Simulation and virtual reality in medical education and therapy: a protocol.

Continuing medical education has historically been provided primarily by didactic lectures, though adult learners prefer experiential or self-directed learning. Young physicians have extensive experience with computer-based or "video" games, priming them for medical education--and treating their patients--via new technologies. We report our use of standardized patients (SPs) to educate physicians on the diagnosis and treatment of biological and chemical warfare agent exposure. We trained professional actors to serve as SPs representing exposure to biological agents such as anthrax and smallpox. We rotated workshop participants through teaching stations to interview, examine, diagnose and treat SPs. We also trained SPs to simulate a chemical mass casualty (MASCAL) incident. Workshop participants worked together to treat MASCAL victims, followed by discussion of key teaching points. More recently, we developed computer-based simulation (CBS) modules of patients exposed to biological agents. We compare the strengths and weaknesses of CBS vs. live SPs. Finally, we detail plans for a randomized controlled trial to assess the efficacy of virtual reality (VR) exposure therapy compared to pharmacotherapy for post-traumatic stress disorder (PTSD). PTSD is associated with significant disability and healthcare costs, which may be ameliorated by the identification of more effective therapy.     

Asymmetry in judgments of moral blame and praise: the role of perceived metadesires

Abstract - An important consideration in judging the blameworthiness (or praiseworthiness) of an action is whether the agent had sufficient control over it. In three experiments, we investigated judgments of moral blame and praise elicited when individuals were presented with vignettes describing actions that were performed either carefully and deliberately or impulsively and uncontrollably. Experiment 1 uncovered an asymmetry between judgments of positive versus negative actions—negative impulsive actions elicited a discounting of moral blame, but positive impulsive actions did not elicit a discounting of moral praise. Experiments 2 and 3 showed that this asymmetry arises because individuals judge agents on the basis of their metadesires (the degree to which the agents embrace or reject the impulses leading to their actions). Individuals assume that an agent would embrace an uncontrollable positive impulse, and reject an uncontrollable negative impulse.     

抗菌药物合理应用的宏观和微观问题

抗菌药物不合理应用现象长期得不到纠正,细菌耐药稳步攀升,正引起医学界、社会和政府的高度关注。本文就宏观上的抗菌药物使用政策与微观上的临床用药两方面存在的问题进行探讨。介绍了国际上关于抗菌药物政策的研究以及抗菌药物合理使用的新观点（尽早开始经验性治疗、“降阶梯”治疗策略、运用抗菌药物PK／PD原理指导临床用药、短程治疗）。主张调整宏观抗生素策略,去除该政策单纯、片面限制使用和应用药敏实验结果指导临床用药绝对化的做法。吸纳国际上的新成果,强化监管力度,更多采用教育和技术手段。     

Toddlers’ social evaluations of agents who act on false beliefs

Mature social evaluations privilege agents’ intentions over the outcomes of their actions, but young children often privilege outcomes over intentions in verbal tasks probing their social evaluations. In three experiments (N = 118), we probed the development of intention-based social evaluation and mental state reasoning using nonverbal methods with 15-month-old toddlers. Toddlers viewed scenarios depicting a protagonist who sought to obtain one of two toys, each inside a different box, as two other agents observed. Then, the boxes’ contents were switched in the absence of the protagonist and either in the presence or the absence of the other agents. When the protagonist returned, one agent opened the box containing the protagonist's desired toy (a positive outcome), and the other opened the other box (a neutral outcome). When both agents had observed the toys move to their current locations, the toddlers preferred the agent who opened the box containing the desired toy. In contrast, when the agents had not seen the toys move and therefore should have expected the desired toy's location to be unchanged, the toddlers preferred the agent who opened the box that no longer contained the desired toy. Thus, the toddlers preferred the agent who intended to make the protagonist's desired toy accessible, even when its action, guided by a false belief concerning that toy's location, did not produce a positive outcome. Well before children connect beliefs to social behavior in verbal tasks, toddlers engage in intention-based evaluations of social agents with false beliefs.     

Formation of taste aversions in rats following prior exposure to sickness

Findings from the present experiments extend those of earlier studies and show that rats form weaker conditioned taste aversions if they are exposed to a sickness-inducing agent prior to a single training trial. The present experiments appear to rule out the possible confounding factors that, during pretraining, (1) animals became addicted to the drugs that were intended to induce sickness during training, (2) drug tolerances were created and hence reduced the effectiveness of the same or different sickness-inducing agents used to induce sickness during training, or (3) associations between other stimuli and sickness were formed and interfered with or blocked the formation of subsequent taste aversions. It was concluded that the associative capacity of sickness can be reduced through pre-exposure.     

