Right anterior cerebellum BOLD responses reflect age related changes in Simon task sequential effects

Participants are slower to report a feature, such as color, when the target appears on the side opposite the instructed response, than when the target appears on the same side. This finding suggests that target location, even when task-irrelevant, interferes with response selection. This effect is magnified in older adults. Lengthening the inter-trial interval, however, suffices to normalize the congruency effect in older adults, by re-establishing young-like sequential effects (Aisenberg et al., 2014). We examined the neurological correlates of age related changes by comparing BOLD signals in young and old participants performing a visual version of the Simon task. Participants reported the color of a peripheral target, by a left or right-hand keypress. Generally, BOLD responses were greater following incongruent than congruent targets. Also, they were delayed and of smaller amplitude in old than young participants. BOLD responses in visual and motor regions were also affected by the congruency of the previous target, suggesting that sequential effects may reflect remapping of stimulus location onto the hand used to make a response. Crucially, young participants showed larger BOLD responses in right anterior cerebellum to incongruent targets, when the previous target was congruent, but smaller BOLD responses to incongruent targets when the previous target was incongruent. Old participants, however, showed larger BOLD responses to congruent than incongruent targets, irrespective of the previous target congruency. We conclude that aging may interfere with the trial by trial updating of the mapping between the task-irrelevant target location and response, which takes place during the inter-trial interval in the cerebellum and underlays sequential effects in a Simon task.

Systematic review and economic modelling of the relative clinical benefit and cost-effectiveness of laparoscopic surgery and robotic surgery for removal of the prostate in men with localised prostate cancer

BACKGROUND

Complete surgical removal of the prostate, radical prostatectomy, is the most frequently used treatment option for men with localised prostate cancer. The use of laparoscopic (keyhole) and robot-assisted surgery has improved operative safety but the comparative effectiveness and cost-effectiveness of these options remains uncertain.

OBJECTIVE

This study aimed to determine the relative clinical effectiveness and cost-effectiveness of robotic radical prostatectomy compared with laparoscopic radical prostatectomy in the treatment of localised prostate cancer within the UK NHS.

DATA SOURCES

MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index and Cochrane Central Register of Controlled Trials were searched from January 1995 until October 2010 for primary studies. Conference abstracts from meetings of the European, American and British Urological Associations were also searched. Costs were obtained from NHS sources and the manufacturer of the robotic system. Economic model parameters and distributions not obtained in the systematic review were derived from other literature sources and an advisory expert panel.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies of men with clinically localised prostate cancer (cT1 or cT2); outcome measures included adverse events, cancer related, functional, patient driven and descriptors of care. Two reviewers abstracted data and assessed the risk of bias of the included studies. For meta-analyses, a Bayesian indirect mixed-treatment comparison was used. Cost-effectiveness was assessed using a discrete-event simulation model.

RESULTS

The searches identified 2722 potentially relevant titles and abstracts, from which 914 reports were selected for full-text eligibility screening. Of these, data were included from 19,064 patients across one RCT and 57 non-randomised comparative studies, with very few studies considered at low risk of bias. The results of this study, although associated with some uncertainty, demonstrated that the outcomes were generally better for robotic than for laparoscopic surgery for major adverse events such as blood transfusion and organ injury rates and for rate of failure to remove the cancer (positive margin) (odds ratio 0.69; 95% credible interval 0.51 to 0.96; probability outcome favours robotic prostatectomy = 0.987). The predicted probability of a positive margin was 17.6% following robotic prostatectomy compared with 23.6% for laparoscopic prostatectomy. Restriction of the meta-analysis to studies at low risk of bias did not change the direction of effect but did decrease the precision of the effect size. There was no evidence of differences in cancer-related, patient-driven or dysfunction outcomes. The results of the economic evaluation suggested that when the difference in positive margins is equivalent to the estimates in the meta-analysis of all included studies, robotic radical prostatectomy was on average associated with an incremental cost per quality-adjusted life-year that is less than threshold values typically adopted by the NHS (£30,000) and becomes further reduced when the surgical capacity is high.

LIMITATIONS

The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.

CONCLUSIONS

This study demonstrated that robotic prostatectomy had lower perioperative morbidity and a reduced risk of a positive surgical margin compared with laparoscopic prostatectomy although there was considerable uncertainty. Robotic prostatectomy will always be more costly to the NHS because of the fixed capital and maintenance charges for the robotic system. Our modelling showed that this excess cost can be reduced if capital costs of equipment are minimised and by maintaining a high case volume for each robotic system of at least 100-150 procedures per year. This finding was primarily driven by a difference in positive margin rate. There is a need for further research to establish how positive margin rates impact on long-term outcomes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Matrons are not going to solve all the problems

Most nurses would support the view that patients in hospital do not always get the level of care they need in an environment best suited to healthcare delivery. This situation has arisen because of lack of investment in the ward infrastructure. At the same time the workload has increased because of more highly dependent patients, a quicker throughput, increasing demands to meet targets and escalating bureaucracy.

