A New Validation of Montreal Cognitive Assessment on a Large Sample of Elderly Patients Undergoing Elective Orthopedic Surgery

Objective

The hip and knee arthroplasties are reliable and suitable surgical procedures aimed at restoring the patients' functioning. The most representative age range for these replacement surgeries is between 65 and 84 years for females. With aging, the likelihood of developing cognitive deficits increases, and there is evidence that elderly patients undergoing surgery orthopedic are at higher risk of developing cognitive problems in the postoperative phase. The Montreal Cognitive Assessment (MoCA) is often used for cognitive evaluation, but different cut-offs and validations are available in the literature. Given the importance of the problem, in this work we studied a hospitalized population candidate for orthopedic surgery to determine a new specific validation of the MoCA to assess the risk of MCI.

Method

We applied MoCA and Mini-Mental State Examination (MMSE) to a sample of 492 (333 women) hospitalized patients for knee (74%) or hip surgery. A non-parametric receiver operating characteristic (ROC) curve analysis was conducted to investigate the predictive accuracy of the MoCA to assess cognitive impairment, using MMSE as the gold standard.

Results

A score of 22.52 gives a sensitivity of 70% and a specificity of 78%. This value is providing a more coherent diagnosis with the MMSE as compared to the other cut-offs presented in the other available validations. No differences were found between patients in terms of age and gender, suggesting a general uniformity of the selected sample.

Conclusions

Deepening the coherence in MCI diagnosis between MMSE and the other MoCA's scoring considered, our new cut-off seems reasonably better than previous Italian validation on an elderly population in matching MMSE classification.

Neuropsychological and Pet Study of Depersonalization and Derealization: A Single Case Report

The present work depicts the case of a young man suffering from a depersonalization and derealization (DD) disorder, which mainly affects his own body. When the symptoms concern something else, they almost exclusively affect living beings. Neuropsychological and neuropsychiatric studies, as well as functional neuroanatomy studies, have led to hypothesize possible relationships among cognitive-neurofunctional alterations and symptoms of depersonalization and derealization. The present study suggests that a malfunction of the left frontal and prefrontal cortex causes deficits of working memory, producing some of the symptoms of DD.

Memory performance predicts interrogative suggestibility better than global cognition in older adults with subjective cognitive complaints

The present study aims to investigate to which extent global cognition and verbal memory can estimate interrogative suggestibility (IS) in elderly people with subjective cognitive complaints (SCCs). We used the Gudjonsson Suggestibility Scale (GSS 2) subscales (i.e., Yield 1, Yield 2 and Shift) as measures of IS. Data from a sample of consecutive patients (N = 94) who referred to neuropsychology units for the first time were collected. Our results showed that verbal memory is a better predictor of IS than global cognition. Moreover, memory impairment led to significantly higher IS independently of global cognitive status. These findings suggest that the assessment of verbal memory allows to estimate individual levels of IS better than global cognition, even in elders with objective cognitive deficits. Implications for forensic assessment of senior witnesses are discussed.

Abnormal ankle-brachial index (ABI) predicts primary and secondary cardiovascular risk and cancer mortality

BACKGROUND

An abnormal ankle-brachial pressure index (ABI) is a marker of the risk for increased total and cardiovascular (CV) mortality. However, it is not clear whether it is associated with an even worse prognosis in patients with previous CV events or with cancer mortality.

MATERIALS AND METHODS

Consecutive subjects undergoing ABI assessment for suspected peripheral artery disease or for stratification of CV risk in ten centers in the Veneto Region (northeast Italy), between 2011 and 2014 were enrolled. The ABI was expressed as normal ≥0.9 to ≤1.3, and abnormal <0.9 or >1.3. All-cause mortality and CV or cancer mortality and hospitalizations for CV disease were collected from administrative databases up to December 2018.

RESULTS

The study enrolled 1,177 patients. ABI was abnormal in 57.2%. Median follow-up was 61.6 months (53.4-70.1). All-cause, CV and cancer mortality were higher in patients with abnormal than normal ABI, with hazard ratios (HR) respectively 2.0 (95% CI 1.48-2.69), 1.98 (95% CI 1.24-3.17) and 1.85 (95% CI 1.09-3.15). Among subjects with abnormal ABI, the risk of overall mortality, HR 1.57 (95% CI 1.17-2.12), and CV mortality, HR 2.39 (95% CI 1.43-3.99), was higher in those with previous CV events. These latter also had a higher risk of hospitalization for myocardial infarction and stroke: HR 1.85 (95% CI 1.023.37) and 2.17 (95% CI 1.10-4.28).

