Safety and feasibility of establishing an adjuvant hepatic artery infusion program.

BACKGROUND: Hepatic artery infusion (HAI) is less frequently used in the adjuvant setting for resectable colorectal liver metastasis (CRLM) due to concerns regarding toxicity. Our objective was to evaluate the safety and feasibility of establishing an adjuvant HAI program. METHODS: Patients who underwent HAI pump placement between January 2019 and February 2023 for CRLM were identified. Complications and HAI delivery were compared between patients who received HAI in the unresectable and adjuvant settings. RESULTS: Of 51 patients, 23 received HAI for unresectable CRLM and 28 in the adjuvant setting. Patients with unresectable CRLM more commonly had bilobar disease (n = 23/23 vs n = 18/28, p < 0.01) and more preoperative liver metastases (median 10 [IQR 6-15] vs 4 [IQR 3-7], p < 0.01). Biliary sclerosis was the most common complication (n = 2/23 vs n = 4/28); however, there were no differences in postoperative or HAI-specific complications. In the most recent two years, 0 patients in the unresectable group vs 2 patients in the adjuvant group developed biliary sclerosis. All patients were initiated on HAI with no difference in treatment times or dose reductions. CONCLUSION: Adjuvant HAI is safe and feasible for patients with resectable CRLM. HAI programs can carefully consider including patients with resectable CRLM if managed by an experienced multidisciplinary team with quality assurance controls in place.

Age effects on category learning, categorical perception, and generalization.

Age deficits in memory for individual episodes are well established. Less is known about how age affects another key memory function: the ability to form new conceptual knowledge. Here we studied age differences in concept formation in a category-learning paradigm with face-blend stimuli, using several metrics: direct learning of category members presented during training, generalisation of category labels to new examples, and shifts in perceived similarity between category members that often follow category learning. We found that older adults were impaired in direct learning of training examples, but that there was no significant age deficit in generalisation once we accounted for the deficit in direct learning. We also found that category learning affected the perceived similarity between members of the same versus opposing categories, and age did not significantly moderate this effect. Lastly, we compared traditional category learning to categorisation after a learning task in which a category label (shared last name) was presented alongside stimulus-specific information (unique first names that individuated category members). We found that simultaneously learning stimulus-specific and category information resulted in decreased category learning, and that this decrement was apparent in both age groups.

Impact of Pharmacist Involvement on the Utility of a Gram-Negative Blood Culture Identification Panel on Antimicrobial Usage.

Background: A rapid molecular diagnostic test (MDT) is a test used to identify several different species of gram-negative bacteria and their genetic resistance markers. However, the impact of rapid MDT has not been established when combined with pharmacist involvement. Objective: To determine the impact of pharmacy involvement on patient outcomes when using rapid MDT. The primary outcome is the time from gram stain result to the first dose of the targeted antibiotic. Methods: This is a single-center, quasi-experimental, 1-group pretest-posttest design study of patients with gram-negative bacteremia in a community hospital. Hospitalized patients 18 years or older were included if they had a gram-negative blood culture. Patients were excluded if they were discharged or expired prior to culture results. Outcomes were compared between patients prior to and after implementation of the automated MDT. This research was determined to be exempt from institutional review board oversight consistent with West Florida Healthcare and in accordance with institutional policy. Results: The use of rapid MDT combined with pharmacist intervention resulted in a statistically significant decrease in the time to targeted antibiotic therapy (pre-intervention group, n = 77, 44.8 ± 17.8 hours versus post-intervention group, n= 80, 4.4 ± 5.8 hours; P ≤.001). There was no significant difference found between secondary outcomes. Limitations included small sample size as well as inconsistent documentation. Conclusions: The use of rapid MDT combined with pharmacist intervention resulted in a statistically significant decrease in the time to targeted antibiotic therapy.

Sensory Representations Supporting Memory Specificity: Age Effects on Behavioral and Neural Discriminability.

