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OBJECTIVE: Using an evidence-based approach, a Vermont Oxford Network focus group whose goal was to reduce brain injury developed and implemented a number of potentially better practices. Each center approached implementation of the practices differently. Reducing the incidence of intraventricular hemorrhage and periventricular leukomalacia are important for improving long-term outcomes for low birth weight infants. METHODS: Implementation approaches for some but not all of the practices at the various centers are discussed. The practices reviewed include optimal peripartum management, such as resuscitation, avoidance of hypothermia, optimal surfactant delivery, early neonatal management by the most experienced providers, and measures to minimize pain and stress. Additional practices include maintenance of neutral head positioning, fluid volume therapy for hypotension, indomethacin prophylaxis, ventilator management, avoidance of routine suctioning, and limiting the use of sodium bicarbonate and postnatal dexamethasone. RESULTS: Approaches to implementation were center specific, and results vary. Although some practices were easier to implement than others, communication, education, and leadership were critical to the process. CONCLUSIONS: The quality improvement multidisciplinary approach is a useful tool for finding ways to reduce the incidence of intraventricular hemorrhage and periventricular leukomalacia. [ABSTRACT FROM AUTHOR]

Epidemiologic studies demonstrate that long-term use of NSAIDs is associated with a reduced risk for the development of Alzheimer disease (AD). In this study, 20 commonly used NSAIDs, dapsone, and enantiomers of flurbiprofen were analyzed for their ability to lower the level of the 42-amino-acid form of amyloid beta protein (Abeta42) in a human H4 cell line. Thirteen of the NSAIDs and the enantiomers of flurbiprofen were then tested in acute dosing studies in amyloid beta protein precursor (APP) transgenic mice, and plasma and brain levels of Abeta and the drug were evaluated. These studies show that (a). eight FDA-approved NSAIDs lower Abeta42 in vivo, (b). the ability of an NSAID to lower Abeta42 levels in cell culture is highly predicative of its in vivo activity, (c). in vivo Abeta42 lowering in mice occurs at drug levels achievable in humans, and (d). there is a significant correlation between Abeta42 lowering and levels of ibuprofen. Importantly, flurbiprofen and its enantiomers selectively lower Abeta42 levels in broken cell gamma-secretase assays, indicating that these compounds directly target the gamma-secretase complex that generates Abeta from APP. Of the compounds tested, meclofenamic acid, racemic flurbiprofen, and the purified R and S enantiomers of flurbiprofen lowered Abeta42 levels to the greatest extent. Because R-flurbiprofen reduces Abeta42 levels by targeting gamma-secretase and has reduced side effects related to inhibition of cyclooxygenase (COX), it is an excellent candidate for clinical testing as an Abeta42 lowering agent. [ABSTRACT FROM AUTHOR]

Effectively engaging parents in the provision of child welfare services is a crucial component of the helping process; however, it has proven to be an ongoing challenge for workers in this service area. The literature indicates that outcomes are improved for children and families when parents are actively involved in service provision. This article presents a literature review specific to parental engagement in child welfare services, identifies gaps in service provision, and introduces the Family-Directed Structural Assessment Tool, which addresses several challenges of engaging parents in this process. The pilot utilization of this assessment tool by two Bachelor of Social Work students is also presented. Finally, implications for child welfare practice are described.

Objective: Collaborative quality improvement techniques were used to facilitate local quality improvement in the management of pain in infants. Several case studies are presented to highlight this process., Methods: Twelve NICUs in the Neonatal Intensive Care Quality Improvement Collaborative 2002 focused on improving neonatal pain management and sedation practices. These centers developed and implemented evidence-based potentially better practices for pain management and sedation in neonates. The group introduced changes through plan-do-study-act cycles and tracked performance measures throughout the process., Results: Strategies for implementing potentially better practices varied between centers on the basis of local characteristics. Individual centers identified barriers to implementation, developed tools for improvement, and shared their experience with the collaborative. Baseline data from the 12 sites revealed substantial opportunities for improved pain management, and local potentially better practice implementation resulted in measurable improvements in pain management at participating centers., Conclusions: The use of collaborative quality improvement techniques enhanced local quality improvement efforts and resulted in effective implementation of potentially better practices at participating centers.

