A Distinct Metabolite Signature in Military Personnel Exposed to Repetitive Low-Level Blasts.

Military Breachers and Range Staff (MBRS) are subjected to repeated sub-concussive blasts, and they often report symptoms that are consistent with a mild traumatic brain injury (mTBI). Biomarkers of blast injury would potentially aid blast injury diagnosis, surveillance and avoidance. Our objective was to identify plasma metabolite biomarkers in military personnel that were exposed to repeated low-level or sub-concussive blast overpressure. A total of 37 military members were enrolled (18 MBRS and 19 controls), with MBRS having participated in 8-20 breaching courses per year, with a maximum exposure of 6 blasts per day. The two cohorts were similar except that the number of blast exposures were significantly higher in the MBRS, and the MBRS cohort suffered significantly more post-concussive symptoms and poorer health on assessment. Metabolomics profiling demonstrated significant differences between groups with 74% MBRS classification accuracy (CA). Feature reduction identified 6 metabolites that resulted in a MBRS CA of 98%, and included acetic acid (23.7%), formate (22.6%), creatine (14.8%), acetone (14.2%), methanol (12,7%), and glutamic acid (12.0%). All 6 metabolites were examined with individual receiver operating characteristic (ROC) curve analyses and demonstrated areas-under-the-curve (AUCs) of 0.82-0.91 (P ≤ 0.001) for MBRS status. Several parsimonious combinations of three metabolites increased accuracy of ROC curve analyses to AUCs of 1.00 (P < 0.001), while a combination of volatile organic compounds (VOCs; acetic acid, acetone and methanol) yielded an AUC of 0.98 (P < 0.001). Candidate biomarkers for chronic blast exposure were identified, and if validated in a larger cohort, may aid surveillance and care of military personnel. Future point-of-care screening could be developed that measures VOCs from breath, with definitive diagnoses confirmed with plasma metabolomics profiling.

"Mombrain and Sticky DNA": The Impacts of Neurobiological and Epigenetic Framings of Motherhood on Women's Subjectivities.

The fields of epigenetics and neuroscience have come to occupy a significant place in individual and public life in biomedicalized societies. Social scientists have argued that the primacy and popularization of the "neuro" has begun to shape how patients and other lay people experience themselves and their lifeworlds in increasingly neurological and genetic terms. Pregnant women and new mothers have become an important new target for cutting edge neuroscientific and epigenetic research, with the Internet constituting a highly active space for engagement with knowledge translations. In this paper, we analyze the reception by women in North America of translations of nascent epigenetic and neuroscientific research. We conducted three focus groups with pregnant women and new mothers. The study was informed by a prior scoping investigation of online content. Our focus group findings record how engagement with translations of epigenetic and neuroscientific research impact women's perinatal experience, wellbeing, and self-construal. Three themes emerged in our analysis: (1) A kind of brain; (2) The looping effects of biomedical narratives; (3) Imprints of past experience and the management of the future. This data reveals how mothers engage with the neurobiological style-of-thought increasingly characteristic of public health and popular science messaging around pregnancy and motherhood. Through the molecularization of pregnancy and child development, a typical passage of life becomes saturated with "susceptibility," "risk," and the imperative to preemptively make "healthy' choices." This, in turn, redefines and shapes the experience of what it is to be a "good," "healthy," or "responsible" mother/to-be.

Reimbursement models to tackle market failures for antimicrobials: Approaches taken in France, Germany, Sweden, the United Kingdom, and the United States.

