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STUDY DESIGN: Retrospective observational cohort. OBJECTIVES: This study explores the impact of Intraoperative hypotension (IOH)on post-op complications for major thoracolumbar spine fusion procedures. SUMMARY OF BACKGROUND DATA: IOH with mean arterial pressure (MAP) < 65 mmHg is associated with post-op acute kidney injury (AKI) in general surgery. In spinal deformity surgery, IOH is a contributing factor to MEP changes and spinal cord dysfunction with deformity correction. METHODS: 539 thoracolumbar fusion cases, > 6 surgical levels and > 3 hours duration were identified. Anesthetic/surgical data included OR time, fluid volume, blood loss, blood product replacement and use of vasopressors. Arterial-line based MAP data was collected at 1 min intervals. Cummulative duration of MAP < 65 mmHg was recorded. IOH within the first hour of surgery vs. the entire case was determined. Post-op course and complications including SSI, GI complications, pulmonary complications, MI, DVT, PE, AKI and encephalopathy were noted. Cumulative complications were grouped as none, 1-2 complications, or >3 complications. RESULTS: There was a significant association between occurrence of complications and duration of IOH within the first hour of surgery (8.2 vs. 5.6 min, P<0.001) and across the entire procedure (28.1 vs. 19.3 min, P=0.008). This association persisted for individual major complications including SSI, acute respiratory failure, PE, ileus requiring NGT and post-operative cognitive dysfunction. Comparison of patients with 0 vs. 1-2 vs. 3 or more complications demonstrated that patients with 3 or more complications had a longer duration of IOH in the first hour of the surgery and that patients who had no complications received less vasopressor than patients who had 1-2 or 3 or more complications. CONCLUSION: This study identifies duration of IOH during the first hour of surgery as a previously unrecognized modifiable risk associated with major complications for multi-level lumbar fusion surgery.

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Recent evidence reported that activation of the mechanistic target of rapamycin complex 1 (mTORC1) induces terminal differentiation of neural stem cells (NSCs) in the neonatal subventricular zone (SVZ), but did not affect their proliferation. Here, we investigated whether such an effect of hyperactive mTORC1 would be recapitulated in young adults following removal of the negative mTORC1 regulator TSC1as seen in the neurological disorder tuberous sclerosis complex, TSC. Conditional mTORC1 activation in NSCs of 3-4 weeks old mice resulted in the generation of proliferative (Ki67+) cells and newborn neuroblasts. However, hyperactive mTORC1 did not induce NSCs to proliferate, consistent with the findings that mTORC1 induces symmetric division and differentiation of slow-cycling NSCs into proliferative daughter cells. Taken together these data suggest that hyperactivity of mTORC1 could lead to the progressive loss of NSCs over time.

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Treatment adherence and nonadherence is the current paradigm for understanding why people with serious mental illnesses have low rates of participation in many evidence-based practices. The authors propose the concept of self-determination as an evolution in this explanatory paradigm. A review of the research literature led them to the conclusion that notions of adherence are significantly limited, promoting a value-based perspective suggesting people who do not opt for prescribed treatments are somehow flawed or otherwise symptomatic. Consistent with a trend in public health and health psychology, ideas of decisions and behavior related to health and wellness are promoted. Self-determination frames these decisions as choices and is described herein via the evolution of ideas from resistance and compliance to collaboration and engagement. Developments in recovery and hope-based mental health systems have shepherded interest in self-determination. Two ways to promote self-determination are proffered: aiding the rational actor through approaches such as shared decision making and addressing environmental forces that are barriers to choice. Although significant progress has been made toward self-determination, important hurdles remain.

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OBJECTIVE: Although representative payeeship provided within clinical settings is believed to have therapeutic benefits, its potential negative impact on the therapeutic alliance or client-provider relationship is of concern. This study examined the effects of payeeship and perceived financial leverage on positive and negative dimensions of the client-provider relationship. METHODS: The sample consisted of 205 adults ages 18 to 65 with axis I disorders who were receiving mental health services from a large urban community mental health clinic. Information about money management characteristics and ratings of the client-provider relationship were collected via face-to-face interview. RESULTS: Fifty-three percent of the sample had a payee or money manager, and 79% of this group had a clinician payee. Respondents with co-occurring psychotic and substance use disorders, lower functioning, and lower insight about their illness were more likely to have a clinician payee. Forty percent of those with a clinician payee reported perceived financial leverage. Having a clinician payee was also associated with perceived financial leverage and with higher levels of conflict in the case management relationship. When examined in combination, financial leverage was found to mediate the effects of payeeship on conflict in the case management relationship (mean+/-SE=2.37+/-1.33, 95% confidence interval=16-5.52, p<.05). That is, payeeship appeared to increase conflict in the therapeutic alliance when used as a source of treatment leverage. CONCLUSIONS: Although payeeship provides important support and may enhance functional outcomes for the patient, decisions about using the mechanism for promoting treatment adherence should take into account the potential disruption to the client-provider relationship.

