New Method of Destroying Waste Anesthetic Gases Using Gas-Phase Photochemistry.

BACKGROUND: The inhalation anesthetics are potent greenhouse gases. To reduce the global environmental impact of the health care sector, technologies are sought to limit the release of waste anesthetic gas into the atmosphere. METHODS: Using a photochemical exhaust gas destruction system, removal efficiencies for nitrous oxide, desflurane, and sevoflurane were measured at various inlet concentrations (25% and 50%; 1.5%, 3.0%, and 6.0%; and 0.5%, 1.0%, and 2.0%, respectively) with flow rates ranging from 0.25 to 2.0 L/min. To evaluate the economic competitiveness of the anesthetic waste gas destruction system, its price per ton of carbon dioxide equivalent was calculated and compared to other greenhouse gas abatement technologies and current market prices. RESULTS: All inhaled anesthetics evaluated demonstrate enhanced removal efficiencies with decreasing flow rates (P < .0001). Depending on the anesthetic and its concentration, the photochemical exhaust gas destruction system exhibits a constant first-order removal rate, k. However, there was not a simple relation between the removal rate k and the species concentration. The costs for removing a ton of carbon dioxide equivalents are <$0.005 for desflurane, <$0.114 for sevoflurane, and <$49 for nitrous oxide. CONCLUSIONS: Based on this prototype study, destroying sevoflurane and desflurane with this photochemical anesthetic waste gas destruction system design is efficient and cost-effective. This is likely also true for other halogenated inhalational anesthetics such as isoflurane. Due to differing chemistry of nitrous oxide, modifications of this prototype photochemical reactor system are necessary to improve its removal efficiency for this gas.

Dementia palliative care in the acute psychiatric hospital: A feasibility study.

PURPOSE: We explored the feasibility of a clinical pathway to identify hospitalized patients with dementia who would benefit from a palliative intervention. DESIGN AND METHODS: Consecutive geropsychiatric admissions were screened for terminal dementia to be randomized to a palliative consultation vs usual care. FINDINGS: A total of 43 of the 188 patients (23%) had dementia; however, dementia stages were severe but not terminal. The pathway was not feasible because of the lack of the target population in the inpatient setting for the intervention. PRACTICE IMPLICATIONS: New clinical pathways are needed to identify patients with dementia who would benefit from palliative care.

A Survey of the American Society of Anesthesiologists Regarding Environmental Attitudes, Knowledge, and Organization.

Our planet is in the midst of an environmental crisis. Government and international agencies such as the Intergovernmental Panel on Climate Change urge radical and transformative change at every level of how we conduct our personal and professional lives. The health care industry contributes to climate change. According to a study from the University of Chicago, the health care sector accounts for 8% of the United States' total greenhouse gas emissions. In an effort to understand the current state of environmental practice, attitudes, and knowledge among anesthesiologists in the United States, we conducted a survey of American anesthesiologists regarding environmental sustainability. The environmental survey was sent out by e-mail to a random sampling of 5200 members of the American Society of Anesthesiologists. This process was repeated a second time. A total of 2189 anesthesiologists of 5200 responded to the survey, a 42% response rate. Of the survey respondents, 80.1% (confidence interval, 78.2%-81.9%) were interested in recycling. Respondents reported recycling in 27.7% of operating rooms where they work. The majority of respondents (67%; confidence interval, 64%-69%) reported there was insufficient information on how to recycle intraoperatively. Respondents supported sustainability practices such as reprocessing equipment, using prefilled syringes, and donating unused equipment and supplies. The affirmative response rate was 48.4% for reprocessing equipment, 56.6% for using prefilled syringes, and 65.1% for donating equipment and supplies to medical missions. Questions about hospital-wide organization of sustainability programs elicited many "I don't know" responses. Eighteen percent of responders indicated the presence of a sustainability or "green" task force. A total of 12.6% of responders indicated the presence of a mandate from hospital leadership to promote sustainability programs. Two important conclusions drawn from the survey data are a lack of hospital-wide organization of sustainability programs and a belief among survey responders that they lack adequate information on recycling and sustainability.

