Cognitive, Affective, & Behavioral Neuroscience

The mind minds minds: The effect of intentional stance on the neural encoding of joint attention Abstract Recent neuroimaging studies have observed that the neural processing of social cues from a virtual reality character appears to be affected by "intentional stance" (i.e., attributing mental states, agency, and "humanness"). However, this effect could also be explained by individual differences or perceptual effects resulting from the design of these studies. The current study used a new design that measured centro-parietal P250, P350, and N170 event-related potentials (ERPs) in 20 healthy adults while they initiated gaze-related joint attention with a virtual character ("Alan") in two conditions. In one condition, they were told that Alan was controlled by a human; in the other, they were told that he was controlled by a computer. When participants believed Alan was human, his congruent gaze shifts, which resulted in joint attention, generated significantly larger P250 ERPs than his incongruent gaze shifts. In contrast, his incongruent gaze shifts triggered significantly larger increases in P350 ERPs than his congruent gaze shifts. These findings support previous studies suggesting that intentional stance affects the neural processing of social cues from a virtual character. The outcomes also suggest the use of the P250 and P350 ERPs as objective indices of social engagement during the design of socially approachable robots and virtual agents.

Mapping articulatory and grammatical subcomponents of fluency deficits in post-stroke aphasia Abstract Fluent speech production is a critical aspect of language processing and is central to aphasia diagnosis and treatment. Multiple cognitive processes and neural subsystems must be coordinated to produce fluent narrative speech. To refine the understanding of these systems, measures that minimize the influence of other cognitive processes were defined for articulatory deficits and grammatical deficits. Articulatory deficits were measured by the proportion of phonetic errors (articulatory and prosodic) in a word repetition task in 115 participants with aphasia following left hemisphere stroke. Grammatical deficits were assessed in 46 participants based on two measures—proportion of closed class words and proportion of words in sentences—generated during semistructured narrative speech production (telling the Cinderella story). These measures were used to identify brain regions critical for articulatory and grammatical aspects of speech production using a multivariate lesion-symptom mapping approach based on support vector regression. Phonetic error proportion was associated with damage to the postcentral gyrus and the inferior parietal lobule (particularly the supramarginal gyrus). Proportion of closed class words in narrative speech did not have consistent lesion correlates. Proportion of words in sentences was strongly associated with frontal lobe damage, particularly the inferior and middle frontal gyri. Grammatical sentence structuring relies on frontal regions, particularly the inferior and middle frontal gyri, whereas phonetic-articulatory planning and execution relies on parietal regions, particularly the postcentral and supramarginal gyri. These results clarify and extend current understanding of the functional components of the frontoparietal speech production system.

Adaptation to Animacy Violations during Listening Comprehension Abstract The goal of this study was to examine adaptation to various types of animacy violations in cartoon-like stories. We measured the event-related potentials (ERPs) elicited by words at the beginning, middle, and end of four-sentence stories in order to examine adaptation over time to conflicts between stored word knowledge and context-derived meaning (specifically, to inanimate objects serving as main characters, as they might in a cartoon). The fourth and final sentence of each story contained a predicate that required either an animate or an inanimate subject. The results showed that listeners quickly adapted to stories in the Inanimate Noun conditions, consistent with previous research (Filik & Leuthold, 2008; Nieuwland & Van Berkum, 2006). They showed evidence of processing difficulty for animacy-requiring predicates in the Inanimate Noun conditions in Sentence 1, but the effect dissipated in Sentences 2 and 3. In Sentences 2 and 4, we measured ERPs at three critical points where it was possible to observe the influence of both context-based expectations and expectations from prior knowledge on processing. Overall, the pattern of results demonstrates how listeners flexibly adapt to unusual, conflict-ridden input, using previous context to generate expectations about upcoming input, but that current context is weighted appropriately in combination with expectations from background knowledge and prior language experience.

Explore or reset? Pupil diameter transiently increases in self-chosen switches between cognitive labor and leisure in either direction Abstract When people invest effort in cognitive work, they often keep an eye open for rewarding alternative activities. Previous research suggests that the norepinephrine (NE) system regulates such trade-offs between exploitation of the current task and exploration of alternative possibilities. We examined the possibility that the NE system is involved in another trade-off, i.e., the trade-off between cognitive labor and leisure. We conducted two pre-registered studies (total N = 62) in which participants freely chose to perform either a paid 2-back task (labor) versus a non-paid task (leisure), while we tracked their pupil diameter—which is an indicator of the state of the NE system. In both studies, consistent with prior work, we found (a) increases in pupil baseline and (b) decreases in pupil dilation when participants switched from labor to leisure. Unexpectedly, we found the same pattern when participants switched from leisure back to labor. Both increases in pupil baseline and decreases in pupil dilation were short-lived. Collectively, these results are more consistent with a role of norepinephrine in reorienting attention and task switching, as suggested by network reset theory, than with a role in motivation, as suggested by adaptive gain theory.

Neural signatures underlying deliberation in human foraging decisions Abstract Humans have a remarkable capacity to mentally project themselves far ahead in time. This ability, which entails the mental simulation of events, is thought to be fundamental to deliberative decision making, as it allows us to search through and evaluate possible choices. Many decisions that humans make are foraging decisions, in which one must decide whether an available offer is worth taking, when compared to unknown future possibilities (i.e., the background). Using a translational decision-making paradigm designed to reveal decision preferences in rats, we found that humans engaged in deliberation when making foraging decisions. A key feature of this task is that preferences (and thus, value) are revealed as a function of serial choices. Like rats, humans also took longer to respond when faced with difficult decisions near their preference boundary, which was associated with prefrontal and hippocampal activation, exemplifying cross-species parallels in deliberation. Furthermore, we found that voxels within the visual cortices encoded neural representations of the available possibilities specifically following regret-inducing experiences, in which the subject had previously rejected a good offer only to encounter a low-valued offer on the subsequent trial.

How the depth of processing modulates emotional interference – evidence from EEG and pupil diameter data Abstract The ability to process emotionally conflicting information is an important requirement for emotional self-control. While it seems obvious that the impact of interfering emotional information critically depends on how deeply this interfering information is processed, it is still unknown what cognitive subprocesses are most affected by manipulating the depth of processing of emotionally interfering information. We examine these aspects integrating neurophysiological (EEG) and source localization data with pupil diameter data as an indirect index of the norepinephrine (NE) system activity. We show that when processing depth of interfering emotional stimulus dimensions is increased, emotional Stroop effects become stronger. The EEG data show that this was associated with modulations of decision-making processes, as reflected by the P3 event-related potential. Notably, the integration with pupil diameter data suggests that these decision processes were modulated by the NE system, especially when the depth of processing of interfering emotional stimulus dimensions was increased. This likely reflects gain modulation processes to facilitate processing of complex interfering, emotional information. The source localization results suggest that regions in the parietal (BA7) and insular cortex (BA13) are associated with these modulatory effects. The results suggest that overcoming more complex emotional interference triggers engagement of the norepinephrine system (indexed by pupil diameter) to facilitate action control mechanisms in a time-specific manner when deeper processing of emotional stimulus dimensions is required.

Increasing self-other bodily overlap increases sensorimotor resonance to others' pain Abstract Empathy for another person's pain and feeling pain oneself seem to be accompanied by similar or shared neural responses. Such shared responses could be achieved by mapping the bodily states of others onto our own bodily representations. We investigated whether sensorimotor neural responses to the pain of others are increased when experimentally reducing perceived bodily distinction between the self and the other. Healthy adult participants watched video clips of the hands of ethnic ingroup or outgroup members being painfully penetrated by a needle syringe or touched by a cotton swab. Manipulating the video presentation to create a visuospatial overlap between the observer's and the target's hand increased the perceived bodily self-attribution of the target's hand. For both ingroup and outgroup targets, this resulted in increased neural responses to the painful injections (compared with nonpainful contacts), as indexed by desynchronizations of central mu and beta scalp rhythms recorded using electroencephalography. Furthermore, these empathy-related neural activations were stronger in participants who reported stronger bodily self-attribution of the other person's hand. Our findings provide further evidence that empathy for pain engages sensorimotor resonance mechanisms. They also indicate that reducing bodily self-other distinction may increase such resonance for ingroup as well as outgroup targets.

