Effects of electroconvulsive therapy on cortical thickness in depression: a systematic review.

OBJECTIVE: Electroconvulsive therapy (ECT) is one of the most studied and validated available treatments for severe or treatment-resistant depression. However, little is known about the neural mechanisms underlying ECT. This systematic review aims to critically review all structural magnetic resonance imaging studies investigating longitudinal cortical thickness (CT) changes after ECT in patients with unipolar or bipolar depression. METHODS: We performed a search on PubMed, Medline, and Embase to identify all available studies published before April 20, 2023. A total of 10 studies were included. RESULTS: The investigations showed widespread increases in CT after ECT in depressed patients, involving mainly the temporal, insular, and frontal regions. In five studies, CT increases in a non-overlapping set of brain areas correlated with the clinical efficacy of ECT. The small sample size, heterogeneity in terms of populations, comorbidities, and ECT protocols, and the lack of a control group in some investigations limit the generalisability of the results. CONCLUSIONS: Our findings support the idea that ECT can increase CT in patients with unipolar and bipolar depression. It remains unclear whether these changes are related to the clinical response. Future larger studies with longer follow-up are warranted to thoroughly address the potential role of CT as a biomarker of clinical response after ECT.

Chrono-Nutritional Patterns, Medical Comorbidities, and Psychological Status in Patients with Severe Obesity.

Chrono-nutrition studies dietary habits and their role in the onset of metabolic diseases. The aim of this study is to describe chrono-nutritional patterns based on the analysis of the eating habits of patients with severe obesity during the 24-h cycle and investigate a possible relationship between these profiles, the comorbidities, and the psychological status. From the overall evaluation of the chrono-nutritional profiles of 173 patients with severe obesity, four predominant eating patterns were obtained with a refined statistical model. A regression analysis was performed to determine the relationship between chrono-nutritional patterns, medical comorbidities, and psychological status. Profile 1 was the most frequent (46.2%) and characterised by the regular presence of the three main meals. The distribution of the chrono-nutritional profiles did not vary with BMI. Chrono-nutritional profiles affected predominantly psychological variables, with lower performances among chrono-nutritional profiles 3 (to eat during all the 24-h, with nibbling and snacking also during the night) and 4 (like the fourth but without night-eating). This finding could be useful in the assessment and treatment of patients with obesity, allowing the identification of patients with a higher probability of suffering from a psychopathological condition simply by knowing the patients' dietary profiles.

Expectancy to Eat Modulates Cognitive Control and Attention Toward Irrelevant Food and Non-food Images in Healthy Starving Individuals. A Behavioral Study.

It is thought that just as hunger itself, the expectancy to eat impacts attention and cognitive control toward food stimuli, but this theory has not been extensively explored at a behavioral level. In order to study the effect of expectancy to eat on attentional and cognitive control mechanisms, 63 healthy fasting participants were presented with an affective priming spatial compatibility Simon task that included both food and object (non-food) distracters. The participants (N = 63) were randomly assigned to two groups: an "immediate expectancy" group made up of participants who expected to eat immediately after the task (N = 31; females = 21; age = 26.8 ± 9.6) and a "delayed expectancy" cohort made up of individuals who expected to eat a few hours later (N = 32; females = 21; age = 25.0 ± 8.0). Slower reaction times (RTs) toward the food and non-food distracters and a more pronounced effect on the RTs in the incompatible condition [i.e., the Simon effect (SE)] were noted in both groups. The effect of the food and non-food distracters on the RTs was more pronounced in the immediate with respect to the delayed expectancy group. The magnitude of the SE for the food and the non-food distracters was also greater in the immediate with respect to the delayed expectancy group. These results seem to indicate that when the expectancy to eat is short, the RTs are delayed, and the SE is more pronounced when food and non-food distracters are presented. Instead, when the expectancy to eat is more distant, the distracters have less of an effect on the RTs and the correspondence effect is smaller. Our results suggest that the expectancy to eat can modulate both attention orienting and cognitive control mechanisms in healthy fasting individuals when distracting details are competing with information processing during goal directed behavior.

The effect of age, educational level, gender and cognitive reserve on visuospatial working memory performance across adult life span.

