Search

Abstract Background Criteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania. Objective The prevalence of eclampsia in MNH is high (≈6%) with the majority of cases arriving after start of convulsions. In 2004–2005 the case-fatality rate in eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric data base). A criteria-based audit (CBA) was used to evaluate the quality of care for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania after implementation of recommendations of a previous audit. Methods A CBA of eclampsia cases was conducted at MNH. Management practices were evaluated using evidence-based criteria for appropriate care. The Ministry of Health (MOH) guidelines, local management guidelines, the WHO manual supplemented by the WHO Reproductive Health Library, standard textbooks, the Cochrane database and reviews in peer reviewed journals were adopted. At the initial audit in 2006, 389 case notes were assessed and compared with the standards, gaps were identified, recommendations made followed by implementation. A re-audit of 88 cases was conducted in 2009 and compared with the initial audit. Results There was significant improvement in quality of patient management and outcome between the initial and re-audit: Review of management plan by senior staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001), proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2 hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%; P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0% vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs. 39%; P=0.018). However, there was no significant change in terms of delivery within 24 hours of admission (69% vs. 63%; P=0.33). There was significant reduction of maternal deaths (7.7% vs. 0%; P=0.001). Conclusion CBA is applicable in low resource setting and can help to improve quality of care in obstetrics including management of pre-eclampsia and eclampsia.

Abstract Background Breast cancer is the leading cause of cancer mortality among Jordanian women. Breast malignancies are detected at late stages as a result of deferred breast health-seeking behaviour. The aim of this study was to explore Jordanian women’s views and perceptions about breast cancer and breast health. Methods We performed an explorative qualitative study with purposive sampling. Ten focus groups were conducted consisting of 64 women (aged 20 to 65 years) with no previous history and no symptoms of breast cancer from four governorates in Jordan. The transcribed data was analysed using latent content analysis. Results Three themes were constructed from the group discussions: a) Ambivalence in prioritizing own health; b) Feeling fear of breast cancer; and c) Feeling safe from breast cancer. The first theme was seen in women’s prioritizing children and family needs and in their experiencing family and social support towards seeking breast health care. The second theme was building on women’s perception of breast cancer as an incurable disease associated with suffering and death, their fear of the risk of diminished femininity, husband’s rejection and social stigmatization, adding to their apprehensions about breast health examinations. The third theme emerged from the women’s perceiving themselves as not being in the risk zone for breast cancer and in their accepting breast cancer as a test from God. In contrast, women also experienced comfort in acquiring breast health knowledge that soothed their fears and motivated them to seek early detection examinations. Conclusions Women’s ambivalence in prioritizing their own health and feelings of fear and safety could be better addressed by designing breast health interventions that emphasize the good prognosis for breast cancer when detected early, involve breast cancer survivors in breast health awareness campaigns and catalyse family support to encourage women to seek breast health care.

Abstract Background Intimate partner violence against women is a prevailing public health problem in Tanzania, where four of ten women have a lifetime exposure to physical or sexual violence by their male partners. To be able to suggest relevant and feasible community and health care based interventions, we explored community members' understanding and their responses to intimate partner violence. Methods A qualitative study using focus group discussions with 75 men and women was conducted in a community setting of urban Tanzania. We analysed data using a grounded theory approach and relate our findings to the ecological framework of intimate partner violence. Results The analysis resulted in one core category, "Moving from frustration to questioning traditional gender norms", that denoted a community in transition where the effects of intimate partner violence had started to fuel a wish for change. At the societal level, the category "Justified as part of male prestige" illustrates how masculinity prevails to justify violence. At the community level, the category "Viewed as discreditable and unfair" indicates community recognition of intimate partner violence as a human rights concern. At the relationship level, the category "Results in emotional entrapment" shows the shame and self-blame that is often the result of a violent relationship. At the individual level, the risk factors for intimate partner violence were primarily associated with male characteristics; the category "Fed up with passivity" emerged as an indication that community members also acknowledge their own responsibility for change in actions. Conclusions Prevailing gender norms in Tanzania accept women's subordination and justify male violence towards women. At the individual level, an increasing openness makes it possible for women to report, ask for help, and become proactive in suggesting preventive measures. At the community level, there is an increased willingness to intervene but further consciousness-raising of the human rights perspective of violence, as well as actively engaging men. At the macro level, preventive efforts must be prioritized through re-enforcement of legal rights, and provision of adequate medical and social welfare services for both survivors and perpetrators.

