Cognitive impairment in recipients of liver transplantation and relation to hepatic encephalopathy

Background Liver transplantation (LT) helped to save the life of end stage liver disease (ESLD) patients; however, there is a debate on the persistence of cognitive impairment. The study aimed to evaluate cognitive functions in patients with ESLD before and after liver transplantation and to assess its relation to hepatic encephalopathy (HE). Thirty recipients 47.6 ± 11 years undergone living donor liver transplantation at the transplantation center of both Ain Shams Center for Organ Transplant and Egypt air organ transplant unit were prospectively assessed by Trail Making Test, Wechsler Memory Scale–Revised, Benton Visual Retention—for the evaluation of cognitive functions before and 3 months after transplantation. Results The mean age of the patients was 47.6 ± 11 years, 17 males and 13 females. Eight out of 30 (26.7%) had past history of hepatic encephalopathy. The study reported significant improvement in the post-operative 3 months scores of Trail Making Test part (A), the digit span forward test, digit span backward test and the correct score difference of the Benton Visual Retention, as p value was (0.02), (0.01) (0.02), and (0.01) respectively, compared to the pre-operative scores. However, there was no difference in the scores of part (B), verbal association I, II, information subtest of WMS. Cognitive performance showed no significant difference between patients with or without history of HE. Conclusions Patients with ESLD have significant cognitive impairment that showed improvement after LT; HE did not correlate with cognitive function. Hence, transplantation has a favorable outcome on the cognitive impairment.

Brazilian Jiu-Jitsu–Related Post-Concussion Symptoms Ameliorated With Neurorehabilitation

ObjectiveDiscuss neurorehabilitation efficacy in a case of concussion without direct head impact.BackgroundWhile there is growing concern about the prevalence and severity of concussion in mixed martial arts, a grappling component, Brazilian Jiu-Jitsu, is not typically perceived as high risk. Rapid acceleration or deceleration without direct head trauma led to a concussion for a 15-year-old male during jiu-jitsu throwing drills. The subject and parents reported difficulty with academic performance, social interactions, and emotional regulation. Symptoms persisted for 4 months before care was sought by the subject and his parents. Without direct head trauma or impact, concussion was not initially suspected.Design/MethodsThirteen sessions of treatment were performed in a neurorehabilitation setting utilizing joint manipulation, vestibular rehabilitation with a whole-body off-axis rotation device, oculomotor exercises, neuromuscular re-education, and electrical stimulation. C3 Logix was utilized as a baseline (immediately preceding second treatment due to equipment difficulties) and at discharge to measure effects of treatment.ResultsData is reported as “(baseline, discharge, percent-change).” Graded Symptom Checklist score out of 162 (91, 20; −78.02%), Trail Making Test A (sec) (26.8, 19.7; −26.49%), Trail Making Test B (sec) (69.9, 37.9; −45.78%), Digit-Symbol Matching speed (# of symbols) (66, 71; +7.58%), Choice reaction time (msec) (452, 397; −12.17), Static:Dynamic Visual Acuity (line difference) (1, 0.4; −60%). Subjectively, the subject and his parents reported improved academic performance, social interactions, and emotional regulation leading to a better home and educational experience for all involved.ConclusionsThis case displays positive clinical improvements with a functional neurology approach to outpatient neurorehabilitation. Further investigation into this multimodal rehabilitation for post-concussion symptoms, with and without direct head impact, is recommended. Continued concussion education and awareness are recommended for sports with rapid acceleration or deceleration and limited direct head impact.

