Dynamics of serotonergic neurons revealed by fiber photometry

This work was developed in the context of the MIT Portugal Program, area of Bioengineering Systems, in collaboration with the Champalimaud Research Programme, Champalimaud Center for the Unknown, Lisbon, Portugal. The project entitled Dynamics of serotonergic neurons revealed by fiber photometry was carried out at Instituto Gulbenkian de Ciência, Oeiras, Portugal and at the Champalimaud Research Programme, Champalimaud Center for the Unknown, Lisbon, PortugalSerotonin is an important neuromodulator implicated in the regulation of many physiological and cognitive processes. It is one of the most studied neuromodulators and one of the main targets of psychoactive drugs, since its dysregulation can contribute to altered perception and pathological conditions such as depression and obsessive-compulsive disorder. However, it is still one of the most mysterious and least understood neuromodulatory systems of the brain. In order to study the activity of serotonergic neurons in behaving mice, we used genetically encoded calcium indicators and developed a fiber photometry system to monitor neural activity from genetically defined populations of neurons. This approach was developed to study serotonin neurons but it can be used in any genetically defined neuronal population. To validate our approach, we first confirmed that increased neural activity, induced by electrical microstimulation, indeed produced increases in fluorescence detected by the system. We then used it to monitor activity in the dorsal striatum of freely behaving mice. We show that the two projection pathways of the basal ganglia are both active during spontaneous contraversive turns. Additionally, we show that this balanced activity in the two pathways is needed for such contraversive movements. Finally, we used the fiber photometry system to study the role of serotonin in learning and behavioral control and to compare it to that of dopamine, another important neuromodulator. Dopamine and serotonin are thought to act jointly to orchestrate learning and behavioral control. While dopamine is thought to invigorate behavior and drive learning by signaling reward prediction errors, i.e. better-than-expected outcomes, serotonin has been implicated in behavioral inhibition and aversive processing. More specifically, serotonin has been implicated in preventing perseverative responses in changing environments. However, whether or how serotonin neurons signal such changes is not clear. To investigate these issues, we used a reversal learning task in which mice first learned to associate different odor cues with specific outcomes and then we unexpectedly reversed these associations. We show that dorsal raphe serotonin neurons, like midbrain dopamine neurons, are specifically recruited following prediction errors that occur after reversal. Yet, unlike dopamine neurons, serotonin neurons are similarly activated by surprising events that are both better and worse than expected. Dopamine and serotonin responses both track learned cue-reward associations, but serotonin neurons are slower to adapt to the changes that occur at reversal. The different dynamics of these neurons following reversal creates an imbalance that favors dopamine activity when invigoration is needed to obtain rewards and serotonin activity when behavior should be inhibited. Our data supports a model in which serotonin acts by rapidly reporting erroneous associations, expectations or priors in order to suppress behaviors driven by such errors and enhance plasticity to facilitate error correction. Contrary to prevailing views, it supports a concept of serotonin based on primary functions in prediction, control and learning rather than affect and mood

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status