In all five experiments rare oddballs occurred randomly within longer sequences of more frequent standards. Oddballs and standards all consisted of rapidly-presented runs of five pure tones (Experiments 1 and 5) or five colored annuli (Experiments 2 through 4) somewhat analogous to simultaneously-presented feature-present and feature-absent stimuli in typical visual search tasks. In easy tasks feature-present reaction times and P300 latencies were shorter than feature-absent ones, similar to findings in search tasks with simultaneously-presented stimuli. Moreover the P3a subcomponent of the P300 ERP was strongly apparent only in the feature-present condition. In more difficult tasks requiring focused attention, however, RT and P300 latency differences disappeared but the P300 amplitude difference was significant. Importantly in all five experiments d’ for feature-present targets was larger than that for feature-absent targets. These results imply that sequential search asymmetry arises from discriminability differences between feature-present and feature-absent targets. Response time and P300 latency differences can be attributed to the use of different attention strategies in search for feature-present and feature-absent targets, indexed by the presence of a dominant P3a subcomponent in the feature-present target-evoked P300s that is lacking in the P300s to the feature-absent targets.We conducted five experiments in order to explore the generalizability of a new type of search asymmetry, which we have termed  What happens when such a stimulus is not a distractor but instead signals the occurrence of a sought-after target? We address such questions in the context of a novel “search” paradigm utilizing longer sequences comprised of brief runs of auditory and visual stimuli. These stimuli are similar enough to previously used ones to invoke similar explanatory principles but different enough to shed new light on some old problems.What is the relationship between search through a static environment and search through a dynamic environment? Do we use similar mechanisms to look for features in a dynamic environment as in a static environment? In particular, does search through dynamic environments lead to asymmetries with respect to the presence or absence of particular features in the stimuli as it does in static environments? What do such asymmetries have to do with the P3a and P3b event-related potential (ERP) components? Moreover, the P3a is supposed to be related to the attention orienting response caused by a rare, unpredictable but very salient patterns, however, generated a P300 ERP response only in conscious controls and weakly in a few minimally conscious patients. These data suggest that detecting this kind of pattern change is not automatic and does require somewhat intact consciousness and sustained focal attention.We had replicated, conceptually and for a different purpose, a study by Bekinschtein and colleagues . That stWhile performing our replication of the Bekinschtein et al.  protocolThese two different stimulus sequences thus seem to make very different demands upon attention. Detecting rare patterns that include a tone change would seem to require only diffuse voluntary (top-down) ongoing attention to the sequence of unchanging patterns, as the deviant tone in a rare changing pattern easily recruits bottom-up attention when it is encountered. In contrast, detection of the rare patterns that lack a tone change would seem to require sustained, voluntary (top-down) focused attention to each pattern in a sequence mostly comprised of patterns that possess a tone change, as there is no tone deviant to recruit bottom-up attention in the unchanging pattern .visual search asymmetry phenomena, begun by Neisser [feature present condition the item with the extra feature popped out, and search time was consistently low regardless of number of distractors. For example, a symbol like the letter Q pops out amongst an array of Os (feature absent condition), however, search for a target with a missing feature was said to be serial and self-terminating, and search time varied with the number of distractors. Search time for an O amongst an array of Q-like symbols, for example, is longer and increases with the number of Qs. This kind of search asymmetry is consistent with Treisman’s feature integration theory [This speculation is reminiscent of a large body of work on  Neisser  and popu Neisser ,5 as a t Neisser , in partay of Os . When thn theory , as itemflat run) or is different from them in frequency . These auditory stimuli aren’t completely analogous to the visual stimuli, however, as what differs between the visual stimuli is the addition of a feature, not a feature change. Indeed, the auditory frequency of the tones in our stimuli is what Treisman and Souther [The two rare auditory pattern detection tasks from our replication of the Bekinschtein et al.  study an Souther  called a Souther . Thus, fOne critical difference between the paradigms is that distractors are not simultaneously present in the Bekinschtein et al. paradigm. We will deal with this difference in what follows. Another is that it is difficult to manipulate distractor set size in order to confirm a flat search slope for pop-out targets. Thus, other techniques must be used to identify different search strategies, as parallel processing of the entire array is ruled out by the serial nature of the stimulus presentation. Electrophysiological measures will help in this regard.differences in search strategy. Rather some other feature of the stimuli and/or task must be responsible for those differences. One rather obvious possibility, given the earlier discussion of auditory and visual feature maps, would be that feature-present targets stand out more in the relevant feature maps in the brain. Hereafter, we sometimes refer to this possibility as a “perceptual” locus for the asymmetry, emphasizing that some aspect of perceptual processing, unrelated to any difference in attention strategy, is responsible for the observed differences in response to targets in the different conditions.Luck and Hillyard  conceptuOf special interest here, is the study by Luck and Hillyard . They foshapes of the P300 responses in Luck and Hillyard’s [In addition to peak latencies and amplitudes differing, however, the llyard’s  experimellyard’s ,10. One llyard’s . The P3allyard’s . The P3allyard’s . A seconllyard’s , it is ld’) in detecting the warble-tone target among the pure-tone distractors than in detecting the pure-tone target among the warble-tone distractors. In the context of a number of other variations designed to rule out some peripheral auditory processing mechanisms as the source of this asymmetry, they concluded that the use of different search strategies was the best explanation for the auditory search asymmetry that they had observed.Search asymmetries have been discovered in other sensory modalities as well. Several studies have confirmed similar asymmetries in haptic search –15, but The mismatch negativity (MMN) has been used to investigate how the auditory system responds to deviations in tone patterns in long sequences –19. A feFive experiments were conducted to address the above-described issues. As mentioned in the introduction, the first was a conceptual replication of the Bekinschtein et al.  auditoryaway from a participant’s current task, because the P3a is typically studied as a response to highly salient and unpredictable task-irrelevant oddballs. The P3a contribution to P300 responses made to rare salient and unpredictable task-relevant oddballs, and subsequent behavioral responses, has therefore been largely ignored. Exploring the relationship between P3a/P3b and behavioral responses to task-relevant oddballs may provide a deeper understanding of when and how the proposed attention-orienting mechanisms are used during search tasks, and in particular how they may be associated with search asymmetry behavior.To date, attention-orienting models involving the P3a have only been associated with attention orienting As mentioned in the introduction, Experiment 1 was a conceptual replication of the study by Bekinschtein and colleagues  and alsodifferent P300 responses to the easy (for example search for a Q among O’s) and difficult (search for an O among Q’s) visual search tasks. Given the apparently different demands of the two auditory pattern search tasks described above it seems likely that there should be different ERP responses to the two auditory pattern types (changing patterns embedded in unchanging ones and unchanging patterns embedded in changing ones) as in the two visual array types in the Luck and Hillyard [Bekinschtein et al.  establisHillyard  study. THillyard , we analData were collected initially from 20 participants who were recruited via the UBC Psychology Department’s online experimental participant recruitment site and via a poster on the Department’s participant recruitment bulletin board. From 15–25 participants has been shown in previous studies in our lab and others to yield reliable EEG data for either ERP or connectivity analyses given the numbers of stimulus trials in the study design. Data collection was stopped after the indicated number of participants had been included. Data from three participants were excluded because of excessive noise in their EEG. Thus the analysis to be described is based on 17 participants . All aspects of the experimental protocol, including the recruitment and consent procedures, were approved