Prehospital Naloxone Administration Patterns during the Era of Synthetic Opioids.

Background: The opioid epidemic is an ongoing public health emergency, exacerbated in recent years by the introduction and rising prevalence of synthetic opioids. The National EMS Scope of Practice Model was changed in 2017 to recommend allowing basic life support (BLS) clinicians to administer intranasal (IN) naloxone. This study examines local IN naloxone administration rates for 4 years after the new recommendation, and Glasgow Coma Scale (GCS) scores and respiratory rates before and after naloxone administration.Methods: This retrospective cohort study evaluated naloxone administrations between April 1st 2017 and March 31st 2021 in a mixed urban-suburban EMS system. Naloxone dosages, routes of administration, and frequency of administrations were captured along with demographic information. Analysis of change in the ratio of IN to intravenous (IV) naloxone administrations per patient was performed, with the intention of capturing administration patterns in the area. Analyses were performed for change over time of IN naloxone rates of administration, change in respiratory rates, and change in GCS scores after antidote administration. ALS and BLS clinician certification levels were also identified. Bootstrapping procedures were used to estimate 95% confidence intervals for correlation coefficients.Results: Two thousand and ninety patients were analyzed. There was no statistically significant change in the IN/parenteral ratio over time (p = 0.79). Repeat dosing increased over time from 1.2 ± 0.4 administrations per patient to 1.3 ± 0.5 administrations per patient (r = 0.078, 95% CI: 0.036 - 0.120; p = 0.036). Mean respiratory rates before (mean = 12.6 - 12.6, r = -0.04, 95% CI: -0.09 - 0.01; p = 0.1) and after (mean = 15.2 - 14.9, r = -0.03, 95% CI: -0.08 - 0.01; p = 0.172) naloxone administration have not changed. While initial GCS scores have become significantly lower, GCS scores after administration of naloxone have not changed (initial median GCS 10 - 6, p < 0.001; final median GCS 15 - 15, p = 0.23).Conclusions: Current dosing protocols of naloxone appear effective in the era of synthetic opioids in our region, although patients may be marginally more likely to require repeat naloxone doses.

Hippocampal and medial prefrontal ensemble spiking represents episodes and rules in similar task spaces.

Episodic memory requires the hippocampus and prefrontal cortex to guide decisions by representing events in spatial, temporal, and personal contexts. Both brain regions have been described by cognitive theories that represent events in context as locations in maps or memory spaces. We query whether ensemble spiking in these regions described spatial structures as rats performed memory tasks. From each ensemble, we construct a state-space with each point defined by the coordinated spiking of single and pairs of units in 125-ms bins and investigate how state-space locations discriminate task features. Trajectories through state-spaces correspond with behavioral episodes framed by spatial, temporal, and internal contexts. Both hippocampal and prefrontal ensembles distinguish maze locations, task intervals, and goals by distances between state-space locations, consistent with cognitive mapping and relational memory space theories of episodic memory. Prefrontal modulation of hippocampal activity may guide choices by directing memory representations toward appropriate state-space goal locations.

Mitochondria dysregulation contributes to secondary neurodegeneration progression post-contusion injury in human 3D in vitro triculture brain tissue model.

Traumatic Brain injury-induced disturbances in mitochondrial fission-and-fusion dynamics have been linked to the onset and propagation of neuroinflammation and neurodegeneration. However, cell-type-specific contributions and crosstalk between neurons, microglia, and astrocytes in mitochondria-driven neurodegeneration after brain injury remain undefined. We developed a human three-dimensional in vitro triculture tissue model of a contusion injury composed of neurons, microglia, and astrocytes and examined the contributions of mitochondrial dysregulation to neuroinflammation and progression of injury-induced neurodegeneration. Pharmacological studies presented here suggest that fragmented mitochondria released by microglia are a key contributor to secondary neuronal damage progression after contusion injury, a pathway that requires astrocyte-microglia crosstalk. Controlling mitochondrial dysfunction thus offers an exciting option for developing therapies for TBI patients.