CONCLUSIONS

The co-existence of abnormal ABI and a history of CV events identifies subjects at higher risk, who call for a more aggressive approach. Abnormal ABI is also a predictor of cancer mortality.

Research priority setting in women's health: a systematic review

BACKGROUND

Developing a shared agenda is an important step in ensuring future research has the necessary relevance.

OBJECTIVE

To characterise research priority setting partnerships (PSPs) relevant to women's health.

SEARCH STRATEGY

Included studies were identified by searching MEDLINE and the James Lind Alliance (JLA) database.

SELECTION CRITERIA

Priority setting partnerships using formal consensus methods.

DATA COLLECTION AND ANALYSIS

Descriptive narrative to describe the study characteristics, methods, and results.

MAIN RESULTS

Ten national and two international PSPs were identified. All PSPs used the JLA method to identify research priorities. Nine PSPs had published a protocol. Potential research uncertainties were gathered from guidelines (two studies), Cochrane reviews (five studies), and surveys (12 studies). The number of healthcare professionals (31-287), patients (44-932), and others (33-139) who responded to the survey, and the number of uncertainties submitted (52-4767) varied. All PSPs entered confirmed research uncertainties (39-104) into interim priority setting surveys and healthcare professionals (31-287), patients (44-932), and others (33-139) responded. All PSPs entered a short list of research uncertainties into a consensus development meeting, which enabled healthcare professionals (six to 21), patients (eight to 14), and others (two to 13) to identify research priorities (ten to 15). Four PSPs have published their results.

CONCLUSION

Future research priority setting studies should publish a protocol, use formal consensus development methods, and ensure their methods and results are comprehensively reported.

TWEETABLE ABSTRACT

Research published in @BJOGtweets highlights future research priorities across women's health, including @FertilityTop10, @jamesmnduffy.

Visually evoked responses from the blind field of hemianopic patients

Hemianopia is a visual field defect characterized by decreased vision or blindness in the contralesional visual field of both eyes. The presence of well documented above-chance unconscious behavioural responses to visual stimuli presented to the blind hemifield (blindsight) has stimulated a great deal of research on the neural basis of this important phenomenon. The present study is concerned with electrophysiological responses from the blind field. Since previous studies found that transient Visual Evoked Potentials (VEPs) are not entirely suitable for this purpose here we propose to use Steady-State VEPs (SSVEPs). A positive result would have important implications for the understanding of the neural bases of conscious vision. We carried out a passive SSVEP stimulation with healthy participants and hemianopic patients. Stimuli consisted of four black-and-white sinusoidal Gabor gratings presented one in each visual field quadrant and flickering one at a time at a 12Hz rate. To assess response reliability a Signal-to-Noise Ratio analysis was conducted together with further analyses in time and frequency domains to make comparisons between groups (healthy participants and patients), side of brain lesion (left and right) and visual fields (sighted and blind). The important overall result was that stimulus presentation to the blind hemifield yielded highly reliable responses with time and frequency features broadly similar to those found for cortical extrastriate areas in healthy controls. Moreover, in the intact hemifield of hemianopics and in healthy controls there was evidence of a role of prefrontal structures in perceptual awareness. Finally, the presence of different patterns of brain reorganization depended upon the side of lesion.

Predicting acoustic dose associated with marine mammal behavioural responses to sound as detected with fixed acoustic recorders and satellite tags

To understand the consequences of underwater noise exposure for cetaceans, there is a need for assessments of behavioural responses over increased spatial and temporal scales. Bottom-moored acoustic recorders and satellite tags provide such long-term and large spatial coverage of behaviour compared to short-duration acoustic-recording tags. However, these tools result in a decreased resolution of data from which an animal response can be inferred, and no direct recording of the sound received at the animal. This study discusses the consequence of the decreased resolution of data from satellite tags and fixed acoustic recorders on the acoustic dose estimated by propagation modelling and presents a method for estimating the range of sound levels that animals observed with these methods have received. This problem is illustrated using experimental results obtained during controlled exposures of northern bottlenose whales (Hyperoodon ampullatus) exposed to naval sonar, carried out near Jan Mayen, Norway. It is shown that variability and uncertainties in the sound field, resulting from limited sampling of the acoustic environment, as well as decreased resolution in animal locations, can lead to quantifiable uncertainties in the estimated acoustic dose associated with the behavioural response (in this case avoidance and cessation of foraging).

Outcome of assisted reproduction in women with congenital uterine anomalies: a prospective observational study

OBJECTIVES

To assess the prevalence of congenital uterine anomalies, including arcuate uterus, and their effect on reproductive outcome in subfertile women undergoing assisted reproduction.