INTRODUCTION: The pipeline of new antibacterials remains limited. Reasons include low research investments, limited commercial prospects, and scientific challenges. To complement existing initiatives such as research grants, governments are exploring policy options for providing new market incentives to drug developers. MATERIALS AND METHODS: Reimbursement interventions for antibacterials in France, Germany, Sweden, US, and UK were reviewed and analysed by the authors. RESULTS: In France, Germany, and the US, implemented interventions centre on providing exceptions in cost-containment mechanisms to allow higher prices for certain antibacterials. In the US, also, certain antibacterials are granted additional years of protection from generic competition (exclusivity) and faster regulatory review. The UK is piloting a model that will negotiate contracts with manufacturers to pay a fixed annual fee for ongoing supply of as many units as needed. Sweden is piloting a model that will offer manufacturers of selected antibacterials contracts that would guarantee a minimum annual revenue. A similar model of guaranteed minimal annual revenues is under consideration in the US (PASTEUR Act). CONCLUSIONS: The UK and Sweden are piloting entirely novel procurement and reimbursement models. Existing interventions in the US, France, and Germany represent important, but relatively minor interventions. More countries should explore the use of novel models and international coordination will be important for 'pull' incentives to be effective. If adopted, the PASTEUR legislation in the US would constitute a significant 'pull' incentive.

Feasibility Study of the World Health Organization Health Care Facility-Based Antimicrobial Stewardship Toolkit for Low- and Middle-Income Countries.

Antimicrobial stewardship (AMS) has emerged as a systematic approach to optimize antimicrobial use and reduce antimicrobial resistance. To support the implementation of AMS programs, the World Health Organization developed a draft toolkit for health care facility AMS programs in low- and middle-income countries. A feasibility study was conducted in Bhutan, the Federated States of Micronesia, Malawi, and Nepal to obtain local input on toolkit content and implementation of AMS programs. This descriptive qualitative study included semi-structured interviews with national- and facility-level stakeholders. Respondents identified AMS as a priority and perceived the draft toolkit as a much-needed document to further AMS program implementation. Facilitators for implementing AMS included strong national and facility leadership and clinical staff engagement. Barriers included lack of human and financial resources, inadequate regulations for prescription antibiotic sales, and insufficient AMS training. Action items for AMS implementation included improved laboratory surveillance, establishment of a stepwise approach for implementation, and mechanisms for reporting and feedback. Recommendations to improve the AMS toolkit's content included additional guidance on defining the responsibilities of the committees and how to prioritize AMS programming based on local context. The AMS toolkit was perceived to be an important asset as countries and health care facilities move forward to implement AMS programs.

The relationship between methods of scoring the alternate uses task and the neural correlates of divergent thinking: Evidence from voxel-based morphometry.

Divergent thinking tests have been used extensively in neuroscientific studies of creativity. However, output from tests of divergent thinking can be scored in different ways, and those scores can influence assessments of divergent thinking performance and its relationship with brain activation. Here we sought to investigate the relationship between various methods of scoring the Alternate Uses Task (AUT)-a well-known test of divergent thinking-and regional grey matter volume (GMV) using voxel-based morphometry (VBM). We assessed AUT performance based on (a) traditional approaches that involve scoring participants' output on fluency, flexibility, originality, and elaboration, (b) a subjective approach that involves scoring output directly on "snapshot" creativity, and (c) the definitional approach that involves scoring output separately on novelty and usefulness-the two criteria deemed necessary and jointly sufficient to categorize an idea as creative. Correcting for age, sex, intracranial volume, verbal IQ and working memory capacity, we found negative correlations between regional GMV in the left inferior temporal gyrus (ITG) and novelty and usefulness scores, but no correlation involving other scoring approaches. As part of the brain's core semantic system, this region is involved in concept retrieval and integration. We discuss the implications of these findings for our understanding of the neural bases of divergent thinking, and how ITG could be related to the generation of novel and useful responses.

Identifying targets for antibiotic stewardship interventions through analysis of the antibiotic prescribing process in hospitals - a multicentre observational cohort study.

