Does an aptitude for surgery exist and can we predict it? an experimental study

BACKGROUND

The selection and allocation of surgeons with a greater potential for high surgical performance are essential aspects of improving the quality, safety and effectiveness of surgical procedures. Objective of this trial was to determine the existence of basic skills and traits that would predict better performance in surgery, and those predictive factors that constitute a driving force in different stages of training.

MATERIALS AND METHODS

The randomized crossover training trial took place from January 2021 to December 2021 and was conducted at an educational training center for minimally invasive surgery. A total of n=87 physicians (residents and experts) from surgical disciplines and n=239 fifth-year medical students were studied. The participants underwent extensive neuropsychological testing and surgical training, which was performed with conventional as well as robot-assisted laparoscopy by way of identical brief tasks conducted six times in a randomized crossover setting. Main Outcome was the latent factor structure of "psychomotor skills", "personality" and "motivation" based on structural equation modeling.

RESULTS

The training performance of both students and physicians was significantly explained by the interaction of the three factors (explained variance: 8.2% for students, 23.8% for physicians). In students, motivation (explained variance 8.4%) and personality (explained variance 4.5%) revealed the highest contribution to surgical training performance (explained variance through psychomotor skills 1.1%). In physicians, psychomotor skills (explained variance 27.4%) made the greatest contribution to surgical training performance (explained variance through motivation 2.3%; explained variance through personality 10.5%).

CONCLUSION

The study showed that surgical performance is sensitive to, and fragile in regard of non-surgery-related general individual traits. This aligns with the notion that early selection of surgeons with prospects of high surgical performance is possible, and perhaps even necessary in order to keep up with future demands on the medical system.

The impact of psychosocial adversity on brain and behaviour: an overview of existing knowledge and directions for future research

Environmental experiences play a critical role in shaping the structure and function of the brain. Its plasticity in response to different external stimuli has been the focus of research efforts for decades. In this review, we explore the effects of adversity on brain's structure and function and its implications for brain development, adaptation, and the emergence of mental health disorders. We are focusing on adverse events that emerge from the immediate surroundings of an individual, i.e., microenvironment. They include childhood maltreatment, peer victimisation, social isolation, affective loss, domestic conflict, and poverty. We also take into consideration exposure to environmental toxins. Converging evidence suggests that different types of adversity may share common underlying mechanisms while also exhibiting unique pathways. However, they are often studied in isolation, limiting our understanding of their combined effects and the interconnected nature of their impact. The integration of large, deep-phenotyping datasets and collaborative efforts can provide sufficient power to analyse high dimensional environmental profiles and advance the systematic mapping of neuronal mechanisms. This review provides a background for future research, highlighting the importance of understanding the cumulative impact of various adversities, through data-driven approaches and integrative multimodal analysis techniques.

Altered frontolimbic activity during virtual reality-based contextual fear learning in patients with posttraumatic stress disorder

BACKGROUND

Deficiency in contextual and enhanced responding in cued fear learning may contribute to the development of posttraumatic stress disorder (PTSD). We examined the responses to aversive Pavlovian conditioning with an unpredictable spatial context as conditioned stimulus compared to a predictable context. We hypothesized that the PTSD group would demonstrate less hippocampal and ventromedial prefrontal cortex (vmPFC) activation during acquisition and extinction of unpredictable contexts and an over-reactive amygdala response in the predictable contexts compared to controls.

METHODS

A novel combined differential cue-context conditioning paradigm was applied using virtual reality with spatial contexts that required configural and cue processing. We assessed 20 patients with PTSD, 21 healthy trauma-exposed (TC) and 22 non-trauma-exposed (HC) participants using functional magnetic resonance imaging, skin conductance responses, and self-report measures.

RESULTS

During fear acquisition, patients with PTSD compared to TC showed lower activity in the hippocampi in the unpredictable and higher activity in the amygdalae in the predictable context. During fear extinction, TC compared to patients and HC showed higher brain activity in the vmPFC in the predictable context. There were no significant differences in self-report or skin conductance responses.

CONCLUSIONS

Our results suggest that patients with PTSD differ in brain activation from controls in regions such as the hippocampus, the amygdala, and the vmPFC in the processing of unpredictable and predictable contexts. Deficient encoding of more complex configurations might lead to a preponderance of cue-based predictions in PTSD. Exposure-based treatments need to focus on improving predictability of contextual processing and reducing enhanced cue reactivity.

