[Knowledge and practices of the steps prior to the sterilization of heat-resistant medical devices: Study at University Hospital Centre of Sahloul, Sousse-Tunisia - 2022]. / Connaissances et pratiques des étapes préalables à la stérilisation des dispositifs médicaux thermorésistants : étude au centre hospitalo-universitaire Sahloul, Sousse-Tunisie ­ 2022.

OBJECTIVES: The standard process of central sterilization is crucial for the optimal functioning of the operating room. The outcome of this process is closely linked to the steps preceding the steps prior to the sterilization step itself. These steps include pre-disinfection carried out in the operating rooms and other stages, namely washing, drying and packaging, which must be performed in the central sterilization unit. In this context, this study aimed to describe the knowledge of the staff in the operating rooms and the central sterilization unit at Sahloul University Hospital in Sousse (Tunisia) in 2022, regarding the steps prior to the sterilization of reusable thermoresistant medical devices and to describe their practices in terms of compliance with these steps. METHOD: A descriptive study was conducted from January 2022 to June 2022 with the aforementioned staff, using a self-administered questionnaire to assess their knowledge of the pre-sterilization steps and a direct observation audit of their practices with regard to these steps. Both measurement instruments were pre-tested. RESULTS: Out of 102 self-administered questionnaires (knowledge assessment) distributed to the staff concerned, only 80 were returned and correctly filled out, giving a response rate of 78.4%. Participants' responses regarding the order of steps prior to the sterilization were incorrect in 64% of cases. With regard to the evaluation of professional practices, 224 observations were made in the study area (practice audit). In 82% of these observations, the pre-disinfection step was confused with the washing step. The use of Betadine brushes and scrubbing pads for device washing was noted in 89.3%, along with the absence of swabbing of the canals and hollow parts in 9.4% of cases and the absence of drying of the canals with compressed air. CONCLUSION: Mastery of the steps prior to sterilisation of reusable thermoresistant medical devices was insufficient in our institution, suggesting the importance of reinforcing the implementation of the procedure through a continuous training program followed by action plans.

The role of cognitive estimation in understanding the mental states of others.

Previous studies have emphasized the critical role of the prefrontal cortex in cognitive estimation and theory of mind, however, none of them has questioned the possible role of cognitive estimation processes in understanding the mental states of others. In this study, we compared 30 patients with focal prefrontal cortex damage and 30 control subjects matched by gender, age, and education level on their performances on a cognitive estimation task and two tasks assessing theory of mind: the "Faux-Pas" task and the Reading the Mind in the Eyes task. The results showed that patients were significantly impaired compared with control subjects on both abilities of cognitive estimation and theory of mind. Moreover, regression analyses showed that performance on theory of mind was predicted by the scores on cognitive estimation. Finally, using voxel-based lesion analysis, we identified a partially common bilaterally distributed prefrontal network involved in both these domains centred within the ventral and dorsomedial areas with extension to the dorsolateral prefrontal cortex.

Phenotypic intrafamilial variability including H syndrome and Rosai-Dorfman disease associated with the same c.1088G > A mutation in the SLC29A3 gene.

BACKGROUND: Mutations in the SLC29A3 gene, which encodes the nucleoside transporter hENT3, have been implicated in syndromic forms of histiocytosis including H syndrome, pigmented hypertrichosis with insulin-dependent diabetes, Faisalabad histiocytosis and Familial Rosai-Dorfman disease (RDD). Herein, we report five new patients from a single family who present with phenotypes that associate features of H syndrome and Familial Rosai-Dorfman disease. METHODS: We investigated the clinical, biochemical, histopathological and molecular findings in five Tunisian family members' diagnosed with Familial RDD and/or H syndrome. The solute carrier family 29 (nucleoside transporters), member 3 (SLC29A3) gene was screened for molecular diagnosis using direct Sanger sequencing. RESULTS: Genetic analysis of all affected individuals revealed a previously reported missense mutation c.1088 G > A [p.Arg363Gln] in exon 6 of the SLC29A3 gene. Four affected members presented with clinical features consistent with the classical H syndrome phenotype. While their cousin's features were in keeping with Familial Rosai-Dorfman disease diagnosis with a previously undescribed cutaneous RDD presenting as erythematous nodular plaques on the face. This report underlines the clinical variability of SLC29A3 disorders even with an identical mutation in the same family. CONCLUSION: We report a rare event of 5 Tunisian family members' found to be homozygous for SLC29A3 gene mutations but showing a different phenotype severity. Our study reveals that despite a single mutation, the clinical expression of the SLC29A3 disorders may be significantly heterogeneous suggesting a poor genotype-phenotype correlation for the disease.

