161 THE ROLE OF THE GERIATRIC DAY HOSPITAL DURING THE COVID 19 PANDEMIC

Background

Methods

Results

Conclusion

163 EVALUATING THE ROLE OF THE GERIATRIC DAY HOSPITAL IN MEDICATION OPTIMISATION

Background

The geriatric day hospital (GDH) provides outpatient geriatric medical, nursing and rehabilitation care to older adults. The aim of this study was to assess whether medication optimisation occurs in this setting. We believe the GDH would be an ideal location for mediation optimisation due to the stable community dwelling patients and close follow up by specialised physicians.

Methods

Electronic patient records of the new patients ≥65 years seen in the GDH over a 3-month period were reviewed. Potentially inappropriate prescriptions (PIPs) and potentially prescribing omissions (PPOs) were identified using the STOPP/START prescribing tool on admission to the GDH and again at discharge from the GDH.

Results

One-hundred and sixty-seven patient records were reviewed; mean age 80.8 (SD6.5) years, 62.9% female, median clinical frailty scale score 6 (IQR5–6), mean number of conditions 5.79 (SD3), mean number of medications 7.57 (SD3.7). Patients had a median of 4 (IQR2–7) consultations. The number of patients prescribed at least 1 STOPP-PIP reduced by 10% (42.4% vs 38%; p < 0.001). Vasodilator drugs in patients with orthostatic hypotension were deprescribed most frequently (6.5% vs 3%; p < 0.001). PPOs were reduced by 36% (47.5% vs 30.6%;p < 0.001). The largest improvement was identified in the prescription of vitamin D in patients experiencing falls (17.4% vs 13.8%;p < 0.001). Logistic regression was performed to ascertain the influence of age, gender, falls, dementia, co-morbidity number and medication number on the likelihood of a patient experiencing a PIP or PPO. For every medication prescribed, the odds of experiencing a PIP increased by 11.8% (OR1.187, 95%CI 1.052–1.339). Being female increased the odds of experiencing a PPO by 21.7% (OR2.17, 95%CI 10.53–4.468).

Conclusion

Medication optimisation is key in avoiding side effects from potentially inappropriate medications. The frequency of patient attendances coupled with geriatricians’ expertise makes the GDH an ideal setting for medication optimisation in multi-morbid frail community-dwelling older adults.

Loss of dysbindin-1 affects GABAergic transmission in the PFC

It has been shown that dystrobrevin-binding protein 1 gene that encodes the protein dysbindin-1 is associated with risk for cognitive deficits, and studies have shown decreases in glutamate and correlated decreases in dysbindin-1 protein in the prefrontal cortex (PFC) and hippocampus of post-mortem tissue from schizophrenia patients. The PFC and the hippocampus have been shown to play a fundamental role in cognition, and studies in dysbindin-1 null mice have shown alterations in NMDAR located in pyramidal neurons as well as perturbation in LTP and cognitive deficits. The balance between excitatory and inhibitory transmission is crucial for normal cognitive functions; however, there is a dearth of information regarding the effects of loss of dysbindin-1 in GABAergic transmission. Using in vitro whole-cell clamp recordings, Western blots, and immunohistochemistry, we report here that dysbindin-1-deficient mice exhibit a significant decrease in the frequency of sIPSCs and in the amplitude of mIPSCs and significant decreases in PV staining and protein level. These results suggest that loss of dysbindin-1 affects GABAergic transmission at pre- and postsynaptic level and decreases parvalbumin markers.

