Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines.

OBJECTIVES: Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. METHODS: A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. RESULTS: This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. CONCLUSIONS: Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.

Pediatric Emergency Medicine Training in Procedural Sedation: Is It Time for a Standardized Curriculum?

OBJECTIVES: Pediatric procedural sedation (PS) has been performed with increasing frequency by pediatric emergency physicians for recent years. Accreditation Council for Graduate Medical Education Pediatric Emergency Medicine fellowship core competency requirements do not specify the manner in which fellows should become proficient in pediatric PS. We surveyed the variety of training experience provided during fellowship and whether those surveyed felt that their training was sufficient. METHODS: A 35-question survey offered to pediatric emergency fellows and recent (within 10 years) graduates collected data on pediatric PS training during fellowship. A follow-up questionnaire was sent to fellowship directors at programs where fellow or graduate respondents stated that a sedation curriculum that existed asked details of their program. RESULTS: There were 95 respondents to the survey, 62% of which had completed pediatric emergency medicine fellowship training. Of respondents, 65% reported having a formal sedation curriculum during fellowship. Of those who participated in a formal curriculum, 82% of respondents felt comfortable performing sedation, whereas the remaining 18% required additional preceptorship and/or more formal training to feel proficient. Fifty-six percent of respondents reported having to complete a set number of sedations before being allowed to sedate independently. Of 17 programs contacted, 9 fellowship directors responded. All 9 included didactics, 6 (66.6%) of 9 included evidence-based medicine literature review, and 6 (66.6%) of 9 included simulation. Other modalities used included supervised clinical experience in a pediatric sedation unit, a 2-week rotation with a hospital sedation team, online sedation modules, and precepted sedations using each pharmacologic agent including nitrous oxide, ketamine, propofol, and ketamine-propofol combination. Ketamine was the most frequently used agent for sedation (87%). CONCLUSIONS: Pediatric emergency medicine fellowship requirements lack a clearly defined pathway for training in PS. Data collected from both current and former fellows depict inconsistency in training experience and suboptimal comfort level in performing these procedures. We suggest that fellows receive a more comprehensive and varied experience with multiple teaching modalities to improve proficiency with this critical and complex aspect of emergency pediatric care.

Volume measurements and fluorescent staining indicate an increase in permeability for organic cation transporter substrates during apoptosis.

Extensive membrane blebbing is one of the earliest observable changes in HeLa cells stimulated with apoptosis inducers. Blebbing caused by actinomycin D or camptothecin, but not by anti-Fas antibody, is accompanied by an almost 10% volume increase as measured by transmission-through-dye microscopy. When the experiment is carried out in DMEM medium, the swelling appears to result from activation of amiloride-sensitive channels. Low-sodium choline-, but not N-methyl(-)D-glucamine-based, medium, also supports swelling during the blebbing phase of apoptosis; this indicates that the membrane becomes permeable to choline as well. Because choline can enter the cells through organic cation transporters (OCT), we tested three fluorescent dyes (2-[4-(dimethylamino)styryl]-1-methylpyridinium iodide, rhodamine 123 and ethidium bromide) that have been reported to utilize OCT for cell entry. Intact HeLa cells are poorly permeable for these fluorophores, and initially they accumulate on the plasma membranes. Blebbing results in an enhanced penetration of these dyes into the cell interior, as was demonstrated both by direct observation and by FRET. The increased membrane permeability is specific for OCT substrates; the other tested cationic dyes apparently cross the membrane by other routes and exhibit a markedly different behavior. Our results reveal a previously unknown feature of apoptosis and the utility of cationic dyes for studying membrane transport.

GABAergic and glutamatergic cells in the inferior colliculus dynamically express the GABAAR γ1 subunit during aging.

Age-related hearing loss may result, in part, from declining levels of γ-amino butyric acid (GABA) in the aging inferior colliculus (IC). An upregulation of the GABAAR γ1 subunit, which has been shown to increase sensitivity to GABA, occurs in the aging IC. We sought to determine whether the upregulation of the GABAAR γ1 subunit was specific to GABAergic or glutamatergic IC cells. We used immunohistochemistry for glutamic acid decarboxylase and the GABAAR γ1 subunit at 4 age groups in the IC of Fisher Brown Norway rats. The percentage of somas that expressed the γ1 subunit and the number of subunits on each soma were quantified. Our results show that GABAergic and glutamatergic IC cells increasingly expressed the γ1 subunit from young age until expression peaked during middle age. At old age (∼77% of life span), the number of GABAAR γ1 subunits per cell sharply decreased for both cell types. These results, along with previous studies, suggest inhibitory and excitatory IC circuits may express the GABAAR γ1 subunit in response to the age-related decline of available GABA.