BACKGROUND: In order to change antibiotic prescribing behaviour, we need to understand the prescribing process. The aim of this study was to identify targets for antibiotic stewardship interventions in hospitals through analysis of the antibiotic prescribing process from admission to discharge across five groups of infectious diseases. METHODS: We conducted a multi-centre, observational cohort study, including patients with lower respiratory tract infections, exacerbation of chronic obstructive pulmonary disease, skin- and soft tissue infections, urinary tract infections or sepsis, admitted to wards of infectious diseases, pulmonary medicine and gastroenterology at three teaching hospitals in Western Norway. Data was collected over a 5-month period and included antibiotics prescribed and administered during admission, antibiotics prescribed at discharge, length of antibiotic therapy, indication for treatment and discharge diagnoses, estimated glomerular filtration rate (eGFR) on admission, antibiotic allergies, place of initiation of therapy, admittance from an institution, patient demographics and outcome data. Primary outcome measure was antibiotic use throughout the hospital stay, analysed by WHO AWaRe-categories and adherence to guideline. Secondary outcome measures were a) antibiotic prescribing patterns by groups of diagnoses, which were analysed using descriptive statistics and b) non-adherence to the national antibiotic guidelines, analysed using multivariate logistic regression. RESULTS: Through analysis of 1235 patient admissions, we identified five key targets for antibiotic stewardship interventions in our population of hospital inpatients; 1) adherence to guideline on initiation of treatment, as this increases the use of WHO Access-group antibiotics, 2) antibiotic prescribing in the emergency room (ER), as 83.6% of antibiotic therapy was initiated there, 3) understanding prescribing for patients admitted from other institutions, as this was significantly associated with non-adherence to guideline (OR = 1.44 95% CI 1.04, 2.00), 4) understanding cultural and contextual drives of antibiotic prescribing, as non-adherent prescribing differed significantly between the sites of initiation of therapy (between hospitals and ER versus ward) and 5) length of therapy, as days of antibiotic therapy was similar across a wide range of diagnoses and with prolonged therapy after discharge. CONCLUSIONS: Analysing the process of antibiotic prescribing in hospitals with patient-level data identified important targets for antibiotic stewardship interventions in hospitals.

Energy Balance of Canadian Armed Forces Personnel during an Arctic-Like Field Training Exercise.

Operating in temperature extremes frequently leads to a discrepancy in energy balance. Investigating the effects of operating in extreme cold temperatures on metabolic requirements has not been well described in Canadian Armed Forces (CAF) personnel. The objective was to accurately assess energy deficits using the "gold standard" methodology for measuring energy intake (EI) and energy expenditure (EE). Nutritional intake of a convenience sample of 10 CAF Class A Reservists, completing a basic military qualification (land) course under winter weather conditions, was assessed using the daily measured food intake/food waste collections. EE was measured by the doubly-labelled water method. Average EI was 2377 ± 1144 kcal/day, which was below the EE (4917 ± 693 kcal/day), despite having ~5685 kcal available in the field rations. A significant body weight loss of 2.7% was associated with the average daily energy deficit of 2539 ± 1396 kcal. As a result, participants demonstrated voluntary anorexia. Such results may have important implications for the impairment of performance and health under longer duration operations.

A behavioural approach to specifying interventions: what insights can be gained for the reporting and implementation of interventions to reduce antibiotic use in hospitals?

BACKGROUND: Reducing unnecessary antibiotic exposure is a key strategy in reducing the development and selection of antibiotic-resistant bacteria. Hospital antimicrobial stewardship (AMS) interventions are inherently complex, often requiring multiple healthcare professionals to change multiple behaviours at multiple timepoints along the care pathway. Inaction can arise when roles and responsibilities are unclear. A behavioural perspective can offer insights to maximize the chances of successful implementation. OBJECTIVES: To apply a behavioural framework [the Target Action Context Timing Actors (TACTA) framework] to existing evidence about hospital AMS interventions to specify which key behavioural aspects of interventions are detailed. METHODS: Randomized controlled trials (RCTs) and interrupted time series (ITS) studies with a focus on reducing unnecessary exposure to antibiotics were identified from the most recent Cochrane review of interventions to improve hospital AMS. The TACTA framework was applied to published intervention reports to assess the extent to which key details were reported about what behaviour should be performed, who is responsible for doing it and when, where, how often and with whom it should be performed. RESULTS: The included studies (n = 45; 31 RCTs and 14 ITS studies with 49 outcome measures) reported what should be done, where and to whom. However, key details were missing about who should act (45%) and when (22%). Specification of who should act was missing in 79% of 15 interventions to reduce duration of treatment in continuing-care wards. CONCLUSIONS: The lack of precise specification within AMS interventions limits the generalizability and reproducibility of evidence, hampering efforts to implement AMS interventions in practice.