Effects of fingolimod administration in a genetic model of cognitive deficits

Notwithstanding recent advances, cognitive impairments are among the most difficult-to-treat symptoms in neuropsychiatric disorders. Deficits in information processing contributing to memory and sociability impairments are found across neuropsychiatric-related disorders. Previously, we have shown that mutations in the DTNBP1 gene (encoding dystrobrevin-binding protein 1 [dysbindin-1]) lead to abnormalities in synaptic glutamate release in the prefrontal cortex (PFC) and hippocampus and to cognitive deficits; glutamatergic transmission is important for cortical recurrent excitation that allows information processing in the PFC. To investigate possible means of restoring glutamate release and improving cognitive impairments, we assess the effects of increasing endogenous levels of brain-derived neurotrophic factor (BDNF) in a dysbindin-1-deficient mouse model. Increasing endogenous levels of BDNF may aid in remediating cognitive deficits, given the roles of BDNF in synaptic transmission, plasticity, and neuroprotection. To increase BDNF, we use a novel strategy, repeated intraperitoneal injections of fingolimod (Gilenya). Sphingolipids have recently been shown to have therapeutic value in several neurology-related disorders. Both wild-type (WT) and mutant (MUT) genotypes were tested for sociability and recognition memory, followed by measuring endogenous BDNF levels and presynaptic [Ca²⁺ ]_i within the PFC. Both genotypes were treated for 1 week with either saline or fingolimod. Relative to WT mice, MUT mice demonstrated impairments in sociability and recognition memory and lower presynaptic calcium. After fingolimod treatment, MUT mice exhibited significant improvements in sociability and recognition memory and increases in presynaptic calcium and endogenous concentrations of BDNF. These results show promise for counteracting the cognitive impairments seen in neuropsychiatric disorders and may shed light on the role of dysbindin-1. © 2016 Wiley Periodicals, Inc.

alpha2-Noradrenergic receptors activation enhances excitability and synaptic integration in rat prefrontal cortex pyramidal neurons via inhibition of HCN currents

Stimulation of alpha(2)-noradrenergic (NA) receptors within the PFC improves working memory performance. This improvement is accompanied by a selective increase in the activity of PFC neurons during delay periods, although the cellular mechanisms responsible for this enhanced response are largely unknown. Here we used current and voltage clamp recordings to characterize the response of layer V-VI PFC pyramidal neurons to alpha(2)-NA receptor stimulation. alpha(2)-NA receptor activation produced a small hyperpolarization of the resting membrane potential, which was accompanied by an increase in input resistance and evoked firing. Voltage clamp analysis demonstrated that alpha(2)-NA receptor stimulation inhibited a caesium and ZD7288-sensitive hyperpolarization-activated (HCN) inward current. Suppression of HCN current by alpha(2)-NA stimulation was not dependent on adenylate cyclase but instead required activation of a PLC-PKC linked signalling pathway. Similar to direct blockade of HCN channels, alpha(2)-NA receptor stimulation produced a significant enhancement in temporal summation during trains of distally evoked EPSPs. These dual effects of alpha(2)-NA receptor stimulation - membrane hyperpolarization and enhanced temporal integration - together produce an increase in the overall gain of the response of PFC pyramidal neurons to excitatory synaptic input. The net effect is the suppression of isolated excitatory inputs while enhancing the response to a coherent burst of synaptic activity.

Oceanographic conditions in North and Northwest Iberia and their influence on the Prestige oil spill

Oceanographic conditions at the time of the Prestige oil spill (November 2002) and following months are analyzed based on a set of hydrographic cruises. The ship sank off one of the flanks of the Galician Bank, an offshore seamount, and a major oil spill drifted to the N and NW Iberian coast mainly driven by dominant winds. Coastal circulation was characterized by freshwater plumes and the poleward slope current, and could have affected the fate of the oil spill and influenced stranding places. Seasonal evolution of oceanographic conditions in this particular year is compared with the long-term average and reveals specific features that need to be taken into account in studies of the impact of the oil spill on populations. Spring conditions commenced earlier than other years in the Southern Bay of Biscay, contrastingly in western Iberia. The lack of subsurface intrusion of subtropical waters suggests a low intense penetration of the poleward current in Spanish Biscay slopes. In western Iberia, the slope poleward current observed in late autumn weakens and is exported off slope during upwelling pulses in the spring, with no strong intrusion of the poleward current on the slope at the time of the spring bloom. A description of current velocities near the wreck on the Galician Bank is obtained after the analysis of a mooring line.