by the University of British Columbia Behavioural Research Ethics Board in accordance with the provisions of the World Medical Association Declaration of Helsinki. Participants gave written informed consent by reading and signing the approved consent document, and were offered monetary compensation ($10/hr) for their participation. Participants were all right-handed and reported no hearing or neurological difficulties.flat runs and change runs  script. The tones were administered binaurally at 70 dB through insert earphones (EAR 3A) in a sound-attenuating chamber. Stimuli were presented and responses registered using Presentation software . Tone runs were generated using Audacity (Sourceforge). Auditory stimuli consisted of two types of five-tone runs called runs see . Flat runot every time they heard a tone that differed from the previous tone.Once participants were comfortably seated in the sound-attenuating chamber they were familiarized with the stimuli and protocol. Each participant heard four extended oddball sequences of tone runs (about 35 mins per sequence) in randomized order per subject see . Each seEEG signals were digitized at 500 Hz  from a 60-channel electrode cap  referenced to the right mastoid. Before digitization EEG signals were amplified and analog bandpass filtered from 0.1 Hz to 100 Hz . Eye movements were recorded with four periocular electrodes. All electrode impedances were kept below 10 kΩ (input impedance of the amplifier was > 2 gΩ)EEG data were analyzed using EEGLAB software . First tP300s were characterized as difference waves between a P300 response to the final tone of a run when that run was the target run compared to when that run was the standard non-target run. For example, we used a change run when that run was the rare target run and that same run when it was the frequent standard run to characterize a feature-present P300. This allowed a determination of the effect of the longer-sequence role alone on the P300, independent of the physical makeup of the run. Latencies were determined by measuring the time difference between the onset of the final tone in a run and the moment of the maximum amplitude of the average difference wave between 200–1000 ms after final tone onset, for each participant separately. This range represents rough estimates of the beginning and end of the entire P300 ERP morphology, taken from the grand average difference wave  of each condition from the zero crossing where the potential begins to ascend from zero to the second zero crossing where the potential descends to zero. Amplitudes were determined by taking the average amplitude of the grand average difference wave (as above) over an interval 20 ms to either side of the maximum, for each participant separately. We did not do adaptive filtering, either here or in the following experiments, to compensate for latency jitter ,27. Prevη2 as effect size for the overall analysis and partial η2 (η2p) for the univariate F-tests for planned comparisons  the ‘feature-absent’ condition, and those in which the rare runs were the change runs (change-up and change-down) the ‘feature-present’ condition even though “feature-change absent” and “feature-change present” is what is meant. Mean response times and ERP latencies and amplitudes were compared with MANOVA for repeated measures with sons see .d’s are compared using a variance estimate based on the number of overall signal present and signal absent trials in this yes-no-type design. The results of this analysis for Experiment 1 and those for all subsequent experiments are given in d’ in Experiment 1 differs between the two conditions although both d’s are large, indicating excellent discriminability overall. Nonetheless these results indicate that discriminability of feature-present targets is significantly greater than that of feature-absent targets. This result is consistent with the response latency results and indicates that there was no large speed-accuracy tradeoff.We computed difference waves from the ERPs to the final tone (onset at 600 ms relative to the onset of the first tone) of each run type when that run type was rare and when it was common. These difference waves reveal the ERP effect of detecting a feature-present target or feature-absent target in the absence of any physical differences between the stimuli. The difference waves comparing the ERPs to the identical run type when it was rare and when it was common are displayed in F1,16 = 17.44, p = 0.001, η2 = 0.27). No other effects were significant. F-tests for each of the (planned) comparisons described above.The overall effect of the feature-present vs feature-absent factor  for P300 latency was significant in the repeated measures MANOVA . The planned contrast between conditions at electrodes Fz and FCz also was significant . This result is consistent with the presence of a larger P3a subcomponent in the P300 response in the feature-present condition that was lacking in the feature-absent condition. There were also significant main effects of condition as described above  and electrode .In addition to the difference in peak latency just described, the P300 response differed in scalp topography between feature-present and feature-absent conditions  to confirm that the similarities between visual and sequential auditory search behavior discovered in Experiment 1 are generalizable to sequential search tasks regardless of stimulus modality (Experiments 2 and 3), and b) to investigate whether the effect in our sequential paradigm arises from differences in target-distractor discriminability between feature-present and feature-absent conditions, or rather if it only arises upon the deployment of different attention strategies to deal with different stimulus contexts (Experiments 4 and 5). Experiments 2, 3, and 4 are presented together as their stimuli and study designs are almost identical and their data were taken from the same group of participants. The data from these experiments, however, were analyzed separately, for reasons that will become clear. Experiment 5 is presented separately as it not only uses a very different design but also a different group of participants.substitutive features [For our visual analog of the auditory runs of Experiment 1, we created sequences of common and rare flat and change runs of visual stimuli that required serial search just as did the auditory runs. Experiments 2 and 3 were designed to confirm that sequential visual search yields comparable results to sequential auditory search showing that the sequential search results aren’t unique to the auditory system. Experiment 2 used color differences (yellow and blue) whereas Experiment 3 used contrast differences (black and white) to explore sequential search asymmetry. Both color and contrast are features  where thData were collected from 19 participants who all participated in Experiments 2, 3, and 4. Participants were recruited via the UBC Psychology Department’s online experiment participant recruitment site and via a poster on the Department’s participant recruitment bulletin board. From 15–25 participants has been shown in previous studies in our lab and others to yield reliable EEG data for either ERP or connectivity analyses given the numbers of stimulus trials in the study design. Data collection was stopped after the indicated number of participants had been included. Data from 3 participants were excluded due to excessive EEG noise or stimulus presentation error. The analysis is based on 16 participants . All aspects of the experimental protocol, including the recruitment and consent procedures, were approved by the University of British Columbia Behavioural Research Ethics Board in accordance with the provisions of the World Medical Association Declaration of Helsinki. Participants gave written informed consent by reading and signing the approved consent document, and were offered monetary compensation ($10/hr) for their participation. Participants were all right handed and reported no vision or neurological difficulties.2) and blue  in Experiment 2, black  and white  in Experiment 3, and two different shades of grey in Experiment 4, where the lighter shade was always . The darker shade varied between  and  to accommodate each participant’s ability to discriminate between the flat and change runs at these low contrast levels. One participant required a larger difference: light  and dark .Visual stimuli were generated and presented using Presentation software , and they appeared on an 18.5-in CRT monitor running at 77 Hz placed at a viewing distance of approximately 60 cm from the participant. Stimuli in each experiment consisted of two types of five ring (annulus) runs, flat runs and change runs. Flat runs consisted of five identical rings whereas change runs consisted of four identical rings followed by a fifth ring that differed by some feature. The fifth ring of the change runs differed in color in Experiment 2, in contrast in Experiment 3, and grey-scale value in Experiment 4. Runs consisted of a combination of 2 dimensions of the same feature: yellow  were presented in the same random order and participants were asked to verbally identify each run by saying “flat” or “change.” The shades of grey were adjusted as necessary so that each participant could identify every run with near perfect  accuracy. The calibration was repeated until each participant reached this accuracy threshold. This calibration was only performed for Experiment 4 because during a behavioral-only pilot run of this