Triggering palliative care referrals through the identification of poor prognosis in older patients presented to emergency departments in rural Australia

Background: Without objective screening for risk of death, the palliative care needs of older patients near the end of life may be unrecognised and unmet. Aim: This study aimed to estimate the usefulness of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool in determining older patients' risk of death within 3-months after initial hospital admission. Methods: A prospective cohort study of 235 patients aged 70+ years, who presented to two rural emergency departments in two adjacent Australian states, was utilised. The 'risk of death' of each patient was screened with the CriSTAL prognostic tool. Their 3-month follow-up outcomes were assessed through telephone interviews and a clinical record review. Findings: A CriSTAL cut-off score of more than 7 yielded a sensitivity of 80.7% and specificity of 70.81% for a 3-month risk of death. Palliative care services were only used by 31% of the deceased in their last trimester of life. Conclusion: Prognostic tools provide a viable means of identifying individuals with a poor prognosis. Identification can trigger an earlier referral to palliative care, which will benefit the patient's wellbeing and quality of life.

63 USING CO-DESIGN TO DEVELOP A CORE COMPETENCY FRAMEWORK FOR INTERPROFESSIONAL COLLABORATION WITHIN INTEGRATED CARE TEAMS FOR OLDER PEOPLE IN IRELAND

Background

Fundamental to the successful delivery of integrated care for older people in Ireland and internationally, is sustainable interprofessional collaboration (IPC). Current evidence, however, offers little guidance in terms of how IPC can be fostered and sustained within the context of integrated care and older people. This research aimed to design a framework that describes core competencies for IPC within integrated care teams (ICTs) for older people, and outline mechanisms by which ICTs could start to develop the necessary knowledge, skills and behaviours to demonstrate proficiency.

Methods

Using a co-design approach, academic health systems researchers, members of the National Integrated Care Programme for Older People in Ireland (IPC subcommittee), and public and patient representatives (nominated by Age Friendly Ireland) collaborated across three studies to devise a core competency framework. Study 1 used co-design workshops to develop and gain consensus on core competencies; study 2 employed semi-structured interviews to explore current working practice within two existing interprofessional ICTs and study 3, combined findings from study 1 and 2, validated the agreed upon competencies and finalised the IPC competency framework.

Results

Six competencies, within three domains, were agreed. Domain one, knowledge of the team, includes the competencies, understanding roles and making referrals. Domain two, communication, includes sharing information and communicating effectively and domain three, shared decision-making, includes the final two competencies, supporting decision making with older people and collective clinical decision-making.

Conclusion

This co-designed framework provides the scaffold for curriculum development for the training of health and social care professionals around interdisciplinary team working for the care of older people. The core competencies prioritise mutual respect and active elicitation of input from all disciplines, thereby empowering disciplinary-specific expertise. Finally, and perhaps most critically, the will and preferences of the older person are deemed central to effective integrated interprofessional working within the developed IPC framework.

Interneuronal mechanisms for learning-induced switch in a sensory response that anticipates changes in behavioral outcomes

Sensory cues in the natural environment predict reward or punishment, important for survival. For example, the ability to detect attractive tastes indicating palatable food is essential for foraging while the recognition of inedible substrates prevents harm. While some of these sensory responses are innate, they can undergo fundamental changes due to prior experience associated with the stimulus. However, the mechanisms underlying such behavioral switching of an innate sensory response at the neuron and network levels require further investigation. We used the model learning system of Lymnaea stagnalis^1-3 to address the question of how an anticipated aversive outcome reverses the behavioral response to a previously effective feeding stimulus, sucrose. Key to the switching mechanism is an extrinsic inhibitory interneuron of the feeding network, PlB (pleural buccal^4,5), which is inhibited by sucrose to allow a feeding response. After multi-trial aversive associative conditioning, pairing sucrose with strong tactile stimuli to the head, PlB's firing rate increases in response to sucrose application to the lips and the feeding response is suppressed; this learned response is reversed by the photoinactivation of a single PlB. A learning-induced persistent change in the cellular properties of PlB that results in an increase rather than a decrease in its firing rate in response to sucrose provides a neurophysiological mechanism for this behavioral switch. A key interneuron, PeD12 (Pedal-Dorsal 12), of the defensive withdrawal network^5,6 does not mediate the conditioned suppression of feeding, but its facilitated output contributes to the sensitization of the withdrawal response.

