Supporting the on-call primary care physician with community paramedicine.

Prior to being referred to the emergency department (ED), patients such as the frail elderly often call their primary care physician. However, the on-call primary care physician or covering provider does not always have the tools to make an accurate and safe assessment over the phone or to treat patients remotely. This often results in preventable transport to an ED, avoidable admissions and iatrogenic events. An opportunity exists to reduce unnecessary ED referrals by enhancing the capabilities of the on-call primary care physician. In this communication, we describe the development of a community paramedicine programme that supports on-call primary care providers managing a high-risk patient population with the goal of reducing avoidable ED referrals.

Melanopsin ganglion cells extend dendrites into the outer retina during early postnatal development.

Melanopsin ganglion cells express the photopigment melanopsin and are the first functional photoreceptors to develop in the mammalian retina. They have been shown to play a variety of important roles in visual development and behavior in the early postnatal period (Johnson et al., 2010; Kirkby and Feller, 2013; Rao et al., 2013; Renna et al., 2011). Here, we probed the maturation of the dendritic arbors of melanopsin ganglion cells during this developmental period in mice. We found that some melanopsin ganglion cells (mainly the M1-subtype) transiently extend their dendrites not only into the inner plexiform layer (where they receive synaptic inputs from bipolar and amacrine cells) but also into the outer plexiform layer, where in mature retina, rod and cone photoreceptors are thought to contact only bipolar and horizontal cells. Thus, some immature melanopsin ganglion cells are biplexiform. This feature is much less common although still present in the mature retina. It reaches peak incidence 8-12 days after birth, before the eyes open and bipolar cells are sufficiently mature to link rods and cones to ganglion cells. At this age, some outer dendrites of melanopsin ganglion cells lie in close apposition to the axon terminals of cone photoreceptors and express a postsynaptic marker of glutamatergic transmission, postsynaptic density-95 protein (PSD-95). These findings raise the possibility of direct, monosynaptic connections between cones and melanopsin ganglion cells in the early postnatal retina. We provide a detailed description of the developmental profile of these processes and consider their possible functional and evolutionary significance.