Characterizing the spiking dynamics of subthalamic nucleus neurons in Parkinson's disease using generalized linear models

Accurately describing the spiking patterns of neurons in the subthalamic nucleus (STN) of patients suffering from Parkinson's disease (PD) is important for understanding the pathogenesis of the disease and for achieving the maximum therapeutic benefit from deep brain stimulation (DBS). We analyze the spiking activity of 24 subthalamic neurons recorded in Parkinson's patients during a directed hand movement task by using a point process generalized linear model (GLM). The model relates each neuron's spiking probability simultaneously to factors associated with movement planning and execution, directional selectivity, refractoriness, bursting, and oscillatory dynamics. The model indicated that while short-term history dependence related to refractoriness and bursting are most informative in predicting spiking activity, nearly all of the neurons analyzed have a structured pattern of long-term history dependence such that the spiking probability was reduced 20–30 ms and then increased 30–60 ms after a previous spike. This suggests that the previously described oscillatory firing of neurons in the STN of Parkinson's patients during volitional movements is composed of a structured pattern of inhibition and excitation. This point process model provides a systematic framework for characterizing the dynamics of neuronal activity in STN

Community Impact and Benefit Activities of Critical Access, Other Rural, and Urban Hospitals, 2017

Non-profit and publicly-owned hospitals, including Critical Access Hospitals (CAHs), have obligations to address the health needs of their communities. Non-profit hospitals are required to report their community benefit activities to the Internal Revenue Service using Form 990, Schedule H. Community benefit activities include programs and services that provide treatment and/or promote health in response to identified community needs. Publicly-owned hospitals are also held accountable to the needs of their communities through the oversight of their governing boards and local governments. To monitor the community impact and benefit activities of CAHs and to understand whether and how their community impact and benefit profiles differ from those of other hospitals, we compared CAHs to other rural and urban hospitals using a set of indicators developed by the FMT. This report enables State Flex Programs and CAH administrators to compare the community impact and benefit profiles of CAHs nationally (Tables 1 and 2) to the performance of CAHs in their state (see links to state-specific tables on page 5). Table 1 provides data for select measures of community impact and benefit, including the provision of essential health care services that are typically difficult to access in rural communities. Table 2 provides data on hospital charity care, bad debt, and uncompensated care activities. The Flex Monitoring Team also produces state-specific reports with more detailed results

Reward and reinforcement activity in the nucleus accumbens during learning

The nucleus accumbens core (NAcc) has been implicated in learning associations between sensory cues and profitable motor responses. However, the precise mechanisms that underlie these functions remain unclear. We recorded single-neuron activity from the NAcc of primates trained to perform a visual-motor associative learning task. During learning, we found two distinct classes of NAcc neurons. The first class demonstrated progressive increases in firing rates at the go-cue, feedback/tone and reward epochs of the task, as novel associations were learned. This suggests that these neurons may play a role in the exploitation of rewarding behaviors. In contrast, the second class exhibited attenuated firing rates, but only at the reward epoch of the task. These findings suggest that some NAcc neurons play a role in reward-based reinforcement during learning

Non-stationary discharge patterns in motor cortex under subthalamic nucleus deep brain stimulation

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) directly modulates the basal ganglia (BG), but how such stimulation impacts the cortex upstream is largely unknown. There is evidence of cortical activation in 6-hydroxydopamine (OHDA)-lesioned rodents and facilitation of motor evoked potentials in Parkinson's disease (PD) patients, but the impact of the DBS settings on the cortical activity in normal vs. Parkinsonian conditions is still debated. We use point process models to analyze non-stationary activation patterns and inter-neuronal dependencies in the motor and sensory cortices of two non-human primates during STN DBS. These features are enhanced after treatment with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), which causes a consistent PD-like motor impairment, while high-frequency (HF) DBS (i.e., ≥100 Hz) strongly reduces the short-term patterns (period: 3–7 ms) both before and after MPTP treatment, and elicits a short-latency post-stimulus activation. Low-frequency DBS (i.e., ≤50 Hz), instead, has negligible effects on the non-stationary features. Finally, by using tools from the information theory [i.e., receiver operating characteristic (ROC) curve and information rate (IR)], we show that the predictive power of these models is dependent on the DBS settings, i.e., the probability of spiking of the cortical neurons (which is captured by the point process models) is significantly conditioned on the timely delivery of the DBS input. This dependency increases with the DBS frequency and is significantly larger for high- vs. low-frequency DBS. Overall, the selective suppression of non-stationary features and the increased modulation of the spike probability suggest that HF STN DBS enhances the neuronal activation in motor and sensory cortices, presumably because of reinforcement mechanisms, which perhaps involve the overlap between feedback antidromic and feed-forward orthodromic responses along the BG-thalamo-cortical loop

