A Novel Approach to Delivering Evidence-based, High-quality Care in Psychiatry Through an Electronic Integrated Care Pathway (eICP) Pilot.

Integrated care pathways (ICPs) are evidence-based decision support tools intended to reduce variation and improve quality of care. Historically, adoption of ICPs has been difficult to measure, as the pathways were outside of the electronic health record (EHR), where care delivery documentation and orders were completed. This Technology Column describes the innovative development and implementation of a diagnosis specific electronic ICP that directly embeds pathway steps into an EHR to facilitate order sets, clinical decision-making, and usage tracking. The pathway was implemented at a seven-hospital academic medical center, and details the technology, team structure, early adoption results, and future directions. As such, the importance of investing and organizing resources to create an eICP (e.g., time, technology, and specialized teams) to provide a user-friendly experience to support early adoption is underscored. Preliminary findings show that the eICP had consistent use in the first year of implementation. This manuscript is intended to serve as a practical guide to build eICPs within behavioral health service areas across institutions.

Subthalamic Nucleus Deep Brain Stimulation Modulates 2 Distinct Neurocircuits.

OBJECTIVE: Current understanding of the neuromodulatory effects of deep brain stimulation (DBS) on large-scale brain networks remains elusive, largely due to the lack of techniques that can reveal DBS-induced activity at the whole-brain level. Using a novel 3T magnetic resonance imaging (MRI)-compatible stimulator, we investigated whole-brain effects of subthalamic nucleus (STN) stimulation in patients with Parkinson disease. METHODS: Fourteen patients received STN-DBS treatment and participated in a block-design functional MRI (fMRI) experiment, wherein stimulations were delivered during "ON" blocks interleaved with "OFF" blocks. fMRI responses to low-frequency (60Hz) and high-frequency(130Hz) STN-DBS were measured 1, 3, 6, and 12 months postsurgery. To ensure reliability, multiple runs (48 minutes) of fMRI data were acquired at each postsurgical visit. Presurgical resting-state fMRI (30 minutes) data were also acquired. RESULTS: Two neurocircuits showed highly replicable, but distinct responses to STN-DBS. A circuit involving the globus pallidus internus (GPi), thalamus, and deep cerebellar nuclei was significantly activated, whereas another circuit involving the primary motor cortex (M1), putamen, and cerebellum showed DBS-induced deactivation. These 2 circuits were dissociable in terms of their DBS-induced responses and resting-state functional connectivity. The GPi circuit was frequency-dependent, selectively responding to high-frequency stimulation, whereas the M1 circuit was responsive in a time-dependent manner, showing enhanced deactivation over time. Finally, activation of the GPi circuit was associated with overall motor improvement, whereas M1 circuit deactivation was related to reduced bradykinesia. INTERPRETATION: Concurrent DBS-fMRI using 3T revealed 2 distinct circuits that responded differentially to STN-DBS and were related to divergent symptoms, a finding that may provide novel insights into the neural mechanisms underlying DBS. ANN NEUROL 2020;88:1178-1193.

Substance Use Disorders in Later Life: A Review and Synthesis of the Literature of an Emerging Public Health Concern.

Substance use disorders (SUDs) among older persons are among the fastest growing health problems in the United States. The number of older persons is projected to exceed 72.1 million persons by 2030, following a trend of general population growth in the mid-1940s to 1960s. The generation, known as "baby boomers," who refashioned drug use during their 20-30s, are increasingly continuing drug habits into later life. This review aims to assess the epidemiology, impact, and treatment of geriatric SUDs. Academic databases including PubMed, PsychInfo, Ovid, and Medline, were queried up to December 2018 for terms of "geriatric," "older," "elderly," "substance abuse," "drug," "drug use," "drug abuse," "drug dependency," "illicit drugs," and "geriatric psychiatry." Articles identified included 17 government documents, 29 studies based upon government documents, 43 studies not related to US government surveys, 19 review articles, 9 commentary pieces, 4 newspaper articles, 2 textbooks, and 1 published abstract. Evaluated studies and documents together suggest that older individuals are using illicit drugs and meeting criteria for SUDs at higher rates than previous geriatric cohorts resulting in substantial negative impacts on medical and psychiatric conditions. These findings represent a novel trend since previous cohorts of older individuals were thought to rarely use illicit substances. Current treatment models are inadequate to address the new wave of older individuals with SUDs. The fields of geriatrics, addiction, and geriatric psychiatry must work together to establish comprehensive care models and treatment modalities for addressing this emerging public health concern.

Measuring complex behaviors of local oscillatory networks in deep brain local field potentials.

