Optimising Medications for Patients With Cancer and Multimorbidity: The Case for Deprescribing.

The majority of patients diagnosed with cancer are aged over 65 years and have two or more chronic conditions in addition to cancer and the risk of chronic conditions increases further after cancer. The presence of multimorbidity adds complexity to care, as patients' goals of care and the focus of treatment can change with a diagnosis of cancer. Multimorbidity is frequently associated with polypharmacy, the use of potentially inappropriate medications, the presence of adverse drug reactions and potential drug-drug interactions: all of which impact on health outcomes and the cost of care. Consequently, it is vital that a systematic approach is taken to regularly review cancer patients' medication regimens to ensure that they support an optimal balance of benefits with acceptable levels of harm. Several patient and clinician resources are presented to guide the process of medication review and deprescribing.

Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada.

BACKGROUND: Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed. METHODS: This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER's processes. CONCLUSION: We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement. TRIAL REGISTRATION: Clinicaltrials.gov NCT03689049 ; registered September 28, 2018.

Potentiators of responses to activation of gamma-aminobutyric acid (GABAA) receptors.

Quantitative aspects of the potentiation of GABA and muscimol by benzodiazepines and barbiturates are reviewed, taking account of both electrophysiological and receptor binding data. It has been a consistent finding that barbiturates cause a greater maximal potentiation than do benzodiazepines. The steroid anaesthetic alphaxalone and some naturally occurring steroids were compared as potentiators of electrophysiological responses to muscimol. From the relative potencies, important structural features of the steroid molecule for this effect have been identified. The possibility of the barbiturates and the steroids having a common mode of action as potentiators of GABA and muscimol is discussed, together with the idea that this action may involve perturbation of membrane lipids rather than a barbiturate/steroid receptor site. The GABA-potentiating effect of ethanol may also be barbiturate-like but potentiations by chlormethiazole and ketamine appear to involve different mechanisms. It is predicted that any endogenous potentiators of GABA would be unlikely to have more than a modest effect.

Antagonism of the presumed presynaptic action of L-AP4 on GABAergic transmission in the ventrobasal thalamus by the novel mGluR antagonist MPPG.

The metabotropic glutamate receptor (mGluR) agonists CCG-I and L-AP4, acting at Group II and Group III mGluRs respectively, can reduce GABAergic synaptic inhibition on single neurones in the rat thalamus in vivo via a presumed presynaptic mechanism. The actions of L-AP4 were antagonized by (+/-)-alpha-methyl-4-phosphonophenylglycine (MPPG), whereas CCG-I was significantly less affected. Thus MPPG may be a useful tool for detecting physiological roles for Group III mGluRs.

Evaluation of agonists and antagonists acting at Group I metabotropic glutamate receptors in the thalamus in vivo.

Recordings were made from single neurones in the ventrobasal thalamus of anaesthetised rats in order to evaluate the properties of several agonists and antagonists of Group I mGlu receptors. The selective mGlu1 receptor antagonist LY367385 was found to reduce excitatory responses to iontophoretically applied ACPD and DHPG whereas the mGlu5 agonist CHPG was resistant to antagonism. The antagonists LY367366 and LY393053 reduced responses to all three agonists, but without reducing responses to NMDA or AMPA. Although AIDA was also found to reduce mGlu agonist-evoked responses, this antagonist also produced significant reductions in responses to NMDA and AMPA. These data suggest that there are functional mGlu1 and mGlu5 receptors in the thalamus. Furthermore, LY367385 is a useful tool for investigating mGlu1 functions whereas LY367366 and LY393053 have a broader spectrum of action. The usefulness of AIDA as an antagonist in physiological experiments would appear to be limited by its effects against NMDA and AMPA.

Group II and III metabotropic glutamate receptors and the control of the nucleus reticularis thalami input to rat thalamocortical neurones in vitro.