Older adults' difficulty in distinguishing between old and new information contributes to memory decline, which may occur because older adults are less likely than young adults to retrieve specific sensory details necessary to distinguish between similar items. In male and female human subjects, the present study measured the extent of age differences in the specificity of memory representations using a false memory paradigm in which studied items were linked to retrieval items at multiple levels of similarity. Older adults showed poorer behavioral discrimination than young adults, driven primarily by false recognition of lures that differed from targets only in perceptual details. Patterns of activation across several regions within ventral visual cortex could be used to distinguish between targets and lures when they differed in both perceptual details and a semantic label. However, of ventral visual regions, only signals in the midline occipital cortex could be used to distinguish targets from lures when they differed only in perceptual details. Although there was an overall age deficit for this neural discrimination in this region, the positive relationship between neural and behavioral discriminability did not differ across age groups. In contrast, age moderated the relationship between neural and behavioral discriminability in lateral occipital and fusiform cortices, suggesting that activation patterns within these regions represent different types of information in each age group. Therefore, the quality of perceptual signals is a key contributor to memory discrimination across age groups, with evidence that age differences in the nature of representations emerges outside early visual cortex.SIGNIFICANCE STATEMENT Age-related memory decline is due in part to older adults' difficulties in discriminating between old and new information. We tested whether this deficit arises from lack of specificity in the sensory representations underlying older adults' recognition judgments. Using pattern classification analyses in ventral visual cortices, we found that signals in a region early in the visual stream could distinguish between targets and lures at the highest level of similarity. The discriminability of targets and lures in this region was positively related to behavioral discriminability across age groups despite an overall age deficit in classification accuracy. Together, results showed that older adults' memory deficits are related to reduced discriminability of cognitive processes (old/new recognition) in portions of visual cortex.

Generalization and the hippocampus: More than one story?

Memory-based cognition depends on both the ability to remember specific details of individual experiences and the ability to combine information across experiences to generalize and derive new knowledge. A hippocampal role in rapid encoding of specific events is long established. More recent research also demonstrates hippocampal contributions to generalization, but their nature is still debated. The current review provides an overview of hippocampal-based generalization in two lines of research-episodic inference and categorization-and discusses evidence for four candidate mechanisms and representational schemes that may underpin such generalization. We highlight evidence showing that the hippocampus contributes specific memories to generalization decisions, but also forms generalized representations that integrate information across experiences. Multiple views are currently plausible of how such generalized representations form and relate to specific memories. Future research that uses behavioral and neural indices of both generalization and specificity may help resolve between the candidate generalization mechanisms, with the possibility that more than one view of hippocampal-based generalization may be valid. Importantly, all views share the emphasis on the broader role of the hippocampus in cognition that goes beyond remembering the past.

Determination of the Optimal Procalcitonin Threshold for Infection in Patients With Impaired Renal Function at a Community Hospital.

Background: Procalcitonin (PCT) is a biomarker that can help identify bacterial infections but can be difficult to interpret in the presence of renal dysfunction, which can elevate PCT even in the absence of infection. Objective: To determine the optimal PCT threshold to identify infection in patients with renal dysfunction and pneumonia or sepsis. Methods: A retrospective analysis was performed for inpatients with creatinine clearance of ≤60 mL/min and PCT level from 2018 to 2019. A pharmacist blinded to study outcomes classified patients as infected or noninfected based on predetermined criteria. Receiver operating characteristic curve analysis was performed to establish the optimal PCT threshold overall, as well as in subgroups of patients with chronic kidney disease (CKD), acute kidney injury (AKI), and end-stage renal disease (ESRD). Institutional review board approval was obtained. Results: A total of 198 patients were included in the study (99 infected, 99 noninfected). The optimal threshold in the AKI, CKD, and ESRD subgroups was determined to be 1.5 ng/mL, 0.1 ng/mL, and 1.75 ng/mL, respectively. Conclusion: The results of this study show that PCT thresholds were specific to type of renal dysfunction. These results differ from the traditionally accepted PCT threshold of 0.5 ng/mL for sepsis and 0.25 mg/mL for pneumonia. Future studies should confirm the appropriate PCT threshold in ESRD and CKD patient populations.

Abstract Memory Representations in the Ventromedial Prefrontal Cortex and Hippocampus Support Concept Generalization.