Abstract P1-10-08: Development of a first-in-class oral selective ERα covalent antagonist (SERCA) for the treatment of ERαWT and ERαMUT breast cancer

Mutations in estrogen receptor alpha (ERα) are detected in up to 30% of breast cancer patients who have relapsed during endocrine therapy. ERα mutations functionally confer resistance to existing classes of endocrine therapies, likely through gaining constitutive activity. The fact that current ER-directed therapies are only partially effective in the ERα mutant setting, and that a significant proportion of resistant breast cancer metastases continue to remain dependent on ERα signaling for growth/survival, highlights the critical need to develop the next generation of ERα antagonists that can overcome aberrant ERα activity. Using structure-based drug design approaches we have identified a novel class of ERα antagonist referred to as Selective ERα Covalent Antagonist (SERCA) that inactivate both wild-type and mutant ERα by targeting a unique cysteine residue that is not conserved among other steroid hormone receptors. Biophysical, biochemical and cellular analyses confirm the covalent mechanism of action, specific binding to ER and selective inhibition of ERα-dependent transcription of SERCAs. H3B-6545 is a highly selective SERCA that potently antagonizes wild-type and mutant ERα in biochemical and cell based assays demonstrating increased potency over standard of care and other experimental agents. In vivo, H3B-6545 shows superior efficacy to fulvestrant in the MCF-7 xenograft model with once daily oral dosing, achieving maximal antitumor activity at doses >10x below the maximum tolerated dose in mice. In addition, H3B-6545 shows superior antitumor activity to both tamoxifen and fulvestrant in patient derived xenograft models of breast cancer carrying estrogen receptor mutations. In summary, H3B-6545 is a first-in-class, orally available and selective ER covalent antagonist with a compelling pre-clinical profile that is being developed for the treatment of ERα positive breast cancer.

Citation Format: Korpal M, Puyang X, Furman C, Zheng GZ, Banka D, Wu J, Zhang Z, Thomas M, Mackenzie C, Yao H, Rimkunas V, Kumar P, Caleb B, Karr C, Subramanian V, Irwin S, Larsen N, Vaillancourt F, Nguyen T-V, Davis A, Chan B, Hao MH, O'Shea M, Prajapati S, Agoulnik S, Kuznetsov G, Kumar N, Yu Y, Lai G, Hart A, Eckley S, Fekkes P, Bowser T, Joshi JJ, Selvaraj A, Wardell S, Norris J, Smith S, Reynolds D, Mitchell L, Wang J, Yu L, Kim A, Rioux N, Sahmoud T, Warmuth M, Smith PG, Zhu P. Development of a first-in-class oral selective ERα covalent antagonist (SERCA) for the treatment of ERαWT and ERαMUT breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-10-08.

Automated Catheter Navigation With Electromagnetic Image Guidance

This paper describes a novel method of controlling an endoscopic catheter by using an automated catheter tensioning system with the objective of providing clinicians with improved manipulation capabilities within the patient. Catheters are used in many clinical procedures to provide access to the cardiopulmonary system. Control of such catheters is performed manually by the clinicians using a handle, typically actuating a single or opposing set of pull wires. Such catheters are generally actuated in a single plane, requiring the clinician to rotate the catheter handle to navigate the system. The automation system described here allows closed-loop control of a custom bronchial catheter in tandem with an electromagnetic tracking of the catheter tip and image guidance by using a 3D Slicer. An electromechanical drive train applies tension to four pull wires to steer the catheter tip, with the applied force constantly monitored through force sensing load cells. The applied tension is controlled through a PC connected joystick. An electromagnetic sensor embedded in the catheter tip enables constant real-time position tracking, whereas a working channel provides a route for endoscopic instruments. The system is demonstrated and tested in both a breathing lung model and a preclinical animal study. Navigation to predefined targets in the subject's airways by using the joystick while using virtual image guidance and electromagnetic tracking was demonstrated. Average targeting times were 29 and 10 s, respectively, for the breathing lung and live animal studies. This paper presents the first reported remote controlled bronchial working channel catheter utilizing electromagnetic tracking and has many implications for future development in endoscopic and catheter-based procedures.

Effects of Resin Rheology on the Extrusion Foaming Characteristics of PET

Extrusion foaming by injection of inert gases (carbon dioxide, nitrogen, argon) in the polymer melt is increasingly finding applications for a wide variety of resins, competing with chemical blowing agents, volatile organic compounds or microcellular foaming. The molecular weight and molecular weight distribution of the resin affect its rheological characteristics (shear and elongational viscosity, melt elasticity, melt strength), its process characteristics and control cell size and stability of the resulting foam. In the present work, a variety of PET resins (including virgin materials, recycled and post-reactor modified) having different rheological characteristics were foamed by direct carbon dioxide injection and through the use of chemical blowing agents. Formability as related to density and cell size and distribution was evaluated and correlated with rheological characteristics of the particular resin, process conditions and type of blowing agent.