Rehabilitation of Persistent Symptoms and Neurocognitive Deficits Following Sports-Related Concussion in a Professional Hockey Player: Case Study

ObjectiveTo demonstrate decreased post-concussive symptomatology and neurocognitive improvements in a professional hockey player following a multimodal, functional neurology approach to neurorehabilitation.BackgroundHockey is one of the top 3 sports in which concussions occur and has one of the top 10 highest participation numbers of sports in the northern hemisphere. The investigation of treatment modalities is warranted given the prevalence of hockey throughout society. This case study presents a 31-year-old male professional hockey athlete who had sustained 5 diagnosed concussions with additional suspected concussions throughout his career. His symptoms remained after independently receiving physical therapy and vestibular rehabilitation, causing an inability to continue playing hockey at a professional level.Design/MethodsThe patient was prescribed 10 treatment sessions over 5 contiguous days at an outpatient neurorehabilitation center specializing in functional neurology. The C3Logix neurocognitive assessment and graded symptom checklist were utilized at intake and discharge. Multimodal treatment interventions included transcranial photobiomodulation, non-invasive neuromodulation of the lingual branch of the trigeminal nerve, hand-eye coordination training, vestibular rehabilitation utilizing a three-axis whole-body off-axis rotational device, and cognitive training.ResultsOn intake, their composite symptom score was reported as 16/162, Trail Making Test Part B was 24.1 seconds, Simple Reaction Time was 274 milliseconds, and Choice Reaction Time was 496 milliseconds. On discharge, the patient experienced an 81% in self-reported symptoms, Trail Making Test Part B improved to 17 seconds (+29.46%), Simple Reaction Time was 252 milliseconds (8% faster), and Choice Reaction Time was 465 milliseconds (24% faster).ConclusionsThe present case study results demonstrated meaningful improvements in both self-rated concussion symptoms and neurocognitive performance for this patient. The Press suggest further investigation into functional neurology-based, multimodal, intensive approaches to decrease chronic post-concussion symptoms and improve neurocognitive performance in athletes that engage in hockey.

Association of Negative Symptoms of Schizophrenia Assessed by the BNSS and SNS Scales With Neuropsychological Performance: A Gender Effect

Objective: The relationship between negative symptoms and neurocognitive performance in schizophrenia is well documented, but the mechanism of these connections remains unclear. The study aims to measure the relationship between the results on the new scales for the assessment of negative symptoms such as Brief Negative Symptom Scale (BNSS) and Self-evaluation of Negative Symptoms (SNS), and the results of some neurocognition tests. The second aim is to assess a possible gender effect on these associations.Methods: The study included 80 patients (40 men, 40 women) with schizophrenia, aged 19–63 (mean 38 years), during the improvement period (total PANSS score <80, unchanged pharmacological treatment in the last 3 weeks). They were assessed using the BNSS, SNS, Personal and Social Performance (PSP) scales, and the tests for neuropsychological performance such as the Trail Making Test (TMT-A, TMT-B), Stroop Color-Word Interference Test, Verbal fluency tests (VFT), Category fluency test (CFT), and Digit Symbol Substitution Test (DSST).Results: Male patients obtained higher scores than females on some PANSS and BNSS items. No gender differences were observed for the SNS scale. Female patients scored better in the PSP and CFT. In male patients, a significant positive correlation between the intensity of negative symptoms measured by the BNSS and the results of PSP with the Trail Making Test was observed. In female patients, we found a positive correlation between the results of BNSS and PSP with the Stroop Color-Word Interference Test.Conclusion: The obtained results confirm the relationship between negative symptoms and neurocognition in schizophrenia patients. However, in male and female patients such association was observed for different cognitive domains. Further research is needed to explain the nature of these differences.

Change in Balance and Neuropsychological Measures Post-Lumbar Drain Trial in Patients with Suspected Normal Pressure Hydrocephalus

<b><i>Objective:</i></b> Ventriculoperitoneal (VP) shunting is commonly used to treat normal pressure hydrocephalus (NPH). Assessment of cognition and balance pre- and post-lumbar drain (LD) can be used to provide objective metrics which may help determine the potential benefit of VP shunting. The aim of this investigation was to determine which measures identify clinical change as a result of a LD trial and to develop recommendations for standard NPH clinical assessment procedures. <b><i>Methods:</i></b> The Berg Balance Scale (BBS) and a brief battery of commonly used neuropsychological tests pre- and post-LD (MMSE, trail making test, animal fluency, Hopkins Verbal Learning Test – Revised, and digit span) were administered to 86 patients with a diagnosis of NPH. Subjects were divided into groups based on whether or not clinical change was present, and thus, VP shunting was recommended post-LD, and predictors of group membership were examined. <b><i>Results:</i></b> Significant improvements (<i>p</i> &#x3c; 0.05) were seen on the BBS and Trail Making Part B in the VP shunt-recommended group, with no other significant changes over time in either group. Regression analyses found that VP shunt recommendation was accurately predicted for 80% of the sample using the BBS score alone, with accuracy increasing to 85% when Trails B was added. <b><i>Conclusions:</i></b> Scores from the BBS and Trails B were most likely to change in those chosen to undergo VP shunting post-LD. Given that the typical clinical presentation of NPH includes gait disturbance and cognitive impairment, it is recommended that a standard pre-/post-LD evaluation include the BBS and trail making test.