Hippocampal and Medial Prefrontal Cortex Fractal Spiking Patterns Encode Episodes and Rules.

A central question in neuroscience is how the brain represents and processes information to guide behavior. The principles that organize brain computations are not fully known, and could include scale-free, or fractal patterns of neuronal activity. Scale-free brain activity may be a natural consequence of the relatively small subsets of neuronal populations that respond to task features, i.e., sparse coding. The size of the active subsets constrains the possible sequences of inter-spike intervals (ISI), and selecting from this limited set may produce firing patterns across wide-ranging timescales that form fractal spiking patterns. To investigate the extent to which fractal spiking patterns corresponded with task features, we analyzed ISIs in simultaneously recorded populations of CA1 and medial prefrontal cortical (mPFC) neurons in rats performing a spatial memory task that required both structures. CA1 and mPFC ISI sequences formed fractal patterns that predicted memory performance. CA1 pattern duration, but not length or content, varied with learning speed and memory performance whereas mPFC patterns did not. The most common CA1 and mPFC patterns corresponded with each region's cognitive function: CA1 patterns encoded behavioral episodes which linked the start, choice, and goal of paths through the maze whereas mPFC patterns encoded behavioral "rules" which guided goal selection. mPFC patterns predicted changing CA1 spike patterns only as animals learned new rules. Together, the results suggest that CA1 and mPFC population activity may predict choice outcomes by using fractal ISI patterns to compute task features.

Goal Choices Modify Frontotemporal Memory Representations.

Adapting flexibly to changing circumstances is guided by memory of past choices, their outcomes in similar circumstances, and a method for choosing among potential actions. The hippocampus (HPC) is needed to remember episodes, and the prefrontal cortex (PFC) helps guide memory retrieval. Single-unit activity in the HPC and PFC correlates with such cognitive functions. Previous work recorded CA1 and mPFC activity as male rats performed a spatial reversal task in a plus maze that requires both structures, found that PFC activity helps reactivate HPC representations of pending goal choices but did not describe frontotemporal interactions after choices. We describe these interactions after choices here. CA1 activity tracked both current goal location and the past starting location of single trials; PFC activity tracked current goal location better than past start location. CA1 and PFC reciprocally modulated representations of each other both before and after goal choices. After choices, CA1 activity predicted changes in PFC activity in subsequent trials, and the magnitude of this prediction correlated with faster learning. In contrast, PFC start arm activity more strongly modulated CA1 activity after choices correlated with slower learning. Together, the results suggest post-choice HPC activity conveys retrospective signals to the PFC, which combines different paths to common goals into rules. In subsequent trials, prechoice mPFC activity modulates prospective CA1 signals informing goal selection.SIGNIFICANCE STATEMENT HPC and PFC activity supports cognitive flexibility in changing circumstances. HPC signals represent behavioral episodes that link the start, choice, and goal of paths. PFC signals represent rules that guide goal-directed actions. Although prior studies described HPC-PFC interactions preceding decisions in the plus maze, post-decision interactions were not investigated. Here, we show post-choice HPC and PFC activity distinguished the start and goal of paths, and CA1 signaled the past start of each trial more accurately than mPFC. Postchoice CA1 activity modulated subsequent PFC activity, so rewarded actions were more likely to occur. Together, the results show that in changing circumstances, HPC retrospective codes modulate subsequent PFC coding, which in turn modulates HPC prospective codes that predict choices.

Peripheral sensitization is demonstrated in subacromial pain syndrome, with central sensitization found only in females.