A stable and replicable neural signature of lifespan adversity in the adult brain

Environmental adversities constitute potent risk factors for psychiatric disorders. Evidence suggests the brain adapts to adversity, possibly in an adversity-type and region-specific manner. However, the long-term effects of adversity on brain structure and the association of individual neurobiological heterogeneity with behavior have yet to be elucidated. Here we estimated normative models of structural brain development based on a lifespan adversity profile in a longitudinal at-risk cohort aged 25 years (n = 169). This revealed widespread morphometric changes in the brain, with partially adversity-specific features. This pattern was replicated at the age of 33 years (n = 114) and in an independent sample at 22 years (n = 115). At the individual level, greater volume contractions relative to the model were predictive of future anxiety. We show a stable neurobiological signature of adversity that persists into adulthood and emphasize the importance of considering individual-level rather than group-level predictions to explain emerging psychopathology.

Methyl-CpG binding protein 2 expression is associated with symptom severity in patients with PTSD in a sex-dependent manner

Traumatic events may lead to post-traumatic stress disorder (PTSD), with higher prevalence in women. Adverse childhood experiences (ACE) increase PTSD risk in adulthood. Epigenetic mechanisms play important roles in PTSD pathogenesis and a mutation in the methyl-CpG binding protein 2 (MECP2) in mice provide susceptibility to PTSD-like alterations, with sex-dependent biological signatures. The present study examined whether the increased risk of PTSD associated with ACE exposure is accompanied by reduced MECP2 blood levels in humans, with an influence of sex. MECP2 mRNA levels were analyzed in the blood of 132 subjects (58 women). Participants were interviewed to assess PTSD symptomatology, and asked to retrospectively report ACE. Among trauma-exposed women, MECP2 downregulation was associated with the intensification of PTSD symptoms linked to ACE exposure. MECP2 expression emerges as a potential contributor to post-trauma pathophysiology fostering novel studies on the molecular mechanisms underlying its potential sex-dependent role in PTSD onset and progression.

Gray matter differences in adults and children with posttraumatic stress disorder: A systematic review and meta-analysis of 113 studies and 11 meta-analyses

BACKGROUND

In this systematic review and meta-analysis, we aimed to provide a comprehensive overview of gray matter alterations of adult- and underage patients with posttraumatic stress disorder (PTSD) in comparison to healthy trauma-exposed (TC) and non-exposed (HC) individuals.

METHODS

We subdivided our groups into patients with PTSD after trauma exposure in adulthood (aa) or childhood (ac) as well as children with PTSD (cc). We identified 113 studies, including 6.800 participants in our review, which we divided into studies focusing on whole-brain and region-of-interest (ROI) analysis. We performed a coordinate-based meta-analysis on 14 studies in the group of aa-PTSD.

RESULTS

We and found lower gray matter volume in patients with PTSD (aa) in the medial frontal gyrus (PTSD<HC/TC) and Culmen/posterior cingulate cortex (PTSD<TC). Results from ROI-based studies mainly show alterations for patients with PTSD in the prefrontal cortex, hippocampus, anterior cingulate cortex, insula, corpus callosum, and amygdala.

LIMITATIONS

Due to a limited number of studies reporting whole-brain results, the meta-analyses could only be performed in one subgroup and within this subgroup for a limited number of studies.

CONCLUSIONS

Our results are in line with psychobiological models of PTSD that associate the identified regions with brain circuits involved in context processing, threat detection and emotion regulation.

Neurostructural associations with traumatic experiences during child- and adulthood

Adverse experiences can lead to severe mental health problems, such as posttraumatic stress disorder (PTSD), throughout the lifespan. In individuals with PTSD, both global and local brain volume reductions have been reported-especially in the amygdala and hippocampus-while the literature on childhood maltreatment suggests a strong dependency on the timing of adverse events. In the present study, we pooled data from two studies to contrast the effects of reported trauma exposure during neurodevelopmentally sensitive periods in early life with trauma exposure during adulthood. A total of 155 women were allocated into one of six age-matched groups according to the timing of traumatization (childhood vs adulthood) and psychopathology (PTSD vs trauma-exposed healthy vs trauma-naïve healthy). Volumes of the amygdala and hippocampus were compared between these groups. Six additional exploratory regions of interest (ROI) were included based on a recent meta-analysis. Amygdala volume was strongly dependent on the timing of traumatization: Smaller amygdala volumes were observed in participants with childhood trauma and PTSD compared to the healthy control groups. In contrast, larger amygdala volumes were observed in both groups with trauma exposure during adulthood compared to the trauma-naïve control group. Hippocampal volume comparisons revealed no statistically significant differences, although the descriptive pattern was similar to that found for the amygdala. The remaining exploratory ROIs showed significant group effects, but no timing effects. The timing might be an important moderator for adversity effects on amygdala volume, potentially reflecting neurodevelopmental factors. Albeit confounded by characteristics like trauma type and multiplicity, these findings pertain to typical childhood and adulthood trauma as often observed in clinical practice and speak against a simple association between traumatic stress and amygdala volume.