Solving difficult problems creatively: a role for energy optimised deterministic/stochastic hybrid computing

How is the brain configured for creativity? What is the computational substrate for ‘eureka’ moments of insight? Here we argue that creative thinking arises ultimately from a synergy between low-energy stochastic and energy-intensive deterministic processing, and is a by-product of a nervous system whose signal-processing capability per unit of available energy has become highly energy optimised. We suggest that the stochastic component has its origin in thermal (ultimately quantum decoherent) noise affecting the activity of neurons. Without this component, deterministic computational models of the brain are incomplete.

Antecedents of the child behavior checklist-dysregulation profile in children born extremely preterm

OBJECTIVE

Extremely preterm newborns are at heightened risk for emotional and behavioral dysregulation later in childhood. Our goal was to systematically evaluate the antenatal and early postnatal antecedents that might mediate the association between extreme preterm birth and emotional and behavioral dysregulation at age 2 years (corrected age).

METHOD

In a multi-site prospective study, the parents of 826 infants born before 28 weeks gestation completed a Child Behavior Checklist (CBCL) when the child was 2 years corrected age. We compared the maternal, pregnancy, placenta, delivery, and newborn characteristics, as well as early postnatal characteristics and exposures of those who satisfied criteria for the CBCL-Dysregulation Profile (CBCL-DP) to those of their peers. We then used time-oriented logistic regression models, starting first with antenatal variables that distinguished children with the CBCL-DP profile from their peers, and then added the distinguishing postnatal variables.

RESULTS

Approximately 9% of the children had a CBCL-DP. In the time-oriented logistic regression model with antenatal variables only, low maternal education achievement, passive smoking, and recovery of Mycoplasma from the placenta were associated with increased risk, whereas histologic chorioamnionitis was associated with reduced risk. None of the postnatal variables added statistically significant discriminating information.

CONCLUSION

Very preterm newborns who later manifest the CBCL-DP at age 2 years differ in multiple ways from their preterm peers who do not develop the CBCL-DP, raising the possibility that potentially modifiable antenatal and early postnatal phenomena contribute to the risk of developing emotional and behavioral dysregulation.

A novel long non-coding natural antisense RNA is a negative regulator of Nos1 gene expression

Long non-coding natural antisense transcripts (NATs) are widespread in eukaryotic species. Although recent studies indicate that long NATs are engaged in the regulation of gene expression, the precise functional roles of the vast majority of them are unknown. Here we report that a long NAT (Mm-antiNos1 RNA) complementary to mRNA encoding the neuronal isoform of nitric oxide synthase (Nos1) is expressed in the mouse brain and is transcribed from the non-template strand of the Nos1 locus. Nos1 produces nitric oxide (NO), a major signaling molecule in the CNS implicated in many important functions including neuronal differentiation and memory formation. We show that the newly discovered NAT negatively regulates Nos1 gene expression. Moreover, our quantitative studies of the temporal expression profiles of Mm-antiNos1 RNA in the mouse brain during embryonic development and postnatal life indicate that it may be involved in the regulation of NO-dependent neurogenesis.

A 2-year review of the general internal medicine admissions to the British Role 3 Hospital in Camp Bastion, Afghanistan

BACKGROUND

Detailed knowledge of the likely volume and nature of the diseases presenting to deployed secondary care facilities aids operational planning. Now the British operation in Afghanistan has ended and a record of the experience is useful to preserve the lessons learned.

METHODS

Over a 2-year period from April 2011, prospective demographic and clinical data were collected on consecutive general internal medicine admissions to the Role 3 Hospital in Camp Bastion, Afghanistan. Up to four different symptoms and diagnoses were coded using the WHO International Classification of Disease, V.10 for each patient.

RESULTS

A total of 1368 medical patients were admitted. Of 1131 military admissions, 612 were from the UK (54.1%) and the remainder from 13 allied countries; 237 civilians came from 23 countries. Civilians were older than the military patients (p<0.001) but included five children. The 20 most frequent presenting symptoms were identified and there were 1626 diagnoses made. The 10 most frequent diagnoses were infectious gastroenteritis (12.6%), heat illness (4.3%), pneumonia (3.6%), epilepsy (2.6%), cellulitis (2.7%), migraine (1.8%), peptic ulcer disease (1.2%), myocardial infarction (1.2%), venous thromboembolism (1.2%) and pericarditis (0.7%). In 252 cases (18.4%) a firm diagnosis was not reached and a symptom was recorded. The five most frequent of these were undifferentiated febrile illnesses (4.6%), syncope (3.7%), chest pain (2.8%), headache (0.8%) and palpitations (0.7%). The mean hospital length of stay was 1.59 days and 72.2% of UK military patients were 'returned to unit'. Three civilian patients died in hospital or following aeromedical evacuation and there were no deaths of any military patients.