Abstract Background The functional referral system is important in backing-up antenatal, labour and delivery, and postnatal services in the primary level of care facilities. The aim of this study was to evaluate the effectiveness of the maternal referral system through determining proportion of women reaching the hospitals after referral advice, appropriateness of the referral indications, reasons for non-compliance and to find out if compliance to referrals makes a difference in the perinatal outcome. Methods A follow-up study was conducted in Rufiji rural district in Tanzania. A total of 1538 women referred from 18 primary level of care facilities during a 13 months period were registered and then identified at hospitals. Those not reaching the hospitals were traced and interviewed. Results Out of 1538 women referred 70% were referred for demographic risks, 12% for obstetric historical risks, 12% for prenatal complications and 5.5% for natal and immediate postnatal complications. Five or more pregnancies as well as age Conclusion Majority of the maternal referrals were due to demographic risks, where few women complied. To improve compliance to maternal referrals there is need to review the referral indications and strengthen counseling on birth preparedness and complication readiness.

Abstract Background The high rate of antenatal care attendance in sub-Saharan Africa, should facilitate provision of information on signs of potential pregnancy complications. The aim of this study was to assess quality of antenatal care with respect to providers' counselling of pregnancy danger signs in Rufiji district, Tanzania. Methods A cross-sectional study was conducted in 18 primary health facilities. Thirty two providers were observed providing antenatal care to 438 pregnant women. Information on counselling on pregnancy danger signs was collected by an observer. Exit interviews were conducted to 435 women. Results One hundred and eighty five (42%) clients were not informed of any pregnancy danger signs. The most common pregnancy danger sign informed on was vaginal bleeding 50% followed by severe headache/blurred vision 45%. Nurse auxiliaries were three times more likely to inform a client of a danger sign than registered/enrolled nurses (OR = 3.7; 95% CI: 2.1-6.5) and Maternal Child Health Aides (OR = 2.3: 95% CI: 1.3-4.3) and public health nurses (OR = 2.5; CI: 1.4-4.2) were two times more likely to provide information on danger signs than registered/enrolled nurses. The clients recalled less than half of the pregnancy danger signs they had been informed during the interaction. Conclusion Two out of five clients were not counselled on pregnancy danger signs. The higher trained cadre, registered/enrolled nurses were not informing majority of clients pregnancy danger signs compared to the lower cadres. Supportive supervision should be made to enhance counselling of pregnancy danger signs. Nurse auxiliaries should be encouraged and given chance for further training and upgrading to improve their performance and increase human resource for health.

Abstract Background Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR). Methods From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient. Results The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors. Conclusion There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.

Abstract Background Criteria-based audits have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the introduction of a criteria-based audit in a tertiary hospital in an African setting, assesses the quality of care among eclampsia patients and discusses possible interventions in order to improve the quality of care. Methods We conducted a criteria based audit of 389 eclampsia patients admitted to Muhimbili National Hospital (MNH), Dar es Salaam Tanzania between April 14, 2006 and December 31, 2006. Cases were assessed using evidence-based criteria for appropriate care. Results Antepartum, intrapartum and postpartum eclampsia constituted 47%, 41% and 12% of the eclampsia cases respectively. Antepartum eclampsia was mostly (73%) preterm whereas the majority (71%) of postpartum eclampsia cases ware at term. The case fatality rate for eclampsia was 7.7%. Medical histories were incomplete, the majority (75%) of management plans were not reviewed by specialists in obstetrics, specialist doctors live far from the hospital and do not spend nights in hospital even when they are on duty, monitoring of patients on magnesium sulphate was inadequate, and important biochemical tests were not routinely done. Two thirds of the patient scheduled for caesarean section did not undergo surgery within agreed time. Conclusion Potential areas for further improvement in quality of emergency care for eclampsia relate to standardizing management guidelines, greater involvement of specialists in the management of eclampsia and continued medical education on current management of eclampsia for junior staff.