protocol participants reported that discriminating the stimuli in Experiments 2 and 3 was very easy without adjustment, whereas discriminating the stimuli in Experiment 4 was overall much more difficult and the difficulty varied across participants.Each subject participated in all three experiments, and the order of their presentation was determined using a Latin square design. Each experiment consisted of 4 oddball sequences (about 4 mins each) presented in randomized order. Each sequence consisted of two run types: one common and one rare. Sequences began with 30 instances of the common run. Thereafter rare runs were presented randomly among common runs. Rare runs were presented on 20% of occasions and common runs were presented on 80% of occasions, so in each sequence participants saw between 21 and 29 rare runs (except that Experiment 3 one participant saw 16 rare runs in one sequenced and in Experiment 4 a different participant saw 39 rare runs in one sequence). At least two common runs occurred before and after each rare run. Participants were instructed to click a mouse every time they saw a rare run and their reaction times were recorded. It should be noted that it was made clear to participants that they were only to respond when they saw a rare run, not every time they saw a ring that differed from the previous ring.EEG recording and ERP extraction were nearly identical to that of Experiment 1 save for the latency windows from which the peak amplitudes were determined. The latency window for Experiments 2 and 3 was 200 to 700 ms and for Experiment 4 it was 350 to 750 ms after the onset of the last ring. As in Experiment 1 these ranges represent rough estimates of the beginning and end of the entire P300 ERP, taken from the grand average difference wave  of each condition for each experiment.Data analyses and terminology are identical to those used for Experiment 1.d’ was greater for the feature-present than for the feature-absent conditions for both Experiments 2 and 3, again consistent with the response latency results and ruling out a large speed-accuracy tradeoff.The response times to correctly detect the rare target run (hits) were calculated from the onset of the fifth ring in the run separately for feature-absent and feature-present conditions for all three experiments . Tables d’ was significantly greater for feature-present targets than for feature—absent targets  in each run type are displayed in Figs F1,15 = 5.04, p = 0.04, η2 = 0.13, and F1,15 = 7.05, p = 0.018, η2 = 0.19 respectively) and no other effects were significant. Similarly, the main effect of that factor was significant for P300 amplitude  and again no other effects were significant. Tables F-tests of P300 difference waves for the separate conditions of Experiments 2 and 3.The overall main effect of the feature-present vs feature-absent factor in the repeated measures MANOVA was significant for P300 latency in both Experiments 2 and 3 . No other effects were significant.In Experiment 4 the P300 responses are somewhat different ; the interactions largely reflected a slower decline in P300 amplitude away from Pz for the feature-present condition than for the feature-absent condition  and the main effect of electrode was significant for Experiments 3 and 4 .These impressions were confirmed by MANOVAs for repeated measures (again collapsing across the different change and flat runs) with condition and electrode as factors (same as in Experiment 1). In both Experiments 2 and 3 the interaction between condition and electrode was significant  within the change runs, whether rare or common, like those present in Experiments 1, 2, and 3. By using this roving paradigm we expected to be able to obtain converging evidence of the locus of the sequential asymmetry effect.Data were collected initially from 23 participants. Participants were recruited via the UBC Psychology Department’s online experiment participant recruitment site and via a poster on the Department’s participant recruitment bulletin board. From 15–25 participants has been shown in previous studies in our lab and others to yield reliable EEG data for either ERP or connectivity analyses given the numbers of stimulus trials in the study design. Data collection was stopped after the indicated number of participants had been included. Two participants opted to discontinue the task prior to completion and thus these data were not included in analysis. Of the 21 remaining participants, data from three participants were excluded due to extreme behavioral measures  for either feature-present or feature-absent conditions, or for excessive noise in the EEG recordings. Thus the analysis to be described is based on 18 participants . All aspects of the experimental protocol, including the recruitment and consent procedures, were approved by the University of British Columbia Behavioural Research Ethics Board in accordance with the provisions of the World Medical Association Declaration of Helsinki. Participants gave written informed consent by reading and signing the approved consent document, and were offered monetary compensation ($10/hr) for their participation. All participants but one were right-handed and no participants reported hearing or neurological difficulties.flat runs and change runs as in Experiment 1. In Experiment 5 however flat runs and change runs were built from combinations of nine different frequencies that ranged from 450 Hz to 850 Hz and were separated by 50 Hz steps. There were seven different flat runs which consisted of 500 Hz, 550 Hz, 600 Hz, 650 Hz, 700 Hz, 750 Hz, and 800 Hz tones. There were 14 different change runs where the first four tones were one of the seven frequencies used to build the flat runs, and the fifth tone was either one step higher or one step lower than the previous four. For example there were two change runs that began with 500 Hz tones, but one change run ended with a 450 Hz tone whereas the other ended with a 550 Hz tone  script. Individual tones in a run were stitched together using Audacity (Sourceforge). Tones were presented binaurally at 70 dB via insert earphones (EAR 3A) in a sound-attenuating chamber. Stimuli were presented and responses registered using Presentation software . Auditory stimuli consisted of two types of five-tone runs not every time they heard a tone that differed from the previous tone.Once participants were comfortably seated in the sound-attenuating chamber they were familiarized with the stimuli and protocol. Each participant heard eight extended oddball sequences of tone runs (about 4.5 mins per sequence) in randomized order per subject. Each sequence began with 30 instances of common runs. From then on the rare run was presented on a random 20% of occasions among 80% common runs. In each sequence rare runs were heard between 18 and 30 times. There were always at least two common runs before and after each rare run. The base frequency of each run was randomly selected from the range of stimulus frequencies (described above) with the exception that each run, common or rare, was never identical in base frequency to the run that preceded it. The eight sequences of runs consisted of two types that were each repeated four times: (1) common flat/rare change; (2) common change/rare flat. Participants were instructed to click a mouse every time they heard a pattern oddball (rare run) and their response times were recorded. It should be noted that it was made clear to participants that they were only to respond when they heard a change in the global pattern, i.e. a rare run, EEG recording and ERP extraction were identical to that of Experiments 1–4. The latency window from which the peak amplitudes were determined was 200 to 1000 ms after the onset of the last tone.Data analyses and terminology were identical to those used for Experiments 1–4, except that in Experiment 5 there were many more different flat and change run stimuli than in the previous experiments, and thus there were many fewer trials of each specific stimulus run. In other words whereas all of the stimuli in Experiments 1 through 4 comprised four different specific runs, two change and two flat, Experiment 5 consisted of 21 different specific run stimuli, seven flat and 14 change. These 21 different run stimuli were distributed roughly evenly among each block depending on block type, although in feature-present-target blocks there were 80% flat runs and in feature-absent-target blocks there were 80% change runs, which is the same across all five experiments. Having fewer trials of each run meant that all change runs and all flat runs needed to be collapsed within each condition so that the ERP and behavioral analyses would be based on sufficient trials per condition. Collapsing across specific run stimuli prevented an analysis of the P300 difference wave generated by subtracting the ERP to the exact same run when it was common from that when it was rare, as was done in Experiments 1 through 4. Instead the P300 difference wave generated by subtracting the ERPs to all flat runs when they were common from those when they were rare, and all those for change runs when they were common from those for when they were rare, regardless of their specific tonal composition, was used to determine the ERP latency and amplitude results of Experiment 5.t-test. False alarm responses to common (non-target) runs were very infrequent, about 1.6% overall. As for the previous experiments, the pooled d’ analysis in Experiment 5 indicated that feature-present targets were