Evaluation of a multimodal diagnostic algorithm for prediction of cognitive impairment in elderly patients with dizziness

BACKGROUND

The current diagnostic workup for chronic dizziness in elderly patients often neglects neuropsychological assessment, thus missing a relevant proportion of patients, who perceive dizziness as a subjective chief complaint of a concomitant cognitive impairment. This study aimed to establish risk prediction models for cognitive impairment in chronic dizzy patients based on data sources routinely collected in a dizziness center.

METHODS

One hundred patients (age: 74.7 ± 7.1 years, 41.0% women) with chronic dizziness were prospectively characterized by (1) neuro-otological testing, (2) quantitative gait assessment, (3) graduation of focal brain atrophy and white matter lesion load, and (4) cognitive screening (MoCA). A linear regression model was trained to predict patients' total MoCA score based on 16 clinical features derived from demographics, vestibular testing, gait analysis, and imaging scales. Additionally, we trained a binary logistic regression model on the same data sources to identify those patients with a cognitive impairment (i.e., MoCA < 25).

RESULTS

The linear regression model explained almost half of the variance of patients' total MoCA score (R2 = 0.49; mean absolute error: 1.7). The most important risk-predictors of cognitive impairment were age (β = - 0.75), pathological Romberg's sign (β = - 1.05), normal caloric test results (β = - 0.8), slower timed-up-and-go test (β = - 0.67), frontal (β = - 0.6) and temporal (β = - 0.54) brain atrophy. The binary classification yielded an area under the curve of 0.84 (95% CI 0.70-0.98) in distinguishing between cognitively normal and impaired patients.

CONCLUSIONS

The need for cognitive testing in patients with chronic dizziness can be efficiently approximated by available data sources from routine diagnostic workup in a dizziness center.

Spontaneous visual exploration during locomotion in patients with phobic postural vertigo

Background

Earlier studies on stance and gait with posturographic and EMG-recordings and automatic gait analysis in patients with phobic postural vertigo (PPV) or visual height intolerance (vHI) revealed similar patterns of body stiffening with muscle co-contraction and a slow, cautious gait. Visual exploration in vHI patients was characterized by a freezing of gaze-in-space when standing and reduced horizontal eye and head movements during locomotion.

Objective

Based on the findings in vHI patients, the current study was performed with a focus on visual control of locomotion in patients with PPV while walking along a crowded hospital hallway.

Methods

Twelve patients with PPV and eleven controls were recruited. Participants wore a mobile infrared video eye-tracking system that continuously measured eye-in-head movements in the horizontal and vertical planes and head orientation and motion in the yaw, pitch, and roll planes. Visual exploration behavior of participants was recorded at the individually preferred speed for a total walking distance of 200 m. Gaze-in-space directions were determined by combining eye-in-head and head-in-space orientation. Walking speeds were calculated based on the trial duration and the total distance traversed. Participants were asked to rate their feelings of discomfort during the walk on a 4-point numeric rating scale. The examiners rated the crowdedness of the hospital hallway on a 4-point numeric rating scale.

Results

The major results of visual exploration behavior in patients with PPV in comparison to healthy controls were: eye and head positions were directed more downward in the vertical plane towards the ground ahead with increased frequency of large amplitude vertical orientation movements towards the destination, the end of the ground straight ahead. The self-adjusted speed of locomotion was significantly lower in PPV. Particularly those patients that reported high levels of discomfort exhibited a specific visual exploration of their horizontal surroundings. The durations of fixating targets in the visual surroundings were significantly shorter as compared to controls.

Conclusion

Gaze control of locomotion in patients with PPV is characterized by a preferred deviation of gaze more downward and by horizontal explorations for suitable auxiliary means for potential postural support in order to prevent impending falls. These eye movements have shorter durations of fixation as compared to healthy controls and patients with vHI. Finally, the pathological alterations in eye–head coordination during locomotion correlate with a higher level of discomfort and anxiety about falling.