Neurophysiological correlates of visuospatial attention and the social dynamics of gaze processing Abstract The reflexive orienting response triggered by nonpredictive gaze cues is thought to be driven by a dedicated social neural network responsible for directing attention toward socially salient information. However, atypical processing of eye gaze using concomitant perceptual features has been proposed to underlie attentional orienting in groups with impairments in social cognition. Here, we examined the neurophysiological indices of visuospatial attention during a spatial cueing task, considering individual variability in social cognition in typically developing individuals, and the relative salience of social gaze and perceptual motion cues. We found enhanced neural activation to incongruent cues, wherein modulation of the N2b serves as a marker of the allocation of attention in the spatial domain. Our findings suggest the social gaze cue is less salient for those with greater autistic traits. An attentional bias toward perceptual motion cues correlated with greater social anxiety and alexithymia, and thus may reflect reduced sensitivity to social stimuli. These results provide evidence for likely neurophysiological mechanisms underlying gaze cueing and offer insight into the use of qualitatively different cognitive mechanisms used to access social information. Such paradigms provide potential insight into normative orienting responses reported in atypical groups and would benefit investigations of gaze following abilities in clinical populations.

The importance of agency in human reward processing Abstract Converging evidence suggests that reinforcement learning (RL) signals exist within the human brain and that they play a role in the modification of behaviour. According to RL theory, prediction errors are used to update values associated with actions and/or predictive cues, thus facilitate decision-making. For example, the reward positivity—a feedback-sensitive component of the event-related brain potential (ERP)—is thought to index an RL prediction error. An unresolved question, however, is whether or not action is required to elicit a reward positivity. Reinforcement learning theory would predict that the reward positivity should diminish or disappear in the absence of action, but evidence for this claim is conflicting. To investigate the impact of cue, choice, and action on the amplitude of the reward positivity, we altered a two-armed bandit task by systematically removing these factors. The reward positivity was greatly reduced or absent in the altered versions of the task. This result highlights the key role of agency in producing learning signals, such as the reward positivity.

Causal underpinnings of working memory and Stroop interference control: Testing the effects of anodal and cathodal tDCS over the left DLPFC Abstract By means of transcranial direct current stimulation applied to the left dorsolateral prefrontal cortex, we investigated the causal role of increased or decreased excitability of this brain region for two facets of executive functions: working memory and Stroop interference control. We tested 1) whether anodal tDCS of the left DLPFC enhances working memory 15 minutes after termination of stimulation and in the absence of direct task practice under stimulation; 2) whether anodal tDCS of the left DLPFC enhances interference control, as evidenced by Stroop performance and Stroop sequence effects; and 3) whether cathodal tDCS leads to compromised executive functioning compared to anodal stimulation. In a between-subject design with 88 healthy psychology students, we compared the impact of anodal and cathodal stimulation against a sham condition, on performance on a Stroop task (during active stimulation) and on an n-back task (completed 15 minutes after active stimulation ended). We found significantly enhanced accuracy in the n-back task after anodal stimulation compared with sham, as well as speeded reactions in the Stroop tasks independent of trial type. By contrast, we found no modulation of Stroop interference effects or Stroop sequence effects. No inhibitory effects of cathodal stimulation were observed. These results support the causal role of the left DLPFC in working memory but lend no support to its involvement in Stroop interference control.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Psychopharmacology

NMDA receptor antagonists traxoprodil and lanicemine improve hippocampal-prefrontal coupling and reward-related networks in rats Abstract Rationale The N-methyl-d-aspartate receptor (NMDAR) antagonist ketamine is known to have not only a rapid antidepressant effect but also dissociative side effects. Traxoprodil and lanicemine, also NMDA antagonists, are candidate antidepressant drugs with fewer side effects. Objectives In order to understand their mechanism of action, we investigated the acute effects of traxoprodil and lanicemine on brain connectivity using resting-state functional magnetic resonance imaging (rs-fMRI). Methods Functional connectivity (FC) alterations were examined using interregional correlation networks. Graph theoretical methods were used for whole brain network analysis. As interest in NMDAR antagonists as potential antidepressants was triggered by the antidepressant effect of ketamine, results were compared to previous findings from our ketamine studies. Results Similar to ketamine but to a smaller extent, traxoprodil increased hippocampal-prefrontal (Hc-PFC) coupling. Unlike ketamine, traxoprodil decreased connectivity within the PFC. Lanicemine had no effect on these properties. The improvement of Hc-PFC coupling corresponds well to clinical result, showing ketamine to have a greater antidepressant effect than traxoprodil, while lanicemine has a weak and transient effect. Connectivity changes overlapping between the drugs as well as alterations of local network properties occurred mostly in reward-related regions. Conclusion The antidepressant effect of NMDA antagonists appears to be associated with enhanced Hc-PFC coupling. The effects on local network properties and regional connectivity suggest that improvement of reward processing might also be important for understanding the mechanisms underlying the antidepressant effects of these drugs.

Relative insensitivity to time-out punishments induced by win-paired cues in a rat gambling task Abstract Rationale Pairing rewarding outcomes with audiovisual cues in simulated gambling games increases risky choice in both humans and rats. However, the cognitive mechanism through which this sensory enhancement biases decision-making is unknown. Objectives To assess the computational mechanisms that promote risky choice during gambling, we applied a series of reinforcement learning models to a large dataset of choices acquired from rats as they each performed one of two variants of a rat gambling task (rGT), in which rewards on "win" trials were delivered either with or without salient audiovisual cues. Methods We used a sampling technique based on Markov chain Monte Carlo to obtain posterior estimates of model parameters for a series of RL models of increasing complexity, in order to assess the relative contribution of learning about positive and negative outcomes to the latent valuation of each choice option on the cued and uncued rGT. Results Rats which develop a preference for the risky options on the rGT substantially down-weight the equivalent cost of the time-out punishments during these tasks. For each model tested, the reduction in learning from the negative time-outs correlated with the degree of risk preference in individual rats. We found no apparent relationship between risk preference and the parameters that govern learning from the positive rewards. Conclusions The emergence of risk-preferring choice on the rGT derives from a relative insensitivity to the cost of the time-out punishments, as opposed to a relative hypersensitivity to rewards. This hyposensitivity to punishment is more likely to be induced in individual rats by the addition of salient audiovisual cues to rewards delivered on win trials.

Reward and avoidance learning in the context of aversive environments and possible implications for depressive symptoms Abstract Background Aversive stimuli in the environment influence human actions. This includes valence-dependent influences on action selection, e.g., increased avoidance but decreased approach behavior. However, it is yet unclear how aversive stimuli interact with complex learning and decision-making in the reward and avoidance domain. Moreover, the underlying computational mechanisms of these decision-making biases are unknown. Methods To elucidate these mechanisms, 54 healthy young male subjects performed a two-step sequential decision-making task, which allows to computationally model different aspects of learning, e.g., model-free, habitual, and model-based, goal-directed learning. We used a within-subject design, crossing task valence (reward vs. punishment learning) with emotional context (aversive vs. neutral background stimuli). We analyzed choice data, applied a computational model, and performed simulations. Results Whereas model-based learning was not affected, aversive stimuli interacted with model-free learning in a way that depended on task valence. Thus, aversive stimuli increased model-free avoidance learning but decreased model-free reward learning. The computational model confirmed this effect: the parameter lambda that indicates the influence of reward prediction errors on decision values was increased in the punishment condition but decreased in the reward condition when aversive stimuli were present. Further, by using the inferred computational parameters to simulate choice data, our effects were captured. Exploratory analyses revealed that the observed biases were associated with subclinical depressive symptoms. Conclusion Our data show that aversive environmental stimuli affect complex learning and decision-making, which depends on task valence. Further, we provide a model of the underlying computations of this affective modulation. Finally, our finding of increased decision-making biases in subjects reporting subclinical depressive symptoms matches recent reports of amplified Pavlovian influences on action selection in depression and suggests a potential vulnerability factor for mood disorders. We discuss our findings in the light of the involvement of the neuromodulators serotonin and dopamine.

