The terminology used to describe neuropathic pain appears to be conserved across languages, which facilitates the translation of validated neuropathic pain screening tools into other languages. However, this assumption has not been assessed in an African language. Therefore we investigated the terminology used by 54 patients whose native language was isiZulu, a major Bantu language of Africa, when describing their symptomatic HIV-associated sensory neuropathy. Also, because English is a commonly spoken second-language in the region, we assessed these patients’ knowledge and understanding of 21 English terms commonly used to describe neuropathic pain. English translations of the most commonly used isiZulu symptom descriptors included: “hot/burning” (50%), “cramping” (35%), “painful/sore/aching” (32%), “itching” (22%), “numb” (22%), “cold/freezing” (17%), and “stabbing/pricking/pins-and-needles” (13%). Thus, the isiZulu terminology to describe neuropathic pain was very similar to that used in non-African languages. However, knowledge and understanding of English neuropathic pain descriptors by these non-native English speakers was highly variable. For example, knowledge of English terms ranged from>98%  to <25% , and true understanding of English terms ranged from>90%  to <35% . In conclusion, we show significant similarity in the terms used to describe neuropathic pain in isiZulu compared to non-African languages, thus indicating that translation of existing neuropathic pain screening tools into this, and possibly other Bantu languages, is a viable option. However, the usefulness of English-language screening tools in this non-native English speaking population may be limited. Data on the prevalence and impact of pain of neuropathic origin in Africa are poor. Collecting reliable epidemiological data on neuropathic pain requires an accurate diagnosis, and several neuropathic pain screening tools, which incorporate various combinations of symptoms and clinical signs, have been developed Developing new tools that are tailored to local languages and culture is the optimal approach, but the process is complicated and time consuming, especially in countries with multiple languages . Instead, translating existing tools into local languages has been the strategy used most commonly outside of Sub-Saharan Africa. In support of this translation approach, numerous studies have demonstrated that the core symptomatology assessed by screening tools remains largely unaltered after translation and validation across diverse language groups Thus, there are potential problems associated with cross-cultural translation of symptoms and using neuropathic pain screening tools in their original language form in populations who do not speak the language as a first language. Therefore, we investigated the symptomatology of peripheral neuropathy, as described spontaneously by black African patients in their home-language. We also investigated these patients’ understanding of English terms commonly found in neuropathic pain screening tools. We investigated these questions in patients who spoke isiZulu as their home-language, the Bantu language with the second-most native speakers in Africa The study was approved by the Human Research Ethics Committee  of the University of the Witwatersrand (clearance number: M090669), and written informed consent was obtained from all participants. An interpreter fluent in isiZulu facilitated the recruitment, consent and interview procedures.Participants were recruited from the Virology Clinic at Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa. They were invited to take part in the study if they had a confirmed HIV diagnosis, experienced any pain or abnormal sensations in their feet and lower legs, had signs indicative of a peripheral neuropathy, were on stable antiretroviral therapy for at least one month, and spoke isiZulu as their primary language and English as a secondary language. We defined primary language as the participant’s preferred language of communication when conversing with family and friends. Fifty-four (54) participants met the inclusion criteria and agreed to participate in the interview component of the study.The ACTG Brief Peripheral Neurological Screening Tool was used to diagnose the presence of HIV-SN The interview consisted of two components: firstly, participants were asked to spontaneously describe, in isiZulu, the pain and abnormal sensations in their feet and lower legs, and what triggered the sensations. Patients were not prompted, but were encouraged to give a complete description of all the sensations and triggers for the sensations. Secondly, a list of English neuropathic symptom descriptors was read to participants and they were asked to identify any terms which accurately described their symptoms. Before the list was read to them, it was clarified to the participants that the descriptive words about to be read out referred to the sensations in their lower legs and feet only. Participants were required to answer “yes, I have the symptom”, “no, I do not have the symptom” or “I do not know the term” after each term was read to them. When participants identified themselves as having a symptom, they were asked to provide an equivalent isiZulu term for the English term they had identified. Each interview was recorded and lasted 20 to 30 minutes.The inventory of English terms used in the list of neuropathic symptoms descriptors was constructed from terms currently used in the English-language versions of the McGill Pain Questionnaire (MPQ) The wordlist initially consisted of 33 words and phrases, but was reduced to 22 items after three pilot interviews showed that none of the patients knew the meaning of the following terms: “bursting”, “strange/unusual”, “squeezing”, “dull”, “intense”, “lancinating”, “gnawing”, “splitting”, “piercing”, “tender” and “sensitive”. This lack of knowledge caused the participants to become visibly embarrassed and uncomfortable during the interview. None of the terms omitted are used in the DN4, LANSS, or ID Pain (tools designed to help identify pain of neuropathic origin). The terms “cold” and “freezing” were combined after the first 3 interviews because participants could not distinguish between the two words, leaving a final list of 21 items .All audio recordings were transcribed and all isiZulu sections of the transcriptions translated into English by two independent translators. In all cases, the two independent translations were compared, and where the translations differed both translators were consulted and a consensus translation agreed on. Data was collected until data saturation was achieved. Descriptive statistics and content analysis were used to analyse the data. We extracted all the terms and phrases used by participants to describe their symptoms and symptom triggers from the original isiZulu transcript and English translation. From the list of English terms read to participants, we calculated the percentage of participants who identified that they had the symptom and the percentage that declared that they did not know the English term.To confirm whether participants correctly understood the words chosen from the English list we compared the meaning of the English terms chosen to the meaning of the isiZulu terms they provided for each English term. If the back-translation of the isiZulu term matched the English term, or matched an English word belonging to the same grouping of words on the MPQ, then the participant was judged as having understood the English term. For the term “numbness” participants were judged to have this sensation if they described a lack of sensation in their feet and lower legs. Finally a percentage concordance was calculated between the terms and phrases provided during the spontaneous description of neuropathic pain and those selected from the prompted English list to determine whether participants consistently used the same words when describing their neuropathic pain symptoms in both languages.Demographic information for the 54 participants is provided in root –shisa) was used to describe “hot” and “burning” sensation, with the difference in intensity given by the context in which the word was used. Similarly, the contextual use of a single term (root –hlaba) was used to indicate the intensity of punctate mechanical sensations “knife-like/stabbing,” “pricking” and “pins-and-needles”. Thus we collapsed the terms describing noxious heat sensations under the heading “hot/burning”, and the terms describing punctate mechanical sensations under the heading “stabbing/pricking/pins-and-needles” for our analyses.Initial parsing of the spontaneous verbal descriptions showed that the same isiZulu term  were seldom used to spontaneously describe the symptoms in isiZulu or when prompted with English terms, and understanding of these English terms was poor.A potential source of error in this study was the reliance on accurate translation of the isiZulu symptom descriptions. However, by generating a consensus translation based on the outputs of two independent translators, who were native isiZulu speakers that were fluent in English, we believe that we achieved accurate translations of the isiZulu component of the interview. Another potential limitation was the use of a convenience sample of patients with symptomatic HIV-associated sensory neuropathy instead of a cohort of patients with a variety of different neuropathic conditions. However, there is no clear indication that the symptomatology of neuropathic pain is pathognomonic for the precipitating event  The most common spontaneously expressed symptom in isiZulu was “hot/burning”. The terms “hot” and “burning” commonly are found on neuropathic pain screening tools, and offer good discriminative properties when distinguishing neuropathic from non-neuropathic pain IsiZulu equivalents of the terms “tingling”, “electric shocks” and “shooting” were not used spontaneously by our patients, but these terms form part of the symptomatology assessed by several screening tools Our data illustrate a clear gap in comprehension between some terms that are routinely assessed in English neuropathic pain screening tools and what non-native speakers of the language may be familiar with. This comprehension gap could lead to significant under-reporting of neuropathic pain if English screening tools are used in our patient population. The problem of English proficiency when using English versions of screening tools is highlighted by the case of the symptom “numbness”, which is assessed in all major neuropathic pain screening tools except the LANSS “Cramping” was the second-most used term when participants spontaneously described their neuropathy symptoms, and was the most commonly selected term when they were prompted with the list of English terms. The English term was almost universally understood by patients. Indeed, in addition to using the isiZulu term “amajaqamba,” to describe cramp-like pain, many participants used isiZulu derivatives of the English term, such as “ama-cramps” or “namacramps’’, to describe their pain. Our finding that neuropathic pain may be cramping in quality is consistent with the results obtained by Dubuisson and Melzack In summary, we provide the first evidence of robust similarity in the symptomatology of neuropathic pain between a major Bantu language, isiZulu, and non-African languages. We determined this similarity directly by asking patients to spontaneously describe their symptomatology in their native language rather than inferring similarity indirectly through testing the sensitivity and specificity of translated neuropathic pain screening tools. Moreover, we demonstrate high variability in the knowledge and understanding of English neuropathic terminology by moderately educated native isiZulu speakers who spoke English as second language. Based on our findings we believe that translation of existing questionnaires into isiZulu, and possibly other related Bantu languages, is a legitimate pursuit. But, the use of these tools in their English format, as has been recommended


