Can rifaximin for hepatic encephalopathy be discontinued during broad-spectrum antibiotic treatment?

Hepatic encephalopathy (HE) is a formidable complication in patients with decompensated cirrhosis, often necessitating the administration of rifaximin (RFX) for effective management. RFX, is a gut-restricted, poorly-absorbable oral rifamycin derived antibiotic that can be used in addition to lactulose for the secondary prophylaxis of HE. It has shown notable reductions in infection, hospital readmission, duration of hospital stay, and mortality. However, limited data exist about the concurrent use of RFX with broad-spectrum antibiotics, because the patients are typically excluded from studies assessing RFX efficacy in HE. A pharmacist-driven quasi-experimental pilot study was done to address this gap. They argue against the necessity of RFX in HE during broad-spectrum antibiotic treatment, particularly in critically ill patients in intensive care unit (ICU). The potential for safe RFX discontinuation without adverse effects is clearly illuminated and valuable insight into the optimization of therapeutic strategies is offered. The findings also indicate that RFX discontinuation during broad-spectrum antibiotic therapy was not associated with higher rates of delirium or coma, and this result remained robust after adjustment in multivariate analysis. Furthermore, rates of other secondary clinical and safety outcomes, including ICU mortality and 48-hour changes in vasopressor requirements, were comparable. However, since the activity of RFX is mainly confined to the modulation of gut microbiota, its potential utility in patients undergoing extensive systemic antibiotic therapy is debatable, given the overlapping antibiotic activity. Further, this suggests that the action of RFX on HE is class-specific (related to its activity on gut microbiota), rather than drug-specific. A recent double-blind randomized controlled (ARiE) trial provided further evidence-based support for RFX withdrawal in critically ill cirrhotic ICU patients receiving broad-spectrum antibiotics. Both studies prompt further discussion about optimal therapeutic strategy for patients facing the dual challenge of HE and systemic infections. Despite these compelling results, both studies have limitations. A prospective, multi-center evaluation of a larger sample, with placebo control, and comprehensive neurologic evaluation of HE is warranted. It should include an exploration of longer-term outcome and the impact of this protocol in non-critically ill liver disease patients.

Working Memory in Patients with Varying Degree of Hepatic Encephalopathy (HE): A Pilot EEG-fNIRS Study.

It is known that patients with covert hepatic encephalopathy (CHE) exhibit working memory abnormalities, but to date there is no study comparing patients with cirrhosis with/without CHE and controls with both electrophysiological and hemodynamic data collected at the same time.Here we collected behavioral [accuracy and reaction times (RTs), electrophysiological (evoked potentials) and hemodynamic (oxygenated and deoxygenated haemoglobin) correlates of an n-back task [formed by a control (0-back) condition, a low (1-back) and a high (2-back) working memory load conditions] in patients with cirrhosis with/without CHE: (1) at baseline (n = 21, males = 15, 58±8 yrs), and by comparison with controls (n = 21, males = 15, 57±11 yrs) and (2) after a 3-month course of rifaximin (n = 18, males = 12, 61±11 yrs), and by comparison to baseline.All patients showed slower RTs (p < 0.0001) and lower P2 amplitude compared with controls (p = 0.018); moreover, patients with CHE showed reduced accuracy (p < 0.0001) compared with controls, and patients without CHE showed higher oxygenated haemoglobin in the central dorsolateral prefrontal cortex in the 2-back compared with patients with CHE. Post-rifaximin, oxygenated haemoglobin increased in the central frontopolar cortex. In addition, in patients without CHE the RTs of the 2-back became comparable to those of the 0-back and P3 showed higher amplitude.In conclusion, the presence of cirrhosis seemed to have more effects than CHE on working memory at baseline. A course of treatment with rifaximin was more beneficial to patients without CHE, who probably had more room for improvement in this complex task.

Animal naming test is a simple and valid tool for detecting covert hepatic encephalopathy and predicting outcomes in Chinese-speaking regions: a preliminary study.