Intracellular recordings were made from neurones in the thalamic reticular nucleus (TRN) and ventro-basal (VB) thalamus in slices of rat midbrain in vitro. Electrical stimulation of the medial lemniscus or TRN resulted in the generation of complex synaptic potentials containing disynaptic inhibitory post-synaptic potentials (IPSPs) in VB thalamocortical neurones. Analysis of the excitatory synaptic responses in TRN neurones indicates they can produce burst output response irrespective of the level of sub-threshold membrane potential. This suggests that network-evoked IPSPs in VB thalamocortical neurones occur following a burst of TRN action potentials. Using ionotropic glutamate receptor antagonists, the activation of these disynaptic events was blocked, and the monosynaptic IPSPs that resulted from the direct activation of the TRN could be isolated. The selective Group II agonists LY354740 (1-10 microM) and N-acetyl-aspartyl-glutamate (NAAG; 100-500 microM) both caused a reversible depression of these monosynaptic TRN IPSPs without any effect on membrane potential or input resistance. Likewise, the specific Group III agonist L-2-amino-4-phosphonobutanoate (10-500 microM), but not (RS)-4-phosphonophenylglycine (1 and 30 microM) also caused a reversible depression of these IPSPs, again without any effect on membrane potential or input resistance.Thus, the IPSPs recorded in VB thalamocortical neurones, evoked by TRN activation, can be depressed by the activation of either Group II or III metabotropic glutamate receptors. This is consistent with the location of these receptor types on the presynaptic terminals of TRN axons in the VB thalamus. This raises the possibility that, during periods of intense excitatory activity, glutamate release could influence the release of GABA from TRN axon terminals in the thalamus. In addition, as NAAG is located in the axons and terminals arising from the TRN, there is the possibility that this dipeptide is also released by these terminals to control the release of GABA during periods of high activity in the TRN.

Reduction of sensory and metabotropic glutamate receptor responses in the thalamus by the novel metabotropic glutamate receptor-1-selective antagonist S-2-methyl-4-carboxy-phenylglycine.

Previous work has shown that responses of thalamic neurons in vivo to the metabotropic glutamate receptor agonists 1S,3R-aminocyclopentane-1,3-dicarboxylate and S-3,5-dihydroxyphenylglycine can be reduced by a variety of phenylglycine antagonists. Responses of thalamic neurons to noxious thermal somatosensory stimuli were reduced in parallel by these antagonists, indicating that these responses are mediated by Group I metabotropic glutamate receptors (i.e. metabotropic glutamate receptor-1 and/or metabotropic glutamate receptor-5), which are known to be linked to phosphoinositol phosphate hydrolysis. The recent development of S-2-methyl-4-carboxyphenylglycine as an antagonist which is highly selective for metabotropic glutamate receptor-1 compared to metabotropic glutamate receptor-5 on human receptors expressed in AV-12 cells, now offers the possibility of discriminating between these two receptor subtypes in order to distinguish which is involved in thalamic responses. We have made recordings from single somatosensory neurons in the thalamus of the rat, and find that S-2-methyl-4-carboxy-phenylglycine is able to reduce responses of neurons to 1S,3R-aminocyclopentane-1,3-dicarboxylate, S-3,5-dihydroxyphenylglycine, and noxious stimuli without significant effect on responses to either N-methyl-D-aspartate or (+/-)-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate. These results suggest that excitatory responses of thalamic neurons to 1S,3R-aminocyclopentane-1,3-dicarboxylate and S-3,5-dihydroxyphenylglycine may be mediated by metabotropic glutamate receptor-1. Furthermore, the reduction of nociceptive responses by S-2-methyl-4-carboxy-phenylglycine indicates that metabotropic glutamate receptor-1 is involved in thalamic nociceptive processing and that such antagonists may have analgesic properties.

Synaptic activation of the group I metabotropic glutamate receptor mGlu1 on the thalamocortical neurons of the rat dorsal lateral geniculate nucleus in vitro.

