Behavioral pain scale may not be reliable in awake non-verbal intensive care patients: a case control study.

BACKGROUND: The evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools. METHODS: Prospective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest. RESULTS: Data was collected from 75 patients. Neither the NRS nor the EQ-Pain (r < .15) correlated with the BPS. However, NRS and EQ-Pain were significantly correlated (r = .78, p = < 0.001), indicating the reliability of the self-reporting by these patients. Neither the duration of intubation/tracheostomy, nor cause for ICU treatment, nor BPS subcategories had an influence on these results. CONCLUSIONS: Behavioral pain assessment tools in non-verbal patients who are awake and not in delirium appear unreliable in estimating pain during rest. Before a behavioral assessment tool such as the BPS is used, the application of high-tech AACs should be strongly considered. TRIAL REGISTRATION: German Clinical Trials Register, Registration number: DRKS00021233. Registered 23 April 2020 - Retrospectively registered, https://drks.de/search/en/trial/DRKS00021233 .

Can frequent long stimulus onset ansynchronies (SOAs) foster the representation of two separated task-sets in dual-tasking?

Recent findings suggest that in dual-tasking the elements of the two tasks are associated across tasks and are stored in a conjoint memory episode, meaning that the tasks are not represented as isolated task-sets. In the current study, we tested whether frequent long stimulus onset ansynchronies (SOAs) can foster the representation of two separated task-sets thereby reducing or even hindering participants to generate conjoint memory episodes-compared to an integrated task-set representation induced by frequent short SOAs. Alternatively, it is conceivable that conjoint memory episodes are an inevitable consequence of presenting two tasks within a single trial. In two dual-task experiments, we tested between consecutive trials whether repeating the stimulus-response bindings of both tasks would lead to faster responses than repeating only one of the two tasks' stimulus-response bindings. The dual-task consisted of a visual-manual search task (VST) and an auditory-manual discrimination task (ADT). Overall, the results suggest that, after processing two tasks within a single trial, generating a conjoint memory episode seems to be a default process, regardless of SOA frequency. However, the respective SOA frequency affected the participants' strategy to group the processing of the two tasks or not, thereby modulating the impact of the reactivated memory episode on task performance.

Element-level features in conjoint episodes in dual-tasking.

The usual way of thinking about dual-tasking is that the participants represent the two tasks separately. However, several findings suggest that the participants rather seem to integrate the elements of both tasks into a conjoint episode. In three experiments, we aimed at further testing this task integration account in dual-tasking. To this end, we investigated how the processing of the previous Trial n-1 shapes the processing of the current Trial n. We observed performance benefits when the stimulus-response mappings of both tasks repeat in consecutive trials (full repetition: FR) as compared to when only one such mapping repeats (partial repetition: PR). In particular, our experiments focused on the question which elements of the two tasks in dual-tasking might be bound together. For this purpose, in Experiments 1 and 2, all participants performed a dual-task consisting of a visual-manual search task (VST) and an auditory-manual discrimination task (ADT). In the VST the stimulus-response mappings were variable, so that none of the stimuli of this task systematically predicted a certain response. In Experiment 1, the stimuli and responses of the VST were either both repeated or both changed in consecutive trials. In Experiment 2, we removed the stimulus repetitions in the VST and only the responses repeated across trials. In Experiment 3, we changed the ADT into a visual-auditory matching task (VAMT) with variable stimulus-response mappings, so that in both tasks only the responses repeated across trials. In Experiments 1 and 2, we observed better performance for FR than for PR, while this difference disappeared in Experiment 3. Together, the results suggest that the stimulus of one task is sufficient to retrieve the entire episode from the previous trial.

Approach to the basic needs in patients on invasive ventilation using eye-tracking devices for non-verbal communication.

PURPOSE: To analyze the feasibility of eye-tracking (ET) devices as a communicative approach to the basic needs (BN) of intensive care unit (ICU) and invasively ventilated nonverbal patients. METHODS: Prospective, monocentric, and observational study including all patients without delirium, with an endotracheal tube or tracheostomy tube, with a history of invasive ventilation for more than 48 h, and inadequate nonverbal communication skills. The investigation was performed with commercially available ET devices (Tobii Dynavox I-15+) to express BN of ICU patients following a standardized 30-item yes-or-no questionnaire. RESULTS: A total of 64 patients with a mean age of 58.6 years were included. The main diagnoses for ICU admission were major trauma (43.6%), sepsis (21.8%), and acute abdomen (15.6%). Pain during repositioning (69%), thirst (69%), sleep disorders (66%), fatigue (64%), and anxiety regarding the lifelong need for assistance (64%) were the main problems reported by the patients. However, most of the patients described expectations of health improvement (78%), good family support (66%), and an improvement in quality of life due to the use of ET devices (67%). CONCLUSION: The use of ET in selected ICU patients with impaired communication is feasible, allowing them to express their BN. Apart from knowing the patients' individual BN, the results of our BN questionnaire may provide guidance for improvement measures in the care of patients in the ICU who are unable to speak. We believe that ET is useful for inquiring about and expressing BN and, therefore, may be capable of improving patient-medical team interactions and patient satisfaction.

Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey.

BACKGROUND: The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized. METHODS: Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point. RESULTS: Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients. CONCLUSIONS: The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.

Learning of across- and within-task contingencies modulates partial-repetition costs in dual-tasking.

Dual-task costs might result from confusions on the task-set level as both tasks are not represented as distinct task-sets, but rather being integrated into a single task-set. This suggests that events in the two tasks are stored and retrieved together as an integrated memory episode. In a series of three experiments, we tested for such integrated task processing and whether it can be modulated by regularities between the stimuli of the two tasks (across-task contingencies) or by sequential regularities within one of the tasks (within-task contingencies). Building on the experimental approach of feature binding in action control, we tested whether the participants in a dual-tasking experiment will show partial-repetition costs: they should be slower when only the stimulus in one of the two tasks is repeated from Trial n - 1 to Trial n than when the stimuli in both tasks repeat. In all three experiments, the participants processed a visual-manual and an auditory-vocal tone-discrimination task which were always presented concurrently. In Experiment 1, we show that retrieval of Trial n - 1 episodes is stable across practice if the stimulus material is drawn randomly. Across-task contingencies (Experiment 2) and sequential regularities within a task (Experiment 3) can compete with n - 1-based retrieval leading to a reduction of partial-repetition costs with practice. Overall the results suggest that participants do not separate the processing of the two tasks, yet, within-task contingencies might reduce integrated task processing.

Investigating time-based expectancy beyond binary timing scenarios: evidence from a paradigm employing three predictive pre-target intervals.

When the duration of a pre-target interval probabilistically predicts the identity of the target, participants typically form time-based expectancies: they respond faster to frequent interval-target combinations than to infrequent ones. Yet, previous research investigating the cognitive time-processing mechanisms underlying time-based expectancy assessed time-based expectancy always in situations with a binary set of intervals (i.e. short vs. long). Here we aim to test whether time-based expectancy transfers to more complex settings with three different predictive time intervals (short, medium, long) in which each predicts one of three different target stimuli with 80% probability. In three experiments we varied how the medium interval was computed (arithmetic mean, geometric mean, or in between both). Our results showed that participants were able to learn the time-event contingencies for the short and the long as well as for the medium interval, and were, thus able to flexibly redirect their target expectancy two times during the course of a trial. The evidence concerning the impact of the manipulation of the medium intervals' absolute duration on time-based expectancy was, however, mixed, as time-based expectancy for the medium interval could only be observed in one of three reported experiments. In sum, the findings of the present study suggest a previously unknown cognitive flexibility underlying time-based expectancy and offer important theoretical implications, challenging future research on the timing mechanisms involved in time-based expectancy.

Parallel and serial task processing in the PRP paradigm: a drift-diffusion model approach.

Even after a long time of research on dual-tasking, the question whether the two tasks are always processed serially (response selection bottleneck models, RSB) or also in parallel (capacity-sharing models) is still going on. The first models postulate that the central processing stages of two tasks cannot overlap, producing a central processing bottleneck in Task 2. The second class of models posits that cognitive resources are shared between the central processing stages of two tasks, allowing for parallel processing. In a series of three experiments, we aimed at inducing parallel vs. serial processing by manipulating the relative frequency of short vs. long SOAs (Experiments 1 and 2) and including no-go trials in Task 2 (Experiment 3). Beyond the conventional response time (RT) analyses, we employed drift-diffusion model analyses to differentiate between parallel and serial processing. Even though our findings were rather consistent across the three experiments, they neither support unambiguously the assumptions derived from the RSB model nor those derived from capacity-sharing models. SOA frequency might lead to an adaptation to frequent time patterns. Overall, our diffusion model results and mean RTs seem to be better explained by participant's time expectancies.

Texts and pictures serve different functions in conjoint mental model construction and adaptation.

