Micro-CT analyses of historical bone samples presenting with osteomyelitis

OBJECTIVE

Osteomyelitis is an inflammation of the bone marrow mainly caused by bacteria such as Staphylococcus aureus. It typically affects long bones, e.g. femora, tibiae and humeri. Recently micro-computed tomography (μCT) techniques offer the opportunity to investigate bone micro-architecture in great detail. Since there is no information on long bone microstructure in osteomyelitis, we studied historic bone samples with osteomyelitis by μCT.

MATERIALS AND METHODS

We investigated 23 femora of 22 individuals suffering from osteomyelitis provided by the Collection of Anatomical Pathology, Museum of Natural History, Vienna (average age 44 ±19 years); 9 femora from body donors made available by the Department of Applied Anatomy, Medical University of Vienna (age range, 56-102 years) were studied as controls. Bone microstructure was assessed by μCT VISCOM X 8060 II with a minimal resolution of 18 μm.

RESULTS

In the osteomyelitic femora, most prominent alterations were seen in the cortical compartment. In 71.4% of the individuals with osteomyelitis, cortical porosity occurred. 57.1% of the individuals showed cortical thinning. In 42.9% trabecularisation of cortical bone was observed.

CONCLUSION

Osteomyelitis is associated with severe alterations of cortical bone structure otherwise typically observed at old age such as cortical porosity and cortical thinning.

A functional polymorphism in the prodynorphin gene affects cognitive flexibility and brain activation during reversal learning

Whether the opioid system plays a role in the ability to flexibly adapt behavior is still unclear. We used fMRI to investigate the effect of a nucleotide tandem repeat (68-bp VNTR) functional polymorphism of the prodynorphin (PDYN) gene on cerebral activation during a reversal learning task in which participants had to flexibly adapt stimulus-response associations. Past studies suggested that alleles with 3 or 4 repeats (HH genotype) of this polymorphism are associated with higher levels of dynorphin peptides than alleles with 1 or 2 repeats (LL genotype). On the behavioral level, the HH group made more perseverative errors than the LL group. On the neural level, the HH group demonstrated less engagement of left orbitofrontal cortex (lOFC) and cortico-striatal circuitry, and lower effective connectivity of lOFC with anterior midcingulate cortex and anterior insula/ventrolateral prefrontal cortex during reversal learning and processing negative feedback. This points to a lower ability of the HH genotype to monitor or adapt to changes in reward contingencies. These findings provide first evidence that dynorphins may contribute to individual differences in reversal learning, and that considering the opioid system may shed new light on the neurochemical correlates of decision-making and behavioral regulation.

Item Response Model Investigation of the (German) Interpersonal Reactivity Index Empathy Questionnaire

Abstract. The interpersonal reactivity index (IRI) is a widely used personality questionnaire for measuring empathy. We investigated the psychometric properties of the German version using the partial credit model. If this model fits the data, the raw-scores are fair measures of the latent construct. Only in such a case, further analyses based on the raw-scores are accurate and valid. The results showed model fit only for the subscale empathic concern. The subscales perspective taking and fantasy consisted of two theoretically explainable sub-dimensions. For the subscale personal distress, no model fit could be achieved. Our study provides important information on the psychometric qualities of the IRI that has been repeatedly used to assess, for example, group differences. It demonstrates that these analyses were not warranted by the psychometric quality of the questionnaire. Our results provide direct suggestions (e.g., theoretically explainable sub-dimensions) for further developments of the IRI to overcome this limitation.

Neuroanatomical profiles of alexithymia dimensions and subtypes

Alexithymia, a major risk factor for a range of psychiatric and neurological disorders, has been recognized to comprise two dimensions, a cognitive dimension (difficulties identifying, analyzing, and verbalizing feelings) and an affective one (difficulties emotionalizing and fantasizing). Based on these dimensions, the existence of four distinct alexithymia subtypes has been proposed, but never empirically tested. In this study, 125 participants were assigned to four groups corresponding to the proposed alexithymia subtypes: Type I (impairment on both dimensions), Type II (impairment on the cognitive, but not the affective dimension), Type III (impairment on the affective, but not the cognitive dimension), and Lexithymics (no impairment on either dimension). By means of voxel-based morphometry, associations of the alexithymia dimensions and subtypes with gray and white matter volumes were analyzed. Type I and Type II alexithymia were characterized by gray matter volume reductions in the left amygdala and the thalamus. The cognitive dimension was further linked to volume reductions in the right amygdala, left posterior insula, precuneus, caudate, hippocampus, and parahippocampus. Type III alexithymia was marked by volume reduction in the MCC only, and the affective dimension was further characterized by larger sgACC volume. Moreover, individuals with the intermediate alexithymia Types II and III showed gray matter volume reductions in distinct regions, and had larger corpus callosum volumes compared to Lexithymics. These results substantiate the notion of a differential impact of the cognitive and affective alexithymia dimensions on brain morphology and provide evidence for separable neuroanatomical representations of the different alexithymia subtypes.