Systematic review and meta-analyses of the long-term efficacy of narrative exposure therapy for adults, children and perpetrators

Objective: Narrative Exposure Therapy (NET) is a short-term trauma-focused intervention originally developed for treating survivors of war and torture. The neurobiological theoretical foundations of NET would suggest that the approach should have long term beneficial effects. We tested this assumption and also provided an extensive overview of all NET studies for adults, for children (KIDNET), and for perpetrators (Forensic Offender Rehabilitation NET; FORNET).Method: Following a systematic literature review, we conducted meta-analyses with all studies that had control conditions, and with all Randomized Controlled Trials (RCTs). We assessed between-groups short- (< 6 months) and long-term (≥ 6 months) effect sizes for symptoms of posttraumatic stress disorder (PTSD) and depression.Results: In a total of 56 studies from 30 countries comparing 1370 participants treated with NET to 1055 controls, we found large between group effect sizes regarding the reduction of PTSD symptoms in favor of NET. Analyses of RCTs with active controls yielded small to medium effect sizes in the short-term, and large effect sizes in the long-term.Conclusions: NET, KIDNET, and FORNET yield beneficial and sustainable treatment results for severely traumatized individuals living in adverse circumstances. Studies in highly developed health care systems comparing NET with other evidence-based trauma-focused interventions are needed.

Structural white and gray matter differences in a large sample of patients with Posttraumatic Stress Disorder and a healthy and trauma-exposed control group: Diffusion tensor imaging and region-based morphometry

Differences in structural white and gray matter in survivors of traumatic experiences have been related to the development and maintenance of Posttraumatic Stress Disorder (PTSD). However, there are very few studies on diffusion tensor imaging and region based morphometry comparing patients with PTSD to two control groups, namely healthy individuals with or without trauma experience. It is also unknown if differences in white and gray matter are associated. In this cross-sectional study, we examined white- and gray matter differences between 44 patients with PTSD, 49 trauma control and 61 healthy control subjects. We compared the groups applying Tract-Based Spatial Statistics (TBSS) for a whole brain white matter analysis as well as region of interest analyses for white and gray matter. First, trauma control subjects in comparison to patients with PTSD and healthy control subjects showed significantly a) higher fractional anisotropy (FA) in the left corticospinal tract and inferior fronto-occipital fasciculus than patients with PTSD, b) higher FA in the left inferior fronto-occipital-, right inferior- and right superior longitudinal fasciculi, c) higher FA in the forceps minor and d) higher volume of the left and right anterior insulae. Second, we show significant correlations between the FA in the forceps minor and the gray matter volume in the left and right anterior insulae. Third, the mean FA value in the forceps minor correlated negatively with symptom severity of PTSD and depression as well as trait anxiety, whereas the gray matter volume in the left anterior insula correlated negatively with symptom severity in PTSD. Our findings underline the importance of brain structures critically involved in emotion regulation and salience mapping. While previous studies associated these processes primarily to functional and task-based differences in brain activity, we argue that morphometrical white and gray matter differences could serve as targets in neuroscientifically-informed prevention and treatment interventions for PTSD.

Neural Signatures of Gender Differences in Interpersonal Trust

Trust plays a critical role in nearly every aspect of social life. Parental investment theory and social role theory predict that women trust less than men due to a higher sensitivity to risk and betrayal, while men trust more than women to maximize resources and to signal their willingness to lose something. However, the underlying neuropsychological underpinnings for this gender difference are still obscure. In this study, we used functional magnetic resonance imaging (fMRI) to investigate the neural signatures of gender differences in trust by simultaneously scanning 11 male and 11 female same-gender, fixed dyads who played a multi-round binary trust game with varying levels of payoff (low/moderate/high) as an indicator of social risk. Our results showed that men trusted more than women and payoff level moderated the effect of gender on trust. While men trusted the same at all payoff levels, women trusted less with higher payoff levels. This pattern was supported by our neuroimaging finding: men showed a higher activation in the left inferior frontal gyrus (ventrolateral prefrontal cortex) and right precuneus than women, indicating that men exert more effort to inhibit the information of payoff levels and to use self-referencing to infer the strategies of partners with the goal of maximizing profit. Furthermore, men showed equivalent activation in the subgenual anterior cingulate cortex across payoff levels, whereas women showed a decreased activation with increasing payoff level - indicating decreased group bonding with higher risk in women. In conclusion, our results imply that women are more sensitive to social risk while trusting, which has implications for financial interactions, interpersonal relationships, and social involvement.