Intracellular recordings were made from thalamocortical neurons in slices of rat dorsal lateral geniculate nucleus in vitro, where ionotropic glutamate receptors and ionotropic and metabotropic GABA receptors had been blocked. The activation of specific metabotropic glutamate receptors by exogenous agonists and by the electrical stimulation of the corticothalamic pathway was then assessed using selective antagonists. The specific group I agonist (S)-3, 5-dihydoxyphenylglycine and the non-selective agonist (1S, 3R)-1-aminocyclo-pentane-1,3-dicarboxylic acid both caused a concentration-dependent depolarization of membrane potential. These effects were associated with an increase in the apparent input resistance, and a more robust expression of both the depolarizing sag of the voltage response and the low-threshold Ca(2+) potential and an increase in thalamocortical neuron excitability. However, group I agonists selective for the mGlu5 receptor and agonists selective for group II and III receptors did not have these effects. Consequently, these data suggested that these actions were mediated specifically by the group I mGlu1 receptor. The activation of cortical fibres, with trains of 50 stimuli at 50Hz, resulted in a two-component depolarizing response. The first part of this synaptic response and the agonist-induced depolarization of membrane potential were depressed by the novel group I receptor antagonists LY367366 and LY367385, which are active at mGlu1 receptors. However, they were not blocked by 6-methyl-2-(phenylethyl)-pyridine, a highly selective mGlu5 receptor antagonist.Thus, the membrane potential depolarization of thalamocortical neurons caused either by exogenous agonists or by the stimulation of cortical fibres resulted from the specific activation of mGlu1 but not mGlu5 receptors. This result is consistent with the location of this receptor type on the distal dendrites of thalamocortical neurons in the dorsal lateral geniculate nucleus of the thalamus.

Tonic activation of presynaptic GABA(B) receptors on thalamic sensory afferents.

The presence and role of presynaptic GABA(B) receptors in the control of excitatory amino acid-medicated transmission were investigated (using sharp electrode recordings) in the rat dorsal lateral geniculate nucleus and ventrobasal thalamus in vitro by comparing the effects of the selective GABA(B) receptor agonist, (+ or -)-baclofen, and of two antagonists, CGP 35348 and 2-hydroxy-saclofen, on the excitatory postsynaptic potentials evoked in thalamocortical neurons by stimulation of the sensory afferents. Application of CGP 35348 alone blocked the GABA(B) receptor-mediated inhibitory postsynaptic potential evoked in the dorsal lateral geniculate nucleus by stimulation of the optic tract (n = 5), but had no effect on the resting membrane potential and input resistance of thalamocortical cells (n = 6). In contrast, 2-hydroxy-saclofen caused a hyperpolarization (6.9 + or - 0.5 mV, n = 10) and a decrease in the apparent input resistance (26.3 + or - 2.6%, n = 10). This effect of 2-hydroxy-saclofen was antagonized by CGP 35348. When bicuculline was present in the perfusion medium and following intracellular injection of QX 314, GABA(A) and GABA(B) receptors in the recorded neurons were blocked. Under this condition, application of baclofen decreased the amplitude of the medial lemniscus- and optic tract-evoked excitatory postsynaptic potentials in the two thalamic nuclei investigated. This effect was fully antagonized by CGP 35348 and only partially by 2-hydroxy-saclofen. CGP 35348 alone increased (19.3 + or - 4.3%, n = 5) and 2-hydroxy-saclofen alone decreased (29.9 + or - 8.6%, n = 5) the amplitude of the excitatory postsynaptic potential. This effect of 2-hydroxy-saclofen was not blocked by CGP 35348. These results indicate that presynaptic GABA(B) receptors are present on the terminals of the sensory afferents in the rat dorsal lateral geniculate nucleus and in the ventrobasal thalamus. These receptors are tonically activated by endogenous GABA, at least in vitro, and provide a negative control mechanism by which the excitatory amino acid-mediated transmission within these nuclei can be regulated. In contrast, the endogenous GABA level is not sufficient for a tonic activation of postsynaptic GABA(B) receptors. Furthermore, these results indicate that 2-hydroxy-saclofen acts as a partial agonist on postsynaptic CGP 35348-sensitive GABA(B) receptors, and that, in addition to its antagonist action on presynaptic CGP 35348-sensitive GABA(B) receptors, it also has an effect on either presynaptic, CGP 35348-insensitive GABA(B) receptors and/or another presynaptic receptor type.

Gamma-hydroxybutyrate promotes oscillatory activity of rat and cat thalamocortical neurons by a tonic GABAB, receptor-mediated hyperpolarization.