Working memory (WM) is a limited capacity cognitive system that temporarily holds information for processing. In the present study, we tested the effect of age, gender and cognitive reserve in terms of educational level, working and leisure time activities on an active visuospatial WM task. One-hundred thirty-four participants between 20 and 80 years old performed an n-back task with different degree of WM demanding. Reaction times (RTs) became slower and accuracy decreased with age; the former started to decline in participants that were 35 years old, the latter in participants that were 57 years old. Males were faster than females. Educational level (10 years in accuracy and 15 years in RTs) showed a positive effect on accuracy and RTs. Cognitive reserve had a positive effect on accuracy but no effect on RTs. In conclusion, age-related decline influenced earlier the speed and later the accuracy in a task that required active processes. While male was faster independently of WM demanding and age, middle school degree and an average cognitive reserve prevent errors during performance. Coherently, high school degree prevents slowing down but only in low demanding condition.

Psychological predictors of poor weight loss following LSG: relevance of general psychopathology and impulsivity.

PURPOSE: After bariatric surgery (BS) a significant minority of patients do not reach successful weight loss or tend to regain weight. In recent years, interest for the psychological factors that predict post-surgical weight loss has increased with the objective of developing interventions aimed to ameliorate post-surgical outcomes. In the present study, predictive models of successful or poor weight loss 12 months after BS were investigated considering pre-surgery level of psychopathological symptoms, dysfunctional eating behaviors and trait impulsivity at baseline (pre-surgery). METHODS: Sixty-nine patients with morbid obesity canditates for laparoscopic sleeve gastrectomy were assessed regarding metabolic and psychological dimensions. Successful post-surgery weight loss was defined as losing at least 50% of excess body weight (%EWL). RESULTS: Logistic models adjusted for patient sex, age and presence of metabolic diseases showed that the baseline presence of intense psychopathological symptoms and low attentional impulsivity predict poor %EWL (< 50%), as assessed 12-month post-surgery. CONCLUSIONS: The present findings suggest that intensity of general psychopathology and impulsivity, among other psychological factors, might affect post-surgery %EWL. Conducting adequate psychological assessment at baseline of patients candidates for BS seems to be crucial to orient specific therapeutic interventions. LEVEL OF EVIDENCE: Level III, case-control analytic study.

ERP correlates of cognitive control and food-related processing in normal weight and severely obese candidates for bariatric surgery: Data gathered using a newly designed Simon task.

Although there have been suggestions that altered cognitive control and food reward sensitivity contribute to overeating in obese individuals, neurophysiological correlates of these mechanisms have been poorly investigated. The current study investigated event-related potentials (ERP) in 24 severely obese and 26 normal weight individuals in fasting condition, using a novel Simon task with food and object distractors. The study showed that conflict in the Simon task for the food distractor increased with hunger in both groups but was larger with respect to a neutral condition only in the obese individuals. ERP showed higher N1amplitudes in both groups for food distractor, reflecting early food processing. The P2 latency was delayed and the effect of distractors on N2 amplitude was smaller in the obese subjects, reflecting altered neural mechanisms associated with selective attention and cognitive control, all contributing hypothetically to delay response selection of these individuals faced with food distractor.

Impaired cognitive processing speed in type 1 diabetic patients who had severe/recurrent hypoglycaemia.

AIMS: To detect whether adults with type 1 diabetes mellitus (T1DM) have lower cognitive performance than healthy individuals and to detect risk factors for low cognitive performance. METHODS: Twenty-six adults with T1DM and twenty-six healthy subjects matched for age, gender and educational level were compared for cognitive performance by a chronometric computerized test measuring visuo-spatial working memory (N-Back) and by two validated neuropsychological tests (Mini Mental State Examination, Animal Naming Test). Clinical data about diabetes duration, average daily insulin dosage, glycated haemoglobin, retinopathy, urine albumin-creatinine ratio, previous hypoglycaemic coma and awareness of hypoglycaemia were obtained from medical records. Basal pre-test glycemia and blood pressure were measured for each patient. RESULTS: No differences were found between patients (n = 26) and healthy controls (n = 26) in neuropsychological tests. Within diabetic patients, those with impaired awareness of hypoglycaemia (n = 7) or history of coma in the recent 1-3 years (n = 5) had psychomotor slowing at the N-Back test (592 ±â€¯35 vs. 452 ±â€¯21 ms and 619 ±â€¯40 vs. 462 ±â€¯19 ms, respectively; both p < 0.01). The variables related to diabetic severity did not show a relationship with reaction times of the N-Back test. CONCLUSION: Psychomotor speed slowing is detectable in patients with T1DM who have a history of previous hypoglycaemic episodes or coma.

