An umbrella review of randomized control trials on the effects of physical exercise on cognition.

Extensive research links regular physical exercise to an overall enhancement of cognitive function across the lifespan. Here we assess the causal evidence supporting this relationship in the healthy population, using an umbrella review of meta-analyses limited to randomized controlled trials (RCTs). Despite most of the 24 reviewed meta-analyses reporting a positive overall effect, our assessment reveals evidence of low statistical power in the primary RCTs, selective inclusion of studies, publication bias and large variation in combinations of pre-processing and analytic decisions. In addition, our meta-analysis of all the primary RCTs included in the revised meta-analyses shows small exercise-related benefits (d = 0.22, 95% confidence interval 0.16 to 0.28) that became substantially smaller after accounting for key moderators (that is, active control and baseline differences; d = 0.13, 95% confidence interval 0.07 to 0.20), and negligible after correcting for publication bias (d = 0.05, 95% confidence interval -0.09 to 0.14). These findings suggest caution in claims and recommendations linking regular physical exercise to cognitive benefits in the healthy human population until more reliable causal evidence accumulates.

The brain in flow: A systematic review on the neural basis of the flow state.

BACKGROUND: Flow state is a subjective experience that people report when task performance is experienced as automatic, intrinsically rewarding, optimal and effortless. While this intriguing phenomenon is the subject of a plethora of behavioural studies, only recently researchers have started to look at its neural correlates. Here, we aim to systematically and critically review the existing literature on the neural correlates of the flow state. METHODS: Three electronic databases (Web of Science, Scopus and PsycINFO) were searched to acquire information on eligible articles in July, 2021, and updated in March, 2022. Studies that measured or manipulated flow state (through questionnaires or employing experimental paradigms) and recorded associated brain activity with electroencephalography (EEG), functional magnetic resonance (fMRI) or functional near-infrared spectroscopy (fNIRS) or manipulated brain activity with transcranial direct current stimulation (tDCS) were selected. We used the Cochrane Collaboration Risk of Bias 2 (RoB 2) tool to assess the methodological quality of eligible records. RESULTS: In total, 25 studies were included, which involved 471 participants. In general, the studies that experimentally addressed flow state and its neural dynamics seem to converge on the key role of structures linked to attention, executive function and reward systems, giving to the anterior brain areas (e.g., the DLPC, MPFC, IFG) a crucial role in the experience of flow. However, the dynamics of these brain regions during flow state are inconsistent across studies. DISCUSSION: In light of the results, we conclude that the current available evidence is sparse and inconclusive, which limits any theoretical debate. We also outline major limitations of this literature (the small number of studies, the high heterogeneity across them and their important methodological constraints) and highlight several aspects regarding experimental design and flow measurements that may provide useful avenues for future studies on this topic.

Ensemble of coupling forms and networks among brain rhythms as function of states and cognition.

The current paradigm in brain research focuses on individual brain rhythms, their spatiotemporal organization, and specific pairwise interactions in association with physiological states, cognitive functions, and pathological conditions. Here we propose a conceptually different approach to understanding physiologic function as emerging behavior from communications among distinct brain rhythms. We hypothesize that all brain rhythms coordinate as a network to generate states and facilitate functions. We analyze healthy subjects during rest, exercise, and cognitive tasks and show that synchronous modulation in the micro-architecture of brain rhythms mediates their cross-communications. We discover that brain rhythms interact through an ensemble of coupling forms, universally observed across cortical areas, uniquely defining each physiological state. We demonstrate that a dynamic network regulates the collective behavior of brain rhythms and that network topology and links strength hierarchically reorganize with transitions across states, indicating that brain-rhythm interactions play an essential role in generating physiological states and cognition.

Intolerance of uncertainty and decisions about delayed, probabilistic rewards: A replication and extension of Luhmann, C. C., Ishida, K., & Hajcak, G. (2011).