BACKGROUND AND AIMS: Hepatic encephalopathy (HE) implies high morbidity and mortality. The assessment of covert HE (CHE) [i.e. minimal HE (MHE) plus grade 1 HE] is often neglected in Taiwan. Therefore, the aim was to investigate the potential of the animal naming test (ANT1 and simplified ANT1 (S-ANT1)) for assessing CHE in Chinese-speaking regions, specifically Taiwan. METHODS: A prospective cohort study was conducted, comprising 65 cirrhotic patients and 29 healthy controls (relatives of the patients). Patients were followed up every three months and censored after two years or until death. Hospitalization for overt HE (OHE) and mortality were considered. All subjects underwent ANT1, psychometric HE score (PHES), and mini-mental state examination (MMSE). The patients underwent an electroencephalogram (EEG) to detect slowing indicative of MHE. Cut-off values for ANT1 and S-ANT1 were assessed by ROC analysis and Youden's index, considering CHE as a reference. The prognostic values for OHE and OHE-free survival were assessed. RESULTS: Preliminary analysis confirmed that PHES ≤-4 is a good discriminant point for abnormal results. CHE was found in 29 patients: 9 had MHE (PHES ≤ -4 or altered EEG) and 20 had grade 1 HE. ANT1 and S-ANT1 were found to have diagnostic values for CHE: AUC = 0.807, 0.786; cut off: 18 and 19, respectively. ANT1 and S-ANT1 were found to have prognostic value for OHE, number of hospitalization episodes for OHE, and OHE recurrence-free survival. CONCLUSIONS: ANT1 shows promise as a tool for CHE detection, quantification, and follow-up in Taiwan and other Chinese-speaking regions.Key messagesThe animal naming test (ANT1) is a simple and valid semantic fluency test that can be easily performed in outpatient or bedside settings in one minute and can also be used as a tool for covert hepatic encephalopathy (CHE) detection, quantification, and follow-up in Taiwan, other Chinese-speaking regions, and many other countries.The diagnostic value of ANT1 and S-ANT1 for CHE were found to be significant, with area under the receiver operating characteristic curve (AUROC) values of 0.807 and 0.786 respectively, and cut-off scores of 18 and 19.ANT1 and S-ANT1 have prognostic value for the first breakthrough of overt hepatic encephalopathy (OHE), number of hospitalization episodes for OHE, and OHE recurrence-free survival, independent of the MELD score.

A preliminary attempt to investigate mirror self-recognition in Octopus vulgaris.

Mirror self-recognition (MSR) is a potential indicator of self-awareness. This capability has been widely investigated among vertebrates, yet it remains largely unstudied in invertebrates. Here we report preliminary data about behavioural responses exhibited by common octopuses (Octopus vulgaris) toward reflected images of themselves and explore a procedure for marking octopus' skin in order to conduct the Mark test. Octopuses (n = 8) received four familiarization trials with a mirror and four familiarization trials with a control stimulus: a non-reflective panel (Panel group, n = 4) or the sight of a conspecific housed in an adjacent tank (Social group, n = 4). Subsequently, octopuses were marked with non-toxic nail polish in the area where the Frontal White Spots are usually expressed, and they received one test trial with the mirror and one control trial with no mirror. We found that octopuses in the Panel group tended to exhibit a stronger exploratory response toward the mirror than the non-reflective panel, but performed agonistic responses only in the presence of the mirror. In contrast, octopuses in the Social group exhibited comparable exploratory and agonistic behaviours toward the mirror and the sight of the conspecific. In the Mark test, octopuses frequently explored the mark via their arms. However, mark-directed behaviours were also observed in the absence of the mirror and in sham-marked individuals, thus suggesting that proprioceptive stimuli drove these responses. Despite the limitations associated with our marking procedure, the baseline data collected in this pilot study may facilitate the further testing of MSR in the octopus and other cephalopods.

Little evidence that Eurasian jays protect their caches by responding to cues about a conspecific's desire and visual perspective.

Eurasian jays have been reported to protect their caches by responding to cues about either the visual perspective or current desire of an observing conspecific, similarly to other corvids. Here, we used established paradigms to test whether these birds can - like humans - integrate multiple cues about different mental states and perform an optimal response accordingly. Across five experiments, which also include replications of previous work, we found little evidence that our jays adjusted their caching behaviour in line with the visual perspective and current desire of another agent, neither by integrating these social cues nor by responding to only one type of cue independently. These results raise questions about the reliability of the previously reported effects and highlight several key issues affecting reliability in comparative cognition research.