Memory function involves both the ability to remember details of individual experiences and the ability to link information across events to create new knowledge. Prior research has identified the ventromedial prefrontal cortex (VMPFC) and the hippocampus as important for integrating across events in the service of generalization in episodic memory. The degree to which these memory integration mechanisms contribute to other forms of generalization, such as concept learning, is unclear. The present study used a concept-learning task in humans (both sexes) coupled with model-based fMRI to test whether VMPFC and hippocampus contribute to concept generalization, and whether they do so by maintaining specific category exemplars or abstract category representations. Two formal categorization models were fit to individual subject data: a prototype model that posits abstract category representations and an exemplar model that posits category representations based on individual category members. Latent variables from each of these models were entered into neuroimaging analyses to determine whether VMPFC and the hippocampus track prototype or exemplar information during concept generalization. Behavioral model fits indicated that almost three-quarters of the subjects relied on prototype information when making judgments about new category members. Paralleling prototype dominance in behavior, correlates of the prototype model were identified in VMPFC and the anterior hippocampus with no significant exemplar correlates. These results indicate that the VMPFC and portions of the hippocampus play a broad role in memory generalization and that they do so by representing abstract information integrated from multiple events.SIGNIFICANCE STATEMENT Whether people represent concepts as a set of individual category members or by deriving generalized concept representations abstracted across exemplars has been debated. In episodic memory, generalized memory representations have been shown to arise through integration across events supported by the ventromedial prefrontal cortex (VMPFC) and hippocampus. The current study combined formal categorization models with fMRI data analysis to show that the VMPFC and anterior hippocampus represent abstract prototype information during concept generalization, contributing novel evidence of generalized concept representations in the brain. Results indicate that VMPFC-hippocampal memory integration mechanisms contribute to knowledge generalization across multiple cognitive domains, with the degree of abstraction of memory representations varying along the long axis of the hippocampus.

Differential Functional Connectivity along the Long Axis of the Hippocampus Aligns with Differential Role in Memory Specificity and Generalization.

The hippocampus contributes to both remembering specific events and generalization across events. Recent work suggests that information may be represented along the longitudinal axis of the hippocampus at varied levels of specificity: detailed representations in the posterior hippocampus and generalized representations in the anterior hippocampus. Similar distinctions are thought to exist within neocortex, with lateral prefrontal and lateral parietal regions supporting memory specificity and ventromedial prefrontal and lateral temporal cortices supporting generalized memory. Here, we tested whether functional connectivity of anterior and posterior hippocampus with cortical memory regions is consistent with these proposed dissociations. We predicted greater connectivity of anterior hippocampus with putative generalization regions and posterior hippocampus with putative memory specificity regions. Furthermore, we tested whether differences in connectivity are stable under varying levels of task engagement. Participants learned to categorize a set of stimuli outside the scanner, followed by an fMRI session that included a rest scan, passive viewing runs, and category generalization task runs. Analyses revealed stronger connectivity of ventromedial pFC to anterior hippocampus and of angular gyrus and inferior frontal gyrus to posterior hippocampus. These differences remained relatively stable across the three phases (rest, passive viewing, category generalization). Whole-brain analyses further revealed widespread cortical connectivity with both anterior and posterior hippocampus, with relatively little overlap. These results contribute to our understanding of functional organization along the long axis of the hippocampus and suggest that distinct hippocampal-cortical connections are one mechanism by which the hippocampus represents both individual experiences and generalized knowledge.

Repeated study of items with and without repeated context: aging effects on memory discriminability.

Presenting items multiple times during encoding is a common way to enhance recognition accuracy. Under such conditions, older adults often show an increase in false recognition that counteracts benefits of repeated study. Using a false-memory paradigm with related study items and related lures, we tested whether repetition within the same encoding task or repetition across two different encoding tasks would be more beneficial to older adults' memory discriminability. Results showed that, compared to items not repeated at study, items repeated in the same context and items repeated across different contexts showed improvements in memory discriminability in both young and older adults. This improvement was primarily reflected in improved recollection responses for both age groups across both repeat study conditions, as compared to no repetition. Importantly, the results demonstrated that repetition can be used to successfully mitigate age-related deficits by increasing memory discriminability and without incurring a cost of false recognition specific to any one age group.

Modulation of target recollection and recollection rejection networks due to retrieval facilitation and interference.

To better understand neural recollection processing, we induced interference in target recollection by presenting related lures before their respective targets and facilitated recollection rejection of lures by presenting targets before their related lures. Target recollection following interference recruited visual and prefrontal cortices, showing that these regions support recollection when related information has disrupted target representations. Recollection rejection following target presentation recruited angular gyrus, indicating that this region supports recollection rejection when target representations are strong and highly accessible. Thus, recollection networks are sensitive to the accessibility of target representations that are affected by the presentation of related information during retrieval.