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Lu R, Michael E, Scrivener CL, Jackson JB, Duncan J, Woolgar A. Parietal alpha stimulation causally enhances attentional information coding in evoked and oscillatory activity. Brain Stimul 2025; 18:114-127. [PMID: 39778653 DOI: 10.1016/j.brs.2025.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Revised: 10/29/2024] [Accepted: 01/05/2025] [Indexed: 01/11/2025] Open
Abstract
BACKGROUND Selective attention is a fundamental cognitive mechanism that allows people to prioritise task-relevant information while ignoring irrelevant information. Previous research has suggested key roles of parietal event-related potentials (ERPs) and alpha oscillatory responses in attention tasks. However, the informational content of these signals is less clear, and their causal effects on the coding of multiple task elements are yet unresolved. OBJECTIVE To test the causal roles of alpha oscillations and ERPs in coding different types of attentional information (where to attend, what to attend to, and features of thevisual stimulus). METHODS We first used EEG to examine the temporal dynamics of alpha oscillations and ERPs in coding attentional information. Then, we applied rhythmic-TMS (rh-TMS) at individual alpha frequency over the right intraparietal sulcus (IPS), while concurrently measuring EEG, to causally manipulate parietal alpha power and ERPs and investigate their roles in coding multiple task features in a selective attention task. RESULTS EEG-only data suggested that ERPs coded all three types of task-relevant information with distinct temporal dynamics, while alpha oscillations carried information regarding both where to attend and what to attend to. TMS-EEG results indicated that, compared to arrhythmic-TMS, alpha rh-TMS increased alpha power and inter-trial phase coherence and yielded more negative posterior-contralateral ERPs. Moreover, alpha rh-TMS specifically and causally improved multivariate decoding of information about where to attend (but not what to attend to or visual feature information) during task performance, with decoding improvements predicting changes in behavioural performance. CONCLUSIONS These findings illuminate the dynamics with which the complementary aspects of a selective attention task are encoded in evoked and oscillatory brain activity. Moreover, they reveal a specific and causal role of IPS-controlled evoked and oscillatory activity in carrying behaviour-driving information exclusively about where to focus attention.
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Affiliation(s)
- Runhao Lu
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK.
| | - Elizabeth Michael
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Catriona L Scrivener
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK; School of Philosophy, Psychology and Language Sciences, University of Edinburgh, Edinburgh, UK
| | - Jade B Jackson
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - John Duncan
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Alexandra Woolgar
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK; Department of Psychology, University of Cambridge, Cambridge, UK
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Adámek P, Grygarová D, Jajcay L, Bakštein E, Fürstová P, Juríčková V, Jonáš J, Langová V, Neskoroďana I, Kesner L, Horáček J. The Gaze of Schizophrenia Patients Captured by Bottom-up Saliency. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:21. [PMID: 38378724 PMCID: PMC10879495 DOI: 10.1038/s41537-024-00438-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/19/2024] [Indexed: 02/22/2024]
Abstract
Schizophrenia (SCHZ) notably impacts various human perceptual modalities, including vision. Prior research has identified marked abnormalities in perceptual organization in SCHZ, predominantly attributed to deficits in bottom-up processing. Our study introduces a novel paradigm to differentiate the roles of top-down and bottom-up processes in visual perception in SCHZ. We analysed eye-tracking fixation ground truth maps from 28 SCHZ patients and 25 healthy controls (HC), comparing these with two mathematical models of visual saliency: one bottom-up, based on the physical attributes of images, and the other top-down, incorporating machine learning. While the bottom-up (GBVS) model revealed no significant overall differences between groups (beta = 0.01, p = 0.281, with a marginal increase in SCHZ patients), it did show enhanced performance by SCHZ patients with highly salient images. Conversely, the top-down (EML-Net) model indicated no general group difference (beta = -0.03, p = 0.206, lower in SCHZ patients) but highlighted significantly reduced performance in SCHZ patients for images depicting social interactions (beta = -0.06, p < 0.001). Over time, the disparity between the groups diminished for both models. The previously reported bottom-up bias in SCHZ patients was apparent only during the initial stages of visual exploration and corresponded with progressively shorter fixation durations in this group. Our research proposes an innovative approach to understanding early visual information processing in SCHZ patients, shedding light on the interplay between bottom-up perception and top-down cognition.
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Affiliation(s)
- Petr Adámek
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic.