Discrimination and externalizing problems among Moroccan- and Romanian-origin early adolescents in Italy: Moderating role of cultural orientations and impulse control.

OBJECTIVE: Although discrimination is a common stressor in the everyday life of immigrant youth, individuals are not equally susceptible to its adverse effects. This cross-sectional study aimed to examine whether cultural orientation preferences and impulse control (IC) moderate the association between perceived discrimination and externalizing problems among Moroccan- and Romanian-origin early adolescents in Italy. METHOD: The sample included 126 Moroccan and 126 Romanian youths (46% girls, 42% first-generation) aged 11-13 years and their parents. Perceived discrimination and cultural orientations were assessed using self-report questionnaires, while IC was evaluated via a computerized version of the Iowa Gambling Task. Externalizing behaviors were assessed via parental report. RESULTS: Cluster analysis identified separated, assimilated, and integrated early adolescents. Regression analyses revealed that when facing discrimination, youths who endorsed separation and exhibited low levels of IC were more vulnerable to externalizing problems. In contrast, among assimilated adolescents the discrimination-externalizing difficulties link was significant at high levels of IC. Furthermore, low levels of IC were associated with more externalizing problems for Romanian, but not for Moroccan early adolescents. CONCLUSIONS: Findings underscore the need to consider both cultural orientation processes and early adolescents' ability to control their impulses when developing interventions aimed to reduce discrimination-related problem behaviors in immigrant youth. Implications for theory and practice are discussed. (PsycINFO Database Record

Cognitive reserve is a resilience factor for cognitive dysfunction in hepatic encephalopathy.

Cognitive Reserve (CR) modulates symptoms of brain disease. The aim of this study was: to evaluate the effect of CR on cognition in cirrhosis and on the mismatch between cognitive and neurophysiologic assessment of hepatic encephalopathy (HE). Eighty-two outpatient patients with cirrhosis without overt HE were studied [73% males; age: 62 (54-68) (median, interq. range) yrs.; education: 8 (6-13) yrs.]. The Psychometric Hepatic Encephalopathy Score (PHES) was used as cognitive measure of HE. The spectral analysis of the electroencephalogram (EEG) was used as neurophysiologic measure of HE. The CR was assessed by the CR Index (CRI), which was measured by the CRI questionnaire (CRIq) ( http://cri.psy.unipd.it ). The PHES was altered in 28% of patients and the EEG in 41%. Altered PHES was related to the severity of cirrhosis as assessed by Child-Pugh classification (R = 0.31, p < 0.005). Patients with maintained PHES had higher CRI than those with altered PHES (CRI = 100 ± 20 vs. 88 ± 12 vs., p < 0.01), but not the ones with normal EEG compared to those with abnormal EEG (CRI = 96 ± 17 vs. 98 ± 17 vs. p: n.s.).The PHES, but not the EEG, was found to be related to the CRI (r = 0.35, p < 0.01). The mismatch between cognitive and neurophysiologic evaluation of non-overt HE (the ratio between PHES and the mean dominant frequency -MDF- of the EEG i.e., cognitive performance normalized by EEG speed) was found to be correlated to the CRI (r = 0.36, p < 0.005). CR is a resilience factor for cognitive dysfunction in cirrhosis, and is easily measurable by CRIq.

Food allergy and attitudes to close interpersonal relationships: An exploratory study on attachment.

