Mental subtraction and multiplication recruit both phonological and visuospatial resources: evidence from a symmetric dual-task design.

Previous studies pointed out a selective interaction between different working memory subsystems (i.e., phonological and visuospatial) and arithmetic operations (i.e., multiplication and subtraction). This was interpreted to support the idea that multiplication and subtraction predominantly rely on a phonologically or spatially organized number code, respectively. Here, we investigated this idea in two groups (multiplication and subtraction group) using a dual-task paradigm. Going beyond previous studies, we carefully controlled and balanced the difficulty of both working memory and calculation tasks within and across participants. This allowed us to test the reciprocal impact of calculations on working memory. We observed no selective interaction between different working memory subsystems and arithmetic operations. Instead, both types of arithmetic operations were impaired by both types of concurrent working memory tasks. Likewise, both types of working memory tasks were impaired by both types of concurrent arithmetic. Our findings suggest that multiplication and subtraction depend on both phonological and visuospatial codes and highlight the importance of balancing task demands within and between participants in the context of dual-task studies.

Exploring the boundary conditions of unconscious numerical priming effects with continuous flash suppression.

The scope and limits of unconscious processing are a controversial topic of research in experimental psychology. Particularly within the visual domain, a wide range of paradigms have been used to experimentally manipulate perceptual awareness. A recent study reported unconscious numerical processing during continuous flash suppression (CFS), which is a powerful variant of interocular suppression and disrupts the conscious perception of visual stimuli for up to seconds. Since this finding of a distance-dependent priming effect contradicts earlier results showing that interocular suppression abolishes semantic processing, we sought to investigate the boundary conditions of this effect in two experiments. Using statistical analyses and experimental designs that precluded an effect of target numerosity, we found evidence for identity priming, but no conclusive evidence for distance-dependent numerical priming under CFS. Our results suggest that previous conclusions on high-level numerical priming under interocular suppression may have been premature.

A decision aid regarding treatment options for patients with an asymptomatic abdominal aortic aneurysm: a randomised clinical trial.

OBJECTIVE: Abdominal aortic aneurysm patients tend to be informed inconsistently and incompletely about their disorder and the treatment options open to them. The objective of this trial was to evaluate whether these patients are better informed and experience less decisional conflict regarding their treatment options after viewing a decision aid. DESIGN: A six-centre, randomised clinical trial comparing a decision aid plus regular information versus regular information from the surgeon. METHODS: Included patients had recently been diagnosed with an asymptomatic abdominal aortic aneurysm at least 4 cm in diameter. The decision aid consisted of a one-time viewing of an interactive CD-ROM elaborating on elective surgery versus watchful waiting. Generally, the decision aid advised patients with aneurysms less than 5.5 cm to agree to watchful waiting, for larger aneurysms the decision aid provided insight into the balance of benefit and harm of surgical and conservative approaches, taking into account age, co-morbidity and size of the aneurysm. The primary outcome was patient decisional conflict measured at 1 month follow-up (Decisional Conflict Scale). Secondary outcomes were patient knowledge, anxiety and satisfaction. RESULTS: In 178 aneurysm patients, decisional conflict scores did not differ significantly between the decision aid and the regular information groups (22 vs. 24 on the 0-100 Decisional Conflict Scale; p = .33). Patients in the decision aid group had significantly better knowledge (10.0 vs. 9.4 out of 13 points; p = .04), whereas anxiety levels (4.4 and 5.0 on a 0-21 scale; p = .73) and satisfaction scores (74 and 73 on a 0-100 scale; p = .81) were similar in both groups. CONCLUSION: In addition to regular patient-surgeon communication, a decision aid helps to share treatment decisions with abdominal aortic aneurysm patients by increasing their knowledge about the disorder and available treatment options without raising anxiety levels; however, it does not reduce decisional conflict, nor does it improve satisfaction.

Practical skills training influences knowledge and attitude of dental students towards emergency medical care.

BACKGROUND: Medical emergencies in dental practice are generally perceived as being rare. Nonetheless, recent studies have shown that incidents occur on a regular basis. Therefore, patients have the right to expect necessary skills to manage life-threatening situations from every dentist. OBJECTIVE: To observe students' attitude and self-assessment towards emergency medical care (EMC) and its practical appliance. MATERIAL AND METHODS: Students of dentistry took part in small group sessions for adult and paediatric basic life support. Participants filled out pre-post questionnaires regarding knowledge and attitude towards EMC (6, respectively, 10-point Likert scale). Additionally, feedback was asked for the quality of course and tutors. RESULTS: Forty dental students in their last 2 years of study registered for the EMC courses. The majority had never attended any first-aid course; the mean age was 25% and 75% were women. A comparison between pre- and post-evaluation showed that the participation in practical training easily enhances the students' awareness of EMC importance as well as self-confidence in managing emergencies. After the course, 71% shared the opinion that retraining should be obligatory for all medical personnel. At the same time, students' self-assessment of confidence for specific tasks got significant upgrades in every aspect. CONCLUSION: The evaluation data clearly show the participants' needs to deal with topics of EMC within the curriculum of dentistry. The proposed course is able to change participants' attitudes towards EMC and its importance for their daily practice. The considerable enhancement of self-confidence in performing EMC-techniques might also lead to more willingness to manage emergency situations.

Implementation of evidence-based practice: outside the box, throughout the hospital.