Investigation of perioperative work processes in provision of antibiotic prophylaxis: a prospective descriptive qualitative study across surgical specialties in Norway.

OBJECTIVE: Surgical site infections are known postoperative complications, yet the most preventable of healthcare-associated infections. Correct provision of surgical antibiotic prophylaxis (SAP) is crucial. Use of the WHO Safe Surgical Checklist (SSC) has been reported to improve provision of SAP, and reduce infections postoperatively. To understand possible mechanisms and interactions generating such effects, we explored the underlying work processes of SAP provision and SSC performance at the intersection of perioperative procedures and actual team working. DESIGN: An ethnographic study including observations and in-depth interviews. A combination of deductive and inductive content analysis of the data was conducted. SETTING: Operating theatres with different surgical specialities, in three Norwegian hospitals. PARTICIPANTS: Observations of perioperative team working (40 hours) and in-depth interviews of 19 experienced perioperative team members were conducted. Interview participants followed a maximum variation purposive sampling strategy. RESULTS: Analysis identified provision of SAP as a process of linked activities; sequenced, yet disconnected in time and space throughout the perioperative phase. Provision of SAP was handled in relation to several interactive factors: preparation and administration, prescription accuracy, diversity of prescription order systems, patient-specific conditions and changes in operating theatre schedules. However, prescription checks were performed either as formal SSC reviews of SAP items or as informal checks of relevant documents. In addition, use of cognitive reminders and clinical experiences were identified as mechanisms used to enable administration of SAP within the 60 min timeframe described in the SSC. CONCLUSION: Provision of SAP was identified as a complex process. Yet, a key element in provision of SAP was the given 60 min. timeframe of administration before incision, provided in the SSC. Thus, the SSC seems beneficial in supporting timely SAP administration practice by either being a cognitive tool and/or as a cognitive intervention.

The Use of a Mobile Application to Increase Access to Interpreters for Cancer Patients With Limited English Proficiency: A Pilot Study.

BACKGROUND: Language barriers can influence the quality of health care and health outcomes of limited English proficient patients with cancer. The use of medical interpretation services can be a valuable asset for improving communications in emergency care settings. OBJECTIVE: To evaluate whether a mobile translation application increased call frequency to interpreter services among providers in an Urgent Care Center at a comprehensive cancer center and to assess provider satisfaction of the mobile application. RESEARCH DESIGN: Prospective pre-post nonrandomized intervention of a mobile translation application with access to an over the phone interpreter (OPI) service at the push of a button and poststudy satisfaction survey. SUBJECTS: Sixty-five clinicians working at the Urgent Care Center in a cancer center in New York City. MEASURES: Mean call frequency to OPI services, tested by the nonparametric Wilcoxon Mann Whitney test, and self-reported provider satisfaction descriptives. RESULTS: The mobile application contributed to increasing the frequency of phone calls to OPI services during the intervention period (mean=12.8; P=0.001) as compared with the preintervention period (mean=4.3), and showed continued use during the postintervention period (mean=5.7). Most clinicians were satisfied with the use of the mobile application and access to the OPI services. CONCLUSIONS: The results suggest that mobile application tools contribute to increasing the use and ease of access to language services. This has the potential to improve the quality of communication between medical providers and limited English proficient patients in the delivery of cancer care in urgent care settings.

The association between adherence to national antibiotic guidelines and mortality, readmission and length of stay in hospital inpatients: results from a Norwegian multicentre, observational cohort study.