Eurasian jays, Garrulus glandarius, are members of the crow family. These large-brained birds hide food when it is abundant, and eat it later, when it is scarce. Previous studies have found that jays avoid theft by other jays by carefully deciding what food to hide, and where. In one study, they preferred to hide their food behind an opaque barrier, rather than a transparent one, when another jay was watching. In a second study, they preferred to hide food that the watching jay had already eaten enough of, and thus did not want. These studies suggest that jays have flexible cognitive skills when it comes to protecting their food. They respond to whether a potential thief can see their hiding place and to how much a thief might want the food they are stashing. The next question is, can Eurasian jays combine these two pieces of information? For example, if a jay has two types of food they could hide when another jay is present, but only has one place to hide them (either in view or out-of-view of the other jay), does the first jay prefer to stash the food that the second jay has already eaten, and therefore does not want anymore, only when the hiding place is visible to second jay? To find out, Amodio et al. watched Eurasian jays hiding macadamia nuts or peanuts in the presence of another jay. In the first setup, jays were given one food to hide and two possible hiding places, one opaque and one transparent, while being watched by a jay that had either had its fill of the food, or not tried it. In the second setup, jays were given both foods to hide, but only had one place to hide them (either transparent or opaque); while being watched by a jay that had eaten enough of one of the foods. Contrary to expectations, the jays did not seem to be able to combine the information about what the other jay could see and what it had been eating. In fact, they seemed unable to respond to either piece of information. When Amodio et al. repeated the original experiments, the jays did not seem to prefer to hide food out of sight, or to hide food that the watcher had already eaten. These results raise questions about the repeatability of experiments on food hiding strategies in birds of the crow family. It suggests that previous findings should be further investigated, potentially to identify important factors that might affect the repeatability of food-hiding tactics. Repeating the experiments may show how best to investigate behavioural patterns in jays in the future.

Bipedal locomotion in Octopus vulgaris: A complementary observation and some preliminary considerations.

Lacking an external shell and a rigid endoskeleton, octopuses exhibit a remarkable flexibility in their movements. Bipedal locomotion is perhaps the most iconic example in this regard. Until recently, this peculiar mode of locomotion had been observed only in two species of tropical octopuses: Amphioctopus marginatus and Abdopus aculeatus. Yet, recent evidence indicates that bipedal walking is also part of the behavioral repertoire of the common octopus, Octopus vulgaris. Here we report a further observation of a defense behavior that encompasses both postural and locomotory elements of bipedal locomotion in this cephalopod. By highlighting differences and similarities with the other recently published report, we provide preliminary considerations with regard to bipedal locomotion in the common octopus.

Lights and Shadows in Hepatic Encephalopathy Diagnosis.

Hepatic encephalopathy (HE) is a form of brain dysfunction that is caused by liver insufficiency and/or portal-systemic shunting. The exact nature of HE is debated; as such, conflicting uses of the term "HE" may cause inconsistencies in its detection and management. This review highlights the meaning of the term "HE" on the basis of its historical origins and current consensus. It also provides criteria for the diagnosis of the condition based on its phenotypes and risk factors for its occurrence. The procedure for differential diagnosis from other conditions which result in similar phenotypes is considered, together with precipitants and confounders. Finally, the current multidimensional approach for the correct clinical reporting of HE episodes is discussed.

Testing two competing hypotheses for Eurasian jays' caching for the future.

Previous research reported that corvids preferentially cache food in a location where no food will be available or cache more of a specific food in a location where this food will not be available. Here, we consider possible explanations for these prospective caching behaviours and directly compare two competing hypotheses. The Compensatory Caching Hypothesis suggests that birds learn to cache more of a particular food in places where that food was less frequently available in the past. In contrast, the Future Planning Hypothesis suggests that birds recall the 'what-when-where' features of specific past events to predict the future availability of food. We designed a protocol in which the two hypotheses predict different caching patterns across different caching locations such that the two explanations can be disambiguated. We formalised the hypotheses in a Bayesian model comparison and tested this protocol in two experiments with one of the previously tested species, namely Eurasian jays. Consistently across the two experiments, the observed caching pattern did not support either hypothesis; rather it was best explained by a uniform distribution of caches over the different caching locations. Future research is needed to gain more insight into the cognitive mechanism underpinning corvids' caching for the future.

Spontaneous portosystemic shunts in cirrhosis: Detection, implications, and clinical associations.