METHODS

Consecutive women referred for subfertility between May 2009 and November 2015 who underwent assisted reproduction were included in the study. As part of the initial assessment, each woman underwent three-dimensional transvaginal sonography. Uterine morphology was classified using the modified American Fertility Society (AFS) classification of congenital uterine anomalies proposed by Salim et al. If the external contour of the uterus was uniformly convex or had an indentation of < 10 mm, but there was a cavity indentation, it was defined as arcuate or septate. Arcuate uterus was further defined as the presence of a concave fundal indentation with a central point of indentation at an obtuse angle. Subseptate uterus was defined as the presence of a septum, not extending to the cervix, with the central point of the septum at an acute angle; if the septum extended to the internal cervical os, the uterus was defined as septate. Reproductive outcomes, including live birth, clinical pregnancy and preterm birth, were compared between women with a normal uterus and those with a congenital uterine anomaly. Subgroup analysis by type of uterine morphology and logistic regression analysis adjusted for age, body mass index, levels of anti-Müllerian hormone, antral follicle count and number and day of embryo transfer were performed.

RESULTS

A total of 2375 women were included in the study, of whom 1943 (81.8%) had a normal uterus and 432 (18.2%) had a congenital uterine anomaly. The most common anomalies were arcuate (n = 387 (16.3%)) and subseptate (n = 16 (0.7%)) uterus. The rate of live birth was similar between women with a uterine anomaly and those with a normal uterus (35% vs 37%; P = 0.47). The rates of clinical pregnancy, mode of delivery and sex of the newborn were also similar between the two groups. Preterm birth before 37 weeks' gestation was more common in women with uterine anomalies than in controls (22% vs 14%, respectively; P = 0.03). Subgroup analysis by type of anomaly showed no difference in the incidence of live birth and clinical pregnancy for women with an arcuate uterus, but indicated worse pregnancy outcome in women with other major anomalies (P = 0.042 and 0.048, respectively).

CONCLUSIONS

Congenital uterine anomalies as a whole, when defined using the modified AFS classification, do not affect clinical pregnancy or live-birth rates in women following assisted reproduction, but do increase the incidence of preterm birth. The presence of uterine abnormalities more severe than arcuate uterus significantly worsens all pregnancy outcomes. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Inadvertent P-hacking among trials and systematic reviews of the effect of progestogens in pregnancy? A systematic review and meta-analysis

BACKGROUND

Progestogens have been evaluated in numerous trials and meta-analyses, many of which concluded they were effective. However, two large trials PROMISE and OPPTIMUM have recently concluded that progesterone was ineffective. This raises the possibility that earlier studies and reviews had been biased by either selective publication or selective choice of outcomes, so called "P-hacking".

OBJECTIVES

To compare the findings all progestogen trials and systematic reviews with those of trials with pre-registered primary outcomes which avoided selective outcome reporting.

SEARCH STRATEGY

Search of PubMed, the Cochrane Library and trial registries. Registration PROSPERO CRD42016035303.

SELECTION CRITERIA

Systematic reviews of randomised trials comparing progestogen with placebo in pregnancy and the individual trials included in those reviews. The subset of trials reporting a pre-registered primary outcome were compared with the totality of trials and reviews.

DATA COLLECTION AND ANALYSIS

For reviews all outcomes were included. For individual trials all outcomes reported in the systematic reviews were included. For the comparison group we recorded the registered primary outcome from trials that were either registered before they started, or registered during the recruitment phase and also double blind.

MAIN RESULTS

Nineteen of twenty-nine meta-analyses concluded that progestogens were effective. Twenty-two trials reported their pre-registered primary outcomes. There was no effect of progesterone on primary registered dichotomous outcome RR 1.00 (95% CI 0.94-1.07). Only one of the 22 showed a nominally statistically significant benefit.

AUTHOR'S CONCLUSIONS

When evaluated in registered double-blind trials with analysis restricted to predefined primary outcomes, progestational agents in pregnancy are ineffective.

TWEETABLE ABSTRACT

Progestogens to prevent pregnancy loss, an example of P-hacking.

Shyness Ratings: Stability and Correlates in Early Childhood

This study explores the stability and correlates of shyness from infancy to 6 years of age using five sets of data from a large representative sample. Included in each set are maternal ratings on a temperament dimension named Approach which assesses reactions to new people and situations, and is the measure of shyness employed here. Two issues are examined: (1) the stability of shyness as revealed by log-linear analyses, in comparison to other temperamental attributes, and when comparing extreme groups to those with moderate scores; (2) the correlates of shyness in infancy and at 5-6 years. The results suggest that the stability of shyness from 1-2 years onwards is moderate, and similar in level and patterning to other temperamental attributes. Comparisons of four subgroups differing on shyness indicate differences on other temperamental and behavioural characteristics; shyness was related to general "difficultness" in infancy, but at 5-6 years was associated with the presence of internalising problems and the absence of externalising problems.