Repeated cocaine administration alters the electrophysiological properties of prefrontal cortical neurons

Recently it has become clear that some of the symptoms of addiction such as relapse to drug-taking behavior arise, in part, from a dysfunction in cognitive and emotional processing. This realization has promoted investigations into the physiology and pathophysiology of forebrain circuits that are both innervated by dopamine and play an important role in cognitive processing, including the prefrontal cortex. In order to study long-term neuroadaptations occurring in the prefrontal cortex of the rat as a consequence of psychostimulant administration, cocaine was repeatedly administered in either a contingent or a non-contingent manner. At least 2 weeks following the last cocaine injection, in vivo intracellular recordings were made from neurons located in the deep layers of the prefrontal cortex. Repeated cocaine administration abolished the presence of membrane bistability normally present in neurons located in the limbic prefrontal cortex. These results indicate that repeated exposure to cocaine produces enduring changes in the basal activity of neurons in the prefrontal cortex that may contribute to previously identify cognitive and emotional dysfunctions in cocaine addicts.

Stimulation of D1-type dopamine receptors enhances excitability in prefrontal cortical pyramidal neurons in a state-dependent manner

Prefrontal cortex neurons recorded in vivo exhibit bistable activity states, consisting of a depolarized phase (-55mV) and a hyperpolarized phase (-85mV). These "up" and "down" states have durations ranging from 800ms to 1s and a periodicity of approximately 1Hz. This study examines the state-dependency of prefrontal cortical neuron responses to dopamine, in which the bistable-state was approximated in vitro by intracellular current injection. At resting membrane potential (n=10), dopamine caused a significant depolarization of the membrane potential without altering any of the other electrophysiological characteristics tested. In contrast, both dopamine (30 microM, 5min) and the D1 receptor agonist SKF 38393 (5 and 10 microM) increased cell excitability when the cell was in the depolarized state (i.e., -55mV) but not the hyperpolarized state (i.e., -85 mV; n=10). This increase in excitability was accompanied by a decrease in the rheobase current. The SKF 38393-enhanced excitability was dose-dependent and could be blocked by bath administration of the D1 receptor antagonist SCH 23390 (5 and 10 microM). Administration of the GABA antagonist bicuculline (7 microM) plus the N-methyl-D-aspartate channel blocker CPP (10 microM) produced an additional increase in the excitability of prefrontal cortex neurons that was not dependent on the membrane potential. From these data we suggest that dopamine exerts state-dependent modulatory effects on the excitability of neurons in deep layers of the prefrontal cortex.

Regulation of limbic information outflow by the subthalamic nucleus: excitatory amino acid projections to the ventral pallidum

The subthalamic nucleus (STN), a component of the basal ganglia motor system, sends an excitatory amino acid (EAA)-containing projection to the ventral pallidum (VP), a major limbic system output region. The VP contains both NMDA and AMPA subtypes of EAA receptors. To characterize the physiology of the subthalamic pathway to the VP, and to determine the influence of EAA receptor subtypes, in vivo intracellular recordings, and in vivo extracellular recordings combined with microiontophoresis, were made from VP neurons in anesthetized rats. Of the intracellularly recorded neurons, 86% responded to STN stimulation, and these displayed EPSPs with an onset of 8.7 msec, consistent with a monosynaptic input. The EPSPs evoked in spontaneously firing neurons were nearly twice the amplitude of those in nonfiring cells (13.1 vs 6.8 mV, respectively). As neurons were depolarized by current injection, the latency for spiking decreased from 24.2 to 14.2 msec, although EPSP latency was unaffected. Eighty-seven percent of the extracellularly recorded VP neurons responded to STN stimulation with a rapid and robust enhancement of spiking; the response onset, like the EPSP onset, equaled 8.7 msec. Firing rate was enhanced by NMDA in 94% of the STN-excited cells, and AMPA increased firing in 94% as well. The NMDA-selective antagonist AP-5 attenuated 67% of the STN-evoked excitatory responses, and the AMPA-selective antagonist CNQX attenuated 52%. Both antagonists attenuated 33% of responses, and 78% were attenuated by at least one. This evidence suggests that a great majority of VP neurons are directly influenced by STN activation and that both NMDA and non-NMDA receptors are involved. Moreover, the VP response to STN stimulation appears to be strongly dependent on the depolarization state of the neuron.