False memory formation in cannabis users: a field study Abstract Rationale Cannabis use is widespread and has previously been associated with memory impairments. However, the role of cannabis in relation to false memory production, i.e., memories of events that were not experienced, is less well-understood. Objective The aim of the current field study was to examine the impact of cannabis use on false memory production. Methods The Deese/Roediger-McDermott (DRM) paradigm was used to induce false memories. In this paradigm, participants study word lists that are associatively related to a non-presented word, termed the critical lure. In a later memory test, true recognition rates and false alarm rates toward critical lures and unrelated items are assessed. Memory performance was compared between three groups: regular cannabis consumers who were acutely intoxicated (n = 53), regular cannabis consumers who were sober (n = 50), and cannabis-naïve controls (n = 53). The participants were approached in Dutch coffee shops (cannabis outlets) and cafes and asked to participate in our study. After collecting general information on their cannabis use, they were subjected to the DRM procedure. Results Although false memory rates for critical lures did not statistically differ between groups, both intoxicated and sober cannabis consumers falsely recognized more unrelated items than control participants. Also, individuals without a history of cannabis use demonstrated higher memory accuracy compared with the intoxicated group. Conclusion It is concluded that cannabis intoxication and history of cannabis use induce a liberal response criterion for newly presented words for which the level of association with previously learned words is low and uncertainty is high.

CB1 receptor antagonism in capuchin monkeys alters social interaction and aversive memory extinction Abstract Rationale The endocannabinoid system (eCS) is an important modulator of social anxiety and social reward, as well as memory functions. Objectives The present study evaluated the role of eCS in social interactions and aversive memory extinction in capuchin monkeys (Sapajus spp.) by blocking the cannabinoid type 1 receptor (CB1r). Methods In experiment 1, spontaneous social and non-social behaviors of five capuchin males, each one living in triads with two other females, were observed after AM251 treatment (vehicle, 0.3, 1.0, and 3.0 mg/kg; i.m.). In experiment 2, seven male capuchin monkeys were trained to reach for a reward inside a wooden box. After training, they were given either vehicle or a 3.0-mg/kg i.m. dose of AM251 before a single aversive encounter with a live snake in the box. The latency to return to reach the reward inside the box in subsequent trials was measured. Results The 3.0-mg/kg dose significantly increased the time spent performing self-directed behaviors, while decreasing that of social interactions. No changes were observed in vigilance or locomotion. AM251 increased the latency to reach the reward after the aversive encounter. Conclusion Taken together, these results suggest that CB1r antagonism induces social deficits without increasing anxiety levels and impairs the extinction of aversive memories. This behavioral profile in monkeys underscores the potential involvement of eCS signaling in the deficits observed in autism spectrum disorders.

L-DOPA improves extinction memory retrieval after successful fear extinction Abstract Rationale A promising strategy to prevent a return of fear after exposure-based therapy in anxiety disorders is to pharmacologically enhance the extinction memory consolidation presumed to occur after exposure. Accumulating evidence suggests that the effect of a number of pharmacological consolidation enhancers depends on a successful fear reduction during exposure. Here, we employed the dopamine precursor L-DOPA to clarify whether its documented potential to enhance extinction memory consolidation is dependent on successful fear extinction. Methods In two double-blind, randomized and placebo-controlled experiments (experiment 1: N = 79, experiment 2: N = 32) comprising fear conditioning (day 1), extinction followed by administration of 150 mg L-DOPA or placebo (day 2) and a memory test (day 3) in healthy male adults, conditioned responses were assessed as differential skin conductance responses. We tested whether the effect of L-DOPA on conditioned responses at test depended on conditioned responses at the end of extinction in an experiment with a short (10 trials, experiment 1) and long (25 trials, experiment 2) extinction session. Results In both experiments, the effect of L-DOPA was dependent on conditioned responses at the end of extinction. That is, post-extinction L-DOPA compared to placebo administration reduced conditioned responses at test only in participants showing a complete reduction of conditioned fear at the end of extinction. Conclusion The results support the potential use of L-DOPA as a pharmacological adjunct to exposure treatment, but point towards a common boundary condition for pharmacological consolidation enhancers: a successful reduction of fear in the exposure session.

Preconception maternal cocaine self-administration increases the reinforcing efficacy of cocaine in male offspring Abstract Rationale Although the influence of gestational cocaine exposure on offspring has been the focus of a sustained research effort, the effect of preconception cocaine self-administration by dams on progeny has received far less attention. Method In the current study, adult female rats were allowed to self-administer cocaine 2 h a day for 60 days and then after a 10-day wash out period, bred to naïve males. Maternal behavior was measured in dams until weaning. When male and female progeny reached adulthood, anxiety-like behavior, memory, and cocaine self-administration were assessed in separate cohorts of rats. Results Despite a total of at least 30 days of cocaine abstinence, the quality of maternal behaviors was negatively affected by previous cocaine exposure as reflected by less time spent with pups as well as an excess of other maladaptive maternal behaviors. Measures of anxiety-like behavior and memory were not affected by maternal cocaine intake in either male or female offspring. In contrast, male, but not female, the progeny of dams exposed to cocaine showed increased reinforcing efficacy of cocaine as measured by cocaine self-administration under a progressive ratio schedule. The fact that cocaine self-administration was influenced only in the male offspring of cocaine-exposed dams argues against this phenotype being linked to altered maternal behavior, although this possibility cannot be ruled out completely. Conclusions Collectively, these results indicate that preconception cocaine self-administration by dams results in the relatively selective enhancement of cocaine addiction-like behavior in male offspring.

The effect of acute cocoa flavanol intake on the BOLD response and cognitive function in type 1 diabetes: a randomized, placebo-controlled, double-blinded cross-over pilot study Abstract Rationale Type 1 diabetes (T1D), a chronic autoimmune disease, can result in cognitive dysfunction and is associated with vascular dysfunction. Cocoa flavanols (CFs) can stimulate nitric oxide-dependent vasodilation, resulting in enhanced hemodynamic responses and better cognitive function. Objectives To investigate whether acute CF supplementation can improve cognitive function and hemodynamic responses in T1D. Methods In this randomized, double-blinded, cross-over pilot study, 11 patients with T1D and their healthy matched controls consumed CF (900 mg CF) and placebo (15 mg CF) 2 h before a flanker test. fMRI was used to measure blood oxygen level–dependent (BOLD) response during the cognitive test. Repeated measure ANOVAs were used to test the effects of CF and T1D on BOLD response and cognitive performance. Results CF improved reaction time on the flanker test and increased the BOLD response in the supramarginal gyrus parietal lobe and inferior frontal gyrus, compared to placebo, in both groups. In patients with T1D, cognitive performance was not deteriorated while the BOLD response was smaller in T1D compared to healthy controls in the subgyral temporal lobe and the cerebellum. Conclusions Acute CF intake improved reaction time on the flanker test and increased the BOLD response in the activated brain areas in patients with T1D and their matched controls.

A comparison of regional brain volumes and white matter connectivity in subjects with stimulant induced psychosis versus schizophrenia Abstract Rationale Schizophrenia and stimulant-induced psychosis (SIP) represent two different forms of psychotic disorder, with different etiologies. While many of the symptoms of psychosis are common to both disorders, there have been few direct comparisons between these conditions, especially when controlling for stimulant use in individuals with schizophrenia. Objectives We directly compared both psychotic disorders with a comprehensive battery of clinical, neurocognitive and neuroanatomical measures. This included one group with SIP (and concurrent stimulant dependence) and two groups with schizophrenia (either with or without concurrent stimulant dependence). Methods Ninety-six participants were recruited from a marginalized urban population, which included 39 with SIP (and concurrent stimulant dependence), 18 with schizophrenia (without stimulant dependence), and 39 with schizophrenia (with concurrent stimulant dependence). All subjects had extensive clinical and neurocognitive evaluations, complemented with structural MRI including diffusion tensor imaging (DTI) sequences to determine regional brain volumes and white matter connectivity. Results Both positive and negative symptoms were greater in the SZ-dependent group than the other two. Neurocognitive function was broadly similar. The structural brain imaging revealed lateralized changes to the left parietal/temporal lobe, in which regional volumes were smaller in the SZ-dependent than the SZ-non-dependent group. DTI analysis indicated extensive decreases in fractional anisotropy, with parallel increases in radial diffusivity, in the SIP group compared to the SZ-dependent group. Conclusions These findings reveal both similarities and differences between SIP and schizophrenia. Furthermore, schizophrenia with concurrent stimulant dependence may be associated with a different clinical and neuroanatomical profile as compared to schizophrenia alone.