Lower Cognitive Set Shifting Ability Is Associated With Stiffer Balance Recovery Behavior and Larger Perturbation-Evoked Cortical Responses in Older Adults

The mechanisms underlying associations between cognitive set shifting impairments and balance dysfunction are unclear. Cognitive set shifting refers to the ability to flexibly adjust behavior to changes in task rules or contexts, which could be involved in flexibly adjusting balance recovery behavior to different contexts, such as the direction the body is falling. Prior studies found associations between cognitive set shifting impairments and severe balance dysfunction in populations experiencing frequent falls. The objective of this study was to test whether cognitive set shifting ability is expressed in successful balance recovery behavior in older adults with high clinical balance ability (N = 19, 71 ± 7 years, 6 female). We measured cognitive set shifting ability using the Trail Making Test and clinical balance ability using the miniBESTest. For most participants, cognitive set shifting performance (Trail Making Test B-A = 37 ± 20 s) was faster than normative averages (46 s for comparable age and education levels), and balance ability scores (miniBESTest = 25 ± 2/28) were above the threshold for fall risk (23 for people between 70 and 80 years). Reactive balance recovery in response to support-surface translations in anterior and posterior directions was assessed in terms of body motion, muscle activity, and brain activity. Across participants, lower cognitive set shifting ability was associated with smaller peak center of mass displacement during balance recovery, lower directional specificity of late phase balance-correcting muscle activity (i.e., greater antagonist muscle activity 200–300 ms after perturbation onset), and larger cortical N1 responses (100–200 ms). None of these measures were associated with clinical balance ability. Our results suggest that cognitive set shifting ability is expressed in balance recovery behavior even in the absence of profound clinical balance disability. Specifically, our results suggest that lower flexibility in cognitive task performance is associated with lower ability to incorporate the directional context into the cortically mediated later phase of the motor response. The resulting antagonist activity and stiffer balance behavior may help explain associations between cognitive set shifting impairments and frequent falls.

Intensity of Walking Training Impacts Cognition Among Assisted Living Residents With Frailty

Exercise has many proven cognitive benefits but the precise intensity to modify cognition is unclear. This pilot study investigated the role of exercise intensity on cognitive outcomes among assisted living residents. We enrolled n=33 frail or pre-frail residents who completed an 8 week, twice-weekly walking intervention. Participants were 66% female, and on average were 88 years old with a MMSE score=25.6, and low cognitive scores (Category Fluency Animals=10.45, Category Fluency Vegetables=7.67, Trail Making Test A=60.82 seconds, Trail Making Test B=155.18 seconds). Walking sessions used 5-minute intervals focused on maximizing steps, fast speeds, and multi-directions for 45 minutes per session. Participants in the high intensity group walked at &gt;70% heart rate maximum or RPE 15-17 and those randomized to the casual intensity group walked at &lt;60% heart rate maximum or RPE &lt;13. Results showed the casual-intensity group improved more on Category Fluency tests (increase of 0.88 animals and 1.06 vegetables) compared to the high-intensity group (increase of 0.12 animals and increase of 0.35 vegetables). On Trail Making Test A, high-intensity participants had a 7.47 second decrease in time to complete compared to the casual-intensity group (2.00 seconds increase). On Trail Making Test B, high-intensity participants decreased time to complete by 27.13 seconds compared to a 26.19 decrease in the casual-intensity group. Results show promising trends in the role of exercise intensity in impacting different elements of cognition among assisted living residents.