The actions of gamma-hydroxybutyrate, a drug known to lead to an increase in nocturnal slow wave sleep and induce epileptic states following systemic application, on the membrane properties of thalamocortical neurons from brain slices of the rat and cat dorsal lateral geniculate nucleus were studied using sharp electrode intracellular recordings. Gamma-hydroxybutyrate applied by addition to the perfusion medium led to a concentration-dependent and reversible hyperpolarization of the membrane potential accompanied by a decrease in apparent input resistance (0.1 mM: 2.3 +/- 0.3 mV, 9.5 +/- 1.0%; 10 mM: 11.3 +/- 1.3 mV, 37.5 +/- 10.8%, respectively). In six of seven neurons the iontophoretic or bath (0.1-0.2 mM) application of low concentrations of gamma-hydroxybutyrate led to a hyperpolarization accompanied by the appearance of low-frequency (< 4 Hz) membrane potential oscillations crowned by bursts of action potentials, when the membrane potential of these neurons was initially set depolarized to the range where ongoing oscillatory activity occurred. The gamma-hydroxybutyrate-elicited hyperpolarization was reversibly antagonized by the co-application of the GABAB receptor antagonist CGP 35348 (0.4-1 mM), but was not affected by the putative gamma-hydroxybutyrate receptor antagonist NCS 382 (0.1-5 mM) or tetrodotoxin (1 microM), suggesting that gamma-hydroxybutyrate tonically activates postsynaptic GABAB receptors. The gamma-hydroxybutyrate-induced promotion of oscillatory activity and action potential burst firing of thalamocortical neurons may be one mechanism by which gamma-hydroxybutyrate leads to an increase in the deep stages of sleep and the generation of electroencephalogram and behavioural patterns typical of absence epilepsy.

Anion transport blockers inhibit DL-2-amino-4-phosphonobutyrate responses induced by quisqualate in the rat cerebral cortex.

1. Depolarizing responses to DL-2-amino-4-phosphonobutyrate (AP4) and related amino acids have been studied in the rat cerebral cortex slice following the application of quisqualate (Quis). 2. Before exposure to Quis, 500 microM DL-AP4 had little or no effect. However, following a single application of 40 microM Quis for 2 min, DL-AP4 produced depolarizing responses. With repeated applications of DL-AP4, there was a decline in response amplitude. A second application of Quis restored the depolarizing potency of DL-AP4 to a level above that for the first DL-AP4 response after the first Quis application. With a sequence of alternate applications of Quis and DL-AP4, the amplitude of DL-AP4 responses became maximal after the second Quis application. Responses to DL-AP4 could also be induced by the application of 1 microM Quis for 60 min, but were smaller in amplitude. 3. Responses to the normally inactive amino acids L-cysteine (Cys), L-cystathionine (CTN) and L-alpha-aminoadipate (AA) were also induced once Quis was applied. These responses were also maximized after a second application of Quis, except those to L-Cys, which failed to reach a plateau after three Quis applications. 4. The co-application of DL-AP4 with the first Quis application depressed the subsequent mean DL-AP4 response by 47%. Re-application of Quis restored the amplitude of DL-AP4 responses to levels comparable to control. L-alpha-AA also suppressed the induction of DL-AP4 responses, when co-applied with the first Quis exposure, reducing mean response amplitude by 98%. Unlike DL-AP4, however, the effect with L-alpha-AA persisted so that DL-AP4 responses were significantly suppressed compared to control, even after further applications of Quis. 5. The effects of the anion transport blockers, 4,4'-diisothiocyanatostilbene-2,2'-disulphonic acid (DIDS) and 4-acetoamido-4'-isothiocyanatostilbene-2,2'-disulphonic acid (SITS) on the induction process and the DL-AP4 responses themselves were examined. DIDS (100 microM) significantly inhibited the DL-AP4 responses, and to a lesser extent the induction of the responses by 40 microM Quis (2 min), while SITS (300 microM) only inhibited the DL-AP4 responses. However, the induction of responses by 1 microM Quis (60 min) was significantly affected by this concentration of SITS. 6. DIDS (100 microM) had no effect on responses to alpha-amino-3-hydroxy-5-methyl-4-isoxazoleproprionate (AMPA), but selectively potentiated those to Quis. Examination of the full concentration-response curve for Quis revealed that, while the Rmax remained constant, the Hill slope was increased and the EC50 was decreased in the presence of DIDS. SITS (300 microM), however, antagonized responses to AMPA, and had little effect on responses to Quis except at the highest concentration of Quis tested (20 microM), where a potentiation was observed, suggesting that it is a non-NMDA receptor antagonist.7. These observations indicate that the production of depolarizing responses to a number of amino acids, including DL-AP4, in the cerebral cortex is mediated via an anion transport mechanism sensitive to DIDS and SITS, and that the exchange of DL-AP4 for a sequestered excitatory amino acid receptor agonist, probably Quis, could underlie the production of these responses. Indeed, Quis is apparently sequestered via a similar process. However, the involvement of such a process in the induction of these responses remains inconclusive.