BACKGROUND: Food allergy is a common immunologic disease that includes potentially fatal reactions. It impacts considerably on patients' social life including close interpersonal relationships. Attachment theory provides a theoretic framework to evaluate the quality of close interpersonal relationships in chronic disorders. Attachment insecurity, mainly characterized by attachment avoidance, has been found in a variety of health conditions, but still needs to be investigated in food allergy. The study aimed to investigate attachment, as attitude to close interpersonal relationships, among food-allergic young patients, compared to healthy controls. METHODS: This is a cross-sectional study involving patients suffering from IgE-mediated food allergy sequentially recruited and matched to healthy controls for age and gender. The Attachment Style Questionnaire (ASQ) was used to assess five factors and two attachment dimensions (Anxiety-Avoidance). Associations with anaphylaxis and adrenaline prescription were explored among patients. RESULTS: 174 participants were assessed (female=45%; mean age=17.51; SD=4.26). Food-allergic patients reported significantly higher levels of Discomfort with Closeness (P<.05), Relationships as Secondary (P<.05) and Attachment Avoidance (P<.0001) compared to controls. CONCLUSIONS: Clinicians should be aware of implications of insecure attachment for health and illness. They should support patients in limiting social impairment finding a balance between safety and psychologic well-being.

The animal naming test: An easy tool for the assessment of hepatic encephalopathy.

Screening for hepatic encephalopathy (HE) that does not cause obvious disorientation or asterixis (minimal HE [MHE]/grade 1 HE) is important. We examined if the animal naming test (ANT1 ) (maximum number of animals listed in 1 minute) is useful in this context. In total, 208 healthy controls, 40 controls with inflammatory bowel disease, and 327 consecutive patients with cirrhosis underwent the ANT1 . Patients were tested for MHE by the psychometric HE score, and 146 were assessed by electroencephalography; 202 patients were followed up regarding the occurrence of overt HE and death. In the healthy controls, ANT1 was influenced by limited education (<8 years) and advanced age (>80 years, P < 0.001). Using an age and education adjusting procedure, the simplified ANT1 (S-ANT1 ) was obtained. An S-ANT1 of <10 animals was abnormal. Of the patients, 169 were considered unimpaired, 32 as having HE ≥grade 2, and 126 as having MHE/grade 1 HE. This group had lower S-ANT1 than unimpaired patients (12 ± 0.4 versus 16 ± 0.7, P < 0.001) and higher S-ANT1 than those with HE ≥grade 2 (4 ± 0.9). In grade 1 HE the S-ANT1 was lower than in MHE. Following receiver operating characteristic analysis (Youden's index), 15 animals produced the best discrimination between unimpaired and MHE/grade 1 HE patients. Thus, a three-level score (0 for S-ANT1 ≥15, 1 for 10 ≤ S-ANT1 < 15, 2 for S-ANT1 <10) was obtained. This score was correlated both to the psychometric HE score (P < 0.0001) and to electroencephalography (P = 0.007). By sample random split validation, both S-ANT1 and its three-level score showed prognostic value regarding the 1-year risk of overt HE and death. No inflammatory bowel disease control had S-ANT <15. CONCLUSION: The S-ANT1 is an easily obtainable measure useful for the assessment of HE. (Hepatology 2017;66:198-208).

Aging and risky decision-making: New ERP evidence from the Iowa Gambling Task.

Several pieces of evidence have highlighted the presence of an age-related decline in risky decision-making (DM), but the reason of this decline is still unclear. The aim of the present study was to investigate the neural correlates of feedback processing in risky DM. Twenty-one younger (age <50 years) and 15 older (age >50 years) adults were tested with the Iowa Gambling Task (IGT) during Event Related Potentials (ERP) recording. The analysis was focused on the feedback-related negativity (FRN) and P3, two ERP components that represent different stages of feedback processing. Behavioral results revealed that older adults, despite showing a significant learning trend, completed the IGT with a gain of a smaller amount of money compared to the younger ones. ERP results revealed that while the FRN response was comparable in the two groups, the P3 amplitude was significantly reduced after negative feedback in older adults, compared with the younger ones. Furthermore, the difference in the P3 amplitude evoked by positive and negative feedback was significantly correlated with age. Hence, the present findings suggest that older adults seem to be less willing to shift attention from positive to negative information, and that this relevant change in the later stages of feedback processing could be the cause of a poor performance in risky DM contexts.

Dopaminergic Medication Modulates Learning from Feedback and Error-Related Negativity in Parkinson's Disease: A Pilot Study.