- Third Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Dominika Grygarová
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lucia Jajcay
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic
- Institute of Computer Science of the Czech Academy of Sciences, Prague, Czech Republic
- Faculty of Electrical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Eduard Bakštein
- Early Episodes of SMI Research Center, National Institute of Mental Health, Klecany, Czech Republic
- Department of Cybernetics, Faculty of Electrical Engineering, Czech Technical University, Prague, Czech Republic
| | - Petra Fürstová
- Early Episodes of SMI Research Center, National Institute of Mental Health, Klecany, Czech Republic
| | - Veronika Juríčková
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic
- First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Juraj Jonáš
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic
- Faculty of Humanities, Charles University, Prague, Czech Republic
| | - Veronika Langová
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Iryna Neskoroďana
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic
| | - Ladislav Kesner
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic
- Department of Art History, Masaryk University, Brno, Czech Republic
| | - Jiří Horáček
- Center for Advanced Studies of Brain and Consciousness, National Institute of Mental Health, Klecany, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Constable PA, Loh L, Prem-Senthil M, Marmolejo-Ramos F. Visual search and childhood vision impairment: A GAMLSS-oriented multiverse analysis approach. Atten Percept Psychophys 2023; 85:968-977. [PMID: 36823260 PMCID: PMC10167137 DOI: 10.3758/s13414-023-02670-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/25/2023]
Abstract
The aim of this report was to analyze reaction times and accuracy in children with a vision impairment performing a feature-based visual search task using a multiverse statistical approach. The search task consisted of set sizes 4, 16, and 24, consisting of distractors (circle) and a target (ellipse) that were presented randomly to school-aged individuals with or without a vision impairment. Interactions and main effects of key variables relating to reaction times and accuracy were analyzed via a novel statistical method blending GAMLSS (generalized additive models for location, scale, and shape) and distributional regression trees. Reaction times for the target-present and target-absent conditions were significantly slower in the vision impairment group with increasing set sizes (p < .001). Female participants were significantly slower than were males for set sizes 16 and 24 in the target-absent condition (p < .001), with male participants being significantly slower than females in the target-present condition (p < .001). Accuracy was only significantly worse (p = .03) for participants less than 14 years of age for the target-absent condition with set sizes 16 and 24. There was a positive association between binocular visual acuity and search time (p < .001). The application of GAMLSS with distributional regression trees to the analysis of visual search data may provide further insights into underlying factors affecting search performance in case-control studies where psychological or physical differences may influence visual search outcomes.
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Affiliation(s)
- Paul A Constable
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, South Australia, Australia.
| | - Lynne Loh
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, South Australia, Australia
| | - Mallika Prem-Senthil
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, South Australia, Australia
| | - Fernando Marmolejo-Ramos
- Centre for Change and Complexity in Learning, The University of South Australia, Adelaide, South Australia, Australia
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Zhang Q, Luo C, Ngetich R, Zhang J, Jin Z, Li L. Visual Selective Attention P300 Source in Frontal-Parietal Lobe: ERP and fMRI Study. Brain Topogr 2022; 35:636-650. [PMID: 36178537 DOI: 10.1007/s10548-022-00916-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 09/03/2022] [Indexed: 11/28/2022]
Abstract
Visual selective attention can be achieved into bottom-up and top-down attention. Different selective attention tasks involve different attention control ways. The pop-out task requires more bottom-up attention, whereas the search task involves more top-down attention. P300, which is the positive potential generated by the brain in the latency of 300 ~ 600 ms after stimulus, reflects the processing of attention. There is no consensus on the P300 source. The aim of present study is to study the source of P300 elicited by different visual selective attention. We collected thirteen participants' P300 elicited by pop-out and search tasks with event-related potentials (ERP). We collected twenty-six participants' activation brain regions in pop-out and search tasks with functional magnetic resonance imaging (fMRI). And we analyzed the sources of P300 using the ERP and fMRI integration with high temporal resolution and high spatial resolution. ERP results indicated that the pop-out task induced larger P300 than the search task. P300 induced by the two tasks distributed at frontal and parietal lobes, with P300 induced by the pop-out task mainly at the parietal lobe and that induced by the search task mainly at the frontal lobe. Further ERP and fMRI integration analysis showed that neural difference sources of P300 were the right precentral gyrus, left superior frontal gyrus (medial orbital), left middle temporal gyrus, left rolandic operculum, right postcentral gyrus, and left angular gyrus. Our study suggests that the frontal and parietal lobes contribute to the P300 component of visual selective attention.