Survey of sensitive information written in patient notes by psychiatry trainees.

OBJECTIVE: Allowing psychiatric patients access to their electronic medical record (EMR) may cause difficulty related to the sensitivity of the note content. The authors investigated whether notes written by psychiatry trainees were ready for release to patients. METHODS: Authors conducted a review of 128 PGY-3 to PGY-5 outpatient notes not explicitly marked as "highly confidential." One psychiatrist and one non-psychiatrist read each note from the patient's perspective. Reviewers assigned a score of 0-2 (0: No Concern; 1: Some Concern; 2: Major Concern) for each note. RESULTS: Eighty-nine notes (70%) were assessed as "No Concern" by both reviewers; 30 (23%) were of "Some Concern;" and 9 (7%) were of "Major Concern;" 92 (72%) were deemed of "No Concern" by a psychiatrist, as compared with 120 (94%) by the non-psychiatrist. CONCLUSIONS: Trainee EMR outpatient notes are not likely to cause major concerns for patients who read them. Psychiatrist-reviewers identified more concerns than non-psychiatrist-reviewers.

Spiritual well-being and spiritual practices in elderly depressed psychiatric inpatients.

This study's aims were to describe the spirituality of depressed elderly psychiatric inpatients and to examine associations among spirituality, depression, and quality of life (QOL). Forty-five persons participated. Most reported frequent, stable spiritual practices and experiencing spiritual comfort and guidance. Some reported spiritual distress and changes in spirituality. During hospitalization, participants demonstrated increased spiritual well-being (SWB) and peacefulness, and reduced hopelessness, worthlessness, and guilt. Positive associations were found between SWB and QOL and negative associations between SWB and depression.

Improvement of quality of life in hospitalized depressed elderly.

BACKGROUND: Quality of life is important for all individuals, but is frequently overlooked in psychiatric populations. Our purpose was to assess the quality of life (QOL) of depressed psychiatrically hospitalized elderly patients, examine the association of QOL and depression, and explore any QOL differences related to electroconvulsive therapy (ECT). METHODS: This Institutional Review Board (IRB)-approved prospective study recruited geropsychiatric inpatients aged 65 years and older who were depressed, had Mini-mental State Examination (MMSE) scores >18/30, and adequate communication skills. Surveys were completed upon admission and discharge to measure depression (Hamilton Depression Rating Scale (HDRS)), quality of life (Linear Analogue Scales of Assessment (LASA); Medical Outcomes Short Form-36 Health Survey (SF-36)), cognitive function (MMSE; Executive Interview (EXIT 25)), and coping (Brief COPE Inventory (COPE)). Spearman correlations and Wilcoxon signed rank tests were used to assess changes in measures during hospitalization and relationships among variables. RESULTS: The 45 study participants who completed the study had a mean age of 74 years. The majority were female (67%), married (58%), Protestant (60%), with at least high school education (78%). Admission scores demonstrated severe depression (HDRS 24.88 ± 10.14) and poor QOL (LASA overall QOL 4.4 ± 2.79, and SF-36 mental [27.68 ± 9.63] and physical [46.93 ± 10.41] component scores). At discharge, there was a significant improvement of depression (HDRS 24.88v12.04, p < 0.0001) and QOL (LASA overall QOL 4.4v6.66, p < 0.0001; and SF-36 mental [27.68v39.10, p < 0.0001] and physical [46.93v50.98, p = 0.003] component scores). Not surprisingly, depression was negatively correlated with overall QOL, mental well-being, physical well-being, and emotional well-being at both admission and discharge. For the group who received ECT, there was a greater magnitude of improvement in SF-36 vitality (p = 0.002) and general health perception (p = 0.04), but also a reduction in EXIT 25 scores at discharge (p = 0.008). CONCLUSIONS: There was improvement of both QOL and depression during the course of hospitalization. Additionally, improvement of QOL was associated with improvement of depression. Perhaps future studies could develop interventions to improve both mood and QOL in elderly depressed inpatients.