Depressive Symptoms are the Main Predictor for Subjective Sleep Quality in Patients with Mild Cognitive Impairment--A Controlled Study

Objective

Controlled data on predictors of subjective sleep quality in patients with memory complaints are sparse. To improve the amount of comprehensive data on this topic, we assessed factors associated with subjective sleep quality in patients from our memory clinic and healthy individuals.

Methods

Between February 2012 and August 2014 patients with mild cognitive impairment (MCI) and subjective cognitive decline (SCD) from our memory clinic and healthy controls were recruited. Apart from a detailed neuropsychological assessment, the subjective sleep quality, daytime sleepiness and depressive symptoms were assessed using the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS) and the Beck Depression Inventory (BDI-II).

Results

One hundred fifty eight consecutive patients (132 (84%) MCI patients and 26 (16%) SCD patients) and 75 healthy controls were included in the study. Pairwise comparison of PSQI scores showed that non-amnestic MCI (naMCI) patients (5.4±3.5) had significantly higher PSQI scores than controls (4.3±2.8, p = .003) Pairwise comparison of PSQI subscores showed that naMCI patients (1.1±0.4) had significantly more “sleep disturbances” than controls (0.9±0.5, p=.003). Amnestic MCI (aMCI) (0.8±1.2, p = .006) and naMCI patients (0.7±1.2, p = .002) used “sleep medication” significantly more often than controls (0.1±0.6) Both, aMCI (11.5±8.6, p<.001) and naMCI (11.5±8.6, p<.001) patients showed significantly higher BDI-II scores than healthy controls (6.1±5.3). Linear regression analysis showed that the subjective sleep quality was predicted by depressive symptoms in aMCI (p<.0001) and naMCI (p<.0001) patients as well as controls (p<.0001). This means, that more depressive symptoms worsened subjective sleep quality. In aMCI patients we also found a significant interaction between depressive symptoms and global cognitive function (p = .002)

Discussion

Depressive symptoms were the main predictor of subjective sleep quality in MCI patients and controls, but not in SCD patients. Better global cognitive function ameliorated the negative effect of depressive symptoms on the subjective sleep quality in aMCI patients.

Visuo-constructional functions in patients with mild cognitive impairment, Alzheimer's disease, and Parkinson's disease

BACKGROUND

Several recently proposed criteria for assessing cognitive disorder require measuring the cognitive domain of visuo-constructional function. The aims of the present study were to develop a new test (Vienna Visuo-constructional Test-VVT) measuring visuo-constructional functions and to determine the reliability and validity of the VVT in patients with mild cognitive impairment (MCI), Parkinson's disease (PD), and Alzheimer's disease (AD). We further examined age and sex effects and the psychometric quality of the VVT.

METHODS

The study included 76 healthy controls and 103 patients who were referred to the Department of Neurology, Medical University of Vienna for neurocognitive assessment. An administering and scoring system for the VVT was developed.

RESULTS

Internal consistency (Cronbach's alpha) was found to range from 0.82 for the healthy control group to 0.93 for the total patient group. There was no sex effect, but age had a negative effect on VVT performance. The VVT successfully differentiated healthy controls from MCI patients, AD patients, and PD patients, respectively.

CONCLUSION

The VVT shows satisfactory validity and reliability and can be administered easily in clinical practice. It constitutes a new measure that can successfully be used to identify visuo-constructional problems in patients with cognitive dysfunction.