Central Visual Persistence as Measured by the Redundant Target Effect

We measured the duration of central visual persistence by testing normal subjects for the redundant target effect (RTE), ie the speeding up of reaction time to redundant visual stimuli in comparison to similar single stimuli. Brief LED-generated flashes were presented to normal subjects either singly or in a pair at peripheral visual field locations (5 or 30 deg along the horizontal meridian). Stimulus pairs could appear either in the same hemifield at different locations or in opposite hemifields with a stimulus onset asynchrony (SOA) ranging between 0 and 100 ms. The subject's task was to press a key as soon as possible following the appearance of either a single stimulus or of the first stimulus in a pair. We found a robust and consistent overall RTE with double stimuli yielding faster RTs than single stimuli for both intrafield and interfield presentations. The effect decreased significantly from 0 ms to 40 ms SOA and at longer SOAs the speed of response to stimulus pairs was indistinguishable from that to a single stimulus. We believe that the longest SOA compatible with a reliable RTE (40 ms) reflects the duration of central persistence. Evoked-potential evidence gathered in our laboratory suggests that the locus of such persistence may be the extrastriate visual cortex.

Behavioural recovery after treatment for varicose veins

BACKGROUND

The aim of this study was to assess behavioural recovery from the patient's perspective as a prespecified secondary outcome in a multicentre parallel-group randomized clinical trial comparing ultrasound-guided foam sclerotherapy (UGFS), endovenous laser ablation (EVLA) and surgery for the treatment of primary varicose veins.

METHODS

Participants were recruited from 11 UK sites as part of the CLASS trial, a randomized trial of UGFS, EVLA or surgery for varicose veins. Patients were followed up 6 weeks after treatment and asked to complete the Behavioural Recovery After treatment for Varicose Veins (BRAVVO) questionnaire. This is a 15-item instrument that covers eight activity behaviours (tasks or actions an individual is capable of doing in an idealized situation) and seven participation behaviours (what the individual does in an everyday, real-world situation) that were identified to be important from the patient's perspective.

RESULTS

A total of 798 participants were recruited. Both UGFS and EVLA resulted in a significantly quicker recovery compared with surgery for 13 of the 15 behaviours assessed. UGFS was superior to EVLA in terms of return to full-time work (hazard ratio 1·43, 95 per cent c.i. 1·11 to 1·85), looking after children (1·45, 1·04 to 2·02) and walks of short (1·48, 1·19 to 1·84) and longer (1·32, 1·05 to 1·66) duration.

CONCLUSION

Both UGFS and EVLA resulted in more rapid recovery than surgery, and UGFS was superior to EVLA for one-quarter of the behaviours assessed. The BRAVVO questionnaire has the potential to provide important meaningful information to patients about their early recovery and what they may expect to be able to achieve after treatment.

The High Incidence of Reading Disability in Twin Boys and Its Implications for Genetic Analyses

In 1975 the Australian Council of Educational Research (ACER) conducted a nationwide survey of literacy and numeracy in 10- to 14-year olds. A total of 297 of the 12875 children involved were twins. By age 14, only 42% of the twin boys achieved adequate standards of literacy compared with 71% of single-born boys. The deficit in twin girls was much less and twins of both sexes were only moderately behind in numeracy. A survey of 9-13-year-old twin boys in the La Trobe Twin Study (LTS) produced similar results with 75% being below average in reading skills and 23% behind by 18 months or more, despite above average IQs. The ACER data are corroborated by teachers' reports obtained in the same survey, which indicate also how few of the twins with problems are receiving remediation and the high incidence of classroom problems in spelling and reading reversals. The pattern of mistakes twins make on specific items in the ACER survey can be explained as resulting either from specific cognitive deficits or from problems in concentration. The same factors influence performance on different tasks, so that literacy and numeracy are much more closely interrelated in twins than in singletons, and also correlate more with a measure of verbal intelligence. Implications for genetic analysis of scholastic achievement are examined, centering around the different factor structure of abilities in twins and common family environmental effects which are unique to twins.

Consensus Document on Intermittent Claudication from the Central European Vascular Forum (C.E.V.F.)-3rd revision (2013) with the sharing of the Mediterranean League of Angiology and Vascular Surgery, and the North Africa and Middle East Chapter of International Union of Angiology

This paper is the review of the Consensus Document on Intermittent Claudication of the Central European Vascular Forum (CEVF), published in 2008, and and shared with the North Africa and Middle East Chapter of International Union of Angiology and the Mediterranean League of Angiology and Vascular Surgery. The Document presents suggestions for general practitioners and vascular specialists for more precise and appropriate management of PAD, particularly of intermittent claudication, and underlines the investigations that should be required by GPs and what the GP should expect from the vascular specialist (angiologist, vascular surgeon). The idea of the Faculty is to produce a short document, which is an easy reference in daily clinical practice, both for the GPs and vascular specialists.