Objective: The objectives of this study were to review the use of oral sucrose for procedural pain management in NICUs, develop potentially better practice guidelines that are based on the best current evidence, and provide ideas for the implementation of these potentially better practices., Methods: A collaboration of 12 centers of the Vermont Oxford Network worked together to review the strength of the evidence, clinical indications, dosage, administration, and contraindications and identify potential adverse effects for the use of sucrose analgesia as the basis of potentially better practices for sucrose analgesia guidelines. Several units implemented the guidelines., Results: Through reviews and inputs from all centers of the evidence, consensus was reached and guidelines that included indication, dosage per painful procedure, age-related dosage over 24 hours, method of delivery, and contraindications were developed., Conclusions: Guidelines now are available from a consensus group, and suggestions for implementation of guidelines, based on implementation of other pain management strategies, were developed.

Family-Directed Structural Therapy (FDST) is an approach to family therapy built on traditional concepts of Structural Family Therapy, the Strengths Model, and Group Work Theory. The FDST approach is a goal-oriented, time limited approach that enables the family to identify strengths and areas of concern, as well as to enhance family functioning. This process is facilitated via the use of a common vocabulary and a concretely organized, easily administered FDST Assessment Tool that is completed by adult family members. This article presents the essential features of the FDST approach, including the use and scoring of the FDST Assessment Tool. It concludes with an extensive case example.

Objective: Neonatal care providers from 5 institutions formed a multidisciplinary focus group with the purpose of identifying potentially better practices, the implementation of which would lead to a reduction in the incidence of intracranial hemorrhage and periventricular leukomalacia in very low birth weight infants., Methods: Practices were analyzed, 4 benchmark neonatal intensive care units were identified and evaluated, and the literature was assessed using an evidence-based approach. The work was also reviewed by a nationally respected expert., Results: Ten potentially better clinical practices were identified. In addition, variability in cranial ultrasound practice, related to both procedural process and interpretation, was identified as a confounding problem in evaluating quality. Using the same process, potentially better cranial ultrasound practices were also identified., Conclusions: Implementation of these practices will improve clinical outcomes as well as the reliability of sonogram interpretation, the basis for evaluating the quality of the team's work.

This was a 4-week, three-center, double-blind, randomized, parallel, placebo-controlled evaluation of the efficacy and safety of bupropion in hospitalized depressed patients. Results from 27 placebo and 48 bupropion-treated patients were analyzed for efficacy and safety. Assessments of efficacy and safety were made at baseline and weekly during the study. Preliminary and secondary measures of efficacy included the Clinical Global Impressions for severity (CGI-S) and improvement (CGI-I) of illness, Hamilton Depression and Hamilton Anxiety Scales, and the Zung Self-Rating Scales for depression and anxiety. Assessments of safety included vital signs, electrocardiogram, clinical laboratory tests, and adverse experiences. Dosages of bupropion were 300-600 mg/day. Results showed that bupropion was significantly (P less than 0.01) more effective than placebo at termination of study on the CGI-S, CGI-I, Hamilton Depression and Hamilton Anxiety Scales. On the Zung Self-Rating Depression and Anxiety Scales, statistical trends favored bupropion at termination of study over placebo (P less than 0.10). Adverse events in the bupropion and placebo groups were minimal with notable absence of sedation and anticholinergic- and cardiovascular-related side effects. We conclude that bupropion was significantly more effective than placebo in treating depression and accompanying anxiety in depressed inpatients.

The anxiolytic properties of nabilone, a synthetic cannabinoid resembling the natural cannabinoids, were studied in 25 outpatients suffering from anxiety. The drug was compared with a placebo in a double-blind manner over a 28-day treatment period. Patients were seen weekly by the physician and were rated by the Hamilton Rating Scale for Anxiety and the Patient's Global Evaluation as well as by patient-rated evaluations. The results of the study showed a dramatic improvement in anxiety in the nabilone group when compared with placebo (P less than 0.001). Side effects reported were dry mouth, dry eyes, and drowsiness. Patients did not report any of the subjective "altered state" experience of marihuana.

The study compared prazepam with diazepam, chlorazepate dipotassium, and placebo in the treatment of anxious out-patients. Patients were screened for participation in the study to be sure they met the criteria for inclusion. Patients were excluded if they had complicating physical or mental problems. All patients signed an informed consent. Seventy-three patients entered the study, thirteen did not complete at least two weeks of treatment and were not used in the data analysis. Of these thirteen, ten did not return and were lost to follow-up, tow entered the hospital for reasons unrelated to the drug study, and one patient on diazepam was terminated because of increased anxiety. Six patients were used in the data analysis, thirty-six males and twenty-four females with an age range of 21-61 years. Side-effects were minimal. Drowsiness was reported by two people in the placebo group, one taking chlorazepate dipotassium, three on prazepam and one on diazepam. One diazepam patient reported nausea and vomitting. Scores on the Zung Self-Rating Scale for Anxiety showed all three drug groups to be superior to placebo. The Hopkins Symptom Check-list found prazepam and diazepam to be superior to placebo and chlorazepate. No differences among the groups were found in the Hamilton Anxiety Scale. Prazepam may offer advantages over the other available benzodiazepines since it may be more readily absorbed than chlorazepate and has less side-effects than diazepam.