Abstract Background Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess women's awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania. Methods A total of 1118 women who had been pregnant in the past two years were interviewed. A list of medically recognized potentially life threatening obstetric signs was obtained from the responses given. Chi- square test was used to determine associations between categorical variables and multivariate logistic regression analysis was used to identify factors associated with awareness of obstetric danger signs. Results More than 98% of the women attended antenatal care at least once. Half of the women knew at least one obstetric danger sign. The percentage of women who knew at least one danger sign during pregnancy was 26%, during delivery 23% and after delivery 40%. Few women knew three or more danger signs. According to multivariate logistic regression analysis having secondary education or more increased the likelihood of awareness of obstetric danger signs six-fold (OR = 5.8; 95% CI: 1.8–19) in comparison with no education at all. The likelihood to have more awareness increased significantly by increasing age of the mother, number of deliveries, number of antenatal visits, whether the delivery took place at a health institution and whether the mother was informed of having a risks/complications during antenatal care. Conclusion Women had low awareness of danger signs of obstetric complications. We recommend the following in order to increase awareness of danger signs of obstetrical complications: to improve quality of counseling and involving other family members in antenatal and postnatal care, to use radio messages and educational sessions targeting the whole community and to intensify provision of formal education as emphasized in the second millennium development goal.

Abstract Background To our knowledge, no studies of the possible association of early life environment with snoring in adulthood have been published. We aimed to investigate whether early life environment is associated with snoring later in life. Methods A questionnaire including snoring frequency in adulthood and environmental factors in early life was obtained from 16,190 randomly selected men and women, aged 25–54 years, in Sweden, Norway, Iceland, Denmark and Estonia (response rate 74%). Results A total of 15,556 subjects answered the questions on snoring. Habitual snoring, defined as loud and disturbing snoring at least 3 nights a week, was reported by 18%. Being hospitalized for a respiratory infection before the age of two years (adjusted odds ratio (OR) = 1.27; 95% confidence interval (CI) 1.01–1.59), suffering from recurrent otitis as a child (OR = 1.18; 95%CI 1.05–1.33), growing up in a large family (OR = 1.04; 95%CI 1.002–1.07) and being exposed to a dog at home as a newborn (OR = 1.26; 95%CI 1.12–1.42) were independently related to snoring later in life and independent of a number of possible confounders in adulthood. The same childhood environmental factors except household size were also related with snoring and daytime sleepiness combined. Conclusion The predisposition for adult snoring may be partly established early in life. Having had severe airway infections or recurrent otitis in childhood, being exposed to a dog as a newborn and growing up in a large family are environmental factors associated with snoring in adulthood.

Studies of subjective well-being have conventionally relied upon self-report, which directs subjects' attention to their emotional experiences. This method presumes that attention itself does not influence emotional processes, which could bias sampling. We tested whether attention influences experienced utility (the moment-by-moment experience of pleasure) by using functional magnetic resonance imaging (fMRI) to measure the activity of brain systems thought to represent hedonic value while manipulating attentional load. Subjects received appetitive or aversive solutions orally while alternatively executing a low or high attentional load task. Brain regions associated with hedonic processing, including the ventral striatum, showed a response to both juice and quinine. This response decreased during the high-load task relative to the low-load task. Thus, attentional allocation may influence experienced utility by modulating (either directly or indirectly) the activity of brain mechanisms thought to represent hedonic value.

Multivariate pattern analysis (MVPA) is a relatively recent innovation in functional magnetic resonance imaging (fMRI) methods. MVPA is increasingly widely used, as it is apparently more effective than classical general linear model analysis (GLMA) for detecting response patterns or representations that are distributed at a fine spatial scale. However, we demonstrate that widely used approaches to MVPA can systematically admit certain confounds that are appropriately eliminated by GLMA. Thus confounds rather than distributed representations may explain some cases in which MVPA produced positive results but GLMA did not. The issue is that it is common practice in MVPA to conduct group tests on single-subject summary statistics that discard the sign or direction of underlying effects, whereas GLMA group tests are conducted directly on single-subject effects themselves. We describe how this common MVPA practice undermines standard experiment design logic that is intended to control at the group level for certain types of confounds, such as time on task and individual differences. Furthermore, we note that a simple application of linear regression can restore experimental control when using MVPA in many situations. Finally, we present a case study with novel fMRI data in the domain of rule representations, or flexible stimulus-response mappings, which has seen several recent MVPA publications. In our new dataset, as with recent reports, standard MVPA appears to reveal rule representations in prefrontal cortex regions, whereas GLMA produces null results. However, controlling for a variable that is confounded with rule at the individual-subject level but not the group level (reaction time differences across rules) eliminates the MVPA results. This raises the question of whether recently reported results truly reflect rule representations, or rather the effects of confounds such as reaction time, difficulty, or other variables of no interest., (Copyright © 2013 Elsevier Inc. All rights reserved.)