Distinct neural processes are engaged in the modulation of mimicry by social group-membership and emotional expressions

People often spontaneously engage in copying each other's postures and mannerisms, a phenomenon referred to as behavioral mimicry. Social psychology experiments indicate that mimicry denotes an implicit affiliative signal flexibly regulated in response to social requirements. Yet, the mediating processes and neural underpinnings of such regulation are largely unexplored. The present functional magnetic resonance imaging (fMRI) study examined mimicry regulation by combining an automatic imitation task with facial stimuli, varied on two social-affective dimensions: emotional expression (angry vs happy) and ethnic group membership (in- vs out-group). Behavioral data revealed increased mimicry when happy and when out-group faces were shown. Imaging results revealed that mimicry regulation in response to happy faces was associated with increased activation in the right temporo-parietal junction (TPJ), right dorsal premotor cortex (dPMC), and right superior parietal lobule (SPL). Mimicry regulation in response to out-group faces was related to increased activation in the left ventral premotor cortex (vPMC) and inferior parietal lobule (IPL), bilateral anterior insula, and mid-cingulate cortex (MCC). We suggest that mimicry in response to happy and to out-group faces is driven by distinct affiliative goals, and that mimicry regulation to attain these goals is mediated by distinct neuro-cognitive processes. Higher mimicry in response to happy faces seems to denote reciprocation of an affiliative signal. Higher mimicry in response to out-group faces, reflects an appeasement attempt towards an interaction partner perceived as threatening (an interpretation supported by implicit measures showing that out-group members are more strongly associated with threat). Our findings show that subtle social cues can result in the implicit regulation of mimicry. This regulation serves to achieve distinct affiliative goals, is mediated by different regulatory processes, and relies on distinct parts of an overarching network of task-related brain areas. Our findings shed new light on the neural mechanisms underlying the interplay between implicit action control and social cognition.

Distinct neural networks underlying empathy for pleasant and unpleasant touch

In spite of considerable progress in the understanding of the neural mechanisms underlying the experience of empathy, the majority of previous investigations have focused on how we share negative affective states (and in particular pain) of others, whereas only few studies have targeted empathy for positive emotions. This bias has precluded addressing one of the central tenets of the shared representations account of empathy, which is that different networks should be engaged when empathizing with emotions that are represented on different neural levels. The aim of the present study was to overcome this limitation and to test whether empathy for pleasant and unpleasant affective touch is underpinned by different neural networks. To this end we used functional magnetic resonance imaging (fMRI), with two independent replication experiments (N = 18, N = 32), and a novel paradigm enabling the joint investigation of first-hand and vicarious responses to pleasant and unpleasant affect induced via visuo-tactile stimulation. This revealed that empathy is subserved by distinct neural networks, with those regions recruited in the first-hand experience of positive or negative affective states also being specifically recruited when empathizing with these respective states in others. More specifically, the first-hand and vicarious experience of pleasant touch commonly recruited medial orbitofrontal cortex (OFC), while unpleasant touch was associated with shared activation in the right fronto-insular cortex. The observation that specifically tailored subsystems of the human brain are engaged to share positive versus negative touch of others brings fresh evidence to one of the major goals of the social neuroscience of empathy: to identify which specific aspects of the affective states of others are shared, and what role this plays in enabling the understanding of the emotions of others.

Affective empathy differs in male violent offenders with high- and low-trait psychopathy

This study investigated affective and cognitive empathic processes in incarcerated violent offenders with lower and higher psychopathic traits and healthy controls. Participants witnessed painful expressions of others displayed on video clips. Skin conductance responses (SCR) were recorded to assess autonomic emotional arousal, and various empathy ratings were used as measures of self-reported vicarious responses. Reduced SCRs occurred during the observation of pain in others in lower and higher psychopathic-trait participants alike, compared to controls. Despite these diminished autonomic responses indicating reduced vicarious responses, only inmates with higher psychopathic traits provided empathy ratings comparable to those of the controls. These findings indicate that violent offenders display reduced autonomic arousal in response to distress cues of others, irrespective of psychopathy. However, only higher psychopathic-trait offenders were able to provide self-report in a way that let them appear to be as empathic as controls-enabling them to know, yet not to feel, what others feel.