The objective of this study was to explore whether hypersensitivity in patients with subacromial pain syndrome (SPS) manifests purely as localized peripheral sensitization or central sensitization, is influenced by the presence of subacromial pain, and presents similarly in male and female patients. Pressure pain threshold was assessed in both a patient cohort with unilateral SPS and an uninjured matched control group. Control subjects were assessed twice, with a 15 minute rest period between testing, while patients were assessed at baseline and after an almost instantaneous reduction in pain arising from an anesthetic injection in patients. Patients received a subacromial injection consisting of both anesthetics (3 cc of 2% lidocaine and 6 cc 0.5% Marcaine with Epinephrine) and a corticosteroid agent (1 cc DepoMedrol). Patients demonstrated hypersensitivity across the involved shoulder only, providing evidence for peripheral sensitization. There were trends for hypersensitivity across remote joints, however when separated by sex, only female patients demonstrated both peripheral and central sensitization. Immediate pain reduction had no influence on hypersensitivity in the short-term. Clinical Significance: Neuropathic components are likely present in some patients with subacromial pain syndrome, and female patients may be particularly at risk for presenting with neuropathic pain. These findings are applicable towards understanding the heterogeneous etiology underlying subacromial pain syndrome and informing clinical management.

EMS Non-Transport of Low-Risk COVID-19 Patients.

Objectives: COVID-19 infections in the community have the potential to overwhelm both prehospital and in-hospital resources. Transport of well-appearing patients, in the absence of available emergency department treatment capacity, increases strain on the hospital and EMS system. In May of 2020, the Connecticut Office of EMS issued a voluntary, EMS-initiated, non-transport protocol for selected low-risk patients with symptoms consistent with COVID-19. We evaluated the implementation of this non-transport protocol in a mixed urban/suburban EMS system.Methods: We conducted a retrospective review of contemporaneously recorded quality improvement documentation for uses of the Connecticut COVID-19 non-transport protocol by EMS clinicians within our EMS system during two implementations: from 12/14/2020 to 5/1/21, and again from 1/3/22 to 2/18/22, which coincided with large COVID-19 case surges in our region.Results: The vast majority of patients treated under the non-transport protocol were not reevaluated by EMS or in our emergency departments in the subsequent 24 hours. There was reasonable adherence to the protocol, with 83% of cases appropriate for the non-transport protocol. The most common reasons for protocol violations were age outside of protocol scope (pediatric patients), failure of documentation, or vital signs outside of the established protocol parameters. We did not find an increased 24-hour ED visit rate in patients who were inappropriately triaged to the protocol. Of patients who had ED visits within 24 hours, only two were admitted, none to higher levels of care.Conclusion: Within this small study, EMS clinicians in our system were able to safely and accurately apply a non-transport protocol for patients presenting with symptoms consistent with COVID-19. This is consistent with previous literature suggesting that EMS-initiated non-transport is a viable strategy to reduce the burden on health systems.

An Evaluation of Prehospital Adenosine Use.

BACKGROUND: Adenosine has been safely used by paramedics for the treatment of stable supraventricular tachycardia since the mid-1990s. However, there continues to be variability in paramedics' ability to identify appropriate indications for adenosine administration. As the first of a planned series of studies aimed at improving the accuracy of SVT diagnosis and successful administration of adenosine by paramedics, this study details the current usage patterns of adenosine by paramedics. METHODS: This cross-sectional retrospective study investigated adenosine use within a large northeast EMS region from January 1, 2019, through September 30, 2021. Excluding pediatric and duplicate case reports, we created a dataset containing patient age, sex, and vital signs before, during, and after adenosine administration; intravenous line location; and coded medical history from paramedic narrative documentation, including a history of atrial fibrillation, suspected arrhythmia diagnosis, and effect of adenosine. In cases with available prehospital electrocardiograms (EKGs) for review, two physicians independently coded the arrhythmia diagnosis and outcome of adenosine administration. Statistical analysis included interrater reliability with Cohen's kappa statistic. RESULTS: One hundred eighty-three cases were included for final analysis, 84 did not have a documented EKG for review. Categorization of presenting rhythms in these cases occurred by a physician reviewing EMS narrative and documentation. Forty of these 84 cases (48%) were adjudicated as SVT likely, 32 (38%) as SVT unlikely and 12 (14%) as uncategorized due to lack of supporting documentation. Of the 99 cases with EKGs available to review, there was substantial agreement of arrhythmia diagnosis interpretation between physician reviewers (Cohen's kappa 0.77-1.0); 54 cases were adjudicated as SVT by two physician reviewers. Other identified cardiac rhythms included atrial fibrillation (16), sinus tachycardia (11), and ventricular tachycardia (2). Adenosine cardioversion occurred in 47 of the 99 cases with EKGs available for physician review (47.5%). Adenosine cardioversion was also deemed to occur in 87% (47/54) of cases when the EKG rhythm was physician adjudicated SVT. CONCLUSIONS: This study supports the use of adenosine as a prehospital treatment for SVT while highlighting the need for continued efforts to improve paramedics' identification and management of tachyarrhythmias.