Assessing patient safety culture in 15 intensive care units: a mixed-methods study.

BACKGROUND: Within hospitals, intensive care units (ICUs) are particularly high-risk areas for medical errors and adverse events that could occur due to the complexity of care and the patients' fragile medical conditions. Assessing patient safety culture (PSC) is essential to have a broad view on patient safety issues, to orientate future improvement actions and optimize quality of care and patient safety outcomes. This study aimed at assessing PSC in 15 Tunisian ICUs using mixed methods approach. METHODS: A cross-sectional mixed methods approach using a sequential explanatory design was conducted from December 2019 to January 2020. The first quantitative stage was conducted in 15 ICUs belonging to the two university hospitals in the region of Sousse (Tunisia). All the 344 healthcare professionals (clinical staff) working for more than 1 month in these ICUs were contacted in order to take part in the study. In the second qualitative stage 12 participants were interviewed based on purposive sampling. RESULTS: All of the PSC dimensions had a score of less than 50%. The developed dimension was 'teamwork within units' (48.8%). The less developed dimensions were 'frequency of event reporting' (20.8%), 'communication openness' (22.2%) and 'non-punitive response to error' (19.7%). Interviews' thematic analysis revealed four main themes including "Hospital management/system failure", "Teamwork and communication", "Error management" and "Working conditions". CONCLUSION: This research revealed that PSC is still in need of improvement and provided a clearer picture of the patient safety issues that require specific attention. Improving PSC through the use of quality management and error reporting systems may help to improve patient safety outcomes.

Patient safety culture as perceived by operating room professionals: a mixed-methods study.

BACKGROUND: Routine assessments of patient safety culture within hospitals have been widely recommended to improve patient safety. Experts suggested that mixed-methods studies can help gain a deeper understanding of the concept. However, studies combining quantitative and qualitative approaches exploring patient safety culture are still lacking. This study aimed to explore patient safety culture as perceived by operating room professionals of two university hospitals in Sousse, Tunisia. METHODS: Based on a mixed-methods approach, a cross-sectional survey followed by semi-structured interviews were conducted over a period of two months (December 2019 to January 2020). This study took place in all the operating rooms of two public university hospitals in the district of Sousse, Tunisia. To collect data for this survey, the French version of the Hospital Survey On Patient Safety Culture was used. For interviews, 13 participants were selected purposively using a critical case sampling approach and a topic guide was prepared. Anonymity and confidentiality were respected. RESULTS: Overall, twelve operating rooms, with different surgical specialties, were included in the study. Survey feedback was provided by 297 professionals representing a response rate of 85.6%. Concerning patient safety culture, the 10 dimensions had low scores (below 50%) and were considered "to be improved". The highest score was found in 'teamwork within units' (45%). Whereas, the lowest scores were allocated to 'non-punitive response to error' (22.9%), followed by "frequency of adverse event reported" (25.6%) and "communication openness" (26.3%). Per qualitative data, participants provided a more detailed picture of patient safety issues such as underreporting, absence of an effective reporting system, lack of freedom of expression, and an existing blame culture in operating rooms. CONCLUSIONS: The findings of this study showed a concerning perception held by participants about the lack of a patient safety culture in their operating rooms. It seems essential to design, implement and evaluate strategies that promote a positive patient safety culture and obliterate punitive climate in operating rooms.

Predictors of evidence-based practice competency among Tunisian nursing students.