We examined whether older adults differ from younger adults in how they learn from rewarding and aversive outcomes. Human participants were asked to either learn to choose actions that lead to monetary reward or learn to avoid actions that lead to monetary losses. To examine age differences in the neurophysiological mechanisms of learning, we applied a combination of computational modeling and fMRI. Behavioral results showed age-related impairments in learning from reward but not in learning from monetary losses. Consistent with these results, we observed age-related reductions in BOLD activity during learning from reward in the ventromedial PFC. Furthermore, the model-based fMRI analysis revealed a reduced responsivity of the ventral striatum to reward prediction errors during learning in older than younger adults. This age-related reduction in striatal sensitivity to reward prediction errors may result from a decline in phasic dopaminergic learning signals in the elderly.

Humans are adept at switching between goal-directed behaviors quickly and effectively. The prefrontal cortex (PFC) is thought to play a critical role by encoding, updating, and maintaining internal representations of task context in working memory. It has also been hypothesized that the encoding of context representations in PFC is regulated by phasic dopamine gating signals. Here we use multimodal methods to test these hypotheses. First we used functional MRI (fMRI) to identify regions of PFC associated with the representation of context in a working memory task. Next we used single-pulse transcranial magnetic stimulation (TMS), guided spatially by our fMRI findings and temporally by previous event-related EEG recordings, to disrupt context encoding while participants performed the same working memory task. We found that TMS pulses to the right dorsolateral PFC (DLPFC) immediately after context presentation, and well in advance of the response, adversely impacted context-dependent relative to context-independent responses. This finding causally implicates right DLPFC function in context encoding. Finally, using the same paradigm, we conducted high-resolution fMRI measurements in brainstem dopaminergic nuclei (ventral tegmental area and substantia nigra) and found phasic responses after presentation of context stimuli relative to other stimuli, consistent with the timing of a gating signal that regulates the encoding of representations in PFC. Furthermore, these responses were positively correlated with behavior, as well as with responses in the same region of right DLPFC targeted in the TMS experiment, lending support to the hypothesis that dopamine phasic signals regulate encoding, and thereby the updating, of context representations in PFC.

Recent studies have begun to elucidate the neural correlates of evidence accumulation in perceptual decision making, but few of them have used a combined modeling-electrophysiological approach to studying evidence accumulation. We introduce a multivariate approach to EEG analysis with which we can perform a comprehensive search for the neural correlate of dynamics predicted by accumulator models. We show that the dynamics of evidence accumulation are most strongly correlated with ramping of oscillatory power in the 4-9 Hz theta band over the course of a trial, although it also correlates with oscillatory power in other frequency bands. The rate of power decrease in the theta band correlates with individual differences in the parameters of drift diffusion models fitted to individuals' behavioral data.

We examined whether older adults differ from younger adults in the degree to which they favor immediate over delayed rewards during decision-making. To examine the neural correlates of age-related differences in delay discounting we acquired functional MR images while participants made decisions between smaller but sooner and larger but later monetary rewards. The behavioral results show age-related reductions in delay discounting. Less impulsive decision-making in older adults was associated with lower ventral striatal activations to immediate reward. Furthermore, older adults showed an overall higher percentage of delayed choices and reduced activity in the dorsal striatum than younger adults. This points to a reduced reward sensitivity of the dorsal striatum in older adults. Taken together, our findings indicate that less impulsive decision-making in older adults is due to a reduced sensitivity of striatal areas to reward. These age-related changes in reward sensitivity may result from transformations in dopaminergic neuromodulation with age.

In some cases people judge it morally acceptable to sacrifice one person's life in order to save several other lives, while in other similar cases they make the opposite judgment. Researchers have identified two general factors that may explain this phenomenon at the stimulus level: (1) the agent's intention (i.e. whether the harmful event is intended as a means or merely foreseen as a side-effect) and (2) whether the agent harms the victim in a manner that is relatively "direct" or "personal". Here we integrate these two classes of findings. Two experiments examine a novel personalness/directness factor that we call personal force, present when the force that directly impacts the victim is generated by the agent's muscles (e.g., in pushing). Experiments 1a and b demonstrate the influence of personal force on moral judgment, distinguishing it from physical contact and spatial proximity. Experiments 2a and b demonstrate an interaction between personal force and intention, whereby the effect of personal force depends entirely on intention. These studies also introduce a method for controlling for people's real-world expectations in decisions involving potentially unrealistic hypothetical dilemmas.