In this study we examined the different functions of text and pictures during text-picture integration in multimedia learning. In Study 1, 144 secondary school students (age = 11 to 14 years; 72 females, 72 males) received six text-picture units under two conditions. In the delayed-question condition, students first read the units without a specific question (no-question phase), to stimulate initial coherence-oriented mental model construction. Afterward the question was presented (question-answering phase), to stimulate task-adaptive mental model specification. In the preposed-question condition, students received a specific question from the beginning, stimulating both kinds of processing. Analyses of the participants' eye movement patterns confirmed the assumption that students allocated a higher percentage of available resources to text processing during the initial mental model construction than during adaptive model specification. Conversely, students allocated a higher percentage of available resources to picture processing during adaptive mental model specification than during the initial mental model construction. In Study 2 (N = 12, age = 12 to 16; seven females, five males), we ruled out that these findings were due to the effect of rereading, by implementing a no-question phase either once or twice. To sum up, texts seem to provide more explicit conceptual guidance in mental model construction than pictures do, whereas pictures support mental model adaptation more than text does, by providing flexible access to specific information for task-oriented updates.

Implicit sequence learning despite multitasking: the role of across-task predictability.

One often replicated finding is that implicit sequence learning is hampered in dual-task situations. Thus, one crucial question has been whether implicit learning processes require attentional resources. Meanwhile, focusing exclusively on limited attentional resources might be considered as too unspecific. Overall, the focus lies now rather on the possibility that the impairment is due to interference coming along with (a) task integration (e.g., Schmidtke and Heuer in Psychol Res 60(1-2):53-71, 1997)-or with (b) parallel response selection (Schumacher and Schwarb in J Exp Psychol Gen 138(2):270-290, 2009). Yet, other explanations have also been put forward-and there is still no agreement. Our goal here is to contribute to this debate by testing several constraints that have been suggested in the literature within one single paradigm, originating by Schumacher and Schwarb (J Exp Psychol Gen 138(2):270-290, 2009). Therefore, we paired the same visual-manual serial reaction time task (SRTT; Nissen and Bullemer in Cogn Psychol 19(1):1-32, 1987) with different auditory-vocal tone-discrimination tasks across seven dual-task conditions. We manipulated (a) its relation to the SRTT and/or (b) the difficulty of response selection. The results suggest that task integration is indeed a crucial factor for implicit sequence learning: since the tone-task is a potential source of noisy patterns of covariation in a complex arrangement of task components, sequence learning is disrupted. In line with Rah, Reber, and Hsiao (Psychon Bull Rev 7(2):309-313, 2000), the usefulness (in terms of sequence learning) of task integration seems to depend on the predictive value of across-task stimulus and/or response events.

Tied to expectations: Predicting features speeds processing even under adverse circumstances.

When participants predict the upcoming stimulus in a randomized choice reaction task, a match between prediction and stimulus increases processing speed at a level similar to that observed in cueing studies with highly valid cues. This might be taken to suggest that people cannot help but fully use their self-generated, verbalized predictions for preparing task processing. Thus, we tested how flexibly participants can control formation and implementation of predictions. In Experiment 1, we varied validity and response-relevance of predictions. We observed that prediction effects on RT can be boosted by increasing validity, but prevail under adverse circumstances. This was not the case in a control group who read rather than predicted the feature words, suggesting that the effect was specific to predictions as such. Experiment 2 provided further evidence for limited control of participants over implementing and forming predictions. Participants were provided with practice on stimuli occurring with varying frequency, but neither learned to strategically choose predictions to maximize the number of match trials, nor did they reduce the amount of prediction-based preparation when predicting an infrequent stimulus. As sequential aftereffects of prediction match did not vary with validity, they were identified as an independent effect of verbalizing a response-relevant stimulus feature. The results are consistent with the view that the predicted stimulus feature is represented in the focus of attention in working memory and that the amount of implementation can be subject to weighting.

Motivation by potential gains and losses affects control processes via different mechanisms in the attentional network.