BACKGROUND: Evidence-based practice (EBP) is an important competency of undergraduate nursing students which should be cultivated before graduation by increasing future healthcare providers' knowledge, skills and attitudes towards EBP. This study aimed to describe nursing students' competencies (attitudes, knowledge, skills) in Evidence-based practice (EBP) and to determine factors predicting EBP competency. METHODS: A descriptive cross-sectional study was conducted at the Higher School of Health Sciences and Techniques of Sousse (Tunisia) among 365 nursing students. Data were collected using the validated Evidence Based Practice Competencies Questionnaire (EBP-COQ). Multiple linear regression was performed to determine factors predicting EBP competencies. RESULTS: The overall score of EBP-COQ questionnaire was 3.26 ± 0.53 out of 5. The attitude, skills and knowledge subscales received 4.04 ± 0.41; 3.05 ± 0.77 and 2.70 ± 0.74 as mean scores respectively. Multiple linear regression analysis (table 4) revealed that significant related factors were academic level (ß = 0.271, p = 0.001), English-language reading skills (ß = 0.435, p < 0.001), facing staff resistance in implementing a new evidence-based procedure (ß = - 0.081, p = 0.035) difficulties in obtaining full-text papers (ß = - 0.127, p < 0.001) and training in methodology (ß = 0.232, p < 0.001) and also in statistics (ß = 0.205, p < 0.001). CONCLUSIONS: These results help to understand students' attitudes, knowledge and skills in EBP and can be therefore a starting point to develop effective strategies for EBP curricula.

Evaluation of the Impact of Intraoperative Distractions on Teamwork, Stress, and Workload.

BACKGROUND: Within the operating rooms (ORs), distractions occur on a regular basis, which affect the surgical workflow and results in the interruption of urgent tasks. This study aimed to observe the occurrence of intraoperative distractions in Tunisian ORs and evaluate associations among distractions, teamwork, workload, and stress. METHODS: This observational cross-sectional study was conducted in four different ORs (orthopedic, urology, emergency, and digestive surgery) of Sahloul University Hospital for a period of 3 mo in 2018. Distractions and teamwork were recorded and rated in real time during the intraoperative phase of each case using validated observation sheets. Besides, at the end of each operation, stress and workload of team members were measured. RESULTS: Altogether, 50 cases were observed and 160 participants were included. Distractions happened in 100% of the included operations. Overall, we recorded 933 distractions that occurred once every 3 min, with a mean frequency of M = 18.66 (standard deviation [SD] = 8.24) per case. It is particularly noticeable that procedural distractions occurred significantly higher during teaching cases compared with nonteaching cases (M = 3.85, M = 0.60, respectively, P < 0.001). The mean global teamwork score was M = 3.85 (SD = 0.67), the mean workload score was M = 58.60 (SD = 24.27), and the mean stress score was M = 15.29 (SD = 4.00). Furthermore, a higher stress level among surgeons was associated with distractions related to equipment failures and people entering or exiting the OR (r = 0.206, P < 0.01 and r = 0.137, P < 0.01, respectively). Similarly, nurses reported a higher workload in the presence of distractions related to the work environment in the OR (r = 0.313, P < 0.05). CONCLUSIONS: This study highlighted a serious problem, which often team members seem to ignore or underestimate. Taking our findings into consideration, we recommend the implementation of the Surgical Checklist and preoperative briefings to reduce the number of surgical distractions. Also, a continuous teamwork training should be adopted to ensure that OR staff can avoid or handle distractions when they happen.

Prevalence of burnout among health sciences students and determination of its associated factors.

Burnout is a major issue among healthcare students and a public health issue in general. Indeed, the consequences of student burnout are as complex as other mental distress factors, such as those concerned with smoking and alcohol consumption, or an unhealthy lifestyle.  This study aimed to determine the prevalence of burnout among health sciences students and to determine its associated factors. This is a cross-sectional descriptive study conducted among 368 students of a Tunisian institution using the French validated version of the MBI-SS. The prevalence of burnout was 64.4%. The presence of a diagnosed health problem, a diagnosed mental disorder or sleep problems were associated with burnout. Students who live alone are significantly the most emotionally exhausted (p=0.010) and the most cynical (p=0.033). Students who had a low socio-economic level are significantly more cynical than those who had a medium or high socio-economic level (p=0.032). Performing leisure activities and practicing physical activities were associated with emotional exhaustion (p=0.007, p= 0.008, respectively).In our study, burnout is prevalent among Tunisian health sciences students. Many factors were found to be associated with this syndrome. These findings reinforce the need to establish early preventive strategies to encounter this problem and its consequent risks.