The proportion of incompletely immunized children in Pakistan varies from 37-58%, and this has recently resulted in outbreaks of measles and polio. The aim of this paper is to determine the factors associated with incomplete immunization among children aged 12-23 months in Pakistan.Secondary analysis was conducted on nationally representative cross-sectional survey data from the Pakistan Demographic and Health Survey, 2006-07. The analysis was limited to ever-married mothers who had delivered their last child during the 23 months immediately preceding the survey . ‘Complete immunization’ was defined as the child having received twelve doses of five vaccines, and ‘incomplete immunization’ was defined if he/she had missed at least one of these twelve doses. The association between child immunization status and determinants of non-utilization of vaccines was assessed by calculating unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals using a multivariable binary logistic regression.The findings of this research showed that nearly 66% of children were incompletely immunized against seven preventable childhood diseases. The likelihood of incomplete immunization was significantly associated with the father’s occupation as a manual worker , lack of access to information , non-use of antenatal care , children born in Baluchistan region  and delivery at home .Despite governmental efforts to increase rates of immunization against childhood diseases, the proportion of incompletely immunized children in Pakistan is still high. Targeted interventions are needed to increase the immunization rates in Pakistan. These interventions need to concentrate on people with low socioeconomic and educational status in order to improve their knowledge of this topic. Vaccination is one of the major contributors to public health. It has eliminated some of the most dreaded childhood diseases, such as polio, from all over the world except in a few countries . ChildhoIn 1974, the World Health Organization (WHO) launched its Expanded Program on Immunization (EPI) with the aim of controlling six childhood diseases: tuberculosis, diphtheria, pertussis (whooping cough), tetanus, polio and measles. Consistent with the WHO’s recommendations, Pakistan launched its EPI in 1978 under the guidance of the WHO . CurrentIn Pakistan, the Health Department provides the immunization schedule for the national EPI in accordance with the WHO guidelines. The EPI is funded by the United Nations International Children’s Fund (UNICEF). It is provided free of charge at all state-run health facilities, which are present in every district across Pakistan. Despite having a national immunization program, and a quarterly anti-polio campaign, Pakistan is still one of the few countries that is not polio free . The WHOAlthough the trends in immunization coverage show improvement for individual doses, especially polio, the percentage of fully immunized children aged 12-23 months who have received specific vaccines was only 47.3% -12, whilThe benefits of getting a child immunized are hardly questionable, yet studies have shown that, in many developing countries, a sizeable number of parents, usually belonging to socioeconomically disadvantaged populations, resist child immunization ,13. The Secondary data analysis was conducted on data from the Pakistan Demographic and Health Survey (PDHS) 2006-07. The PDHS is a publicly available dataset produced by ORC Macro for the Measure DHS  Project. It is funded by the US Agency for International Development (USAID). The PDHS contains a wide range of health-related information and is considered to be free of systematic bias [The PDHS is the largest household survey conducted in Pakistan. It is comprised of a nationally representative sample of over 95,000 households collected using a stratified two-stage cluster sampling procedure. However, for security and political reasons, some areas, such as Federally Administered Tribal Areas (FATA), Federally Administered National Areas (FANA) and Azad Jammu and Kashmir (AJK), were not part of the survey. Amongst several modules on fertility, nutrition, reproductive health and malaria in the PDHS, one is on child immunization . The detOur data was limited to mothers with a last-born child (youngest child) between the ages of 12 to 23 months, resulting in a sample size of 2,435. The reason for the selection of this age group was that, until 2006, the course of basic vaccinations  for children was completed by the age of 9 months. Some previous studies have also used the same age-group for studying the utilization of immunization ,11,14. WWe selected twelve variables, which showed “Received: BCG, polio , DPT , HBV  and measles”. These variables had five response categories: No, vaccination date on card, reported by mother, vaccination marked on card and DK (don’t know). We recoded each variable in a similar way. No and DK responses were recoded as “0” and considered as “not received the vaccine”, while the other responses “vaccination date on card, reported by mother, vaccination marked on card” were recoded as “1” and considered as “received the vaccine”. Later, we added all twelve vaccine variables and labeled them “Immunization status”. The immunization status was recoded as “0” if the child had received all twelve doses of the above-mentioned vaccinations and categorized as “complete immunization”, and “1” if the child had missed one or more vaccinations, and categorized as “incomplete immunization”.We defined “complete immunization” in accordance with the WHO, which considers a child completely immunized if “he or she has received a BCG vaccination against tuberculosis; three doses of DPT vaccine to prevent diphtheria, pertussis, and tetanus (DPT); at least three doses of polio vaccine; and one dose of measles vaccine.” Previously published studies have defined “complete immunization” in a similar way ,23.Based on a literature review -15 and aThe remaining independent variables were computed and recoded, and limited to categories between two and four because of the small number of cases in some categories. The variable: “seeking formal advice/treatment” was computed using three variables from the PDHS, a) Seek advice/treatment from doctor, b) Seek advice/treatment from Midwife/LHV/nurse and c) Seek advice/treatment from Lady Health Worker (LHW). After computation, the variable was recoded into “0” if the mother has not taken advice/treatment from any of these sources and categorized as “no”, and “1” if the mother has taken advice from one or more of these sources and categorized as “yes”. Similarly, the variable “access to information” was computed and recoded using three variables: a) Access to radio, b) Access to television and c) Access to computer. The data was recoded into “0” if the mother has no access to any of these sources and categorized as “no”, and “1” if the mother had access to one or more of the above-mentioned sources and categorized as “yes”.All the data were weighted and analyzed using SPSS version 17 to account for selection probability, non-response, and sampling differences between regions to produce national estimates of the population. Descriptive statistics for both groups (incomplete immunization and complete immunization) were presented as frequency distributions and percentages. Simple binary logistic regression analysis was carried out to examine the relationship between “incomplete immunization” and the independent variables. In the multiple logistic model, three variables  were adjusted and fixed. We entered all the independent variables that were significant at the 0.05 level one by one into the model. We also assessed the multicollinearity between the variables and highly correlated variables were eliminated from the logistical model. Multicollinearity was assessed between mother’s and father’s age through Pearson correlation and it was significant at the 0.01 level, so the father’s age variable was eliminated from the model.This study is based on secondary analysis of publicly available data; hence no ethical approval was required from our institutions. Permission to use the PDHS-2006-07 data was obtained from Measure DHS.The mean age of mothers and fathers was 29.42 (SD ± 6.49) years and 36.99 (SD ± 10.0) years respectively. Two thirds of the selected children (66%) were incompletely immunized. The proportion of incompletely immunized was slightly higher among female children (68.6%) than among male children (64.0%)  were more likely to be incompletely immunized , had not used antenatal care  or delivered at home  were more likely to have children with incomplete immunization  and incomplete child immunization , it is lInformation could play a pivotal role in determining the health behavior of an individual. We found that lack of access to information among mothers increases the likelihood of incomplete immunization for their children. In Pakistan generally, public awareness about immunization, especially among mothers from poor socioeconomic strata, is very low. Therefore, the government of Pakistan dedicates a few days every year to the National Immunization Campaign to increase the level of awareness and motivation about timely completion of the immunization process for children.Similarly, the level of social development of a region could influence the extent to which parents can avail themselves of preventive health services. Our study showed that region of residence is associated with incomplete immunization. For instance, children in relatively less developed provinces, such as Sindh and Baluchistan, were more likely to have incomplete immunization than those in Punjab, which is more socially and economically developed. Even in North Western Frontier province, now called Khyber Pakhtoon Khawa, complete immunization is much better than other regions because many international organizations such as UNICEF, USAID, the World Bank, UN Women and national organizations such as the Aurat Foundation, PAIMAN and others are working to improve maternal and child health.Immunization may not be an isolated phenomenon; its timely dispensation is linked with parents’ previous interactions with the health-care system ,24. For In patriarchal societies, including Pakistan, a male baby is more valued than a female baby, because males are considered to have economic and social utility in families . HoweverThe above findings ought to be considered in light of certain limitations: Firstly, the analysis was restricted to the last child born during the 23 months immediately preceding the survey; hence, it cannot be generalized to all children under five years of age. Secondly, the analysis conducted cannot establish causal relationships between immunization status and any of the independent variables because of the cross-sectional nature of the survey. Lastly, information on child immunization in the survey is based on either immunization cards or the self-reports of women and the information received through self-reports is subject to recall and social desirability biases. Due to this fact, the completeness of vaccination might be overestimated, because self-reports by the mother were handled in the same way as information from vaccination cards. Additionally, a binary categorization (vaccination received vs. not received) was used, which may lead to a loss of information.The rate of incomplete immunization of children in Pakistan is alarming. Father’s occupation as an unskilled worker, residence in less developed regions such as Baluchistan, lack of access to health information, non-use of antenatal care and home deliveries were found to be independently associated with incomplete immunization of children in Pakistan. Despite limitations, this study shows that EPI services are not reaching the target population and efforts should be made to provide full coverage of vaccination to all children in Pakistan. Therefore, modified interventions are needed to increase the rates of fully immunized children in Pakistan. Additionally, a longitudinal study is needed to explore the factors associated with incomplete immunization levels for each vaccination.The authors declare that they have no competing interests.ASB and RR drafted the initial manuscript. RZ, MZZ and MN supervised and reviewed manuscript writing. ASB and RR contributed in data analysis while RZ supervised data analysis. FF and RM contributed to reviewing final manuscript. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/232/prepub


