Community and Academic Physicians Working Together in Integrated Health Care Systems.

OBJECTIVE: To examine best practices and policies for effectively merging community and academic physicians in integrated health care systems. METHODS: Deans of US allopathic medical schools were systematically interviewed between February and June 2017 regarding growth in their faculty practice plan (FPP), including logistics and best practices for integration of community physicians. RESULTS: The survey was completed by 107 of 143 (74.8) of US medical school deans approached. Of these institutions, 73 met criteria for final analysis (research-based medical schools with FPPs of >300 physicians). Most academic medical center-based FPPs have increased in size over the last 5 years, with further growth anticipated via adding community physicians (85%). Because of disparate practice locations, integration of community and academic physicians has been slow. When fully integrated, community physicians predominantly have a clinical role with productivity incentives. Deans report that cultural issues must be addressed to avoid conflict. Consensus exists that transparent clinical work requirements for all FPP members, clearly defined productivity incentives, additional promotion tracks, and early involvement of department chairs and other leaders enhances trust and creates better synergy among all physician providers. CONCLUSION: Findings from this study should help guide FPPs, academic medical center leaders, chief medical officers, and professional and trade organizations in working toward positive physician synergy in consolidated health care organizations. Work and cultural considerations must be addressed to honor distinct talents of each physician group, facilitating smooth transition from disparate groups to healthy synergy.

Perineuronal net expression in the brain of a hibernating mammal.

During hibernation, mammals like the 13-lined ground squirrel cycle between physiological extremes. Most of the hibernation season is spent in bouts of torpor, where body temperature, heart rate, and cerebral blood flow are all very low. However, the ground squirrels periodically enter into interbout arousals (IBAs), where physiological parameters return to non-hibernating levels. During torpor, neurons in many brain regions shrink and become electrically quiescent, but reconnect and regain activity during IBA. Previous work showed evidence of extracellular matrix (ECM) changes occurring in the hypothalamus during hibernation that could be associated with this plasticity. Here, we examined expression of a specialized ECM structure, the perineuronal net (PNN), in the forebrain of ground squirrels in torpor, IBA, and summer (non-hibernating). PNNs are known to restrict plasticity, and could be important for retaining essential connections in the brain during hibernation. We found PNNs in three regions of the hypothalamus: ventrolateral hypothalamus, paraventricular nucleus (PVN), and anterior hypothalamic area. We also found PNNs throughout the cerebral cortex, amygdala, and lateral septum. The total area covered by PNNs within the PVN was significantly higher during IBA compared to non-hibernating and torpor (P < 0.01). Additionally, the amount of PNN coverage area per Nissl-stained neuron in the PVN was significantly higher in hibernation compared to non-hibernating (P < 0.05). No other significant differences were found across seasons. The PVN is involved in food intake and homeostasis, and PNNs found here could be essential for retaining vital life functions during hibernation.

Seasonal and regional differences in gene expression in the brain of a hibernating mammal.

Mammalian hibernation presents a unique opportunity to study naturally occurring neuroprotection. Hibernating ground squirrels undergo rapid and extreme physiological changes in body temperature, oxygen consumption, and heart rate without suffering neurological damage from ischemia and reperfusion injury. Different brain regions show markedly different activity during the torpor/arousal cycle: the cerebral cortex shows activity only during the periodic returns to normothermia, while the hypothalamus is active over the entire temperature range. Therefore, region-specific neuroprotective strategies must exist to permit this compartmentalized spectrum of activity. In this study, we use the Illumina HiSeq platform to compare the transcriptomes of these two brain regions at four collection points across the hibernation season: April Active, October Active, Torpor, and IBA. In the cerebral cortex, 1,085 genes were found to be differentially expressed across collection points, while 1,063 genes were differentially expressed in the hypothalamus. Comparison of these transcripts indicates that the cerebral cortex and hypothalamus implement very different strategies during hibernation, showing less than 20% of these differentially expressed genes in common. The cerebral cortex transcriptome shows evidence of remodeling and plasticity during hibernation, including transcripts for the presynaptic cytomatrix proteins bassoon and piccolo, and extracellular matrix components, including laminins and collagens. Conversely, the hypothalamic transcriptome displays upregulation of transcripts involved in damage response signaling and protein turnover during hibernation, including the DNA damage repair gene RAD50 and ubiquitin E3 ligases UBR1 and UBR5. Additionally, the hypothalamus transcriptome also provides evidence of potential mechanisms underlying the hibernation phenotype, including feeding and satiety signaling, seasonal timing mechanisms, and fuel utilization. This study provides insight into potential neuroprotective strategies and hibernation control mechanisms, and also specifically shows that the hibernator brain exhibits both seasonal and regional differences in mRNA expression.

Regulation of bat echolocation pulse acoustics by striatal dopamine.

The ability to control the bandwidth, amplitude and duration of echolocation pulses is a crucial aspect of echolocation performance but few details are known about the neural mechanisms underlying the control of these voice parameters in any mammal. The basal ganglia (BG) are a suite of forebrain nuclei centrally involved in sensory-motor control and are characterized by their dependence on dopamine. We hypothesized that pharmacological manipulation of brain dopamine levels could reveal how BG circuits might influence the acoustic structure of bat echolocation pulses. A single intraperitoneal injection of a low dose (5 mg kg(-1)) of the neurotoxin 1-methyl-4-phenylpyridine (MPTP), which selectively targets dopamine-producing cells of the substantia nigra, produced a rapid degradation in pulse acoustic structure and eliminated the bat's ability to make compensatory changes in pulse amplitude in response to background noise, i.e. the Lombard response. However, high-performance liquid chromatography (HPLC) measurements of striatal dopamine concentrations revealed that the main effect of MPTP was a fourfold increase rather than the predicted decrease in striatal dopamine levels. After first using autoradiographic methods to confirm the presence and location of D(1)- and D(2)-type dopamine receptors in the bat striatum, systemic injections of receptor subtype-specific agonists showed that MPTP's effects on pulse acoustics were mimicked by a D(2)-type dopamine receptor agonist (Quinpirole) but not by a D(1)-type dopamine receptor agonist (SKF82958). The results suggest that BG circuits have the capacity to influence echolocation pulse acoustics, particularly via D(2)-type dopamine receptor-mediated pathways, and may therefore represent an important mechanism for vocal control in bats.

Mapping vocalization-related immediate early gene expression in echolocating bats.

Recent studies of spontaneously vocalizing primates, cetaceans, bats and rodents suggest these animals possess a limited but meaningful capacity to manipulate the timing and acoustic structure of their vocalizations, yet the neural substrate for even the simplest forms of vocal modulation in mammals remains unknown. Echolocating bats rapidly and routinely manipulate the acoustic structure of their outgoing vocalizations to improve echolocation efficiency, reflecting cognitive rather than limbic control of the vocal motor pathways. In this study, we used immunohistochemical localization of immediate early gene (c-fos) expression to map neural activity in the brains of spontaneously echolocating stationary Mexican free-tailed bats. Our results support the current model of vocal control obtained largely through microstimulation studies, but also provide evidence for the contributions of two novel regions, the dorsolateral caudate nucleus and mediodorsal thalamic nucleus, which together suggest a striatothalamic feedback loop may be involved in the control of echolocation pulse production. Additionally, we found evidence of a motivation pathway, including the lateral habenula, substantia nigra pars compacta, and raphe nuclei. These data provide novel insights into where and how mammalian vocalizations may be regulated by sensory, contextual and motivational cues.