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The helping relationship or alliance is theorized to be an important process variable in case management services for people with serious mental illness. Previous studies of the case management relationship borrow concepts and measures from psychotherapy research and therefore may overlook important differences in tasks, settings, and clinical roles across settings. A study of client-provider relationships as perceived by case managers, based on a qualitative study of two intensive case management (ICM) teams, is presented. The findings, which delineate positive and negative experiential elements, may be used to improve measurement of the case management relationship in future research.

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Evidence from pre-clinical infrahuman investigations, open-label clinical trials, and a single controlled trial found acute nicotine treatment potentiated up to 4 weeks neuroleptic-induced reductions of dyskinetic symptoms characterizing Tourette's syndrome (TS). Given the attentional disturbances associated with this syndrome, and the improvements in attentional processes reported with nicotine, this randomized, double-blind, placebo-controlled trial examined the acute (4 h) and sustained (2 weeks) effects of a single dose of transdermal nicotine on clinical (i.e., tics), attentional (continuous performance task, event-related potential, patient and parental reports) and behavioral symptoms in 23 children and adolescents with TS receiving neuroleptic treatment. In the 14 evaluable patients with complete primary efficacy data, nicotine (compared to placebo) failed to alter symptoms at 4 h but counteracted ERP-P300 signs of diminished attention seen 2 weeks following placebo treatment. Secondary efficacy measures, including patient self-reports and parental ratings, found nicotine to reduce complex tics and improve behaviors related to inattention. Additional work with intermittent dosing schedules is required to characterize optimal clinical and cognitive effects with nicotine treatment.

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This article describes a model and design for evaluating a comprehensive community health promotion initiative. The theoretically based model was designed by the authors to evaluate a countywide initiative based on developmental assets, a framework for healthy youth development promoted by the Search Institute in Minneapolis, Minnesota. The model includes the components of a typical logic model and incorporates concepts proposed by diffusion of innovations, social cognitive theory, and Search Institute's conceptual model for community change. The model highlights the priorities of local stakeholders and directs evaluation activities in multiple community sectors over time. The evaluation design is presented according to the Centers for Disease Control and Prevention framework for program evaluation in public health.

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OBJECTIVE: To identify characteristics that distinguish between school personnel who do and do not adopt asset-building behaviors in the formative stage of a countywide initiative. METHODS: An anonymous questionnaire, assessing constructs from diffusion of innovation and social cognitive theories, was administered to 467 adult personnel in 3 school districts. RESULTS: Discriminant analysis revealed that implementation of asset building was most closely related to rating the initiative high on trialability, relative advantage, compatibility, and observability and low on complexity. CONCLUSIONS: Efforts to implement asset-building initiatives need to assess perceptions of adult personnel and should not assume that positive youth development will be widely supported in schools.

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OBJECTIVE: To assist with interpretations of findings from a survey assessing the diffusion of an asset-building innovation in 3 school districts. METHODS: Eight focus groups were conducted with 69 school administrators, teachers, and guidance counselors in 3 school districts. Three reviewers examined transcripts for common themes. RESULTS: The themes that arose related to effective communication channels, barriers that prevent diffusion in the schools, the need for improved relationships, and addressing of students' needs. CONCLUSIONS: The study illustrates the advantages of linking qualitative and quantitative methods when performing evaluations by enhancing both the validity and usefulness of findings.

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This study investigated the effects of continuous slow infusion of cholecystokinin tetrapeptide (CCK-4), a neuropeptide with panicogenic properties, on functional hemispheric differences, as indexed by quantitative electroencephalographic (EEG) asymmetry and coherence measures. Twenty-four adult volunteers (15 females and 9 males) were assigned to infusion with either placebo or CCK-4 in a randomized, double-blind, parallel-group design, with EEG being recorded before and during (10 and 40 min) a 60-min infusion period. No significant treatment differences were observed for absolute EEG power but, compared to placebo, CCK-4 infusion increased asymmetry and reduced coherence of slow-wave activity at midtemporal recording sites. These findings support the contention that functional imbalance of the temporal cortex, perhaps mediated by CCK-4, is involved in panic disorder (PD).