American Academy of Pediatrics. Committee on Child Abuse and Neglect and Committee on Community Health Services. Investigation and review of unexpected infant and child deaths

Although there is a continuing need for timely review of child deaths, no uniform system exists for investigation in the United States. Investigation of a death that is traumatic, unexpected, obscure, suspicious, or otherwise unexplained in a child younger than 18 years requires a scene investigation and an autopsy. Review of these deaths requires the participation of pediatricians and other professionals, usually as a child death review team. An appropriately constituted team should evaluate the death investigation process, review difficult cases, and compile child death statistics.

Dopamine modulates the responsivity of mediodorsal thalamic cells recorded in vitro

The mediodorsal thalamic nucleus (MD) receives convergent inputs from subcortical limbic structures that overlap with a dopaminergic (DA) innervation. In this study, we describe the effects of DA agonists on the basal and evoked electrophysiological activity of identified thalamic cells of rats recorded in vitro. Administration of the D1 agonist SFK 38393 (10 microM) did not produce a clear effect on the physiological properties of the thalamic cells recorded. In contrast, bath administration of the D2 agonist quinpirole (10 microM) resulted in an enhancement of membrane excitability, facilitation of the occurrence of low-threshold spikes (LTSs), and changes in the resting membrane potential of the thalamic cells tested. The quinpirole-mediated responses were reversed by administration of the D2 antagonist haloperidol. Results from experiments performed with different [K+] and K+ channel blockers suggest that the effects of quinpirole are mediated at least in part by changes in K+ conductances. The results from this study suggest that DA can modulate the excitability of thalamic cells and in turn may influence the way that the thalamocortical system integrates information.

Response of the ventral pallidal/mediodorsal thalamic system to antipsychotic drug administration: involvement of the prefrontal cortex

Intracellular recordings were obtained from rat ventral pallidal (VP) and mediodorsal thalamic (MD) cells in vivo and the effects of antipsychotic drugs on their basal and evoked electrophysiological characteristics were assessed. Administration of either haloperidol or clozapine caused a significant decrease in the average firing rate, accompanied by a hyperpolarization of the membrane potential in the VP cells recorded. However, neither drug induced a substantial change in the other basic membrane properties of the MD cells or VP cells tested. In addition, in 50% of the MD cells tested, both antipsychotic drugs caused a change in spike discharge from an oscillatory pattern to a tonic discharge mode. In rats that had received ibotenic acid lesions of the prefrontal cortex (PFCtx) 4-8 weeks prior to recording, cells in the VP exhibited similar changes in firing frequency in response to haloperidol administration as those in the intact rats. However, in contrast to the intact rats, MD cells recorded from rats with PFCtx lesions exhibited a significant increase in firing rate after haloperidol administration. The results from this study suggest that the prefrontal cortex plays a role in modulating the response of the thalamus to antipsychotic drugs.

Computer reminders improve on-time immunization rates

OBJECTIVES

This study examines the effectiveness of computer-generated telephone reminders in improving infants receiving on-time immunizations. A computer called parents at home, reminded them of their child's visit, and asked if they could keep the appointment. If parents either canceled or failed to honor the appointment, the computer called back a few days later and asked them to reschedule.

METHODS

A medical assistant recruited 124 consecutive mothers to receive automated computer reminders. These mothers' infants were younger than 6 months, were being seen at an outpatient clinic for a first visit, and were patients of three attending physicians and three nurse practitioners. These infants were compared to 89 infants from the same clinic, in the same age range, who were being seen for the first time during the same period by the same providers but not contacted by the medical assistant. Subjects were selected from mothers who brought their infants for their first visit in an outpatient urban clinic that serves predominantly minority clients. A research assistant reviewed patients' medical records and collected the infants' birthday, mothers' age, race, source of payments, and the immunization record of the infants. Immunization was considered to be late if, at the time of the first visit, it was more than 30 days past due for any of the recommended immunizations of the American Academy of Pediatrics, except for Hepatitis B vaccine which was not recommended at the time of the study. The dependent variable was on-time immunization. The independent variables were age of the mother at baseline, age of the child at baseline, and membership in either the comparison or the experimental group. Chi-square tests and logistic regression were used to analyze the data.

