Goals of Care Conversations in Long-Term Care during the First Wave of the COVID-19 Pandemic.

Goals of care discussions typically focus on decision maker preference and underemphasize prognosis and outcomes related to frailty, resulting in poorly informed decisions. Our objective was to determine whether navigated care planning with nursing home residents or their decision makers changed care plans during the first wave of the COVID-19 pandemic. The MED-LTC virtual consultation service, led by internal medicine specialists, conducted care planning conversations that balanced information-giving/physician guidance with resident autonomy. Consultation included (1) the assessment of co-morbidities, frailty, health trajectory, and capacity; (2) in-depth discussion with decision makers about health status and expected outcomes; and (3) co-development of a care plan. Non-parametric tests and logistic regression determined the significance and factors associated with a change in care plan. Sixty-three residents received virtual consultations to review care goals. Consultation resulted in less aggressive care decisions for 52 residents (83%), while 10 (16%) remained the same. One resident escalated their care plan after a mistaken diagnosis of dementia was corrected. Pre-consultation, 50 residents would have accepted intubation compared to 9 post-consultation. The de-escalation of care plans was associated with dementia, COVID-19 positive status, and advanced frailty. We conclude that during the COVID-19 pandemic, a specialist-led consultation service for frail nursing home residents significantly influenced decisions towards less aggressive care.

Expression of Hsp27 in retinal ganglion cells of the rat during postnatal development.

The small heat shock protein Hsp27 has been shown to protect neurons from apoptosis. We have recently shown the expression of Hsp27 in a subset of injured adult retinal ganglion cells (RGCs), a response that is muted by the administration of brain-derived neurotrophic factor. This work has suggested a role for Hsp27 in the long-term survival of RGCs following injury. The purpose of this study was to investigate the expression of Hsp27 during postnatal retinal development, based on Hsp27's role as a neuronal survival factor and on its up-regulation in the adult injured retina. Expression of Hsp27 in the developing retina was examined at various times postnatally (between P0 and P24) by using immunohistochemical techniques. We report that Hsp27 expression peaks in the ganglion cell layer between P6 and P12 and is not detected at earlier (P0-P3) or later (P15-P24) times. Double labeling of the Hsp27-positive cells with Fluorogold applied to the superior colliculus confirmed that Hsp27-positive cells in the ganglion cell layer are RGCs. We have shown developmentally regulated expression of Hsp27 in RGCs of the postnatal rat. The retinal expression of Hsp27 correlates temporally with innervation of the tectum by late-born RGCs and with onset of spontaneous retinotectal activity. We propose that the expression of Hsp27 may play an important role in retinal development during a critical period of RGC functional connectivity with the superior colliculus.