Assessment of lead exposure of children from K-XRF measurements of shed teeth

Lead is accumulated and immobilized for long periods of time in teeth. Thus the Pb concentration of a tooth can be used as an indicator of the cumulative Pb intake of a child. Shed and extracted teeth were collected from children in Beijing, China and some industrial regions in the Middle Urals in Russia. The Pb levels in the teeth were measured in Philadelphia, PA using an X-ray fluorescence (XRF) technique. Since Pb deposits in the tooth during the entire period that it is in the child, the measured tooth Pb level was divided by the age of the child when the tooth was shed and expressed in terms of (microgram/g-yr). 10% (n = 100) of the teeth from Beijing, China had Pb levels exceeding 5.5 and 3% above 9 micrograms/g-yr. For comparison, in the 1970s when urban environmental Pb levels were elevated, the tooth Pb levels in Philadelphia children were similar, i.e. 10% (n = 298) of the teeth had Pb levels exceeding 7.5 and 6% were above 9 micrograms/g-yr. Children in a more rural setting, Bennington, VT, had no detectable tooth Pb (n = 200). The Pb levels in the teeth from the Urals were much higher; 50% (n = 134) of the teeth had Pb levels exceeding 7.5 and 10% exceeding 17.8 micrograms/g-yr. The tooth Pb levels observed in the teeth from Beijing, and more so from the Urals, indicate that these children are residing in Pb polluted environments. Further studies are required to determine the extent of the Pb pollution and to explore the possibility that there are associated Pb-related health deficits.

Strategic planning in patient education

Patient education is an important part of health promotion. It can be described as a planned, systematic process designed to influence the behaviour of those who come into contact with the health services. It produces changes in their knowledge, attitudes and the skills required to maintain and improve health. Patient education involves health care professionals in activities which help patients and their relatives learn and incorporate new behaviours into their everyday lives. The author describes a strategic planning tool aimed at achieving this.

Patient education: a literature review

The literature review has been carried out to examine the role of nurses as patient teachers. It attempts to determine why patient education is necessary and why it should be part of the nurse's role. Included is an account of the abilities required by the nurse in order to function in that role. It is generally agreed that it is part of the nurse's role to educate patients but this is often not carried out in reality. Where it is done it is mostly unplanned and haphazard in manner and the effectiveness uncertain. There are many reasons cited why this is the case and many of these reasons relate to the inadequate education and training of nurses for this role. Registered nurses are responsible for the nursing care of patients which should include their education. In order to be able to provide the necessary education nurses must have the opportunity to be taught to develop the appropriate skills during basic training. As a result, a study is now underway to attempt to determine the extent to which student nurses are being prepared for their role as patient educators during basic training.

Reversal of midazolam sedation with anexate

Anexate (Ro 15-1788) a specific benzodiazepine antagonist, was assessed for its action in reversing midazolam-induced sedation. Sixty-five patients undergoing prostatic surgery under subarachnoid anaesthesia received midazolam for intraoperative sedation (mean dose 16 mg) followed by either active drug (anexate) or placebo given as a randomized, double-blind i.v. injection. The anexate dose sufficient to reverse sedation (0.36 +/- 0.09 mg), produced immediate and dramatic improvements in ability to comprehend and obey commands, in orientation in time and space and in degree of anterograde amnesia. These changes remained significantly different from the control group for 60 min after injection. There was no effect on arterial pressure, heart rate or ventilatory rate and no anxiety states were observed. After initial complete awakening, sedation increased gradually in drug-treated patients, while in the control group, sedation scores and cognitive testing scores all diminished over the 4-h study period. Anexate used in doses up to 0.5 mg provided safe and effective antagonism of midazolam-induced sedation in a clinical setting.

Finger systolic pressure: its use in screening for hypertension and monitoring

A finger sphygmomanometer was compared with a mercury column sphygmomanometer for its ability to screen for hypertension. A total of 881 patients used each machine, both in initial screening and then for monitoring. The finger sphygmomanometer had a specificity of 98.5% in routine screening as compared with 97.6% for the mercury column device. Sensitivity of the finger device was 98.2%. These findings suggest that the finger sphygmomanometer using finger systolic pressure alone is adequate for screening and monitoring blood pressure.