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Affiliation(s)
- Qiuzhu Zhang
- MOE Key Lab for Neuroinformation, High-Field Magnetic Resonance Brain Imaging Key Laboratory of Sichuan Province, Center for Psychiatry and Psychology, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054, China
| | - Cimei Luo
- MOE Key Lab for Neuroinformation, High-Field Magnetic Resonance Brain Imaging Key Laboratory of Sichuan Province, Center for Psychiatry and Psychology, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054, China
| | - Ronald Ngetich
- MOE Key Lab for Neuroinformation, High-Field Magnetic Resonance Brain Imaging Key Laboratory of Sichuan Province, Center for Psychiatry and Psychology, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054, China
| | - Junjun Zhang
- MOE Key Lab for Neuroinformation, High-Field Magnetic Resonance Brain Imaging Key Laboratory of Sichuan Province, Center for Psychiatry and Psychology, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054, China
| | - Zhenlan Jin
- MOE Key Lab for Neuroinformation, High-Field Magnetic Resonance Brain Imaging Key Laboratory of Sichuan Province, Center for Psychiatry and Psychology, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054, China
| | - Ling Li
- MOE Key Lab for Neuroinformation, High-Field Magnetic Resonance Brain Imaging Key Laboratory of Sichuan Province, Center for Psychiatry and Psychology, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610054, China.
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Perrottelli A, Giordano GM, Brando F, Giuliani L, Pezzella P, Mucci A, Galderisi S. Unveiling the Associations between EEG Indices and Cognitive Deficits in Schizophrenia-Spectrum Disorders: A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12092193. [PMID: 36140594 PMCID: PMC9498272 DOI: 10.3390/diagnostics12092193] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022] Open
Abstract
Cognitive dysfunctions represent a core feature of schizophrenia-spectrum disorders due to their presence throughout different illness stages and their impact on functioning. Abnormalities in electrophysiology (EEG) measures are highly related to these impairments, but the use of EEG indices in clinical practice is still limited. A systematic review of articles using Pubmed, Scopus and PsychINFO was undertaken in November 2021 to provide an overview of the relationships between EEG indices and cognitive impairment in schizophrenia-spectrum disorders. Out of 2433 screened records, 135 studies were included in a qualitative review. Although the results were heterogeneous, some significant correlations were identified. In particular, abnormalities in alpha, theta and gamma activity, as well as in MMN and P300, were associated with impairments in cognitive domains such as attention, working memory, visual and verbal learning and executive functioning during at-risk mental states, early and chronic stages of schizophrenia-spectrum disorders. The review suggests that machine learning approaches together with a careful selection of validated EEG and cognitive indices and characterization of clinical phenotypes might contribute to increase the use of EEG-based measures in clinical settings.
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Sklar AL, Coffman BA, Longenecker JM, Curtis M, Salisbury DF. Load-dependent functional connectivity deficits during visual working memory in first-episode psychosis. J Psychiatr Res 2022; 153:174-181. [PMID: 35820225 PMCID: PMC9846371 DOI: 10.1016/j.jpsychires.2022.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Aberrant network connectivity is a core deficit in schizophrenia and may underlie many of its associated cognitive deficits. Previous work in first-episode schizophrenia spectrum illness (FESz) suggests preservation of working memory network function during low-load conditions with dysfunction emerging as task complexity increases. This study assessed visual network connectivity and its contribution to load-dependent working memory impairments. METHODS Magnetoencephalography was recorded from 35 FESz and 28 matched controls (HC) during a lateralized change detection task. Impaired alpha desynchronization was previously identified within bilateral dorsal occipital (Occ) regions. Here, whole-brain alpha-band connectivity was examined using phase-locking (PLV) and bilateral Occ as connectivity seeds. Load effects on connectivity were assessed across participants, and PLV modulation within networks was compared between groups. RESULTS Occ exhibited significant load modulated connectivity with six regions (FDR-corrected). HC exhibited PLV enhancement with load in all connections. FESz failed to show PLV modulation between right Occ and left inferior frontal gyrus, lateral occipito-temporal sulcus, and anterior intermediate parietal sulcus. Smaller PLVs in all three network connections during both memory load conditions were associated with increased reality distortion in FESz (FDR-corrected.) CONCLUSION: Examination of functional connectivity across the visual working memory network in FESz revealed an inability to enhance communication between perceptual and executive networks in response to increasing cognitive demands. Furthermore, the degree of network communication impairment was associated with positive symptoms. These findings provide insights into the nature of brain dysconnectivity and its contribution to symptoms in early psychosis and identify potential targets for future interventions.