Young adults with coeliac disease may be at increased risk of early atherosclerosis

BACKGROUND

Accelerated progression of atherosclerosis and increased cardiovascular risk have been described in immune-mediated disorders, but few data are available in coeliac disease.

AIM

To evaluate instrumental and biochemical signs of atherosclerosis risk in 20 adults at first diagnosis of coeliac disease and after 6-8 months of gluten-free diet with mucosal recovery.

METHODS

We analysed total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, triglycerides, homocysteine, C-reactive protein, folate and vitamin B12; ultrasound measurement of carotid intima-media thickness (IMT) and endothelium-dependent dilatation were both carried on at diagnosis and after gluten withdrawal. Twenty-two healthy members of the hospital staff served as matched controls for vascular examinations.

RESULTS

At baseline, mean total and HDL-cholesterol (HDL-C) were both within normal range, while mean LDL-cholesterol concentration was slightly increased; diet was associated with an increment in total and HDL-C (68.2 ± 17.4 vs. 51.4 ± 18.6 mg/dL; P < 0.001) and a significant improvement in total/HDL-C ratio (3.05 ± 0.71 vs. 3.77 ± 0.92; P < 0.02). Mean plasma homocysteine was elevated and not influenced by diet. C-reactive protein significantly decreased with diet (1.073 ± 0.51 vs. 1.92 ± 1.38 mg/dL; P < 0.05). At baseline, in coeliacs, IMT was increased (0.082 ± 0.011 vs. 0.058 ± 0.012 cm; P < 0.005), while endothelium-dependent dilatation was decreased (9.3 ± 1.3 vs. 11.2 ± 1.2%; P < 0.05). Both parameters improved after gluten abstinence.

CONCLUSIONS

Adults with coeliac disease seem to be at potentially increased risk of early atherosclerosis as suggested by vascular impairment and unfavourable biochemical risk pattern. Chronic inflammation might play a determining role. Gluten abstinence with mucosal normalisation reverts to normal the observed alterations.

Irritable bowel syndrome with constipation: a European-focused systematic literature review of disease burden

OBJECTIVE

To conduct a systematic literature review to assess burden of disease and unmet medical needs in patients with irritable bowel syndrome (IBS) with constipation (IBS-C), with a focus on five European countries (France, Germany, Italy, Spain, UK).

METHODS

MEDLINE, EMBASE, and grey literature searches were carried out using terms for IBS and constipation, to identify studies reporting epidemiological, clinical, humanistic, or economic outcomes for IBS-C, published between 2000 and 2010.

RESULTS

Searches identified 885 unique abstracts and 33 supplementary articles, of which 100 publications and six grey literature sources met the inclusion criteria. Among patients with IBS, the prevalence estimates of IBS-C ranged from 1 to 44%. Co-morbid conditions, such as personality traits, psychological distress, and stress, were common. Patients with IBS-C had lower health-related quality-of-life (HRQoL) compared with the general population, and clinical trials suggested that effectively treating IBS-C improves HRQoL. The European societal cost of IBS-C is largely unknown, as no IBS-C-specific European cost-of-illness studies were identified. Two cost analyses demonstrated the substantial societal impact of IBS-C, including reduced productivity at work and work absenteeism. Guidelines offered similar recommendations for the diagnosis and management of IBS; however, recommendations specifically for IBS-C varied by country. Current IBS-C treatment options have limited efficacy and the risk:benefit profile of early 5-HT(4) agonists restricts clinical use.

CONCLUSIONS

This systematic review indicates a clear need for European-focused IBS-C burden-of-disease and cost-of-illness studies to address identified evidence gaps. There is a need for new therapies for IBS-C that are effective, well tolerated, and have a positive impact on HRQoL.

Odour perception following bilateral damage to the olfactory bulbs: a possible case of blind smell

INTRODUCTION

Unconsciously detected chemicals may affect human behaviour (Kirk-Smith et al., 1983; Stern and McClintock, 1998; Zucco et al., 2009), likeability judgements (Li et al., 2007) and brain activity (Lorig et al., 1990; Sobel et al., 1999). No studies, however, have investigated blind smell - the hypothetical olfactory counterpart of blindsight (Weiskrantz et al., 1974).

