Validation of the delirium diagnostic tool-provisional (DDT-Pro) in geriatric medical inpatients with diagnostic permutations of the 3Ds with and without delirium.

OBJECTIVE: Validations of brief delirium tools have not included analysis of psychiatric disorders comorbidities or control groups. We validated the Delirium Diagnostic Tool-Provisional (DDT-Pro) in 422 geriatric inpatients with high incidence of depression and/or dementia. METHODS: Cross-sectional study using two delirium reference standards, DSM-5-TR and Delirium Rating Scale-Revised-98 (DRS-R98). We assessed concurrent and construct DDT-Pro validity too. RESULTS: There were 117 (27.7%) delirium cases using DDT-Pro, 104 (24.6%) per DSM-5-TR and 93 (22.0%) per DRS-R98; 133 patients (31.5%) had depression and 105 (24.9%) dementia, some comorbid with delirium. DDT-Pro accuracy (AUC under ROC curve) ranges were 88.3-95.9% vs DSM-5-TR and 92.7-95.0% vs DRS-R98 for whole sample and four diagnostic groups, without statistical differences. DDT-Pro ≤6 had the most balanced sensitivity-specificity for delirium diagnosis against both DSM-5-TR and DRS-R98 with similar specificity but higher sensitivity for DRS-R98 than DSM-5-TR delirium, with the highest values in patients with depression and dementia (≥92% sensitivity, ≥81% specificity). Positive and negative likelihood ratios support diagnostic strength. Concurrent validity was high reflected by significant correlations (p < 0.001) of DDT-Pro total and item scores with DRS-R98 and Delirium Frontal Index scores, highest in groups with comorbid depression and/or dementia. The DDT-Pro represented a single construct for delirium demonstrated by one factor with high item loadings and high internal consistency reliability of its items. CONCLUSIONS: The DDT-Pro demonstrated strong performance metrics in general hospital elderly inpatients with preexisting depression and/or dementia, which is unique among brief delirium tools. Its optimized cutoff score was the same as in other populations.

Practical Application of a Battery of Brief Tools to Evaluate Geriatric Medical Inpatients for the Three Ds.

OBJECTIVE: The investigators aimed to identify the clinical characteristics of patients with or without delirium and preexisting depression, dementia, both, or neither by using validated tools easily administered in clinical practice. METHODS: In this cross-sectional prospective observational study conducted in Medellín, Colombia, 200 geriatric inpatients were evaluated with the Delirium Diagnostic Tool-Provisional (DDT-Pro), Informant Questionnaire on Cognitive Decline in the Elderly, Hachinski Ischemic Scale, Cornell Scale for Depression in Dementia, and Charlson Comorbidity Index-short form. Delirium motor subtype, mortality, and length of hospital stay were assessed. RESULTS: The study included 134 patients without delirium (67%), 14 with delirium only (7%), 16 with delirium and dementia (8%), 13 with delirium and depression (7%), and 23 with delirium, dementia, and depression (the three Ds) (12%). Prevalence rates of dementia (59%) and depression (55%) among 66 patients with delirium were higher than prevalence rates among patients without delirium (13% and 28%, respectively), suggesting that both conditions are risk factors. Main medical diagnoses, mortality, and dementia type did not differ among groups. Motor subtypes were similar among delirium groups. Patients in the delirium groups, except those in the delirium and depression group, were older than patients without delirium. Medical burden was highest among the patients with delirium and dementia and those with all three conditions. Delirium and dementia were more severe when comorbid with each other. Depression was most severe among patients with delirium and depression. Patients with all three conditions had a longer length of hospital stay than those without delirium. CONCLUSIONS: Using brief tools to detect dementia and depression in conjunction with the DDT-Pro to assess delirium diagnosis and severity is feasible and enables a more in-depth evaluation of elderly hospitalized patients. Because previous longitudinal research suggests that these comorbid conditions influence prognosis following a delirium episode, better identification of the three Ds offers proactive interventional opportunities. Depression is an underrecognized risk factor for delirium.

Hippocampal CaMKII inhibition induces reactivation-dependent amnesia for extinction memory and causes fear relapse.

