Objective To investigate the association of morphine exposure in very preterm infants with cerebral volumes and neurodevelopmental outcome from birth through middle childhood. Study design Observational study of very preterm infants in the Victorian Infant Brain Study cohort. 230 infants born <30 weeks’ gestational age or <1,250 g were recruited from all admissions to the neonatal intensive care unit (NICU) of the Royal Women’s Hospital. 57 (25%) infants received morphine analgesia during their NICU stay at the attending physician’s discretion. Primary outcomes were regional brain volumes at term and 7 years; neurobehavioral performance at term; and cognitive, motor, emotional, behavioral, communication, and executive function scores at age 2 and 7 years. Linear regressions were used to compare outcomes between participants who did and did not receive morphine. Results At term, preterm infants who received morphine had similar rates of grey matter injury to no-morphine infants, but a trend towards smaller cortical volumes in the orbitofrontal (pleft=0.002, pright=0.01) and subgenual (pleft=0.01) regions. At seven years, cortical volumes did not differ between groups. At 2 years, morphine-exposed children were more likely to show behavioral dysregulation (p=0.007) than no-morphine children, but at seven years no detrimental impacts of morphine on neurobehavioral outcome were observed. Conclusions Low-dose morphine analgesia received during neonatal intensive care was associated with early alterations in cerebral structure and short-term neurobehavioral problems that did not persist into childhood.

We investigated whether participation in a university-based, service learning mentoring program could affect college students' learning about social inequities and the effects of poverty. The program we examined combined four critical components: (a) Mentor training, (b) mentoring youth on-site in their high-poverty environments, (c) mentors' ongoing reflecting, and (d) class discussion of issues related to poverty and social inequities. By analyzing students' ongoing reflective journals in relation to Kolb's learning cycle, we sought to determine (a) experiences students reported to engage in while mentoring and (b) the relation between students' experiences and learning about poverty. Mentees' input was obtained via interviews to corroborate mentors' perspectives. Based on findings, recommendations for the field are proposed.

BACKGROUND: Electroencephalographic (EEG) brain monitoring during general anesthesia provides information on hypnotic depth. We hypothesized that anesthesia clinicians could be trained rapidly to recognize typical EEG waveforms occurring with volatile-based general anesthesia. METHODS: This was a substudy of a trial testing the hypothesis that EEG-guided anesthesia prevents postoperative delirium. The intervention was a 35-minute training session, summarizing typical EEG changes with volatile-based anesthesia. Participants completed a preeducational test, underwent training, and completed a posteducational test. For each question, participants indicated whether the EEG was consistent with (1) wakefulness, (2) non–slow-wave anesthesia, (3) slow-wave anesthesia, or (4) burst suppression. They also indicated whether the processed EEG (pEEG) index was discordant with the EEG waveforms. Four clinicians, experienced in intraoperative EEG interpretation, independently evaluated the EEG waveforms, resolved disagreements, and provided reference answers. Ten questions were assessed in the preeducational test and 9 in the posteducational test. RESULTS: There were 71 participants; 13 had previous anesthetic-associated EEG interpretation training. After training, the 58 participants without prior training improved at identifying dominant EEG waveforms (median 60% with interquartile range [IQR], 50%–70% vs 78% with IQR, 67%–89%; difference: 18%; 95% confidence interval [CI], 8–27; P < .001). In contrast, there was no significant improvement following the training for the 13 participants who reported previous training (median 70% with IQR, 60%–80% vs 67% with IQR, 67%–78%; difference: −3%; 95% CI, −18 to 11; P = .88). The difference in the change between the pre- and posteducational session for the previously untrained versus previously trained was statistically significant (difference in medians: 21%; 95% CI, 2–28; P = .005). Clinicians without prior training also improved in identifying discordance between the pEEG index and the EEG waveform (median 60% with IQR, 40%–60% vs median 100% with IQR, 75%–100%; difference: 40%; 95% CI, 30–50; P < .001). Clinicians with prior training showed no significant improvement (median 60% with IQR, 60%–80% vs 75% with IQR, 75%–100%; difference: 15%; 95% CI, −16 to 46; P = .16). Regarding the identification of discordance, the difference in the change between the pre- and posteducational session for the previously untrained versus previously trained was statistically significant (difference in medians: 25%; 95% CI, 5–45; P = .012). CONCLUSIONS: A brief training session was associated with improvements in clinicians without prior EEG training in (1) identifying EEG waveforms corresponding to different hypnotic depths and (2) recognizing when the hypnotic depth suggested by the EEG was discordant with the pEEG index.

Surgical pulmonary embolectomy is a procedure that is often used to rescue patients with massive pulmonary embolism (PE) and circulatory collapse that have failed or may not be ideal candidates for other systemic and endovascular treatment modalities. This procedure typically involves a sternotomy and the use of cardiopulmonary bypass (CPB), which requires full systemic anticoagulation. Here, we report the case of a surgical pulmonary embolectomy performed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) rather than CPB to minimize systemic anticoagulation. The patient had suffered a cardiac arrest due to a saddle PE and required VA-ECMO which was complicated by a concomitant intracranial hemorrhage. The patient tolerated the surgical pulmonary embolectomy performed on VA-ECMO without procedure-related complications, and the ECMO support did not substantially complicate the technical performance of the procedure. In contrast to surgical pulmonary embolectomy performed on CPB, greater attention must be paid to volume status when performing the procedure on VA-ECMO since there is no blood reservoir. This case suggests cardiopulmonary support on ECMO as a viable strategy for surgical embolectomy in patients with unstable PEs in whom thrombolysis or full systemic anticoagulation are contraindicated.

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