A baseline assessment of patient safety culture and its associated factors from the perspective of critical care nurses: Results from 10 hospitals.

INTRODUCTION: Critical care nurses are considered the key to patient safety improvement and play a vital role in enhancing quality of care in intensive care units (ICUs) where adverse events are frequent and have severe consequences. Moreover, there is recognition of the importance of the assessment and the development of patient safety culture (PSC) as a strategic focus for the improvement of patient safety and healthcare quality, notably in critical care settings. OBJECTIVES: This study aimed to assess critical care nurses' perception of PSC and to determine its associated factors. METHODS: This cross-sectional study was conducted among nurses working in the ICUs of the Tunisian centre (six Tunisian governorates). The study instrument was the French validated version of the Hospital Survey on Patient Safety Culture questionnaire, comprising 10 dimensions and a total of 50 items. RESULTS: A total of 249 nurses from 18 ICUs participated in the study, with a participation rate of 87.36%. The dimensions scores ranged between 17.2% for the dimension "frequency of events reported" and 50.1% for the dimension "teamwork within units". Multivariable logistic regression indicated that respondents who worked in private hospitals were five times more likely to have a developed PSC (adjusted odds ratio [AOR]: 5.34; 95% confidence interval [CI], [2.28, 12.51]; p < 10-3). Similarly, participants who worked in a certified hospital were two times more likely to have a more developed PSC than respondents who work in noncertified hospitals (AOR: 2.51; 95% CI, [.92-6.82]; p = 0.041). In addition, an increased nurse-per-patient ratio (i.e., reduced workload) increased PSC (AOR: 1.10; 95% CI, [1.02-1.12]; p = 0.018). CONCLUSION: This study has shown that the state of critical care nurses' PSC is critically low and these baseline results can help to form a plan of actions for improvements.

Effects of cold water immersion on aerobic capacity and muscle strength of young footballers.

AIMS: The main aim was to compare aerobic performance data, determined before «period1¼ and after «period2¼ cold water immersion in two groups of footballers (CWI and no-CWI groups). METHODS: This is an experimental study with matching and randomization. The 20 male footballers, aged 17 to 20 years, were divided into two groups (n = 10 for each) following a random draw. The two groups were age-, height- and weight matched. 1000-m race was made during the two periods. Heart-rate (HR, % of theoretical maximum HR) and hemoglobin oxygen saturation (Oxy-sat, %) were measured before and after the race, and the time of the race (min) was noted. An Oxy-sat decrease > 4 points retained the diagnosis of exercise-induced desaturation. Eight CWI sessions (one per week), until the hip in a standing position (10 min; temperature: 11-12 °C) were performed. RESULTS: The two groups were age-, height- and weight matched. Comparatively to the race time of «period1¼, this of «period2¼ was decreased in the CWI group (3.21±0.04 vs. 3.15±0.04 min) and was increased in the no-CWI group (3.23±0.05 vs. 3.27±0.07 min). Comparatively to the HRs (before, after the race) of «period1¼, these of «period2¼ were decreased in the CWI group (36±1 vs. 34±1%; 56±3 vs. 44±2%) and were increased in the no-CWI group (35±2 vs. 36±1%; 55±2 vs. 57±2%). Comparatively to the after race Oxy-sat' of the «period1¼, this of «period2¼ was increased in the CWI group (96±1 vs. 98±0%) and was decreased in the no-CWI group (96±1 vs. 95±1%). While in the CWI group, the percent of desaturators was decreased between «period1¼ and «period2¼ (30 vs. 0%), in the no-CWI group, percentages remained similar (50 vs. 90%). CONCLUSION: CWI improves aerobic capacity and muscle strength of young footballers.

Contribution of different regions of the prefrontal cortex and lesion laterality to deficit of decision-making on the Iowa Gambling Task.

