticity and is necessary for proper hippocampal-dependent memory formation. The known lipoprotein receptor ligand Reelin is important for normal synaptic plasticity, dendritic morphology, and cognitive function; however, the in vivo effect of enhanced Reelin signaling on cognitive function and synaptic plasticity in wild-type mice is unknown. The present studies test the hypothesis that in vivo enhancement of Reelin signaling can alter synaptic plasticity and ultimately influence processes of learning and memory. Purified recombinant Reelin was injected bilaterally into the ventricles of wild-type mice. We demonstrate that a single in vivo injection of Reelin increased activation of adaptor protein Disabled-1 and cAMP-response element binding protein after 15 min. These changes correlated with increased dendritic spine density, increased hippocampal CA1 long-term potentiation (LTP), and enhanced performance in associative and spatial learning and memory. The present study suggests that an acute elevation of in vivo Reelin can have long-term effects on synaptic function and cognitive ability in wild-type mice.

Racial/ethnic disparities in access to medicare home health care: the disparate impact of policy.

The Balanced Budget Act of 1997 dramatically decreased reimbursements for traditional Medicare home health patients. A multivariate analysis of Medicare Current Beneficiary Survey data showed that African American and "other" users experienced greater decreases in home care between 1996 and 1998 than did White users. These results suggest (a) race/ethnicity is an independent factor in determining service use post-BBA and (b) health policy has a disparate impact on minority older adults. Capitated payment systems must be pursued cautiously to avoid negative effects on vulnerable populations. The potential for current and future Medicare policy changes to negatively affect vulnerable populations is also discussed.

ApoE mimetic peptide decreases Abeta production in vitro and in vivo.

BACKGROUND: Apolipoprotein E (apoE) is postulated to affect brain Abeta levels through multiple mechanisms--by altering amyloid precursor protein (APP) processing, Abeta degradation, and Abeta clearance. We previously showed that an apoE-derived peptide containing a double repeat of the receptor-binding region was similarly effective in increasing APP processing in vivo. Here, we further examined whether peptides containing tandem repeats of the apoE receptor-binding region (amino acids 141-149) affected APP trafficking, APP processing, and Abeta production. RESULTS: We found that peptides containing a double or triple tandem repeat of the apoE receptor-binding region, LRKLRKRLL, increased cell surface APP and decreased Abeta levels in PS1-overexpressing PS70 cells and in primary neurons. This effect was potentiated by a sequential increase in the number of apoE receptor-binding domain repeats (trimer > dimer > monomer). We previously showed that the apoE dimer increased APP CTF in vivo; to determine whether the dimer also affected secreted APP or Abeta levels, we performed a single hippocampal injection of the apoE dimer in wild-type mice and analyzed its effect on APP processing. We found increased sAPPalpha and decreased Abeta levels at 24 hrs after treatment, suggesting that the apoE dimer may increase alpha-secretase cleavage. CONCLUSIONS: These data suggest that small peptides consisting of tandem repeats of the apoE receptor-binding region are sufficient to alter APP trafficking and processing. The potency of these peptides increased with increasing repeats of the receptor binding domain of apoE. In addition, in vivo administration of the apoE peptide (dimer) increased sAPPalpha and decreased Abeta levels in wild-type mice. Overall, these findings contribute to our understanding of the effects of apoE on APP processing and Abeta production both in vitro and in vivo.

Enhancement of cell recovery for dissociated human embryonic stem cells after cryopreservation.

Due to widespread applications of human embryonic stem (hES) cells, it is essential to establish effective protocols for cryopreservation and subsequent culture of hES cells to improve cell recovery. We have developed a new protocol for cryopreservation of dissociated hES cells and subsequent culture. We examined the effects of new formula of freezing solution containing 7.5% dimethylsulfoxide (DMSO) (v/v %) and 2.5% polyethylene glycol (PEG) (w/v %) on cell survival and recovery of hES cells after cryopreservation, and further investigated the role of the combination of Rho-associated kinase (ROCK) inhibitor and p53 inhibitor on cell recovery during the subsequent culture. Compared with the conventional slow-freezing method which uses 10% DMSO as a freezing solution and then cultured in the presence of ROCK inhibitor at the first day of culture, we found out that hES cell recovery was significantly enhanced by around 30 % (P < 0.05) by the new freezing solution. Moreover, at the first day of post-thaw culture, the presence of 10 microM ROCK inhibitor (Y-27632) and 1 microM pifithrin-mu together further significantly improved cell recovery by around 20% (P < 0.05) either for feeder-dependent or feeder-independent culture. hES cells remained their undifferentiated status after using this novel protocol for cryopreservation and subsequent culture. Furthermore, this protocol is a scalable cryopreservation method for handling large quantities of hES cells.

