Decreased cerebellar-cerebral connectivity contributes to complex task performance.

The cerebellum's role in nonmotor processes is now well accepted, but cerebellar interaction with cerebral targets is not well understood. Complex cognitive tasks activate cerebellar, parietal, and frontal regions, but the effective connectivity between these regions has never been tested. To this end, we used psycho-physiological interactions (PPI) analysis to test connectivity changes of cerebellar and parietal seed regions in complex (2-digit by 1-digit multiplication, e.g., 12 × 3) vs. simple (1-digit by 1-digit multiplication, e.g., 4 × 3) task conditions ("complex - simple"). For cerebellar seed regions (lobule VI, hemisphere and vermis), we found significantly decreased cerebellar-parietal, cerebellar-cingulate, and cerebellar-frontal connectivity in complex multiplication. For parietal seed regions (PFcm, PFop, PFm) we found significantly increased parietal-parietal and parietal-frontal connectivity in complex multiplication. These results suggest that decreased cerebellar-cerebral connectivity contributes to complex task performance. Interestingly, BOLD activity contrasts revealed partially overlapping parietal areas of increased BOLD activity but decreased cerebellar-parietal PPI connectivity.

Dissociating estimation from comparison and response eliminates parietal involvement in sequential numerosity perception.

It has been widely debated whether the parietal cortex stores an abstract representation of numerosity that is activated for Arabic digits as well as for non-symbolic stimuli in a sensory modality independent fashion. Some studies suggest that numerical information in time-invariant (simultaneous) symbolic and non-symbolic visual stimuli is represented in the parietal cortex. In humans, whether the same representation is activated for time-variant (sequential) stimuli and for stimuli coming from different modalities has not been determined. To investigate this idea, we measured the brain activation of healthy adults performing estimation and/or comparison of sequential visual (series of dots) and auditory (series of beeps) numerosities. Our experimental design allowed us to separate numerosity estimation from comparison and response related factors. The BOLD response in the parietal cortex increased only when participants were engaged in the comparison of two consecutive numerosities that required a response. Using multivariate pattern analysis we trained a classifier to decode numerosity in various regions of interest (ROI). We failed to find any parietal ROI where the classifier could decode numerosities during the estimation phase. Rather, when participants were not engaged in comparison we were able to decode numerosity in an auditory cortex ROI for auditory stimuli and in a visual cortex ROI for visual stimuli. On the other hand, during the response period the classifier successfully decoded numerosity information in a parietal ROI for both visual and auditory numerosities. These results were further confirmed by support vector regression. In sum, our study does not support the involvement of the parietal cortex during estimation of sequential numerosity in the absence of an active task with a response requirement.

Construct development: The Suicide Trigger Scale (STS-2), a measure of a hypothesized suicide trigger state.

BACKGROUND: This study aims to develop the construct of a 'suicide trigger state' by exploring data gathered with a novel psychometric self-report instrument, the STS-2. METHODS: The STS-2, was administered to 141 adult psychiatric patients with suicidal ideation. Multiple statistical methods were used to explore construct validity and structure. RESULTS: Cronbach's alpha (0.949) demonstrated excellent internal consistency. Factor analyses yielded two-component solutions with good agreement. The first component described near-psychotic somatization and ruminative flooding, while the second described frantic hopelessness. ROC analysis determined an optimal cut score for a history of suicide attempt, with significance of p < 0.03. Logistic regression analysis found items sensitive to history of suicide attempt described ruminative flooding, doom, hopelessness, entrapment and dread. CONCLUSIONS: The STS-2 appears to measure a distinct and novel clinical entity, which we speculatively term the 'suicide trigger state.' High scores on the STS-2 associate with reported history of past suicide attempt.

Trends in the diagnosis of diseases of despair in the United States, 2009-2018: a retrospective cohort study.