Intolerance of Uncertainty (IU) is thought to lead to maladaptive behaviours and dysfunctional decision making, both in the clinical and healthy population. The seminal study reported by Luhmann and collaborators in 2011 [1] showed that IU was negatively associated with choosing a delayed, but more probable and valuable, reward over choosing an immediate, but less probable and valuable, reward. These findings have been widely disseminated across the field of personality and individual differences because of their relevance for the understanding of the role of IU in the development and maintenance of anxiety-related disorders. Given their importance it would be desirable to have replications of this study, but none have been carried out so far. The current study has been designed to replicate and extend Luhmann et al.'s results. Our sample will include 266 healthy participants (more than five times the sample size used by Luhmann et al.) to detect with a power of 95% the effect size that can be detected with a power of 33% in the original study. To increase our chances of getting such a sample size, the experiment will be conducted online, To increase our chances of getting such a sample size, the experiment will be conducted online, adding check trials to the original decision-making task to monitor participants' engagement. Additionally, we will explore the role of impulsivity in the relationship between IU and willingness to wait. This study will add empirical evidence about the role of IU in decision making and, in case of replication of Luhmann et al.'s results, will support the hypothesis that high-IU individuals may engage in inefficient or costly behaviour in exchange for less time enduring an uncertain situation.

Different underlying mechanisms for high and low arousal in probabilistic learning in humans.

Humans are uniquely capable of adapting to highly changing environments by updating relevant information and adjusting ongoing behaviour accordingly. Here we show how this ability -termed cognitive flexibility- is differentially modulated by high and low arousal fluctuations. We implemented a probabilistic reversal learning paradigm in healthy participants as they transitioned towards sleep or physical extenuation. The results revealed, in line with our pre-registered hypotheses, that low arousal leads to diminished behavioural performance through increased decision volatility, while performance decline under high arousal was attributed to increased perseverative behaviour. These findings provide evidence for distinct patterns of maladaptive decision-making on each side of the arousal inverted u-shaped curve, differentially affecting participants' ability to generate stable evidence-based strategies, and introduces wake-sleep and physical exercise transitions as complementary experimental models for investigating neural and cognitive dynamics.

Is the habit system altered in individuals with obesity? A systematic review.

Habit-like eating behavior is repeatedly pointed to as a key cognitive mechanism contributing to the emergence and maintenance of obesity. Here, we conducted a systematic review of the literature to assess the existent behavioral evidence for the Habit Hypothesis for Overeating (HHO) which states that obesity is the consequence of an imbalance between the habit and goal-directed reward learning systems, leading to overconsumption of food. We found a total of 19 studies implementing a variety of experimental protocols (i.e., free operant paradigm, slips-of-action test, two-step task, Pavlovian-to-Instrumental paradigm, probabilistic learning task) and manipulations. Taken together, the studies on clinical (binge eating disorder) and non-clinical individuals with overweight or obesity do not support the HHO conclusively. While the scientific literature on HHO is still in its infancy, the heterogeneity of the extant studies makes it difficult to evaluate the degree of convergence of these findings. Uncovering the role of reward learning systems in eating behaviors might have a transformative impact on public health.

Novel evidence on the effect of tramadol on self-paced high-intensity cycling.

The use of tramadol is a controversial topic in cycling. In order to provide novel evidence on this issue, we tested 29 participants in a pre-loaded cycling time trial (TT; a 20-min TT preceded by 40-min of constant work-rate at 60% of the VO2max) after ingesting 100 mg of tramadol (vs placebo and paracetamol (1.5 g)). Participants performed the Psychomotor Vigilance Task (PVT) at rest and a Sustained Attention to Response Task (SART) during the 60 min of exercise. Oscillatory electroencephalography (EEG) activity was measured throughout the exercise. The results showed higher mean power output during the 20-min TT in the tramadol vs. paracetamol condition, but no reliable difference was reported between tramadol and placebo (nor paracetamol vs. placebo). Tramadol resulted in faster responses in the PVT and higher heart rate during exercise. The main effect of substance was reliable in the SART during the 40-min constant workload (no during the 20-min TT), with slower reaction time, but better accuracy for tramadol and paracetamol than for placebo. This study supports the increased behavioural and neural efficiency at rest for tramadol but not the proposed ergogenic or cognitive (harmful) effect of tramadol (vs. placebo) during self-paced high-intensity cycling.

Exercise practice associates with different brain rhythmic patterns during vigilance.