DISCUSSION

This study demonstrates the wide variety of presentations seen by physicians at an established military field hospital. This information informs the core syllabus of military physician training and will help facilitate planning for future medical support to similar military operations.

TRIAL REGISTRATION NUMBER

RCDM/Res/Audit/1036/12/0305.

Interneuronal mechanism for Tinbergen's hierarchical model of behavioral choice

Recent studies of behavioral choice support the notion that the decision to carry out one behavior rather than another depends on the reconfiguration of shared interneuronal networks [1]. We investigated another decision-making strategy, derived from the classical ethological literature [2, 3], which proposes that behavioral choice depends on competition between autonomous networks. According to this model, behavioral choice depends on inhibitory interactions between incompatible hierarchically organized behaviors. We provide evidence for this by investigating the interneuronal mechanisms mediating behavioral choice between two autonomous circuits that underlie whole-body withdrawal [4, 5] and feeding [6] in the pond snail Lymnaea. Whole-body withdrawal is a defensive reflex that is initiated by tactile contact with predators. As predicted by the hierarchical model, tactile stimuli that evoke whole-body withdrawal responses also inhibit ongoing feeding in the presence of feeding stimuli. By recording neurons from the feeding and withdrawal networks, we found no direct synaptic connections between the interneuronal and motoneuronal elements that generate the two behaviors. Instead, we discovered that behavioral choice depends on the interaction between two unique types of interneurons with asymmetrical synaptic connectivity that allows withdrawal to override feeding. One type of interneuron, the Pleuro-Buccal (PlB), is an extrinsic modulatory neuron of the feeding network that completely inhibits feeding when excited by touch-induced monosynaptic input from the second type of interneuron, Pedal-Dorsal12 (PeD12). PeD12 plays a critical role in behavioral choice by providing a synaptic pathway joining the two behavioral networks that underlies the competitive dominance of whole-body withdrawal over feeding.

•

Behavioral choice between mutually exclusive behaviors is hierarchically organized

•

Touch-induced whole-body withdrawal inhibits sucrose-driven feeding rhythms

•

Two interneurons with asymmetrical connectivity allow withdrawal to override feeding

•

Suppression of feeding is due to the enhancement of tonic inhibition

Susceptibility of memory consolidation during lapses in recall

Memories that can be recalled several hours after learning may paradoxically become inaccessible for brief periods after their formation. This raises major questions about the function of these early memory lapses in the structure of memory consolidation. These questions are difficult to investigate because of the lack of information on the precise timing of lapses. However, the use of a single-trial conditioning paradigm in Lymnaea solves this problem. Here we use electrophysiological and behavioural experiments to reveal lapses in memory recall at 30 min and 2 h post conditioning. We show that only during these lapses is consolidation of long-term memory susceptible to interruption by external disturbance. These shared time points of memory lapse and susceptibility correspond to transitions between different phases of memory that have different molecular requirements. We propose that during periods of molecular transition memory recall is weakened, allowing novel sensory cues to block the consolidation of long-term memory.

Memory lapses during memory consolidation are periods when the memory becomes briefly inaccessible after its formation. Marra and colleagues study memory lapses in the mollusc Lymnaea, and find that only during these lapses is consolidation of memories susceptible to interruption by external disturbances.

Does aggressive phototherapy increase mortality while decreasing profound impairment among the smallest and sickest newborns?

OBJECTIVE

Aggressive phototherapy (AgPT) is widely used and assumed to be safe and effective for even the most immature infants. We assessed whether the benefits and hazards for the smallest and sickest infants differed from those for other extremely low-birth-weight (ELBW; ≤ 1000 g) infants in our Neonatal Research Network trial, the only large trial of AgPT.

STUDY DESIGN

ELBW infants (n=1974) were randomized to AgPT or conservative phototherapy at age 12 to 36 h. The effect of AgPT on outcomes (death, impairment, profound impairment, death or impairment (primary outcome), and death or profound impairment) at 18 to 22 months of corrected age was related to BW stratum (501 to 750 g; 751 to 1000 g) and baseline severity of illness using multilevel regression equations. The probability of benefit and of harm was directly assessed with Bayesian analyses.

RESULT

Baseline illness severity was well characterized using mechanical ventilation and FiO(2) at 24 h age. Among mechanically ventilated infants ≤ 750 g BW (n=684), a reduction in impairment and in profound impairment was offset by higher mortality (P for interaction <0.05) with no significant effect on composite outcomes. Conservative Bayesian analyses of this subgroup identified a 99% (posterior) probability that AgPT increased mortality, a 97% probability that AgPT reduced impairment, and a 99% probability that AgPT reduced profound impairment.

