Clinical frailty and polypharmacy in older emergency critical care patients: a single-centre retrospective case series.

BACKGROUND AND OBJECTIVES: Admission of complex and frail patients to critical care units is common. Little is known about the relationship between clinical frailty and polypharmacy measures in critical care patients or how a critical care admission affects polypharmacy.We sought to: (1) Describe the extent and relationship between clinical frailty and polypharmacy in a cohort of older emergency general critical care patients, and to (2) Describe the effect of the critical care pathway on patient polypharmacy measures. METHODS: A retrospective evaluation was undertaken in all patients ≥70 years of age, admitted as emergencies to the general critical care units of a single large UK academic hospital, over a 2-year period (March 2016 to February 2018) (n=762). Patient Clinical Frailty Scale (CFS) and polypharmacy measures on admission were described and association was tested. Medication changes and documentation on care transitions were analysed in a randomly selected convenience cohort of critical care survivors (n=77). RESULTS: On admission patients had a median of 9 (5;12) medicines, of which a median of 3 (2;5) were high-risk medicines. Polypharmacy (5-9 medicines) and hyperpolypharmacy (≥10 medicines) occurred in 80.7% (615/762) and 43.2% (329/762) of patients, respectively. A degree of frailty was the standard (median CFS 4 (3;5)) with 45.7% (348/762) CFS 4-5 and 20% (153/762) CFS ≥6. The patient median CFS increased by 1 with polypharmacy classification increments (p<0.001). In the survivor cohort, a median of 6 (4;8) and 5 (4;8) medication changes occurred on critical care and hospital discharges, respectively. A minority of patients had detailed medication continuity plans on care transitions. CONCLUSIONS: Polypharmacy and frailty were very common in this UK single-centre cohort of older emergency critical care patients. There was a significant association between the degree of polypharmacy and frailty score. The critical care pathway created extensive changes in patient medication therapy. Medication changes on care transitions often lacked detailed documentation.

SLO, SLO, quick, quick, slow: calcium-activated potassium channels as regulators of Caenorhabditis elegans behaviour and targets for anthelmintics.

Large-conductance calcium and voltage-activated potassium channels, termed SLO-1 (or BK), are pivotal players in the regulation of cell excitability across the animal phyla. Furthermore, emerging evidence indicates that these channels are key mediators of a number of neuroactive drugs, including the most recent new anthelmintic, the cyclo-octadepsipeptide emodepside. Detailed reviews of the structure, function and pharmacology of BK channels have recently been provided (Salkoff et al. in Nat Rev Neurosci 7:921-931, 2006; Ghatta et al. in Pharmacol Ther 110:103-116, 2006) and therefore these aspects will only briefly be covered here. The purpose of this review is to discuss how SLO-1 channels might function as regulators of neural transmission and network activity. In particular, we focus on the role of SLO-1 in the regulation of Caenorhabditis elegans behaviour and highlight the role of this channel as an effector for pleiotropic actions of neuroactive drugs, including emodepside. On the premise that C. elegans is a 'model nematode' with respect to many aspects of neural function, the intention is that this might inform a broader understanding of the role of these channels in the nematodes and their potential as novel anthelmintic targets.

The calcium-activated potassium channel, SLO-1, is required for the action of the novel cyclo-octadepsipeptide anthelmintic, emodepside, in Caenorhabditis elegans.

The cyclo-octadepsipeptide anthelmintic, emodepside, has pleiotropic effects on the behaviour of the model genetic animal Caenorhabditis elegans: it inhibits locomotion, feeding, egg-laying and slows development. Previous studies on pharyngeal muscle indicated a role for latrophilin-dependent signalling and therefore prompted the suggestion that this is a common effector of this drug's actions. However, whilst a C. elegans functional null mutant for latrophilin (lat-1) is less sensitive to the effect of emodepside on the pharynx it remains sensitive to the inhibitory effects of emodepside on locomotion. Here we show that this is not due to functional redundancy between two C. elegans latrophilins, as the double mutant, lat-2, lat-1, also remains sensitive to the effects of emodepside on locomotion. Therefore, emodepside has latrophilin-independent effects. To define the molecular basis for this we performed a mutagenesis screen. We recovered nine alleles of slo-1, which encodes a Ca(2+)-activated K(+) channel. These mutants were highly resistant to the inhibitory effect of emodepside on both pharyngeal and locomotor activity. The slo-1 alleles are predicted to reduce or eliminate SLO-1 signalling, suggesting that emodepside may signal through a SLO-1-dependent pathway. The observation that gain-of-function slo-1 alleles phenocopy the effects of emodepside, but are not themselves emodepside hypersensitive, favours a model whereby emodepside directly acts through a SLO-1-dependent pathway. Tissue-specific genetic rescue experiments reveal that emodepside acts through SLO-1 expressed in either body wall muscle or in neurones to inhibit locomotion. In contrast, in the pharyngeal system, emodepside acts through SLO-1 in neurones, but not muscle, to inhibit feeding. These data further inform understanding of the mode of action of emodepside and suggest that emodepside causes inhibition of feeding via a neuronal SLO-1-dependent pathway which is facilitated by LAT-1 whilst it signals through a latrophilin-independent, SLO-1-dependent pathway, in either neurones or body wall muscle, to inhibit locomotion.