Hippocampal GluN2B subunit-containing NMDAR (GluN2B-NMDAR) activation during recall destabilizes fear extinction memory, which must undergo brain-derived neurotrophic factor (BDNF)-dependent reconsolidation to persist. Ca2+/calmodulin-dependent protein kinase II (CaMKII) is a Ser/Thr protein kinase essential for hippocampus-dependent memory processing that acts downstream GluN2B-NMDAR and controls BDNF expression, but its participation in fear extinction memory reconsolidation has not yet been studied. Using a combination of pharmacological and behavioral tools, we found that in adult male Wistar rats, intra dorsal-CA1 administration of the CaMKII inhibitors autocamtide-2-related inhibitory peptide (AIP) and KN-93, but not of their inactive analogs scrambled AIP and KN-92, after fear extinction memory recall impaired extinction and caused GluN2B-NMDAR-dependent recovery of fear. Our results indicate that hippocampal CaMKII is necessary for fear extinction reconsolidation, and suggest that modulation of its activity around the time of recall controls the inhibition that extinction exerts on learned fear.

NMDARs control object recognition memory destabilization and reconsolidation.

Object recognition memory (ORM) allows identification of previously encountered items and is therefore crucial for remembering episodic information. In rodents, reactivation during recall in the presence of a novel object destabilizes ORM and initiates a Zif268 and protein synthesis-dependent reconsolidation process in the hippocampus that links the memory of this object to the reactivated recognition trace. Hippocampal NMDA receptors (NMDARs) modulate Zif268 expression and protein synthesis and regulate memory stability but their possible involvement in the ORM destabilization/reconsolidation cycle has yet to be analyzed in detail. We found that, in adult male Wistar rats, intra dorsal-CA1 administration of the non-subunit selective NMDAR antagonist AP5, or of the GluN2A subunit-containing NMDAR antagonist TCN201, 5 min after an ORM reactivation session in the presence of a novel object carried out 24 h post-training impaired retention 24 h later. In contrast, pre-reactivation administration of the GluN2B subunit-containing NMDAR antagonist RO25-6981 had no effect on ORM recall or retention but impeded the amnesia caused by Zif268 silencing and protein synthesis inhibition in dorsal CA1. Our results indicate that GluN2B-containing hippocampal NMDARs are necessary for ORM destabilization whereas GluN2A-containing NMDARs are involved in ORM reconsolidation, and suggest that modulation of the relative activity of these receptor subtypes during recall regulates ORM persistence.

Antigenic Landscape Analysis of Individuals Vaccinated with a Universal Influenza Virus Vaccine Candidate Reveals Induction of Cross-Subtype Immunity.

Current influenza virus vaccines have to be closely matched to circulating strains to provide good protection, and antigenic drift and emerging pandemic influenza virus strains present a difficult challenge for them. Universal influenza virus vaccines, including chimeric hemagglutinin (cHA)-based constructs that target the conserved stalk domain of hemagglutinin, are in clinical development. Due to the conservation of the stalk domain, antibodies directed to it show broad binding profiles, usually within group 1 and group 2 influenza A or influenza B virus phylogenies. However, determining the binding breadth of these antibodies with commonly used immunological methods can be challenging. Here, we analyzed serum samples from a phase I clinical trial (CVIA057, NCT03300050) using an influenza virus protein microarray (IVPM). The IVPM technology allowed us to assess immune responses not only to a large number of group 1 hemagglutinins but also group 2 and influenza B virus hemagglutinins. In CVIA057, different vaccine modalities, including a live attenuated influenza virus vaccine and inactivated influenza virus vaccines with or without adjuvant, all in the context of cHA constructs, were tested. We found that vaccination with adjuvanted, inactivated vaccines induced a very broad antibody response covering group 1 hemagglutinins, with limited induction of antibodies to group 2 hemagglutinins. Our data show that cHA constructs do indeed induce very broad immune responses and that the IVPM technology is a useful tool to measure this breadth that broadly protective or universal influenza virus vaccines aim to induce. IMPORTANCE The development of a universal influenza virus vaccine that protects against seasonal drifted, zoonotic, or emerging pandemic influenza viruses would be an extremely useful public health tool. Here, we test a technology designed to measure the breadth of antibody responses induced by this new class of vaccines.