ESND is a wiki-based, publicly editable and open-content platform, exploiting the whole power of the scientific community in collectively and collaboratively managing scientific nomenclature. Based on community curation, ESND is capable of achieving accurate, standard, and comprehensive scientific nomenclature, demonstrating a valuable application of community intelligence in knowledge curation.Harnessing community intelligence in knowledge curation bears significant promise in dealing with communication and education in the flood of scientific knowledge. As knowledge is accumulated at ever-faster rates, scientific nomenclature, a particular kind of knowledge, is concurrently generated in all kinds of fields. Since nomenclature is a system of terms used to name things in a particular discipline, accurate translation of scientific nomenclature in different languages is of critical importance, not only for communications and collaborations with English-speaking people, but also for knowledge dissemination among people in the non-English-speaking world, particularly young students and researchers. However, it lacks of accuracy and standardization when translating scientific nomenclature from English to other languages, especially for those languages that do not belong to the same language family as English. To address this issue, here we propose for the first time the application of community intelligence in scientific nomenclature management, namely, harnessing collective intelligence for translation of scientific nomenclature from English to other languages. As community intelligence applied to knowledge curation is primarily aided by wiki and Chinese is the native language for about one-fifth of the world’s population, we put the proposed application into practice, by developing a wiki-based English-to-Chinese Scientific Nomenclature Dictionary (ESND;  Although the openness of editorial capacity to the community may lead to potential vandalism, it is reported that Wikipedia not only achieves more content coverage than BBC (British Broadcasting Corporation) and CNN (Cable News Network) combined Nature to elaborate the current state and future of knowledge curation; they stated that keeping biological knowledge up-to-date and comprehensive is increasingly lagging behind knowledge creation, inevitably requiring a large number of people getting involved in knowledge curation With the exponentially increasing volume of knowledge, harnessing community intelligence in knowledge curation has gained significant attention to deal with communication and education in the flood of scientific knowledge As knowledge is accumulated at ever-faster rates, a large collection of scientific nomenclature is concurrently developed or evolved in all kinds of fields. Scientific nomenclature, a particular kind of knowledge, is a system of terms used to name things and to describe processes/phenomenon in a particular discipline. Rapid advancements in science and technology further lead to a growing quantity of new scientific terms. Therefore, accurate translation of scientific nomenclature in different languages is of critical significance, not only for effectively facilitating communications and collaborations with English-speaking people, but also for efficiently disseminating knowledge among people in the non-English-speaking world, especially young students and researchers, and thus laying a solid foundation for domestic scientific activities. An accurate translation of a scientific term should be not only expressed equivalently in another language but also widely accepted by the scientific community. However, there are inaccurate and/or unacknowledged translations of scientific nomenclature from English to other languages, particularly for those languages that do not belong to the same language family as English To address this issue, here we propose for the first time the application of community intelligence in scientific nomenclature management, namely, harnessing collective intelligence for translation of scientific nomenclature from English to other languages. As community intelligence applied to knowledge curation is primarily aided by wiki and Chinese is the native language for about one-fifth of the world’s population (or over one billion people) http://www.mediawiki.org), a free, open-source, and widely used wiki engine . To develop ESND, we used MediaWiki (Version 1.19.1), MySQL , and PHP  on a Red Hat Enterprise Linux Server.ESND is built on wiki, which was first proposed by Ward Cunningham ESND is a wiki-based, publicly editable, open-content platform for collaborative management of English-to-Chinese scientific nomenclature. Scientific nomenclature is a system of terms in different fields. In ESND, terms are extracted from the scientific literature and classified according to their corresponding fields. Currently, ESND primarily focuses on biological terms; it contains 2679 terms in life sciences, 770 terms in computer science and 135 terms in chemistry.In ESND, each wiki page represents a specific term, which generally contains a collection of relevant information, including English abbreviation, English interpretation, Chinese interpretation, Chinese translation(s) and the corresponding detailed note(s) . Specifiwài xiǎn zǐ and “nèi hán zǐ). However, recent studies have demonstrated that not all exons are encoded into proteins and not all introns are not transcribed, advocating that “wài yuán zǐ) and “nèi yuán zǐ) are more appropriate translations, respectively jìn huà) and “yǎn huà). Nowadays, some people believe that it might be better translated as “biàn yǎn), since “biàn) indicates mutation and “yǎn) represents the process of natural selection.It is likely that one English term may have multiple Chinese translations. In life sciences, for instance, there are two terms “exon” and “intron” that are often translated as “To tackle this issue, ESND incorporates a “vote” function for each wiki page to engage community intelligence in dealing with multiple translations for a given English term. The number of votes indicates the recognition of the corresponding translation accepted by the scientific community. For the term “exon” as mentioned above, higher vote for a Chinese translation indicates that it is more acknowledged by the scientific community . Therefohttp://esnd.big.ac.cn/index.php/template:AddNor) to easily add a new term. For example, when adding the term “Gene” (To facilitate adding new terms, ESND provides an open template for creating new wiki pages in correspondence to new terms. Users can adopt the template (m “Gene” , “Abbr” http://esnd.big.ac.cn, allowing any user to view and search for any content. Most important, ESND is a collaborative platform for collective management of English-to-Chinese scientific nomenclature, allowing people to participate in sharing their knowledge on specific terms of their own interest. If one term is not available, or incomplete, or you think of a better translation, you can share your knowledge by adding information to ESND. In addition, any user can make vote when there are multiple translations available for a given English term and thus the most voted translation indicates the wide acceptance by the scientific community. “With enough eyeballs, all bugs are shallow” ESND is freely available at Future developments include the addition of more scientific nomenclature from different fields and the improvement of user interface for term management. To our knowledge, it is for the first time that collective intelligence is applied for community management of scientific nomenclature and ESND is the first implementation to harnessing community intelligence for scientific nomenclature management. Based on community curation, ESND is capable of achieving accurate, standard, and comprehensive scientific nomenclature, demonstrating a valuable application of community intelligence in knowledge curation.


Episodic memory often is conceptualized as a uniquely human system of long-term memory that makes available knowledge accompanied by the temporal and spatial context in which that knowledge was acquired. Retrieval from episodic memory entails a form of first–person subjectivity called autonoetic consciousness that provides a sense that a recollection was something that took place in the experiencer's personal past. In this paper I expand on this definition of episodic memory. Specifically, I suggest that (1) the core features assumed unique to episodic memory are shared by semantic memory, (2) episodic memory cannot be fully understood unless one appreciates that episodic recollection requires the coordinated function of a number of distinct, yet interacting, “enabling” systems. Although these systems—ownership, self, subjective temporality, and agency—are not traditionally viewed as memorial in nature, each is necessary for episodic recollection and jointly they may be sufficient, and (3) the type of subjective awareness provided by episodic recollection (autonoetic) is relational rather than intrinsic—i.e., it can be lost in certain patient populations, thus rendering episodic memory content indistinguishable from the content of semantic long-term memory. What is episodic memory? As initially conceptualized, it is a system of long-term memory whose content provided its owner with a record of the temporal, spatial and self-referential features of the context in which the original learning transpired  also can be on display in semantic memory experience. Indeed, there appears no principled reason why the content of these two systems should differ. This is demonstrated rather dramatically in a case presented by Stuss and Guzman . An indithe basis for classification.Thus, there is no logical argument or empirical evidence supporting the assertion that only episodic memory makes reference to the “where and when” of past personal experience. While the fact that two potentially separate systems share criteria is not a “death sentence” for a taxonomy, it highlights the severe difficulties faced by those who would adopt the “time, place, and self” criteria as In summary, the “time, space, and self” criterion for distinguishing between semantic and episodic memory is insufficient for the task for which it originally was designed. By contrast, the autonoetic/noetic criterion for classification does good work both in capturing a fundamental feature of our memory phenomenology and in serving as fertile theoretical and empirical grounds for exploring the complexities of the types of systems subsumed under the general designator “memory”  long has been recognized. And, it has been a persistent thorn in the side of psychologists and philosophers grappling with the problem of placing a current mental state in a relation to the past. And, for the relation to do good work, it must be of the “right type.”past original. That condition is the fact that the imagined be expressly referred to the past, thought as in the past … But even that would not be memory. Memory requires more than mere dating of a fact in the past. It must be dated in my past. In other words, I must think that I directly experienced its occurrence. It must have … ‘warmth and intimacy’… ”  numerous criteria have been proposed to do the work of differentiating memory from a non-memorial mental content.Among modern psychological investigators, the work of Johnson and her colleagues represents the most systematic attempt to tackle this vexing problem  awareness. Thus, a causal analysis is required to place an occurrent semantic memory in a relation to the past.The content retrieved from semantic memory, on Tulving's account, can (at most) be given , is part of the subjective quality of the mental event. As Nagel , autonoetic awareness is (1) intrinsic  to episodic memory—i.e., it is a part, or constituent, of “episodic” content, or (2) it has a relational  connection to memory content—i.e., while under normal