BACKGROUND: Spontaneous portosystemic shunts (SPSS) are common in cirrhosis. Their characterization and clinical implications remain unclear. AIMS: To devise a system of assessment of these shunts, and assess their clinical implications METHODS: We retrospectively studied patients with cirrhosis who underwent imaging in a liver transplant program. A novel index was computed to assess total SPSS -the diameter of a circle having an area equivalent to the sum of the areas of all the existing shunts. This 'SPSS equivalent diameter' was compared with the clinical variables. RESULTS: Among 127 patients, 70% (CI95% 62-77) had SPSS, and 57% (CI95% 62-77) had multiple SPSS. The risk for SPSS was related to the severity of cirrhosis (Child-Pugh B/C vs. A: OR 2.4 CI95% 1.1-5.4) and alcoholic aetiology (OR 2.9 CI95% 1.2-7.1). The SPSS equivalent diameter was related to a history of HE, cognitive impairment (EEG/PHES) and ammonia(p<0.05). The diameter of the inferior cava vein >19.5 mm was a predictor of large SPSS (AUC 0.77, CI95%:0.68-0.87, p ≤ 0.001). CONCLUSIONS: The SPSS equivalent diameter, a comprehensive assessment of portosystemic shunting, was associated with severity of liver disease, hyperammonemia, and cognitive dysfunction. The diameter of the inferior vena cava was a good predictor of SPSS.

How intelligent is a cephalopod? Lessons from comparative cognition.

The soft-bodied cephalopods including octopus, cuttlefish, and squid are broadly considered to be the most cognitively advanced group of invertebrates. Previous research has demonstrated that these large-brained molluscs possess a suite of cognitive attributes that are comparable to those found in some vertebrates, including highly developed perception, learning, and memory abilities. Cephalopods are also renowned for performing sophisticated feats of flexible behaviour, which have led to claims of complex cognition such as causal reasoning, future planning, and mental attribution. Hypotheses to explain why complex cognition might have emerged in cephalopods suggest that a combination of predation, foraging, and competitive pressures are likely to have driven cognitive complexity in this group of animals. Currently, it is difficult to gauge the extent to which cephalopod behaviours are underpinned by complex cognition because many of the recent claims are largely based on anecdotal evidence. In this review, we provide a general overview of cephalopod cognition with a particular focus on the cognitive attributes that are thought to be prerequisites for more complex cognitive abilities. We then discuss different types of behavioural flexibility exhibited by cephalopods and, using examples from other taxa, highlight that behavioural flexibility could be explained by putatively simpler mechanisms. Consequently, behavioural flexibility should not be used as evidence of complex cognition. Fortunately, the field of comparative cognition centres on designing methods to pinpoint the underlying mechanisms that drive behaviours. To illustrate the utility of the methods developed in comparative cognition research, we provide a series of experimental designs aimed at distinguishing between complex cognition and simpler alternative explanations. Finally, we discuss the advantages of using cephalopods to develop a more comprehensive reconstruction of cognitive evolution.

Hepatic encephalopathy: Novel insights into classification, pathophysiology and therapy.

Hepatic encephalopathy (HE) is a frequent and serious complication of both chronic liver disease and acute liver failure. HE manifests as a wide spectrum of neuropsychiatric abnormalities, from subclinical changes (mild cognitive impairment) to marked disorientation, confusion and coma. The clinical and economic burden of HE is considerable, and it contributes greatly to impaired quality of life, morbidity and mortality. This review will critically discuss the latest classification of HE, as well as the pathogenesis and pathophysiological pathways underlying the neurological decline in patients with end-stage liver disease. In addition, management strategies, diagnostic approaches, currently available therapeutic options and novel treatment strategies are discussed.

Hepatic Encephalopathy and Spontaneous Bacterial Peritonitis Improve Cirrhosis Outcome Prediction: A Modified Seven-Stage Model as a Clinical Alternative to MELD.

Classification of cirrhosis based on clinical stages is rapid and based on five stages at present. Two other relevant events, hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), can be considered in a clinical perspective but no study has implemented a seven-stage classification and confirmed its value before. In addition, long-term validation of the Model for End-Stage Liver Disease (MELD) in large cohorts of patients with cirrhosis and comparison with clinical findings are insufficient. Therefore, we performed a study to address these items. From the Chang-Gung Research Database (CGRD), 20,782 patients with cirrhosis were enrolled for an historical survival study. The MELD score, the five-stage clinical score (i.e., occurrence of esophageal varices (EV), EV bleeding, ascites, sepsis) and a novel seven-stage clinical score (i.e., occurrence of EV, EV bleeding, ascites, sepsis, HE, SBP) were compared with their Cox models by receiver operating characteristic (ROC) analysis. The addition of HE and SBP to the seven-stage model had a 5% better prediction result than the five-stage model did in the survival ROC analysis. The result showed that the seven clinical stages are associated with an increased risk for mortality. However, the predicted performances of the seven-stage model and MELD system are likely equivalent. In conclusion, the study (i) proved that clinical staging of cirrhosis based on seven items/stages had higher prognostic value than the five-stage model and (ii) confirmed the validity of the MELD criteria vs. clinical assessment.

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.

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.