A secret agent? How infants learn about the identity of objects in a causal scene

Four experiments examined the role of correlations between dynamic and static parts on 12- to 16-month-olds' ability to learn the identity of agents and recipients in a simple causal event. Infants were habituated to events in which objects with a dynamic or static part acted as an agent or a recipient and then were tested with an event in which the part-causal role relations were switched. Experiment 1 revealed that 16-month-olds, but not 12-month-olds, associate a dynamic part with the role of agent and a static part with the role of recipient. Experiment 2 showed that 12- and 16-month-olds do not associate a static part with the role of agent or a dynamic part with the role of recipient. Experiment 3 demonstrated that 14-month-olds will learn the relations presented in Experiment 1 and Experiment 2. Experiment 4 revealed that 12-month-olds were able to discriminate the two geometric figures in the events. The results are discussed with respect to infants' developing ability to attend to correlations between dynamic and static cues and the mechanism underlying early object concept acquisition.     

Food preferences before and during treatment for a pediatric feeding disorder

Little is known about the food preferences of children with a feeding disorder and medical diagnoses. Therefore, we conducted repeated paired-stimulus-preference assessments with foods to which we either exposed or did not expose 3 children with a feeding disorder and medical diagnoses during clinical treatment. Responding was relatively equivalent for exposure and nonexposure foods throughout the preference assessments, suggesting that preferences for foods did not change due to exposure during treatment.     

Do infants apply the principle of rational action to human agents?

Twelve- to fourteen-month-old infants’ reactions to violations of the principle of rational action [Cognition 56 (1995) 165] were studied in two experiments, using humanlike puppets and human agents rather than computerized shapes as stimuli. In Experiment 1, infants watched a puppet approaching another puppet on a stage, while in Experiment 2 a videotaped sequence of a person approaching another person was shown. In both experiments, a rational and a non-rational approach condition were contrasted in the habituation phase. In the rational approach condition, an obstacle had to be overcome by climbing or jumping. In the non-rational approach condition, the agent made a detour approach in the absence of an obstacle. In the test phase, infants watched direct and indirect-approach events. In both experiments, infants in the rational approach condition looked significantly longer at indirect-approach than at direct-approach test events, while no difference between the two types of test events was observed in the non-rational approach condition. These findings support the assumption that one-year-old infants have principled expectations about rational goal approaches of human agents.     

Visual memory for agents and their actions

Humans spend a considerable amount of time remembering other individuals' actions. Nevertheless, it is unclear how the visual system stores information about the identities of agents and their actions. To address this, I used a change detection method where observers were asked to remember agents and the actions they performed. Results show that observers can maintain information about both 2-3 agents and 2-3 actions simultaneously. However, they are highly impaired for remembering which agent performed which action, indicating that agent and action information are retained separately in visual working memory. Further experiments show that agent and action information can be bound together when the visual input contains the appropriate cues. However, this binding process significantly reduces the total amount of information that can be retained. Together, these results show that (1) an additional, resource-demanding process is needed to integrate agent and action information stored in separate working memory stores, and (2) the extent to which these two types of information are bound into integrated units depends largely on the presence of specific cues in the visual input.     

Three-Year-Old Children Detect Social Exclusion in Third-Party Interactions

Humans are motivated to connect with others and are sensitive to social exclusion—intentionally leaving out others. This ability to detect social exclusion is suggested to be evolutionarily adaptive, biologically hardwired, and an important feature of social-cognitive development. Yet it is unclear when children start to independently detect social exclusion. Previous developmental research on social exclusion has focused on children older than 4 years of age, but recent infancy research has suggested younger children may be able to process complex social interactions such as social exclusion. The present study is the first to examine whether 2- to 3-year-old children detect social exclusion and if they prefer to affiliate with individuals who have been excluded over individuals who exclude others. Across 2 experiments, 2- and 3-year-old children (N = 140) viewed exclusive group interactions, in which 2 agents unjustly excluded 1 agent, and children were asked to choose whether they preferred to play with an excluded agent or an exclusive agent. Three-year-old children consistently preferred to play with the excluded agent, whereas 2-year-old children showed no preference. Three-year-old children did not show a preference among agents engaged in inclusive interactions and did not prefer an agent who refused to engage with a group, showing that 3-year-old children distinguish unjust exclusion from other types of interactions. Together, these findings suggest 3-year-old children detect social exclusion and are motivated to affiliate with unjustly excluded agents over those who exclude others, whereas these capacities are still developing in 2-year-old children.     