significantly more discriminable than were feature-absent targets from their surrounding sequences  to the same run type when it was rare and when it was common, are displayed in F4,76 = 41.86, p < 0.000001, η2 = 0.53).The P300 response in Experiment 5 was greatest at the parietal scalp sites for both feature-present and feature-absent targets  and visual arrays (Experiments 2 and 3) resemble those of search through static visual arrays  and anald’ values) and P300 amplitudes were significantly different between conditions, suggesting that, despite the more challenging tasks, the feature-present target was still easier to correctly identify than was the feature-absent target. Considering that d’ values were significantly different between conditions across all five experiments, it would appear that the feature-present target was consistently more easily identified than the feature-absent target, irrespective of the time it took to identify these targets. It is possible that reaction time differences may only be associated with the asymmetry in the context of certain task demands.Experiments 4 and 5 also provide evidence of an asymmetry. Although not the kind typically associated with classic search asymmetry, the discriminability asymmetry resembles that reported by Cusak and Carlyon . WhereasThis interpretation is consistent with the ERP results. It would appear that the different task demands of identifying the feature-present and feature-absent targets do in fact elicit different contributions of these neural responses in the first three experiments. The feature-present condition seems to elicit characteristics of both the P3a and P3b subcomponents, namely the sharp early peak of the P3a but with a slow return to baseline, taking approximately 400 ms, which is characteristic of the P3b. This is consistent with the current understanding of the conditions under which the P3a and P3b are typically observed: the feature-present target is not only a task-relevant oddball (P3b) but also contains a salient perceptual oddball that is both infrequent and unpredictable (P3a). We will use the study design of Experiment 1 (auditory) to illustrate this in detail. In every longer sequence of runs the target run was heard at a 20% probability. Given that each run consisted of 5 tones, in any feature-present sequence of, e.g., 100 trials, participants would hear on average 480 instances of the same tone , and only 20 instances of the other possible tone . Not only were these infrequent and unpredictable tones also highly perceptually salient given the tonal context, they also indexed the target stimulus. Therefore, it is not surprising that the feature-present target P300 response is characteristic of both the P3a and the P3b, because the target shared properties with the types of stimuli with which these responses are typically associated. This same logic can also be applied to the results of Experiments 2 and 3.not contain a highly perceptually salient feature change, nor is there any perceptually infrequent or unpredictable stimulus indexing the feature-absent target. It is simply made up of five of the most frequent stimuli (tones or rings) instead of only containing four of them. Therefore it is not surprising that the feature-absent target does not elicit a P3a.In contrast, the broad and relatively flat shapes of the P300 ERPs in response to the feature-absent targets, and their scalp topographies, suggest that they are mostly P3b ERPs, which is also consistent with the literature ,10. In cdoes contain a relatively infrequent, perceptually salient, different fifth tone (or ring) at the end of each run, so one might think that each change run might produce a P3a response. To make this clear, using the previous example (Experiment 1), in any block of 100 trials where the feature-absent run was the rare target, participants would hear on average 420 instances of the same tone  and 80 instances of the other tone . Though the perceptually-salient stimulus in this case is also relatively infrequent in the context of the feature-absent condition, it is nonetheless highly predictable, occurring on 80% of runs, and therefore should not generate a P3a. This is indeed what was found in the present study, as can be seen in The frequent change run in this condition, however, In Experiment 5, however, neither the feature-present nor the feature-absent targets appear to elicit a substantial P3a subcomponent, only a P3b. This is consistent with the above characterization of the P3a and P3b in the context of the roving paradigm. Because the tonal context is constantly changing in both conditions, the different fifth tone of the change runs is not unique or salient in the feature-present condition and therefore will not elicit a P3a. The absence of the P3a could account for the lack of P300 peak latency and reaction time differences between the two conditions.The distractor-evoked P3a ,10 does One difficulty for this interpretation is that in general P300 latencies and behavioral reaction times have been considered to be independent –37. TherAlthough they didn’t characterize their P300 ERPs in terms of their subcomponents, Luck and Hillyard  reportedd’s) feature-absent condition for Experiments 1–3. An infrequent unpredictable target that is easy to discriminate from standards is also likely to be highly perceptually salient and thus might elicit a stronger P3a subcomponent than would a target that is very similar to the standards. This could be one reason for the difference in P300 peak latencies and morphologies found by Comerchero and Polich [It has been shown in 3-stimulus  visual and auditory oddball paradigms that both the peak latency and the morphology of the P300 ERP are sensitive to the discriminability of the target ,39. Comed Polich ,39 for ed’ differences between conditions suggest that there still exists a perceptual asymmetry, meaning that the feature difference present in the change runs renders the feature-present targets perceptually more discriminable than the feature-absent targets. A perceptual asymmetry indexed by a difference in accuracy measures between feature-present and feature-absent conditions was also found earlier by Cusak and Carlyon [d’ values, the addition of the highly salient feature difference of the change run in Experiments 1–3 may have engaged the P3a attention orienting network, which is a faster network than the P3b context updating network. This then would be responsible for the faster responses to the feature-present target than to the feature-absent target in those experiments.In the absence of a prominent P3a subcomponent that could produce a reaction time difference in Experiment 5, the P300 amplitude (at Pz) and  Carlyon . They co Carlyon . Therefod’ values between conditions across all five experiments would indicate. They also suggest, however, that the task demands of the experiment influence which attention strategies are used to perform the task. When the target contains a rare, unpredictable, and perceptually salient feature, a diffuse attention strategy may be all that is necessary to perform the task, as the stimulus-driven attention-orienting P3a network could be automatically activated by that stimulus even if it indexes a target. On the other hand when a target does not contain a highly salient and perceptually salient feature, a focused attention strategy is required to correctly identify the stimulus.Overall the results of this study suggest that the search asymmetry in our sequential paradigm likely arises from differences in the perceptual processing of the feature-present and feature-absent targets, possibly reflecting differences in activations of sensory feature maps, as the differences in S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S3 Fig(PDF)Click here for additional data file.S4 Fig(PDF)Click here for additional data file.S5 Fig(PDF)Click here for additional data file.S6 FigFP (blue) indicates feature-present condition; FA (red) indicates feature-absent condition.(PDF)Click here for additional data file.


Supplemental Digital Content is available in the text We evaluated the oncologic outcomes of patients with rectal cancer who demonstrated pathologic near-total regression (NTR) after preoperative chemoradiotherapy (PCRT) and compared with total regression (TR).Pathologic NTR in rectal cancer by tumor regression grade (TRG) is usually considered to indicate a good response, when evaluating tumor response to PCRT.We retrospectively analyzed the outcomes in 263 patients who received PCRT for advanced T3/4 or N+ rectal cancer followed by radical resection. Patients were diagnosed with TR (n = 132) or NTR (n = 131) according to the TRG. Recurrence-free survival (RFS) was evaluated and compared between groups. For evaluating the consistency between the result and previously published data, meta-analysis for summing up survival curve was performed using generalized linear mixed model.P = 0.003). The cumulative recurrence rate was higher in the NTR group . The 5-year RFS was lower in the NTR group . Significant differences in the RFS rate were found in comparison with the published literature.ypT status was heterogeneous in the NTR group as follows; 3 Tis (2.3%), 21 T1 (16%), 72 T2 (55%), and 35 T3 (26.7%). Metastatic lymph nodes were more frequently found in the NTR group (6.8% in TR vs 24.4% in NTR patients; Based on differences in the oncologic outcomes between the TR and NTR groups, it might not be suitable to use NTR as an indicator of good response to PCRT