Reversible intermolecular-coupled-intramolecular (RICI) proton transfer occurring on the reaction-radius a of 2-naphthol-6,8-disulfonate photoacid

Steady-state and time-resolved fluorescence techniques were employed to study the excited-state proton transfer (ESPT) from a reversibly dissociating photoacid, 2-naphthol-6,8-disulfonate (2N68DS). The reaction was carried out in water and in acetonitrile-water solutions. We find by carefully analyzing the geminate recombination dynamics of the photobase-proton pair that follows the ESPT reaction that there are two targets for the proton back-recombination reaction: the original O^- dissociation site and the SO₃ ^- side group at the 8 position which is closest to the proton OH dissociation site. This observation is corroborated in acetonitrile-water mixtures of χ_water < 0.14, where a slow intramolecular ESPT occurs on a time scale of about 1 ns between the OH group and the SO₃ ^- group via H-bonding water. The proton-transferred R^*O^- fluorescence band in mixtures of χ_water < 0.14 where only intramolecular ESPT occurs is red shifted by about 2000 cm^-1 from the free R^*O^- band in neat water. As the water content in the mixture increases above χ_water = 0.14, the R^*O^- fluorescence band shifts noticeably to the blue region. For χ_water > 0.23 the band resembles the free anion band observed in pure water. Concomitantly, the ESPT rate increases when χ_water increases because the intermolecular ESPT to the solvent (bulk water) gradually prevails over the much slower intramolecular via the water-bridges ESPT process.

Excited-State Proton Transfer to H2O in Mixtures of CH3CN-H2O of a Superphotoacid, Chlorobenzoate Phenol Cyanine Picolinium (CBCyP)

Steady-state and time-resolved fluorescence techniques were employed to study a superphotoacid with a p K_a* of ∼-7, the chlorobenzoate phenol cyanine picolinium salt (CBCyP) in acetonitrile-water mixtures. We found that the time-resolved fluorescence is bimodal. The amplitude of the short-time component depends on χ_water; the larger χ_water, the greater the amplitude. We found that the excited-state proton-transfer (ESPT) rate constant, k_PT, is ≥5 × 10¹² s^-1 in mixtures of χ_water ≥ 0.08, whereas in neat water, k_PT = 6 × 10¹² s^-1. The long-time component has a lifetime of 50 ps at χ_water = 0.75. We attribute this time component to the CBCyP molecules that are not hydrogen-bonded to H₂O clusters. The results suggest that the ESPT rate constant to water in acetonitrile-water mixtures depends only slightly on the water cluster size and structure surrounding the CBCyP molecule. We attribute the independence of the ESPT rate on the average water-cluster size to the large photoacidity of CBCyP. QM TD-DFT calculations found that in the excited-state the RO^-(S₁) species that is formed by the ESPT process is more stable than the ROH(S₁) species by -5 kcal/mol when four water molecules accept the proton, and when six water molecules accept the proton, the RO^-(S₁) drops to -10 kcal/mol. The calculations show that energy stabilities are kept constant in implicit CH₃CN-H₂O solvent mixtures of dielectric constant of ε ≥ 45.

Excited-State Proton Transfer of Phenol Cyanine Picolinium Photoacid

Steady-state and time-resolved fluorescence techniques as well as quantum-mechanical calculations were used to study the photophysics and photochemistry of a newly synthesized photoacid-the phenol cyanine picolinium salt. We found that the nonradiative rate constant k nr of the excited protonated form of the photoacid is larger than that of the excited-state proton transfer (ESPT) to the solvent, k ESPT. We estimate that the quantum efficiency of the ESPT process is about 0.16. The nonradiative process is explained by a partial trans-cis isomerization reaction, which leads to the formation of a "dark" excited state that can cross to the ground state by nonadiabatic coupling. Moreover, the ESPT process is coupled to the photo-isomerization reaction, as this latter reaction enhances the photoacidity of the studied compound, as a result of photoinduced charge transfer. To prevent trans-cis isomerization of the cyanine bridge, we conducted experiments of PCyP adsorbed on cellulose in the presence of water. We found that the steady-state fluorescence intensity increased by about a factor of 50 and the lifetime of the ROH band increased by the same factor. The fluorescence intensity of the RO- band with respect to that of the ROH band was the same as in aqueous solution. This explains why inhibiting the photo-isomerization reaction by adsorbing the PCyP on cellulose does not lead to a higher ESPT rate.