Cardiovascular fitness has repeatedly been associated to enhanced cognitive and brain functioning, generally in the form of differences in reaction time and response accuracy, as well as in event-related potentials (ERPs) and blood-oxygen-level-dependent imaging while participants performed executive demanding tasks. However, the evidence regarding potential differences in oscillatory neural activity, an inherent characteristic of brain functioning, is scarce. To fill this gap, here, we extracted and analysed (using a data-driven exploratory approach) brain oscillatory activity, both tonic (overall electroencephalographic - EEG - oscillatory activity) and transient (event related spectral perturbation [ERSP] and inter-trial coherence [ITC]), from a previous published dataset (Luque-Casado et al. 2016), where we showed different behavioural and ERP patterns during a vigilance/sustained attention task as a function of cardiovascular fitness in young adults. The ERSP results of the current study revealed increased theta (4-8 Hz) and upper beta (20-40 Hz) power and reduced lower beta (14-20 Hz) suppression after the target stimulus presentation in the higher-fit group compared to their lower-fit peers, but these differences disappeared in the second part of the task. ITC results mimicked the ERSP pattern within theta (4-8 Hz), while no differences were observed for the remaining frequency bands. Interestingly, the overall time-dependent effect in transient oscillatory activity followed the reaction time pattern of results. The analysis of the overall EEG oscillatory (tonic) dynamics did not show significant differences between groups. In sum, cardiorespiratory fitness was related to a brain oscillatory differential response pattern over a wide range of the frequency spectrum and spatio-temporal distribution, which seems to underlie the positive relationship between aerobic fitness and behavioural performance in a sustained attention task. Future studies are warranted to study the causal nature (beyond mere association) of these findings.

Circadian rhythms and decision-making: a review and new evidence from electroencephalography.

Since emotions and regulatory control are relevant for decision-making, their circadian fluctuation should influence the outcome of such decisions, but this question has been rarely addressed. A review of the literature suggests that the evidence regarding circadian synchrony effects (better performance at optimal vs. non-optimal times of day according to chronotype) on decision-making is mixed, likely due to the use of different approaches to estimate chronotype. The current experiment studied economic decision-making as a function of both chronotype and the time of day when decisions are made. The influence of chronotype (Morning-type: N = 28 vs. Evening-type: N = 30) and time of day (8 am vs. 10 pm) on decision-making was measured by the acceptance rate of unfair and fair offers in the Ultimatum Game, and the event-related potentials time-locked to such offers. Subjective affect (PANAS), and appraisal of emotional images (IAPS) were also measured. Chronotype was estimated through questionnaires (MEQ, rMEQ, MCTQ) and the circadian rhythm of wrist temperature. Synchrony effects were found for both wrist temperature and subjective affect, but not for behavioral performance. Morning-types showed earlier phases of circadian rhythms in temperature, reported better sleep quality, more positive affective balance, accepted more unfair offers, and their frontal P200 potential was attenuated as compared to Evening-types in the Ultimatum Game. Acceptance rate of unfair offers correlated with the chronotype measured by questionnaires (positive correlation with rMEQ and MEQ scores, and negative correlation with Midsleep time in workdays -MSWsc from MCTQ) but not with midsleep time estimated through wrist temperature. Finally, participants who accepted more unfair offers later judged positive IAPS stimuli as more pleasant. We did not observe a synchrony effect in the Ultimatum Game, but morningness was related to rational decision-making as indexed by increased acceptance of unfair offers. Since morning-types show higher emotional regulation and positive mood than evening-types, it is possible that unfair offers did not elicit negative emotions as intense in morning-types as in evening-types, making it easier for them to accept.Abbreviations: ACC: anterior cingulate cortex; ANOVA: analysis of variance; BART: Balloon Analogue Risk Task; DLPFC: dorsolateral prefrontal cortex; EEG: electroencephalography; IAPS: International Affective Picture System; ICA: Independent component analysis; KSS: Karolinska Sleepiness Scale; LPP: Late Positive Potential; M: mean; MCTQ: Munich Chronotype Questionnaire; MEQ: Morningness Eveningness Questionnaire; MFN: Medial Frontal Negativity; MSWsc: midsleep time for working days corrected for sleep debt; MSFsc: midsleep time for free days corrected for sleep debt; N: number of participants; PANAS: Positive and Negative Affect Schedule; PSQI: Pittsburgh Sleep Quality Index; PVT: Psychomotor Vigilance Task; rMEQ: reduced Morningness Eveningness Questionnaire; RNA: Ribonucleic acid; RT: reaction time; SAM: Self-Assessment Manikin; SD: standard deviation; UG: Ultimatum Game.

The relationship between vigilance capacity and physical exercise: a mixed-effects multistudy analysis.