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Given the putative role of serotonin in the modulation of smoking withdrawal and the central actions of nicotine, this study examined the affective and neuroelectric correlates of smoking abstinence and cigarette smoking following depletion of the serotonin precursor, tryptophan. In a randomized, double-blind two session (tryptophan depletion [TD] vs. nondepletion), placebo-controlled design, spectrally analyzed electroencephalogram (EEG), self-ratings of withdrawal symptoms and mood states were assessed in 18 male cigarette smokers before smoking abstinence, 5 h postsmoking abstinence and again following sham smoking and the smoking of one cigarette. Compared to a nutritionally balanced amino acid (AA) mixture containing tryptophan (i.e., placebo mixture), oral ingestion of a similar mixture devoid of tryptophan resulted in a 70% reduction of plasma tryptophan but failed to alter the appearance or reversal (by acute cigarette smoking) of withdrawal symptoms, negative mood states and increased slow wave EEG in male smokers deprived of cigarettes. These results, although not supporting a role for the serotonergic system in acute smoking and early smoking abstinence symptoms, are discussed in relation to the neuropharmacology of smoking behavior and suggestions for future work.

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Electroencephalographic (EEG) coherence is an index of brain regional coupling that has been found to be abnormal in people with schizophrenia but has not been systematically examined in response to neuroleptics. EEG coherence in slow (delta and theta) frequencies was assessed in 17 treatment-resistant people with schizophrenia at baseline, 2 hr after their first oral dose (25 mg) and after 6 weeks of clozapine treatment. Compared with EEG norms, participants exhibited significant interhemispheric and intrahemispheric coherence abnormalities prior to treatment. Both acute and chronic treatments altered coherence but differed with respect to their relationship to symptom reduction and their ability to normalize or augment pretreatment abnormalities. Findings are discussed in relation to "disconnection" theories of schizophrenia.

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This study investigated the effects of a continuous slow infusion of cholecystokinin tetrapeptide (CCK-4), a neuropeptide with panicogenic properties, on brain event-related potentials (ERPs) in healthy adults. Twenty-four volunteers, 15 females and 9 males, were assigned to infusion with either placebo or CCK-4 in a randomized, double-blind, parallel group design. ERPs, elicited within a standard auditory odd-ball paradigm requiring the counting of rare (20%) occurring 'deviant' tones interspersed among more frequent (80%) occurring 'standard' tones, were assessed once before infusion, and at 10 min and 40 min after the onset of infusion. Compared with the placebo, CCK-4 delayed the latencies of N100 and P200 components elicited by 'deviant' stimuli. No significant treatment differences were observed with respect to N200, P300b, mood or adverse symptoms. These preliminary findings suggest that CCK-4 may interfere with information processing relating to the selection of significant stimuli and as such, may be of relevance to mechanisms underlying panic disorder.

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Single dose administration of efficacious antidepressant agents elicit characteristic pharmaco-electroencephalographic (EEG) profiles in healthy volunteers but acute and chronic pharmaco-EEG profiling of antidepressant action in depressed patients has been relatively lacking. This study sought to examine the quantitative topographic EEGs of depressed patients in response to paroxetine treatment. Thirty male patients, meeting DSM-IV criteria for major depression, were examined before and after a single 20 mg dose. These, and an additional 40 patients, were also assessed following 6 weeks of treatment. Eyes-closed resting EEG, collected from 21 scalp sites, was spectrally analyzed to yield regional measures of absolute/relative power and mean frequency in delta, theta, alpha, beta and total spectrum frequency bands. Chronic treatment resulted in a significant reduction in scores on the Hamilton Rating Scale for Depression (HAM-D), with 80% of treatment completers exhibiting a >50% reduction in depression ratings at the end of the 6th week. Acute paroxetine did not alter EEG in patients but chronic treatment was associated with significant alterations as shown by diffuse decreases in alpha power and increases in slow (delta and theta) and anterior fast (beta) wave power, Mean theta and alpha (occipital) frequency were slowed while mean total frequency was accelerated at frontal sites and decreased at occipital sites. The chronic pharmaco-EEG response pattern reflects both sedating and activating actions in regional specific areas which are relevant to the pathophysiology and the pharmacotherapeutic treatment of depression.

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