Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia.

BACKGROUND: Pneumatic dilation and laparoscopic Heller's myotomy (LHM) are established treatments for idiopathic achalasia. Peroral endoscopic myotomy (POEM) is a less invasive therapy with promising early study results. METHODS: In a multicenter, randomized trial, we compared POEM with LHM plus Dor's fundoplication in patients with symptomatic achalasia. The primary end point was clinical success, defined as an Eckardt symptom score of 3 or less (range, 0 to 12, with higher scores indicating more severe symptoms of achalasia) without the use of additional treatments, at the 2-year follow-up; a noninferiority margin of -12.5 percentage points was used in the primary analysis. Secondary end points included adverse events, esophageal function, Gastrointestinal Quality of Life Index score (range, 0 to 144, with higher scores indicating better function), and gastroesophageal reflux. RESULTS: A total of 221 patients were randomly assigned to undergo either POEM (112 patients) or LHM plus Dor's fundoplication (109 patients). Clinical success at the 2-year follow-up was observed in 83.0% of patients in the POEM group and 81.7% of patients in the LHM group (difference, 1.4 percentage points; 95% confidence interval [CI], -8.7 to 11.4; P = 0.007 for noninferiority). Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group. Improvement in esophageal function from baseline to 24 months, as assessed by measurement of the integrated relaxation pressure of the lower esophageal sphincter, did not differ significantly between the treatment groups (difference, -0.75 mm Hg; 95% CI, -2.26 to 0.76), nor did improvement in the score on the Gastrointestinal Quality of Life Index (difference, 0.14 points; 95% CI, -4.01 to 4.28). At 3 months, 57% of patients in the POEM group and 20% of patients in the LHM group had reflux esophagitis, as assessed by endoscopy; at 24 months, the corresponding percentages were 44% and 29%. CONCLUSIONS: In this randomized trial, POEM was noninferior to LHM plus Dor's fundoplication in controlling symptoms of achalasia at 2 years. Gastroesophageal reflux was more common among patients who underwent POEM than among those who underwent LHM. (Funded by the European Clinical Research Infrastructure Network and others; ClinicalTrials.gov number, NCT01601678.).

How learning shapes the empathic brain.

Deficits in empathy enhance conflicts and human suffering. Thus, it is crucial to understand how empathy can be learned and how learning experiences shape empathy-related processes in the human brain. As a model of empathy deficits, we used the well-established suppression of empathy-related brain responses for the suffering of out-groups and tested whether and how out-group empathy is boosted by a learning intervention. During this intervention, participants received costly help equally often from an out-group member (experimental group) or an in-group member (control group). We show that receiving help from an out-group member elicits a classical learning signal (prediction error) in the anterior insular cortex. This signal in turn predicts a subsequent increase of empathy for a different out-group member (generalization). The enhancement of empathy-related insula responses by the neural prediction error signal was mediated by an establishment of positive emotions toward the out-group member. Finally, we show that surprisingly few positive learning experiences are sufficient to increase empathy. Our results specify the neural and psychological mechanisms through which learning interacts with empathy, and thus provide a neurobiological account for the plasticity of empathic reactions.

Hidden Reward: Affect and Its Prediction Errors as Windows Into Subjective Value.

Scientists increasingly apply concepts from reinforcement learning to affect, but which concepts should apply? And what can their application reveal that we cannot know from directly observable states? An important reinforcement learning concept is the difference between reward expectations and outcomes. Such reward prediction errors have become foundational to research on adaptive behavior in humans, animals, and machines. Owing to historical focus on animal models and observable reward (e.g., food or money), however, relatively little attention has been paid to the fact that humans can additionally report correspondingly expected and experienced affect (e.g., feelings). Reflecting a broader "rise of affectivism," attention has started to shift, revealing explanatory power of expected and experienced feelings-including prediction errors-above and beyond observable reward. We propose that applying concepts from reinforcement learning to affect holds promise for elucidating subjective value. Simultaneously, we urge scientists to test-rather than inherit-concepts that may not apply directly.

Affective prediction errors in persistence and escalation of aggression.

People generally empathize with others and find harm aversive. Yet aggression, for example, between groups, abounds. How do people learn to overcome this aversion in order to aggress? Many models of learning emphasize outcome prediction errors-deviations from expected outcomes in the environment-but aggression may also be fueled by affective prediction errors (affective PEs)-deviations from how we expect to feel. Across five preregistered online experiments that hold outcome prediction errors constant (N = 4,607), participants choosing aggressive or nonaggressive actions aggressed more against disliked group members and often escalated or persisted in taking actions that felt better than expected (positive affective PE), especially when those actions were aggressive. Crucially, inducing incidental empathy toward the group of the target rendered affective PE signals sensitive to group identification-participants escalated aggression that felt better than expected relatively less toward liked versus disliked group members. That said, affective PEs did not always add explanatory power beyond levels of postoutcome affect alone; we discuss the importance and implications of these results. In summary, we reveal affective PE integration as a candidate algorithm facilitating exceptions to harm aversion in intergroup conflict. More broadly, we highlight for affective science and decision-making researchers the necessity of appropriately testing separable components of affective signals in predicting subsequent behavior. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Activating episodic simulation increases affective empathy.

Affective empathy, feeling what others feel, is a powerful emotion that binds us to one another. Here we ask whether how we mentally represent the scene in which another suffers informs our emotions. For example, when we learn about someone suffering outside of the here and now, such as a refugee devastated by violence or famine, does a manipulation potentiating our ability to simulate the scene around the victim heighten our empathic response? Expanding recent advances in the memory literature, we investigate the link between activating our ability to imagine events-episodic simulation-and empathy for in-group and out-group members in a series of online and laboratory studies (N = 1010). Incidental manipulations of episodic simulation, unrelated in content and structure to the empathy judgment task, increased overall empathy for both in-group as well as out-group members. This relationship was mediated by participant-generated episodic detail of the victim's surroundings.

The neuroscience of intergroup emotion.

What happens to our emotions and in our brains when we experience the world through the lens of our group memberships rather than as individuals? Here we review recent advances in social and affective neuroscience that have identified potential input variables and processing mechanisms underlying one widely studied emotion in intergroup contexts: empathy. There is a well-documented in-group bias in empathy but the mental processes that generate it are poorly understood. Drawing from recent insights in memory research, we suggest that episodic simulation-the ability to imagine events-is an underexplored candidate process that is likely to be involved in shaping emotional experience in intergroup settings.