Spontaneous improvement in both obstructive sleep apnea and cognitive impairment after stroke

BACKGROUND

Knowledge available about the relationship between obstructive sleep apnea (OSA) and cognitive impairment after stroke is limited. The evolution of OSA and cognitive performance after stroke is not sufficiently described.

METHODS

We prospectively enrolled and examined acute stroke patients without previously diagnosed OSA. The following information was collected: (1) demographics, (2) sleep cardio-respiratory polygraphy (PG) at 72 h, day seven, month three, and month 12 after stroke, (3) post-stroke functional disability tests at entry and at months three and 12, and (4) cognition (attention and orientation, memory, verbal fluency, language, and visual-spatial abilities) using the revised Addenbrooke's Cognitive Examination (ACE-R) at months three and 12.

RESULTS

Of 68 patients completing the study, OSA was diagnosed in 42 (61.8%) patients. The mean apnea/hypopnea index (AHI) at study entry of 21.0 ± 13.7 spontaneously declined to 11.6 ± 11.2 at month 12 in the OSA group (p < 0.0005). The total ACE-R score was significantly reduced at months three (p = 0.005) and 12 (p = 0.004) in the OSA group. Poorer performance on the subtests of memory at months 3 (p = 0.039) and 12 (p = 0.040) and verbal fluency at months 3 (p < 0.005) and 12 (p < 0.005) were observed in the OSA group compared to non-OSA group. Visual-spatial abilities in both the OSA (p = 0.001) and non-OSA (p = 0.046) groups and the total ACE-R score in the OSA (p = 0.005) and non-OSA (p = 0.002) groups improved.

CONCLUSIONS

A high prevalence of OSA and cognitive decline were present in patients after an acute stroke. Spontaneous improvements in both OSA and cognitive impairment were observed.

Associated Information Increases Subjective Perception of Duration

Our sense of time is prone to various biases. For instance, one factor that can dilate an event's perceived duration is the violation of predictions; when a series of repeated stimuli is interrupted by an unpredictable oddball. On the other hand, when the probability of a repetition itself is manipulated, predictable conditions can also increase estimated duration. This suggests that manipulations of expectations have different or even opposing effects on time perception. In previous studies, expectations were generated because stimuli were repeated or because the likelihood of a sequence or a repetition was varied. In the natural environment, however, expectations are often built via associative processes, for example, the context of a kitchen promotes the expectation of plates, appliances, and other associated objects. Here, we manipulated such association-based expectations by using oddballs that were either contextually associated or nonassociated with the standard items. We find that duration was more strongly overestimated for contextually associated oddballs. We reason that top-down attention is biased toward associated information, and thereby dilates subjective duration for associated oddballs. Based on this finding, we propose an interplay between top-down attention and predictive processing in the perception of time.

Predictions penetrate perception: Converging insights from brain, behaviour and disorder

It is argued that during ongoing visual perception, the brain is generating top-down predictions to facilitate, guide and constrain the processing of incoming sensory input. Here we demonstrate that these predictions are drawn from a diverse range of cognitive processes, in order to generate the richest and most informative prediction signals. This is consistent with a central role for cognitive penetrability in visual perception. We review behavioural and mechanistic evidence that indicate a wide spectrum of domains-including object recognition, contextual associations, cognitive biases and affective state-that can directly influence visual perception. We combine these insights from the healthy brain with novel observations from neuropsychiatric disorders involving visual hallucinations, which highlight the consequences of imbalance between top-down signals and incoming sensory information. Together, these lines of evidence converge to indicate that predictive penetration, be it cognitive, social or emotional, should be considered a fundamental framework that supports visual perception.