Background: Clinical antibiotic prescribing guidelines are essential in defining responsible use in the local context. Our objective was to investigate the association between adherence to national antibiotic prescribing guidelines and patient outcomes across a wide range of infectious diseases in hospital inpatients. Methods: Over five months in 2014, inpatients receiving antibiotics under the care of pulmonary medicine, infectious diseases and gastroenterology specialties across three university hospitals in Western Norway were included in this observational cohort study. Patient and antibiotic prescribing data gathered from electronic medical records included indication for antibiotics, microbiology test results, discharge diagnoses, length of stay (LOS), comorbidity, estimated glomerular filtration rate (eGFR) on admission and patient outcomes (primary: 30-day mortality; secondary: in-hospital mortality, 30-day readmission and LOS). Antibiotic prescriptions were classified as adherent or non-adherent to national guidelines according to documented indication for treatment. Patient outcomes were analysed according to status for adherence to guidelines using multivariate logistic, linear and competing risk regression analysis with adjustments made for comorbidity, age, sex, indication for treatment, seasonality and whether the patient was admitted from an institution or not. Results: In total, 1756 patients were included in the study. 30-day-mortality and in-hospital mortality were lower (OR = 0.48, p = 0.003 and OR = 0.46, p = 0.001) in the guideline adherent group, compared to the non-adherent group. Adherence to guideline did not affect 30-day readmission. In linear regression analysis there was a trend towards shorter LOS when LOS was analysed for patients discharged alive (predicted mean difference - 0.47, 95% CI (- 1.02, 0.07), p = 0.081). In competing risk analysis of LOS, the adherent group had a subdistribution hazard ratio (SHR) of 1.17 95% CI (1.02, 1.34), p = 0.025 for discharge compared to the non-adherent group. Conclusions: Adhering to antibiotic guidelines when treating infections in hospital inpatients was associated with favourable patient outcomes in terms of mortality and LOS.

Use of microbiology tests in the era of increasing AMR rates- a multicentre hospital cohort study.

Background: Effective use of microbiology test results may positively influence patient outcomes and limit the use of broad-spectrum antibiotics. However, studies indicate that their potential is not fully utilized. We investigated microbiology test ordering practices and the use of test results for antibiotic decision-making in hospitals. Methods: A multicentre cohort study was conducted during five months in 2014 in Medical departments across three hospitals in Western Norway. Patients treated with antibiotics for sepsis, urinary tract infections, skin and soft tissue infections, lower respiratory tract infections or acute exacerbations of chronic obstructive pulmonary disease were included in the analysis. Primary outcome measures were degree of microbiology test ordering, compliance with microbiology testing recommendations in the national antibiotic guideline and proportion of microbiology test results used to inform antibiotic treatment. Data was obtained from electronic- and paper medical records and charts and laboratory information systems. Results: Of the 1731 patient admissions during the study period, mean compliance with microbiology testing recommendations in the antibiotic guideline was 89%, ranging from 81% in patients with acute exacerbations of chronic obstructive pulmonary disease to 95% in patients with sepsis. Substantial additional testing was performed beyond the recommendations with 298/606 (49%) of patients with lower respiratory tract infections having urine cultures and 42/194 (22%) of patients with urinary tract infections having respiratory tests. Microbiology test results from one of the hospitals showed that 18% (120/672) of patient admissions had applicable test results, but only half of them were used for therapy guidance, i.e. in total, 9% (63/672) of patient admissions had test results informing prescription of antibiotic therapy. Conclusions: This study showed that despite a large number of microbiology test orders, only a limited number of tests informed antibiotic treatment. To ensure that microbiology tests are used optimally, there is a need to review the utility of existing microbiology tests, test ordering practices and use of test results through a more targeted and overarching approach.

Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries-A qualitative study.

BACKGROUND: Most of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings. MATERIALS AND METHODS: Healthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources. RESULTS: 54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/ 7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, one hospital in India provided the best example of interdisciplinary ASP, championed through organisational leadership. CONCLUSIONS: ASP initiatives in this study were restricted by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. There needs to be promotion of interdisciplinary team work including pharmacists and nurses, depending on the available healthcare workforce in different countries, in ASP. The surgical pathway remains a hard to reach, but critical target for ASP globally. There is a need to develop contextually driven ASP targeting the surgical pathway in different resource settings.