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Affiliation(s)
- Alfredo L Sklar
- Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian A Coffman
- Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julia M Longenecker
- Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VISN 4 Mental Illness Research Education and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Mark Curtis
- Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dean F Salisbury
- Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Francisco AA, Foxe JJ, Horsthuis DJ, Molholm S. Early visual processing and adaptation as markers of disease, not vulnerability: EEG evidence from 22q11.2 deletion syndrome, a population at high risk for schizophrenia. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2022; 8:28. [PMID: 35314711 PMCID: PMC8938446 DOI: 10.1038/s41537-022-00240-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/21/2022] [Indexed: 01/17/2023]
Abstract
We investigated visual processing and adaptation in 22q11.2 deletion syndrome (22q11.2DS), a condition characterized by an increased risk for schizophrenia. Visual processing differences have been described in schizophrenia but remain understudied early in the disease course. Electrophysiology was recorded during a visual adaptation task with different interstimulus intervals to investigate visual processing and adaptation in 22q11.2DS (with (22q+) and without (22q−) psychotic symptoms), compared to control and idiopathic schizophrenia groups. Analyses focused on early windows of visual processing. While increased amplitudes were observed in 22q11.2DS in an earlier time window (90–140 ms), decreased responses were seen later (165–205 ms) in schizophrenia and 22q+. 22q11.2DS, and particularly 22q−, presented increased adaptation effects. We argue that while amplitude and adaptation in the earlier time window may reflect specific neurogenetic aspects associated with a deletion in chromosome 22, amplitude in the later window may be a marker of the presence of psychosis and/or of its chronicity/severity.
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Affiliation(s)
- Ana A Francisco
- The Cognitive Neurophysiology Laboratory, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - John J Foxe
- The Cognitive Neurophysiology Laboratory, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neuroscience, Rose F. Kennedy Center, Albert Einstein College of Medicine, Bronx, NY, USA.,The Cognitive Neurophysiology Laboratory, Department of Neuroscience, The Ernest J. Del Monde Institute for Neuroscience, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Douwe J Horsthuis
- The Cognitive Neurophysiology Laboratory, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sophie Molholm
- The Cognitive Neurophysiology Laboratory, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA. .,Department of Neuroscience, Rose F. Kennedy Center, Albert Einstein College of Medicine, Bronx, NY, USA. .,The Cognitive Neurophysiology Laboratory, Department of Neuroscience, The Ernest J. Del Monde Institute for Neuroscience, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.
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Lack of neural load modulation explains attention and working memory deficits in first-episode schizophrenia. Clin Neurophysiol 2022; 136:206-218. [DOI: 10.1016/j.clinph.2022.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/29/2022] [Accepted: 02/02/2022] [Indexed: 11/23/2022]
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Sklar AL, Coffman BA, Salisbury DF. Fronto-parietal network function during cued visual search in the first-episode schizophrenia spectrum. J Psychiatr Res 2021; 141:339-345. [PMID: 34304038 PMCID: PMC8364882 DOI: 10.1016/j.jpsychires.2021.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/15/2021] [Accepted: 07/12/2021] [Indexed: 11/18/2022]
Abstract
Cognitive impairments account for significant morbidity in schizophrenia and are present at disease onset. Controlled processes are particularly susceptible and may contribute to pervasive selective attention deficits. The present study assessed fronto-parietal attention network (FPAN) functioning during cue presentation on a visual search task in first-episode schizophrenia spectrum patients (FE) and its relation to symptom burden and community functioning. Brain activity was recorded with magnetoencephalography from 38 FE and 38 healthy controls (HC) during blocks of pop-out and serial search target detection. Activity during cue presentation was compared between groups across bilateral FPAN regions (frontal eye fields (FEF), inferior frontal gyrus (IFG), midcingulate cortex (MCC), and intraparietal sulcus (IPS)). FE exhibited greater right hemisphere IFG activity despite worse performance relative to HC. Performance and FPAN activity were not correlated in HC. Among FE, however, stronger activity within right hemisphere FEF and IFG was associated with faster responses. Stronger right IPS and left IFG activity in patients was also associated with reduced negative symptoms and improved community functioning, respectively. Increased reliance on the FPAN for task completion suggests an inefficient cognitive control network and might reflect a compensation for impaired attentional deployment during target detection, a strategy employed by those with less severe illness. These findings represent a critical step towards identifying the neural substrates of negative symptoms and impaired neurocognition at disease onset.
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Affiliation(s)
- Alfredo L Sklar
- Clinical Neurophysiology Research Laboratory, Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian A Coffman
- Clinical Neurophysiology Research Laboratory, Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dean F Salisbury
- Clinical Neurophysiology Research Laboratory, Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Western Psychiatric Hospital, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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