Cortical Integration of Contextual Information across Objects

Recognizing objects in the environment and understanding our surroundings often depends on context: the presence of other objects and knowledge about their relations with each other. Such contextual information activates a set of medial lobe brain regions, the parahippocampal cortex and the retrosplenial complex. Both regions are more activated by single objects with a unique contextual association than by objects not associated with any specific context. Similarly they are more activated by spatially coherent arrangements of objects when those are consistent with their known spatial relations. The current study tested how context in multiple-object displays is represented in these regions in the absence of relevant spatial information. Using an fMRI slow-event-related design, we show that the precuneus (a subpart of the retrosplenial complex) is more activated by simultaneously presented contextually related objects than by unrelated objects. This suggests that the representation of context in this region is cumulative, representing integrated information across objects in the display. We discuss these findings in relation to processing of visual information and relate them to previous findings of contextual effects in perception.

Blood glucose control using a computer-guided glucose management system in allogeneic hematopoietic cell transplant recipients

Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative treatment for patients with hematological malignancies. However, is associated with substantial rates of morbidity and mortality. We and others have shown that malglycemia is associated with adverse transplant outcome. Therefore, improving glycemic control may improve transplant outcome. In this prospective study we evaluated the feasibility of using Glucommander (a Computer-Guided Glucose Management System; CGGM) in order to achieve improved glucose control in hospitalized HCT patients. Nineteen adult patients contributed 21 separate instances on CGGM. Patients were on CGGM for a median of 43 h. Median initial blood glucose (BG) on CGGM was 244 mg/dL, and patients on 20 study instances reached the study BG target of 100-140 mg/dL after a median of 6 h. After BG reached the target range, the median average BG level per patient was 124 mg/dL. Six patients had a total of 10 events of BG <70 mg/dL (0.9% of BG measurements), and no patients experienced BG level <40 mg/dL. The total estimated duration of BG <70 mg/dL was 3 h (0.2% of the total CGGM time). In conclusion, our study demonstrates that stringent BG control in HCT patients using CGGM is feasible.

Subliminal Visual Priming

Masked pictures of objects were flashed so briefly that only 13.5% of them could be named. Forced-choice accuracy for the unidentified objects was at chance. When the pictures were shown again, about 15 min and 20 intervening trials later, without any indication of possible repetitions, naming accuracy increased to 34.5%. The priming was completely visual, rather than semantic or verbal, as there was no priming of same-name, different-shape images. This is the first demonstration of facilitatory visual recognition priming by unidentified pictures when the subject could not anticipate if, when, or where the previously unidentified picture was to be shown again. A change in the position of the object reduced but did not eliminate the priming, allowing a speculation that the locus of subliminal visual priming is at an intermediate stage in the ventral cortical pathway for shape recognition.

Forming first impressions of others in schizophrenia: impairments in fast processing and in use of spatial frequency information

Individuals form first impressions of others all the time, which affects their social functioning. Typical adults form threat impressions in faces with neutral expressions quickly, requiring less than 40 ms. These impressions appear to be mediated by low spatial frequency (LSF) content in the images. Little is known, however, about mechanisms of first impression formation in schizophrenia. The current study investigated how quickly individuals with schizophrenia can form consistent impressions of threat compared with controls and explored the mechanisms involved. Patients and controls were presented intact, LSF- or high spatial frequency (HSF)-filtered faces with durations that varied from 39 to 1703 ms and were asked to rate how threatening each face was on a scale from 1 to 5. In order to assess the speed of impression formation for intact faces, correlations were calculated for ratings made at each duration compared to a reference duration of 1703 ms for each group. Controls demonstrated a significant relation for intact faces presented for 39 ms, whereas patients required 390 ms to demonstrate a significant relation with the reference duration. For controls, LSFs primarily contributed to the formation of consistent threat impressions at 39 ms, whereas patients showed a trend for utilizing both LSF and HSF information to form consistent threat impressions at 390 ms. Results indicate that individuals with schizophrenia require a greater integration time to form a stable "first impression" of threat, which may be related to the need to utilize compensatory mechanisms such as HSF, as well as LSF, information.