The treatment of neuropathic pain

Neuropathic pain is responsible for a significant amount of the morbidity associated with generalized and focal peripheral neuropathies. It is a consequence of alterations in neuronal function, chemistry, and structure that occur secondary to nerve injury. These manifestations of neuronal plasticity occur in the peripheral nerve, spinal cord, and brain. A variety of agents from diverse pharmacologic classes, the so-called adjuvant analgesics, have been used to treat neuropathic pain. These include antidepressants, first- and second-generation anticonvulsants, antiarrhythmic agents, topical agents, N-methyl-D-aspartate receptor antagonists, and opioid analgesics. The use of these adjuvant analgesics, either alone or in combination, should result in the alleviation of neuropathic pain in most patients. Recent advances in the understanding of pain mechanisms at multiple central nervous system levels should pave the way toward more effective treatment modalities.     

Environmental factors associated with a spectrum of neurodevelopmental deficits

A number of environmental agents have been shown to demonstrate neurotoxic effects either in human or laboratory animal studies. Critical windows of vulnerability to the effects of these agents occur both pre- and postnatally. The nervous system is relatively unique in that different parts are responsible for different functional domains, and these develop at different times (e.g., motor control, sensory, intelligence and attention). In addition, the many cell types in the brain have different windows of vulnerability with varying sensitivities to environmental agents. This review focuses on two environmental agents, lead and methylmercury, to illustrate the neurobehavioral and cognitive effects that can result from early life exposures. Special attention is paid to distinguishing between the effects detected following episodes of poisoning and those detected following lower dose exposures. Perinatal and childhood exposure to high doses of lead results in encephalopathy and convulsions. Lower-dose lead exposures have been associated with impairment in intellectual function and attention. At high levels of prenatal exposure, methylmercury produces mental retardation, cerebral palsy and visual and auditory deficits in children of exposed mothers. At lower levels of methylmercury exposure, the effects in children have been more subtle. Other environmental neurotoxicants that have been shown to produce developmental neurotoxicity include polychlorinated biphenyls (PCBs), dioxins, pesticides, ionizing radiation, environmental tobacco smoke, and maternal use of alcohol, tobacco, marijuana and cocaine. Exposure to environmental agents with neurotoxic effects can result in a spectrum of adverse outcomes from severe mental retardation and disability to more subtle changes in function depending on the timing and dose of the chemical agent.     

Learning to Manipulate and Categorize in Human and Artificial Agents

This study investigates the acquisition of integrated object manipulation and categorization abilities through a series of experiments in which human adults and artificial agents were asked to learn to manipulate two‐dimensional objects that varied in shape, color, weight, and color intensity. The analysis of the obtained results and the comparison of the behavior displayed by human and artificial agents allowed us to identify the key role played by features affecting the agent/environment interaction, the relation between category and action development, and the role of cognitive biases originating from previous knowledge.     

论医生的双重角色及其激励相容

在医患关系中,医生充当着双重角色,不仅作为患者的代理人或顾问为患者利益着想,同时也作为医疗服务的提供者为自己的利益着想。在这种双重角色下极易发生供者诱导需求,并进而导致过度医疗与医疗费用的上升。因此,有必要在支付机制、成本费用约束和外在监督等方面实现对医生的激励相容,以规范医疗行为,切实降低医疗费用。     

IDENTIFICATION OF BRIEF PRESENTATIONS OF FACIAL EXPRESSIONS OF AFFECTS IN SCHIZOPHRENICS

Two experiments were designed to test information extraction capacity from briefly shown photographs depicting simple familiar objects and facial/affective stimuli. Photographs were presented tachistoscopically at six exposure times, 1 sec, 200 msec, 40 msec, 20 msec, 4 msec, 2 msec, to chronic schizophrenic patients, general medical patients, and nonpatient control subjects. Experiment 1 was conducted using the number of correct responses (true scores) and experiment 2 using the number of trials taken (error scores) to identify the target stimuli, as the dependent measures. In experiment 1, schizophrenics did not differ from general medical patients but both were inferior to nonpatient controls in identifying brief visual stimuli. However, in experiment 2, schizophrenics required significantly more trials than general medical patients, who in turn required significantly more trials than nonpatient controls in identifying brief visual stimuli.     

A review of the treatment for refractory obsessive-compulsive disorder: from medicine to deep brain stimulation

This article provides an overview of the etiology, epidemiology, and first-line treatment options for obsessive-compulsive disorder (OCD). The subject of treatment-resistant and treatment-refractory OCD is then discussed, including a definition of these often-debated terms, and the latest treatment options delineated. This includes a review of the latest research concerning the pharmacological agents that have been studied as monotherapy or augmenting agents for the treatment of OCD, the use of experimental medications and procedures, treatment with reversible, minimally invasive procedures, such as vagal nerve stimulation and transcranial magnetic stimulation, invasive but the potentially reversible deep brain stimulation, and irreversible lesioning with ablative psychosurgery. A discussion of the role of psychotherapy in the treatment of OCD is also included.     