Mutagenic induction of an ultra-fast water-chain proton wire

Replacement of the hydroxyl group of a hydrophilic sidechain by an H atom in the proton wire of GFP induces formation of a water-chain proton wire. Surprisingly, this "non-native" water chain functions as a proton wire with response times within 10 ps of the wild type protein. This remarkable rate retention is understood as a natural consequence of the well-known Grotthuss mechanism of proton transfer in water.

Irradiation by blue light in the presence of a photoacid confers changes to colony morphology of the plant pathogen Colletotrichum gloeosporioides

We used the photoacid 8-hydroxy-1,3,6-pyrenetrisulfonate (HPTS) that converts blue photons to acidic protons in water, with an efficiency of close to 100%, and determined that this treatment conferred changes to colony morphology of the plant pathogen Colletotrichum gloeosporioides. The time elapsed until hyphal collapse is noticed depends on both the laser intensity in mW/cm², and the concentration of HPTS in the Agar hydrogel. The time elapsed until hyphal collapse is noticed varies by only ±8% at HPTS concentrations of 500μM and at lower concentrations of HPTS the variance increases as the inverse of the concentration. We found that the effect on C. gloeosporioides was photoacid concentration and irradiation dose dependent. In the presence of 500μM of HPTS within the agar hydrogel-based medium, hyphae collapsed after 37±3.5min of irradiation at 405nm at an intensity of 25mW/cm². We propose two mechanisms for such photo-alteration of C. gloeosporioides. One is based on the pH drop in the extracellular environment by the photo-protolytic process that the photoacid molecule undergoes. The second mechanism is based on an intracellular mechanism in which there is an uptake of HPTS into the interior of the fungus. We suggest that both mechanisms for photo-alteration which we found in this study may occur in plants during fungal infection.

New Phenol Benzoate Cyanine Picolinium Salt Photoacid Excited-State Proton Transfer

Steady-state and time-resolved fluorescence techniques were employed to study the excited-state proton transfer (ESPT) to water and D₂O of a new photoacid, phenol benzoate cyanine picolinium salt (BCyP). We found that the ground-state pK_a is about 6.5, whereas the excited-state pK_a* is about -4.5. The ESPT rate constant, k_PT, to water is ∼0.5 × 10¹²s^-1 (τ_PT ≈ 2 ps) and in D₂O the rate is 0.33 × 10¹² s^-1. We determined that the BCyP photoacid belongs to the third regime of photoacids, the solvent-controlled regime.

Photoprotolytic Processes of Lumazine

Steady-state and time-resolved UV-vis spectroscopies were used to study the photoprotolytic properties of lumazine, which belongs to a class of biologically important compounds-the petridines. We found that in water an excited-state proton transfer occurs with a time constant of ∼70 ps and competes with a nonradiative rate of about the same value. The nonradiative rate of the protonated form of lumazine in polar and nonpolar solvents is large k_nr ≥ 1.5 × 10¹⁰s^-1. The fluorescence properties indicate that in water, the ground-state neutral form of lumazine is already stable in two tautomeric forms. The fluorescence of the deprotonated form is quenched by protons in acidic solutions with a diffusion-controlled reaction rate. We conclude that the neutral form of lumazine is an irreversible mild photoacid.

[Fear of Heights in Primary School Children]

The life-time prevalence of visual height intolerance in adults is 28 percent, whereas in primary school children, as recently shown, it develops in 34 percent. Triggers and symptoms are similar in children and adults. A significant difference in visual height intolerance of prepubertal children compared to adults is the good prognosis with mostly spontaneous remission within a few years, possibly facilitated by repeated exposure to the triggering situations.

Photoprotolytic Processes of Umbelliferone and Proposed Function in Resistance to Fungal Infection

The photoprotolytic processes of 7-hydroxy-coumarin (Umb) were investigated by steady-state and time-resolved-fluorescence techniques. We found that the Umb compound is a photoacid with pK(a)* ≈ 0.4 and a rate constant of the excited-state proton transfer (ESPT) to water of 2 × 10(10) s(-1). Umb is also a photobase and accepts an excess proton in solution and also directly from weak acids like acetic acid. When Umb is adsorbed on cellulose it also functions as a photoacid and a photobase. Hydroxycoumarins are known to accumulate next to fungal-, bacterial-, and viral-infected regions in the leaves and stems of plants in general and also in trees. We propose that these compounds when irradiated by sunlight UV, combat the fungi or bacteria by excited-state proton-transfer reactions. These photoprotolytic reactions provide a universal resistance mechanism to infections in plants.