A substantial body of work has depicted a positive association between physical exercise and cognition, although the key factors driving that link are still a matter of scientific debate. Here, we aimed to contribute further to that topic by pooling the data from seven studies (N = 361) conducted by our research group to examine whether cardiovascular fitness (VO2), sport type participation (externally-paced (e.g., football or basketball) and self-paced (e.g., triathlon or track and field athletes) vs. sedentary), or both, are crucial factors to explain the association between the regular practice of exercise and vigilance capacity. We controlled for relevant variables such as age and the method of VO2 estimation. The Psychomotor Vigilance Task was used to measure vigilance performance by means of reaction time (RT). The results showed that externally-paced sport practice (e.g., football) resulted in significantly shorter RT compared to self-paced sport (e.g., triathlon) and sedentary condition, depicting larger effects in children and adolescents than in adults. Further analyses revealed no significant effect of cardiovascular fitness and self-paced sport practice, in comparison to the sedentary condition, on RT. Our data point to the relevance of considering the type of sport practice over and above the level of cardiovascular fitness as crucial factor to explain the positive association between the regular practice of exercise and vigilance capacity.

Transcranial direct current stimulation (tDCS) over the left prefrontal cortex does not affect time-trial self-paced cycling performance: Evidence from oscillatory brain activity and power output.

OBJECTIVES: To test the hypothesis that transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex (DLPFC) influences performance in a 20-min time-trial self-paced exercise and electroencephalographic (EEG) oscillatory brain activity in a group of trained male cyclists. DESIGN: The study consisted of a pre-registered (https://osf.io/rf95j/), randomised, sham-controlled, single-blind, within-subject design experiment. METHODS: 36 trained male cyclists, age 27 (6.8) years, weight 70.1 (9.5) Kg; VO2max: 54 (6.13) ml.min-1.kg-1, Maximal Power output: 4.77 (0.6) W/kg completed a 20-min time-trial self-paced exercise in three separate sessions, corresponding to three stimulation conditions: anodal, cathodal and sham. tDCS was administered before each test during 20-min at a current intensity of 2.0 mA. The anode electrode was placed over the DLPFC and the cathode in the contralateral shoulder. In each session, power output, heart rate, sRPE and EEG (at baseline and during exercise) was measured. RESULTS: There were no differences (F = 0.31, p > 0.05) in power output between the stimulation conditions: anodal (235 W [95%CI 222-249 W]; cathodal (235 W [95%CI 222-248 W] and sham (234 W [95%CI 220-248 W]. Neither heart rate, sRPE nor EEG activity were affected by tDCS (all Ps > 0.05). CONCLUSION: tDCS over the left DLFC did not affect self-paced exercise performance in trained cyclists. Moreover, tDCS did not elicit any change on oscillatory brain activity either at baseline or during exercise. Our data suggest that the effects of tDCS on endurance performance should be taken with caution.

Oscillatory brain activity during acute exercise: Tonic and transient neural response to an oddball task.

Intense physical exercise exerts measurable changes at various physiological levels that are well documented in the literature. However, despite the key role of the brain in processing inputs from internal organ systems and the external environment to coordinate and optimize behavior, little is known about brain dynamics during exercise. The present study investigates tonic and transient oscillatory brain activity in a group of participants performing an oddball task during a single bout of aerobic exercise. Twenty young males (19-32 years) were recruited for two experimental sessions on separate days. EEG activity was recorded during a session of cycling at 80% (moderate-to-high intensity) of VO2max (maximum rate of oxygen consumption) while participants responded to infrequent targets (red square and big blue circle) presented among frequent nontargets (small blue circle). This was compared to a (baseline) light intensity session (30% VO2max ) to control any potential effect of dual tasking (i.e., pedaling and performing the oddball task). A cluster-based nonparametric permutations test revealed an increase in power across the entire frequency spectrum during the moderate-to-high intensity exercise compared to light intensity. Furthermore, the more salient target (red square) elicited a lower increase in (stimulus-evoked) theta power in the 80% VO2max than in the light intensity condition. Alpha and lower beta power decreased less in the standard trials (small blue circle) during the moderate-to-high exercise condition than in the light exercise condition. The present study unveils, for the first time, a complex brain activity pattern during vigorous exercise while attending to task-relevant stimuli.

Physical exercise increases overall brain oscillatory activity but does not influence inhibitory control in young adults.