BACKGROUND AND OBJECTIVE: Increasing mortality and decreasing life expectancy in the USA are largely attributable to accidental overdose, alcohol-related disease and suicide. These 'deaths of despair' often follow years of morbidity, yet little is known about trends in the clinical recognition of 'diseases of despair'. The objective of this study is to characterise rates of clinically documented diseases of despair over the last decade and identify sociodemographic risk factors. DESIGN: Retrospective study using a healthcare claims database with 10 years of follow-up. SETTING: Participants resided nationwide but were concentrated in US states disproportionately affected by deaths of despair, including Pennsylvania, West Virginia and Delaware. PARTICIPANTS: Cohort included 12 144 252 participants, with no restriction by age or gender. OUTCOME MEASURES: Diseases of despair were defined as diagnoses related to alcohol misuse, substance misuse and suicide ideation/behaviours. A lookback period was used to identify incident diagnoses. Annual and all-time incidence/prevalence estimates were computed, along with risk for current diagnosis and patterns of comorbidity. RESULTS: 515 830 participants received a disease of despair diagnosis (58.5% male, median 36 years). From 2009 to 2018, the prevalence of alcohol-related, substance-related and suicide-related diagnoses respectively increased by 37%, 94%, and 170%. Ages 55-74 had the largest increase in alcohol/substance-related diagnoses (59% and 172%). Ages <18 had the largest increase in suicide-related diagnoses (287%). Overall, odds for current-year diagnosis were higher among men (adjusted OR (AOR) 1.49, 95% CI 1.47 to 1.51), and among those with Affordable Care Act or Medicare coverage relative to commercial coverage (AOR 1.30, 1.24 to 1.37; AOR 1.51, 1.46 to 1.55). CONCLUSIONS: Increasing clinical rates of disease of despair diagnoses largely mirror broader societal trends in mortality. While the opioid crisis remains a top public health priority, parallel rises in alcohol-related diagnoses and suicidality must be concurrently addressed. Findings suggest opportunities for healthcare systems and providers to deploy targeted prevention to mitigate the progression of morbidities towards mortality.

Dual plate fixation results in improved union rates in comminuted distal femur fractures compared to single plate fixation.

PURPOSE: The treatment of distal femur fractures with extensive metaphyseal comminution is frequently complicated by high rates of nonunion and varus collapse. Dual plating with lateral and medial locking plates for these types of fractures has shown promising results in the recent literature. We hypothesize that dual plating of comminuted distal femur fractures leads to higher union rates and lower revision rates compared to an isolated lateral locking plate. METHODS: A retrospective medical chart review between January 2015 and December 2017 was conducted. Inclusion criteria included patients 18 years of age and older who sustained a complex distal femur fracture (AO/OTA 33-C2/33-C3 or periprosthetic fracture with significant metaphyseal comminution) and at least 6 months of follow up. Patients with simple fracture patterns, alternative fixation methods, and inadequate follow up were excluded. All patients in the single plating group were treated with a lateral distal femoral locking plate using a lateral approach. In the patients treated with dual plating, an extensile parapatellar approach was utilized for fracture reduction and placement of an adjunctive medial plate. Demographic information, fracture types, injury severity score (ISS), medical comorbidities, type of surgical fixation, union rates, complications, knee range of motion, time to follow up, and need for revision surgery were extrapolated from the medical charts for analysis. RESULTS: Twenty-one patients were included in the study. Thirteen patients underwent single plate fixation and 8 underwent dual plate fixation. There were no significant differences in demographics, number of co-morbidities, fracture classification, or ISS between single and dual plate groups (p > 0.05 for all). There was a statistically significant difference in union rates between the single plate group (6 nonunions, 4 unions, and 3 delayed unions) and the dual plate group, with no nonunions or delayed unions (p = 0.0049). Although not statistically significant, 4 patients treated with single plating underwent revision ORIF, compared to none in the dual plating group (p = 0.13). There were no significant differences in time to follow up, time to full weight bearing, or infection rates (p > 0.1 for all). CONCLUSION: Based on these results, the medial and lateral locked plating technique demonstrates a higher union rate, with possible lower rates of revision surgery, compared to a single lateral plate in highly comminuted distal femur fractures. LEVEL OF EVIDENCE: Level 3. Retrospective Cohort Study.

Risk Factors for Unnecessary Antibiotic Prescribing for Acute Respiratory Tract Infections in Primary Care.

OBJECTIVE: To determine independent risk factors for inappropriate antibiotic prescribing for acute respiratory tract infections (ARIs) in internal medicine (IM) residency-based primary care offices. PATIENTS AND METHODS: A retrospective study was conducted to measure antibiotic prescribing rates, and multivariable analysis was utilized to identify predictors of inappropriate prescribing among patients presenting to IM residency-based primary care office practices. Patients with an office visit at either of 2 IM residency-based primary care office practices from January 1, 2016, through December 31, 2016, with a primary encounter diagnosis of ARI were included. RESULTS: During the study period, 911 unique patient encounters were included with 518 for conditions for which antibiotics were considered always inappropriate. Antibiotics were not indicated in 85.8% (782 of 911) of encounters. However, antibiotics were prescribed in 28.4% (222 of 782) of these encounters. Inappropriate antibiotic prescribing occurred in 111 of 518 (21.4%) encounters for conditions for which antibiotics are always inappropriate. Using multivariable logistic regression analysis to assess for independent risk factors when adjusted for other potential risk factors for office visits at which antibiotics were not indicated, IM resident-associated visits (odds ratio, 0.25; 95% CI, 0.18-0.36) was the only variable independently associated with lower risk of inappropriate antibiotic prescribing. CONCLUSION: For ARI visits at which antibiotics were not indicated, IM resident comanagement was associated with lower rates of inappropriate prescribing.