circumstances it is observed to be coextensive with “episodic” content, this connection is one of contingency rather than necessity.So what exactly is the once it has been retrieved.On the relational view, the neuro-cognitive mechanisms that make possible autonoetic awareness are functionally independent of the mechanisms that make available the content of long-term memory. What makes a memory experience episodic or semantic is not the nature of the content, or the hypothesized system in which content resides while in “storage,” but rather an act of temporal  awareness that becomes associated with the content This is the view I champion in this paper. Although evidence in support is scarce, suggestive findings have been reported in a study by Piolino and colleagues . Using tper se. Rather, there is memory content that can, if a suitable candidate for temporal specification is present in consciousness  can be acted on by the autonoetic subsystem to confer a sense of temporal subjectivity on the content retrieved.In sum, the relational view implies that memory content is neither episodic nor semantic; rather retrieved content is classifiable as episodic or semantic by virtue of a concurrent act of autoneotic awareness, whose association (or lack thereof) is used to classify an occurrent mental state as episodic or semantic. Seen in this light, there are no systems of episodic and semantic memory Many contemporary treatments of episodic memory focus on the encoding, storage and retrieval of memory content , has direct bearing on this issue.apparent memories, even in early stages of the disorder, likely are delusions in some sense  speaks to the reality of this possibility. For example, in a largely speculative treatment, Jaynes  argued tOf particular importance, then, is the case of patient R. B.  and Oxycontin to alleviate the considerable pain he endured. As the intensity of his pain subsided, he weaned himself off medication. Importantly, at the time of testing R. B. was not on any pain medication. In addition, his long and short-term memory impairments, aphasia and fluency deficits had resolved.feel the content experienced belonged to him. In his words, they lacked “ownership”Not all cognitive function, however, had returned to normal. Of direct bearing on the question at hand—the relation of autonoetic awareness to episodic memory—R. B. was able to remember particular incidents from his life accompanied by clear temporal, spatial and self-referential content. But he did not This particular type of memory impairment—recollection absent a sense of personal ownership—is a form of memory dissociation that, to my knowledge, has not previously been documented in the amnesic literature , were unaccompanied by a sense of personal ownership. And, absent that sense, the ability to Lacking the experience of personal ownership, R. B. simultaneously lost a direct, personal connection with his past. It thus appears that loss of ownership equates to an inability to draw on the resources provided by autonoetic awareness to identify the content of a current mental state as a part of one's personal history. For example, approximately 2 months following release from the hospital, R. B. offered the following description of what it is like for him to recall personal events:“… I did not own any memories that came before my injury. I knew things that came before my injury. In fact, it seemed that my memory was just fine for things that happened going back years in the past (the period close to the injury was more disrupted). I could answer any question about where I lived at different times in my life, who my friends were, where I went to school, activities I enjoyed. But none of it was ‘me.’ It was the same sort of knowledge I might have about how my parents met or the history of the Civil War or something like that.”In my review of taxonomies of long-term memory, I noted that psychologists traditionally have characterized episodic recollections as temporal, spatial, and self-referential. By these criteria, R. B.'s descriptions of his memorial experience leave little doubt that they are episodic recollections, appropriately situated in time and space, rather than factual, atemporal semantic knowledge. As I also suggested, however, there is no principled reason why a semantic fact could not contain spatial, temporal and self-referential content, or be correctly referred to a person's past—albeit a past constructed inferentially rather than autonoetically given. And therein resides a puzzle. Do R. B.'s unowned memories consist in episodic content divorced from its relational connection to autonoetic awareness, or are they rather un-categorized  content retrieved from storage but divorced from the sense of personal ownership conferred by an act of autoneotic awareness?R. B. addresses the question directly. When asked to recall of events from his childhood he replies:“I was remembering scenes, not facts … I was recalling scenes … that is … I could clearly recall a scene of me at the beach in New London with my family as a child. But the feeling was that the scene was not my memory. As if I was looking at a photo of someone else's vacation.”must be representative of past personal experience, he does not know this by virtue of a direct, felt connection to the past. In short, he has no sense of re-living the experiences retrieved.All of R. B.'s memories were substantiated by third parties as valid renditions of events that actually transpired in his life. While his recollections satisfy the traditional criteria for episodic memory—time, place, and self-accompanied by clear imagistic representation of  unique events —they simultaneously exhibit an absence of experienced ownership: While he can infer that the events recalled The absence of ownership also is evident in R. B.'s response to instructions to recall personal memories from time spent in graduate school:“I can picture the scene perfectly clearly … studying with my friends in our study lounge. I can ‘relive’ it in the sense of re-running the experience of being there. But it has the feeling of imagining, (as if) re-running an experience that my parents described from their college days. It did not feel like it was something that really had been a part of my life. Intellectually I suppose I never doubted that it was a part of my life. Perhaps because there was such continuity of memories that fit a pattern that lead up to the present time. But that in itself did not help change the feeling of ownership.”He continues:“Things that were in the present, like my name, I continue to own. Having been to MIT had two different issues … my memories of having been at MIT I did not own. Those scenes of being at MIT were vivid, but they were not mine. But I owned ‘the fact that I had a degree from MIT’… that might have simply been a matter of rational acceptance of fact.”2). This proposal is reflected in the way R. B. treats his perspectival, but not personally, owned pre-injury memory content, both during its separation from autonoetic awareness and following their eventual recoupling—at which point memory retrieval previously experienced as “unowned” takes on a decidedly episodic flavor:Once again, R. B.'s memory performance adheres to the traditional definition of episodic recollection: He can vividly remember where the specific event transpired, when the specific event took place, and that it directly involved him. But, autonoetic awareness is missing. In short, on the view presented here, the notions of episodic and semantic can be seen to refer not to different stores or systems of memory content, but rather to how that content, once retrieved, is acted on by mechanisms  to enact a reference to one's past  at will. I have normal control over remembering facts and scenes from my past. But when I remember scenes from before the injury, they do not feel as if they happened to me—though intellectually I know they did—they feel as if they happened to someone else.”With respect to the recovery of episodic ownership:“When I did ‘take ownership’ of a memory, it was actually quite isolated. A single memory I might own, yet another memory connected to it I would not own. It was a startling experience to have no rhyme or reason to which memories I slowly took ownership of, one at a time at random over a period of weeks and months.”He continues:“What happened over the coming months … was interesting. Every once in a while, I would suddenly think about something in my past and I would ‘own’ it. That was indeed something ‘I’ had done and experienced. Over time, one by one, I would come to ‘own’ different memories. Eventually, after perhaps 8 months or so, it seemed as if it was all owned … as if once enough individual memories were owned, it was all owned. For example, the MIT memory, the one in the lounge … I now own it. It's clearly part of my life, my past.”There appears to be an intimate connection with, and possibility of separation between, the content of a memory experience and whether that experience is autonoetic. R. B.'s confusion with regard to “content ownership” highlights the intimate relation between autonoetic awareness and ownership: Absent a sense of ownership, R. B. cannot mentally travel back in time to claim as his own the re-presentation of the experience from which the occurrent content was derived. Instead he relies on inference and logical possibility to (often correctly) infer that, given the specific elements of the content retrieved, it likely represents aspects of his personal past.sense of re-living a personal experience—i.e., episodic recollection. This neural machinery in R. B. seems to have been compromised by his injury, but only for those events that occurred in the time period preceding his injury. That is, R. B. suffered a form of retrograde amnesia that compromised his ability to experience his personal recollections as his own. During the non-ownership period, R. B. had memory of pre-injury events and could locate them, via inference, in his personal past. But he lacked a sense of numerical personal identity with the experiences retrieved. The case of R. B. thus suggests that the sense of numerical personal identity is quite narrowly circumscribed: R. B. had factual self-knowledge, trait self-knowledge, and knowledge of personally experienced episodes, but he did not have a pre-reflectively given sense of continuity with his past person.The apparent paradox presented by the case of patient R. B.