New anticonvulsant medication uses in bipolar disorder

Therapy of bipolar disorders is a rapidly evolving field. Lithium has efficacy in classic bipolar disorders whereas divalproex sodium and carbamazepine may have broader spectrum efficacy that includes non-classic bipolar disorder. In the last 10 years, a series of anticonvulsants have been approved for marketing in the United States. Gabapentin has indirect g-aminobuytric acid-ergic actions, is generally well tolerated, and appears to have anxiolytic, analgesic, and hypnotic effects. Lamotrigine has antiglutamatergic actions and is generally well tolerated (aside from rash in 1 in 10, and serious rash in 1 in 1,000 patients). Lamotrigine is indicated for maintenance treatment in bipolar disorder. Emerging evidence suggests lamotrigine may have utility in bipolar disorder patients with depression and treatment-refractory rapid cycling, as well as analgesic effects. Topiramate and zonisamide may allow both weight loss, while topiramate may have specific efficacy in bulimia, binge eating disorder, and alcohol dependence. Two small studies found oxcarbazepine had similar efficacy to lithium and haloperidol in acute mania. Phenytoin, an older anticonvulsant, may have adjunctive acute mania efficacy. Levetiracetam, a newer anticonvulsant, may be worth exploring and has minimal drug-drug interactions. None of these newer agents has been shown effective in a large placebo controlled trial for acute mania. Although the clinical profiles of these newer anticonvulsants do not appear to overlap markedly with divalproex and carbamazepine (except perhaps for oxcarbazepine), these novel agents may still offer important new options in relieving a variety of specific target symptoms in patients with bipolar disorder.     

Attribution of beliefs by 13-month-old infants

In two experiments, we investigated whether 13-month-old infants expect agents to behave in a way that is consistent with information to which they have been exposed. Infants watched animations in which an animal was either provided information or prevented from gathering information about the actual location of an object. The animal then searched successfully or failed to retrieve the object. Infants' looking times suggest that they expected searches to be effective when--and only when--the agent had had access to the relevant information. This result supports the view that infants possess an incipient metarepresentational ability that permits them to attribute beliefs to agents. We discuss the viability of more conservative explanations and the relation between this early ability and later forms of theory of mind that appear only after children have become experienced verbal communicators.     

Learning data-driven decision-making policies in multi-agent environments for autonomous systems

Autonomous systems such as Connected Autonomous Vehicles (CAVs), assistive robots are set improve the way we live. Autonomous systems need to be equipped with capabilities to Reinforcement Learning (RL) is a type of machine learning where an agent learns by interacting with its environment through trial and error, which has gained significant interest from research community for its promise to efficiently learn decision making through abstraction of experiences. However, most of the control algorithms used today in current autonomous systems such as driverless vehicle prototypes or mobile robots are controlled through supervised learning methods or manually designed rule-based policies. Additionally, many emerging autonomous systems such as driverless cars, are set in a multi-agent environment, often with partial observability. Learning decision making policies in multi-agent environments is a challenging problem, because the environment is not stationary from the perspective of a learning agent, and hence the Markov properties assumed in single agent RL does not hold. This paper focuses on learning decision-making policies in multi-agent environments, both in cooperative settings with full observability and dynamic environments with partial observability. We present experiments in simple, yet effective, new multi-agent environments to simulate policy learning in scenarios that could be encountered by an autonomous navigating agent such as a CAV. The results illustrate how agents learn to cooperate in order to achieve their objectives successfully. Also, it was shown that in a partially observable setting, an agent was capable of learning to roam around its environment without colliding in the presence of obstacles and other moving agents. Finally, the paper discusses how data-driven multi-agent policy learning can be extended to real-world environments by augmenting the intelligence of autonomous vehicles.     

Glutamate as a transmitter in the CNS and its presumed significance in the pathogenesis of cerebral seizure forms--recent aspects

Glutamate is believed to be quantitatively the most outstanding of the excitatory transmitters in the CNS. Certain conformationally related analogues, e. g. kainate, N-methyl-D-aspartate, ibotenate, and homocysteate, act as glutamate agonists. The local or systemic administration of these "excitotoxic" compounds induces epileptiform activity pointing out new and deeper insights into the epileptic process. Additionally, the glutamate transmitter hypothesis is expected to give a chance of a causal comprehension for choreatic processes as well as for the mode of action of anticonvulsant and antispastic agents.