In an effort to clarify how deductive reasoning is accomplished, an fMRI study was performed to observe the neural substrates of logical reasoning and mathematical calculation. Participants viewed a problem statement and three premises, and then either a conclusion or a mathematical formula. They had to indicate whether the conclusion followed from the premises, or to solve the mathematical formula. Language areas of the brain (Broca's and Wernicke's area) responded as the premises and the conclusion were read, but solution of the problems was then carried out by non-language areas. Regions in right prefrontal cortex and inferior parietal lobe were more active for reasoning than for calculation, whereas regions in left prefrontal cortex and superior parietal lobe were more active for calculation than for reasoning. In reasoning, only those problems calling for a search for counterexamples to conclusions recruited right frontal pole. These results have important implications for understanding how higher cognition, including deduction, is implemented in the brain. Different sorts of thinking recruit separate neural substrates, and logical reasoning goes beyond linguistic regions of the brain.

Traditional theories of moral development emphasize the role of controlled cognition in mature moral judgment, while a more recent trend emphasizes intuitive and emotional processes. Here we test a dual-process theory synthesizing these perspectives. More specifically, our theory associates utilitarian moral judgment (approving of harmful actions that maximize good consequences) with controlled cognitive processes and associates non-utilitarian moral judgment with automatic emotional responses. Consistent with this theory, we find that a cognitive load manipulation selectively interferes with utilitarian judgment. This interference effect provides direct evidence for the influence of controlled cognitive processes in moral judgment, and utilitarian moral judgment more specifically.

Decision conflict occurs when people feel uncertain as to which option to choose from a set of similarly attractive (or unattractive) options, with many studies demonstrating that this conflict can lead to suboptimal decision making. In this article, we investigate the neurobiological underpinnings of decision conflict, in particular, the involvement of the anterior cingulate cortex (ACC). Previous studies have implicated the ACC in conflict monitoring during perceptual tasks, but there is considerable controversy as to whether the ACC actually indexes conflict related to choice, or merely conflict related to selection of competing motor responses. In a functional magnetic resonance imaging study, we dissociate the decision and response phases of a decision task, and show that the ACC does indeed index conflict at the decision stage. Furthermore, we show that it does so for a complex decision task, one that requires the integration of beliefs and preferences and not just perceptual judgments.

Current theories hypothesize that dopamine neuronal firing encodes reward prediction errors. Although studies in nonhuman species provide direct support for this theory, functional magnetic resonance imaging (fMRI) studies in humans have focused on brain areas targeted by dopamine neurons [ventral striatum (VStr)] rather than on brainstem dopaminergic nuclei [ventral tegmental area (VTA) and substantia nigra]. We used fMRI tailored to directly image the brainstem. When primary rewards were used in an experiment, the VTA blood oxygen level-dependent (BOLD) response reflected a positive reward prediction error, whereas the VStr encoded positive and negative reward prediction errors. When monetary gains and losses were used, VTA BOLD responses reflected positive reward prediction errors modulated by the probability of winning. We detected no significant VTA BOLD response to nonrewarding events.

Cognitive control is required to regulate interactions between brain regions to produce effective, purposeful behavior. We used functional magnetic resonance imaging to investigate the nature of these interactions and the role of prefrontal cortex (PFC) in cognitive control as subjects switched between simple face and word categorization tasks. Face and word stimuli were used because previous research has shown them to activate distinguishable cortical regions, allowing us to measure levels of activity in task-selective brain regions during task switching. We found that activity in brain regions selective for the currently irrelevant task predicted the behavioral cost associated with switching tasks. This finding supports the theory that between-task competition is a critical determinant of behavior. Task switching was also associated with increased activity in a network of regions implicated in cognitive control, including lateral PFC and parietal cortex. Within this network of regions, we observed dissociations between task-selective and general purpose mechanisms. These findings provide support for theories that propose a control hierarchy comprising regions responsible for maintaining task-specific information about rules or goals, and regions involved in the coordination of these goals.