On the effect of hippocampal c-Jun N-terminal kinase inhibition on object recognition memory.

c-Jun N-terminal kinase (JNK) phosphorylates the transcription factor c-Jun in response to stress stimuli and contributes to both hippocampal synaptic plasticity and memory processing in mammals. Object recognition memory (ORM) is essential for remembering facts and events. In rodents, ORM consolidation and reconsolidation require a functional hippocampus. However, the possible involvement of hippocampal JNK on ORM processing has not yet been studied. Here we show that when injected into dorsal CA1 5 min, but not 6 h, after training adult male rats in the novel object recognition learning task, the JNK inhibitor SP600125 impaired ORM for at least 7 days without affecting exploratory activity, short-term ORM retention, or the functional integrity of the hippocampus. SP600125 did not hinder ORM retention when given in CA1 after a memory reactivation session carried out 24 h post-training in the presence of the same two objects presented during the training session, but caused time-dependent amnesia when one of the objects presented at training was replaced by a different but behaviorally equivalent novel one. Taken together, our results indicate that hippocampal JNK activity is necessary for ORM consolidation and reconsolidation but not for ORM recall or short-term retention.

Optogenetic inactivation of the medial septum impairs long-term object recognition memory formation.

Theta is one of the most prominent extracellular synchronous oscillations in the mammalian brain. Hippocampal theta relies on an intact medial septum (MS) and has been consistently recorded during the training phase of some learning paradigms, suggesting that it may be implicated in hippocampus-dependent long-term memory processing. Object recognition memory (ORM) allows animals to identify familiar items and is essential for remembering facts and events. In rodents, long-term ORM formation requires a functional hippocampus but the involvement of the MS in this process remains controversial. We found that training adult male Wistar rats in a long-term ORM-inducing learning task involving exposure to two different, but behaviorally equivalent novel stimuli objects increased hippocampal theta power, and that suppressing theta via optogenetic MS inactivation caused amnesia. Importantly, the amnesia was specific to the object the animals were exploring when the MS was inactivated. Taken together, our results indicate that the MS is necessary for long-term ORM formation and suggest that hippocampal theta activity is causally linked to this process.

PyRAT: An Open-Source Python Library for Animal Behavior Analysis.

Here we developed an open-source Python-based library called Python rodent Analysis and Tracking (PyRAT). Our library analyzes tracking data to classify distinct behaviors, estimate traveled distance, speed and area occupancy. To classify and cluster behaviors, we used two unsupervised algorithms: hierarchical agglomerative clustering and t-distributed stochastic neighbor embedding (t-SNE). Finally, we built algorithms that associate the detected behaviors with synchronized neural data and facilitate the visualization of this association in the pixel space. PyRAT is fully available on GitHub: https://github.com/pyratlib/pyrat.

Reactivation-dependent amnesia for object recognition memory is contingent on hippocampal theta-gamma coupling during recall.

Hippocampal dopamine D1/D5 receptor-dependent destabilization is necessary for object recognition memory (ORM) updating through reconsolidation. Dopamine also regulates hippocampal theta and gamma oscillations, which are involved in novelty and memory processing. We found that, in adult male rats, ORM recall in the presence of a novel object, but not in the presence of a familiar one, triggers hippocampal theta-gamma coupling. Hippocampal theta-gamma coupling (hPAC) does not happen when ORM destabilization is prevented by blocking D1/D5 receptors, but artificial hPAC generation during recall in the presence of a familiar object enables the amnesic effect of reconsolidation inhibitors. Therefore, hPAC controls ORM destabilization, and its modulation could increase reconsolidation-based psychotherapy efficacy.

Avoidance memory requires CaMKII activity to persist after recall.

Avoidance memory is destabilized when recalled concurrently with conflicting information, and must undergo a hippocampus-dependent restabilization process called reconsolidation to persist. CaMKII is a serine/threonine protein kinase essential for memory processing; however, its possible involvement in avoidance memory reconsolidation has not yet been studied. Using pharmacological, electrophysiological and optogenetic tools, we found that in adult male Wistar rats hippocampal CaMKII is necessary to reconsolidate avoidance memory, but not to keep it stored while inactive, and that blocking reconsolidation via CaMKII inhibition erases learned avoidance responses.

Dopamine controls whether new declarative information updates reactivated memories through reconsolidation.