Dopamine systems mediate key aspects of reward learning. Parkinson's disease (PD) represents a valuable model to study reward mechanisms because both the disease process and the anti-Parkinson medications influence dopamine neurotransmission. The aim of this pilot study was to investigate whether the level of levodopa differently modulates learning from positive and negative feedback and its electrophysiological correlate, the error related negativity (ERN), in PD. Ten PD patients and ten healthy participants performed a two-stage reinforcement learning task. In the Learning Phase, they had to learn the correct stimulus within a stimulus pair on the basis of a probabilistic positive or negative feedback. Three sets of stimulus pairs were used. In the Testing Phase, the participants were tested with novel combinations of the stimuli previously experienced to evaluate whether they learned more from positive or negative feedback. PD patients performed the task both ON- and OFF-levodopa in two separate sessions while they remained on stable therapy with dopamine agonists. The electroencephalogram (EEG) was recorded during the task. PD patients were less accurate in negative than positive learning both OFF- and ON-levodopa. In the OFF-levodopa state they were less accurate than controls in negative learning. PD patients had a smaller ERN amplitude OFF- than ON-levodopa only in negative learning. In the OFF-levodopa state they had a smaller ERN amplitude than controls in negative learning. We hypothesize that high tonic dopaminergic stimulation due to the dopamine agonist medication, combined to the low level of phasic dopamine due to the OFF-levodopa state, could prevent phasic "dopamine dips" indicated by the ERN needed for learning from negative feedback.

A low-cost, user-friendly electroencephalographic recording system for the assessment of hepatic encephalopathy.

UNLABELLED: Electroencephalography (EEG) is useful to objectively diagnose/grade hepatic encephalopathy (HE) across its spectrum of severity. However, it requires expensive equipment, and hepatogastroenterologists are generally unfamiliar with its acquisition/interpretation. Recent technological advances have led to the development of low-cost, user-friendly EEG systems, allowing EEG acquisition also in settings with limited neurophysiological experience. The aim of this study was to assess the relationship between EEG parameters obtained from a standard-EEG system and from a commercial, low-cost wireless headset (light-EEG) in patients with cirrhosis and varying degrees of HE. Seventy-two patients (58 males, 61 ± 9 years) underwent clinical evaluation, the Psychometric Hepatic Encephalopathy Score (PHES), and EEG recording with both systems. Automated EEG parameters were calculated on two derivations. Strong correlations were observed between automated parameters obtained from the two EEG systems. Bland and Altman analysis indicated that the two systems provided comparable automated parameters, and agreement between classifications (normal versus abnormal EEG) based on standard-EEG and light-EEG was good (0.6 < κ < 0.8). Automated parameters such as the mean dominant frequency obtained from the light-EEG correlated significantly with the Model for End-Stage Liver Disease score (r = -0.39, P < 0.05), fasting venous ammonia levels (r = -0.41, P < 0.01), and PHES (r = -0.49, P < 0.001). Finally, significant differences in light-EEG parameters were observed in patients with varying degrees of HE. CONCLUSION: Reliable EEG parameters for HE diagnosing/grading can be obtained from a cheap, commercial, wireless headset; this may lead to more widespread use of this patient-independent tool both in routine liver practice and in the research setting. (

Qualifying and quantifying minimal hepatic encephalopathy.

Minimal hepatic encephalopathy is the term applied to the neuropsychiatric status of patients with cirrhosis who are unimpaired on clinical examination but show alterations in neuropsychological tests exploring psychomotor speed/executive function and/or in neurophysiological variables. There is no gold standard for the diagnosis of this syndrome. As these patients have, by definition, no recognizable clinical features of brain dysfunction, the primary prerequisite for the diagnosis is careful exclusion of clinical symptoms and signs. A large number of psychometric tests/test systems have been evaluated in this patient group. Of these the best known and validated is the Portal Systemic Hepatic Encephalopathy Score (PHES) derived from a test battery of five paper and pencil tests; normative reference data are available in several countries. The electroencephalogram (EEG) has been used to diagnose hepatic encephalopathy since the 1950s but, once popular, the technology is not as accessible now as it once was. The performance characteristics of the EEG are critically dependent on the type of analysis undertaken; spectral analysis has better performance characteristics than visual analysis; evolving analytical techniques may provide better diagnostic information while the advent of portable wireless headsets may facilitate more widespread use. A large number of other diagnostic tools have been validated for the diagnosis of minimal hepatic encephalopathy including Critical Flicker Frequency, the Inhibitory Control Test, the Stroop test, the Scan package and the Continuous Reaction Time; each has its pros and cons; strengths and weaknesses; protagonists and detractors. Recent AASLD/EASL Practice Guidelines suggest that the diagnosis of minimal hepatic encephalopathy should be based on the PHES test together with one of the validated alternative techniques or the EEG. Minimal hepatic encephalopathy has a detrimental effect on the well-being of patients and their care-givers. It responds well to treatment with resolution of test abnormalities and the associated detrimental effects on quality of life, liver-related mortality and morbidity. Patients will only benefit in this way if they can be effectively diagnosed. Corporate efforts and consensus agreements are needed to develop effective diagnostic algorithms.