Excited-State Proton Transfer in Resveratrol and Proposed Mechanism for Plant Resistance to Fungal Infection

Steady-state and time-resolved fluorescence techniques were employed to study the photophysics and photochemistry of trans-resveratrol. trans-Resveratrol is found in large quantities in fungi-infected grapevine-leaf tissue and plays a direct role in the resistance to plant disease. We found that trans-resveratrol in liquid solution undergoes a trans-cis isomerization process in the excited state at a rate that depends partially on the solvent viscosity, as was found in previous studies on trans-stilbene. The hydroxyl groups of the phenol moieties in resveratrol are weak photoacids. In water and methanol solutions containing weak bases such as acetate, a proton is transferred to the base within the lifetime of the excited state. When resveratrol is adsorbed on cellulose (also a component of the plant's cell wall), the cis-trans process is slow and the lifetime of the excited state increases from several tens of picoseconds in ethanol to about 1.5 ns. Excited-state proton transfer occurs when resveratrol is adsorbed on cellulose and acetate ions are in close proximity to the phenol moieties. We propose that proton transfer from excited resveratrol to the fungus acid-sensing chemoreceptor is one of the plant's resistance mechanisms to fungal infection.

Manipulating and Monitoring On-Surface Biological Reactions by Light-Triggered Local pH Alterations

Significant research efforts have been dedicated to the integration of biological species with electronic elements to yield smart bioelectronic devices. The integration of DNA, proteins, and whole living cells and tissues with electronic devices has been developed into numerous intriguing applications. In particular, the quantitative detection of biological species and monitoring of biological processes are both critical to numerous areas of medical and life sciences. Nevertheless, most current approaches merely focus on the "monitoring" of chemical processes taking place on the sensing surfaces, and little efforts have been invested in the conception of sensitive devices that can simultaneously "control" and "monitor" chemical and biological reactions by the application of on-surface reversible stimuli. Here, we demonstrate the light-controlled fine modulation of surface pH by the use of photoactive molecularly modified nanomaterials. Through the use of nanowire-based FET devices, we showed the capability of modulating the on-surface pH, by intensity-controlled light stimulus. This allowed us simultaneously and locally to control and monitor pH-sensitive biological reactions on the nanodevices surfaces, such as the local activation and inhibition of proteolytic enzymatic processes, as well as dissociation of antigen-antibody binding interactions. The demonstrated capability of locally modulating the on-surface effective pH, by a light stimuli, may be further applied in the local control of on-surface DNA hybridization/dehybridization processes, activation or inhibition of living cells processes, local switching of cellular function, local photoactivation of neuronal networks with single cell resolution and so forth.

Solvent dependence of excited-state proton transfer from pyranine-derived photoacids

Steady-state and time-resolved techniques were employed to study the excited-state proton-transfer (ESPT) rate of two newly synthesized 8-hydroxy-1,3,6-pyrenetrisulfonate (pyranine, HPTS) derived photoacids in three protic solvents, water, methanol and ethanol. The ESPT rate constant k(PT) of tris(1,1,1,3,3,3-hexafluoropropan-2-yl)-8-hydroxypyrene-1,3,6-trisulfonate, 1a, whose pK(a)* ~ -4, in water, methanol and ethanol is 3 × 10(11) s(-1), 8 × 10(9) s(-1) and 5 × 10(9) s(-1) respectively. (8-Hydroxy-N1,N3,N6-tris(2-hydroxyethyl)-N1,N3,N6-trimethylpyrene-1,3,6 trisulfonamide, 1b) is a weaker acid than 1a but still a strong photoacid with pK(a)* ~ -1 and the ESPT rate in water, methanol and ethanol is 7 × 10(10) s(-1), 4 × 10(8) s(-1) and 2 × 10(8) s(-1). We qualitatively explain our kinetic results by a Marcus-like free-energy correlation which was found to have a general form suitable for describing proton transfer reactions in both the proton-adiabatic and the proton-non-adiabatic limits.