Consolidation and reconsolidation are independent memory processes. Consolidation stabilizes new memories, whereas reconsolidation restabilizes memories destabilized when reactivated during recall. However, the biological role of the destabilization/reconsolidation cycle is still unknown. It has been hypothesized that reconsolidation links new information with reactivated memories, but some reports suggest that new and old memories are associated through consolidation mechanisms instead. Object-recognition memory (ORM) serves to judge the familiarity of items and is essential for remembering previous events. We took advantage of the fact that ORM consolidation, destabilization, and reconsolidation can be pharmacologically dissociated to demonstrate that, depending on the activation state of hippocampal dopamine D1/D5 receptors, the memory of a novel object presented during recall of the memory of a familiar one can be formed via reconsolidation or consolidation, but only reconsolidation can link them. We also found that recognition memories formed through reconsolidation can be destabilized even if indirectly reactivated. Our results indicate that dopamine couples novelty detection with memory destabilization to determine whether a new recognition trace is associated with an active network and suggest that declarative reminders should be used with caution during reconsolidation-based psychotherapeutic interventions.

GluN2B and GluN2A-containing NMDAR are differentially involved in extinction memory destabilization and restabilization during reconsolidation.

Extinction memory destabilized by recall is restabilized through mTOR-dependent reconsolidation in the hippocampus, but the upstream pathways controlling these processes remain unknown. Hippocampal NMDARs drive local protein synthesis via mTOR signaling and may control active memory maintenance. We found that in adult male Wistar rats, intra dorsal-CA1 administration of the non-subunit selective NMDAR antagonist AP5 or of the GluN2A subunit-containing NMDAR antagonist TCN201 after step down inhibitory avoidance (SDIA) extinction memory recall impaired extinction memory retention and caused SDIA memory recovery. On the contrary, pre-recall administration of AP5 or of the GluN2B subunit-containing NMDAR antagonist RO25-6981 had no effect on extinction memory recall or retention per se but hindered the recovery of the avoidance response induced by post-recall intra-CA1 infusion of the mTOR inhibitor rapamycin. Our results indicate that GluN2B-containing NMDARs are necessary for extinction memory destabilization whereas GluN2A-containing NMDARs are involved in its restabilization, and suggest that pharmacological modulation of the relative activation state of these receptor subtypes around the moment of extinction memory recall may regulate the dominance of extinction memory over the original memory trace.

mTOR inhibition impairs extinction memory reconsolidation.

Fear-motivated avoidance extinction memory is prone to hippocampal brain-derived neurotrophic factor (BDNF)-dependent reconsolidation upon recall. Here, we show that extinction memory recall activates mammalian target of rapamycin (mTOR) in dorsal CA1, and that post-recall inhibition of this kinase hinders avoidance extinction memory persistence and recovers the learned aversive response. Importantly, coadministration of recombinant BDNF impedes the behavioral effect of hippocampal mTOR inhibition. Our results demonstrate that mTOR signaling is necessary for fear-motivated avoidance extinction memory reconsolidation and suggests that BDNF acts downstream mTOR in a protein synthesis-independent manner to maintain the reactivated extinction memory trace.

Scombroid poisoning secondary to tuna ingestion: a case report / [Intoxicación escombroide secundaria al consumo de atún: presentación de un caso].

Scombroid poisoning is caused by the consumption of certain types of fish (from the Scombridae family), especially tuna. Due to inadequate refrigeration procedures, these fish have high levels of histamine which generate symptoms similar to those of a food allergy in their consumers, so it is frequently underdiagnosed. It is self-limited in a few hours and the symptoms are usually not serious, except for specific cases reported in the literature of hypotension, bronchospasm, respiratory distress, tachyarrhythmias, and even acute myocardial infarction. We report here the case of a woman admitted to the emergency department of a third level hospital in Medellín a few minutes after eating tuna with the typical symptoms of intoxication, as well as tachyarrhythmias, a serious and atypical manifestation.

La intoxicación escombroide es ocasionada por el consumo de ciertos tipos de pescado (de la familia Scombridae), comúnmente el atún, los cuales acumulan grandes concentraciones de histamina cuando los procedimientos de refrigeración son inadecuados, ocasionando en quienes los consumen síntomas muy similares a los de una alergia alimentaria, por lo que es frecuente que no se diagnostique correctamente. Generalmente, los síntomas desaparecen en pocas horas y no suelen ser graves, excepto algunos casos descritos en la literatura especializada, de hipotensión, broncoespasmo, dificultad respiratoria, taquicardia supraventricular e, incluso, infarto agudo de miocardio. Este fue, precisamente, el caso de una mujer que ingresó al servicio de urgencias de un hospital de tercer nivel de Medellín a los pocos minutos de haber ingerido atún con una sintomatología típica de la intoxicación, pero con taquicardia supraventricular, una de sus manifestaciones graves y atípicas.