Extant evidence suggests that acute exercise triggers a tonic power increase in the alpha frequency band at frontal locations, which has been linked to benefits in cognitive function. However, recent literature has questioned such a selective effect on a particular frequency band, indicating a rather overall power increase across the entire frequency spectrum. Moreover, the nature of task-evoked oscillatory brain activity associated to inhibitory control after exercising, and the duration of the exercise effect, are not yet clear. Here, we investigate for the first time steady state oscillatory brain activity during and following an acute bout of aerobic exercise at two different exercise intensities (moderate-to-high and light), by means of a data-driven cluster-based approach to describe the spatio-temporal distribution of exercise-induced effects on brain function without prior assumptions on any frequency range or site of interest. We also assess the transient oscillatory brain activity elicited by stimulus presentation, as well as behavioural performance, in two inhibitory control (flanker) tasks, one performed after a short delay following the physical exercise and another completed after a rest period of 15' post-exercise to explore the time course of exercise-induced changes on brain function and cognitive performance. The results show that oscillatory brain activity increases during exercise compared to the resting state, and that this increase is higher during the moderate-to-high intensity exercise with respect to the light intensity exercise. In addition, our results show that the global pattern of increased oscillatory brain activity is not specific to any concrete surface localization in slow frequencies, while in faster frequencies this effect is located in parieto-occipital sites. Notably, the exercise-induced increase in oscillatory brain activity disappears immediately after the end of the exercise bout. Neither transient (event-related) oscillatory activity, nor behavioural performance during the flanker tasks following exercise showed significant between-intensity differences. The present findings help elucidate the effect of physical exercise on oscillatory brain activity and challenge previous research suggesting improved inhibitory control following moderate-to-high acute exercise.

Tramadol effects on physical performance and sustained attention during a 20-min indoor cycling time-trial: A randomised controlled trial.

OBJECTIVES: To investigate the effect of tramadol on performance during a 20-min cycling time-trial (Experiment 1), and to test whether sustained attention would be impaired during cycling after tramadol intake (Experiment 2). DESIGN: Randomized, double-blind, placebo controlled trial. METHODS: In Experiment 1, participants completed a cycling time-trial, 120-min after they ingested either tramadol or placebo. In Experiment 2, participants performed a visual oddball task during the time-trial. Electroencephalography measures (EEG) were recorded throughout the session. RESULTS: In Experiment 1, average time-trial power output was higher in the tramadol vs. placebo condition (tramadol: 220W vs. placebo: 209W; p<0.01). In Experiment 2, no differences between conditions were observed in the average power output (tramadol: 234W vs. placebo: 230W; p>0.05). No behavioural differences were found between conditions in the oddball task. Crucially, the time frequency analysis in Experiment 2 revealed an overall lower target-locked power in the beta-band (p<0.01), and higher alpha suppression (p<0.01) in the tramadol vs. placebo condition. At baseline, EEG power spectrum was higher under tramadol than under placebo in Experiment 1 while the reverse was true for Experiment 2. CONCLUSIONS: Tramadol improved cycling power output in Experiment 1, but not in Experiment 2, which may be due to the simultaneous performance of a cognitive task. Interestingly enough, the EEG data in Experiment 2 pointed to an impact of tramadol on stimulus processing related to sustained attention. TRIAL REGISTRATION: EudraCT number: 2015-005056-96.

The relationship between sustained attention and aerobic fitness in a group of young adults.

BACKGROUND: A growing set of studies has shown a positive relationship between aerobic fitness and a broad array of cognitive functions. However, few studies have focused on sustained attention, which has been considered a fundamental cognitive process that underlies most everyday activities. The purpose of this study was to investigate the role of aerobic fitness as a key factor in sustained attention capacities in young adults. METHODS: Forty-four young adults (18-23 years) were divided into two groups as a function of the level of aerobic fitness (high-fit and low-fit). Participants completed the Psychomotor Vigilance Task (PVT) and an oddball task where they had to detect infrequent targets presented among frequent non-targets. RESULTS: The analysis of variance (ANOVA) showed faster responses for the high-fit group than for the low-fit group in the PVT, replicating previous accounts. In the oddball task, the high-fit group maintained their accuracy (ACC) rate of target detection over time, while the low-fit group suffered a significant decline of response ACC throughout the task. DISCUSSION: Importantly, the results show that the greater sustained attention capacity of high-fit young adults is not specific to a reaction time (RT) sustained attention task like the PVT, but it is also evident in an ACC oddball task. In sum, the present findings point to the important role of aerobic fitness on sustained attention capacities in young adults.