Excited-state proton transfer of weak photoacids adsorbed on biomaterials: 8-hydroxy-1,3,6-pyrenetrisulfonate on chitin and cellulose

Time-resolved and steady-state florescence measurements were used to study the photoprotolytic process of an adsorbed photoacid on cellulose and chitin. For that purpose we used the 8-hydroxy-1,3,6-pyrenetrisulfonate (HPTS) photoacid which transfers a proton to water with a time constant of 100 ps, but is incapable of doing so in methanol or ethanol. We found that both biopolymers accept a proton from the electronically excited acidic ROH form of HPTS. The excited-state proton-transfer (ESPT) rate of HPTS adsorbed on chitin is greater than that on cellulose by a factor of 5. The ESPT on chitin also occurs in the presence of methanol or ethanol, but at a slower rate. The transferred protons can recombine efficiently with the conjugate excited base, the RO(-) form of HPTS.

Fast photoinduced reactions in the condensed phase are nonexponential

Time-resolved measurements of photoinduced reactions reveal that many ultrafast reactions in the femto- to picosecond time scale are nonexponential. In this article we provide several examples of reactions that exhibit a nonexponential rate. We explain the wide range of the nonexponential reaction by the lack of time separation between τ(s), the characteristic fast equilibration time of the population in the reactant potential well, and the longer time τ(e), the characteristic time to cross the energy barrier between the reactant and the product.

Excited-state proton transfer of weak photoacids adsorbed on biomaterials: proton transfer to glucosamine of chitosan

UV-vis steady-state and time-resolved techniques were employed to study the excited-state proton-transfer process from two weak photoacids positioned next to the surface of chitosan and cellulose. Both chitosan and cellulose are linear polysaccharides; chitosan is composed mainly of d-glucosamine units. In order to overcome the problem of the high basicity of the glucosamine, we chose 2-naphthol (pKa* ≈ 2.7) and 2-naphthol-6-sulfonate (pKa* ≈ 1.7) as the proton emitters because of their ground state pKa (≈9). Next to the 1:1 cellulose:water weight ratio, the ESPT rate of these photoacids is comparable to that of bulk water. We found that the ESPT rate of 2-naphthol (2NP) and 2-naphthol-6-sulfonate (2N6S) next to chitosan in water (1:1) weight ratio samples is higher than in bulk water by a factor of about 5 and 2, respectively. We also found an efficient ESPT process that takes place from these photoacids in the methanol environment next to the chitosan scaffold, whereas ESPT is not observed in methanolic bulk solutions of these photoacids. We therefore conclude that ESPT occurs from these photoacids to the d-glucosamine units that make up chitosan.

Insight into the structure and the mechanism of the slow proton transfer in the GFP double mutant T203V/S205A

Mutations near the fluorescing chromophore of the green fluorescent protein (GFP) have direct effects on the absorption and emission spectra. Some mutants have significant band shifts and most of the mutants exhibit a loss of fluorescence intensity. In this study we continue our investigation of the factors controlling the excited state proton transfer (PT) process of GFP, in particular to study the effects of modifications to the key side chain Ser205 in wt-GFP, proposed to participate in the proton wire. To this aim we combined mutagenesis, X-ray crystallography, steady-state spectroscopy, time-resolved emission spectroscopy and all-atom explicit molecular dynamics (MD) simulations to study the double mutant T203V/S205A. Our results show that while in the previously described GFP double mutant T203V/S205V the PT process does not occur, in the T203V/S205A mutant the PT process does occur, but with a 350 times slower rate than in wild-type GFP (wt-GFP). Furthermore, the kinetic isotope effect in the GFP double mutant T203V/S205A is twice smaller than in the wt-GFP and in the GFP single mutant S205V, which forms a novel PT pathway. On the other hand, the crystal structure of GFP T203V/S205A does not reveal a viable proton transfer pathway. To explain PT in GFP T203V/S205A, we argue on the basis of the MD simulations for an alternative, novel proton-wire pathway which involves the phenol group of the chromophore and water molecules infrequently entering from the bulk. This alternative pathway may explain the dramatically slow PT in the GFP double mutant T203V/S205A compared to wt-GFP.