Winning versus losing during gambling and its neural correlates

Humans often make decisions which maximize an internal utility function. For example, humans often maximize their expected reward when gambling and this is considered as a "rational" decision. However, humans tend to change their betting strategies depending on how they "feel". If someone has experienced a losing streak, they may "feel" that they are more likely to win on the next hand even though the odds of the game have not changed. That is, their decisions are driven by their emotional state. In this paper, we investigate how the human brain responds to wins and losses during gambling. Using a combination of local field potential recordings in human subjects performing a financial decision-making task, spectral analyses, and non-parametric cluster statistics, we investigated whether neural responses in different cognitive and limbic brain areas differ between wins and losses after decisions are made. In eleven subjects, the neural activity modulated significantly between win and loss trials in one brain region: the anterior insula ($p=0.01$). In particular, gamma activity (30-70 Hz) increased in the anterior insula when subjects just realized that they won. Modulation of metabolic activity in the anterior insula has been observed previously in functional magnetic resonance imaging studies during decision making and when emotions are elicited. However, our study is able to characterize temporal dynamics of electrical activity in this brain region at the millisecond resolution while decisions are made and after outcomes are revealed

Adoption and Use of Electronic Health Records by Rural Health Clinics: Results of a National Survey [Working Paper]

Rural Health Clinics (RHCs) are a vital source of primary care services with more than 4,000 clinics serving rural communities. Relatively little is known about the extent to which RHCs have adopted and are using electronic health records (EHRs) to support clinical services. Because EHR adoption is an essential element for inclusion in accountable care organizations, patient centered medical homes, and health plan provider networks offered on state and national health insurance marketplaces, EHR implementation will be increasingly important to RHCs if they are to remain competitive participants in the evolving healthcare market. Key Findings: Nearly 72 percent of Rural Health Clinics (RHCs) have an operational electronic health record (EHR), with 63 percent indicating use by 90 percent or more of their staff. Slightly over 17 percent of RHCs without an EHR plan to implement one within six months, and 27 percent plan to do so within seven to twelve months. Common barriers to EHR implementation include acquisition and maintenance costs (72 percent), lack of capital (51 percent), and concerns about productivity and income loss during implementation (45 percent). RHCs continue to lag on some meaningful use measures, but perform well on measures related to clinical care and patient management. With Regional Extension Centers facing the loss of federal funding it is important to identify additional resources to assist RHCs in maximizing EHR adoption and use

Rural Health Clinic Readiness for Patient-Centered Medical Home Recognition: Preparing for the Evolving Healthcare Marketplace [Working Paper]

The patient-centered medical home (PCMH) model reaffirms traditional primary care values including continuity of care, connection with an identified personal clinician, provision of same day- and after-hours access, and positions providers to participate in accountable care and other financing and delivery system models. However, little is known about the readiness of the over 4,000 Rural Health Clinics (RHCs) to meet the PCMH Recognition standards established by the National Council for Quality Assurance (NCQA). The authors present findings from a survey of RHCs that examined their capacity to meet the NCQA PCMH requirements, and discuss the implications of the findings for efforts to support RHC capacity development. Key Findings: Based on their performance on the “must pass” elements and related key factors, Rural Health Clinics (RHCs) are likely to have difficulties gaining National Center for Quality Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) Recognition. RHCs perform best on standards related to recording demographic information and managing clinical activities, particularly for those using an electronic health record. RHCs perform less well on improving access to and continuity of services, supporting patient self-management skills and shared decision-making, implementing continuous quality improvement systems, and building practice teams. RHCs are likely to need substantial technical assistance targeting clinical and operational performance to gain NCQA PCMH Recognition

Meaningful Use of Electronic Health Record by Rural Health Clinics [Policy Brief]

Little information is available on the rate of Electronic Health Record (EHR) adoption by Rural Health Clinics. (RHCs). This study was conducted to identify the rates of EHR adoption among a national random sample of RHCs and the extent to which RHCs that have adopted an EHR are likely to achieve Stage 1 meaningful use. To achieve Stage 1 meaningful use and qualify for meaningful use incentive payments, eligible health professionals must, at a minimum, meet CMS defined criteria for the required 14 core measures. Fifty-nine percent of RHCs report having an EHR, and independent RHCs were more likely than hospital-based RHCs to have an EHR. Common barriers to EHR adoption by RCHs include acquisition and maintenance costs, lack of capital, and potential productivity or income loss during transition

Rural Health Clinic Participation in the Merit-Based Incentive System and Other Quality Reporting Initiatives: Challenges and Opportunities

Rural Health Clinics (RHCs) are an important source of primary care in underserved rural communities with more than 4,200 RHCs providing primary care services to rural Medicare and Medicaid beneficiaries in 44 states. In light of the growing emphasis on quality reporting, it is important to understand factors influencing RHC readiness to participate in quality reporting including the Merit-Based Incentive Payment System (MIPS), Medicaid, and commercial payer quality reporting programs. The exclusion of RHCs from CMS’s quality reporting programs and value-based initiatives may potentially create a perception among consumers and policymakers that RHCs are unable to meet the requirements of these initiatives and are providing lesser quality care than larger, urban-based clinicians. To inform this brief, we conducted an extensive review of the MACRA legislation and regulations, literature on RHC quality reporting and CMS RHC billing manuals, advisory and consulting reports, and monitored listservs relevant to the topic. Additionally, we conducted key informant interviews with national and state organizations associated with RHCs. This brief outlines several challenges faced by RHCs to engage in quality reporting initiatives and highlights the opportunities to support their participation in these initiatives