CONCLUSION

Findings from the only large trial of AgPT suggest that AgPT may increase mortality while reducing impairment and profound impairment among the smallest and sickest infants. New approaches to reduce their serum bilirubin need development and rigorous testing.

Multi-neuronal refractory period adapts centrally generated behaviour to reward

Oscillating neuronal circuits, known as central pattern generators (CPGs), are responsible for generating rhythmic behaviours such as walking, breathing and chewing. The CPG model alone however does not account for the ability of animals to adapt their future behaviour to changes in the sensory environment that signal reward. Here, using multi-electrode array (MEA) recording in an established experimental model of centrally generated rhythmic behaviour we show that the feeding CPG of Lymnaea stagnalis is itself associated with another, and hitherto unidentified, oscillating neuronal population. This extra-CPG oscillator is characterised by high population-wide activity alternating with population-wide quiescence. During the quiescent periods the CPG is refractory to activation by food-associated stimuli. Furthermore, the duration of the refractory period predicts the timing of the next activation of the CPG, which may be minutes into the future. Rewarding food stimuli and dopamine accelerate the frequency of the extra-CPG oscillator and reduce the duration of its quiescent periods. These findings indicate that dopamine adapts future feeding behaviour to the availability of food by significantly reducing the refractory period of the brain's feeding circuitry.

Review of acute cancer beds

A review of admissions to cancer services at University Hospital Galway (UHG) was undertaken to assess the appropriateness of hospital usage. All cancer specialty patients admitted from 26-28 May 2009 were reviewed (n = 82). Chi square tests, Exact tests, and One-way ANOVA were utilised to analyse key issues emerging from the data. Fifty (61%) were classified as emergencies. Twenty three (67%) occupied a designated cancer bed with 24 (30%) in outlying non-oncology wards. The mean length of stay was 29.3 days. Possible alternatives to admission were identified for 15 (19%) patients. There was no evidence of discharge planning for 50 (60%) admissions. There is considerable potential to make more appropriate utilisation of UHG for cancer patients, particularly in terms of reducing bed days and length of stay and the proportion of emergency cancer admissions, and further developing integrated systems of discharge planning.

Improving the ability of mental health nurses to give second opinion in Judicial Reviews: an evaluation study

In New Zealand, concern has been expressed regarding the variable quality of second opinions given by health professionals assisting judicial decisions on the use of compulsory assessment and treatment under mental health legislation. This second opinion is mostly given by registered mental health nurses. An innovative education programme based on experiential learning and adult learning principles was developed to assist health professionals to effectively undertake this role. A mixed method pre-post test intervention research design was developed to evaluate the effectiveness of the programme in assisting health professionals to feel more competent in undertaking the role. Data from the participants (n= 112) was subjected to descriptive statistical analysis and a thematic analysis of open-ended questions. The findings suggested gains in all competencies following the education programme, although there was room for further improvement. These changes were sustained over time at the next occasion when the health professionals undertook the role. There is a need to nationally disseminate such educational innovations to assist more mental health nurses to maximize their input into judicial decisions, which have a marked impact on the lives of those service users involved.

Medical radiation exposure and risk of retinoblastoma resulting from new germline RB1 mutation

Although ionizing radiation induces germline mutations in animals, human studies of radiation-exposed populations have not detected an effect. We conducted a case-control study of sporadic bilateral retinoblastoma, which results from a new germline RB1 mutation, to investigate gonadal radiation exposure of parents from medical sources before their child's conception. Parents of 206 cases from nine North American institutions and 269 controls participated; fathers of 184 cases and 223 friend and relative controls and mothers of 204 cases and 260 controls provided information in telephone interviews on their medical radiation exposure. Cases provided DNA for RB1 mutation testing. Of common procedures, lower gastrointestinal (GI) series conferred the highest estimated dose to testes and ovaries. Paternal history of lower GI series was associated with increased risk of retinoblastoma in the child [matched odds ratio (OR) = 3.6, 95% confidence interval (CI) = 1.2-11.2, two-sided p = 0.02], as was estimated total testicular dose from all procedures combined (OR for highest dose=3.9, 95% CI = 1.2-14.4, p = 0.02). Maternal history of lower GI series was also associated with increased risk (OR = 7.6, 95% CI = 2.8-20.7, p < 0.001) as was the estimated total dose (OR for highest dose = 3.0, 95% CI = 1.4-7.0, p = 0.005). The RB1 mutation spectrum in cases of exposed parents did not differ from that of other cases. Some animal and human data support our findings of an association of gonadal radiation exposure in men and women with new germline RB1 mutation detectable in their children, although bias, confounding, and/or chance may also explain the results.