The proactive brain and the fate of dead hypotheses

A substantial portion of information flow in the brain is directed top-down, from high processing areas downwards. Signals of this sort are regarded as conveying prior expectations, biasing the processing and eventual perception of incoming stimuli. In this perspective we describe a framework of top-down processing in the visual system in which predictions on the identity of objects in sight aid in their recognition. Focus is placed, in particular, on a relatively uncharted ramification of this framework, that of the fate of initial predictions that are eventually rejected during the process of selection. We propose that such predictions are rapidly inhibited in the brain after a competing option has been selected. Empirical support, along with behavioral, neuronal and computational aspects of this proposal are discussed, and future directions for related research are offered.

Direction of magnetoencephalography sources associated with feedback and feedforward contributions in a visual object recognition task

Identifying inter-area communication in terms of the hierarchical organization of functional brain areas is of considerable interest in human neuroimaging. Previous studies have suggested that the direction of magneto- and electroencephalography (MEG, EEG) source currents depend on the layer-specific input patterns into a cortical area. We examined the direction in MEG source currents in a visual object recognition experiment in which there were specific expectations of activation in the fusiform region being driven by either feedforward or feedback inputs. The source for the early non-specific visual evoked response, presumably corresponding to feedforward driven activity, pointed outward, i.e., away from the white matter. In contrast, the source for the later, object-recognition related signals, expected to be driven by feedback inputs, pointed inward, toward the white matter. Associating specific features of the MEG/EEG source waveforms to feedforward and feedback inputs could provide unique information about the activation patterns within hierarchically organized cortical areas.

Neural Correlates of Subliminal Language Processing

Language is a high-level cognitive function, so exploring the neural correlates of unconscious language processing is essential for understanding the limits of unconscious processing in general. The results of several functional magnetic resonance imaging studies have suggested that unconscious lexical and semantic processing is confined to the posterior temporal lobe, without involvement of the frontal lobe—the regions that are indispensable for conscious language processing. However, previous studies employed a similarly designed masked priming paradigm with briefly presented single and contextually unrelated words. It is thus possible, that the stimulation level was insufficiently strong to be detected in the high-level frontal regions. Here, in a high-resolution fMRI and multivariate pattern analysis study we explored the neural correlates of subliminal language processing using a novel paradigm, where written meaningful sentences were suppressed from awareness for extended duration using continuous flash suppression. We found that subjectively and objectively invisible meaningful sentences and unpronounceable nonwords could be discriminated not only in the left posterior superior temporal sulcus (STS), but critically, also in the left middle frontal gyrus. We conclude that frontal lobes play a role in unconscious language processing and that activation of the frontal lobes per se might not be sufficient for achieving conscious awareness.

If it bleeds, it leads: separating threat from mere negativity

Most theories of emotion hold that negative stimuli are threatening and aversive. Yet in everyday experiences some negative sights (e.g. car wrecks) attract curiosity, whereas others repel (e.g. a weapon pointed in our face). To examine the diversity in negative stimuli, we employed four classes of visual images (Direct Threat, Indirect Threat, Merely Negative and Neutral) in a set of behavioral and functional magnetic resonance imaging studies. Participants reliably discriminated between the images, evaluating Direct Threat stimuli most quickly, and Merely Negative images most slowly. Threat images evoked greater and earlier blood oxygen level-dependent (BOLD) activations in the amygdala and periaqueductal gray, structures implicated in representing and responding to the motivational salience of stimuli. Conversely, the Merely Negative images evoked larger BOLD signal in the parahippocampal, retrosplenial, and medial prefrontal cortices, regions which have been implicated in contextual association processing. Ventrolateral as well as medial and lateral orbitofrontal cortices were activated by both threatening and Merely Negative images. In conclusion, negative visual stimuli can repel or attract scrutiny depending on their current threat potential, which is assessed by dynamic shifts in large-scale brain network activity.