Mesencephalic dopamine neurons are believed to facilitate reward-dependent learning by computing errors in reward predictions. We used fMRI to test whether this system was activated as expected in response to errors in predictions about whether a social partner would reciprocate an act of altruism. Nineteen subjects received fMRI scans as they played a series of single-shot Prisoner's Dilemma games with partners who were outside the scanner. In both ventromedial prefrontal cortex and ventral striatum, reciprocated and unreciprocated cooperation were associated with positive and negative BOLD responses, respectively. Our results are consistent with the hypothesis that mesencephalic dopamine projection sites carry information about errors in reward prediction that allow us to learn who can and cannot be trusted to reciprocate favors.

Traditional theories of moral psychology emphasize reasoning and "higher cognition," while more recent work emphasizes the role of emotion. The present fMRI data support a theory of moral judgment according to which both "cognitive" and emotional processes play crucial and sometimes mutually competitive roles. The present results indicate that brain regions associated with abstract reasoning and cognitive control (including dorsolateral prefrontal cortex and anterior cingulate cortex) are recruited to resolve difficult personal moral dilemmas in which utilitarian values require "personal" moral violations, violations that have previously been associated with increased activity in emotion-related brain regions. Several regions of frontal and parietal cortex predict intertrial differences in moral judgment behavior, exhibiting greater activity for utilitarian judgments. We speculate that the controversy surrounding utilitarian moral philosophy reflects an underlying tension between competing subsystems in the brain.

Tasks that engage a theory of mind seem to activate a consistent set of brain areas. In this study, we sought to determine whether two different interactive tasks, both of which involve receiving consequential feedback from social partners that can be used to infer intent, similarly engaged the putative theory of mind neural network. Participants were scanned using fMRI as they played the Ultimatum Game (UG) and the Prisoner's Dilemma Game (PDG) with both alleged human and computer partners who were outside the scanner. We observed a remarkable degree of overlap in brain areas that activated to partner decisions in the two games, including commonly observed theory of mind areas, as well as several brain areas that have not been reported previously and may relate to immersion of participants in real social interactions that have personally meaningful consequences. Although computer partners elicited activation in some of the same areas activated by human partners, most of these activations were stronger for human partners.

The nascent field of neuroeconomics seeks to ground economic decision making in the biological substrate of the brain. We used functional magnetic resonance imaging of Ultimatum Game players to investigate neural substrates of cognitive and emotional processes involved in economic decision-making. In this game, two players split a sum of money;one player proposes a division and the other can accept or reject this. We scanned players as they responded to fair and unfair proposals. Unfair offers elicited activity in brain areas related to both emotion (anterior insula) and cognition (dorsolateral prefrontal cortex). Further, significantly heightened activity in anterior insula for rejected unfair offers suggests an important role for emotions in decision-making.

In choice reaction time tasks, response times and error rates demonstrate differential dependencies on the identities of up to four stimuli preceding the current one. Although the general profile of reaction times and error rates, when plotted against the stimulus histories, may seem idiosyncratic, we show that it can result from simple underlying mechanisms that take account of the occurrence of stimulus repetitions and alternations. Employing a simple connectionist model of a two-alternative forced-choice task, we explored various combinations of repetition and alternation detection schemes in an attempt to account for empirical results from the literature and from our own studies. We found that certain combinations of the repetition and the alternation schemes provided good fits to the data, suggesting that simple mechanisms may serve to explain the complicated but highly reproducible higher order dependencies of task performance on stimulus history.

A growing body of evidence from functional neuroimaging and computational modeling studies indicates that the anterior cingulate cortex (ACC) detects the presence of response conflict and conveys this information to other brain regions, enabling subsequent adjustments in cognitive control. The present study examined previous empirical findings of increased ACC for low-frequency stimuli across three distinct speeded response tasks (two-alternative forced choice, go/no-go, and oddball). Simulations conducted in a neural network model incorporating sequential priming mechanisms (developed in Cho et al., 2002) confirmed that a computational measure of response conflict was higher on low-frequency trials across all three tasks. In addition, the model captured detailed aspects of behavioral reaction time and accuracy data, predicted the dynamics of ACC activity related to trial sequence effects, and provided evidence for the functional role of conflict information in performance monitoring and optimization. The results indicate that the conflict-monitoring hypothesis, augmented by mechanisms for encoding stimulus history, can explain key phenomena associated with performance in sequential speeded response tasks.