Attentional control in demanding cognitive tasks can be improved by manipulating the motivational state. Motivation to obtain gains and motivation to avoid losses both usually result in faster reaction times and stronger activation in relevant brain areas such as the prefrontal cortex, but little is known about differences in the underlying neurocognitive mechanisms of these types of motivation in an attentional control context. In the present functional magnetic resonance imaging (fMRI) study, we tested whether potential gain and loss as motivating incentives lead to overlapping or distinct neural effects in the attentional network, and whether one of these conditions is more effective than the other. A Flanker task with word stimuli as targets and distracters was performed by 115 healthy participants. Using a mixed blocked and event-related design allowed us to investigate transient and sustained motivation-related effects. Participants could either gain money (potential gain) or avoid losing money (potential loss) in different task blocks. Participants showed a congruency effect with increased reaction times for incongruent compared to congruent trials. Potential gain led to generally faster responses compared to the neutral condition and to stronger improvements than potential loss. Potential loss also led to shorter response times compared to the neutral condition, but participants improved mainly during incongruent and not during congruent trials. The event-related fMRI data revealed a main effect of congruency with increased activity in the left inferior frontal gyrus (IFG) and inferior frontal junction area (IFJ), the pre-supplementary motor area (pre-SMA), bilateral insula, intraparietal sulcus (IPS) and visual word form area (VWFA). While potential gain led to increased activity in a cluster of the IFJ and the VWFA only during incongruent trials, potential loss was linked to activity increases in these regions during incongruent and congruent trials. The block analysis revealed greater activity in gain and loss blocks compared to the neutral condition in most of these regions but no differences in the direct comparison of gain and loss blocks. These findings show that potential monetary gain and loss rely on different mechanisms: Gain was more effective in reducing the reaction time compared to potential loss. Brain data indicate that in the gain context attentional control is executed specifically in incongruent trials, whereas the loss context induces an unspecific increase of attentional control. These findings extend previous studies by providing evidence for diverging neural mechanisms for the effects of different types of motivation on attentional control, specifying the underlying activity patterns in task- and stimulus-related regions.

Variable, sometimes absent, but never negative: Applying multilevel models of variability to the backward crosstalk effect to find theoretical constraints.

When performing two tasks at the same time, the congruency of the second task's features influences performance in the first task. This is called the backward crosstalk effect (BCE), a phenomenon that influences both theories of binding and of dual-task capacity limitations. The question of whether the BCE is found in all participants at all times is relevant for understanding the basis of the effect. For example, if the BCE is based on strategic choices, it can be variable, but if it is automatic and involuntary, it should never vary in whether it is present or not. Variability in observed BCE sizes was already documented and discussed when the group average effect was first reported (Hommel, 1998). Yet the theories discussed at the time did not motivate a more direct analysis of this variability, nor did the readily available statistical tools permit it. Some statistical approaches recently applied in cognitive psychology allow such a variability-focused analysis and some more recent theoretical debates would benefit from this as well. We assessed the variability of the BCE as well as a BCE-like free-choice congruency effect by applying a Bayesian multilevel modeling approach to the data from a dual-tasking experiment. Trials consisted of a two- and a four-response task. We manipulated which task was presented first and whether the response to the four-choice task was free or forced choice. RT data were best predicted by a model in which the BCE is zero in part of the population and drawn from a normal distribution truncated at zero (and thus always positive) in the rest of the population. Choice congruency bias data were best predicted by a model assuming this effect to be drawn from a normal distribution truncated at zero (but, in contrast to the RT data, without the subset of the population where it is zero). The BCE is not an inflexible and universal phenomenon that is directly linked to an inherent structural trait of human cognition. We discuss theoretical constraints implied by these results with a focus on what we can infer about the traits of the factors that influence BCE size. We suggest that future research might add further major constraints by using multi-session experiments to distinguish between-person and within-person variability. Our results show that the BCE is variable. The next step is understanding along which axes it is variable and why it varies.

Across-task binding: The development of a representation in learning a continuous movement sequence.

Across-task binding is defined as the stimulus/response of one task being linked to the response of another task. The purpose of the present experiment was to determine across-task binding in a continuous movement sequence task with an auditory task of high and low pitch tones and the development of a movement sequence representation. According to the two systems theory of sequence learning, we expected that the developed representation in the across-task binding context relies on the multi-dimensional system rather than on the unidimensional system which is restricted to a set of modules where each module processed information along one task/dimension. An inter-manual transfer design was used to disentangle the sequence representations. The mirror transfer test required the same pattern of muscle activation and joint angles (motor coordinates) in the contralateral limb as experienced during the acquisition phase, while in the non-mirror transfer test, the visual-spatial locations (spatial coordinates) of the target waveform were reinstated. The main finding was that consistently combining visual-spatial positions in a sequence and auditory dimensions such as the tone pitch does not rely on a multidimensional system as predicted by the two-systems theory.

Perceptions of critically ill individuals with acute and chronic spinal cord injury requiring a tracheostomy tube.