Few studies have examined the contribution of different sub-regions of the prefrontal cortex and lesion laterality to decision-making abilities. In addition, there are inconsistent findings about the role of ventromedial and dorsolateral lesions in decision-making deficit. In this study, decision-making processes are investigated following different damaged areas of the prefrontal cortex. We paid particular attention to the contribution of laterality, lesion location and lesion volume in decision-making deficit. Twenty-seven patients with discrete ventromedial lesions, dorsolateral lesions or extended-frontal lesions were compared with normal subjects on the Iowa Gambling Task (IGT). Our results showed that all frontal subgroups were impaired on the IGT in comparison with normal subjects. We noted also that IGT performance did not vary systematically based on lesion laterality or location. More precisely, our lesion analysis revealed that decision-making processes depend on a large cerebral network, including both ventromedial and dorsolateral areas of the prefrontal cortex. Consistent with past findings, our results support the claim that IGT deficit is not solitarily associated with ventromedial prefrontal cortex lesions.

Assessing patient safety culture in Tunisian operating rooms: A multicenter study.

OBJECTIVE: To assess the patient safety culture (PSC) in operating rooms (ORs) and to determine influencing factors. DESIGN: A cross-sectional descriptive multicenter study which was conducted over a period of 7 months (October 2014-April 2015) using the French validated version of the Hospital Survey On Patient Safety Culture questionnaire. SETTING: Of the note, 15 ORs of public and private healthcare institutions. PARTICIPANTS: In total, there were 368 participants including surgeons, anesthesiologists, surgical and anesthesia technicians, nurses and caregivers, divided into 316 professionals exercising in public sector and 52 working in private one. MAIN OUTCOME MEASURE(S): A self-administrated questionnaire investigating 10 dimensions of PSC (including 45 items), two items examining the staff perception of patient safety quality and reporting events, and five items regarding demographic characteristics of respondents. RESULTS: The participation rate in the study was 70.8%. All 10 dimensions were to be improved. The overall perception of patient safety had a score of 34.9%. The dimension that had the lowest score (20.5%) was the non-punitive response to error, and the one that had the highest score (41.67%) was teamwork in the ORs. Three dimensions were developed in private sector, and none in public hospitals. CONCLUSION: This study showed that the level of the PSC needs to be improved not only in public hospitals but also in private ones. The obtained results highlight the importance of implementing quality management systems and developing PSC.

Pragmatic language comprehension: Role of theory of mind, executive functions, and the prefrontal cortex.

The specific contribution of focal damage of the prefrontal cortex and the cognitive mechanisms accounting for communicative-pragmatic disorders remains unclear. The objective of the current study was to investigate the impact of focal prefrontal cortex damage on the ability to understand indirect speech or hints and to identify the prefrontal neural mechanisms involved. We also examined the underlying cognitive mechanisms of disorders of indirect speech understanding particularly theory of mind and executive functions. Thirty patients with focal prefrontal cortex damage and 30 control subjects were compared on their performances on the Hinting task assessing pragmatic language skills, the "Faux-Pas" task and the Reading the Mind in the Eyes task assessing Theory of Mind and a battery of executive tasks. Patients were significantly impaired compared with control subjects on all these abilities. Both deficits of executive functions and theory of mind were able to predict impaired ability of patients in understanding non-literal meanings on the Hinting task. Finally, using voxel-based lesion analysis we identified a partially shared neural prefrontal network involved in all these abilities centered on the dorsomedial and ventral regions of the prefrontal cortex.

Predictive Factors for Successful Smoking Cessation in Tunisian Smokers, Sousse-Tunisia: 2015-2020.