Does bronchopulmonary dysplasia contribute to the occurrence of cerebral palsy among infants born before 28 weeks of gestation?

OBJECTIVE

To evaluate the relationships among cerebral palsy (CP) phenotypes and bronchopulmonary dysplasia (BPD) severity and, in the process, to generate hypotheses regarding causal pathways linking BPD to CP.

STUDY DESIGN

We studied 1047 infants born before the 28th week of gestation. Receipt of supplemental oxygen at 36 weeks postmenstrual age (PMA), with or without the need for mechanical ventilation (MV) at 36 weeks PMA, defined two levels of BPD. At 24 months, the children underwent neurologic examinations and CP diagnoses were made using an algorithm based on topographic localisation.

RESULTS

The 536 infants with BPD were at increased risk of all three CP phenotypes. In time-oriented multivariable analyses that adjusted for potential confounders, receipt of supplemental oxygen without MV at 36 weeks PMA (BPD) was not associated with increased risk of any CP phenotype. In contrast, BPD accompanied by MV at 36 weeks PMA (BPD/MV) was associated with a nearly sixfold increased risk of quadriparesis and a fourfold increased risk of diparesis.

CONCLUSIONS

Combined treatment with both MV and supplemental oxygen at 36 weeks PMA strongly predicts the more common bilateral CP phenotypes. BPD without MV at 36 weeks PMA was not significantly associated with any form of CP.

Reconciling the STDP and BCM models of synaptic plasticity in a spiking recurrent neural network

Rate-coded Hebbian learning, as characterized by the BCM formulation, is an established computational model of synaptic plasticity. Recently it has been demonstrated that changes in the strength of synapses in vivo can also depend explicitly on the relative timing of pre- and postsynaptic firing. Computational modeling of this spike-timing-dependent plasticity (STDP) has demonstrated that it can provide inherent stability or competition based on local synaptic variables. However, it has also been demonstrated that these properties rely on synaptic weights being either depressed or unchanged by an increase in mean stochastic firing rates, which directly contradicts empirical data. Several analytical studies have addressed this apparent dichotomy and identified conditions under which distinct and disparate STDP rules can be reconciled with rate-coded Hebbian learning. The aim of this research is to verify, unify, and expand on these previous findings by manipulating each element of a standard computational STDP model in turn. This allows us to identify the conditions under which this plasticity rule can replicate experimental data obtained using both rate and temporal stimulation protocols in a spiking recurrent neural network. Our results describe how the relative scale of mean synaptic weights and their dependence on stochastic pre- or postsynaptic firing rates can be manipulated by adjusting the exact profile of the asymmetric learning window and temporal restrictions on spike pair interactions respectively. These findings imply that previously disparate models of rate-coded autoassociative learning and temporally coded heteroassociative learning, mediated by symmetric and asymmetric connections respectively, can be implemented in a single network using a single plasticity rule. However, we also demonstrate that forms of STDP that can be reconciled with rate-coded Hebbian learning do not generate inherent synaptic competition, and thus some additional mechanism is required to guarantee long-term input-output selectivity.

Spike-timing dependent plasticity and the cognitive map

Since the discovery of place cells – single pyramidal neurons that encode spatial location – it has been hypothesized that the hippocampus may act as a cognitive map of known environments. This putative function has been extensively modeled using auto-associative networks, which utilize rate-coded synaptic plasticity rules in order to generate strong bi-directional connections between concurrently active place cells that encode for neighboring place fields. However, empirical studies using hippocampal cultures have demonstrated that the magnitude and direction of changes in synaptic strength can also be dictated by the relative timing of pre- and post-synaptic firing according to a spike-timing dependent plasticity (STDP) rule. Furthermore, electrophysiology studies have identified persistent “theta-coded” temporal correlations in place cell activity in vivo, characterized by phase precession of firing as the corresponding place field is traversed. It is not yet clear if STDP and theta-coded neural dynamics are compatible with cognitive map theory and previous rate-coded models of spatial learning in the hippocampus. Here, we demonstrate that an STDP rule based on empirical data obtained from the hippocampus can mediate rate-coded Hebbian learning when pre- and post-synaptic activity is stochastic and has no persistent sequence bias. We subsequently demonstrate that a spiking recurrent neural network that utilizes this STDP rule, alongside theta-coded neural activity, allows the rapid development of a cognitive map during directed or random exploration of an environment of overlapping place fields. Hence, we establish that STDP and phase precession are compatible with rate-coded models of cognitive map development.