—episodic-like content absent the feeling of personal ownership (and thus lived pastness)—can be understood by situating episodic memory in the context of a system of interrelated memory processes, some of which provide the raw data for experience  and some of which enable the experience to be “mine” . He presumably also had no trouble representing that his body was present for those experiences. He  Donald,  memories Donald,  that hasAlthough the specifics of R. B.'s deficit are, at this point, unclear, it is worth considering the present findings in light of theoretical work by Dalla Barba and colleagues  confer a temporal status on a specific content? That is, what determines if the content, as experienced, is classified as episodic or as semantic? Dalla Barba  suggestscauses the observed correlation between type of temporal subjectivity and stability of content. At present, a compelling explanation is not readily at hand. Despite its conceptual limitations, however, Dalla Barba's model, in conjunction with MTT, provides a provisional (though incomplete) framework for making sense of the dissociation between the experiential and inferential forms of temporality experienced by patient R. B. As the result of a condition in which autonoetic awareness is intact, but unable to access pre-injury content in long-term memory, R. B. remains capable of describing, often in considerable detail, what happened in his pre-injury past—despite being unable to experience his present mental content as a re-living of past personal events. By contrast, autonoetic awareness still can, for reasons not clear, successfully work in conjunction with his post-injury memory content. What we see in the case of R. B. is not a failure of memory content, or a loss of the autonoetic component of recollection, but rather a dissociation between two intact, yet functionally independent, constituents of what, taken in tandem, are essential constituents of what we classify as episodic recollection.Unfortunately, as the reader will have noted, Dalla Barba's “explanation” begs the question of what same memory content that lacked personal ownership during the period of his cognitive impairment. That R. B. was able to regain these functions suggests that the autoneotic aspect of his recollections was not destroyed by his injury; rather it temporarily became decoupled from memory content. The proposition that the mechanisms mediating autonoetic awareness were not lost during his amnesia also is implied by the fact that he had a sense of personal ownership of ongoing experiences that transpired following his accident . Why his mental machinery was able to conjoin autonoetic awareness with content as memories were being built, but not when recollecting memories of pre-injury events, remains unclear.The merit of this explanation of the relation between content and experience is further supported by R. B.'s subsequent recovery of the ability to episodically recollect the The sense of a direct, pre-reflective attachment to the past given by episodic recollection is robust, indeed, it has seemed to many to be a necessary aspect of episodic memory  or logical inference. The former maps to what we call episodic memory, while the latter enables temporally located semantic knowledge—i.e., the intentional placement of retrieved content in the context of one's past .prior to an act of retrieval—a conceptual stance which theoretical and empirical observations presented in this paper call into question. Moreover, Occam's principle of parsimony—i.e., posit no more parameters or variables than are minimally necessary to account for the data  which also are differentially associated with autonoesis.Of course, R. B.'s reports do not rule out the possibility that what he is reporting are inferences based on semantic memory system  rather than “un-labeled” memory content that lacks a felt connection to his past due to compromised autonoetic awareness. However, this possibility assumes that semantic memory is a system whose instantiation is a biological reality Occam's razor resonates with evolutionary considerations as well. Evolution builds on existing biological structures , lacking some of the structures assumed necessary for episodic recollection , nonetheless behave experience of remembering often is characterized by either a feeling of knowing or a feeling of remembering  of explaining why stimuli encoded under the process-based explanations of the remember/known phenomenon. Regardless of whether one subscribes to a dual or single process explanation , an obvious limitation is that identification of the factors responsible for whether retrieved content will be subject to autonoetic embellishment is, at present, unknown. However, a similar indictment can be pressed against most At present, there is no conclusive theoretical or empirical evidence to select between a systems-based and retrieval-based explanation of the episodic/semantic distinction . Occam's principle, while supportive of a retrieval-based view, is best treated as a logically non-binding heuristic rather than as a definitive arbiter of theoretical substantiation. Compelling empirical evidence in support of a retrieval-based interpretation comes from the fact that, on recovery of his sense ownership, the same content formerly unconnected to R. B.'s personal past re-acquired a sense of being an episodic recollection. While definitive evidence for a retrieval-based theory of episodic and semantic memory is not available at present, R. B.'s memory performance, taken in conjunction with considerations of parsimony and evolution, suggest this option should be considered a live possibility.The localization of episodic (and semantic) memory in their neural substrates has been a task that has captured the interest of neuro-imagers for several decades ; rather, the episodic/semantic division of memory comes into play at the level of retrieval rather than storage.This view can accommodate several conflicting findings in the literature. For example, while some clinical dissociations between intact and impaired memory function appear best classified in terms of a functional independence of episodic and semantic memory  content is likely to be under-represented in memory. It thus is more susceptible to neural insult than are the more richly distributed representations that ultimately will constitute semantic memory experience  from the study of a single patient (R. B.) who now has remitted. Accordingly, it is hard to see how the ideas I have proposed can be tested via experimental manipulation. There are several things to note in this regard.manipulation . While the potential for refutation is essential , refutation does not mandate explicit manipulation in an experimental context  has, to date, been underappreciated. For example, Zahn et al.  report tTaken together, these studies focus attention on ownership as an aspect, or form, of consciousness that can come undone under certain conditions . Assuming it possible to simultaneously achieve a high degree of temporal and spatial resolution using various brain scanning technologies  it should be feasible to track both the chronology and localization of neural activity during performance of a “remember/know” task. If temporal resolution is sufficiently sensitive, and the constructs in play sufficiently well defined , it would allow us to examine the stages of memory  activated during the process of declarative remembering. Anatomical localization—in conjunction with “stage” information provided by temporal data—would enable us to bring to focus the systems responsible for storage  followed by those involved in retrieval. If my model has merit, the activation of stored content during performance of the remember/know task will evidence comparable localization(s) regardless of whether the participant's phenomenological report turns out to be “remember” or “know.” Neural separation, by contrast, should be evidenced during the retrieval phase .Fourth, as things currently stand, my theory also submits to empirical testing with N = 1 studies in the development of neuropsychological models. Of course, not everyone shares this view: Some feel that theory construction requires inference from group performance , a recent paper by Rasmussen and Bernsten  attemptsThe present emendation of the episodic/semantic memory distinction awaits the considerable work of empirical conformation and theoretical accommodation. However, despite its provisional status, it has the merit of (1) being consistent with real-world data from case studies , (2) helping bring some order to the debate over whether episodic and semantic memory are best construed as functionally independent neural systems, or rather two ways scientists (though not necessarily nature) have chosen to divide up declarative memory, (3) helping make sense of impairments in mental time travel —can be taken as an “existence proof” for the proposition that the connection between autonoetic awareness and episodic memory is one of contingency rather than one of necessity. That is, R. B.'s memory phenomenology suggests that awareness is not an Memory, Ebbinghaus makes the following observation: “… in the majority of cases we at once recognize the returned mental state as one that has already been experienced; that is, we remember it. Under certain conditions, however, this accompanying consciousness is lacking and we know only indirectly that ‘now’ must be identical with ‘then’… ” (Ebbinghaus, Perhaps ironically, Hermann Ebbinghaus, a name typically associated with an approach to memory now discredited as being overly-influenced by logical positivism (e.g., Bartlett, The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Findings indicate that mindfulness improves the specific component of task set inhibition, which has previously been linked to reduced rumination. Implications regarding the potential role of task set inhibition in mediating between mindfulness and reduced rumination, as well as the role of mindfulness in “being in the present moment” are discussed.Mindfulness practice has been linked to reduced depressive rumination and described as involving inhibition of information that has been relevant in the past and is no longer relevant in the present moment. Backward inhibition (BI) is considered to be one of the purest measures of task set inhibition, and impaired BI has been linked to depressive rumination. BI was contrasted with Competitor Rule Suppression (CRS), which is another phenomenon observed in task switching, yet one which involves episodic memory tagging of information that is currently conflicting rather than active inhibition. Although similar at baseline level, a randomly assigned group ( In a changing environment, the ability to inhibit thoughts and actions which are no longer relevant is crucial for our everyday functioning and well being. Impairments in such inhibition may result in perseveration, being “stuck” in a certain way of thinking, and responding inappropriately rather than adhering to the current situation demands  episodic tagging of Backward Inhibition , and a “waiting list” group. Groups were compared on a measure of BI and CRS both before and after mindfulness training of the mindfulness group.The participants and experimental design were those used by Greenberg et al. . SeventyN = 38) intended to participate in the first program and a waiting list (control) group (N = 38) intended to participate in the second program. No significant differences were found between groups in Age , gender , nor in academic abilities as measured by self reported Psychometric Entrance Test (PET) scores, the Israeli equivalent of the SAT scores . The two groups were additionally equivalent in ratings of happiness, sadness, and general mood . As measured by asking participants to rate their current degree of happiness, sadness, and general mood on a 1–9 Likert scale. Emotion rating data were available for all but one participant later assigned to the mindfulness group. The experiment had received approval from the psychology department’s ethics committee in Ben-Gurion University.Following the first experimental session, participants were randomly assigned to a Mindfulness meditation group . Following this block, participants performed one practice block of 64 trials in which the four tasks were randomly mixed, followed by seven experimental blocks of 64 trials. At the end of each block, participants were instructed to take a short break, stretch or walk around for a short while, and continue when ready. One modification from the paradigm used by Meiran et al.  was pracThis paradigm was used to assess differences between groups in Session 2, after the mindfulness group completed the mindfulness program. This paradigm is a shorter and slightly modified version of the one described in detail by Meiran et al. . ModificA 2 × 2 array of boxes appeared onscreen with one of four possible task related cues in its center, indicating which of the four tasks is to be performed. A target stimulus in the form of one of four possible faces of young adults, two blonde and two dark-haired, then appeared in one of the four boxes. The four tasks were a horizontal location task, a hair color task, a gender task, and a vertical location task  program .A mixed design was used. Group (mindfulness vs. waiting list) was the independent (between subject) variable, and the dependent (within subject) variables were BI  and CRS  and higher than 3500 ms (outliers) were eliminated , as were the two trials following an error or the two trials from the beginning of the block were eliminated, as required to assess BI  as the independent variables, and RT as the dependent variable. A significant main effect was found for CRS, in which participants were overall slower on trials in which the relevant rule was the interfering rule in the previous