The long-standing rationalist tradition in moral psychology emphasizes the role of reason in moral judgment. A more recent trend places increased emphasis on emotion. Although both reason and emotion are likely to play important roles in moral judgment, relatively little is known about their neural correlates, the nature of their interaction, and the factors that modulate their respective behavioral influences in the context of moral judgment. In two functional magnetic resonance imaging (fMRI) studies using moral dilemmas as probes, we apply the methods of cognitive neuroscience to the study of moral judgment. We argue that moral dilemmas vary systematically in the extent to which they engage emotional processing and that these variations in emotional engagement influence moral judgment. These results may shed light on some puzzling patterns in moral judgment observed by contemporary philosophers.

Electrophysiological studies suggest sensitivity of the prefrontal cortex to changes in the probability of an event. The purpose of this study was to determine if subregions of the prefrontal cortex respond differentially to changes in target probabilities using functional magnetic resonance imaging (fMRI). Ten right-handed adults were scanned using a gradient-echo, echo planar imaging sequence during performance of an oddball paradigm. Subjects were instructed to respond to any letter but "X". The frequency of targets (i.e., any letter but X) varied across trials. The results showed that dorsal prefrontal regions were active during infrequent events and ventral prefrontal regions were active during frequent events. Further, we observed an inverse relation between the dorsal and ventral prefrontal regions such that when activity in dorsal prefrontal regions increased, activity in ventral prefrontal regions decreased, and vice versa. This finding may index competing cognitive processes or capacity limitations. Most importantly, these findings taken as a whole suggest that any simple theory of prefrontal cortex function must take into account the sensitivity of this region to changes in target probability., (Copyright 2001 Wiley-Liss, Inc.)

Research suggests that the basal ganglia complex is a major component of the neural circuitry that mediates reward-related processing. However, human studies have not yet characterized the response of the basal ganglia to an isolated reward, as has been done in animals. We developed an event-related functional magnetic resonance imaging paradigm to identify brain areas that are activated after presentation of a reward. Subjects guessed whether the value of a card was higher or lower than the number 5, with monetary rewards as an incentive for correct guesses. They received reward, punishment, or neutral feedback on different trials. Regions in the dorsal and ventral striatum were activated by the paradigm, showing differential responses to reward and punishment. Activation was sustained following a reward feedback, but decreased below baseline following a punishment feedback.

Investigations of working memory (WM) systems in the frontal cortex have revealed two stimulus dimensions along which frontal cortical representations may be functionally organized. One hypothesized dimension dissociates verbal from nonverbal WM processes, dividing left from right frontal regions. The second hypothesized dimension dissociates spatial from nonspatial WM, dividing dorsal from ventral frontal regions. Here we used functional magnetic resonance imaging to probe WM processes associated with three different types of stimuli: letters (verbal and nonspatial), abstract shapes (nonverbal and nonspatial), and locations (nonverbal and spatial). In a series of three experiments using the "n-back" WM paradigm, direct statistical comparisons were made between activation patterns in each pairwise combination of the three stimulus types. Across the experiments, no regions that demonstrated responses to WM manipulations were discovered to be unique to any of the three stimulus types. Therefore, no evidence was found to support either a left/right verbal/nonverbal dissociation or a dorsal/ventral spatial/nonspatial dissociation. While this could reflect a limitation of the present behavioral and imaging techniques, other factors that could account for the data are considered, including subjects' strategy selection, encoding of information into WM, and the nature of representational schemes in prefrontal cortex., (Copyright 2000 Academic Press.)

The anterior cingulate cortex (ACC), on the medial surface of the frontal lobes of the brain, is widely believed to be involved in the regulation of attention. Beyond this, however, its specific contribution to cognition remains uncertain. One influential theory has interpreted activation within the ACC as reflecting 'selection-for-action', a set of processes that guide the selection of environmental objects as triggers of or targets for action. We have proposed an alternative hypothesis, in which the ACC serves not to exert top-down attentional control but instead to detect and signal the occurrence of conflicts in information processing. Here, to test this theory against the selection-for-action theory, we used functional magnetic resonance imaging to measure brain activation during performance of a task where, for a particular subset of trials, the strength of selection-for-action is inversely related to the degree of response conflict. Activity within the ACC was greater during trials featuring high levels of conflict (and weak selection-for-action) than during trials with low levels of conflict (and strong selection-for-action), providing evidence in favour of the conflict-monitoring account of ACC function.