together with TR. The paradigm of clinical medicine is evolving with the concept of precision medicine, which is an integrated effort to treat patients based on their individual characteristics and not by a routine practice guideline. Predicting responses to preoperative chemoradiotherapy (PCRT) is a core step in applying precision medicine to rectal cancer treatment.1 but the degree of tumor response to radiation therapy varies and ranges from complete eradication of the primary tumor to minimal or no radiation-related changes. The benefit of PCRT is optimized in patients who have highly responsive tumor to either radiation or chemotherapy and those patients who have certain clinical characteristics that are associated with superior treatment outcome.4 However, the available data are insufficient regarding patients in which the tumor response is not sustained and salvage resection is subsequently required due to locoregional failure.4Current guidelines suggest PCRT followed by surgery as the standard treatment for all locally advanced rectal cancer patients,5 surgery could be performed without delay. Therefore, in recent years, there has been great interest in identifying the molecular predictors of rectal cancer's response to PCRT.7 In order to identify predictive biomarkers of responsiveness to PCRT, it is critical that we have a standardized classification of response. Tumor regression grade (TRG)—which scores the relative proportion of residual tumor to stromal fibrosis8—has been widely used to determine the level of tumor response to PCRT.Predicting the tumor response to PCRT will lead to different clinical decisions. We will be able to recommend personalized treatment modalities in different sequences according to their predicted response to PCRT. For example, for patients who are unlikely to respond to PCRT and thus do not seem to benefit from neoadjuvant treatment,10 While, several recent studies also report controversial results.12 The pilot analysis of our data showed significantly higher rates of recurrence in NTR patients than TR patients, which led us to question it is appropriate to consider NTR along with TR as an indicator of good response. This study evaluated the oncologic outcomes of patients with rectal cancer showing pathologic NTR on TRG after PCRT, and we compared these outcomes with TR patients in order to determine if NTR is an appropriate indicator of a good response to PCRT.No consensus, however, has yet been reached regarding uniform standards for determining good indicators of response to PCRT. In many studies, patients with pathologic near-total regression (NTR) have been included in similar prognostic groups as patients with pathologic total regression (TR).We included 263 patients with locally advanced, primary, mid-, and low-rectal cancer located within 10 cm of the anal verge. All patients received PCRT followed by radical resection between January 2008 and December 2011 at Asan Medical Center, Seoul, Korea. Tumors were clinically diagnosed as T3/T4 or N+ on magnetic resonance imaging (MRI) and no evidence of distant metastasis on pretreatment work-ups was defined as locally advanced rectal cancer. Patients who were diagnosed with TR or NTR on pathologic examination of the resected specimens were included, while cases with other TRG, including no, minimal, or moderate regression was excluded in this study. Patients with a prior or concurrent malignancy were excluded. Prior to treatment, medical histories were thoroughly noted and physical examinations were used to assess all patients, including digital rectal examination, complete blood count, blood chemistry, measurement of carcinoembryonic antigen (CEA) concentrations, colonoscopy, chest radiography, computed tomography (CT) of the abdomen and pelvis, and pelvic MRI. Each patient provided informed consent before treatment.2 per d) and leucovorin (LV) (20 mg/m2 per d) over 3 days during the 1st and 5th weeks of radiation therapy, or oral capecitabine (1650 mg/m2 per d) was administered twice-daily during radiation therapy. For some patients, an oxaliplatin-based regimen or TS-1 was used. Radical surgical resection was planned for 5 to 8 weeks after completing PCRT. Surgical resection was performed according to the principle of total mesorectal excision.14Preoperative radiotherapy consisted of 45 to 50 Gy administered in 25 fractions to the entire pelvis, followed by a 5.4-Gy boost to the primary tumor administered in 3 fractions. Chemotherapy was delivered as 2 cycles via an intravenous bolus of 5-fluorouracil (FU)  in the fibrotic tissue; moderate regression, dominant irradiation-related changes with residual tumor ; minimal regression, dominant tumor mass with obvious irradiation-related changes; and no regression and no evidence of irradiation-related changes . The grading system used in the present study can be easily translated to the Mandard and Dworak TRG system .Pathologic responses to PCRT were evaluated in the resected specimens using the TRG system suggested by the Gastrointestinal Pathology Study Group of the Korean Society of Pathologists.16 Central review of the TRG was performed by 1 dedicated pathologist who specializes in colorectal malignancy. Patients with TR were classified into the TR group, and patients with NTR were classified into the NTR group.Pathologic stage (ypT and ypN) was determined according to the 7th AJCC TNM classification.17 and distant metastasis was defined as any recurrence outside of the pelvic cavity or dissemination to the peritoneal surface. Recurrence-free survival (RFS) was defined as the time between surgery and the first recurrence event or death.Postoperative follow-up consisted of physical examination, serum CEA measurement, and chest radiography every 3 to 6 months, plus abdominal pelvis and chest CT every 6 months to 1 year. Colonoscopy was performed at 6 months to 1 year postoperatively, and then every 2 to 3 years thereafter. Recurrence was determined according to radiological or histopathological findings. Local recurrence was defined as recurrence in the areas contiguous to the bed of the primary rectal resection or the site of anastomosis,t test, as applicable. Survival curves were constructed using the Kaplan–Meier method and were compared using log-rank tests. The association between clinical factors and RFS were performed using Cox proportional hazard regression. To evaluate the summarized RFS rates of the published studies in the literature, which reported the RFS rates for the TR and NTR, a meta-analysis for summing up survival curve was performed using generalized mixed linear model.18 Here, P < 0.05 was considered significant for all analyses .The clinical characteristics were compared between the TR and NTR using Pearson Chi-squared test, Fisher exact test, or Student P < 0.001; Table The NTR group included more male patients; however, age, tumor location, sphincter preservation rate, and the administered combination chemotherapy regimens did not differ between groups. Neither pretreatment nor preoperative CEA demonstrated significant differences. Lymphovascular invasion and perineural invasion were only observed in the NTR group. Significantly more patients in the NTR group underwent adjuvant chemotherapy Table . The NTRP = 0.003), over the mean follow-up periods of 41 and 42 months, respectively. A single local recurrence case was observed in the TR group, and 3 cases of local recurrence were identified in the NTR group (P = 0.53). There was a significant difference in the distant metastasis rate between groups: 8 cases in the TR group (6.1%) versus 25 cases in the NTR group (19.1%). The lung was the most frequent site of metastasis in both groups. The 5-year RFS rate was significantly higher in the TR group (94.0%) than the NTR group  showed that NTR demonstrates significantly poorer RFS than TR . Furthermore, the lack of a clear pathological definitions for “fibrosis” leads to different interpretations using the TRG system, thereby leading to difficulties when assigning TRG.26 In our study, we questioned whether the current practice of regarding NTR as the same prognostic group as TR, as an indicator of good response to PCRT is appropriate or not. The results demonstrated a significantly higher recurrence rate and poorer RFS in the NTR group than the TR group, which suggests that NTR should not be equally considered as a good prognostic group as TR.Until now, TRG had been widely used to determine the tumor response to PCRT.27 In publications on the correlation between TRG and outcomes, NTR is often analyzed as a uniform group with TR. However, the number of patients is too small and different TRG systems are used in several studies; therefore, whether or not NTR should be included in the same prognostic group as TR remains inconclusive. In fact, a recent study assessed several TRG systems and reported a poor RFS rate in NTR group.12 Our present study also showed that the RFS of NTR overlaps with moderate regression—rather than TR—on both the Mandard and Dworak/Rodel systems. In our dataset, we found that the patients in the NTR group were classified with various ypT and ypN statuses. In NTR patients, the distribution of residual cancer cells within the bowel wall after PCRT and surgery is heterogeneous according to several studies.28 Metastatic lymph nodes were also more frequently found in the NTR group. The reason for the poorer outcomes in the NTR group may be the heterogeneous distribution, in terms of depth of invasion and lymph node metastasis, within