Role of tonic inhibition in associative reward conditioning in lymnaea

Changes in the strength of excitatory synaptic connections are known to underlie associative memory formation in the molluscan nervous system but less is known about the role of synaptic inhibition. Tonic or maintained synaptic inhibition has an important function in controlling the Lymnaea feeding system and is known to suppress feeding in the absence of food or in satiated animals. Tonic inhibition to the feeding network is provided by the N3t interneuron that has inhibitory monosynaptic connection with the central pattern generator interneuron, the N1M. Here we asked whether a reduction in the level of tonic inhibition provided by the N3t cell could play a role in reward conditioning? Semi-intact preparations made from hungry snails were conditioned using a previously developed one-trial chemical conditioning paradigm. We recorded electrical activity in a feeding motoneuron, the B3, at various time-points after conditioning. This allowed us to measure the frequency of spike activity in the N3t interneuron and monitor fictive feeding patterns that generate the rhythmic movements involved in food ingestion. We show that there is a reduction in N3t spiking at 1, 2, 3, and 4 h after conditioning but not at 10 and 30 min and the reduction in N3t firing inversely correlates with an increase in the conditioned fictive feeding response. Computer simulation of N3t–N1M interactions suggests that changes in N3t firing are sufficient to explain the increase in the fictive feeding activity produced by conditioning. A network model is presented that summarizes evidence suggesting that reward conditioning in Lymnaea is due to the combined effects of reduced tonic inhibition and enhanced excitatory synaptic connections between the CS pathway and feeding command neurons.

Sensory driven multi-neuronal activity and associative learning monitored in an intact CNS on a multielectrode array

The neuronal network controlling feeding behavior in the CNS of the mollusc Lymnaea stagnalis has been extensively investigated using intracellular microelectrodes. Using microelectrodes however it has not been possible to record from large numbers of neurons simultaneously and therefore little is known about the population coding properties of the feeding network. Neither can the relationships between feeding and neuronal networks controlling other behaviors be easily analyzed with microelectrodes. Here we describe a multielectrode array (MEA) technique for recording action potentials simultaneously from up to 60 electrodes on the intact CNS. The preparation consists of the whole CNS connected by sensory nerves to the chemosensory epithelia of the lip and esophagus. From the buccal ganglia, the region of the CNS containing the feeding central pattern generator (CPG), a rhythmic pattern of activity characteristic of feeding was readily induced either by depolarizing an identified feeding-command neuron (the CV1a) or by perfusing the chemosensory epithelia with sucrose, a gustatory stimulus known to activate feeding. Activity induced by sucrose is not restricted to the buccal ganglia but is distributed widely throughout the CNS, notably in ganglia controlling locomotion, a behavior that must be coordinated with feeding. The MEA also enabled us to record electrophysiological consequences of the associative conditioning of feeding behavior. The results suggest that MEA recording from an intact CNS enables distributed, multiple-source neural activity to be analyzed in the context of biologically relevant behavior, behavioral coordination and behavioral plasticity.

Acetylcholine binding protein of mollusks is unlikely to act as a regulator of cholinergic neurotransmission at neurite-neurite synaptic sites in vivo

A population of glial cells in the central nervous system of the gastropod mollusk Lymnaea stagnalis produces a soluble protein that specifically binds acetylcholine. This protein is named the acetylcholine binding protein (AChBP). Experiments performed in vitro indicated that AChBP inactivates released acetylcholine at cholinergic synapses. On the basis of these observations, a similar in vivo role for AChBP was hypothesized. To fulfill this function, AChBP-expressing glia ought to be located in close proximity to cholinergic synapses in vivo. To examine this, we have analyzed the cellular and subcellular expression of AChBP in the intact CNS. Using a variety of molecular techniques, we demonstrate here that AChBP expression is confined to a subpopulation of glial cells located within the peripheral zone of each of the ganglia constituting the CNS. This zone contains the cell bodies of neurons, but few synapses. Conversely, glial cells that do not express the AChBP are predominantly located in the synapse-rich central neuropile zone but are rare in the cell body zone. Thus, our findings are not compatible with the previous conclusions drawn from in vitro studies and suggest that AChBP functions in vivo as a regulator of nonsynaptic cholinergic transmission.