Predicting age and gender from network telemetry: Implications for privacy and impact on policy.

The systematic monitoring of private communications through the use of information technology pervades the digital age. One result of this is the potential availability of vast amount of data tracking the characteristics of mobile network users. Such data is becoming increasingly accessible for commercial use, while the accessibility of such data raises questions about the degree to which personal information can be protected. Existing regulations may require the removal of personally-identifiable information (PII) from datasets before they can be processed, but research now suggests that powerful machine learning classification methods are capable of targeting individuals for personalized marketing purposes, even in the absence of PII. This study aims to demonstrate how machine learning methods can be deployed to extract demographic characteristics. Specifically, we investigate whether key demographics-gender and age-of mobile users can be accurately identified by third parties using deep learning techniques based solely on observations of the user's interactions within the network. Using an anonymized dataset from a Latin American country, we show the relative ease by which PII in terms of the age and gender demographics can be inferred; specifically, our neural networks model generates an estimate for gender with an accuracy rate of 67%, outperforming decision tree, random forest, and gradient boosting models by a significant margin. Neural networks achieve an even higher accuracy rate of 78% in predicting the subscriber age. These results suggest the need for a more robust regulatory framework governing the collection of personal data to safeguard users from predatory practices motivated by fraudulent intentions, prejudices, or consumer manipulation. We discuss in particular how advances in machine learning have chiseled away a number of General Data Protection Regulation (GDPR) articles designed to protect consumers from the imminent threat of privacy violations.

Hippocampal signals modify orbitofrontal representations to learn new paths.

We often remember the consequences of past choices to adapt to changing circumstances. Recalling past events requires the hippocampus (HPC), and using stimuli to anticipate outcome values requires the orbitofrontal cortex (OFC).1-3 Spatial reversal tasks require both structures to navigate newly rewarded paths.4,5 Both HPC place6 and OFC value cells7,8 fire in phase with theta (4-12 Hz) oscillations. Both structures are described as cognitive maps: HPC maps space9 and OFC maps task states.10 These similarities imply that OFC-HPC interactions are crucial for using memory to predict outcomes when circumstances change, but the mechanisms remain largely unknown. To investigate possible interactions, we simultaneously recorded ensembles in OFC and CA1 as rats learned spatial reversals in a plus maze. Striking interactions occurred only while rats learned their first reversal: CA1 population vectors predicted changes in OFC activity but not vice versa, OFC spikes phase locked to hippocampal theta oscillations, mixed pairs of CA1 and OFC neurons fired together within single theta cycles, and CA1 led OFC spikes by ∼30 ms. After the new contingency became familiar, CA1 ensembles stably represented distinct spatial paths, whereas OFC ensembles developed more generalized goal arm representations in different paths to identical rewards. These frontotemporal interactions, engaged selectively when new task features inform decision-making, suggest a mechanism for linking novel episodes with expected outcomes, when HPC signals trigger "cognitive remapping" by OFC.11.

An in silico model for determining the influence of neuronal co-activity on rodent spatial behavior.