Causal Analysis of World Health Organization's Surgical Safety Checklist Implementation Quality and Impact on Care Processes and Patient Outcomes: Secondary Analysis From a Large Stepped Wedge Cluster Randomized Controlled Trial in Norway.

OBJECTIVE: We hypothesize that high-quality implementation of the World Health Organization's Surgical Safety Checklist (SSC) will lead to improved care processes and subsequently reduction of peri- and postoperative complications. BACKGROUND: Implementation of the SSC was associated with robust reduction in morbidity and length of in-hospital stay in a stepped wedge cluster randomized controlled trial conducted in 2 Norwegian hospitals. Further investigation of precisely how the SSC improves care processes and subsequently patient outcomes is needed to understand the causal mechanisms of improvement. METHODS: Care process metrics are reported from one of our earlier trial hospitals. Primary outcomes were in-hospital complications and care process metrics, e.g., patient warming and antibiotics. Secondary outcome was quality of SSC implementation. Analyses include Pearson's exact χ test and binary logistic regression. RESULTS: A total of 3702 procedures (1398 control vs. 2304 intervention procedures) were analyzed. High-quality SSC implementation (all 3 checklist parts) improved processes and outcomes of care. Use of forced air warming blankets increased from 35.3% to 42.4% (P < 0.001). Antibiotic administration postincision decreased from 12.5% to 9.8%, antibiotic administration preincision increased from 54.5% to 63.1%, and nonadministration of antibiotics decreased from 33.0% to 27.1%. Surgical infections decreased from 7.4% (104/1398) to 3.6% (P < 0.001). Adjusted SSC effect on surgical infections resulted in an odds ratio (OR) of 0.52 (95% confidence interval (CI): 0.38-0.72) for intervention procedures, 0.54 (95% CI: 0.37-0.79) for antibiotics provided before incision, and 0.24 (95% CI: 0.11-0.52) when using forced air warming blankets. Blood transfusion costs were reduced by 40% with the use of the SSC. CONCLUSIONS: When implemented well, the SSC improved operating room care processes; subsequently, high-quality SSC implementation and improved care processes led to better patient outcomes.

The effect of antibiotic stewardship interventions with stakeholder involvement in hospital settings: a multicentre, cluster randomized controlled intervention study.

Background: There is limited evidence from multicenter, randomized controlled studies to inform planning and implementation of antibiotic stewardship interventions in hospitals. Methods: A cluster randomized, controlled, intervention study was performed in selected specialities (infectious diseases, pulmonary medicine and gastroenterology) at three emergency care hospitals in Western Norway. Interventions applied were audit with feedback and academic detailing. Implementation strategies included co-design of interventions with stakeholders in local intervention teams and prescribers setting local targets for change in antibiotic prescribing behaviour. Primary outcome measures were adherence to national guidelines, use of broad-spectrum antibiotics and change in locally defined targets of change in prescribing behaviour. Secondary outcome measures were length of stay, 30-day readmission, in-hospital- and 30-day mortality. Results: One thousand eight hundred two patients receiving antibiotic treatment were included. Adherence to guidelines had an absolute increase from 60 to 66% for all intervention wards (p = 0.04). Effects differed across specialties and pulmonary intervention wards achieved a 14% absolute increase in adherence (p = 0.003), while no change was observed for other specialties. A pulmonary ward targeting increased use of penicillin G 2 mill IU × 4 for pneumonia and COPD exacerbations had an intended increase of 30% for this prescribing behaviour (p < 0.001). Conclusions: Pulmonary wards had a higher increase in adherence, independent of applied intervention. The effect of antibiotic stewardship interventions is dependent on how and in which context they are implemented. Additional effects of interventions are seen when stakeholders discuss ward prescribing behaviour and agree on specific targets for changes in prescribing practice.

The Reflective Mind: Examining Individual Differences in Susceptibility to Base Rate Neglect with fMRI.