Transient autonomic responses during sustained attention in high and low fit young adults.

Maintaining vigilance over long periods of time is especially critical in performing fundamental everyday activities and highly responsible professional tasks (e.g., driving, performing surgery or piloting). Here, we investigated the role of aerobic fitness as a crucial factor related to the vigilance capacity. To this end, two groups of young adult participants (high-fit and low-fit) were compared in terms of reaction time (RT) performance and event-related heart rate responses in a 60' version of the psychomotor vigilance task. The results showed shorter RTs in high-fit participants, but only during the first 24' of the task. Crucially, this period of improved performance was accompanied by a decelerative cardiac response pattern present only in the high-fit group that also disappeared after the first 24'. In conclusion, high aerobic fitness was related to a pattern of transient autonomic responses suggestive of an attentive preparatory state that coincided with improved behavioural performance, and that was sustained for 24'. Our findings highlight the importance of considering the role of the autonomic nervous system reactivity in the relationship between fitness and cognition in general, and sustained attention in particular.

Dissociation between the cognitive and interoceptive components of mindfulness in the treatment of chronic worry.

OBJETIVES: Despite the increasing interest in mindfulness, the basic components and action mechanisms of mindfulness remain controversial. The present study aims at testing the specific contribution of two components of mindfulness -attention to cognitive experience (metacognition) and awareness of interoceptive sensations (metainteroception)- in the treatment of chronic worry. METHOD: Forty five female university students with high scores in the Penn State Worry Questionnaire were split into three groups: a mindfulness cognitive training group, a mindfulness interoceptive training group, and a non-intervention control group. Participants were assessed before and after the intervention using physiological indices of autonomic regulation (skin conductance, heart rate, heart rate variability, and respiratory sinus arrhythmia) and self-report indices of mindfulness and clinical symptoms (chronic worry, depression, positive and negative affect, and perceived stress). RESULTS: Both mindfulness training groups showed significant improvement after the intervention in self-report indices of mindfulness and clinical symptoms. However, the interoceptive training group was superior in also showing significant improvement in the physiological indices of autonomic regulation. LIMITATIONS: The relatively small sample size may have increased the probabilities of type I and II errors. Our Intervention program was relatively short. The participants were all female. CONCLUSIONS: These results support the hypothesis that, in the context of treating chronic worry, the interoceptive and cognitive components can be somewhat dissociated and that, when both components are applied separately, compared to a non-intervention condition, the interoceptive component is more effective.

Viewing pain and happy faces elicited similar changes in postural body sway.

Affective facial expressions are potent social cues that can induce relevant physiological changes, as well as behavioral dispositions in the observer. Previous studies have revealed that angry faces induced significant reductions in body sway as compared with neutral and happy faces, reflecting an avoidance behavioral tendency as freezing. The expression of pain is usually considered an unpleasant stimulus, but also a relevant cue for delivering effective care and social support. Nevertheless, there are few data about behavioral dispositions elicited by the observation of pain expressions in others. The aim of the present research was to evaluate approach-avoidance tendencies by using video recordings of postural body sway when participants were standing and observing facial expressions of pain, happy and neutral. We hypothesized that although pain faces would be rated as more unpleasant than the other faces, they would provoke significant changes in postural body sway as compared to neutral facial expressions. Forty healthy female volunteers (mean age 25) participated in the study. Amplitude of forward movements and backward movements in the anterior-posterior and medial-lateral axes were obtained. Statistical analyses revealed that pain faces were the most unpleasant stimuli, and that both happy and pain faces were more arousing than neutral ones. Happy and pain faces also elicited greater amplitude of body sway in the anterior-posterior axes as compared with neutral faces. In addition, significant positive correlations were found between body sway elicited by pain faces and pleasantness and empathic ratings, suggesting that changes in postural body sway elicited by pain faces might be associated with approach and cooperative behavioral responses.

Implementation of occult hepatitis screening in the Spanish cohort of HIV-infected pediatric patients.

Regular screening methods may miss the diagnosis of occult hepatitis B infection and seronegative hepatitis C virus infection in immunocompromised patients. A cross-sectional study within a Spanish cohort of HIV-infected children yielded 6 of 254 (2.4%) possible occult hepatitis B infection cases and 2 of 254 (0.8%) seronegative hepatitis C virus-infected patients. Implementation of occult hepatitis screening in the routine care of these children may be warranted.