Context-sensitivity of the feedback-related negativity for zero-value feedback outcomes

The present study investigated whether the same visual stimulus indicating zero-value feedback (€0) elicits feedback-related negativity (FRN) variation, depending on whether the outcomes correspond with expectations or not. Thirty-one volunteers performed a monetary incentive delay (MID) task while EEG was recorded. FRN amplitudes were comparable and more negative when zero-value outcome deviated from expectations than with expected gain or loss, supporting theories emphasising the impact of unexpectedness and salience on FRN amplitudes. Surprisingly, expected zero-value outcomes elicited the most negative FRNs. However, source localisation showed that such outcomes evoked less activation in cingulate areas than unexpected zero-value outcomes. Our study illustrates the context dependency of identical zero-value feedback stimuli. Moreover, the results indicate that the incentive cues in the MID task evoke different reward prediction error signals. These prediction signals differ in FRN amplitude and neuronal sources, and have to be considered in the design and interpretation of future studies.

Beta oscillations reveal ethnicity ingroup bias in sensorimotor resonance to pain of others

People evaluate members of their own social group more favorably and empathize more strongly with their ingroup members. Using electroencephalography (EEG), we explored whether resonant responses of sensorimotor cortex to the pain of others are modulated by the ethnicity of these others. White participants watched video clips of ethnic ingroup and outgroup hands, being either penetrated by a needle syringe or touched by a cotton swab, while EEG was recorded. Time-frequency analysis was applied to Laplacian-transformed signals from the sensors overlying sensorimotor cortex in order to assess event-related desynchronization and synchronization (ERD/ERS) of sensorimotor mu (7-12 Hz) and beta (13-30 Hz) rhythms. When watching needle injections, beta ERD was significantly stronger for ingroup compared with outgroup hands. This ethnicity bias was restricted to painful actions, as beta ERD for ingroup and outgroup hands neither differed when observing no-pain videos, nor during presentation of the hands without any treatment. Such vicarious sensorimotor activation could play a role in social interaction by enhancing the understanding of the feelings and reactions of others and hence facilitating behavioral coordination among group members.

Uncertainty during pain anticipation: the adaptive value of preparatory processes

OBJECTIVES

Anticipatory processes prepare the organism for upcoming experiences. The aim of this study was to investigate neural responses related to anticipation and processing of painful stimuli occurring with different levels of uncertainty.

EXPERIMENTAL DESIGN

Twenty-five participants (13 females) took part in an electroencephalography and functional magnetic resonance imaging (fMRI) experiment at separate times. A visual cue announced the occurrence of an electrical painful or nonpainful stimulus, delivered with certainty or uncertainty (50% chance), at some point during the following 15 s.

PRINCIPAL OBSERVATIONS

During the first 2 s of the anticipation phase, a strong effect of uncertainty was reflected in a pronounced frontal stimulus-preceding negativity (SPN) and increased fMRI activation in higher visual processing areas. In the last 2 s before stimulus delivery, we observed stimulus-specific preparatory processes indicated by a centroparietal SPN and posterior insula activation that was most pronounced for the certain pain condition. Uncertain anticipation was associated with attentional control processes. During stimulation, the results revealed that unexpected painful stimuli produced the strongest activation in the affective pain processing network and a more pronounced offset-P2.

CONCLUSIONS

Our results reflect that during early anticipation uncertainty is strongly associated with affective mechanisms and seems to be a more salient event compared to certain anticipation. During the last 2 s before stimulation, attentional control mechanisms are initiated related to the increased salience of uncertainty. Furthermore, stimulus-specific preparatory mechanisms during certain anticipation also shaped the response to stimulation, underlining the adaptive value of stimulus-targeted preparatory activity which is less likely when facing an uncertain event.

Focused transcranial direct current stimulation (tDCS) over the dorsolateral prefrontal cortex modulates specific domains of self-regulation

Recent neuroscience theories suggest that different kinds of self-regulation may share a common psychobiological mechanism. However, empirical evidence for a domain general self-regulation mechanism is scarce. The aim of this study was to investigate whether focused anodal transcranial direct current stimulation (tDCS), facilitating the activity of the dorsolateral prefrontal cortex (dlPFC), acts on a domain general self-regulation mechanism and thus modulates both affective and appetitive self-regulation. Twenty smokers participated in this within-subject sham controlled study. Effects of anodal left, anodal right and sham tDCS over the dlPFC on affective picture appraisal and nicotine craving-cue appraisal were assessed. Anodal right tDCS over the dlPFC reduced negative affect in emotion appraisal, but neither modulated regulation of positive emotion appraisal nor of craving appraisal. Anodal left stimulation did not induce any significant effects. The results of our study show that domain specific self-regulation networks are at work in the prefrontal cortex. Focused tDCS modulation of this specific self-regulation network could probably be used during the first phase of nicotine abstinence, during which negative affect might easily result in relapse. These findings have implications for neuroscience models of self-regulation and are of relevance for the development of brain stimulation based treatment methods for neuropsychiatric disorders associated with self-regulation deficits.