Impulsivity toward food reward is related to BMI: Evidence from intertemporal choice in obese and normal-weight individuals.

Obesity is a medical condition frequently associated with psychopathological symptoms and neurocognitive and/or personality traits related to impulsivity. Impulsivity during intertemporal choices seems to be typical of obese individuals. However, so far, the specific relationship between different types of reward and neuropsychological and psychopathological profile are yet to be unravelled. Here, we investigated impulsive choice for primary and secondary reward in obese individuals and normal-weight controls with comparable neuropsychological and psychopathological status. Participants performed three intertemporal choice tasks involving food, money, and discount voucher, respectively. Moreover, they completed a battery of neuropsychological tests and psychometric questionnaires assessing psychopathological state, impulsivity, and personality traits. Obese individuals showed increased preference for immediate food reward compared with controls, whereas no group difference emerged concerning money and discount voucher. Moreover, the higher the body mass index (BMI), the steeper the food discounting. These findings emerged in light of comparable neuropsychological and psychopathological profile between groups. Steeper food discounting in obese individuals appears to be related to BMI but not to psychopathological and neuropsychological profile. We suggest using intertemporal choice in the clinical practice as measure of the effectiveness of different types of intervention (e.g., educational, psychological, pharmacological or surgical) aimed at reducing impulsivity toward food and increasing cognitive control during food intake in obese individuals.

Motivation-cognition interaction: how feedback processing changes in healthy ageing and in Parkinson's disease.

BACKGROUND: Several studies have investigated the interaction between motivation and cognition in both young and older adults, but with inconsistent results. A recent hypothesis suggests exploring the role of dopamine to study this interaction. AIMS: To explore how different motivational states can modulate cognitive control, as well as investigate the hypothesis of a dopaminergic role in this phenomenon. METHODS: 27 young subjects, 15 healthy old subjects, and 15 Parkinson's disease (PD) patients took part in this study. The motivational Simon task-a new paradigm in which rewards and punishments are delivered to promote fast and accurate responses-was employed. The participants' performance was evaluated by analysing their reaction times and accuracy, while employing a diffusion model analysis. RESULTS: The employment of positive and negative feedback significantly modulated performance in a conflict task. In both, the young and older participants, the speed-accuracy trade-off significantly changed in response to different motivational incentives (p < .005), although in opposite ways. On the contrary, PD patients showed an absence of performance modulation in response to positive and negative feedback. DISCUSSION AND CONCLUSIONS: In normal conditions, motivation interacts with cognitive control to modulate decisional aspects of a response in a conflict task. The elderly modulate their performance in response to positive and negative feedback differently from young adults, showing a classical positivity effect. The impairment manifested by PD patients, which is compatible with the literature about feedback processing deficits in this clinical condition, can support the hypothesis that the interaction between motivation and cognitive control is mediated by dopaminergic functionality.

A Model for Predicting Development of Overt Hepatic Encephalopathy in Patients With Cirrhosis.