METHODS

In this report, free and cued olfactory identification of suprathreshold odorants varying in irritancy (i.e., low or no irritant odours versus irritant odours), and taste identification abilities, were examined in patient MB who had undergone surgery for a meningioma. Post-operative imaging revealed encephalomalacia in the left gyrus rectus, with ablation of the left olfactory bulb and damage to the right, subcortical abnormality on the left near the orbital cortex, and damage to a small section of the right gyrus rectus.

RESULTS

On free identification MB, while denying a capacity to smell the odours, still correctly identified some and detected others significantly above chance. In contrast, awareness always accompanied correct detections of irritant odours. Cued odour identification was at chance and no taste impairments were observed.

CONCLUSIONS

We suggest, tentatively, that MB's unusual pattern of awareness when detecting and identifying odours relative to irritant odours may represent an example of 'blind smell'.

Anxiety is more common in children with asthma

OBJECTIVE

There are a variety of reasons why there may be an association between asthma and anxiety in children. Research into the relation between asthma and anxiety has been limited by the sole use of parent-reported or self-reported asthma symptoms to define asthma status. The objective of this study was to determine if children with physician-defined asthma are more likely to suffer anxiety than children without asthma.

DESIGN

A population-based, cross-sectional assessment, of self-reported anxiety symptoms.

SETTING AND PARTICIPANTS

Children aged 5-13 years from Barwon region of Victoria, Australia. Asthma status was determined by review with a paediatrician. Controls were a sample of children without asthma symptoms (matched for age, gender and school).

OUTCOME MEASURE

The Spence Children's Anxiety Scale (SCAS) written questionnaire. The authors compared the mean SCAS score, and the proportion of children with an SCAS score in the clinical range, between the groups.

RESULTS

Questionnaires were issued to 205 children with asthma (158 returned, response rate 77%), and 410 controls (319 returned, response rate 78%). The SCAS scores were higher in asthmatics than controls (p<0.001); and were more likely to be in the clinical range (OR=2.5, 95% CI 1.1 to 5.8, p=0.036). There was no evidence that these associations could be explained by known confounding factors.

CONCLUSIONS

Children with asthma are substantially more likely to suffer anxiety than children without asthma. Future studies are required to determine the sequence of events that leads to this comorbidity, and to test strategies to prevent and treat anxiety among children with asthma.

More than health: the added value of health services in remote Scotland and Australia

Health services are suggested to contribute to remote communities in the ways that extend beyond healthcare delivery. This international multiple case-study research provides qualitative evidence of the social, economic and human contributions (the 'added-value') that may be lost should remote communities lose in-situ health provision. We present a typology of added-value contributions that differentiates institutional aspects (residing in buildings, or embodied in the specific status, capabilities and skills of health professionals) and individual aspects (attributable to health professionals' unique personalities and choices). This typology has relevance for communities, policymakers and managers when considering the impacts of potential service changes.

How to run an effective journal club: a systematic review

BACKGROUND

Health-based journal clubs have been in place for over 100 years. Participants meet regularly to critique research articles, to improve their understanding of research design, statistics and critical appraisal. However, there is no standard process of conducting an effective journal club. We conducted a systematic literature review to identify core processes of a successful health journal club.

METHOD

We searched a range of library databases using established keywords. All research designs were initially considered to establish the body of evidence. Experimental or comparative papers were then critically appraised for methodological quality and information was extracted on effective journal club processes.

RESULTS

We identified 101 articles, of which 21 comprised the body of evidence. Of these, 12 described journal club effectiveness. Methodological quality was moderate. The papers described many processes of effective journal clubs. Over 80% papers reported that journal club intervention was effective in improving knowledge and critical appraisal skills. Few papers reported on the psychometric properties of their outcome instruments. No paper reported on the translation of evidence from journal club into clinical practice.

CONCLUSION

Characteristics of successful journal clubs included regular and anticipated meetings, mandatory attendance, clear long- and short-term purpose, appropriate meeting timing and incentives, a trained journal club leader to choose papers and lead discussion, circulating papers prior to the meeting, using the internet for wider dissemination and data storage, using established critical appraisal processes and summarizing journal club findings.

The Early Language in Victoria Study: predicting vocabulary at age one and two years from gesture and object use

The Macarthur-Bates Communicative Development Inventories (CDI) have been used widely to document early communicative development. The paper reports on a large community sample of 1,447 children recruited from low, middle and high socioeconomic (SES) areas across metropolitan Melbourne, Australia. Regression analyses were conducted to determine the extent to which communicative behaviours reported at 0 ; 8 and 1 ; 0 predicted vocabulary development at 1 ; 0 and 2 ; 0. In support of previous findings with smaller, often less representative samples, gesture and object use at 1 ; 0 were better predictors of 2 ; 0 vocabulary than were gesture and object use at 0 ; 8. At 1 ; 0, children from the lower SES groups were reported to understand more words than children from the higher SES groups, but there were no SES differences for words produced at 1 ; 0 or 2 ; 0. The findings add to our understanding of the variability in the development of early communicative behaviours.