this group. Actually, the RFS rates of the patients in the NTR group significantly differed depending on ypT and ypN status, as shown in Figure 11In many studies, patients with pathologic NTR are included in a similar prognostic group as patients with pathologic TR.20 One of them was a meta-analysis of 14 studies.3 The RFS rates of each study were analyzed using generalized linear mixed modeling and we found that NTR had significantly poorer RFS than that of TR.18 Comparison of curves of our present study on the summarized RFS curves revealed similar differences between groups. Contrary to the impressions of each individual study, the RFS rate for NTR was significantly poorer than TR.In an effort to demonstrate a summarized data of the RFS rates of the TR and NTR from the published literature using meta-analysis, we identified 5 studies that report the RFS rates for TR and NTR, respectively.Due to the shortcomings inherent to any retrospective analysis, this study enrolled a heterogeneous patient population that received different preoperative and postoperative chemotherapy regimens, which could have interfered with the oncologic outcomes. The limitations to our study also included the lack of a long follow-up period. Considering the relatively high rate of late recurrence following PCRT, additional long-term follow-up studies are needed.The use of different pathologic TRG systems is 1 of the causes of inconsistent results between studies. Here, we used the uniform TRG system suggested by the Gastrointestinal Pathology Study Group of the Korean Society of Pathologists, and this can be translated into other TRG systems such as Mandard and Dworak TRG. Therefore, the results of our present study have an advantage of getting a fair comparison with other studies. Inter-observer variability among pathologists is 1 of the most important factors that affect the results and quality of a study. In our present analyses, a highly trained, dedicated pathologist who specializes in gastrointestinal malignancy repeatedly graded the tumor responses by centrally reviewing the resected specimens in order to diminish shortcomings. This is relatively large-numbered study incorporating a central review that demonstrated prognostic differences between TR and NTR.In conclusion, NTR demonstrates significantly poorer oncologic outcomes than TR. Therefore, consideration of NTR as an indicator of good response together with TR may not be appropriate. Future prospective studies with a larger number of patients and a longer follow-up duration should provide further subdivision and risk stratification among patients who are treated with PCRT in rectal cancer.


NCT02844452.This study aims to test the feasibility of a randomised clinical trial to evaluate how acupuncture affects atopic dermatitis (AD) symptoms and quality of life and to explore potential biomarkers that may be associated with AD. It is a sham-controlled trial in which 30 eligible patients will be randomly allocated in a 1 : 1 : 1 ratio to one of three groups: verum acupuncture (VA) group 1 (3 times weekly for 4 weeks); VA group 2 (twice weekly for 4 weeks); or sham acupuncture group . SA will consist of nonpenetrating acupuncture. Outcome measures will include the Visual Analogue Scale for itch, SCORing Atopic Dermatitis, and Eczema Area and Severity Index to evaluate AD symptoms improvement along with the Patient Oriented Eczema Measure and Dermatology Life Quality Index to assess quality of life. Measures will be collected at baseline, once weekly during the treatment period, and after a 4-week follow-up period. Blood collection will be at baseline and 4 and 8 weeks after treatment and compared with healthy controls. Illumina sequencing will be used to profile microRNA expression in each group to explore candidate microRNA biomarkers for specific effects of acupuncture in patients with AD. This trial is registered via US National Institutes of Health Clinical Trials registry  on 15 July 2016, identifier:  The prevalence of atopic dermatitis (AD), a chronic relapsing inflammatory skin disease characterized by eczematous and intensely pruritic skin lesions , 2, is iFirst-line therapy of AD is based on the use of emollients and other systemic and/or topical treatments: topical corticosteroid (TCS) and calcineurin inhibitors are recommended as topical management; antimicrobials, systemic immune-modulators, allergen-specific immunotherapy, and phototherapy are used for systemic management –11. HoweIn Korea, patients with AD have frequently used Traditional Korean Medicine, such as acupuncture and herbal medicine, for symptom management ; howeverTo overcome some weaknesses of previous studies and to determine whether acupuncture helps AD symptom management, we will conduct a randomised, sham-controlled feasibility trial comparing two different doses of active acupuncture treatment with a sham acupuncture control. We aim to establish the feasibility of recruitment and to determine key features, including optimal acupuncture treatment dose and outcome measures, to inform a large-scale RCT in patients with AD. Additionally, we will explore novel biomarker candidates that may be associated with the antipruritic effect of acupuncture.The aims of this study are (1) to investigate the feasibility of a large-scale randomised clinical trial to test the antipruritic effect of acupuncture treatment compared with a sham acupuncture in patients with AD; (2) to identify the optimal dose and schedule of acupuncture treatment and to identify outcome measures that will reflect symptoms changes; and (3) to discover biomarkers that may be associated with the therapeutic effects of acupuncture.Acupuncture treatment will mitigate pruritus and other symptoms of AD and will improve quality of life in patients with AD, compared with sham acupuncture.Three times weekly acupuncture treatment over one month will produce better outcomes than twice weekly acupuncture treatment over one month.Certain biomarker levels might be affected by the therapeutic effect of acupuncture and/or development of AD.A randomised, sham-controlled feasibility trial will be conducted at the Kyung Hee University Korean Medicine Hospital from June 2016 to April 2017 . In addi(1) Inclusion Criteria. Participants who meet all of the following criteria will be included:Age 19 and olderMeeting the Hanifin and Rajka criteria , with ADScore > 3 points and <8 points on itch Visual Analogue Scale (VAS): 1–10 scaleSCORing Atopic Dermatitis (SCORAD) index score 10–40Not taking prescription drugs for AD for at least 1 month prior to enrolmentAbility to understand the study protocol and to voluntarily agree to participateNot participating in any other research studies for AD for at least 1 month prior to enrolment.(2) Exclusion Criteria. Participants who meet any of the following criteria will be excluded:Severely fluctuating AD symptomsTreatments that are not allowed in this study, for example, oral corticosteroids, which may affect the study outcomesAsthma or bronchitisOther disorders that may affect the outcomes, for example, anxiety or depression.(1) Inclusion Criteria. Participants who meet all of the following criteria will be included:Age 19 and olderNo present or past history of allergic diseases such as AD, asthma, or allergic rhinitisAbility to understand the study protocol and to voluntarily agree to participate.(2) Exclusion Criteria. Participants who meet any of the following will be excluded:Pregnant or lactating womenHistory of anaphylaxis, severe hypertension, hypotension, or respiratory diseaseRegular use of antihistamines or steroids during the previous month.Advertisements will be posted on notice boards of the hospital and local community centres.After signing the written consent, participants will undergo a screening test to confirm eligibility. The baseline characteristics including demographics, physical examination, medical history, and severity of AD signs will be used to screen the eligible participants according to the inclusion and exclusion criteria. Individuals with AD will be randomly assigned to one of three groups via block randomisation. Healthy volunteers will not be assigned to a treatment group .An independent statistician will produce random numbers with the PROC PLAN of SAS 9.2  and transfer them to the Acupuncture and Meridian Science Research Centre (AMSRC) at Kyung Hee University, where each random number will be sealed in a sequentially numbered opaque envelope by a staff member who is otherwise not involved in this study.At the beginning of the randomisation process, the investigator will call the independent staff in the AMSRC to receive the screening number of the participant. Then the AMSRC staff screening ID and treatment assignment will be documented in the trial master file.Participants and the outcome assessor will be blinded to the treatment allocation in this trial. Since it is impossible to blind the Korean Medicine Doctors (KMDs) who will give acupuncture treatments, they will be excluded from performing the outcome measurements or analysing data. To ensure participant blinding, an eye patch will be applied to patients during the acupuncture treatment, and they will be unable to see the practice procedures. All the acupuncture treatments, regardless of group assignment, will utilise the Park sham device , which is applied at the acupoints to block participants from seeing whether or not the acupuncture needles penetrate the skin . The acuThe acupuncture treatments were based on the revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) 2010 recommendations  22]. Bo. Bo22]. In this study, manual acupuncture treatment is composed of fixed acupuncture treatment and additional acupuncture treatment: partially individualised acupuncture treatment will be performed on the basis of the traditional meridian theory and consensus by experts in acupuncture and AD. The number of applied acupoints per patient per session ranges from 6 to 19: 6 basic points and 10 optional points . All participants with AD will receive acupuncture needling at 6 fixed points: LI11, ST36, and PC6, bilaterally. The optional points include ST43, GB41, LI2, TE3, SI3, TE6, SI2, BL66, LR3, and SP3. The optional acupoints will be added in accordance with individual signs or symptoms, contralaterally to the applied signs or symptoms: ST43 and GB41 for gastric stuffiness or dyspepsia; LI2 and GB41 for tenderness around ST25, diarrhoea, or constipation; TE3 and SI3 for fullness in the chest and hypochondrium; TE3 and TE6 for lower abdominal pain plus tenderness on the chest centre; SI3 and GB41 or SI2 and BL66 for lower abdominal pain, dry skin, or heat in the upper body and cold in the lower body; and LR3 and SP3 for pain in hypogastric region with darkness of the sublingual collateral vessels. A study coordinator will ask participants about symptoms that might require additional acupuncture treatment to reduce the bias. Regardless of group assignment, all manual acupuncture treatment will be performed using Park sham devices to maintain participant blinding. The acupuncture treatment will be done with disposable sterilised stainless needles  or Park sham acupuncture needles  according to the assigned groups. Manipulation technique will be performed to elicit “de qi” sensation. The needle will be inserted up to 5 to 30 mm depending on acupoints and retained for 15 minutes.After removal of needles, intradermal needles using 1.5 mm press tack needles  will be given to three acupoints per participant per session: LI11 bilaterally and auricular-Shenmen contralaterally. This is aimed at mitigating AD-related pruritus with LI11 and reducing anxiety level with auricular-Shenmen , 23, 24.All acupuncture treatments will be carried out by the same KMD, who was trained for 10 hours to guarantee that he could perform the acupuncture treatments identically according to the predefined protocol.Participants assigned to the VA1 will receive 12 acupuncture sessions over 4 weeks, that is, 3 days/week. A telephone interview will take place two weeks after the end of treatment to collect data on the severity of pruritus symptoms, amount of TCS used, and adverse effects. Participants' final visit will occur 4 weeks after the end of treatment. No other intervention will be permitted during the study period.Participants assigned to the VA2 will receive 8 acupuncture sessions over 4 weeks, that is, 2 days/week. A telephone interview will be given two weeks after the end of treatment to collect data on the severity of pruritus symptoms, amount of TCS used, and adverse effects. Participants' final visit will occur 4 weeks after the end of treatment. No other intervention will be permitted during the study period.Participants assigned to the SA group will receive 8 acupuncture sessions over 4 weeks, that is, 2 days/week. Sham acupuncture treatment will be conducted on 6 control points: a point 1 to 2 cm proximal and 1 cm medial to LI7, a point 1 cm proximal and 1 cm medial to LI11, and a point 1 cm proximal and 1 cm lateral to ST36, each bilaterally. Instead of intradermal needles, the same sized stainless steel rings without needles, that is, nonpenetrating intradermal needles, which were designed and validated for blinding for our study, will be attached to three control points: a point 1 cm proximal and 1 cm medial to LI11, bilaterally, and finger point in the ear, contralaterally . Unlike During the study period, each patient will receive either 12 or 8 treatment sessions according to their group assignment. Since frequent hospital visits may be the burden to participants and may induce them to withdraw from the trial, we identified a minimum number of treatments to be considered compliant, as follows: at least 10 sessions of 12 should be completed for VA1, and at least 6 sessions of 8 should be completed for VA2 and SA. For dropouts who did not fulfil the aforementioned compliance criteria, last available data will be taken for the analysis.The study coordinator will maintain regular contact and encourage participants to complete all treatment sessions and follow-up visits. Should a participant withdraw consent, any data collected from the participant will be kept in files safely for 3 years and then will be discarded.One research nurse who is otherwise not involved in this study will conduct a series of outcome measures: its schedule is depicted in Participants with AD will complete all the outcome measures; healthy controls will submit to blood collection and complete the Cold-Heat, Centre for Epidemiologic Studies-Depression Scale (CES-D), and state-trait anger expression inventory (STAXI) questionnaires.SCORAD is a widely used tool for assessing severity of AD. The SCORAD evaluates the intensity and extent of affected regions and estimates subjective discomfort such as pruritus and sleep loss symptoms –28. The The itch VAS is one of the components of the SCORAD index, and it will be particularly applied to assess the severity and reduction of pruritus in this trial. Participants whose itch VAS score is less than 30 or higher than 80 will be excluded because we assumed that they will have lower desire for antipruritic therapy or need more potent treatment .The Eczema Area and Severity Index (EASI) is a validated instrument measuring AD severity , 30. QueThe Patient Oriented Eczema Measure (POEM) is a useful, 7-item tool for monitoring AD severity, which focuses on participant-reported symptoms and illness. Scores range from 0 to 28, and it is suitable for administration in the outpatient clinic or in the clinical trial setting .The Dermatology Life Quality Index (DLQI) is a compact questionnaire which is applicable to individuals with any skin disease. It measures the influence of AD on participant's life over the previous 7 days. It consists of 10 questions with Likert-type responses and its score ranges from 0 to 30; higher scores imply greater influence on health-related quality of life .Only Lidomex  will be permitted as a rescue medicine for severe pruritus, by consensus of the study KMD and the pharmacist at Kyung Hee University Korean Medicine Hospital. Participants will be instructed to apply TCS according to the fingertip method: the ointment will be applied on the surface area of one palm with amount from the tip of index finger to the distal skin crease .Participants using TCS will report the amount used, frequency, and affected regions weekly during this trial. Ointments will also be weighed weekly before being dispensed and then again at the end of this study in order to evaluate the amount of TCS used .To reflect a unique point of view on pattern diagnosis in Traditional Korean Medicine in an objective manner, we adopted the AD pattern questionnaire . ParticiIdentifying cold and heat pattern is a relatively obvious and definite factor of diagnosis in Traditional Korean Medicine and the usual cold-heat pattern of patients plays an important role in choosing treatment modalities and establishing treatment plans . We will2/sec and participants will be instructed to report the beginning of pain by saying “stop” immediately after the perception of pain is transferred from pressure. The examiner will immediately stop pressing and record the pressure pain threshold (PPT) value. The maximum PPT will be limited to 8 kg/cm2 in order to prevent distorted measures. At each assessment, PPT will be measured three times with the intervals of 1 minute [Abdominal examination has been one of the characteristic methods for diagnosis, choosing a therapy, and predicting prognosis in Traditional Korean Medicine . We will1 minute , 39.Since it has been reported that depression is strongly associated with AD, evaluating depressive symptoms of the patient is highly recommended , 41. TheIt is widely reported that AD patients have a higher risk of depressive symptoms and a reduced capacity to cope with stress or anger , 44. WitSTAXI is a validated measure for assessing the experience, expression, and control of anger. It has 3 subscales such as trait anger, anger-inside (anger suppression), and anger-outside (anger expression) and consists of a total of 44 questions . The valTo assess the credibility of the acupuncture treatment used in this study, participants will complete the credibility questionnaire at baseline, at 4 weeks (after the termination of treatment period), and at 8 weeks (after the end of follow-up period) , 48.Various biomarkers have been reported to have different levels in patients with AD, but none has been validated as a definite biomarker –51. In tAbout 4 ml of whole blood will be collected from participants at 3 time points: at baseline; 4 weeks after the completion of acupuncture treatment; and 8 weeks after the follow-up period. Healthy controls will submit to only 1 blood collection (at baseline). Blood will be centrifuged to obtain serum.Changes in various biomarker levels from baseline to 4 weeks in each of the treatment groups will be examined. Between-group differences will be analysed to explore potential associations with the effect of acupuncture. Analysis of changes from 4 weeks to 8 weeks in group will be conducted to evaluate the sustained effect of acupuncture.