Modulation of the GABAA receptor complex by steroids in slices of rat cuneate nucleus.

1. Several derivatives of pregnane and androstane that have hypnotic properties have been investigated for their ability to potentiate responses to the GABAA receptor agonist muscimol and to reduce the effect of the non-competitive GABAA antagonist picrotoxin. 2. Depolarizing responses to muscimol in slices of rat cuneate nucleus were potentiated most potently by 3 alpha-hydroxy,5 alpha-pregnane-11,20-dione (alphaxalone), which gave half-maximal potentiation at 0.15 microM. The 5 beta isomer of alphaxalone had little effect up to 3 microM but in analogues lacking an 11-keto substituent (pregnanolones), both the 5 alpha- and 5 beta-isomers potentiated with potencies 20 and 10 times lower, respectively, than that of alphaxalone. The alpha configuration of the 3-hydroxy was essential in alphaxalone, the 3 beta-hydroxy isomer being inactive. However, there was little difference between the potencies of the 3 alpha- and 3 beta-hydroxy configurations in the pregnanolones, although the maximal effects of the 3 beta-hydroxy isomers were rather lower than those of the 3 alpha-hydroxy isomers. 3. Reductions in the effect of picrotoxin as an antagonist of muscimol were caused most potently by the 3 alpha-hydroxy pregnanolones, with a ten fold reduction in picrotoxin potency at 1 microM concentrations of these steroids. Alphaxalone and its 5 beta-isomer were about half as potent. Androsterone was about 10 times less potent and the 3 beta-hydroxy pregnanolones were ineffective. 4. This difference in the structure-activity relationships for steroidal potentiation of muscimol and reduction in picrotoxin antagonism of muscimol is reminiscent of an analogous distinction found with the barbiturates.

Antagonism of inhibitory amino acids by the steroid derivative RU5135.

The steroid derivative RU5135 has been tested for its ability to antagonize glycine and the gamma-aminobutyric acid (GABA) analogue muscimol on isolated preparations of rat optic nerve and cuneate nucleus, respectively. On the cuneate nucleus, RU5135 antagonized muscimol in a competitive manner with a pA2 value of 8.31. RU5135 shared a common site of action with bicuculline that was separate from the picrotoxin site. On the optic nerve, RU5135 antagonized glycine with a pA2 of 7.67. It shared a common site of action with strychnine.

L-glutamate diethyl ester and deaminated analogues as excitatory amino acid antagonists in rat cerebral cortex.