trial . A just-significant interaction was found between Group, BI, and CRS . Planned comparisons indicate that participants who were later assigned to the mindfulness group exhibited a non-significant trend of a greater BI effect in the non-CRS condition , whereas those later assigned to the waiting list group exhibited a similar trend in the CRS condition . A significant main effect was also found for BI , indicating that participants were overall slower to respond on BI trials than on control trials . A similar ANOVA was conducted with Error Rate as the dependent variable. A significant main effect was found for CRS , indicating that in addition to being slower, participants were also less accurate in CRS trials. A marginally significant main effect was found for BI , indicating that overall, participants made more errors in trials which did not require BI  compared to trials which did require BI . This indicates a tradeoff between speed and accuracy for both groups, in which participants were slower but more accurate in BI trials. No other effects approached significance.A three way analysis of variance (ANOVA) was conducted, with Group (waiting list vs. mindfulness), BI , and CRS  = 0.98, ns; means are listed in Table F = 1.47, ns] after excluding participants who were excluded from analysis of the “faces” paradigm  = 12.80, p < 0.001], in which participants were overall slower on CRS trials. No significant interaction was found between CRS and Group . A main effect was also found for BI , indicating that participants were overall slower on BI trials. The interaction of Group and BI was non-significant , indicating that both groups were equally slower on trials which required BI  = 6.51, p < 0.05], yet it was statistically comparable for both groups, as indicated by the non-significant interaction . No significant main effect was found for BI , yet the groups differed in BI, as indicated by the significant Group X BI interaction , the mindfulness group exhibited an opposite (non-significant) trend  = 4.06, p < 0.05]. Although no differences between groups were found in self reported sadness, happiness, or general mood ratings following the mindfulness program , these ratings have been added as covariates in a separate ANCOVA examining a similar error rate analysis. Differences between groups in BI error rates remained significant in this case as well .A similar ANOVA was conducted with Error Rate as the dependent variable. A significant main effect was found for CRS , and therefore did not react differently to making in error or the tone played.In order to examine whether the mindfulness program altered the way participants reacted to making an error or the tone played when an error was made, post error slowing was calculated by subtracting RT’s of trial in which the previous response was correct from trials in which the previous response was an error. A In sum, with regards to CRS, both groups exhibited a reliable effect in the two experimental sessions, yet did not differ between them. With regards to BI, the waiting list group exhibited a similar BI pattern in both experimental sessions, and adopted a strategy of slower but more accurate performance on BI trials, with no indication of a reliable BI effect. In contrast, the mindfulness group exhibited a different pattern of BI results in the two experimental sessions. While their performance was similar to that of the waiting list group at baseline level , after the program they exhibited a reliable RT-BI effect with a similar trend in error rates, without an indication of speed-accuracy tradeoff. This indicates that mindfulness meditation resulted in a clear and reliable RT-BI effect as opposed to an RT-BI effect resulting from a speed-accuracy tradeoff (rather than processing efficiency) that characterized the control group.Mindfulness practice is said to be characterized by inhibition of information not relevant to the present moment . We posit, however, that such inhibition conduces much more than it impairs attendance to the present moment, as the lack of such inhibition often results in perseveration and getting “stuck” in no longer relevant mental sets  meaning that approximately half of their participants exhibited the same pattern of negative BI performance in error rates as displayed by the sample in the current study. With regards to the reliability of BI measurement, the fact that both groups in the current study exhibited a qualitatively similar tradeoff at baseline level, and that this finding was repeated by the control group at Session 2 indicates that this finding in the absence of mindfulness practice is reliable. In other words, our sample was slightly different in its characteristics than that of Meiran et al. (The speed-accuracy tradeoff observed in the current study was not significantly observed by Meiran et al. , who havn et al. , yet theComparing a randomly assigned mindfulness group with a waiting list group may be taken as a limitation of the current study, as it only enables us to attribute findings to the mindfulness intervention as a whole, rather than to specific components within the intervention, as may have made possible by using an active control group. In addition, although the relation between BI and depressive rumination has been previously established (Whitmer and Banich, The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


These confident words marked a journey of greatness started during childhood, in Figueres, Spain. In this rural town in Catalonia, steeped in artistic heritage, he started to read Voltaire, Nietzsche, Kant, Spinoza, and Descartes, and these philosophers’ notions on the nature of reality created in his mind an abiding sense of purpose.Much of Dalí’s boyhood was spent in his parents’ home at the coastal village of Cadaqués near Port Lligat, where he later made his own home. Rocks from the local beach found their way into many of his works. His early art education benefited from frequent visits with the family of artist Ramón Pichot and from studies at the Municipal School of Drawing in Figueres under engraver Juan Nuñez. Dalí’s earliest surviving works date from this period, during which he also wrote copiously and showed interest in cubism. Soon he entered the famed Academy of San Fernando in Madrid, where he met poet Federico García Lorca, who later published an ode in his honor, “O Salvador Dalí of the olive-colored voice / I do not praise your halting adolescent brush / or your pigments that flirt with the pigments of your times / but I laud your longing for eternity with limits.”As a student in Madrid, Dalí got to know the Prado Museum and the cubist works of Picasso, Georges Braque, Juan Gris, and the metaphysical paintings of Giorgio de Chirico. Encouraged by the attention of his peers and association with Lorca, he ventured outside the restrictions and requirements of the school. Increasingly disenchanted, he was suspended and later expelled by the academy, as he was at some point to be expelled from the surrealist movement, again for unwillingness to color inside the lines.In a long period of experimentation also marked by personal notoriety, Dalí took his work in many directions, from a strictly academic style to cubism. An astonishing draftsman, he drew from nature, the imagination, or classical tradition as he searched for a distinctive style. He traveled to Paris where he eagerly embraced surrealist concepts. A solo exhibition there in 1929 brought a glowing review from poet André Breton, psychiatrist and head of the surrealist group.Surrealists, Dalí among them, wanted to shake up comfortable middle class values, preferring to depict life as lived by the mind. This approach, with its probing of the unconscious, dreams, memories, and psychological associations, formed the foundation of new art rooted in paradox and contradictions rather than mimesis.Daddy Longlegs of the Evening―Hope! on this month’s cover, was inspired by war, the carnage of which Dalí experienced from close up. The Spanish Civil War took him to Paris. Shortly after his departure, the family home in Cadaqués was bombed, his own place at Port Lligat ransacked and destroyed. His friend Lorca was executed; his sister, imprisoned and tortured. Chased to Italy and then again to Paris, he lived there until the outbreak of World War II, when once more he had to flee. His work of this time grew dark and intense, evoking tragedy, melancholy, and confusion. In 1940, he emigrated to the United States, where he was to live for 8 years.Daddy Longlegs of the Evening―Hope! the landscape is denuded. On the right side, an olive tree, the perennial emblem of peace, is bare of leaves. On the horizon, two human figures are engaged in some macabre dance, their elongated shapes and ballooned sleeves mocking similar forms in the foreground. Evening shadows cast a mournful look over the scene. In the center, Dalí places his own image, a melting face drawn in the outline of his familiar beach rocks and joined to Creativity, a hollow figure draped over the tree that once nourished it.In The Philosopher’s Conquest (1914) is held by a crutch, the cannonball melting into distorted body parts, lifeless fluids, a spent sperm-like form. Out of this unlikely background emerges a bandaged Nike of Samothrace, ill-defined and threatened by a decayed horse of the apocalypse leaping from the cannon. In the lower left corner, a winged putto, messenger of love and artistic pursuits, weeps at the spectacle. But despite the devastation, a symbol of hope appears on the artist’s head: daddy longlegs, a token of good luck, amidst swarming ants.Literary and music references, two inkwells and a prominent cello, complete the hollow figure, offering clues about Dali’s state of mind. On the upper left corner, the cannon from Giorgio de Chirico’s painting μύρμηξ [murmex] “ant”) mentioned in The Iliad and described in some detail by Ovid in the Metamorphoses, were a prolific warrior race patterned after ants from whom they allegedly descended by divine transformation. The term, which has survived with various connotations, still at times denotes mindless masses or “hired ruffians,” who make up for unquestioning loyalty with sheer numbers. The term also still evokes somehow the ants of origin―the same plentiful arthropods Dalí sprinkled liberally in his paintings, along with flies and other insects―their glistening bodies clustered around the edges, foreshadowing decomposition.The Myrmidons, ant-men (from “Beautiful as the chance meeting on a dissecting table of a sewing machine and an umbrella,” is how revelatory juxtapositions were viewed by the surrealists. And the marvelous was to be detected in the everyday, the discarded, the coincidental, and the unnoticed. These ideas drove surrealism and, no longer incongruous or farfetched, now find their way in all aspects of life and no less in science.Among health threats, viruses are like the Myrmidons in their sheer numbers. Even though several thousand have been identified, the large masses remain at large. With each new identification, the public health burden increases. And this is where Dalí would insert daddy longlegs. For with each identification, the opportunity also arises for new vaccines or other prevention strategies and effective treatments, as in the case of many known viruses, including the formidable HIV.Like a surrealist painting, emergence of viruses around the globe features realities that by all appearances have nothing to link them, often in settings that by all appearances are not linked. In this issue alone, a new strain of Andes virus associated with fatal human infection was found in central Bolivia; and a new human adenovirus, in Bangladesh. Adenovirus type 7 is emerging in Malaysia. A variant West Nile virus strain, most related to the indigenous Kunjin, was characterized in Australia. Lymphocytic choriomeningitis virus–associated meningitis is reported in southern Spain; and hepatitis E virus infection, in solid organ transplant recipients in the Netherlands. The chance meeting on a “dissecting table” still applies, and the marvelous resides in identifying and controlling the Myrmidons, one by one.