Operational momentum in multiplication and division?

Biases are commonly seen in numerical cognition. The operational momentum (OM) effect shows that responses to addition and subtraction problems are biased in the whole-number direction of the operation. It is not known if this bias exists for other arithmetic operations. To determine whether OM exists in scalar operations, we measured response bias in adults performing symbolic (Arabic digits) and non-symbolic (dots) multiplication and division problems. After seeing two operands, with either a multiplication (×) or division (÷) sign, participants chose among five response choices. Both non-random performance profiles and the significant contribution of both operands in a multiple regression analysis predicting the chosen values, suggest that adults were able to use numerical information to approximate the outcomes in both notations, though they were more accurate on symbolic problems. Performance on non-symbolic problems was influenced by the size of the correct choice relative to alternatives. Reminiscent of the bias in addition and subtraction, we found a significant response bias for non-symbolic problems. Non-symbolic multiplication problems were overestimated and division problems were underestimated. These results indicate that operational momentum is present in non-symbolic multiplication and division. Given the influence of the size of the correct choice relative to alternatives, an interaction between heuristic bias and approximate calculation is possible.

Distinct but overlapping neural networks subserve depression and insecure attachment.

Insecure attachment has been linked to depression and to outcome in psychotherapy. The neural mechanisms subserving the relationship between attachment security and depression are not well understood. We have developed a method to examine attachment-related brain activity in depression. Twenty-eight women, half depressed, viewed images of their mother, a female friend, and female strangers during fMRI scanning. The effects of depression and insecure attachment were determined with whole-brain multiple linear regression of blood-oxygen-level-dependent response against subjects' Beck Depression Inventory and Adult Attachment Interview (AAI) coherence of mind scores. Interaction effects were analyzed with ANOVA. Activity associated with depression and with insecure attachment was found in the cortico-striato-thalamic circuits of affect regulation. For early attachment (mother-friend contrast), depression scores correlated with activation of cortical and sub-cortical components of these circuits, while attachment insecurity correlated with sub-cortical activity in the same circuitry. Depression and attachment insecurity correlated with both cortical and sub-cortical activities for mother-stranger, and areas of overlap and of enhancing interactions between depression and insecure attachment were found. For late attachment (friend-stranger contrast), only cortical effects were found. Depression and attachment insecurity may be subserved by similar but distinct components of affect regulating circuits. Their interactions may explain the greater difficulty of treating depression in insecurely attached patients and suggest a contributing role for insecure attachment in depression. Further, differential sub-cortical vs cortical encoding of early vs late attachment suggests a top-down model of late attachment, potentially relevant to psychotherapeutic outcome.

Panic as an independent risk factor for suicide attempt in depressive illness: findings from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC).

CONTEXT: The relationship between comorbid panic and suicide in depressed persons remains unclear. OBJECTIVE: To examine the relationship of panic attacks and panic symptoms to suicidality in individuals with a major mood disorder meeting DSM-IV criteria for past-year major depressive episodes in a large epidemiologic study. METHOD: In data on 2,679 community-dwelling participants of the National Epidemiologic Survey on Alcohol and Related Conditions (2001-2002) with major depressive episodes, the associations of panic attacks and panic symptoms with lifetime suicidal ideation and suicide attempts were assessed. The adjusted odds ratios (AORs) of suicidal ideation, suicide attempt, and suicide attempt among ideators for subjects with panic attacks were the primary outcome measures. RESULTS: Past-year panic attacks were associated with increased risk of lifetime suicidal ideations (AOR = 1.17; 95% CI, 1.02-1.35) and suicide attempts (AOR = 2.10; 95% CI, 1.77-2.50) and significantly increased risk of suicide attempts among those reporting suicidal ideations (AOR = 1.79; 95% CI, 1.49-2.15). Some panic symptoms, most notably catastrophic cognitions (fear of dying and fear of "losing control" or "going insane"), were more strongly and specifically associated with suicide attempt (AORs = 2.13-2.95), while others were more related to suicidal ideation. CONCLUSIONS: Panic attacks appear to be an independent risk factor for suicide attempt among depressed individuals with and without suicidal ideation. Further, panic attacks, particularly those characterized by prominent catastrophic cognitions, may mediate the transition from suicidal ideations to suicide attempts in subjects with depressive episodes. Assessment of these symptoms may improve prediction of suicide attempts in clinical settings.