Is stress affecting our ability to tune into others? Evidence for gender differences in the effects of stress on self-other distinction

Stress is a ubiquitous challenge in society as we consistently interact with others under the influence of stress. Distinguishing self- from other-related mental representations plays an important role for social interactions, and is a prerequisite for crucial social skills such as action understanding, empathy, and mentalizing. Little is known, however, about the effects of stress on self-other distinction. We assessed how acute stress impacts self-other distinction in the perceptual-motor, the affective, and the cognitive domain, in a male and female sample. In all domains, the results show opposing effects of stress on the two genders: while women showed increases in self-other distinction, men showed decreases. Our findings suggest that women flexibly disambiguate self and other under stress, enabling accurate social responses, while men respond with increased egocentricity and less adaptive regulation. This has crucial implications for explaining gender differences in social skills such as empathy and prosociality.

Congenital lymphangiomatosis and an enteric duplication cyst in a young dog

A two-year-old female poodle with abdominal distention was diagnosed with concurrent enteric duplication cyst and lymphangiomatosis. Both lesions were shown as cystic structures, but some characteristic features of enteric duplication cyst were identified including a thick cyst wall and shared blood supply with the duodenum. Although it was challenging to discriminate between the types of cyst based on diagnostic imaging, this report describes the characteristics of each type of lesion using several different imaging modalities.

A genetic polymorphism of the endogenous opioid dynorphin modulates monetary reward anticipation in the corticostriatal loop

The dynorphin/κ-opioid receptor (KOP-R) system has been shown to play a role in different types of behavior regulation, including reward-related behavior and drug craving. It has been shown that alleles with 3 or 4 repeats (HH genotype) of the variable nucleotide tandem repeat (68-bp VNTR) functional polymorphism of the prodynorphin (PDYN) gene are associated with higher levels of dynorphin peptides than alleles with 1 or 2 repeats (LL genotype). We used fMRI on N = 71 prescreened healthy participants to investigate the effect of this polymorphism on cerebral activation in the limbic-corticostriatal loop during reward anticipation. Individuals with the HH genotype showed higher activation than those with the LL genotype in the medial orbitofrontal cortex (mOFC) when anticipating a possible monetary reward. In addition, the HH genotype showed stronger functional coupling (as assessed by effective connectivity analyses) of mOFC with VMPFC, subgenual anterior cingulate cortex, and ventral striatum during reward anticipation. This hints at a larger sensitivity for upcoming rewards in individuals with the HH genotype, resulting in a higher motivation to attain these rewards. These findings provide first evidence in humans that the PDYN polymorphism modulates neural processes associated with the anticipation of rewards, which ultimately may help to explain differences between genotypes with respect to addiction and drug abuse.

T-lymphocyte-rich thymoma and myasthenia gravis in a Siberian tiger (Panthera tigris altaica)

A 10-year-old captive male Siberian tiger (Panthera tigris altaica) presented with acute onset collapse, vomiting and dyspnoea, preceded by a 6-month period of progressive muscle wasting. Following humane destruction, post-mortem examination revealed a large multilobulated mass in the cranial mediastinum, which was diagnosed as a T-lymphocyte-rich thymoma with the aid of immunohistochemistry. Retrospective serology for acetylcholine receptor antibodies (titre 3.90 nmol/l) confirmed a diagnosis of thymoma-associated myasthenia gravis. Thymomas are reported rarely in wild carnivores, but when detected they appear to be similar in morphology to those seen in domestic carnivores and may also be accompanied by paraneoplastic syndromes. The clinical signs of myasthenia gravis in the tiger were consistent with those reported in cats and dogs and the condition is proposed as an important differential diagnosis for generalized weakness in captive Felidae.