1. The effects of L-glutamate diethyl ester (GDEE) HCl, glutarate diethyl ester (GlrDEE) and glutarate dimethyl ester (GlrDME) on depolarizing responses to alpha-amino-3-hydroxy-5- methyl-4-isoxazolepropionate (AMPA), kainate (Kain), N-methyl-D-aspartate (NMDA) and quisqualate (Quis), and spontaneous paroxysmal discharges (SPDs) were examined. Experiments were performed on slices of rat cingulate cortex using the in vitro grease gap recording technique in nominally Mg(2+)-free Krebs medium. 2. GDEE HCl (3-14 mM) caused a concentration-dependent depolarization of the d.c. baseline potential. L-Glutamate (0.1-0.5 mM), HCl (15 mM) and sucrose (30 mM) also depolarized the baseline. GlrDEE (3-12 mM) and GlrDME (4-26 mM) had no consistent effect on baseline potential. 3. GDEE HCl (10 mM) had no effect on depolarizing responses to AMPA, Kain and NMDA, but caused potentiation of those to Quis with a dose-ratio of 0.53 (0.44-0.63) (n = 4). In two other experiments, where the depolarization of the baseline induced by GDEE HCl was large, a depression of Quis response amplitude was observed. 4. GlrDEE (10 mM) antagonized depolarizing responses to Kain, and to a lesser extent NMDA, with dose-ratios of 2.14 (1.92-2.38) and 1.61 (1.39-1.87), respectively. This concentration of GlrDEE had no effect on AMPA responses, but potentiated Quis responses, with a dose-ratio of 0.64 (0.58-0.71). 5. GlrDME (10 mM) antagonized depolarizing responses to Kain and to Quis, with dose-ratios of 1.66 (1.48-1.85) and 1.22 (1.15-1.29), respectively, and had no effect on responses to NMDA. 6. The SPDs were inhibited by GDEE HCI (IC50 6.7 +/- 0.37mM), GlrDEE (IC50 5.6 +/- 0.38 mM) and GlrDME (IC50 10.4 +/- 0.73 mM). 7. In conclusion, there is little evidence that GDEE HCI is an antagonist of the postsynaptic excitatory amino acid receptors in the rat neocortex, and its effects may result from its contamination with Lglutamate and increased osmolarity of the bathing medium at high concentrations. The deaminated analogues of GDEE are very weak Kain antagonists.

Antagonism of the mGlu5 agonist 2-chloro-5-hydroxyphenylglycine by the novel selective mGlu5 antagonist 6-methyl-2-(phenylethynyl)-pyridine (MPEP) in the thalamus.

Our previous work has shown that Group I mGlu receptors participate in thalamic sensory processing in vivo. However, unequivocal demonstration of mGlu5 participation has not been possible due to the lack of specific ligands. We have therefore made a preliminary study of the in vivo actions of the agonist (R,S)-2-Chloro-5-hydroxyphenylglycine [CHPG] and the novel mGlu5 antagonist 6-methyl-2-(phenylethynyl)-pyridine [MPEP] in order to characterize their suitability for functional studies. Iontophoretically administered MPEP selectively antagonized excitatory responses of single rat thalamic neurones to CHPG compared to the broad-spectrum mGlu agonist (1S,3R)-1-aminocyclopentane-1,3-dicarboxylate. In contrast, the established mGlu1 and mGlu5 antagonist (S)-4-carboxyphenylglycine reduced responses to both agonists. These findings are the first demonstration of an in vivo action of CHPG and its antagonism by a selective mGlu5 antagonist. Furthermore MPEP appears to be a good tool for functional studies of mGlu5.

Characterization of the metabotropic glutamate receptors (mGluRs) which modulate GABA-mediated inhibition in the ventrobasal thalamus.

The ventrobasal thalamus (VB) relays and processes somatosensory information ascending to the cerebral cortex. Several types of mGluR are known to be present in VB, and we have previously shown that Group II and Group III mGluR agonists can reduce inhibitory synaptic transmission by acting at presynaptic receptors on GABAergic terminals in this structure. We have tested the action of several antagonists against the disinhibitory action of the Group II agonist CCG-I [(2S,3S,4S)-alpha-(carboxycyclopropyl)-glycine] and the Group III agonist L-AP4 [L-2-amino-4-phosphonobutyrate] in the VB of anaesthetized rats using extracellular single-neurone recording techniques and iontophoretic applications of mGluR antagonists and agonists. The antagonists MAP4 [alpha-methyl-L-AP4] and MPPG [(+/-)-alpha-methyl-4-phosphonophenylglycine] reduced the disinhibitory actions of L-AP4 whilst having little effect on the disinhibitory action of CCG-I. In contrast, MCCG [alpha-methyl-CCG-I] and MCPG [(+)-alpha-methyl-4-carboxyphenylglycine] antagonized CCG-I, whilst having less effect against L-AP4 responses. These results support the hypothesis that GABAergic inhibitory transmission in VB can be modulated by at least two types of mGluR, belonging to Group II and Group III. Furthermore, the novel antagonists appear to be useful tools for the future study of the physiological role of these receptors in thalamic sensory processing.