Effects of the novel anthelmintic emodepside on the locomotion, egg-laying behaviour and development of Caenorhabditis elegans.

Emodepside, a cyclooctadepsipeptide, is a broad-spectrum anthelmintic previously shown to paralyse body wall muscle and pharyngeal muscle in the model nematode Caenorhabditis elegans. We demonstrate that wild-type C. elegans L4 are less sensitive than adults to emodepside in two independent assays of locomotor behaviour: body bend generation on agar (adult IC(50) 3.7 nM, L4 IC(50) 13.4 nM) and thrashing behaviour in liquid (thrashing behaviour as a % of controls after 1h in 10 microM emodepside: adults 16%, L4 worms 48%). We also show that continuous exposure of wild-type C. elegans to emodepside throughout the life-cycle from egg onwards, slows worm development, an effect that is emodepside concentration-dependent. The rate of worm-hatching from eggs on agar plates containing emodepside was not significantly different from controls, suggesting that it is development post-hatching rather than hatching itself that is affected by the drug. Emodepside also inhibits wild-type C. elegans egg-laying, with acute exposure to the drug at 500 nM resulting in an almost total inhibition within the first hour. However, the rate of egg production was not inhibited and therefore emodepside-treated worms became bloated with eggs, eventually rupturing. This suggests that the effect of emodepside on reproduction is not due to an inhibition of egg production but rather a paralytic effect on the egg-laying muscles. These results, when coupled with previous research, suggest that emodepside interferes with signalling at the neuromuscular junction on the body-wall muscles (Willson et al., 2003), pharynx (Willson et al., 2004) and egg-laying muscles and thus inhibits three important physiological functions: locomotion, feeding and reproduction.

Anatomy, physiology and pharmacology of Caenorhabditis elegans pharynx: a model to define gene function in a simple neural system.

Invertebrate neuroscience has provided a number of very informative model systems that have been extensively utilized in order to define the neurobiological bases of animal behaviours (Sattelle and Buckingham in Invert Neurosci 6:1-3, 2006). Most eminent among these are a number of molluscs, including Aplysia californica, Lymnaea stagnalis and Helix aspersa, crustacean systems such as the crab stomatogastric ganglion and a wide-range of other arthropods. All of these have been elegantly exploited to shed light on the very important phenomenon of the molecular and cellular basis for synaptic regulation that underpins behavioural plasticity. Key to the successful use of these systems has been the ability to study well-defined, relatively simple neuronal circuits that direct and regulate a quantifiable animal behaviour. Here we describe the pharyngeal system of the nematode C. elegans and its utility as a model for defining the genetic basis of behaviour. The circuitry of the nervous system in this animal is uniquely well-defined. Furthermore, the feeding behaviour of the worm is controlled by the activity of the pharynx and this in turn is regulated in a context-dependent manner by a simple nervous system that integrates external signals, e.g. presence or absence of food, and internal signals, e.g. the nutritional status of the animal to direct an appropriate response. The genetics of C. elegans is being effectively exploited to provide novel insight into genes that function to regulate the neuronal network that controls the pharynx. Here we summarise the progress to date and highlight topics for future research. Two main themes emerge. First, although the anatomy of the pharyngeal system is very well-defined, there is a much poorer understanding of its neurochemistry. Second, it is evident that the neurochemistry is remarkably complex for such a simple circuit/behaviour. This suggests that the pharyngeal activity may be subject to exquisitely precise regulation depending on the animal's environment and status. This therefore provides a very tractable genetic model to investigate neural mechanisms for signal integration and synaptic plasticity in a well-defined neuronal network that directs a quantifiable behaviour, feeding.