Measuring coordination of epilepsy care: A mixed methods evaluation of social network analysis versus relational coordination.

OBJECTIVES: Coordination of multidisciplinary care is critical to address the complex needs of people with neurological disorders; however, quality improvement and research tools to measure coordination of neurological care are not well-developed. This study explored and compared the value of social network analysis (SNA) and relational coordination (RC) in measuring coordination of care in a neurology setting. The Department of Veterans Affairs Healthcare System (VA) established an Epilepsy Centers of Excellence (ECOE) hub and spoke model of care, which provides a setting to measure coordination of care across networks of providers. METHODS: In a parallel mixed methods approach, we compared coordination of care of VA providers who formally engage the ECOE system to VA providers outside the ECOE system using SNA and RC. Coordination of care scores were compiled from provider teams across 66 VA facilities, and key informant interviews of 80 epilepsy care team members were conducted concurrently to describe the quality of epilepsy care coordinating in the VA healthcare system. RESULTS: On average, members of healthcare teams affiliated with the ECOE program rated quality of communication and respect higher than non-ECOE physicians. Connectivity between neurologist and primary care providers as well as between neurologists and mental health providers were higher within ECOE hub facilities compared to spoke referring facilities. Key informant interviews reported the important role of formal and informal programming, social support and social capital, and social influence on epilepsy care networks. CONCLUSION: For quality improvement and research purposes, SNA and RC can be used to measure coordination of neurological care; RC provides a detailed assessment of the quality of communication within and across healthcare teams but is difficult to administer and analyze; SNA provides large scale coordination of care maps and metrics to compare across large healthcare systems. The two measures provide complimentary coordination of care data at a local as well as population level. Interviews describe the mechanisms of developing and sustaining health professional networks that are not captured in either SNA or RC measures.

Precocious deposition of perineuronal nets on Parvalbumin inhibitory neurons transplanted into adult visual cortex.

The end of the critical period for primary visual cortex (V1) coincides with the deposition of perineuronal nets (PNN) onto Parvalbumin (PV) inhibitory neurons. Recently, we found that transplantation of embryonic inhibitory neurons into adult V1 reinstates a new critical period. Here we used Wisteria Floribunda Agglutinin (WFA) staining to compare the deposition of PNNs onto neurons during normal development and following transplantation at equivalent cell ages. In accord with previous findings, PV and PNN expression increases from negligible levels at postnatal day 14 (P14) to mature levels by P70. In contrast to P14, PNNs are found on transplanted PV neurons by 21 days after transplantation and persist to 105 days after transplantation. This precocious deposition was specific to PV neurons and excluded transplanted neurons expressing Somatostatin. Notably, the onset of PV expression in transplanted inhibitory neurons follows the timing of PV expression in juvenile V1. Moreover, transplantation has no discernible effect on host PNNs. The precocious deposition of PNNs onto transplanted PV neurons suggests that PNN expression identified by WFA does not reflect neuronal maturity and may be an inaccurate marker for transplant-induced plasticity of cortical circuits.

Inhibitory Neuron Transplantation into Adult Visual Cortex Creates a New Critical Period that Rescues Impaired Vision.

The maturation of inhibitory circuits in juvenile visual cortex triggers a critical period in the development of the visual system. Although several manipulations of inhibition can alter the timing of the critical period, none have demonstrated the creation of a new critical period in adulthood. We developed a transplantation method to reactivate critical period plasticity in the adult visual cortex. Transplanted embryonic inhibitory neurons from the medial ganglionic eminence reinstate ocular dominance plasticity in adult recipients. Transplanted inhibitory cells develop cell-type-appropriate molecular characteristics and visually evoked responses. In adult mice impaired by deprivation during the juvenile critical period, transplantation also recovers both visual cortical responses and performance on a behavioral test of visual acuity. Plasticity and recovery are induced when the critical period would have occurred in the donor animal. These results reveal that the focal reactivation of visual cortical plasticity using inhibitory cell transplantation creates a new critical period that restores visual perception after childhood deprivation.