Intoxicación escombroide secundaria al consumo de atún: presentación de un caso / Scombroid poisoning secondary to tuna ingestion: a case report

Resumen: La intoxicación escombroide es ocasionada por el consumo de ciertos tipos de pescado (de la familia Scombridae), comúnmente el atún, los cuales acumulan grandes concentraciones de histamina cuando los procedimientos de refrigeración son inadecuados, ocasionando en quienes los consumen síntomas muy similares a los de una alergia alimentaria, por lo que es frecuente que no se diagnostique correctamente. Generalmente, los síntomas desaparecen en pocas horas y no suelen ser graves, excepto algunos casos descritos en la literatura especializada, de hipotensión, broncoespasmo, dificultad respiratoria, taquicardia supraventricular e, incluso, infarto agudo de miocardio. Este fue, precisamente, el caso de una mujer que ingresó al servicio de urgencias de un hospital de tercer nivel de Medellín a los pocos minutos de haber ingerido atún con una sintomatología típica de la intoxicación, pero con taquicardia supraventricular, una de sus manifestaciones graves y atípicas.

Abstract: Scombroid poisoning is caused by the consumption of certain types of fish (from the Scombridae family), especially tuna. Due to inadequate refrigeration procedures, these fish have high levels of histamine which generate symptoms similar to those of a food allergy in their consumers, so it is frequently underdiagnosed. It is self-limited in a few hours and the symptoms are usually not serious, except for specific cases reported in the literature of hypotension, bronchospasm, respiratory distress, tachyarrhythmias, and even acute myocardial infarction. We report here the case of a woman admitted to the emergency department of a third level hospital in Medellín a few minutes after eating tuna with the typical symptoms of intoxication, as well as tachyarrhythmias, a serious and atypical manifestation.

Cross-Frequency Phase-Amplitude Coupling between Hippocampal Theta and Gamma Oscillations during Recall Destabilizes Memory and Renders It Susceptible to Reconsolidation Disruption.

Avoidance memory reactivation at recall triggers theta-gamma hippocampal phase amplitude coupling (hPAC) only when it elicits hippocampus-dependent reconsolidation. However, it is not known whether there is a causal relationship between these phenomena. We found that in adult male Wistar rats, silencing the medial septum during recall did not affect avoidance memory expression or maintenance but abolished hPAC and the amnesia caused by the intrahippocampal administration of reconsolidation blockers, both of which were restored by concomitant theta burst stimulation of the fimbria-fornix pathway. Remarkably, artificial hPAC generated by fimbria-fornix stimulation during recall of a learned avoidance response naturally resistant to hippocampus-dependent reconsolidation made it susceptible to reactivation-dependent amnesia. Our results indicate that hPAC mediates the destabilization required for avoidance memory reconsolidation and suggest that the generation of artificial hPAC at recall overcomes the boundary conditions of this process.SIGNIFICANCE STATEMENT Theta-gamma hippocampal phase-amplitude coupling (hPAC) increases during the induction of hippocampus-dependent avoidance memory reconsolidation. However, whether hPAC plays a causal role in this process remains unknown. Using behavioral, electrophysiological, optogenetic, and biochemical tools in adult male Wistar rats, we demonstrate that reactivation-induced hPAC is necessary for avoidance memory destabilization, and that artificial induction of this patterned activity during recall of reconsolidation-resistant aversive memories renders them liable to the amnesic effect of reconsolidation inhibitors.

Recognition memory reconsolidation requires hippocampal Zif268.

Object recognition memory (ORM) serves to distinguish familiar items from novel ones. Reconsolidation is the process by which active memories are updated. The hippocampus is engaged in ORM reconsolidation through a mechanism involving induction of long-term potentiation (LTP). The transcription factor Zif268 is essential for hippocampal LTP maintenance and has been frequently associated with memory processes. However, its possible involvement in ORM reconsolidation has not been determined conclusively. Using Zif268 antisense oligonucleotides in combination with behavioural, biochemical and electrophysiological tools in rats, we found that hippocampal Zif268 is necessary to update ORM through reconsolidation but not to retrieve it or keep it stored. Our results also suggest that knocking down hippocampal Zif268 during ORM reconsolidation deletes the active recognition memory trace.