ATTRIBUTES OF FORM IN THE BUILT ENVIRONMENT THAT INFLUENCE PERCEIVED WALKABILITY

A recent focus of design and building regulations, including form-based codes and the Leadership in Energy and Environmental Design for Neighborhood Development rating system, has been on promoting pedestrian activity. This study assessed perceptions of walkability for residential and commercial streetscapes with different design attributes in order to inform form-based regulations and codes that aim to impact walkability. We scored 424 images on four design attributes purported to influence walkability: variation in building height, variation in building plane, presence of ground-floor windows, and presence of a street focal point. We then presented the images to 45 adults, who were asked to rate the images for walkability. The results showed that perceived walkability varied according to the degree to which a particular design attribute was present, with the presence of ground-floor windows and a street focal point most consistently associated with a space's perceived walkability. Understanding if and which design attributes are most related to walkability could allow planners and developers to focus on the most salient built-environment features influencing physical activity, as well as provide empirical scientific evidence for form-based regulations and zoning codes aimed at impacting walkabilit.

The role of the parahippocampal cortex in cognition

The parahippocampal cortex (PHC) has been associated with many cognitive processes, including visuospatial processing and episodic memory. To characterize the role of PHC in cognition, a framework is required that unifies these disparate processes. An overarching account was proposed whereby the PHC is part of a network of brain regions that processes contextual associations. Contextual associations are the principal element underlying many higher-level cognitive processes, and thus are suitable for unifying the PHC literature. Recent findings are reviewed that provide support for the contextual associations account of PHC function. In addition to reconciling a vast breadth of literature, the synthesis presented expands the implications of the proposed account and gives rise to new and general questions about context and cognition.

Visual predictions in the orbitofrontal cortex rely on associative content

Predicting upcoming events from incomplete information is an essential brain function. The orbitofrontal cortex (OFC) plays a critical role in this process by facilitating recognition of sensory inputs via predictive feedback to sensory cortices. In the visual domain, the OFC is engaged by low spatial frequency (LSF) and magnocellular-biased inputs, but beyond this, we know little about the information content required to activate it. Is the OFC automatically engaged to analyze any LSF information for meaning? Or is it engaged only when LSF information matches preexisting memory associations? We tested these hypotheses and show that only LSF information that could be linked to memory associations engages the OFC. Specifically, LSF stimuli activated the OFC in 2 distinct medial and lateral regions only if they resembled known visual objects. More identifiable objects increased activity in the medial OFC, known for its function in affective responses. Furthermore, these objects also increased the connectivity of the lateral OFC with the ventral visual cortex, a crucial region for object identification. At the interface between sensory, memory, and affective processing, the OFC thus appears to be attuned to the associative content of visual information and to play a central role in visuo-affective prediction.

Affective value and associative processing share a cortical substrate

The brain stores information in an associative manner so that contextually related entities are connected in memory. Such associative representations mediate the brain's ability to generate predictions about which other objects and events to expect in a given context. Likewise, the brain encodes and is able to rapidly retrieve the affective value of stimuli in our environment. That both contextual associations and affect serve as building blocks of numerous mental functions often makes interpretation of brain activation ambiguous. A critical brain region where such activation has often resulted in equivocal interpretation is the medial orbitofrontal cortex (mOFC), which has been implicated separately in both affective and associative processing. To characterize its role more unequivocally, we tested whether activity in the mOFC was most directly attributable to affective processing, associative processing, or a combination of both. Subjects performed an object recognition task while undergoing fMRI scans. Objects varied independently in their affective valence and in their degree of association with other objects (associativity). Analyses revealed an overlapping sensitivity whereby the left mOFC responded both to increasingly positive affective value and to stronger associativity. These two properties individually accounted for mOFC response, even after controlling for their interrelationship. The role of the mOFC is either general enough to encompass associations that link stimuli both with reinforcing outcomes and with other stimuli or abstract enough to use both valence and associativity in conjunction to inform downstream processes related to perception and action. These results may further point to a fundamental relationship between associativity and positive affect.