ApoE4 decreases spine density and dendritic complexity in cortical neurons in vivo.

The three human alleles of apolipoprotein E (APOE) differentially influence outcome after CNS injury and affect one's risk of developing Alzheimer's disease (AD). It remains unclear how ApoE isoforms contribute to various AD-related pathological changes (e.g., amyloid plaques and synaptic and neuron loss). Here, we systematically examined whether apoE isoforms (E2, E3, E4) exhibit differential effects on dendritic spine density and morphology in APOE targeted replacement (TR) mice, which lack AD pathological changes. Using Golgi staining, we found age-dependent effects of APOE4 on spine density in the cortex. The APOE4 TR mice had significantly reduced spine density at three independent time points (4 weeks, 3 months, and 1 year, 27.7% +/- 7.4%, 24.4% +/- 8.6%, and 55.6% +/- 10.5%, respectively) compared with APOE3 TR mice and APOE2 TR mice. Additionally, in APOE4 TR mice, shorter spines were evident compared with other APOE TR mice at 1 year. APOE2 TR mice exhibited longer spines as well as significantly increased apical dendritic arborization in the cortex compared with APOE4 and APOE3 TR mice at 4 weeks. However, there were no differences in spine density across APOE genotypes in hippocampus. These findings demonstrate that apoE isoforms differentially affect dendritic complexity and spine formation, suggesting a role for APOE genotypes not only in acute and chronic brain injuries including AD, but also in normal brain functions.

Intervention with abused older males: conceptual and clinical perspectives.

Men and women experience abuse in different ways and older men have particular treatment needs that must be addressed by clinicians. The current design and configuration of clinical services may create barriers to abused older men receiving treatment fully suited to their needs. In this article, the unique experiential dynamics and help seeking behaviors of older men who experience abuse are delineated and recommendations are given for structuring services to better meet their needs. Gender-sensitive clinical techniques and modalities are described and suggestions for interventions that could prove particularly efficacious in the treatment of older men are offered.

Depression and caregiver burden among rural elder caregivers.

Family caregivers of older adults frequently experience feelings of burden and depression though they may not come to the attention to health and service providers until they are at a point of crisis. Through a simple screening tool, the Maine Primary Partners in Caring (MPPC) project identified individuals providing care to older adults through rural primary care practices, in order to provide upstream interventions before caregivers were in crisis. This paper describes a sample (n=62) of rural family caregivers identified through their physicians' offices. High levels of caregiver burden and depression were reported. Family support and knowledge of caregiver tasks predicted decreased caregiver burden and depression, while isolation predicted increased caregiver burden. Implications of these results for gerontological social workers are outlined.

Early intervention screening for family caregivers of older relatives in primary care practices: establishing a community health service alliance in rural America.

The Maine Primary Partners in Caregiving project provides a prime example of how disparate community health, social service, and higher education institutions can build a successful rural service alliance for the purposes of screening for family members experiencing stress during the provision of care to impaired older relatives. Community primary care practices are featured as prime sites for the early identification of elder caregivers experiencing stress and burden. Initial project results and implementation challenges as well as recommended strategies for nurturing such community partnerships are presented.

[Coping with certain symptoms of acute schizophrenic psychosis]. / Sposoby radzenia sobie z wybranymi objawami w zaostrzeniu schizofrenii.

Coping attempts with selected symptoms of acute schizophrenic psychosis (delusions, hallucinations, formal thought disorders) are described in 40 patients. Their correlations with basic socio-demographic and clinical variables are also analyzed.