BACKGROUND: Neuropsychological and neurophysiological analyses focus on understanding how neuronal activity and co-activity predict behavior. Experimental techniques allow for modulation of neuronal activity, but do not control neuronal ensemble spatiotemporal firing patterns, and there are few, if any, sophisticated in silico techniques which accurately reconstruct physiological neural spike trains and behavior using unit co-activity as an input parameter. NEW METHOD: Our approach to simulation of neuronal spike trains is based on using state space modeling to estimate a weighted graph of interaction strengths between pairs of neurons along with separate estimations of spiking threshold voltage and neuronal membrane leakage. These parameters allow us to tune a biophysical model which is then employed to accurately reconstruct spike trains from freely behaving animals and then use these spike trains to estimate an animal's spatial behavior. The reconstructed spatial behavior allows us to confirm the same information is present in both the recorded and simulated spike trains. RESULTS: Our method reconstructs spike trains (98 ± 0.0013% like original spike trains, mean ± SEM) and animal position (9.468 ± 0.240 cm, mean ± SEM) with high fidelity. COMPARISON WITH EXISTING METHOD(S): To our knowledge, this is the first method that uses empirically derived network connectivity to constrain biophysical parameters and predict spatial behavior. Together, these methods allow in silico quantification of the contribution of specific unit activity and co-activity to animal spatial behavior. CONCLUSIONS: Our novel approach provides a flexible, robust in silico technique for determining the contribution of specific neuronal activity and co-activity to spatial behavior.

Weakness in patients with subacromial pain syndrome is local and more pronounced in females.

BACKGROUND: Subacromial pain syndrome is the predominant cause of shoulder pain, accounting for approximately half of all shoulder complaints. This population presents with weakness of the involved shoulder. However, there is a gap in our understanding of how pain contributes to this weakness, and whether there are sex related differences. METHODS: Regional and global isometric strength was tested at the involved shoulder joint and remote joints (uninvolved shoulder and both knees) in patients with subacromial pain syndrome. Data were collected before and after acute pain reduction with a subacromial injection. FINDINGS: Patients demonstrated weakness at the involved shoulder while remote joints demonstrated normal strength. When compared to healthy controls, male patients were shown to exhibit greater levels of weakness than female patients at the involved shoulder, based on comparisons with sex-matched controls using z-scores. Pain reduction (through an anesthetic injection) had no influence on strength in the short-term. INTERPRETATION: Weakness in patients appears to be sex dependent and is not resolved with reduction of pain. This calls into question the assumptions of the physiological causes of this weakness.

Does precise case disclosure limit precautionary behavior? Evidence from COVID-19 in Singapore.

Limiting the spread of contagious diseases can involve both government-managed and voluntary efforts. Governments have a number of policy options beyond direct intervention that can shape individuals' responses to a pandemic and its associated costs. During its first wave of COVID-19 cases, Singapore was among a few countries that attempted to adjust behavior through the announcement of detailed case information. Singapore's Ministry of Health maintained and shared precise, daily information detailing local travel behavior and residences of COVID-19 cases. We use this policy along with device-level cellphone data to quantify how local and national COVID-19 case announcements trigger differential behavioral changes. We find evidence that individuals are three times more responsive to outbreaks in granularly defined locales. Conditional on keeping infection rates at a manageable level, the results suggest economic value in this type of transparency by mitigating the scope of precautionary activity reductions.

Post-error recruitment of frontal sensory cortical projections promotes attention in mice.

The frontal cortex, especially the anterior cingulate cortex area (ACA), is essential for exerting cognitive control after errors, but the mechanisms that enable modulation of attention to improve performance after errors are poorly understood. Here we demonstrate that during a mouse visual attention task, ACA neurons projecting to the visual cortex (VIS; ACAVIS neurons) are recruited selectively by recent errors. Optogenetic manipulations of this pathway collectively support the model that rhythmic modulation of ACAVIS neurons in anticipation of visual stimuli is crucial for adjusting performance following errors. 30-Hz optogenetic stimulation of ACAVIS neurons in anesthetized mice recapitulates the increased gamma and reduced theta VIS oscillatory changes that are associated with endogenous post-error performance during behavior and subsequently increased visually evoked spiking, a hallmark feature of visual attention. This frontal sensory neural circuit links error monitoring with implementing adjustments of attention to guide behavioral adaptation, pointing to a circuit-based mechanism for promoting cognitive control.

