Medicare beneficiary barriers to genetic counselor services: Implications for patient policy, decision-making, and care.

If passed, the "Access to Genetic Counselor Services Act" will authorize genetic counselors to provide services under Medicare part B. We assert that Medicare policy should be updated through the enactment of this legislation to provide Medicare beneficiaries with direct access to genetic counselor services. In this article, we discuss the background, history, and some recent research relevant to patient access to genetic counselors to provide context and perspective regarding the rationale, justification, and potential results of the proposed legislation. We outline the potential impact of Medicare policy reform, including the effect on access to genetic counselors in high-demand areas or underserved communities. Although the proposed legislation pertains only to Medicare, we argue that private systems will also be impacted by passage as this may lead to an increase in hiring and retention of genetic counselors by health systems, thereby improving access to genetic counselors across the US.

Disparity in Access to Oncology Precision Care: A Geospatial Analysis of Driving Distances to Genetic Counselors in the U.S.

In the US, the growing demand for precision medicine, particularly in oncology, continues to put pressure on the availability of genetic counselors to meet that demand. This is especially true in certain geographic locations due to the uneven distribution of genetic counselors throughout the US. To assess these disparities, access to genetic counselors of all specialties is explored by geography, cancer type, and social determinants of health. Geospatial technology was used to combine and analyze genetic counselor locations and cancer incidence at the county level across the US, with a particular focus on tumors associated with BRCA mutations including ovarian, pancreatic, prostate and breast. Access distributions were quantified, and associations with region, cancer type, and socioeconomic variables were investigated using correlational tests. Nationally, in 2020, there were 4,813 genetic counselors, or 1.49 genetic counselors per 100,000 people, varying between 0.17 to 5.7 per 100,000 at the state level. Seventy-one percent of U.S. residents live within a 30-minute drive-time to a genetic counselor. Drive-times, however, are not equally distributed across the country - while 82% of people in metropolitan areas are 30 minutes from a genetic counselor, only 6% of people in nonmetro areas live within 30 minutes' drive time. There are statistically significant differences in access across geographical regions, socioeconomics and cancer types. Access to genetic counselors for cancer patients differs across groups, including regional, socioeconomic, and cancer type. These findings highlight areas of the country that may benefit from increased genetic counseling provider supply, by increasing the number of genetic counselors in a region or by expanding the use of telegenetics a term used to describe virtual genetic counseling consults that occur via videoconference. Policy intervention to allow genetic counselors to bill for their services may be an effective route for increasing availability of genetic counselors' services However, genetic counselors in direct patient care settings also face other challenges such as salary, job satisfaction, job recognition, overwork/burnout, and appropriate administrative/clinical support, and addressing these issues should also be considered along with policy support. These results could support targeted policy reform and alternative service models to increase access to identified pockets of unmet need, such as telemedicine. Data and analysis are available to the public through an interactive dashboard.

Distal spike initiation zone location estimation by morphological simulation of ionic current filtering demonstrated in a novel model of an identified Drosophila motoneuron.

Studying ion channel currents generated distally from the recording site is difficult because of artifacts caused by poor space clamp and membrane filtering. A computational model can quantify artifact parameters for correction by simulating the currents only if their exact anatomical location is known. We propose that the same artifacts that confound current recordings can help pinpoint the source of those currents by providing a signature of the neuron's morphology. This method can improve the recording quality of currents initiated at the spike initiation zone (SIZ) that are often distal to the soma in invertebrate neurons. Drosophila being a valuable tool for characterizing ion currents, we estimated the SIZ location and quantified artifacts in an identified motoneuron, aCC/MN1-Ib, by constructing a novel multicompartmental model. Initial simulation of the measured biophysical channel properties in an isopotential Hodgkin-Huxley type neuron model partially replicated firing characteristics. Adding a second distal compartment, which contained spike-generating Na+ and K+ currents, was sufficient to simulate aCC's in vivo activity signature. Matching this signature using a reconstructed morphology predicted that the SIZ is on aCC's primary axon, 70 µm after the most distal dendritic branching point. From SIZ to soma, we observed and quantified selective morphological filtering of fast activating currents. Non-inactivating K+ currents are filtered ∼3 times less and despite their large magnitude at the soma they could be as distal as Na+ currents. The peak of transient component (NaT) of the voltage-activated Na+ current is also filtered more than the magnitude of slower persistent component (NaP), which can contribute to seizures. The corrected NaP/NaT ratio explains the previously observed discrepancy when the same channel is expressed in different cells. In summary, we used an in vivo signature to estimate ion channel location and recording artifacts, which can be applied to other neurons.

Differential roles of nonsynaptic and synaptic plasticity in operant reward learning-induced compulsive behavior.

BACKGROUND: Rewarding stimuli in associative learning can transform the irregularly and infrequently generated motor patterns underlying motivated behaviors into output for accelerated and stereotyped repetitive action. This transition to compulsive behavioral expression is associated with modified synaptic and membrane properties of central neurons, but establishing the causal relationships between cellular plasticity and motor adaptation has remained a challenge. RESULTS: We found previously that changes in the intrinsic excitability and electrical synapses of identified neurons in Aplysia's central pattern-generating network for feeding are correlated with a switch to compulsive-like motor output expression induced by in vivo operant conditioning. Here, we used specific computer-simulated ionic currents in vitro to selectively replicate or suppress the membrane and synaptic plasticity resulting from this learning. In naive in vitro preparations, such experimental manipulation of neuronal membrane properties alone increased the frequency but not the regularity of feeding motor output found in preparations from operantly trained animals. On the other hand, changes in synaptic strength alone switched the regularity but not the frequency of feeding output from naive to trained states. However, simultaneously imposed changes in both membrane and synaptic properties reproduced both major aspects of the motor plasticity. Conversely, in preparations from trained animals, experimental suppression of the membrane and synaptic plasticity abolished the increase in frequency and regularity of the learned motor output expression. CONCLUSIONS: These data establish direct causality for the contributions of distinct synaptic and nonsynaptic adaptive processes to complementary facets of a compulsive behavior resulting from operant reward learning.

Phase response theory extended to nonoscillatory network components.

New tools for analysis of oscillatory networks using phase response theory (PRT) under the assumption of pulsatile coupling have been developed steadily since the 1980s, but none have yet allowed for analysis of mixed systems containing nonoscillatory elements. This caveat has excluded the application of PRT to most real systems, which are often mixed. We show that a recently developed tool, the functional phase resetting curve (fPRC), provides a serendipitous benefit: it allows incorporation of nonoscillatory elements into systems of oscillators where PRT can be applied. We validate this method in a model system of neural oscillators and a biological system, the pyloric network of crustacean decapods.

Responses of a bursting pacemaker to excitation reveal spatial segregation between bursting and spiking mechanisms.

Central pattern generators (CPGs) frequently include bursting neurons that serve as pacemakers for rhythm generation. Phase resetting curves (PRCs) can provide insight into mechanisms underlying phase locking in such circuits. PRCs were constructed for a pacemaker bursting complex in the pyloric circuit in the stomatogastric ganglion of the lobster and crab. This complex is comprised of the Anterior Burster (AB) neuron and two Pyloric Dilator (PD) neurons that are all electrically coupled. Artificial excitatory synaptic conductance pulses of different strengths and durations were injected into one of the AB or PD somata using the Dynamic Clamp. Previously, we characterized the inhibitory PRCs by assuming a single slow process that enabled synaptic inputs to trigger switches between an up state in which spiking occurs and a down state in which it does not. Excitation produced five different PRC shapes, which could not be explained with such a simple model. A separate dendritic compartment was required to separate the mechanism that generates the up and down phases of the bursting envelope (1) from synaptic inputs applied at the soma, (2) from axonal spike generation and (3) from a slow process with a slower time scale than burst generation. This study reveals that due to the nonlinear properties and compartmentalization of ionic channels, the response to excitation is more complex than inhibition.

Inclusion of noise in iterated firing time maps based on the phase response curve.

The infinitesimal phase response curve (PRC) of a neural oscillator to a weak input is a powerful predictor of network dynamics; however, many networks have strong coupling and require direct measurement of the PRC for strong inputs under the assumption of pulsatile coupling. We incorporate measured noise levels in firing time maps constructed from PRCs to predict phase-locked modes of activity, phase difference, and locking strength in 78 heterogeneous hybrid networks of 2 neurons constructed using the dynamic clamp. We show that noise may either destroy or stabilize a phase-locked mode of activity.

Predictions of phase-locking in excitatory hybrid networks: excitation does not promote phase-locking in pattern-generating networks as reliably as inhibition.

Phase-locked activity is thought to underlie many high-level functions of the nervous system, the simplest of which are produced by central pattern generators (CPGs). It is not known whether we can define a theoretical framework that is sufficiently general to predict phase-locking in actual biological CPGs, nor is it known why the CPGs that have been characterized are dominated by inhibition. Previously, we applied a method based on phase response curves measured using inputs of biologically realistic amplitude and duration to predict the existence and stability of 1:1 phase-locked modes in hybrid networks of one biological and one model bursting neuron reciprocally connected with artificial inhibitory synapses. Here we extend this analysis to excitatory coupling. Using the pyloric dilator neuron from the stomatogastric ganglion of the American lobster as our biological cell, we experimentally prepared 86 networks using five biological neurons, four model neurons, and heterogeneous synapse strengths between 1 and 10,000 nS. In 77% of networks, our method was robust to biological noise and accurately predicted the phasic relationships. In 3%, our method was inaccurate. The remaining 20% were not amenable to analysis because our theoretical assumptions were violated. The high failure rate for excitation compared with inhibition was due to differential effects of noise and feedback on excitatory versus inhibitory coupling and suggests that CPGs dominated by excitatory synapses would require precise tuning to function, which may explain why CPGs rely primarily on inhibitory synapses.

Ultrasound-induced cell membrane porosity.

Recent studies of ultrasound (US) methods for targeted drug delivery and nonviral gene transfection revealed new, advantageous possibilities. These studies utilized US contrast agents, commonly stabilized microbubbles, to facilitate delivery and suggested that US delivery resulted from cell sonoporation, the formation of temporary pores in the cell membrane induced by US. Using voltage clamp techniques, we obtained real-time measurements of sonoporation of single Xenopus oocyte in the presence of Optison trade mark, an agent consisting of albumin-shelled C(3)F(8) gas bubbles (mean diameter 3.2 microm). Ultrasound increased the transmembrane current as a direct result of decreased membrane resistance due to pore formation. We observed a distinct delay of sonoporation following US activation and characteristic stepwise increases of transmembrane current throughout US duration. We discovered that the resealing of cell membrane following US exposure required Ca(2+) entering the cell through US-induced pores.

Participation of the S4 voltage sensor in the Mg2+-dependent activation of large conductance (BK) K+ channels.

The S4 transmembrane segment is the primary voltage sensor in voltage-dependent ion channels. Its movement in response to changes in membrane potential leads to the opening of the activation gate, which is formed by a separate structural component, the S6 segment. Here we show in voltage-, Ca2+-, and Mg2+-dependent, large conductance K+ channels that the S4 segment participates not only in voltage- but also Mg2+-dependent activation. Mutations in S4 and the S4-S5 linker alter voltage-dependent activation and have little or no effect on activation by micromolar Ca2+. However, a subset of these mutations in the C-terminal half of S4 and in the S4-S5 linker either reduce or abolish the Mg2+ sensitivity of channel gating. Cysteine residues substituted into positions R210 and R213, marking the boundary between S4 mutations that alter Mg2+ sensitivity and those that do not, are accessible to a modifying reagent [sodium (2-sulfonatoethyl)methane-thiosulfonate] (MTSES) from the extracellular and intracellular side of the membrane, respectively, at -80 mV. This implies that interactions between S4 and a cytoplasmic domain may be involved in Mg2+-dependent activation. These results indicate that the voltage sensor is critical for Mg2+-dependent activation and the coupling between the voltage sensor and channel gate is a converging point for voltage- and Mg2+-dependent activation pathways.