RESULTS

The participation rate for appointments for the experimental group was 82%, as compared to a 69% overall participation rate for the clinic providers. The on-time immunization rate for experimental subjects was 67.8%, whereas the comparison group had an on-time immunization rate of 43.4% (differences were significant at alpha levels less than 0.01).

CONCLUSIONS

Computerized reminders sent to the parents led to an increase in participation rate at the clinic and an increase in on-time immunization for their infants.

Physiological properties of rat ventral pallidal neurons recorded intracellularly in vivo

1. The physiology of ventral pallidal (VP) cells was investigated using in vivo intracellular recording and staining techniques in adult rats. Based on electrophysiological criteria, three different types of cells were found: type A cells, which fired phasic spikes that did not exhibit a substantial afterhyperpolarization (AHP), type B cells, which exhibited a slow ramplike depolarization that preceded the short-duration action potential; the spike was followed by a prominent AHP, and type C cells, which were the only cells that fired spikes in couplets or bursts, with the spikes in a burst exhibiting a progressive increase in duration and a decrease in amplitude. These cells also exhibited a rebound low threshold spikelike event. Furthermore, 18% of the VP cells recorded exhibited a slow subthreshold oscillation of the membrane potential (< 1 Hz). 2. The response of VP cells to stimulation of fibers arising from the prefrontal cortex, nucleus accumbens, and mediodorsal thalamic nucleus (MD) was examined. In contrast to our initial predictions, all cells responded to nucleus accumbens stimulation with excitation. Type A and B cells responded to nucleus accumbens stimulation with excitation and to MD stimulation with antidromic-like responses, orthodromic excitation, or evoked inhibitory postsynaptic potentials. Only type A cells responded to prefrontal cortical stimulation. Type C cells only responded to stimulation of the nucleus accumbens, which resulted in evoked excitatory postsynaptic potentials. 3. The cells in the VP therefore can be segregated into three physiologically defined groups according to action potential discharge patterns and their response to afferent fiber stimulation.

A survey of pediatric management of dyslipidemias in New England

We recently surveyed physicians attending the New England Pediatric Preventive Cardiology Society. Sixteen physicians who actively evaluated children with dyslipidemia completed questionnaires; at least one representative from six of the seven medical schools in New England was included. The survey elicited responses to five hypothetical cases of childhood dyslipidemia which were representative of the types of lipid problems commonly referred to pediatric lipid specialists. Diet modification was the initial treatment of choice of all participants. For any set of lipid values, postpubertal age increased the proportion of respondents who would have prescribed medication. When pharmacologic intervention was elected, resin binders (cholestyramine or cholestipol) and niacin were most commonly prescribed. The responses of the physicians showed considerable variation in the threshold for beginning medications. In summary, this survey suggests substantial variation in the approach to pharmacologic management of pediatric dyslipidemias in the New England region.

Electrophysiological changes in substantia nigra after dynorphin administration

The present experiments were designed to explore the electrophysiological changes induced by dynorphin (Dyn) which was administered by pressure ejection into the zona reticulata of the substantia nigra (SNR). Dyn produced a long-lasting (6.0 +/- 4.5 min) decrease in firing rate in 70% of the cells recorded. Naloxone reversed the Dyn-induced decrease in firing rate in all cases, and also induced an increase in firing frequency on most occasions. Dyn did not alter cell activity in 8 of the 10 cells recorded in zona compacta of substantia nigra. It is concluded that Dyn exerts an inhibitory effect on SNR neurons, which appears to be pharmacologically specific since it is reversed by naloxone.

Enzymatic removal of bilirubin from blood: a potential treatment for neonatal jaundice

Current treatments for severe jaundice can result in major complications. Neonatal jaundice is caused by excessive accumulation of bilirubin in the blood. A small blood filter containing immobilized bilirubin oxidase was developed to reduce serum bilirubin concentrations. When human or rat blood was passed through the enzyme filter, more than 90 percent of the bilirubin was degraded in a single pass. This procedure may have important applications in the clinical treatment of neonatal jaundice.