Modeling subjective belief states in computational psychiatry: interoceptive inference as a candidate framework Abstract The nascent field computational psychiatry has undergone exponential growth since its inception. To date, much of the published work has focused on choice behaviors, which are primarily modeled within a reinforcement learning framework. While this initial normative effort represents a milestone in psychiatry research, the reality is that many psychiatric disorders are defined by disturbances in subjective states (e.g., depression, anxiety) and associated beliefs (e.g., dysmorphophobia, paranoid ideation), which are not considered in normative models. In this paper, we present interoceptive inference as a candidate framework for modeling subjective—and associated belief—states in computational psychiatry. We first introduce the notion and significance of modeling subjective states in computational psychiatry. Next, we present the interoceptive inference framework, and in particular focus on the relationship between interoceptive inference (i.e., belief updating) and emotions. Lastly, we will use drug craving as an example of subjective states to demonstrate the feasibility of using interoceptive inference to model the psychopathology of subjective states.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Psychological Injury and Law

Beyond Rare-Symptoms Endorsement: a Clinical Comparison Simulation Study Using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) with the Inventory of Problems-29 (IOP-29) Abstract To date, the MMPI-based, rare-symptom detection strategy is considered one of the most effective ones in symptom validity assessment. Because many of the items of the Inventory of Problems-29 (IOP-29) were designed specifically to provide incremental validity over the MMPI F scales, this study tested whether using the IOP-29 in combination with the MMPI-2 would provide higher classification accuracy compared to using either instrument alone. A total of 155 Italian adult individuals contributed to this study. About half (n = 93) were experimental malingerers (expMAL) instructed to simulate depression without being detected as feigners. The others were either (a) depressed patients in treatment (n = 36) or (b) individuals evaluated for possible malingering associated with work-related stress and considered to be genuinely affected by depression (n = 26). All were administered the Italian versions of both the MMPI-2 and the IOP-29. As expected, both instruments were highly effective in discriminating feigned from bona fide depression, with AUC values ranging from .77 to .90. More importantly, when entering the IOP-29 after each of the MMPI-2 scales under consideration (i.e., F, Fb, and Fp), the logistic regression models predicting group membership (0 = patient; 1 = expMAL) improved significantly. Likewise, each of the three MMPI-2 scales under consideration also significantly improved the prediction of group membership, when entered after the IOP-29. These findings thus indicate that using the MMPI-2 together with the IOP-29 could provide incremental validity over using either instrument alone, when testing depression-related complaints.

Demographically Adjusted Validity Cutoffs on the Finger Tapping Test Are Superior to Raw Score Cutoffs in Adults with TBI Abstract This study was designed to develop validity cutoffs within the Finger Tapping Test (FTT) using demographically adjusted T-scores, and to compare their classification accuracy to existing cutoffs based on raw scores. Given that FTT performance is known to vary with age, sex, and level of education, failure to correct for these demographic variables poses the risk of elevated false positive rates in examinees who, at the level of raw scores, have inherently lower FTT performance (women, older, and less educated individuals). Data were collected from an archival sample of 100 adult outpatients (MAge = 38.8 years, MEducation = 13.7 years, 56% men) consecutively referred for neuropsychological assessment at an academic medical center in the Midwestern USA after sustaining a traumatic brain injury (TBI). Performance validity was psychometrically defined using the Word Memory Test and two validity composites based on five embedded performance validity indicators. Previously published raw score-based validity cutoffs disproportionately sacrificed sensitivity (.13–.33) for specificity (.98–1.00). Worse yet, they were confounded by sex and education. Newly introduced demographically adjusted cutoffs (T ≤ 33 for the dominant hand, T ≤ 37 for both hands) produced high levels of specificity (.89–.98) and acceptable sensitivity (.36–.55) across criterion measures. Equally importantly, they were robust to injury severity and demographic variables. The present findings provide empirical support for a growing trend of demographically adjusted performance validity cutoffs. They provide a practical and epistemologically superior alternative to raw score cutoffs, while also reducing the potential bias against examinees inherently vulnerable to lower raw score level FTT performance.

Post-Exertion Neuropsychological Testing in the Management of Sport-Related Concussion Abstract The objective of this study was to determine the effect of physical exertion on computerized neuropsychological test performance in high school athletes as part of concussion return-to-play protocols. ImPACT data and consultation records were retrospectively reviewed among athletes undergoing their physical stepwise progression for return-to-play following sport-related concussion. Two hundred forty athletes met inclusion criteria and participated in the study. 36.7% of concussed athletes who were symptom-free and had reached an advanced stage of their return-to-play protocol demonstrated cognitive decline following a moderate level of physical exertion. Cognitive changes occurred on all four cognitive ImPACT composites after physical exertion. There was no difference with respect to post-concussive symptoms among within RCI (W-RCI) and below RCI (B-RCI) groups. Return-to-play protocols should include post-exertion neuropsychological testing, as relying on athlete symptom report will miss a significant portion of athletes who are continuing to recover from sport-related concussion, putting them at additional risk for repeat or catastrophic injury.

What Attorneys and Factfinders Need to Know About Mild Traumatic Brain Injuries

The Importance of Demographically Adjusted Cutoffs: Age and Education Bias in Raw Score Cutoffs Within the Trail Making Test Abstract This study was designed to develop validity cutoffs by utilizing demographically adjusted T-scores on the trail making test (TMT), with the goal of eliminating potential age and education-related biases associated with the use of raw score cutoffs. Failure to correct for the effect of age and education on TMT performance may lead to increased false positive errors for older adults and examinees with lower levels of education. Data were collected from an archival sample of 100 adult outpatients (MAge = 38.8, 56% male; MEd = 13.7) who were clinically referred for neuropsychological assessment at an academic medical center in the Midwestern USA after sustaining a traumatic brain injury (TBI). Performance validity was psychometrically determined using the Word Memory Test and two multivariate validity composites based on five embedded performance validity indicators. Cutoffs on the demographically corrected TMT T-scores had generally superior classification accuracy compared to the raw score cutoffs reported in the literature. As expected, the T-scores also eliminated age and education bias that was observed in the raw score cutoffs. Both T-score and raw score cutoffs were orthogonal to injury severity. Multivariate models of T-score based cutoff failed to improve classification accuracy over univariate T-score cutoffs. The present findings provide support for the use of demographically adjusted validity cutoffs within the TMT. They produced superior classification to raw score-based cutoffs, in addition to eliminating the bias against older adults and examinees with lower levels of education.

The Effect of Menstrual Cycle Phase and Hormonal Contraceptive Use on Post-concussive Symptom Reporting in Non-concussed Adults Abstract Post-concussion symptoms are notoriously non-specific and overlap with menstrual symptoms. The goal of the present study was to investigate the relationship between symptoms at different points in the menstrual cycle. Forty-four females, 23 who used hormonal contraceptives, and 34 males completed the Post-Concussive Symptom Scale (PCSS) and the Depression, Anxiety, and Stress Scale on two occasions. There were substantial group differences with regard to test-retest reliability and agreement, with unacceptably low reliability on the PCSS for females on hormonal birth control. Eumenorrheic females had systematic changes in individual symptoms, whereas females taking hormonal contraceptives showed no differences over time. The results highlight the importance of considering hormonal influences in the assessment of post-concussion and psychiatric symptoms in females post-injury.