Heterogeneity in Expectations, Risk Tolerance, and Household Stock Shares: The Attenuation Puzzle.

This paper jointly estimates the relationship between stock share and expectations and risk preferences. The survey allows individual-level, quantitative estimates of risk tolerance and of the perceived mean and variance of stock returns. These estimates have economically and statistically significant association for the distribution of stock shares with relative magnitudes in proportion with the predictions of theories. Incorporating survey measurement error in the estimation model increases the estimated associations twofold, but they are still substantially attenuated being only about 5 percent of what benchmark finance theories predict. Because of the careful attention in the estimation to measurement error, the attenuation likely arises from economic behavior rather than errors in variables.

Flexible spatial learning requires both the dorsal and ventral hippocampus and their functional interactions with the prefrontal cortex.

When faced with changing contingencies, animals can use memory to flexibly guide actions, engaging both frontal and temporal lobe brain structures. Damage to the hippocampus (HPC) impairs episodic memory, and damage to the prefrontal cortex (PFC) impairs cognitive flexibility, but the circuit mechanisms by which these areas support flexible memory processing remain unclear. The present study investigated these mechanisms by temporarily inactivating the medial PFC (mPFC), the dorsal HPC (dHPC), and the ventral HPC (vHPC), individually and in combination, as rats learned spatial discriminations and reversals in a plus maze. Bilateral inactivation of either the dHPC or vHPC profoundly impaired spatial learning and memory, whereas bilateral mPFC inactivation primarily impaired reversal versus discrimination learning. Inactivation of unilateral mPFC together with the contralateral dHPC or vHPC impaired spatial discrimination and reversal learning, whereas ipsilateral inactivation did not. Flexible spatial learning thus depends on both the dHPC and vHPC and their functional interactions with the mPFC.

The nucleus reuniens of the thalamus sits at the nexus of a hippocampus and medial prefrontal cortex circuit enabling memory and behavior.

The nucleus reuniens of the thalamus (RE) is a key component of an extensive network of hippocampal and cortical structures and is a fundamental substrate for cognition. A common misconception is that RE is a simple relay structure. Instead, a better conceptualization is that RE is a critical component of a canonical higher-order cortico-thalamo-cortical circuit that supports communication between the medial prefrontal cortex (mPFC) and the hippocampus (HC). RE dysfunction is implicated in several clinical disorders including, but not limited to Alzheimer's disease, schizophrenia, and epilepsy. Here, we review key anatomical and physiological features of the RE based primarily on studies in rodents. We present a conceptual model of RE circuitry within the mPFC-RE-HC system and speculate on the computations RE enables. We review the rapidly growing literature demonstrating that RE is critical to, and its neurons represent, aspects of behavioral tasks that place demands on memory focusing on its role in navigation, spatial working memory, the temporal organization of memory, and executive functions.

Howard B. Eichenbaum (1947-2017).

Presents an obituary of Howard B. Eichenbaum (1947-2017). Eichenbaum, a world leader in the study of memory and the brain, died in Boston, Massachusetts, on July 21, 2017, at age 69, following recent spine surgery. Eichenbaum was a hugely creative and integrative scientist whose work combined cognitive and lesion analyses with high-density neuronal recordings, providing insights into brain computations and representations that help bridge psychological and physiological mechanisms of memory. His theories and original and elegant experiments in animals have greatly advanced our knowledge of the nature and brain mechanisms of memory in animals and humans alike. (PsycINFO Database Record