Impact and cultural acceptance of the Narrative Exposure Therapy in the aftermath of a natural disaster in Burundi

BACKGROUND

In the aftermath of natural disasters, affected populations are at risk of suffering from trauma-related mental health disorders such as posttraumatic stress disorder (PTSD) or depression. Particularly in poor post-conflict regions, these mental disorders have the potential to impair the ability of individuals to move on with their lives. We aimed to evaluate the feasibility, cultural acceptance, and effect of a trauma-focused psychotherapy, Narrative Exposure Therapy (NET), in the aftermath of a flood disaster in Burundi.

METHODS

Fifty-one individuals who were living in emergency camps overseen by the Burundian Red Cross in the aftermath of a flood disaster, and who had lost homes and close relatives, were invited to participate in semi-structured diagnostic interviews. Trained Burundian psychology students conducted these interviews, and six sessions of NET were offered to the 15 individuals most affected by trauma-related symptoms. An additional group of psychology students, blind to the treatment conditions, conducted three and 9 months follow-ups with them including also 25 participants who had reported significant but less severe trauma-related symptoms, assessing mental health symptoms, acceptance of NET, stigmatization due to trauma symptoms, and participants' economic well-being.

RESULTS

Between baseline and 9-months post-intervention assessment, symptoms of PTSD (Hedges' g = 3.44) and depression (Hedges' g = 1.88) improved significantly within participants who received NET and within those who received no treatment (Hedges' g_PTSD = 2.55; Hedges' g_depression = 0.72). Furthermore, those who received NET felt less stigmatized by their participation in the intervention than by the trauma-related mental health symptoms they experienced. Overall, participants reported that they would be willing to forego as much as 1 month's worth of income in exchange for receiving trauma-focused interventions in the months following the disaster.

CONCLUSIONS

Individuals severely affected by trauma-related mental health symptoms might benefit significantly from NET in the aftermath of natural disasters, while less affected individuals seem to recover spontaneously. Despite significant challenges conducting NET in emergency camps in the aftermath of natural disaster in a post-conflict country, such interventions are feasible, appreciated and might have long-lasting impacts on the lives of survivors if conducted with due respect to participants' privacy.

TRIAL REGISTRATION

UKCR2014 , the 19.06.2014, retrospectively registered.

Structural white matter changes in adults and children with posttraumatic stress disorder: A systematic review and meta-analysis

White matter plasticity occurs throughout life due to learning and can be a protective factor against as well as a vulnerability factor for the development of mental disorders. In this systematic review we summarize findings on structural white matter changes in children and adults with posttraumatic stress disorder (PTSD) and relate them to theoretical accounts of the pathophysiology of PTSD with a focus on the disturbed processing of contexts and associated problems in emotional and cognitive processing and PTSD symptomatology. We particularly examine studies reporting fractional anisotropy (FA) measured with diffusion tensor imaging (DTI). We further subdivided the studies in adult-onset PTSD with traumatic experience in adulthood, adult-onset PTSD with traumatic experience in childhood and children with PTSD. We included 30 studies comprising almost 1700 participants with 450 adults and 300 children suffering from PTSD. Our systematic review showed that for children with PTSD and adult-onset PTSD with childhood trauma, a decrease in FA in the corpus collosum, most prominently in the anterior and posterior midbody, the isthmus and splenium were reported. For adult-onset PTSD with traumatic experience in adulthood, changes in FA in the anterior and posterior part of the cingulum, the superior longitudinal fasciculus and frontal regions were found. Using GingerAle, we also performed a coordinate-based meta-analysis of 14 studies of adult-onset PTSD with traumatic experience in adulthood and did not find any significant clusters. Our results suggest that changes in white matter microstructure vary depending on traumatic experience and are associated with changes in brain circuits related to the processing of contexts. Finally, we present methodological considerations for future studies.

Fluconazole in patients at risk from invasive aspergillosis

We report on four cases of aspergillosis which developed during therapy with fluconazole in patients who were immunosuppressed or granulocytopenic. Fluconazole may obscure the onset of aspergillosis. We feel that it should neither be given prophylactically nor for fever of unknown origin in patients who are at high risk of contracting aspergillosis.