The Myth of High False-Positive Rates on the Word Memory Test in Mild TBI Abstract This study was designed to replicate previous reports of elevated false-positive rates (FPR) on the Word Memory Test (WMT) in patients with mild traumatic brain injury (TBI) and to evaluate previous claims that genuine memory deficits and non-credible responding are conflated on the WMT. Data from a consecutive case sequence of 170 patients with mild TBI referred for neuropsychological assessment were collected. Failure rate on the WMT was compared to that on other performance validity tests (PVTs). The clinical characteristics and neuropsychological profiles of patients who passed and those who failed the WMT and other PVTs were compared. Base rate of failure was the highest on the WMT (44.7%), but comparable to that on other established PVTs (39.4–41.8%). The vast majority of patients (94.7%) who failed the WMT had independent evidence of invalid performance, refuting previous estimates of 20–30% FPR. Failing the WMT was associated with globally lower scores on tests measuring various cognitive domains. The neurocognitive profile of individuals with invalid performance was remarkably consistent across various PVTs. Previously reported FPR of the WMT were not replicated. Failing the WMT typically occurred in the context of failing other PVTs too. Results suggest a common factor behind non-credible responding that is invariant of the psychometric definition of invalid performance. Failure on the WMT should not be discounted based on rational arguments unsubstantiated by objective data. Inferring elevated FPR from high failure rate alone is a fundamental epistemological error.

Geographic Variation and Instrumentation Artifacts: in Search of Confounds in Performance Validity Assessment in Adults with Mild TBI Abstract Regional fluctuations in cognitive ability have been reported worldwide. Given perennial concerns that the outcome of performance validity tests (PVTs) may be contaminated by genuine neuropsychological deficits, geographic differences may represent a confounding factor in determining the credibility of a given neurocognitive profile. This pilot study was designed to investigate whether geographic location affects base rates of failure (BRFail) on PVTs. BRFail were compared across a number of free-standing and embedded PVTs in patients with mild traumatic brain injury (mTBI) from two regions of the US (Midwest and New England). Retrospective archival data were collected from clinically referred patients with mTBI at two different academic medical centers (nMidwest = 76 and nNew England = 84). One free-standing PVT (Word Choice Test) and seven embedded PVTs were administered to both samples. The embedded validity indicators were combined into a single composite score using two different previously established aggregation methods. The New England sample obtained a higher score on the Verbal Comprehension Index of the WAIS-IV (d = .34, small-medium). The difference between the two regions in Full Scale IQ (FSIQ) was small (d = .28). When compared with the omnibus population mean (100), the effect of mTBI on FSIQ was small (d = .22) in the New England sample and medium (d = .53) in the Midwestern one. However, contrasts using estimates of regional FSIQ produced equivalent effect sizes (d: .47–.53). BRFail was similar on free-standing PVTs, but varied at random for embedded PVTs. Aggregating individual indices into a validity composite effectively neutralized regional variability in BRFail. Classification accuracy varied as a function of both geographic region and instruments. Despite small overall effect sizes, regional differences in cognitive ability may potentially influence clinical decision making, both in terms of diagnosis and performance validity assessment. There was an interaction between geographic region and instruments in terms of the internal consistency of PVT profiles. If replicated, the findings of this preliminary study have potentially important clinical, forensic, methodological, and epidemiological implications.

Use of Validity Indicators on the Personality Assessment Inventory to Detect Feigning of Post-traumatic Stress Disorder Abstract This study examined the ability of several Personality Assessment Inventory (PAI) validity indicators to detect feigning of post-traumatic stress disorder (PTSD). Participants included 491 individuals recruited through Amazon Mechanical Turk (MTURK): 44 participants were asked to feign PTSD, 25 participants carried a diagnosis of PTSD and demonstrated at least moderate levels of current symptom, and 422 served as control subjects. Results indicated that all of the PAI negative distortion validity indicators significantly distinguished the true PTSD from the feigned PTSD group. The indicators with the largest effect sizes were the Hong Malingering Function and the Multiscale Feigning Index, both of which demonstrated moderate sensitivity to feigned PTSD with specificity above 90%.

Correction to: Further Validation of the Test of Memory Malingering (TOMM) Trial 1 Performance Validity Index: Examination of False Positives and Convergent Validity Correction of mistake in the original version of this paper, "Further Validation of the Test of Memory Malingering (TOMM) Trial 1 Performance Validity Index: Examination of False Positives and Convergent Validity", the sentence "As indicated in Table 7, TOMM T1 ≤ 40 exhibited sensitivity of .86.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

HNO

Erratum zu: Leitlinie „Rhinosinusitis" – Langfassung Erratum zu: HNO 2018 66:38–74 https://doi.org/10.1007/s00106-017-0401-5 Die Autoren weisen auf folgendes hin. In der Langfassung der o. g. Leitlinie ist uns ein Fehler unterlaufen. Hier wurde „Carboxymethylcellulose" irrtümlich statt „Carboxymethylcystein (Carbocystein)" angegeben. Richtig muss es …

Georgien, ein Land vielfältiger Hilfen aus Deutschland auf dem HNO-Gebiet Zusammenfassung Aufbauend auf einer langjährigen Tradition sind momentan mehrere ärztliche HNO-Arbeitsgruppen an verschiedenen Kliniken in Georgien karitativ unterstützend tätig. In dem Artikel wird zunächst auf die Struktur des Klinik- und Versicherungswesens in dem südkaukasischen Land eingegangen. Es wird das dortige Aus- und Weiterbildungssystem bei Medizinern beschrieben, und dabei werden die Unterschiede gegenüber Deutschland aufgezeigt, die wiederum erklären, warum junge georgische Kollegen Schwierigkeiten bei einem Wechsel von Georgien nach Deutschland haben. Es wird dann einerseits darauf eingegangen, wie sich die typischen Aufenthalte deutscher HNO-Ärzte bei ihren karitativen Einsätzen in Georgien gestalten und andererseits durch Hilfslieferungen medizinischer Geräte und sonstiger Klinikausrüstungsgegenstände von unserem Land aus materielle Unterstützung geleistet wird. Schließlich geht der Artikel darauf ein, welchen „Input" wir deutschen Kolleg(inn)en aus unserer Sicht zu einer Verbesserung der Verhältnisse vor Ort liefern können, und er fasst zukünftig angestrebte Ziele der deutsch-georgischen ärztlichen Zusammenarbeit auf dem HNO-Gebiet zusammen.

Deutsche HNO-Ärzte im weltweiten Einsatz

Der Heilpraktiker – aktuelle Informationen zu einem „schwierigen" Berufsbild

Präaurikuläre Raumforderung – sonographische Differenzialdiagnosen im Fokus

Bedeutung der interdisziplinären Zusammenarbeit für eine optimale Behandlung orbitaler Tumoren Zusammenfassung Die optimale Behandlung von Tumoren mit Orbitabeteiligung kann die Kompetenzen einzelner Fachgebiete überschreiten und eine interdisziplinäre Zusammenarbeit erfordern. Ziel dieser Arbeit ist die Darlegung eines interdisziplinären Behandlungskonzepts anhand der Beispiele eines intraorbitalen Hämangioms und eines in die Orbita einwachsenden Plattenepithelkarzinoms der Nasennebenhöhlen. Für die primäre Einordnung einer intraorbitalen pathologischen Veränderung ist neben einer ausführlichen Anamnese und einer kompletten ophthalmologischen Untersuchung auch eine ausführliche bildtechnische Untersuchung mit standardisierter Echographie sowie Schnittbildverfahren wie einer Orbita-Dünnschicht-Computertomographie (CT) und/oder in vielen Fällen auch Magnetresonanztomographie (MRT) unerlässlich. Abhängig von der Art der Pathologie ist ein rein operatives Vorgehen, wobei die verschiedenen Disziplinen wie Ophthalmologie, Hals-Nasen-Ohren-Heilkunde, Mund-Kiefer-Gesichts-Chirurgie, Neurochirurgie und Pathologie beteiligt sind oder ein überdisziplinäres Behandlungsregime mit (neo)adjuvanter Strahlen- oder Chemotherapie angezeigt. Tumoren der Orbita weisen ein weites Spektrum an möglichen Pathologien auf, welche mitunter komplexe, operative Zugangswege und multimodale Therapieansätze erfordern. Insbesondere bei Ausbreitung in die Nasennebenhöhlen oder nach intrakraniell ist ein multiprofessionelles Team, bestehend aus Pathologen, Neuroradiologen, Mund-Kiefer-Gesichts-Chirurgen, Hals-Nasen-Ohren-Ärzten, Neurochirurgen, Strahlentherapeuten, Ophthalmologen, Onkologen und Psychoonkologen für eine erfolgreiche Therapie essenziell.