Acute hemorrhagic conjunctivitis caused by enterovirus type 70: an epidemic in American Samoa.

From December 1981 to February 1982, an estimated 22,000 cases of acute hemorrhagic conjunctivitis (AHC) caused by enterovirus type 70 (EV 70) occurred among Samoan and non-Samoan residents of American Samoa. The overall attack rate was estimated to be 68%. Samoans of all ages resident in traditional housing and of large family size were at greatest risk of acquiring AHC, while non-Samoan adults resident in western style housing were at lowest risk. Epidemiologic aspects of AHC acquisition were also different for the Samoan and non-Samoan communities; index cases in Samoan households were frequently young adults, whereas index cases in non-Samoan households were commonly school age children, suggesting a role for school transmission in non-Samoans only. In this outbreak, subclinical AHC was rare; of 50 asymptomatic members of affected households, only 3 had neutralizing antibody to EV 70 (all with titers of 1:10). Investigation documented the highly contagious nature of AHC caused by EV 70, and the ease with which epidemic transmission may develop under conditions of crowding and frequent interpersonal contact.

Spontaneous paroxysmal activity induced by zero magnesium and bicuculline: suppression by NMDA antagonists and GABA mimetics.

Slices of rat cerebral cortex developed spontaneous paroxysmal discharges when superfused with Krebs medium containing zero Mg2+ or 50 microM bicuculline. In both situations, the N-methyl-D-aspartate (NMDA) antagonists APV, 100 microM, and ketamine, 100 microM substantially reduced the frequency of the paroxysmal events, the reduction being greater in zero Mg2+. gamma-Aminobutyric acid (GABA) 1 mM, the GABA-A agonist muscimol 2 microM and the GABA-B receptor agonist baclofen 10 microM, each reduced the frequency of events in zero Mg2+ while muscimol and GABA also reduced the amplitude of the events. GABA and baclofen were similarly effective against bicuculline-induced events but the muscimol concentration required was 5-10-fold higher. These results suggest that, under our vitro conditions, neocortical cells are normally restrained from paroxysmal discharges by Mg2+. Inhibition by GABA through GABA-A receptors and inhibition by GABA through GABA-B receptors, may also contribute to this restraint.

Age structure of horn fly (Diptera: Muscidae) populations estimated by pterin concentrations.

Pterins accumulate in the head capsules of horn flies, Haematobia irritans irritans (L.), as a linear function of time and temperature. Pterin concentrations were used to estimate chronological ages and to establish correlations between chronological age and ovarian development and reproductive success in 12 horn fly populations in 1988 and 1989. Male ages were estimated spectrofluorometrically. There were statistically significant differences between years in population age structure measured by pterins. Survival rates estimated from pterin concentration distributions were consistent with a one-parameter exponential model with constant survival rate. Mean daily survival rates were 0.81 for females and 0.84 for males in 1988 and 0.66 and 0.75 in 1989. Mean lifetime egg production was approximately 26 eggs per female in 1988 and 8 in 1989. Female reproductive success was close to the maximum possible, i.e., there were no net delays in oviposition. Analysis of gonotrophic age distributions provided survival estimates that suggested an increasing risk of mortality with age or age-related biases in sampling.

Four years' experience of a senior house officer rotation in general medicine including general practice.

A four-month post in general practice was included as an option available to doctors applying for a year-long medical senior house officer (SHO) rotation since August 1993. This study sought the views of SHOs before and after undertaking the general practice post. SHOs gained an understanding of modern general practice and changed their views about certain aspects of general practice. They reported gaining a range of generic skills, which included communication, consultation, and clinical skills. These perceived benefits suggest that such experience merits wider adoption and further evaluation.