Novel noncoding antisense RNA transcribed from human anti-NOS2A locus is differentially regulated during neuronal differentiation of embryonic stem cells

Here, we report on the discovery of a locus in the human genome, which evolved by gene duplication followed by an internal DNA inversion. This locus exhibits high sequence similarity to the gene for the inducible isoform of NOS protein (NOS2A) and is transcribed into a noncoding RNA containing a region of significant antisense homology with the NOS2A mRNA. We show that this antisense transcript (anti-NOS2A RNA) is expressed in different types of brain tumors, including meningiomas and glioblastomas. More importantly, we demonstrate that the expression profiles of the anti-NOS2A RNA and the NOS2A mRNA exhibit concurrent reciprocal changes in undifferentiated human embryonic stem cells (hESCs) and in hESCs induced to differentiate into neurogenic precursors such as neurospheres. As NOS2A has a role in neurogenesis, our results suggest that the anti-NOS2A RNA is involved in the regulation of neuronal differentiation of hESCs through the modulation of NOS2A gene expression.

Characterization of NO-sensitive guanylyl cyclase: expression in an identified interneuron involved in NO-cGMP-dependent memory formation

In a number of neuronal models of learning signalling by endogenous nitric oxide (NO), produced by the enzyme NO synthase (NOS), is essential for the formation of long-term memory (LTM). For example, in the molluscan model system Lymnaea, NO is required for LTM formation in the first few hours after one-trial reward conditioning. Furthermore, conditioning leads to transient up-regulation of the NOS gene in identified modulatory neurons, the cerebral giant cells (CGCs), which are known to be involved in LTM formation. In Lymnaea nothing is known however about the structure and localization of the major receptor for NO, the soluble guanylyl cyclase (sGC). Here we report on the cloning and characterization of both alpha and beta subunits of NO-sensitive sGC and show that they are coexpressed in the CGCs. Furthermore, our electrophysiological experiments on isolated CGCs show that these neurons respond to NO by generating a prolonged depolarization of the membrane potential. Moreover, we demonstrate that this depolarization is blocked by ODQ, supporting our hypothesis that it is mediated by sGC.

Persistent sodium current is a nonsynaptic substrate for long-term associative memory

Although synaptic plasticity is widely regarded as the primary mechanism of memory [1], forms of nonsynaptic plasticity, such as increased somal or dendritic excitability or membrane potential depolarization, also have been implicated in learning in both vertebrate and invertebrate experimental systems [2-7]. Compared to synaptic plasticity, however, there is much less information available on the mechanisms of specific types of nonsynaptic plasticity involved in well-defined examples of behavioral memory. Recently, we have shown that learning-induced somal depolarization of an identified modulatory cell type (the cerebral giant cells, CGCs) of the snail Lymnaea stagnalis encodes information that enables the expression of long-term associative memory [8]. The Lymnaea CGCs therefore provide a highly suitable experimental system for investigating the ionic mechanisms of nonsynaptic plasticity that can be linked to behavioral learning. Based on a combined behavioral, electrophysiological, immunohistochemical, and computer simulation approach, here we show that an increase of a persistent sodium current of this neuron underlies its delayed and persistent depolarization after behavioral single-trial classical conditioning. Our findings provide new insights into how learning-induced membrane level changes are translated into a form of long-lasting neuronal plasticity already known to contribute to maintained adaptive modifications at the network and behavioral level [8].

Cerebral palsy

Extreme prematurity confers about a 100-fold increase in the risk of cerebral palsy (CP), relative to birth at term gestation. Although CP is primarily a disorder of movement, many children with this disorder have other impairments which may affect their quality of life and life expectancy. Epidemiologic and clinical studies of cerebral palsy have benefited from recent efforts to develop greater uniformity of definition and classification. Particularly noteworthy is the development of the Gross Motor Function Classification System, which is a reliable and valid measure used with increasing frequency in observational and experimental studies. Also of great importance are efforts to quantify reliably the quality of life for children with cerebral palsy, thereby providing a target for medical and community interventions that aim to increase participation and well-being among affected children. During the late 1970s and early 1980s, the rate of CP actually rose, presumably as a result of increased survival of especially vulnerable infants who otherwise would have died. In developed countries over the past two decades (late 1980s to present), CP rates have been either stable or decreasing. Although considerable effort is being directed at prevention, the only perinatal interventions for which there is strong evidence of a beneficial effect on both mortality and the risk of CP is antenatal treatment of the mother with glucocorticoid.

Neuroimaging and neurodevelopmental outcomes in preterm infants

Imaging of the preterm infant brain has advanced dramatically beyond the earliest era of transillumination. Computed tomography (CT), a crucial innovation during the early 1970s, allowed noninvasive visualization of intracerebral lesions, particularly hemorrhage. The capability to document brain injury in the preterm infant led to better clarification of links to developmental outcomes. With the development of cranial ultrasound (CUS), and more recently, magnetic resonance imaging (MRI), CT is used rarely for imaging the brain of preterm infants. Despite extensive experience with neonatal neuroimaging, significant questions still remain. Substantial controversies exist pertaining to when and how neuroimaging should be performed and how images should be interpreted.