Hilfe zur Selbsthilfe Zusammenfassung Nach dem schrecklichen Genozid in Ruanda 1994 war die medizinische Versorgung des kleinen Landes weitgehend zusammengebrochen. In den Folgejahren mussten die verschiedenen Fachbereiche wieder aufgebaut werden. Bis 2009 gab es jedoch im Land noch keine Möglichkeit, einer Weiterbildung zum Hals-Nasen-Ohren-Arzt zu absolvieren. Zusammen mit der Universität von Ruanda wurde ein „Master of Medicine Program" etabliert, das 2010 startete und mit Unterstützung deutscher HNO-Ärzte inzwischen 10 Fachärzte hervorgebracht hat, 15 Kollegen befinden sich derzeit in Weiterbildung.

Soziale Rückvergütung – das Projekt „Lateinamerika" der Spanisch-Deutschen HNO-Gesellschaft (SDGHNO) Zusammenfassung Soziale Projekte sind in der heutigen Zeit meist dermaßen ausgerichtet, dass sie sich nach einem vorgegebenen Zeitraum entweder eigenständig tragen können oder sogar eine pekuniäre Rückvergütung erlauben. In letzterem Fall spricht man in Fachkreisen von einem profitorientierten Reimbursement. Demgegenüber steht das sog. soziale Reimbursement, welches im Gegensatz zur genannten Form keine profitorientierte Ausrichtung besitzt, sondern beispielsweise bereits in der Tatsache einer erfolgreichen Wissensvermittlung seine Aufgabe als erfüllt ansieht. Die Spanisch-Deutsche Gesellschaft für HNO-Heilkunde und Kopf-Hals-Chirurgie (SDGHNO) hat noch unter der Schirmherrschaft des damaligen Präsidenten Prof. Dr. Wolfgang Draf (Fulda) im Jahr 2001 das Projekt „Lateinamerika" ins Leben gerufen. Ziel war und ist es, mit der SDGHNO eine sowohl professionelle als auch kulturelle Plattform für spanisch- und deutschsprachige HNO-Ärzte zu schaffen. Diese kann und soll für professionelle Zwecke genutzt werden, z. B. zum Wissenstransfer. Seit Beginn der Existenz hat das Projekt „Lateinamerika" somit zahlreiche wissenschaftliche Veranstaltungen ins Leben gerufen und spezifische Kontakte geschaffen, welche bis zum heutigen Tag Bestand haben oder sogar fortgeführt und weiterentwickelt worden sind. Als besonders erfolgreiche Beispiele sind Chile, Kolumbien und Peru zu nennen. Hierbei handelt es sich um ein anschauliches Beispiel eines „social reimbursement", denn die partizipierenden deutschsprachigen Mitglieder/Referenten führten ihre Aufgaben komplett ehrenamtlich aus. So wurden weder Reise‑, Verpflegungs- noch Übernachtungskosten von Seiten der SDGHNO getragen. Es werden die Tätigkeiten der SDGHNO im Rahmen des Projekts „Lateinamerika" erläutert.

Aufbau einer umfassenden Versorgung von Ohrenerkrankungen und Schwerhörigkeit in Lusaka, Sambia Zusammenfassung In Sambia bestand vor 2009 keine kontinuierliche ohrenspezifische HNO-fachärztliche Versorgung. Um diesen Mangel zu beheben, wurde eine hochqualitative, erschwingliche Ohren- und Hörgeräteversorgung für bedürftige Menschen in dem Einzugsgebiet von Lusaka, Sambia aufgebaut sowie lokales Personal ausgebildet und die Erstellung eines nationalen HNO-Plans initiiert. Durch diese Maßnahmen wurde das Bewusstsein auf nationaler Ebene für die Notwendigkeit HNO-ärztlicher Versorgung geweckt und die ohrenärztliche Versorgung in mehreren Provinzen Sambias etabliert.

Ohrenhilfe in Myanmar Zusammenfassung Wie das Beispiel eines kleinen Teams – in Myanmar seit 2010 tätig – zeigt, ist mit relativ wenig Aufwand eine nachhaltige Arbeit hinsichtlich Aus- und Weiterbildung, hier in der Mittelohrchirurgie, im Ausland möglich. Voraussetzungen hierfür sind hervorragende Kommunikation des Teams untereinander und mit den Kolleginnen und Kollegen, Behörden und Organisatoren vor Ort, ein achtsames und rücksichtsvolles Arbeiten im Gastland, die kulturellen Besonderheiten berücksichtigend, der interkulturelle Austausch und insbesondere die Motivation der Kolleginnen und Kollegen im Gastland. Verbunden mit einem verlässlich regelmäßigen gegenseitigen Besuch kann eine konstante fachliche Entwicklung entsprechend den aktuellen Bedürfnissen entstehen.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Bioethical Inquiry

Pride Before a Fall: Shame, Diagnostic Crossover, and Eating Disorders Abstract This paper discusses the findings of qualitative research that examined the accounts of five "mostly recovered" ex-patients who had experienced transition between two or more eating disorder diagnoses. This study found that, in the minds of participants, the different diagnostic labels were associated with various good or bad character traits. This contributed to the belief in a diagnostic hierarchy, whereby individuals diagnosed with anorexia nervosa were viewed as morally better than those diagnosed with bulimia nervosa or binge eating disorder. Consequently, diagnostic crossover from a "better" to a "worse" eating disorder was often experienced as shameful moral failing, and a new diagnosis impacted the individual's sense of self-identity. These findings are of significance for both ethicists and clinicians; the paper concludes by outlining the relevance and possible clinical implications of shame in diagnostic crossover and suggesting avenues for future research.

Not Sick: Liberal, Trans, and Crip Feminist Critiques of Medicalization Abstract Medicalization occurs when an aspect of embodied humanity is scrutinized by the medical industry, claimed as pathological, and subsumed under medical intervention. Numerous critiques of medicalization appear in academic literature, often put forth by bioethicists who use a variety of "lenses" to make their case. Feminist critiques of medicalization raise the concerns of the politically disenfranchised, thus seeking to protect women—particularly natal sex women—from medical exploitation. This article will focus on three feminist critiques of medicalization, which offer an alternative narrative of sickness and health. I will first briefly describe the philosophical origins of medicalization. Then, I will present three feminist critiques of medicalization. Liberal feminism, trans feminism, and crip feminism tend to regard Western medicine with a hermeneutics of suspicion and draw out potential harms of medicalization of reproductive sexuality, gender, and disability, respectively. While neither these branches of feminism—nor their critiques—are homogenous, they provide much-needed commentaries on phallocentric medicine. I will conclude the paper by arguing for the continual need for feminist critiques of medicalization, using uterus transplantation as a relevant case study.

Co-payment for Unfunded Additional Care in Publicly Funded Healthcare Systems: Ethical Issues Abstract The burdens of resource constraints in publicly funded healthcare systems urge decision makers in countries like Sweden, Norway and the UK to find new financial solutions. One proposal that has been put forward is co-payment—a financial model where some treatment or care is made available to patients who are willing and able to pay the costs that exceed the available alternatives fully covered by public means. Co-payment of this sort has been associated with various ethical concerns. These range from worries that it has a negative impact on patients' wellbeing and on health care institutions, to fears that co-payment is in conflict with core values of publicly funded health care systems. This article provides an overview of the main ethical issues associated with co-payment, and ethical arguments both in support of and against it will be presented and analyzed.