Tensions between IRBs and researchers in the US and elsewhere have increased, and may affect whether, how, and to what degree researchers comply with ethical guidelines. Yet whether, how, when, and why IRBs respond to these conflicts have received little systematic attention.I contacted 60 US IRBs (every fourth one in the list of the top 240 institutions by NIH funding), and interviewed leaders from 34 (response rate = 55%) and an additional 12 members and administrators. IRBs often try to respond to tensions with researchers and improve relationships in several ways, but range widely in how, when, and to what degree . IRBs varied from open and accessible to more distant and anonymous, and in the amount and type of “PR work” and outreach they do. Many boards seek to improve the quantity, quality, and helpfulness of communication with PIs, but differ in how. IRBs range in meetings from open to closed, and may have clinics and newsletters. Memos can vary in helpfulness and tone . IRBs range considerably, too, in the degrees to which they seek to educate PIs, showing them the underlying ethical principles. But these efforts take time and resources, and IRBs thus vary in degrees of responses to PI complaints.what IRBs communicate to PIs, but how . IRBs can potentially improve relationships with PIs in several ways: using more “open doors” rather than anonymity, engaging in outreach , enhancing the tone as well as content of interactions, educating PIs about the underlying ethics, and helping PIs as much and proactively as possible. Increased awareness of these issues can help IRBs and researchers in the US and elsewhere.This study, the first to explore the mechanisms through which IRBs respond to tensions and interactions with PIs, suggests that these committees seek to respond to conflicts with PIs in varying ways – both formal and informal, involving both the form and content of communications. This study has important implications for future practice, research, and policy, suggesting needs for increased attention to not only  Conflicts between institutional review boards (IRBs) – or research ethics committees (RECs), as they are called in many countries – and researchers have mounted over recent decades, yet little systematic attention has been given to critical questions of whether IRBs acknowledge and respond to these tensions, and if so, how, when, and why. In the US and elsewhere, IRBs have been increasingly faulted for several reasons, including extension of their review into the social sciences , and disstatus quo should be altered, and if so, how. Critics have call for increased centralization  were afraid it wouldn’t get through. Everybody really appreciated it – both the IRB members (because they got better protocols), and the investigators . IRB28""We started doing clinics. Researchers can meet with a subset of the IRB, and talk about what they want to do, and how to write their protocol. That helped. It was in a sense a Such meetings and workshops may enhance openness, transparency, and communication.IRB28""The clinics showed the investigators what we’re thinking, and brought them into the process, rather than just dropping the protocol off in some box, with a closed door. To improve relationships, other IRBs established on-line or in-print newsletters with updates – e.g., a “tip of the week.” As one chair said,IRB world, and don’t know something has changed until it gets sprung on them. They said, “We’d like to know ahead of time what’s going on.” So, we established “The Tip of the Week.” It was easy to email: write it once, click a button, and send. IRB4""We did a newsletter to keep people up-to-date, because they are not in the IRBs can also disseminate such “tips” in response to errors that PIs may make. Thus, such advice can also potentially help prevent problems. This chair continued,IRB4""A couple of investigators changed a study, and the IRB didn’t become aware until the protocol came up for renewal. So, we sent out a “Tip of the Week” that said you can’t do that! “But if a subject is on site, and a procedure needs to be repeated, and the PI’s best medical judgment is that it needs to be repeated, then repeat it. Don’t wait for IRB approval.” We tried to put federal regulations into a real world environment. Such advice may thus be helpful in several ways.Yet these efforts can consume much of a chair’s or administrator’s time. A chair who spends a lot of time with PIs to diminish the IRB’s reputation of being obstructionistic may find that these activities take more time than he or she is compensated for. The chair above said his time is billed at 20%, but is really 35–40%.IRB4""I spend more time with investigators than do any of our members, because I am so sick and tired of hearing that the IRB is a roadblock or a stumbling block. I don’t like the committee having that reputation. So I work very hard with our investigators to make that not the case. vs. limited resources.The time demands of such enhanced IRB availability can necessitate difficult tradeoffs, and cause tensions. IRB chairs and administrators can become overwhelmed, and need to weigh the advantages of open doors Hence, while some chairs are highly concerned about PI complaints and try hard to reduce these, other chairs may be far less responsive or flexible. The latter may remain more removed from PIs, and interact with them more indirectly. IRBs may also struggle to achieve a balance. Boards may try to adopt an overall “open” policy, but adjust and limit their approach with difficult PIs over time.IRB40""Some people are chronically unhappy – complainers. No matter what we do, they’re unhappy. So, we try to be diplomatic, gracious, and non-confrontational, but hold our ground. We’re not going to cave in just because somebody is yelling at us. We can’t turn the world on its head because a PI got his protocol in late! (IRB23)IRBs often sought to improve, too, the quantity, quality, and helpfulness of written communication with individual PIs, but varied in how and to what degree they did so. Both the content and the tone of communication and interactions can be important. Some chairs write lengthy memos to PIs in response to submitted protocols, assisting these PIs in rewriting studies. Yet these activities can take time, and chairs and staff may therefore carefully choose to which PIs and studies to devote such efforts. As one administrator said, “Some people just want you to write the darn thing for them. That’s not my job.” Hence, if a PI has a track history of poorly written proposals, the IRB may invest less such effort.IRB40""For a very flawed study, I am much more likely to write back a three-page letter with 20 points, basically re-writing the protocol for them, than I am to disapprove it. I disapproved one from an investigator with a track record of submitting flawed protocols, and sloppy work – making us do a tremendous amount of work. Instead of doing the work for him for the fifth time, I said, “No. Here are the major problems. Fix it.” Instead of a three-page letter, I write a half-page letter, identifying the major issues, and put the ball back into their court. However, for various reasons, PIs may not all respond to these efforts as IRBs expect or hope. Interviewees felt that PIs revise and resubmit most, but not all, protocols. After receiving the three-page memo mentioned above, this chair said that the PI never resubmitted the proposal.IRB40""I wrote an extensive, helpful letter, and he never responded. My guess is that he couldn’t fix it, and was overwhelmed. He is not a good researcher. But, for 99% of researchers, the concerns are fixable. They fix them, respond, and move on. content of communications, but the tone as well. Several chairs tried hard to use a respectful tenor that gave the message that the IRB wishes to be helpful, not obstructionistic; but such an approach was not always easy to establish and maintain.IRBs also attempt to mitigate friction with individual PIs through not only the Several interviewees described the importance of having what one chair calls a “deft touch.”a deft touch. I don’t know if I’m even good at it – I hope I am. But that’s what I try to do. I’d much rather somebody get a phone call from me, since I’m also a doctor, and have done research, than just hear from somebody in the office that they didn’t do something. IRB32""I always fear that faculty feel worn down by regulations, and don’t have enough time for anything. I just try to get them to keep true to the IRB’s mission, and not just dismiss it as a whole set of hoops they have to jump through. Sometimes that just requires Chairs may thus also be uncertain as to how effective they are in these efforts. Achieving this tone, while simultaneously ensuring that PIs are following the regulations, can also be among the most difficult aspects of IRB work – doing PR while trying to protect subjects as much as possible.tone. IRB16""The hardest part of being an IRB administrator is walking this fine line. We are facilitators as well as monitors, and maintain a positive PR – we’re here to facilitate and help you with the process. At the same time, we’re here to make sure you comply with the regulations. Keeping the line of communication and trust open is critical, and setting the IRB chairs may thus struggle to have their staff use “the right manner” to improve relationships with PIs, but establishing and maintaining such a tone may in part be an innate ability that not everyone equally shares.We don’t want to be one of those IRB offices that people hate, and complain about all the time. IRB18""It’s a challenge not only to find folks who have the talent for IRB work, but to teach people to get the right tone and balance, not shaking a stick at researchers, but trying to be collegial, and knowing when and how to make exceptions, be flexible, or compromise. To strengthen relationships with PIs, and defuse friction, one chair tries to “say no with a smile” (IRB29) for unrealistic requests for rushed approval. An administrator, originally from the South, uses “Southern charm” and a sense of humor. When PIs don’t turn in paperwork, she says she tries to take the blame, rather than confronting them with their negligence.today?” I say that because I’m not saying that they didn’t turn it in. I’m trying to give them an out so that they don’t have to say, “I promised that, but have no idea what happened!” It works a lot better for me to say, “I’m so sorry: it was in my hands and I must have misplaced it. Do you have another copy?” rather than, “Oh, we never received it.” They know they didn’t bring it. But we say, “We have looked high and low for that, but if you bring us another copy this afternoon, we’ll see if we can work it into the schedule.” It just doesn’t do any good to make demands. Let’s just move forward and see what we need to do to get everything running again. IRB13""PIs will say they brought paperwork over, and I know they didn’t. They are sure. So most of the time, if there was an error, or they didn’t send something, I try to be first to say, “You brought that consent form to me the other day, and I have absolutely no idea what I’ve done with it. Could you send me another one, please?” It doesn’t really bother me anymore. PIs will backdate memos to the IRB, but we have a time-clock. I’ll say: “I know you intended to get that over here. I’m so sorry. Can we deal with it now? How can we help you Thus, IRBs can seek to defuse potential tensions before these erupt.