(1) Serum Total IgE Measurement. The role of IgE in the pathogenesis of AD is acknowledged as contributing to allergic sensitisation and indirectly supporting AD severity via sensitisation to various allergens [llergens . It has llergens , 50. In (2) Serum Cytokine/Chemokines Measurement. Based on knowledge of inflammatory mediators and autoimmune responses, a diversity of cytokines have been explored in AD and T cells, and related cytokines are also considered as potential influencing factors in the pathogenesis of AD [is of AD –54. For is of AD , 55, 56.α/CXCL1, Gro-β/CXCL2, I-309/CCL1, IFN-γ, IL-1β, IL-2, IL-4, IL-6, IL-8/CXCL8, IL-10, IL-16, IP-10/CXCL10, I-TAC/CXCL11, MCP-1/CCL2, MCP-2/CCL8, MCP-3/CCL7, MCP-4/CCL13, MDC/CCL22, MIF, MIG/CXCL9, MIP-1α/CCL3, MIP-1δ/CCL15, MIP-3α/CCL20, MIP-3β/CCL19, MPIF-1/CCL23, SCYB16/CXCL16, SDF-1α+β/CXCL12, TARC/CCL17, TECK/CCL25, and TNF-α.In this context, we will use a commercial kit (Bio-Plex Pro Human Chemokine 40-plex Panel) for the following 40 chemokines from extracted serum samples: 6Ckine/CCL21, BCA-1/CXCL13, CTACK/CCL27, ENA-78/CXCL5, Eotaxin/CCL11, Eotaxin-2/CCL24, Eotaxin-3/CCL26, Fractalkine/CX3CL1, GCP-2/CXCL6, GM-CSF, Gro-(3) Serum Cortisol Measurement. Cortisol, also called glucocorticoid, is a well-known stress-related hormone associated with the hypothalamic-pituitary-adrenal (HPA) axis and its mechanisms have been elucidated by analysing physiological change in stress response systems on a variety of psychological issues [l issues –60. In tAD is known as a complex genetic skin disease affected by environmental distress and resulting from abnormal immune responses as well as malfunctions of the skin barrier , 61. ButA miRNA is a small noncoding RNA molecule. Since its function is related to eukaryotic cells, dysregulation of several specific miRNAs has been reported to be associated with several pathological processes, such as chronic lymphocytic leukemia and cardiomyopathy , 63. In Illumina sequencing using serum will be performed for miRNA expression profiling to determine candidate miRNA biomarkers for the effectiveness of acupuncture. The difference between participants with AD and healthy controls at baseline will be analysed to explore potential biomarkers associated with the development of AD. Within the pool of biomarker candidates related to AD, the difference between VA1 or VA2 (whichever is more efficacious) and SA at 4 weeks will be compared, to determine biomarkers related to acupuncture effect. The difference between VA and SA at 8 weeks will also be analysed to examine whether the selected biomarkers at 4 weeks continue to be significant at 8 weeks, to explore sustained effects of acupuncture .The proposed study is a RCT whose primary aim is to investigate the feasibility to recruit and treat participants with AD with acupuncture and to evaluate acupuncture's antipruritic effects. We will calculate the effect sizes of key outcomes including itch VAS and SCORAD index, to inform power calculations for a further large-scale study. A total of 30 individuals with AD and 20 healthy controls will be recruited during the study period; participants with AD will be randomly assigned in a 1 : 1 : 1 ratio to one of two active acupuncture regimens or sham acupuncture. Healthy controls will not receive any treatment. Considering an estimated 20% dropout rate, we identified the sample size with the advice of a statistician. The statistical significance level will be set at 0.1 considering the applied small size.We will perform descriptive analyses for all outcome measures. Categorical variables will be provided with percentages, and continuous variables will be provided as means with standard deviations. An independent statistician will perform statistical analyses using SPSS 21.0 . Missing data will be replaced by carrying forward the most recent nonmissing value, and the time and reason for the missing data will be recorded. Depending on the recorded reasons, multiple imputation by an independent statistician will be done and compared.χ2 test. The difference in effect between VA1 and VA2 will be analysed by examining changes in the itch VAS and SCORAD index, by the Mann–Whitney U test on continuous variables and χ2 test on categorical variables. The difference in therapeutic effect between VA (using the most efficacious dose between VA1 and VA2) and SA will be investigated in the same way. The data will be analysed with a p = 0.1 (two-sided) statistical significance level and 90% confidence intervals will be provided following the statistician's advice for a small sample size. The current data will be used to calculate the number of participants needed to reach a significance level of 0.05 and 80% power.The effectiveness of the intervention will be provided by examining changes in outcome measures between baseline and end of treatment and through the follow-up period, using a repeated measures analysis of variance (ANOVA) and NCT02844452). The trial registration was conducted after the start of participant recruitment due to delays in the preparation of registration.This study protocol was approved by the ethics committee at Kyung Hee University Korean Medicine Hospital (KOMCIRB-160212-HRBR-004). It will be performed in accordance with the standards of the International Committee on Harmonisation on Good Clinical Practice and the revised version of the Declaration of Helsinki. This trial was registered via US National Institutes of Health Clinical Trials registry  on 15 July 2016  [All participating KMDs and outcome assessors will be trained before the beginning of the trial to ensure consistent quality of practices. The training program will cover diagnoses, inclusion and exclusion criteria, location of the acupoints, acupuncture manipulation techniques, measurement of PPT, and filling out case report forms. Participants who discontinue or who withdraw consent will also be thoroughly documented. This study will be monitored by the AMSRC and periodic monitoring will ensure the accuracy and the quality of this study. We checked Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) to improve the quality of clinical trial protocols  .After enrolment, participants' personal information will be accessible only to the investigator. Research data and blood samples will be identified by a unique code to protect confidentiality during and after the trial. All study personnel completed training in protection of personal health information.If a protocol modification is required (such as due to an unanticipated problem or adverse event), the representatives of Kyung Hee University Korean Medicine Hospital and the AMSRC will discuss the matter fully to take the appropriate steps.A recent systematic review failed to identify any RCTs on acupuncture as treatment for AD, as it has not been extensively researched . We descDetermining an optimal dose of acupuncture treatment involves complex decision making , 69. CliWe will limit enrolment to individuals with mild to moderate AD. Since KMDs usually treat severe cases with more intensive combinations of treatment, such as acupuncture and herbal medicine or acupuncture and hospitalisation, we selected acupuncture alone in order to detect differences between treatments without introducing other confounders; in addition, rescue medication will be permitted as we believe that this strategy reflects real world practice.A battery of outcome measures will be used in our study since it is exploratory in nature. We will investigate the effects of acupuncture treatment on AD symptom improvement with a particular focus on antipruritic effect, measured using itch VAS, SCORAD, EASI, and POEM. Information on rescue medication use and quality of life will also be collected. For pattern identification in Korean Medicine, the AD pattern and Cold-Heat questionnaires, along with PPT, will be administered. CES-D and STAXI will examine potential anxiolytic and stress-relieving effects of acupuncture. Through credibility testing, the feasibility of participant blinding to treatment assignment will be thoroughly examined. Some may argue that nonspecific effects may unnecessarily increase in our trial by the increased attention due to a variety of outcome measures. The outcome measures, however, will be given to the participants in all three groups which will make it unlikely for one specific group to experience a larger nonspecific benefit due to the increased attention. We will nevertheless carefully examine whether there will be additional nonspecific benefits in any group and the feasible outcome measures will be selected to work for a main trial. Finally, our study will provide valuable data regarding treatment of AD with acupuncture, but also relative to identifying potential biomarkers associated with its development.Establishing an adequate sham control is essential in an RCT of acupuncture. We will utilise a nonpenetrating sham acupuncture and nonpenetrating intradermal needles as a control group, which receive sham treatment twice a week for 4 weeks. There has been a long debate about the specific effect of acupuncture: acupuncture works mainly via a placebo effect ; or testAttempts have been made to identify biomarkers in order to measure the specific effects of acupuncture and to better understand its mechanism of action –75, but SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents.