Factors Influencing Palliative and End-of-Life Care for Adults with Intellectual Disabilities: A Scoping Review of Health and Care Workers' Experiences.

In developed countries, there has been an increase in the longevity of adults with intellectual disabilities. In the later stages of their lives, people with intellectual disability have specific needs in terms of palliative and end-of-life care that need to be better understood in order to offer appropriate care. This scoping review aimed to identify the main factors influencing the provision of palliative and end-of-life care from the perspective of health and care workers involved with adults with an intellectual disability at the end of life. Seven databases were systematically searched for relevant articles published between 2002 and 2022. NVivo qualitative research analysis software was used to conduct a thematic analysis of the 50 included studies. Three main factors were identified: the location of care and death, the involvement of the person with intellectual disability, and collaborative practices.

L-carnitine, a diet component and organic cation transporter OCTN ligand, displays immunosuppressive properties and abrogates intestinal inflammation.

Allele variants in the L-carnitine (LCAR) transporters OCTN1 (SLC22A4, 1672 C --> T) and OCTN2 (SLC22A5, -207 G --> C) have been implicated in susceptibility to Crohn's disease (CD). LCAR is consumed in the diet and transported actively from the intestinal lumen via the organic cation transporter OCTN2. While recognized mainly for its role in fatty acid metabolism, several lines of evidence suggest that LCAR may also display immunosuppressive properties. This study sought to investigate the immunomodulatory capacity of LCAR on antigen-presenting cell (APC) and CD4+ T cell function by examining cytokine production and the expression of activation markers in LCAR-supplemented and deficient cell culture systems. The therapeutic efficacy of its systemic administration was then evaluated during the establishment of colonic inflammation in vivo. LCAR treatment significantly inhibited both APC and CD4+ T cell function, as assessed by the expression of classical activation markers, proliferation and cytokine production. Carnitine deficiency resulted in the hyperactivation of CD4+ T cells and enhanced cytokine production. In vivo, protection from trinitrobenzene sulphonic acid colitis was observed in LCAR-treated mice and was attributed to the abrogation of both innate [interleukin (IL)-1beta and IL-6 production] and adaptive (T cell proliferation in draining lymph nodes) immune responses. LCAR therapy may therefore represent a novel alternative therapeutic strategy and highlights the role of diet in CD.

Segmental specification of GABAergic inhibition during development of hindbrain neural networks.

A primordial rhythm-generating neural network emerges during the segmental period of vertebrate hindbrain development, suggesting a common genetic basis to both the structure and network activity of the region. We show here that segmentation influenced a postsegmental developmental step by which a GABAergic rhythm generator was incorporated into the primordial network and increased rhythm frequency to near mature values. This process depended on specifications in r3 and r5 that controlled, on the basis of a two-segment repeat, later maturation of GABAergic inhibition.

Primordial respiratory-like rhythm generation in the vertebrate embryo.

Respiration is a rhythmic motor behavior that appears in the fetus and acquires a vital importance at birth. It is generated centrally, within neuronal networks of the hindbrain. This region of the brain is of particular interest since it is the best understood with respect to the cellular and molecular mechanisms that underlie its development. Examination of hindbrain activities in the chick embryo has revealed that the central rhythm generator is active before fetal maturation and conforms to the rhombomeric organization of the embryonic hindbrain. Inactivation of genes required for the normal formation of rhombomeres in mice leads to perturbations of the reticular formation that affect respiration after birth and compromise the probability of survival. From studies of hindbrain development we might gain an understanding of how genes govern the early embryonic development of neuronal networks and how this might specify patterns of motor activities operating throughout life.

The pre-Bötzinger oscillator in the mouse embryo.

Studies of the sites and mechanisms involved in mammalian respiratory rhythm generation point to two clusters of rhythmic neurons forming a coupled oscillator network within the brainstem. The location of these oscillators, the pre-Bötzinger complex (preBötC) at vagal level, and the para-facial respiratory group at facial level, probably result from regional patterning schemes specifying neural types in the hindbrain during embryogenesis. Here, we report evidence that the preBötC oscillator (i) is first active at embryonic stages, (ii) originates in the post-otic hindbrain neural tube and (iii) requires the glutamate vesicular transporter 2 for rhythm generation.

Ontogeny of central rhythm generation in chicks and rodents.

Recent studies help in understanding how the basic organization of brainstem neuronal circuits along the anterior-posterior (AP) axis is set by the Hox-dependent segmentation of the neural tube in vertebrate embryos. Neonatal respiratory abnormalities in Krox20(-/-), Hoxa1(-/-) and kreisler mutant mice indicate the vital role of a para-facial (Krox20-dependent, rhombomere 4-derived) respiratory group, that is distinct from the more caudal rhythm generator called Pre-Bötzinger complex. Embryological studies in the chick suggest homology and conservation of this Krox20-dependent induction of parafacial rhythms in birds and mammals. Calcium imaging in embryo indicate that rhythm generators may derive from different cell lineages within rhombomeres. In mice, the Pre-Bötzinger complex is found to be distinct from oscillators producing the earliest neuronal activity, a primordial low-frequency rhythm. In contrast, in chicks, maturation of the parafacial generator is tightly linked to the evolution of this primordial rhythm. It seems therefore that ontogeny of brainstem rhythm generation involves conserved processes specifying distinct AP domains in the neural tube, followed by diverse, lineage-specific regulations allowing the emergence of organized rhythm generators at a given AP level.

Evidence that elevated glucose causes altered gene expression, apoptosis, and neural tube defects in a mouse model of diabetic pregnancy.

Congenital malformations, including neural tube defects (NTDs), are significantly increased in the offspring of diabetic mothers. We previously reported that in the embryos of a mouse model of diabetic pregnancy, NTDs are associated with reduced expression of the gene Pax-3, which encodes a transcription factor that regulates neural tube development, and that reduced expression of Pax-3 leads to neuroepithelial apoptosis. In this study, we used three approaches to test whether glucose alone could be responsible for these adverse effects of diabetes on embryonic development. First, primary culture of embryo tissue in medium containing 15 mmol/l glucose inhibited Pax-3 expression compared with culture in medium containing 5 mmol/l glucose. Second, inducing hyperglycemia in pregnant mice by subcutaneous glucose administration significantly inhibited Pax-3 expression (P < 0.05), as demonstrated by quantitative reverse transcription-polymerase chain reaction assay of Pax-3 mRNA, and also increased neural tube apoptosis (P < 0.05). NTDs were significantly increased in glucose-injected pregnancies when blood glucose levels were >250 mg/dl (P < 0.002) but not in moderately hyperglycemic pregnancies (150-250 mg/dl, P = 0.37). Third, phlorizin administration to pregnant diabetic mice reduced blood glucose levels and the rate of NTDs. As seen with glucose-injected pregnancies, the rate of NTDs in phlorizin-treated diabetic pregnancies was related to the severity of hyperglycemia, since NTDs were significantly increased in severely hyperglycemic (>250 mg/dl) diabetic pregnancies (P < 0.001) but not in moderately hyperglycemic pregnancies (150-250 mg/dl, P = 0.35). These two findings, that elevated glucose alone can cause the changes in Pax-3 expression observed during diabetic pregnancy and that the NTD rate rises with significant increases in blood glucose levels, suggest that congenital malformations associated with diabetic pregnancy are caused by disruption of regulatory gene expression in the embryo in response to elevated glucose.

Use of TH-EGFP transgenic mice as a source of identified dopaminergic neurons for physiological studies in postnatal cell culture.

The physiological and pharmacological properties of dopaminergic neurons in the brain are of major interest. Although much has been learned from cell culture studies, the physiological properties of these neurons remain difficult to study in such models because they are usually in minority and are difficult to distinguish from other non-dopaminergic neurons. Here we have taken advantage of a recently engineered transgenic mouse model expressing enhanced green fluorescence protein (EGFP) under the control of the tyrosine hydroxylase promoter to establish a more effective dopaminergic neuron cell culture model. We first evaluated the specificity of the EGFP expression. Although ectopic expression of EGFP was found in cultures derived from postnatal day 0 pups, this decreased over time in culture such that after 2 weeks, approximately 70% of EGFP-expressing neurons were dopaminergic. We next sought to validate this dopaminergic neuron culture model. We evaluated whether EGFP-expressing dopaminergic neurons displayed some of the well-established properties of dopaminergic neurons. Autoreceptor stimulation inhibited the activity of dopaminergic neurons while neurotensin receptor activation produced the opposite effect. Confocal imaging of the synaptic vesicle optical tracer FM4-64 in EGFP-expressing dopaminergic neurons demonstrated the feasibility of high resolution monitoring of the activity of single terminals established by these neurons. Together, this work provides evidence that primary cultures of postnatal TH-EGFP mice currently represent an excellent model to study the properties of these cells in culture.

Neural tube patterning by Krox20 and emergence of a respiratory control.

Recent data begin to bridge the gap between developmental events controlling hindbrain neural tube regional patterning and the emergence of breathing behaviour in the fetus and its vital adaptive function after birth. In vertebrates, Hox paralogs and Hox-regulating genes orchestrate, in a conserved manner, the transient formation of developmental compartments in the hindbrain, the rhombomeres, in which rhythmic neuronal networks of the brainstem develop. Genetic inactivation of some of these genes in mice leads to pathological breathing at birth pointing to the vital importance of rhombomere 3 and 4 derived territories for maintenance of the breathing frequency. In chick embryo at E7, we investigated neuronal activities generated in neural tube islands deriving from combinations of rhombomeres isolated at embryonic day E1.5. Using a gain of function approach, we reveal a role of the transcription factor Krox20, specifying rhombomeres 3 and 5, in inducing a rhythm generator at the parafacial level of the hindbrain. The developmental genes selecting and regionally coordinating the fate of CNS progenitors may hold further clues to conserved aspects of neuronal network formation and function. However, the most immediate concern is to take advantage of early generated rhythmic activities in the hindbrain to pursue their downstream cellular and molecular targets, for it seems likely that it will be here that rhythmogenic properties will eventually take on a vital role at birth.

Quantitative evaluation of the effects of L-dopa in torsion dystonia: a case report.

We used electrophysiologic methods in the diagnosis of torsion dystonia and the evaluation of therapy in a 7-year-old child. Electromyographic (EMG) activity patterns in five leg muscles were recorded during specific voluntary and passive movements as well as during gait. We found patterns of coactivation in leg muscles in walking or isolated movements, and a shortening reaction was seen in the tibialis anterior. These findings in combination with clinical observations led to the diagnosis of torsion dystonia and the choice of L-dopa therapy. Beneficial effects of therapy were assessed by the same methods.

In vitro study of newborn rat brain maturation: implication for sudden infant death syndrome.

We have used slice preparation from newborn rats to study the development of the nucleus tractus solitarius neuronal network and brain intracellular phosphorus metabolites. As shown previously on adults, the newborn preparation retains local excitatory and inhibitory synaptic connections and enables study of intrinsic electrical properties in the nucleus tractus solitarius. Electrophysiological investigation of inhibitory synaptic transmission demonstrated a maturational step at days 4-6 after birth. Nuclear magnetic resonance spectroscopy of brain slices revealed a metabolic maturation between postnatal days 11 and 17. Results emphasize the differential maturation steps during the postnatal development of rat central nervous system. Possibly, Sudden Infant Death Syndrome may result from the abnormal timing in the occurrence of these steps.

Onset and maturation of branchio-motor activities in the chick hindbrain.

Branchio-motor activities from trigeminal, facial, glossopharyngeal and vagal nerves, in chick embryos have been recorded using suction electrodes on an isolated preparation of the hindbrain in vitro between developmental stages 20 and 36. They were composed of recurring episodes of cyclical burst discharges first identified at stage 24, therefore constituting one of the earliest organized activities generated in the chick central nervous system. Between stage 24 and 36, both the period between episodes and the number of bursts per episode were increased. This maturation sequence was preserved for several hours in vitro in the absence of supraspinal and sensory inputs. Results are in agreement with rhythmogenic properties constituting an early functional commitment of neuronal networks in this particular region of the neuroepithelium.

Branchiomotor activities in mouse embryo.

Using a novel isolated hindbrain in vitro preparation, we demonstrate that, in the mouse, branchiomotor activities from trigeminal, facial, glossopharyngeal and vagal nerves start during segmentation, a crucial and conserved period of hindbrain embryogenesis. At embryonic day (E) 10.5, branchiomotor nerves are independently active in bursts, become coactive at a low frequency (about 0.5 min-1) at E12.5, before high frequency (about 15 min-1) fetal breathing starts at E14.5. Comparison with observations in chick reveals a transient episodic rhythmic pattern highly similar in mouse at E13.5 and chick at E7. This pattern is proposed as a marker identifying a phylotypic stage during the development of hindbrain neuronal networks in vertebrates.

Respiratory rhythm generation in chick hindbrain: effects of MK-801 and vagotomy.

Hindbrain mechanisms generating the respiratory rhythm in chicks were analysed. In vivo, ventilation and intercostal muscle activity were recorded in chicks (1 and 2.5 weeks-old), vagotomized and treated with the NMDA receptor blocker MK-801 (dizocilpine). In vitro, synaptic transmission from vagal to second-order sensory neurones was studied in the nucleus of the solitary tract, using whole-cell recordings in slices. Vagal afferents were found to act through GABAergic synapses and control two hindbrain systems: a dizocilpine-sensitive control system and a rhythm generator. Although this organization is the same as in mammals, after vagotomy entirely different respiratory patterns emerge: (i) expiratory-inspiratory efforts triggered by the rhythm generator and (ii) periods of apnoea produced by the dizocilpine-sensitive system.

Spontaneous synaptic activities in rat nucleus tractus solitarius neurons in vitro: evidence for re-excitatory processing.

The pattern of synaptic interactions between neurons of the nucleus tractus solitarius (NTS) has been analyzed using whole cell recording in rat brainstem slices. Following tractus solitarius (TS) stimulation 15/55 neurons presented a prolonged (up to 300 ms) increased excitability (PIE neurons) and 40/55 neurons presented a prolonged (up to 200 ms) reduced excitability (PRE neurons). In the absence of afferent sensory input all neurons showed spontaneous synaptic activity. Ongoing synaptic activity in PIE cells was glutamatergic and characterized by the absence of detectable inhibitory potentials while in PRE cells it was 90% GABAergic and 10% glutamatergic. Glutamatergic synaptic currents in PIE cells and GABAergic synaptic currents in PRE were studied using probability density and intensity functions. Distribution of time intervals between synaptic events indicated the latter were generated, in both PIE and PRE cells, by two simultaneous processes: (1) a close to Poisson process generating independent events; and (2) a subsidiary re-excitatory process generating synaptic events separated by intervals shorter than 20 ms. Blockade of glutamatergic transmission by 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX; 10 microM) or blockade of action potentials by tetrodotoxin (TTX; 1 microM) suppressed the subsidiary process. In conclusion, we propose that PIE cells (1) form a re-excitatory network contributing to generation of excitatory activity in the NTS and (2) are located presynaptically with respect to PRE cells.

Extracellular potassium, glial and neuronal potentials in the solitary complex of rat brainstem slices.

Extracellular K+ activities (aKe) and neuronal and glial membrane potentials were recorded in the nucleus tractus solitarius (NTS) and in the dorsal vagal motor nucleus (DVMN) of rat brainstem slices after orthodromic stimulation of the tractus solitarius (TS). In glial cells, repetitive stimulation of the TS induced depolarizations of up to 30 mV followed by repolarizations which were fitted by exponential curves with a time constant of 1.6-5 s. Similar stimulations induced elevations of aKe of up to 8 mM, the recovery of which was fitted by single exponential curves with a time constant ranging between 1.6 and 4 s. These elevations in aKe were reduced by 75% during blockage of synaptic transmission in low Ca2+, high Mg2+ solution, and by 24% with application of 6-cyano-7-nitro-quinoxaline-2,3-dione (CNQX, 50 microM). Perfusion with a low Mg2+ solution increased the aKe response to stimulation of the TS, an effect that was reduced by the addition of 2-amino-5-phosphono-valeric acid (AP7, 50 microM) to the bath. No significant change in aKe and glial potential was seen when superfusing high concentrations of the C-terminal octapeptide of cholecystokinin (CCK8, 1-5 microM) and C-terminal tetrapeptide (CCK4, 50-100 microM). The effect of TS stimulations on solitary complex neurons suggests that extracellular K+ concentration is increased during synaptic activation of non-NMDA or NMDA ionotropic receptors. Conversely, slow depolarizations elicited by repetitive afferent activity or excitation by CCK agonists develop in neurons in the absence of measurable extracellular K+ fluctuations or glial depolarization.

Metabolic action of N-methyl-D-aspartate in newborn rat brain ex vivo: 31p magnetic resonance spectroscopy.

N-methyl-D-aspartate (NMDA) is an agonist used to identify neuronal receptive sites for dicarboxylic amino acid neurotransmitters; NMDA receptors are implicated in neuronal damage of ischemic or hypoglycemic origin in newborns although involved mechanisms remain to be identified. In the present study, 31P magnetic resonance spectroscopy with fast (6/min) data acquisition was used in newborn rat brain slices to measure changes of intracellular phosphocreatine and nucleotide triphosphate levels following extracellular NMDA applications. The rapid exhaustion of phosphocreatine stores in 50% of the total population of brain cells was induced in all cases by application of NMDA (30-45 s, 25-100 mM). It was not reproduced by other excitatory agents: potassium ions (24.6 mM, 4 min), isobutylxanthine (1mM), muscarine (10 mM), serotonin (0.1 mM) or substance P (10 microM). Such an effect of NMDA was not modified after tetrodotoxin (1 microM) and was reduced by extracellular 2-amino-5-phosphonovalerate (50 microM) or magnesium ions (2.2 mM). However it did develop during NMDA-induce neuronal excitations and was reversible within 10-30 min. This action of NMDA was followed by an irreversible decrease of phosphorus metabolites if mitochondrial creatine kinase and adenosine triphosphatase were decoupled by atractyloside (50 microM). Experiments revealed a link between selective NMDA action at neuronal plasma membranes, neurotoxicity and energy production by mitochondria.

Rhythmic activities in the rat solitary complex in vitro.

In adult rat brainstem slices, rhythmic discharge of action potentials occurred spontaneously in 10 out of 197 cells of the solitary complex. In 6 neurones, fast rhythms (2-6 per min) were characterized by volleys of synaptic activity presenting abrupt onset denoting synchronized discharge of presynaptic elements. Synchronizing signals may be generated by cells discharging bursts of high-frequency action potentials and presenting extensive axonal arborization, as observed in one cell. Slower rhythms (0.3-0.8 per min) monitored in three cells did not involve synchronizing processes and could be evoked in non-rhythmic cells by 15-30 min bath application of the cholecystokinin octapeptide (100 nM). These results suggest distinct operating mechanisms of fast and slow rhythms in the solitary complex in vitro.

Responses to repetitive afferent activity of rat solitary complex neurons isolated in brainstem slices.

The response of postsynaptic solitary complex neurons to repetitive stimulation (20-50 Hz) of the tractus solitarius were investigated by intracellular recordings in a brainstem slice preparation. Short duration stimuli (0.5 s) elicited increases in synaptic activity and short-term potentiation of synaptic potentials, both of which lasted approximately 1 min, plus a 10 s repolarization suppressed in the presence of glutamate ionotropic receptors antagonists 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX, 10 microM) and 2-D-amino-7-phosphonoheptanoic acid (AP7, 50 microM). Longer (5 s) stimuli elicited 2-10 min depolarizations accompanied by membrane resistance increases and unaffected by glutamate ionotropic receptors antagonists. Our study reveals several mechanisms by which rhythmic visceral afferents may exert a tonic control of postsynaptic solitary complex neurons.

Metabolic acidosis induced by N-methyl-D-aspartate in brain slices of the neonatal rat: 31P- and 1H-magnetic resonance spectroscopy.

1H- and 31P-magnetic resonance spectroscopy was used to monitor intracellular lactate, phosphorus metabolites and pH in superfused brain slices from 2- to 9-day-old rats. N-Methyl-D-aspartate (NMDA) (100 microM, 0.5-3 min) was applied in the extracellular magnesium-free perfusion medium. NMDA induced intracellular metabolic acidosis, i.e., an increase of freely mobile lactate levels and an 0.3 pH unit acidification. This was abolished when the extracellular glucose supply was reduced. Experiments also indicate that acidosis is not responsible for the cell damage resulting from activation of NMDA receptors in hypoglycemic conditions.