(IRB26).Interviewees felt that PIs and research staff range widely in quality and quantity of prior education concerning research ethics and IRB procedures. Interviewees thought that institutions vary in whether they require training in the Responsible Conduct of Research (RCR) for all staff involved in all research, and if so, how much. Several interviewees want the federal government to mandate comprehensive training more clearly, “requiring education in human subjects protection for everybody” Since IRB members sensed deficits in investigators’ training in these areas, “research ethics training,” now formally required by many institutions, may often consist merely of relatively short on-line exercises. Key aspects of issues, such as definitions of “adverse events,” may not be included in Good Clinical Practices or Responsible Conduct of Research courses. Yet interviewees felt that researchers may resent additional requirements.trainees may pose particular challenges. Interviewees were often unsure where and to what degree junior PIs have learned about research ethics. Interviewees thought that at some institutions, residents and other trainees were mandated to do research, but may lack adequate methodological or research ethics training. IRBs often felt that some trainees may have deficient education in appropriate research design . “Residents say, ‘My faculty mentor told me what I need for the IRB,’ and the mentor is somebody I’ve never heard of, who’s never done research.” (IRB13)Research conducted by Some IRBs try to explicitly show PIs the regulations, to demonstrate that the IRB is not arbitrary in its use of power.IRB25""When you can tell a researcher, “The FDA says, ‘No, you can’t do this,’ or ‘You should do this,’ or ‘have to do this,’” they understand. If you can show them the regs, they’re even happier. Other chairs explain to PIs not just the regulations, but the larger underlying ethical principles as well.what they need to do, but why. It’s not what you say, it’s the way you say it. IRB26""There’s nothing worse than saying, “The regulation’s required.” You always have to tie it back to an ethical principle – say not only Again, how IRBs communicate can thus play important roles, but can vary. Not all IRB staff may offer such broader explanations.Interviewees also felt that challenges existed in getting PIs to appreciate the ethics underlying the regulations. At times, interviewees thought that researchers resisted, or were not interested in these explanations. The guidelines themselves could also shift over time.the reason behind the regulation, is a challenge – being current on regulations and institutional and regulatory expectations. IRB28""Getting faculty or investigator buy-in, so that they understand IRBs often felt that many PIs simply completed the necessary paperwork as requirements, not thinking of these documents as concerning larger ethical principles.IRB28""They don’t think through the reasons why there’s compliance, or put it in an ethical context. Whether the answers are right or not may not matter to them. Several interviewees felt that IRB procedures and protections can themselves evolve to defend the institution from liability more than protect the well-being of subjects – thereby undermining PI dedication to these processes as ethically important.ethics, rather than in institutional protection. IRB28""Optimally, there would be an ethics and integrity arm of research, and the compliance committees’ forms under that – bathed in Encouraging PIs to appreciate the principles underlying IRB concerns or requests regarding a particular study may also require resources that IRBs may lack. This former chair continued,IRB28""Everything would come out better if a staff person would spend time with each investigator to improve understanding of the ethics behind the regulation, and help them write protocols in a more informed way. The science would be better, the subjects would end up better, and the investigator would feel a lot more buy-in. This study, the first to explore the mechanisms through which IRBs respond to tensions with PIs, suggests that these committees react to conflicts with PIs in a variety of ways – both formal and informal, involving both the form and content of interactions and communications. These boards differ in how and to what degree they explicitly address conflicts with PIs – from proactively helping researchers respond to ethical concerns, to being less involved, and more anonymous. These data suggest that IRBs can potentially improve relationships with PIs in several ways, using more “open doors” rather than anonymity, engaging in outreach , enhancing the tone as well as content of interactions, educating PIs about the underlying ethics, and helping PIs as much and proactively as possible. Still, these efforts can require resources, and encounter PI resistance.While prior studies of IRBs have tended to be quantitative, and to view IRBs as static, the present data illuminate how these committees interact with PIs within the context of dynamic and evolving relationships with individuals PIs. These data thus highlight how IRBs operate as part of complex social systems, and serve as critical mediators between federal regulations and individual researchers.IRBs face tensions partly because PIs may in effect “blame the messenger” (the IRB) for the news (that these regulations need to be followed). As IRBs have certain power , they cavs. openness) can exacerbate PI frustrations with, and demonization of, IRBs. It may be easier to demonize an “anonymous” bureaucracy, rather than fellow human beings. IRBs, more than researchers, may prefer the lack of transparency and argue that keeping minutes private is easier than making this documents more available and redacting details. But, that objection may not sufficiently offset the potential benefits of openness in fostering ethical behaviour. Redaction may be possible. These interviewees thus raise questions of how much anonymity is or should be permitted.As bureaucracies, IRBs vary not only in the formal social structures they establish, but in their tone and attitudes, which can shape how communication occurs, both formally and informally. IRBs face choices concerning how, when, and to what degree to interact and communicate with PIs, monitoring and seeking to shape these researchers’ attitudes and behaviours. A lack of transparency , and to examine the lived experiences of IRBs and PIs – the ways interactions about ethics are carried out that can thus shape the effectiveness of these interactions.This study suggests needs for increased attention to not only vs. protecting subjects. The strategies presented here  may not wholly eliminate tensions, but can help.Federal regulations do not explicitly discuss these issues, and some IRBs have developed their own approaches that can potentially be adopted more widely. In part, tensions may exist between IRBs and PIs because of underlying conflicting priorities – pursuing research structure, but the content and tone of interactions are crucial. For full board reviews of multisite studies, for instance, centralization alone thus may not resolve all tensions. To reduce these strains, these data suggest that informal behaviours and attitudes of both IRBs and PIs should also shift.For several reasons, including desires to improve relationships between IRBs and PIs, the ANPRM seeks to make formal structural changes  ,9,22. Bustatus quo can be improved by encouraging IRBs to try to ameliorate strains with PIs by adopting such approaches. Specifically, IRBs should realize more fully that they have a certain degree of latitude in their interactions with PIs, and can strengthen these relationships through not only what, but how they communicate. If an IRB lacks resources to institute some of these practices, the chair can potentially present these possible approaches to institutional leaders, highlighting the benefits, in hopes of garnering additional funds.While limited resources may restrict these committees in certain ways, other IRB approaches to enhancing relationships with PIs require relatively little time and energy . Hence, the informal micro levels as well – at the level of daily interactions and lived experiences.These data thus underscore the importance of trying to enhance IRBs and their interactions with PIs through not only formal macro policy , but more fill these functions. The present data suggest that implicit and explicit attitudes and tone need to be addressed as well, perhaps through further, finer-grained, and more nuanced education, and heightened awareness of these issues. Moreover, IRBs face challenges in part because the system is not static, but fluid, with new scientific methods and new trainees.As a potential solution to many of these problems, the Institute of Medicine (IOM) report of almost 10 years ago supported IRB accreditation, which has since spread widely. Yet the current data suggest limitations in accreditation: it provides standards for formal mechanisms, but does not address many aspects of how IRB personnel in fact Future research is needed to examine more fully how IRBs work within these dynamic relationships with researchers – how often, when, in what ways, and to what degrees IRBs in fact adopt the range of approaches described here; how successful each of these strategies are, and can be; and what factors are associated with IRB decisions to adopt or avoid these techniques. In part, IRB chairs may make these choices based on the degrees to which they and/or their members are “pro-research;” and their prior attitudes and perceptions concerning relationships with PIs. Future studies can thus probe more fully how IRBs make these decisions, and whether and how the approaches presented here can lower tensions, and thereby enhance PI cooperation and compliance with regulations, improving human subject protection.The potential benefits of creating cultures of “compliance” and of “conscience” have been described -25, but These data also have important implications for professional education of IRB chairs, members and staff, research investigators and staff, and trainees – to enhance their interactions as effectively as possible.per se, but are nonetheless valuable in and of themselves. Interviews also did not include PIs at each of the institutions contacted. However, future studies can employ these approaches. These data reflect on in-depth interviews with IRB chairs and members, and did not include direct observation of IRBs engaged in meetings, or of written IRB records. Future research can observe IRBs and examine such documents. Yet these added data may be hard to procure since, anecdotally, IRBs have often required researchers to obtain consent from all IRB members, the PIs, and protocol funders.This study has several potential limitations. These interviews explored subjects’ views now and in the past, but not prospectively over time, to explore changes. Participants’ statements reflect their views and attitudes, and do not necessarily represent objective “fact” In sum, IRBs range considerably in whether, to what degree, and when they adopt strategies that may potentially reduce tensions with PIs. Federal regulations do not mention these approaches; yet increased awareness of the range and benefits of these strategies can potentially improve IRB interactions with researchers, thus enhancing the dual goals of promoting socially beneficial science, while protecting study participants.Note: Additional follow-up questions were asked, as appropriate, with each participant.▪ How do you define research integrity (RI)? Do you think IRBs and PIs view or approach RI differently, and if so, how, when, and why? Have you seen problems in PI non-compliance with IRB regulations? If so, what kinds of problems? How do you address these?▪ What kinds of tensions, if any, has your IRB faced with PIs concerning RI or other, related issues?▪ Has your IRB ever tried to address these tensions? If so, how, when, why, and with what success? What barriers, if any, did you encounter? What, if anything, has helped in addressing these tensions with PIs? How, when, why, and with what result?▪ Do you have any other thoughts about these issues?The authors declare that they have no competing interests.RK designed and conducted the study, and wrote and approved the final manuscript.