BACKGROUND: Multiple oscillations emerging from the same neuronal substrate serve to construct a local oscillatory network. The network usually exhibits complex behaviors of rhythmic, balancing and coupling between the oscillations, and the quantification of these behaviors would provide valuable insight into organization of the local network related to brain states. NEW METHOD: An integrated approach to quantify rhythmic, balancing and coupling neural behaviors based upon power spectral analysis, power ratio analysis and cross-frequency power coupling analysis was presented. Deep brain local field potentials (LFPs) were recorded from the thalamus of patients with neuropathic pain and dystonic tremor. t-Test was applied to assess the difference between the two patient groups. RESULTS: The rhythmic behavior measured by power spectral analysis showed significant power spectrum difference in the high beta band between the two patient groups. The balancing behavior measured by power ratio analysis showed significant power ratio differences at high beta band to 8-20 Hz, and 30-40 Hz to high beta band between the patient groups. The coupling behavior measured by cross-frequency power coupling analysis showed power coupling differences at (theta band, high beta band) and (45-55 Hz, 70-80 Hz) between the patient groups. COMPARISON WITH EXISTING METHOD: The study provides a strategy for studying the brain states in a multi-dimensional behavior space and a framework to screen quantitative characteristics for biomarkers related to diseases or nuclei. CONCLUSIONS: The work provides a comprehensive approach for understanding the complex behaviors of deep brain LFPs and identifying quantitative biomarkers for brain states related to diseases or nuclei.

A novel uni-acupoint electroacupuncture stimulation method for pain relief.

Electroacupuncture stimulation (EAS) has been demonstrated effective for pain relief and treating other various diseases. However, the conventional way of EAS, the bi-acupoint method, is not suitable for basis study of acupoint specificity. Moreover, its operations are inconvenient and difficult to be persevered, especially for long-term, continuous and even imperative treatments. These disadvantages motivate designs of new EAS methods. We present a novel uni-acupoint electrical stimulation method, which is applied at a single acupoint and quite meets the needs of basis study and simpler clinical application. Its pain relief effect has been evaluated by animal tests of Wistar rats. During the experiments, rats were given 30 min 2/100 Hz uni- and bi-acupoint EAS and their nociceptive thresholds before and after EAS were attained by hot-plate test. The analgesic effect was defined as the change of nociceptive threshold and used to evaluate the effectiveness of uni-acupoint EAS for pain relief. The hot-plate test results indicated that analgesic effect of uni-acupoint group was significantly higher than that of the control group and there was no significant difference of analgesic effects between uni- and bi-acupoint EAS. The results suggested that uni-acupoint method was an effective EAS method and had comparable pain relief effect with bi-acupoint method.

Epileptic seizure detection with the local field potential of anterior thalamic of rats aiming at real time application.

Treating epilepsy with deep brain stimulation (DBS) is attracting more and more attention these years, especially the close loop method that gives stimuli when needed so that the implanted device will work longer. People have tried to detect seizure with electrocorticogram (ECoG), but the extra implants put more risks to it. We plan to detect seizure with local field potential (LFP) that recorded with depth electrodes of traditional DBS. To prove the validation of this method, we recorded local field potential (LFP) of anterior thalamic (ANT) of rats who have been induced to acute temporal lobe epilepsy (TLE) by kainic acid injected in hippocampus, and succeeded in detecting electrographic onset (EO) in these data. A variation of generic Osorio-Frei algorithm (GOFA) was used as the detection method with some adjustments which mainly focus on increasing calculation speed and decreasing number of total calculations to meet the future need of transplanting to battery powered embedded medical device.

[Effects of electroacupuncture of unilateral and bilateral "zusanli" (ST 36) on serum TNF-alpha, IL-1 and IL-4 levels in rats with chronic inflammatory pain].

OBJECTIVE: To observe the effect of electroacupuncture (EA) on serum tumor necrosis factor-alpha (TNF-alpha), IL-1 and IL-4 levels in rats with chronic inflammatory pain, so as to investigate its underlying mechanism in relieving pain. Methods Forty-eight SD rats were randomized into control, model, EA-unilateral ST 36, and EA-bilateral ST 36 groups, with 12 rats in each. Chronic inflammatory pain model was established by intradermal injection of Freund's complete adjuvant (0.1 mL) into the right paw. EA (2 Hz/100 Hz, 1-2-3 mA) was applied to the unilateral "Zusanli" (ST 36) and bilateral "Zusanli" (ST 36) for 30 min, once every 3 days and continuously for 4 weeks. Serum TNF-alpha, IL-1 and IL-4 contents were detected by enzyme linked immunosorbent assay. Results Compared with the control group, serum TNF-alpha, IL-1 and IL-4 contents of the model group increased significantly (P < 0.01), while in comparison with the model group, the levels of the 3 indexes were decreased considerably in both unilateral and bilateral ST 36 groups (P < 0.01). No significant differences were found between the unilateral ST 36 and bilateral ST 36 groups in serum TNF-alpha, IL-1 and IL-4 contents (P > 0.05). CONCLUSION: EA can effectively lower serum TNF-alpha, IL-1 and IL-4 levels in inflammatory pain rats, which may contribute to its effect in relieving inflammatory pain.

[Current research and development trend of implantable neuro-stimulator].

This paper introduces the current application of various kinds of implantable neuro-stimulator at home and abroad, and also analyzes its development trend.

The transcutaneous charger for implanted nerve stimulation device.

Implanted nerve stimulation offers many advantages to improve the QOL (quality of life) of the patients suffering from nervous system diseases such as Parkinson's disease and epilepsy. Secondary battery begins to be used instead of primary secondary, service life of the implanted device is extended and the device becomes smaller and lighter. For charging the secondary battery fit in the body, a transcutaneous charger is designed. Two coupling coils designed specially are used to transmit and receive energy. With the mentioned coupling coils, the charger attains 15 mA charge current and the charge requirement is satisfied.