OBJECTIVE: Since 2009, the unit of smoking cessation at Sahloul University Hospital - Tunisia was founded. In this context, the objective of our study was to determine the factors associated with smoking cessation in Tunisian smokers. METHODS: It was a descriptive prospective study over five-years-period 2015-2020. We included all patients who willingly came to the anti-smoking consultation of the Sahloul University hospital Sousse Tunisia. Data were collected during the consultation of all patients. We proceeded to a univariate and then multivariable analysis to identify the predictive factors of smoking cessation. RESULTS: Over 5 years, we included 450 patients, mainly males (91.3%). The average age of the consultants was 46 ±15.58 years. The average age of the first cigarette among our patients was 16.83± 4.34 years. The likelihood of smoking cessation was higher among males (p=0.004, OR=9.708), patients attending minimum 3 anti-smoking consultations (p<10-3, OR=5.714), patients benefiting from nicotine replacement therapy (p=0.034, OR=2.123), with high motivation score for smoking cessation (p=0.001, OR=1.980) and with an advanced age of the first cigarette (p<10-3, OR=1.096). However, the likelihood of smoking cessation was lower among coffee and alcohol consumers (p=0.002, OR=0.252) and smokers with less than 5 years smoking habit (p=0.011, OR=0.069). CONCLUSION: Although the decision to stop smoking is a personal one, it requires medical and psychological support as highlighted by our findings. Our study showed that assiduity and medical assistance for tobacco cessation increase smokers' chances of quitting.

Role of the prefrontal cortex and executive functions in basic emotions recognition: evidence from patients with focal damage to the prefrontal cortex.

Few studies have examined the specific contribution of focal damage of the prefrontal cortex and executive dysfunction to emotion recognition deficits, with results reporting controversial findings. This study investigated the performance of 30 patients with prefrontal cortex damage and 30 matched controls on a battery of executive measures assessing processes of inhibition, flexibility, and planning and a task of emotion recognition with also a particular attention to the examination of the association between these domains. The results showed that compared with control participants, patients with prefrontal cortex damage were impaired in recognizing the three negative emotions of fear, sadness, and anger and were also impaired on all executive measures. Moreover, by examining the association between both these domains, using correlation and regression analyses, we noted that impaired performance in recognizing emotions of fear, sadness, and anger was predicted by impaired performances on the measures of inhibition and flexibility or "set-shifting" suggesting that the ability to recognize emotions could be at least to some extent cognitively mediated. Finally, using a voxel-based lesion technique, we identified a partially common prefrontal network underlying deficits on executive functions and emotions recognition centered on the ventral and medial parts of the prefrontal cortex, reflecting beyond the neural network involved in recognizing negative emotions per se that of the cognitive processes elicited by this emotion task.

Evaluation of Quality of Life in Tunisian patients with Differentiated Thyroid Cancer.

INTRODUCTION: Differentiated thyroid cancer (DTC), despite its good prognosis, affects the quality of life (QOL) of patients by its physical and psychological repercussions and by the toxicity of treatment. A study of the quality of life as well as the potentially associated factors is necessary in order to carry out targeted actions. AIM: This work was conducted to assess the quality of life of patients treated for thyroid cancer. METHODS: 89 patients treated surgically and by iratherapy for DTC responded from January 2018 to December 2019 to the SF36 questionnaire in its validated version in Tunisian dialect. A descriptive and bivariate analysis between the scores of the different domains and the variables of interest was performed. RESULTS: The overall mean score (SMG) of the QOL of our patients ranged from 12.8 to 94.25 with a mean of 58±22%. The factors that proved to have a positive impact on the QOL of patients followed for CDT assessed by the SMG and/or the mental summary score (MSS) and/or the physical summary score (PSS) were: male gender (p=0.034), higher educational level (p=0.037), early TNM stage (p=0.041) and low cumulative iodine-131 dose (≤ 5550 MBq) (p=0.031). CONCLUSION: QOL is strongly influenced by many sociodemographic and clinical factors. More attention should be paid to patients followed for DTC to improve quality of life.

Epidemiological, Bacteriological, and Evolutive Features of Children Hospitalized for Infective Endocarditis in a Tertiary Tunisian Pediatric Department.