Performance on heuristics and bias tasks has been shown to be susceptible to bias. In turn, susceptibility to bias varies as a function of individual differences in cognitive abilities (e.g., intelligence) and thinking styles (e.g., propensity for reflection). Using a classic task (i.e., lawyer-engineer problem), we conducted two experiments to examine the differential contributions of cognitive abilities versus thinking styles to performance. The results of Experiment 1 demonstrated that the Cognitive Reflection Test (CRT)-a well-established measure of reflective thinking-predicted performance on conflict problems (where base rates and intuition point in opposite directions), whereas STM predicted performance on nonconflict problems. Experiment 2 conducted in the fMRI scanner replicated this behavioral dissociation and enabled us to probe their neural correlates. As predicted, conflict problems were associated with greater activation in the ACC-a key region for conflict detection-even in cases when participants responded stereotypically. In participants with higher CRT scores, conflict problems were associated with greater activation in the posterior cingulate cortex (PCC), and activation in PCC covaried in relation to CRT scores during conflict problems. Also, CRT scores predicted activation in PCC in conflict problems (over and above nonconflict problems). Our results suggest that individual differences in reflective thinking as measured by CRT are related to brain activation in PCC-a region involved in regulating attention between external and internal foci. We discuss the implications of our findings in terms of PCC's possible involvement in switching from intuitive to analytic mode of thought.

Structural correlates of Openness and Intellect: Implications for the contribution of personality to creativity.

Openness/Intellect (i.e., openness to experience) is the Big Five personality factor most consistently associated with individual differences in creativity. Recent psychometric evidence has demonstrated that this factor consists of two distinct aspects-Intellect and Openness. Whereas Intellect reflects perceived intelligence and intellectual engagement, Openness reflects engagement with fantasy, perception, and aesthetics. We investigated the extent to which Openness and Intellect are associated with variations in brain structure as measured by cortical thickness, area, and volume (N = 185). Our results demonstrated that Openness was correlated inversely with cortical thickness and volume in left middle frontal gyrus (BA 6), middle temporal gyrus (MTG, BA 21), and superior temporal gyrus (BA 41), and exclusively with cortical thickness in left inferior parietal lobule (BA 40), right inferior frontal gyrus (IFG, BA 45), and MTG (BA 37). When age and sex were statistically controlled for, the inverse correlations between Openness and cortical thickness remained statistically significant for all regions except left MTG, whereas the correlations involving cortical volume remained statistically significant only for left middle frontal gyrus. There was no statistically significant correlation between Openness and cortical area, and no statistically significant correlation between Intellect and cortical thickness, area, or volume. Our results demonstrate that individual differences in Openness are correlated with variation in brain structure-particularly as indexed by cortical thickness. Given the involvement of the above regions in processes related to memory and cognitive control, we discuss the implications of our findings for the possible contribution of personality to creative cognition.

Topographical memory for newly-learned maps is differentially affected by route-based versus landmark-based learning: a functional MRI study.

Humans rely on topographical memory to encode information about spatial aspects of environments. However, even though people adopt different strategies when learning new maps, little is known about the impact of those strategies on topographical memory, and their neural correlates. To examine that issue, we presented participants with 40 unfamiliar maps, each of which displayed one major route and three landmarks. Half were instructed to memorize the maps by focusing on the route, whereas the other half memorized the maps by focusing on the landmarks. One day later, the participants were tested on their ability to distinguish previously studied 'old' maps from completely unfamiliar 'new' maps under conditions of high and low working memory load in the functional MRI scanner. Viewing old versus new maps was associated with relatively greater activation in a distributed set of regions including bilateral inferior temporal gyrus - an important region for recognizing visual objects. Critically, whereas the performance of participants who had followed a route-based strategy dropped to chance level under high working memory load, participants who had followed a landmark-based strategy performed at above chance levels under both high and low working memory load - reflected by relatively greater activation in the left inferior parietal lobule (i.e. rostral part of the supramarginal gyrus known as area PFt). Our findings suggest that landmark-based learning may buffer against the effects of working memory load during recognition, and that this effect is represented by the greater involvement of a brain region implicated in both topographical and working memory.