No interaction between the serotonin transporter polymorphism (5-HTTLPR) and childhood adversity or recent stressful life events on symptoms of depression: results from two community surveys

In this study we investigated interactions between the 5-HTTLPR genotype and environmental risk factors (G x E) on symptoms of depression in two large Australian community samples of adolescents and young adults. We postulated that a significant interaction between the 5-HTTLPR genotype and environmental risk factors of childhood adversity or stressful life events on symptoms of depression would be observed in subjects with at least one short allele (s/l or s/s) compared with subjects with no short alleles (l/l). We did not find significant G x E interactions between the 5-HTTLPR genotype and recent stressful life events or childhood adversity on symptoms of depression in our sample populations. However, we did find adolescents aged 17-18 years homozygous for the long allele (l/l) and exposed to persistently high levels of family adversity over a 6-year period were at a greater risk of depression than subjects with the same genotype exposed to no or persistently low levels of family adversity. This interaction should be interpreted cautiously due to the small number of depressed subjects in the sample with persistently high levels of family adversity.

Effects of smoking on cardiopulmonary baroreceptor activation and peripheral vascular resistance

PATIENTS AND METHODS

We studied 16 healthy smokers and 16 nonsmokers acting as controls. We subjected smokers and nonsmokers to cardiopulmonary baroreceptor stimulation by studying forearm and common carotid haemodynamic and sympathovagal balance. Smokers repeated the tests after smoking one cigarette. Smokers and controls were subjected to passive elevation of the legs and the trunk in a horizontal position with pressure monitoring and measurement of the calibre and flow in the brachial and common carotid arteries using a colourDoppler ultrasound. We calculated forearm resistance and carotid wall tension. We also studied R-R variability, calculating the ratio between low frequency (LF) and high frequency (HF) R-R interval variability.

RESULTS

During stimulation diastolic blood pressure values decreased in controls and in smokers at rest. After smoking one cigarette, smokers showed an increase in systolic and diastolic blood pressure as well as in the heart rate during stimulation. Humeral artery increased the calibre during stimulation in both groups; after cigarette smoking the calibre declined throughout the study phases. Forearm resistance decreased in both groups during stimulation at rest, but increased after cigarette smoking. The LF/HF ratio decreased during stimulation in both groups, and it increased at rest after smoking. Carotid diameter did not change in either group, and wall tension increased in smokers after smoking one cigarette.

CONCLUSIONS

Smoking one cigarette increases resistance, impairs baroreflex and increases carotid wall tension in mild smokers. These findings may explain the higher rate of a cardiovascular event in smokers.

Haemodynamic effects of AT1 inhibition and Ca2+-channel blockade in hypertensive patients during isometric stress

To assess the effects of valsartan and amlodipine on the haemodynamics of forearm circulation in hypertensive patients undergoing isometric stress. A total of 24 patients with essential hypertension were subjected to a double blind-cross-over study. The artery left arm flow (strain gauge plethysmography), distensibility of digital arteries (piezoelectric plethysmography) and blood pressure were measured. District resistance was calculated as the ratio between mean arterial pressure and blood flow. The tests were performed at basal conditions (T0) and after 8 days (T8) of therapy with valsartan (160 mg) or amlodipine (10 mg), at rest and during handgrip (HG); treatments were inverted after 15 days of washout. Valsartan and amlodipine reduced blood pressure after 8 days (P<0.05), handgrip increased systolic and diastolic values and heart rate at T0 and only a slight raising in diastolic values at T8. The recovery time of pressure values was longer in hypertensives treated with amlodipine (P<0.05). The forearm flow increased after HG (at T0 an T8) and increased even further after valsartan (P<0.005). Valsartan increased arteriolar distensibility, expressed by the ratio between time to peak and total time (PT/TT) calculated on the sphygmic wave. Amlodipine did not affect PT/TT ratio, whereas it reduced local resistance (T8 vs T0, P<0.05). The reduction effect of valsartan on resistance was detectable also during handgrip, on the contrary amlodipine did not control the increase. Inhibition of AT1 is able to reduce haemodynamic modifications elicited by isometric stress in hypertensive patients.

Dopamine antagonist modulation of amphetamine response as detected using pharmacological MRI

Functional magnetic resonance imaging (fMRI), employing BOLD-contrast, was used to measure changes in regional brain activation following amphetamine administration, either alone or after pre-treatment with the dopamine D1 receptor antagonist SCH23390, or the dopamine D2 receptor antagonist, sulpiride, in anaesthetised rat. After obtaining baseline data, rats (n=8) were given amphetamine (3 g/kg i.v) and volume data sets collected for 90 mins. Acute amphetamine challenge caused widespread increases in BOLD signal intensity in many subcortical structures with rich dopaminergic innervation, with decreases in BOLD contrast observed in the superficial layers of the cortex. Pretreatment with SCH23390 (n=8, 0.5 mg/kg, i.v) substantially attenuated the increases in BOLD activity in response to amphetamine, with lesser effects on the amphetamine-evoked decreases in BOLD signal. In contrast, sulpiride (n=8, 50 mg/kg, i.v) predominantly blocked the decrease in BOLD signal, having a smaller effect on the increases in BOLD signal. In summary, these data are supportive of the notion that different dopamine receptor types are responsible for separate components of the full amphetamine response. Furthermore the utility of BOLD contrast fMRI as a means of characterising the mechanisms of drug action in the whole brain has been demonstrated. Such studies may be of particular use for investigation of localised action and interaction of different dopaminergic agents.

What kind of visual spatial attention is impaired in neglect?

The distribution of spatial attention across the horizontal meridian of the visual field, as assessed by a simple reaction time (RT) paradigm, is dramatically abnormal in neglect patients. In the contralesional hemifield, RT increases sharply from centre to periphery, while in the ipsilesional hemifield, it decreases paradoxically from centre to mid-periphery. In the present study, we firstly asked whether this abnormal distribution of spatial attention is still present when patients know in advance the location of the impending stimulus, and second whether and to which extent it may be influenced by the concomitant presence of hemianopia. In Experiment 1, the stimuli were presented either predictably (blocks of same-point presentations) or unpredictably (blocks of randomised presentations) to one of several contralesional and ipsilesional field locations. As was the case for control subjects, neglect patients showed an overall RT decrease with same-point presentations. However, their abnormal contralesional RT lengthening and ipsilesional speeding were still present. In Experiment 2, the trials were blocked to same-hemifield presentations. In the ipsilesional field condition, neglect patients with and without hemianopia showed the same distorted distribution of attention favouring mid-periphery over central field locations. Two conclusions can be drawn from these experiments: first, the bulk of the abnormal deployment of spatial attention in neglect patients is related to an impairment of exogenous attention which cannot be compensated for by a spared endogenous control. Second, hemianopia does not affect the paradoxical speeding up of RT typically found in the mid-periphery of the ipsilesional field of neglect patients.

Is there an increase in the prevalence of autism spectrum disorders?

This report summarizes recent prevalence estimates for autism spectrum disorders and outlines possible reasons for an apparent increase in the numbers of children diagnosed with autism and Asperger syndrome.

The simon effect in schizophrenic patients with negative symptoms

Automatic shifting of visual attention was investigated using the Simon task in schizophrenic patients with prevailing negative symptomatology. Reaction times were recorded in condition of spatial correspondence and non-correspondence between side of spatially defined responses and side of stimulus presentation. Schizophrenic patients showed asymmetries between the two hemifields attributable to a slowing down of reaction times for non-corresponding trials in the left hemifield. These results are interpreted as a deficit in the process that inhibits the automatic corresponding response, and in general as a difficulty to inhibit dependence on external stimuli, in the left hemifield/right hemisphere.

Evaluation of a community intervention programme for preschool behaviour problems

OBJECTIVES

To evaluate an early intervention project focused on improving child prereading skills and parent behaviour-management skills, for 4-year-old children in the western suburbs of Melbourne (Victoria, Australia).

METHODOLOGY

Following screening of a large sample of preschoolers, four groups were constructed: (i) children receiving a phonological skills-based prereading package in their normal preschool programme; (ii) children whose parents attended six sessions of child behaviour management skill training; (iii) children who received both interventions; and (iv) a control group. Pre-, post-, 1 and 2 year follow-up measures were taken to assess effects on child behavioural and learning adjustment.

RESULTS AND CONCLUSIONS

This community based intervention resulted in positive effects, despite being of low intensity, in achieving significantly less hyperactive/distractable behaviour in children from the combined intervention group at 2 years postintervention. Anxiety problems were also reduced at the post-treatment phase. The prereading package did not demonstrate any effects on reading skills and was deemed to be insufficiently intensive to affect a population of disadvantaged preschoolers. This universal-type of intervention was well accepted by the community, but there is need for further effort to increase recruitment of families of at-risk children into such programmes.