Three studies assessed the time course of inhibition of predatory aggression and changes in levels of brain serotonin following administration of delta9-THC. In Study One, six groups of six rats each were administered 1.25 mg/kg delta9-THC IV and frog-killing behavior was measured at six postinjection intervals: 30, 60, 90, 150, 210, and 270 minutes. In Study Two, four groups of six rats each were tested. Group One received a vehicle control injection and was tested immediately, i.e. zero-minutes, postinjection. The remaining groups received 1.25 mg/kg delta9-THC, and behavior was measured at 0, 15, and 30 min postinjection. In Study Three, two groups of six rats were treated with the vehicle or 1.25 mg/kg delta9-THC and sacrificed one minute postinjection. Additional drug groups were sacrificed at 30 and 210 min postinjection. Levels of 5-HT were determined in four brain sections: cortex, midbrain, medulla, and cerebellum. Significant inhibition of predatory aggression was found for groups tested at 0, 15, and 30 min postinjection. Brain levels of 5-HT in the midbrain and/or medulla were significantly increased over the same period.

Using classical conditioning procedures, the cardiac conditioned response (CCR) was established by pairing one of two tones with the delivery of a peripheral electric shock in Rhesus monkeys. The other tone had no terminal consequence. Such a procedure results in an anticipatory 'anxiety' or 'fear' response to the impending shock signalled by the reinforced tone. The heart rate before the tone in two of the animals was characterized by tachycardia and by bradycardia in the other animal. The effect of intravenous Delta-9-tetrahydrocannabinol (THC) was compared to various doses of diazepam, chlorpromazine, and morphine. The results indicate that THC blocks the CCR in a does-related manner. The effects of THC were similar to diazepam, an anti-anxiety drug. Chlorpromazine and morphine affected the conditioned response in an unreliable manner, and both drugs would attenuate the response in some cases and potentiate it in other instances.

One hundred and four patients suffering from insomnia took part in four different two-night double-blind crossover trials of triazolam. In three separate studies, triazolam 0-5 mg was compared to placebo, flurazepam 30 mg and chloral hydrate 500 mg. Triazolam 0-5 mg was found to be preferred and to be superior to placebo, flurazepam and chloral hydrate in the treatment of insomnia. Analysis of sleep questionnaire data showed triazolam to be superior to the other treatments on the following: How much did the medication help you sleep, onset of sleep, duration of sleep and number of awakenings. Additionally, triazolam was superior to chloral hydrate on the feeling in the morning parameter. In another comparison of triazolam 0-25 mg to flurazepan 15 mg, triazolam was not significantly better than flurazepam on any of the efficacy parameters except that the patients felt more alert the morning following triazolam that following flurazepam. On all efficacy endpoints, trends for all parameters favoured triazolam 0-25 mg over flurazepam 15 mg. Untoward side-effects in these four studies were minimal.

Recently, it has been argued that benzodiazepines may not be safe or efficacious beyond 3 months continuous dosage. This study was designed to provide data regarding efficacy, safety, possible tolerance development, and possible withdrawal effects of administering ketazolam and diazepam for a 6-month period. Chronic anxiety patients were screened for participation according to specific inclusion and exclusion criteria. Of 139 patients, forty-four terminated prematurely for non-drug related reasons and are not included in the analysis. Of the ninety-five patients remaining, sixty-three were on ketazolam, and thirty-two on diazepam. Efficacy parameters included the Hamilton Anxiety Rating Scale, Physician's Global Impressions, Target Symptoms, Self-Rating Symptom Scale, and Patient's Global Impressions. Patients were evaluated weekly for the first month except for Week 3, and then seen bi-weekly and rated monthly. The results of the study showed that ketazolam was as efficacious as diazepam in treating anxiety and resulted in fewer side-effects. No adverse effects were noted in either group. Both benzodiazepines were safe and well-tolerated. No tolerance or withdrawal effects were noted. The average doses were ketazolam Week 4 (50.0 mg), Week 24 (66.14 mg) and diazepam Week 4 (26.33 mg) and Week 24 (33.0 mg). An increase in anxiety occurred in a significant number of patients after termination of either drug. By 2 weeks after the last dose many patients were free of anxiety and did not require further treatment. These results demonstrate that benzodiazepines are safe and efficacious for at least 6 months of continuous dosage.