A response to "Fragile objects: a visual essay"

Dementia: Unwelcome change has arrived and we are not ready!

The liminal world of dementia Abstract Dementia progressively isolates sufferers from their loved ones, who continue to search for meanings in their actions and words. As the condition progresses, meaning becomes harder and harder to find. Yet the actions of the sufferer may contain patterns, hinting at meanings that tempt observers to interpret from their own standpoint. We report the patterns repeated by a sufferer from Alzheimer's disease, artistic arrangements that take time to make, and appeal to observers. To the sufferer, these arrangements seem to have no value beyond the fact of their creation. We wonder how far we can go as observers in imposing interpretations on these patterns of activity, which seem beautiful and poignant to us, but are evanescent and unremarked by their creator.

A Return Journey: Hope and Strength in the Aftermath of Alzheimer's Abstract Sue Petrovski's short book, A Return Journey: Hope and Strength in the Aftermath of Alzheimer's, is a collection of personal stories as she and her husband cared for her mother during the course of the disease as well as the shared stories of others. A Return Journey provides an insider's view of the challenges of caring for those with Alzheimer's and is useful for current and future caregivers as well as those who are studying and working in the health professions.

Learning From the Cultural Challenge of Dementia Abstract Learning from the profound challenge of dementia is an urgent priority. Success will require a critical deconstruction of current cultural and linguistic representations of this condition, and a kindling of novel and courageous approaches to re-conceptualise dementia's meaning and experience. This symposium collects provocative ideas arising from various discourses, theoretical perspectives, and methodolgical approaches to explore new ways to understand dementia.

Fragile objects: A visual essay Abstract Recognizing the potential hidden artistic contributions of persons with dementia opens new opportunities for interpretation and potential communication. This visual essay explores the authors' responses to the fragile objects of art produced by a person with severe dementia and examines what may be learned from them.

Considering the boundaries of decision-making authority: An NHS Trust v Y [2018] UKSC 46

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Cardiovascular Imaging

Cardiac magnetic resonance-tissue tracking for the early prediction of adverse left ventricular remodeling after ST-segment elevation myocardial infarction Abstract Cardiac magnetic resonance-tissue tracking (CMR-TT)-derived myocardial strain after ST-elevation myocardial infarction (STEMI) is related to adverse cardiac events. We aimed to investigate the feasibility of CMR-TT for the early prediction of adverse left ventricular (LV) remodeling after STEMI. We retrospectively searched our institution's STEMI registry for patients who underwent reperfusion therapy, post-reperfusion CMR within 1 week after STEMI, and follow-up CMR. CMR-TT analysis was performed using cine imaging of post-reperfusion CMR. Adverse LV remodeling was defined as an increase in end-diastolic LV volume by 20% or more on follow-up CMR (median interval between serial CMR exams, 197 days; interquartile, 174–241 days). A total of 82 patients (age, 59.2 ± 11.1 years; male:female = 73:9) were included and divided into two groups: STEMI without (n = 62) and with (n = 20) adverse LV remodeling. Patients with LV remodeling showed significantly higher peak creatine kinase-MB and troponin I levels and a larger infarct size compared with those without LV remodeling (p = 0.001, p = 0.001, and p = 0.010, respectively). Global circumferential, radial, and longitudinal strain (GLS) also differed significantly between the groups (p = 0.001, p = 0.004, and p < 0.001, respectively). Logistic regression and receiver operating characteristic curve analyses demonstrated that GLS was an independent predictor of LV remodeling [odds ratio (OR) = 1.282, 95% confidence interval (CI) = 1.060–1.55 p = 0.011] with an optimal cut-off of − 12.84 (AUC = 0.756, 95% CI = 0.636–0.887, p < 0.001). CMR-TT-derived GLS may aid the early prediction of adverse LV remodeling after reperfusion, within 1 week after STEMI.

Aortic CT angiography using the double region of interest timing bolus technique: feasibility of 80 kVp scanning in lean patients Abstract To investigate the feasibility of aortic computed tomography angiography (CTA) performed at 80 kVp in lean patients using the double region of interest timing bolus (DRTB) technique compared to 100 kVp scanning. This study was approved by the institutional ethics committee, and all patients provided written informed consent. We prospectively included 165 patients from July 2018 to February 2019. We used an 80 kVp protocol when the maximal tube current did not exceed the limit using automatic exposure control; otherwise, 100 kVp was selected. The scan parameters for aortic CTA were determined from the test scan data. Enhancement at six points of the aortoiliac arteries and noise at the bifurcation level were measured. We compared the enhancement and signal to noise ratio (SNR) using Student's t-test. The tube voltage was 80 kVp in 87 patients (53%). The enhancement of the aortoiliac arteries was significantly higher (449.3 ± 77.8 vs 378.7 ± 53.1 HU, p < 0.0001) and the SNR was similar (42.4 ± 11.1 vs 40.0 ± 10.6, p = 0.17), and the amount of contrast medium was lower (33.0 ± 2.5 vs 41.8 ± 3.3 ml, p < 0.001) in the 80 kVp group compared to the 100 kVp group. Reducing the tube current to 80 kVp could decrease the amount of contrast medium used compared to the 100 kVp protocol, while maintaining image quality, for aortic CTA using the DRTB technique.

Editor's note February 2019

Left atrial volume index and left ventricular global longitudinal strain predict new-onset atrial fibrillation in patients with transient ischemic attack Abstract This study aimed to investigate different echocardiographic parameters for predicting atrial fibrillation (AF) in patients with transient ischemic attack (TIA). Echocardiography was performed in 110 patients (median age 65.8 years, 53% males) with TIA and no history of stroke or AF. All patients underwent monitoring with ECG and 72 h Holter-monitoring, and if no AF was found, an insertable cardiac monitor (ICM) was implanted and patients were followed for a median of 2.2 years. AF was found in 14 patients: five with Holter-monitoring and nine with ICM. AF patients had significantly larger left atrial (LA) volumes indexes compared to patients without AF (26.7 vs. 33.7 ml/m2, P = 0.03 for 2D images and 26.5 vs. 33.5 ml/m2, P = 0.0008 for 3D images). Patients with AF also had depressed LA function assessed with LA emptying fraction measured with 2D echocardiography (46.3 vs. 57.3%, P = 0.005 for patients with and without AF, respectively). Patients with AF also had depressed left ventricular (LV) function compared to patients without AF. LV ejection fraction was 55 versus 61%, P = 0.04 in patients with and without AF, respectively. LV global longitudinal strain (absolute value) was 16.7 in patients with AF compared to 21.2 in patients without AF (P = 0.001). Echocardiographic measurements of LA and LV size and function can noninvasively predict AF in patients with TIA and could potentially be used to guide AF monitoring strategy.

Predictive value of exercise stress echocardiography in asymptomatic patients with severe aortic regurgitation and preserved left ventricular systolic function without LV dilatation Abstract The management of asymptomatic patients with severe aortic regurgitation (AR) and preserved left ventricular (LV) systolic function remains controversial. We evaluated the predictive value of exercise stress echocardiography (ESE) in asymptomatic severe AR with preserved LV systolic function for identifying high risk patients who might benefit from early referral for surgery. Symptom-limited treadmill ESE was performed in 67 asymptomatic patients with severe AR (effective regurgitant orifice area > 30 mm2, regurgitant volume > 60 ml) and preserved LV systolic function without LV dilatation [ejection fraction (EF) ≥ 50% and LV end-systolic diameter ≤ 50 mm]. A post-exercise EF increase of > 4% was defined as presence of contractile reserve (CR). The primary outcome was defined as the composite of symptoms development, deterioration in LV function (EF < 50% in echocardiography) and aortic valve replacement (AVR) at follow-up. Operations performed within 60 days of ESE were excluded. Twenty-eight patients were CR (+) and 39 patients were CR (−). Compared with the CR (+) group, the CR (−) group was older (52.0 ± 14.0 years vs. 43.8 ± 10.6 years, p = 0.011) and had higher Ln N-terminal natriuretic peptide (NT-proBNP) [5.2 (4.5–5.7) vs. 4.1 (3.7–5.1), p = 0.001]. The CR (−) group showed lower exercise time than the CR (+) group (576 ± 159 s vs. 671 ± 108 s, p = 0.008). Otherwise, there were no differences in demographics and imaging data between the two groups. During a follow-up duration of 46 ± 23 months, the primary outcome occurred in 17 patients (25%) including development of symptoms (n = 9), new-onset LV systolic dysfunction (n = 1) and AVR (n = 7). Fourteen of 17 were CR (−) group patients. The survival rate during follow-up was significantly lower in the CR (−) group than in the CR (+) group of asymptomatic severe AR patients (log-rank p = 0.035). The absence of CR in ESE is independently associated with deterioration of symptoms or LV systolic function in asymptomatic patients with severe AR and preserved LV systolic function. It can further risk stratify asymptomatic patients with severe AR and preserved LV systolic function and may influence the optimal timing of AVR.