Background: Infective endocarditis is a rare condition in childhood, and there is limited data on this disease in Tunisia. Objective: This study aims to analyze the epidemiological profile, bacteriological data, and prognosis of infective endocarditis in children admitted to the pediatric department of a University Hospital in Tunisia. Methods: We conducted a comparative cross-sectional study in the pediatric department of Sahloul Teaching Hospital in Sousse, a tertiary referral hospital in Tunisia. The study included all children aged ≤ 18 years with infective endocarditis admitted to the tertiary referral center for pediatrics in Sahloul University Hospital from January 1994 to December 2022. The diagnosis of infective endocarditis was based on modified Duke's criteria. Results: Thirty-six patients met the diagnostic criteria for infective endocarditis, resulting in a proportion of 07 cases per 1000 hospital admissions. The mean age was 6 years (range: 40 days to 16 years). Congenital heart disease was identified as the underlying lesion in 23 cases (63.9 %). Blood cultures were positive in 20 patients (55.6 %), predominantly with Staphylococcus species (55 %). The most frequent complications involved the central nervous system (8 cases; 22.2 %). The mortality rate was 25 %, and factors predicting mortality included heart failure on admission or during the hospital stay, increased leukocyte count, and decreased prothrombin time. Conclusion: Our study reveals a shift in the prevalent underlying lesions, with rheumatic heart diseases no longer being the most common. Staphylococcus spp. emerged as the predominant organism in blood cultures. Notably, mortality predictors included heart failure, an elevated leukocyte count, and a decreased prothrombin time rate.

Impaired Perception of Unintentional Transgression of Social Norms after Prefrontal Cortex Damage: Relationship to Decision Making, Emotion Recognition, and Executive Functions.

OBJECTIVE: Patients with prefrontal cortex damage often transgress social rules and show lower accuracy in identifying and explaining inappropriate social behavior. The objective of this study was to examine the relationship between the ability to perceive other unintentional transgressions of social norms and both decision making and emotion recognition as these abilities are critical for appropriate social behavior. METHOD: We examined a group of patients with focal prefrontal cortex damage (N = 28) and a group of matched control participants (N = 28) for their abilities to detect unintentional transgression of social norms using the "Faux-Pas" task of theory of mind, to make advantageous decisions on the Iowa gambling task, and to recognize basic emotions on the Ekman facial affect test. RESULTS: The group of patients with frontal lobe damage was impaired in all of these tasks compared with control participants. Moreover, all the "Faux-Pas", Iowa gambling, and emotion recognition tasks were significantly associated and predicted by executive measures of inhibition, flexibility, or planning. However, only measures from the Iowa gambling task were associated and predicted performance on the "Faux-Pas" task. These tasks were not associated with performance in recognition of basic emotions. These findings suggest that theory of mind, executive functions, and decision-making abilities act in an interdependent way for appropriate social behavior. However, theory of mind and emotion recognition seem to have distinct but additive effects upon social behavior. Results from VLSM analysis also corroborate these data by showing a partially overlapped prefrontal circuitry underlying these cognitive domains.

Neurocognitive and neural mechanisms underlying deficit on the Reading Mind In The Eyes Task: Evidence from patients with focal prefrontal cortex damage.

OBJECTIVE: Conflicting evidence has arisen from the few correlational studies that have examined the relationship between the ability to decode social emotional cues through the eyes and executive functions in individuals with prefrontal cortex damage. The objective of the current study was (1) to investigate the impact of both focal prefrontal and parietal cortex damage on both of these domains; (2) to examine whether impaired ability to decode social emotion cues through the eyes was predicted by executive function deficits and; (3) to explore the neural correlates of both of these components. METHOD: Thirty individuals with prefrontal cortex damage, 15 individuals with parietal cortex damage and 30 matched healthy comparison subjects were subjected to a battery of executive tasks assessing inhibition, flexibility, and planning processes and the Reading the Mind in the Eyes Task (RMET) assessing ability to decode social emotion cues through the eyes. RESULTS: Compared to both comparison groups, individuals with prefrontal cortex damage were impaired in performing RMET and almost all executive tasks. Regression analysis showed that for individuals with prefrontal cortex damage, performance on the Stroop and Hayling tasks predicted scores on the RMET, while for the healthy comparison group, only the verbal fluency performance predicted scores on the RMET. The Voxel lesions-symptom mapping technique showed that both components rely partly on the same neural substrates, reflecting beyond the neural network of RMET per se that of the cognitive processes elicited by this multi-determinant task. CONCLUSION: These findings suggest that the ability to read mental states of mind depends on the inhibition and flexibility executive mechanisms.