Global warming potential of inhaled anesthetics: application to clinical use.

BACKGROUND: Inhaled anesthetics are recognized greenhouse gases. Calculating their relative impact during common clinical usage will allow comparison to each other and to carbon dioxide emissions in general. METHODS: We determined infrared absorption cross-sections for sevoflurane and isoflurane. Twenty-year global warming potential (GWP(20)) values for desflurane, sevoflurane, and isoflurane were then calculated using the present and previously published infrared results, and best estimate atmospheric lifetimes were determined. The total quantity of each anesthetic used in 1 minimal alveolar concentration (MAC)-hour was then multiplied by the calculated GWP(20) for that anesthetic, and expressed as "carbon dioxide equivalent" (CDE(20)) in grams. Common fresh gas flows and carrier gases, both air/oxygen and nitrous oxide (N2O)/oxygen, were considered in the calculations to allow these examples to represent common clinical use of inhaled anesthetics. RESULTS: GWP(20) values for the inhaled anesthetics were: sevoflurane 349, isoflurane 1401, and desflurane 3714. CDE(20) values for 1 MAC-hour at 2 L fresh gas flow were: sevoflurane 6980 g, isoflurane 15,551 g, and desflurane 187,186 g. Comparison among these anesthetics produced a ratio of sevoflurane 1, isoflurane 2.2, and desflurane 26.8. When 60% N2O/40% oxygen replaced air/oxygen as a carrier gas combination, and inhaled anesthetic delivery was adjusted to deliver 1 MAC-hour of anesthetic, sevoflurane CDE(20) values were 5.9 times higher with N2O than when carried with air/O2, isoflurane values were 2.9 times higher, and desflurane values were 0.4 times lower. On a 100-year time horizon with 60% N2O, the sevoflurane CDE(100) values were 19 times higher than when carried in air/O2, isoflurane values were 9 times higher, and desflurane values were equal with and without N2O. CONCLUSIONS: Under comparable and common clinical conditions, desflurane has a greater potential impact on global warming than either isoflurane or sevoflurane. N2O alone produces a sizable greenhouse gas contribution relative to sevoflurane or isoflurane. Additionally, 60% N2O combined with potent inhaled anesthetics to deliver 1 MAC of anesthetic substantially increases the environmental impact of sevoflurane and isoflurane, and decreases that of desflurane. N2O is destructive to the ozone layer as well as possessing GWP; it continues to have impact over a longer timeframe, and may not be an environmentally sound tradeoff for desflurane. From our calculations, avoiding N2O and unnecessarily high fresh gas flow rates can reduce the environmental impact of inhaled anesthetics.

Do the reading disabilities of children with cleft fit into current models of developmental dyslexia?

OBJECTIVE: The purpose of this study was to determine whether the reading problems of children with cleft fit models of developmental dyslexia. DESIGN: The study compared children with nonsyndromic cleft lip and palate who had reading disability (n = 46) with those who did not have reading disability (n = 46). The children were matched for age, sex, and grade. The two groups were compared (t tests) on measures of verbal expression, phonemic awareness, and rapid naming. Also, regression analyses compared the relative relationships of these variables to reading disability. PARTICIPANTS: Children were selected from 154 patients originally screened. RESULTS: Children with reading disability scored significantly lower on rapid naming and verbal expression, with no differences found on phonemic awareness. Rapid naming was shown to have the most significant association with reading disability. CONCLUSION: Children with nonsyndromic cleft lip and palate show symptoms similar to a naming-memory deficit model of developmental dyslexia. Reading treatment should avoid sight word approaches and focus on oral phonics treatment.