Teaching medicine interns minimum geriatrics competencies within a "4 + 2" schedule.

The increased ambulatory training time in an "X + Y" (inpatient + ambulatory) residency schedule affords more opportunities to teach geriatrics principles of care. We describe our internal medicine (IM) residency program's experience in teaching the IM-family medicine (FM) minimum geriatrics competencies (MGC) during a longitudinal geriatrics rotation embedded within interns' yearlong "4 + 2" schedule. Interns spend 1 day of the ambulatory block in a geriatrics outpatient setting (Program of All-Inclusive Care for the Elderly, house calls, nursing home), during which geriatrics division faculty members give core didactic seminars. We revamped core seminars to address MGC related to medication management, cognitive health, complex chronic illnesses, end of life care, and ambulatory care. Three consecutive intern cohorts completed anonymous surveys pre- and postrotation, rating their confidence level in MGC addressed by the curriculum on a 5-point Likert scale. On postrotation surveys, they also rated the curriculum's contribution to geriatrics skills enhancement. Interns who completed both surveys (N = 22, 92%) reported statistically significant improved confidence ratings on all items, with the greatest point gains seen in performance of functional assessment (1.56), practice of optimal geriatric pharmacotherapy (1.78), and identification of older patients eligible for skilled (1.71) and unskilled home-based services (1.65). They rated geriatrics curricular components as being more helpful than other rotations and conferences in enhancing their geriatric skills. In conclusion, we developed a longitudinal geriatrics curriculum within the context of our "4 + 2" immersion schedule which other programs can easily adapt. Aligning curricular content with the MGC has resulted in interns' improved confidence in several important geriatrics skills.

Increases in orbitofrontal cortex thickness following antidepressant treatment are associated with changes in resting state autonomic function in adolescents with major depression - Preliminary findings from a pilot study.

In adults with major depressive disorder (MDD), effective treatment has been associated with increases in both heart rate variability (HRV) and cortical thickness. However, the impact of treatment on these indices has not yet been examined in adolescents. Cortical thickness and HRV were measured in twelve adolescents with MDD before and after 8 weeks of treatment with a selective serotonin reuptake inhibitor (SSRI). We examined treatment-related changes in depression symptoms, HRV, heart rate (HR), and cortical thickness, and analyzed correlations among these change indices. At follow-up, patients showed significantly decreased depression severity, increased HRV and increased thickness of the left medial orbitofrontal cortex (OFC). Clinical improvement was associated with increased HRV and decreased HR. Increased HRV was associated with increased cortical thickness of left lateral OFC and superior frontal cortex. Due to the small sample size, results represent preliminary findings that need replication. Further, in the absence of a placebo arm, we cannot confirm that the observed effects are due solely to medication. These preliminary findings suggest that SSRI treatment in adolescents impacts both cortical thickness and autonomic functioning. Confirmation of these findings would support OFC thickness and HRV as neurobiological mediators of treatment outcome.

Brain structural thickness and resting state autonomic function in adolescents with major depression.

Major depressive disorder (MDD) has been associated with abnormalities in cortical thickness and autonomic function. Adolescence is a time notable for brain development and MDD onset. In healthy adolescents, greater resting state vagal activity (RVA) is associated with lower cortical thickness. The relationship between brain structural thickness and RVA in adolescents with MDD has not previously been studied. This secondary analysis drew on a sample of 37 non-depressed controls and 53 adolescents with MDD. Resting state heart rate and two indices of RVA (HF-HRV and RMSSD) were recorded during a neuroimaging session. Cortical thickness within fronto-limbic regions of interest was measured using Freesurfer analysis of T1-weighted high-resolution structural images. Self-reports of depression severity showed a significant interaction with cortical thickness of the right insula in predicting RMSSD [t = 2.22, P=0.030, ß = 5.44; model fit of the interaction term as indicated by the 'Bayes Factor' (BF): 7.58] and HF-HRV (t = 2.09, P=0.041, ß = 4.72; BF: 7.94). Clinician ratings of depression severity showed further interactions. Findings underscore the important relationships between RVA and cortical development, suggesting two possible explanations: (i) in adolescent MDD, greater fronto-limbic thickness is compensatory for deficits in autonomic regulation or (ii) increased autonomic arousal results in delayed fronto-limbic maturation. Longitudinal research is necessary to further clarify the nature of the relationship between autonomic functioning and cortical development.