BACKGROUND & AIMS: Overt hepatic encephalopathy (HE) affects patients' quantity and quality of life and places a burden on families. There is evidence that overt HE might be prevented pharmacologically, but prophylaxis would be justified and cost effective only for patients at risk. We aimed to identify patients with cirrhosis at risk for overt HE. METHODS: We collected data from October 2009 through December 2012 for 216 consecutive patients with cirrhosis (based on liver biopsy, 96 patients with minimal HE), admitted to the Gastroenterology Unit at the University of Rome. Patients were followed up and evaluated for an average of 14.7 ± 11.6 months; development of overt HE was recorded. We analyzed end-stage liver disease scores, shunt placement, previous overt or minimal HE, psychometric hepatic encephalopathy score (PHES), and levels of albumin, bilirubin, creatinine, and sodium to develop a prediction model. We validated the model in 112 patients with cirrhosis seen at the University of Padua and followed up for 12 ± 9.5 months. RESULTS: During the follow-up period, 68 patients (32%) developed at least 1 episode of overt HE. Based on multivariate analysis, the development of overt HE was associated with previous HE, minimal HE (based on PHES), and level of albumin less than 3.5 g/dL (area under curve [AUC], 0.74). A model that excluded minimal HE but included albumin level and previous HE also identified patients who would develop overt HE (AUC, 0.71); this difference in AUC values was not statistically significant (P = .104). Both models were validated in the independent group of patients (3 variables: AUC, 0.74; 95% confidence interval, 0.66-0.83; and 2 variables: AUC, 0.71; 95% confidence interval, 0.63-0.78). CONCLUSIONS: We developed and validated a model to identify patients with cirrhosis at risk for overt HE based on previous HE, albumin levels, and PHES. If PHES was not available, previous HE and albumin levels still can identify patients at risk. Psychometric evaluation is essential for patients with no history of HE. These findings should aid in planning studies of pharmacologic prevention of overt HE.

Confounders in the detection of minimal hepatic encephalopathy: a neuropsychological and quantified EEG study.

BACKGROUND & AIMS: Chronic alcohol misuse, HCV infection and cirrhosis may cause cognitive alterations. The aim of the present study was to assess the influence of alcohol misuse, HCV infection and cirrhosis per se on the neuropsychological and electroencephalogram (EEG) profile and to evaluate the role of alcohol misuse and HCV infections as potential confounding factors in the detection of minimal hepatic encephalopathy. METHODS: A comprehensive neuropsychological profile and EEG spectral parameters were obtained in six age-matched groups of 30 subjects each: (i) HCV-related hepatitis without cirrhosis, (ii) chronic alcohol abusers, (iii) patients with HCV-related cirrhosis, (iv) alcohol-related cirrhosis, (v) cirrhosis not related to alcohol or HCV and (vi) healthy subjects. Cirrhotic patients were matched for MELD score. RESULTS: The factor 'cirrhosis' was associated with low Phonemic Verbal Fluency (PVF) and Difference between Trail Making Test B and A (TMT) (B-A) (P < 0.001). Chronic alcohol misuse was associated with low PVF, TMT (B-A), Memory with Interference Task at 10 (ITM 10) and 30 s (ITM 30) (all P < 0.05). An interaction was found between the factors 'cirrhosis', 'alcohol misuse' and tests (P < 0.01). HCV hepatitis reduced ITM 10 (P < 0.05), but no interaction was found between 'cirrhosis', 'HCV infection' and tests (P = 0.14). The EEG parameters were mainly influenced by 'cirrhosis' (P < 0.05), and EEG alterations were more pronounced in patients with alcoholic cirrhosis (P = 0.04). CONCLUSIONS: Cirrhosis per se, chronic alcohol misuse and HCV infection were found to be associated with cognitive dysfunction. In patients with cirrhosis, the interaction with alcohol misuse further impinged on brain dysfunction.

A transcranial magnetic stimulation study on response activation and selection in spatial conflict.

In choice reaction tasks, subjects typically respond faster when the relative spatial positions of stimulus and response correspond than when they do not, even when spatial information is irrelevant to the task (e.g. in the Simon task). Cognitive models attribute the Simon effect to automatic response activation elicited by spatial information, which facilitates or competes with the controlled selection of the correct response as required by task demands. In the present study, we investigated the role of the dorsal premotor cortex (PMd) in response activation and selection during spatial conflict. We applied single-pulse transcranial magnetic stimulation (TMS) to the PMd of the right and left hemispheres during the execution of a Simon task, at different times after the onset of the visual stimulus. The results showed that TMS produced a different effect on subjects' performance in two separate time windows. When TMS was applied at an early time [160-ms stimulus onset asynchrony (SOA)], we observed suppression of the Simon effect, resulting from a delay of corresponding trials. When TMS was applied at a late time (220 and 250-ms SOA), we observed an increase in the Simon effect, resulting from a delay of non-corresponding trials. These outcomes revealed that the PMd is involved both in the activation of the spatially triggered response and in response selection during spatial conflict.