This study examines important developmental differences in patterns of activation in the prefrontal cortex during performance of a Go-No-Go paradigm using functional magnetic resonance imaging (fMRI). Eighteen subjects (9 children and 9 adults) were scanned using gradient echo, echo planar imaging during performance of a response inhibition task. The results suggest four general findings. First, the location of activation in the prefrontal cortex was not different between children and adults, which is similar to our earlier pediatric fMRI results of prefrontal activation during a working memory task (Casey et al., 1995). Second, the volume of activation was significantly greater for children relative to adults. These differences in volume of activation were observed predominantly in the dorsal and lateral prefrontal cortices. Third, although inhibitory processes have typically been associated with more ventral or orbital frontal regions, the current study revealed activation that was distributed across both dorsolateral and orbitofrontal cortices. Finally, consistent with animal and human lesion studies, activity in orbital frontal and anterior cingulate cortices correlated with behavioral performance (i.e., number of false alarms). These results further demonstrate the utility of this methodology in studying pediatric populations.

A functional magnetic resonance imaging (fMRI) study was conducted to determine whether prefrontal cortex (PFC) increases activity in working memory (WM) tasks as a specific result of the demands placed on WM, or to other processes affected by the greater difficulty of such tasks. Increased activity in dorsolateral PFC (DLPFC) was observed during task conditions that placed demands on active maintenance (long retention interval) relative to control conditions matched for difficulty. Furthermore, the activity was sustained over the entire retention interval and did not increase when task difficulty was manipulated independently of WM requirements. This contrasted with the transient increases in activity observed in the anterior cingulate, and other regions of frontal cortex, in response to increased task difficulty but not WM demands. Thus, this study established a double-dissociation between regions responsive to WM versus task difficulty, indicating a specific involvement of DLPFC and related structures in WM function.

Functional magnetic resonance imaging (fMRI) using blood oxygenation contrast has rapidly spread into many application areas. In this paper, a new statistical model is used to evaluate the reliability of fMRI activation in a finger opposition motor paradigm for both within-session and between-session data and in a working memory paradigm for between-session data. A slice prescription procedure for between-session reproducibility is introduced. Estimates are made for the probabilities of correctly and falsely classifying voxels as active or inactive and receiver operator characteristic curves are generated. In the motor paradigm, estimated between-session reliability was found to be somewhat reduced relative to within-session reliability; however, this includes additional sources of variation and may not reflect intrinsically lower reliability. After matching false-positive classification probabilities, between-session reliability was found to be nearly identical for both motor and cognitive activation paradigms.

Working memory is responsible for the short-term storage and online manipulation of information necessary for higher cognitive functions, such as language, planning and problem-solving. Traditionally, working memory has been divided into two types of processes: executive control (governing the encoding manipulation and retrieval of information in working memory) and active maintenance (keeping information available 'online'). It has also been proposed that these two types of processes may be subserved by distinct cortical structures, with the prefrontal cortex housing the executive control processes, and more posterior regions housing the content-specific buffers (for example verbal versus visuospatial) responsible for active maintenance. However, studies in non-human primates suggest that dorsolateral regions of the prefrontal cortex may also be involved in active maintenance. We have used functional magnetic resonance imaging to examine brain activation in human subjects during performance of a working memory task. We used the temporal resolution of this technique to examine the dynamics of regional activation, and to show that prefrontal cortex along with parietal cortex appears to play a role in active maintenance.

Although recent neuroimaging studies suggest that prefrontal cortex (PFC) is involved in working memory (WM), the relationship between PFC activity and memory load has not yet been well-described in humans. Here we use functional magnetic resonance imaging (fMRI) to probe PFC activity during a sequential letter task in which memory load was varied in an incremental fashion. In all nine subjects studied, dorsolateral and left inferior regions of PFC were identified that exhibited a linear relationship between activity and WM load. Furthermore, these same regions were independently identified through direct correlations of the fMRI signal with a behavioral measure that indexes WM function during task performance. A second experiment, using whole-brain imaging techniques, both replicated these findings and identified additional brain regions showing a linear relationship with load, suggesting a distributed circuit that participates with PFC in subserving WM. Taken together, these results provide a "dose-response curve" describing the involvement of both PFC and related brain regions in WM function, and highlight the benefits of using graded, parametric designs in neuroimaging research.