STUDY DESIGN: Observational study. OBJECTIVES: To evaluate the perceptions of patients requiring a tracheostomy tube and to identify possible different perceptions in critically ill patients with tracheostomy tubes who have acute (ASCI) or chronic spinal cord injuries (CSCI). SETTING: Medical and surgical intensive care units (ICU) and intermediate care unit of the BG University Hospital Bergmannsheil Bochum, Germany. METHODS: Patients who met the inclusion criteria completed a 25-item questionnaire on two consecutive days regarding their experiences and perceptions in breathing, coughing, pain, speaking, swallowing, and comfort of the tracheostomy tube. RESULTS: A total of 51 persons with ASCI (n = 31) and CSCI (n = 20) were included with a mean age of 53 years. Individuals with ASCI reported significantly more frequent pain and swallowing problems as compared to individuals with CSCI (p ≤ 0.014) at initial assessment. There were no differences between ASCI and CSCI reported with respect to speaking and overall comfort. CONCLUSIONS: It is necessary to regularly assess the perceptions of critically ill patients with tracheostomy tubes with ASCI or CSCI in the daily ICU care routine. We were able to assess these perceptions in different categories. For the future, evaluating the perception of individuals with SCI and a tracheostomy should be implemented to their daily routine care. TRIAL REGISTRATION: DRKS00022073.

Lollipops Help Align Visual and Statistical Fit Estimates in Scatterplots With Nonlinear Models.

Scatterplots overlayed with a nonlinear model enable visual estimation of model-data fit. Although statistical fit is calculated using vertical distances, viewers' subjective fit is often based on shortest distances. Our results suggest that adding vertical lines ("lollipops") supports more accurate fit estimation in the steep area of model curves (https://osf.io/fybx5/).

The Power Is in the Word-Do Laypeople Interpret Descriptors of Dog Emotional States Correctly?

A basic understanding of dog behaviour and emotion is relevant not only for professionals, such as veterinary personnel or dog trainers, but also for dog owners and for people with little contact with dogs. Information about dog behaviour and emotions is mostly conveyed verbally. This study explores whether definitions of dog behaviour and emotion are understood in such a way that they can be allocated to a descriptor (i.e., a label such as "fearful"), even by people with low background knowledge. If people can match descriptors to definitions, this suggests that the definitions are distinct enough and elicit mental representations of behaviour that can fit the label. Good agreement on the definitions is a prerequisite for the validity of the descriptors used; however, no study to date has tested this. A sample of 236 adults was asked to match descriptors of Qualitative Behaviour Assessment (QBA) for veterinary and shelter situations to their correct definitions, e.g., the descriptor "fearful" to its definition "dog may try to flee, hide or freeze; ears back". Matching was substantially above chance; nonetheless, the mean proportion of correct responses was only 50% (SD ± 16.6%) for the veterinary QBA set and 33% (SD ± 14.3%) for the shelter QBA set. Performance in the matching task was positively correlated with measures of experience with dogs. Taken together, the results suggest that descriptor-definition pairs used to describe dog behaviour need to be clearly defined to avoid misinterpretations when teaching laypeople how to interpret canine behaviour.

Color-Encoded Links Improve Homophily Perception in Node-Link Diagrams.

Node-link diagrams enable visual assessment of homophily when viewers can identify and evaluate the relative number of intra-cluster and inter-cluster links. Our online experiment shows that a new design with link type encoded edge color leads to more accurate perception of homophily than a design with same-color edges.

First experiences of communication with mechanically ventilated patients in the intensive care unit using eye-tracking technology.

INTRODUCTION: Eye-tracking (ET) may be a novel tool for communication with intubated and mechanically ventilated critically ill patients. We hypothesized that ET could be learned fast and be used successfully by intensive care unit (ICU) and intermediate care (IMC) patients with artificial airways for communication. METHODS: Including all patients with mechanical ventilation via oral intubation or tracheostomy, who were at least 18 years of age with a score of -1 to +1 points on the Richmond agitation-sedation scale and a history of ventilation for more than 48 h. A commercially available ET was used. The investigations were performed by a physician with the support of a psychologist following a standardized study protocol. RESULTS: During a 4-week period a total of 11 patients completed all of the five steps of our study protocol. The time to complete our study protocol was 64 ± 23.8 min (range 43-125 min) with a mean of 1.5 ± 0.9 sessions (range 1-4 sessions). Seven patients (63.6 %) could run through all of the five steps within their first session. All patients (100%) preferred the gaze fixation technique to control the ET to the wink control. CONCLUSION: Mechanically ventilated ICU and IMC patients are able to use ET in a very short time for communication to indicate their basic needs, answer rating scales and pain scores as well as questionnaires about quality of life and self-esteem.Implications for rehabilitationCOMFORT - The novel communication device improves the patients' ability to communicate with the attending physicians, physiotherapists and nurses in order to provide a tailored rehabilitation approach.COMPLIANCE - The use of the eye-tracking technology enables the patients to communicate special needs and fears during the course of the rehabilitation.COMPLICATIONS - The eye-tracking technology enables the attending rehabilitation team to earlier detect complications (e.g. pain, depression) during the course of the rehabilitation.