On the Involvement of BDNF Signaling in Memory Reconsolidation.

When retrieval occurs concomitantly with novelty detection, mismatch perception or reactivation of conflicting information, consolidated memories can enter into a labile state, and to persist, must be restabilized through a protein synthesis-dependent reconsolidation process during which their strength and content can be modified. Extensive literature implicates brain-derived neurotrophic factor (BDNF), a key regulator of synaptogenesis and synaptic plasticity, in the acquisition, consolidation and extinction of several memory types. However, the participation of BDNF in memory reconsolidation has been less studied. In this review, we discuss recent reports supporting the involvement of BDNF signaling in reactivation-induced memory updating.

An Influenza Virus Hemagglutinin-Based Vaccine Platform Enables the Generation of Epitope Specific Human Cytomegalovirus Antibodies.

Human cytomegalovirus (CMV) is a highly prevalent pathogen with ~60%-90% seropositivity in adults. CMV can contribute to organ rejection in transplant recipients and is a major cause of birth defects in newborns. Currently, there are no approved vaccines against CMV. The epitope of a CMV neutralizing monoclonal antibody against a conserved region of the envelope protein gH provided the basis for a new CMV vaccine design. We exploited the influenza A virus as a vaccine platform due to the highly immunogenic head domain of its hemagglutinin envelope protein. Influenza A variants were engineered by reverse genetics to express the epitope of an anti-CMV gH neutralizing antibody that recognizes native gH into the hemagglutinin antigenic Sa site. We determined that the recombinant influenza variants expressing 7, 10, or 13 residues of the anti-gH neutralizing antibody epitope were recognized and neutralized by the anti-gH antibody 10C10. Mice vaccinated with the influenza/CMV chimeric viruses induced CMV-specific antibodies that recognized the native gH protein and inhibited virus infection. In fact, the influenza variants expressing 7-13 gH residues neutralized a CMV infection at ~60% following two immunizations with variants expressing the 13 residue gH peptide produced the highest levels of neutralization. Collectively, our study demonstrates that a variant influenza virus inserted with a gH peptide can generate a humoral response that limits a CMV infection.

FINDRISC Modified for Latin America as a Screening Tool for Persons with Impaired Glucose Metabolism in Ciudad Bolívar, Venezuela.

OBJECTIVE: The Finnish Diabetes Risk Score (FINDRISC) includes anthropometric, metabolic, and lifestyle factors that predict type 2 diabetes mellitus. The objective of this study was to evaluate the FINDRISC modified for Latin America (LA-FINDRISC) as a screening tool for persons with impaired glucose metabolism in Ciudad Bolívar, Venezuela. METHODS: Subjects aged between 18 and 70 years of both sexes without known diabetes were invited to participate. After informed consent, they were screened with the LA-FINDRISC questionnaire and then given an oral glucose tolerance test, using the American Diabetes Association criteria for diagnosis. To obtain the cutoff point of LA-FINDRISC for predicting impaired glucose regulation, a receiver operating characteristic curve was constructed. RESULTS: A total of 200 subjects were evaluated, 64.5% female, with a mean age of 35.20 ± 13.84 years. Of these, 158 (79%) did not present with carbohydrate metabolism disorder, while 42 (21%) did. Age (p = 0.0001), body mass index (p = 0.011), and waist circumference (p = 0.031) were significantly higher in subjects with impaired glucose regulation when compared to those without it. There were a significantly greater number of sedentary (p = 0.039) and hypertensive subjects (p = 0.0001), as well as those with a history of glucose >100 mg/dL (p = 0.0001), in the impaired glucose metabolism group. A cutoff LA-FINDRISC of 14 points predicted a high risk of impaired glucose regulation with a sensitivity of 45.2% and a specificity of 89.9%. CONCLUSION: A LA-FINDRISC >14 points had low sensitivity but high specificity for predicting carbohydrate metabolism disorders in this group of patients from Ciudad Bolívar.