The impact of social exclusion vs. inclusion on subjective and hormonal reactions in females and males

BACKGROUND

The experience of social exclusion represents an extremely aversive and threatening situation in daily life. The present study examined the impact of social exclusion compared to inclusion on steroid hormone concentrations as well as on subjective affect ratings.

METHODS

Eighty subjects (40 females) participated in two independent behavioral experiments. They engaged in a computerized ball tossing game in which they ostensibly played with two other players who deliberately excluded or included them, respectively. Hormone samples as well as mood ratings were taken before and after the game.

RESULTS

Social exclusion led to a decrease in positive mood ratings and increased anger ratings. In contrast, social inclusion did not affect positive mood ratings, but decreased sadness ratings. Both conditions did not affect cortisol levels. Testosterone significantly decreased after being excluded in both genders, and increased after inclusion, but only in males. Interestingly, progesterone showed an increase after both conditions only in females.

DISCUSSION

Our results suggest that social exclusion does not trigger a classical stress response but gender-specific changes in sex hormone levels. The testosterone decrease after being excluded in both genders, as well as the increase after inclusion in males can be interpreted within the framework of the biosocial status hypothesis. The progesterone increase might reflect a generalized affiliative response during social interaction in females.

Transcranial magnetic stimulation of the left dorsolateral prefrontal cortex decreases cue-induced nicotine craving and EEG delta power

BACKGROUND

TMS has high potential as smoking cessation treatment. However, the neural mechanisms underlying TMS induced reduction of tobacco craving remain unclear. Electroencephalographic (EEG) delta frequency has been associated with the activity of the dopaminergic brain reward system, which is crucial for nicotine induced effects, and decreases after nicotine admission in smokers.

OBJECTIVE

The aim of this study was to investigate EEG delta power changes induced by hf rTMS of the left dorsolateral prefrontal cortex (DLPFC) in nicotine deprived smokers and it's relation to cue-induced nicotine craving.

METHODS

Fourteen healthy smokers meeting ICD-10 criteria for tobacco addiction participated in this within-subject sham controlled study. Participants had to abstain from smoking 6 h before the experiment. Effects of high-frequency repetitive TMS (hf rTMS) (10 Hz) for verum (left DLPFC) and sham (vertex) stimulations on cue-induced nicotine craving and resting state EEG delta power were assessed before and three times within 40 min after rTMS.

RESULTS

Both craving (P = 0.046) and EEG delta power (P = 0.048) were significantly lower after verum stimulation compared to sham stimulation across the whole post stimulation time period assessed. However, changes of craving ratings and delta power did not correlate.

CONCLUSION

Hf rTMS applied to the left DLPFC reduces nicotine craving in short-term abstinent smokers. Changes in delta activity support the idea that stimulation induced effects are mediated by the dopaminergic brain reward system, which presumably plays a prominent, but probably not exclusive, role in this stimulation induced behavioral modulation, making this method a promising smoking cessation treatment candidate.

Blocked versus randomized presentation modes differentially modulate feedback-related negativity and P3b amplitudes

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ERP responses to feedback stimuli with explicit or assigned valence information were investigated with blocked or randomized trial presentation modes.

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Only P3b, but not feedback-related negativity amplitudes were affected by feedback type for both presentation modes.

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Results suggest using blocked design when using different types of feedback stimuli.

Objective

Electrophysiological studies on feedback processing typically use a wide range of feedback stimuli which might not always be comparable. The current study investigated whether two indicators of feedback processing – feedback-related negativity (FRN) and P3b – differ for feedback stimuli with explicit (facial expressions) or assigned valence information (symbols). In addition, we assessed whether presenting feedback in either a trial-by-trial or a block-wise fashion affected these ERPs.

Methods

EEG was recorded in three experiments while participants performed a time estimation task and received two different types of performance feedback.

Results

Only P3b amplitudes varied consistently in response to feedback type for both presentation types. Moreover, the blocked feedback type presentation yielded more distinct FRN peaks, higher effect sizes, and a significant relation between FRN amplitudes and behavioral task performance measures.

Conclusion

Both stimulus type and presentation mode may provoke systematic changes in feedback-related ERPs. The current findings point at important potential confounds that need to be controlled for when designing FRN or P3b studies.

Significance

Studies investigating P3b amplitudes using mixed types of stimuli have to be interpreted with caution. Furthermore, we suggest implementing a blocked presentation format when presenting different feedback types within the same experiment.