Cardiovascular imaging 2018 in the International Journal of Cardiovascular Imaging

Value of 18 F-FDG PET/CT in differentiating malignancy of pulmonary artery from pulmonary thromboembolism: a cohort study and literature review Abstract To determine the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in differentiating malignancy of pulmonary artery (PA) from pulmonary thromboembolism (PTE) based on a larger number of cases by pooling our cases and those from the literature. Consecutive patients with a PA lesion who had undergone 18F-FDG PET/CT in our hospital were retrospectively reviewed. Moreover, PubMed, Embase, and Medline were searched for literature reporting individual maximum standardised uptake value (SUVmax) of the malignant PA lesion and/or PTE. 18F-FDG activity was compared between PA malignancy and PTE by pooling the data from literature and our patients. Receiver operating characteristic curve analysis was performed to determine the ability of SUVmax to differentiate PA malignancy from PTE. From our database, we identified 11 patients with pulmonary artery sarcoma (PAS), and nine cases of PTE. Fifty patients with a malignant PA lesion (40 cases of PAS and 10 cases of tumor embolism) and 22 subjects with PTE were extracted from the literature. In our cases, the SUVmax of PAS (11.1 ± 4.9, range: 5.5–19.9) was significantly higher than that of PTE (1.9 ± 0.6, range: 1.1–3.2; P < 0.001). There was no significant difference in the SUVmax between the literature data and our cases in malignant lesions or in PTE. Based on the pooled analysis of the literature data and our cases (61 cases of malignant lesions and 31 cases of PTE), the area under the curve for SUVmax to differentiate PA malignancy from PTE was 0.996 (95% CI: 0.989–1.000). At a cutoff value of 3.3, the sensitivity, specificity, and accuracy were 98.4%, 96.8%, and 97.8%, respectively. The 18F-FDG uptake value is an accurate index for determining PA malignancy.

Addition of price transparency to an education and feedback intervention reduces utilization of inpatient echocardiography by resident physicians Abstract Previous studies have demonstrated the impact of appropriate use criteria (AUC) education and feedback interventions in reducing unnecessary ordering of transthoracic echocardiography (TTE) by trainees. To our knowledge, no study has evaluated the impact of the addition of price transparency to this education and feedback model on TTE utilization by resident physicians. We performed an education and feedback quality improvement initiative combining charge transparency data with information on AUC. We hypothesized that the initiative would reduce the number of complete TTE ordered and increase the number of limited TTE ordered, anticipating there would be substitution of limited for complete studies. Residents rotating on inpatient teaching cardiology ward teams received education on AUC for TTE, indications for limited TTE, and hospital charges for TTE. Feedback was provided on the quantity and charges for complete and limited TTE ordered by each team. We analyzed the effects of the intervention using a linear mixed effects regression model to adjust for potential confounders. The post-intervention weeks showed a reduction of 4.6 complete TTE orders per 100 patients from previous weekly baseline of 31.3 complete TTE orders per 100 patients (p value = 0.012). Charges for complete TTE decreased $122 from baseline of $980 per patient (p value = 0.040) on a per-week basis. Secondarily, there was no statistically significant change in limited TTE ordering during the intervention period. This initiative shows the feasibility of a house staff-driven charge transparency and education/feedback initiative that decreased medical residents' ordering of inpatient TTE.

Interactive role of diastolic dysfunction and ventricular remodeling in asymptomatic subjects at increased risk of heart failure Abstract Diastolic dysfunction (DD) and left ventricular remodeling (LVR) characterize patients at risk for heart failure (HF). To assess the prognostic impact of different diastolic function algorithms and a complex LVR classification (CRC) in asymptomatic subjects with preserved ejection fraction (EF) at risk for HF. We analyzed 1923 asymptomatic patients (male 43%; age 57, 33–76 years) with at least one cardiovascular risk factor and preserved (> 50%) EF. We used three algorithms for LV diastolic function assessment (Paulus et al. in Eur Heart J 28(20):2539–2550, 2007; Nagueh et al. in J Am Soc Echocardiogr 22(2):107–133, 2009, Eur Heart J Cardiovasc Imaging 17(12):1321–1360, 2016), and two algorithms for LVR (classic and CRC). We considered a composite end-point: cardiac death and hospitalization for HF. The highest presence of DD was diagnosed by Nagueh 2009 (211, 11%), while the prevalence according to Nagueh 2016 (63 patients, 3.2%) turned out to be the lowest (p < 0.001 vs the other algorithms). According to CRC, 780 (48.6%) patients had normal or physiologic hypertrophy, 298 (15.5%) concentric remodeling, 85 (4.4%) eccentric remodeling, 294 (15.3%) concentric hypertrophy, 39 (2%) mixed hypertrophy, 80 (4.1%) dilated hypertrophy, 73 (3.7%) eccentric hypertrophy and 294 (15.3%) were unclassifiable. After 39-month follow-up (261 events, 13.6%), Cox-regression (adjusted for age, gender, history of stable ischemic heart disease, classic remodeling classification) identified CRC (p = 0.01) and Nagueh 2016 (p < 0.001) as independent predictors of end-point. The coexistence of an adverse LVR by CRC and DD by Nagueh 2016 was associated with the worst prognosis. A concurrent structural (CRC) and functional (Nagueh Op. Cit) analysis improves prognostic stratification in asymptomatic subjects at risk for HF with preserved EF.

Procedural findings and early healing response after implantation of a self-apposing bioresorbable scaffold in coronary bifurcation lesions Abstract We aimed to evaluate feasibility, early healing and self-correcting properties of the Desolve 150 bioresorbable scaffold (BRS) implanted in bifurcation lesions, using the simple, provisional side branch (SB) stenting technique. BIFSORB pilot was a proof-of-concept study enrolling 10 patients with stable angina pectoris and a bifurcation lesion with SB ≥ 2.5 mm and less than 50% diameter stenosis. Procedure and 1-month outcome was evaluated by optical coherence tomography (OCT) to assess scaffold performance and healing patterns. Nine patients were treated with Desolve 150 BRS and one delivery to the target bifurcation failed. Thrombus formation in the jailed SB ostium was seen in three cases, but was completely resolved at 1-month. OCT confirmed acute self-correcting properties. No clinical events were reported after six months. Scaffold diameter by OCT increased in the proximal main vessel from 3.09 ± 0.16 mm to 3.34 ± 0.18 mm (p = 0.01) and in distal main vessel from 2.82 ± 0.26 mm to 3.02 ± 0.29 mm (p < 0.01) at one-month follow-up. SB ostial diameter stenosis improved from 42 ± 15% to 34 ± 12% (p = 0.01). Malapposition was effectively reduced after 1 month from 4.1 (1.4; 6.1)% to 0.1 (0; 0.6)% (p = 0.002). Treatment of bifurcation lesions using Desolve 150 BRS was feasible except for a delivery failure and unsettling thrombus formation behind jailing SB struts, which was completely resolved at 1-month. Self-correcting and even self-expanding properties were confirmed.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com