BACKGROUND: Evidence-based practice (EBP) is a generally accepted means to improve healthcare quality. However, not all healthcare professionals and managers apply EBP in daily practice. We investigated EBP attitudes, knowledge and the perceived barriers and facilitators to practising EBP , to define tailor-made interventions for improving evidence-based behaviour. METHODS: In this cross-sectional survey, doctors and nurses from five major specialities of a university hospital were invited to complete the McColl and Barriers questionnaires. RESULTS: Response rates were 70% (305÷435) for doctors and 74% (396÷537) for nurses. They were welcoming towards EBP, but considered time constraints, knowledge gaps and poor availability of evidence as major barriers to implement EBP . They also mentioned contradicting results (75%) and flawed methodology (69%), while nurses frequently mentioned unawareness of (75%), or difficulty in reading and interpreting research papers (70%). Regarding EBP knowledge, 6/8 common EBP terms could be explained by 54% of doctors but by only 15% of nurses. Facilitating factors among doctors concerned the availability and accessibility of high-level evidence and communication of evidence during various clinical meetings and handovers for clinical decision making. Among nurses, promoting factors involved more teaching and instances to incorporate EBP in clinical practice. Both groups desired more managerial support in terms of motivation and opportunities. CONCLUSIONS: Doctors and nurses have embraced the EBP paradigm as an important means to improve quality of clinical patient care, but its application is still cumbersome. This paper offers a tailored programme for implementation and managerial role-models.sustainment of EBP, corroborated by professional and managerial role-models.

Factors influencing long-term adherence to two previously implemented hospital guidelines.

OBJECTIVE AND SETTING: After successful implementation, adherence to hospital guidelines should be sustained. Long-term adherence to two hospital guidelines was audited. The overall aim was to explore factors accounting for their long-term adherence or non-adherence. DESIGN AND PARTICIPANTS: A fluid balance guideline (FBG) and body temperature guideline (BTG) were developed and implemented in our hospital in 2000. Long-term adherence was determined retrospectively based on data from patient files. Focus groups were launched to explore nurses' perceptions of barriers and facilitators regarding long-term adherence. The predominant themes from the nurses' focus groups were posed to clinicians in questionnaires. RESULTS: Nurses involved in the FBG (overall adherence 100%) stated that adherence has immediate advantages in terms of safety and a gain in time. Nurses and oncologists acted unanimously which was thought to enhance adherence. On the other hand, opinions differed on the BTG within the nursing teams and medical staff (overall adherence 50%). Although the guideline discourages routine postoperative body temperature measurements, temperature should be measured according to the guideline in a considerable number of cases due to changes in patient characteristics since the year 2000. Therefore, adherence was judged to be rather complex. CONCLUSIONS: To secure adherence to hospital guidelines after their successful implementation, guidelines should preferably be comprehensive in terms of being applicable to the majority of the patients in that particular setting and to the most common clinical situations. All healthcare professionals involved should be aware of its immediate benefits for themselves or to their patients.

Information communicated with patients in decision making about their abdominal aortic aneurysm.

OBJECTIVES: To explore what kind of information surgeons communicate with patients diagnosed with an abdominal aortic aneurysm, and if the information provided regarding the disorder and treatment options available complies with legal requirements. METHODS: Dutch vascular surgeons sound-recorded consultations with their patients. Recordings were scored using a checklist based on ethical considerations and five statutory categories of information on: (1) the disorder, (2) procedure and aim of surgery, (3) consequences and risks of surgery, (4) watchful observation and (5) individual prognosis regarding state of health. Each category was represented by several information items, which were scored dichotomously ('not mentioned' or 'mentioned'). A category was considered sufficiently addressed if at least one of its items was mentioned. RESULTS: Thirty-five consultations were recorded (13 patients with aneurysmal diameter <5.5 cm and 22 with diameter >or=5.5 cm). In a minority of recordings, all five categories were addressed: 1/13 (8%) and 9/22 (41%), respectively. None of the information items was discussed consistently in every recording. Although most patients were informed about the proposed treatment option (11/13; 85% and 19/22; 86%), the alternative treatment option was mentioned only occasionally (4/13; 31% and 14/22; 64%). CONCLUSIONS: Patients with an abdominal aneurysm are informed inconsistently about their disorder and treatment options. Information is often less than that legally required. This may hinder shared decision making.

A tool to balance benefit and harm when deciding about adjuvant therapy.

Adjuvant therapy aims to prevent outgrowth of residual disease but can induce serious side effects. Weighing conflicting treatment effects and communicating this information with patients is not elementary. This study presents a scheme balancing benefit and harm of adjuvant therapy vs no adjuvant therapy. It is illustrated by the available evidence on adjuvant pelvic external beam radiotherapy (RT) for intermediate-risk stage I endometrial carcinoma patients. The scheme comprises five outcome possibilities of adjuvant therapy: patients who benefit from adjuvant therapy (some at the cost of complications) vs those who neither benefit nor contract complications, those who do not benefit but contract severe complications, or those who die. Using absolute risk differences, a fictive cohort of 1000 patients receiving adjuvant RT is categorised. Three large randomised clinical trials were included. Recurrences will be prevented by adjuvant RT in 60 patients, a majority of 908 patients will neither benefit nor suffer severe radiation-induced harm but 28 patients will suffer severe complications due to adjuvant RT and an expected four patients will die. This scheme readily summarises the different possible treatment outcomes and can be of practical value for clinicians and patients in decision making about adjuvant therapies.

Pediatric oncologists and evidence-based medicine: a postal survey in The Netherlands.

BACKGROUND: The interest in evidence-based medicine (EBM) is still increasing throughout medicine, but the precise role of EBM in the field of pediatric oncology remains unclear. We undertook this survey to evaluate the attitude of Dutch pediatric oncologists and pediatric oncologists in training towards EBM and their views on how to move from opinion-based medicine to EBM. PROCEDURE: A questionnaire was sent to all pediatric oncologists (n = 44) and pediatric oncologists in training (n = 13) of the 8 university medical centers in the Netherlands. RESULTS: The questionnaire was returned by 71% of the pediatric oncologists and pediatric oncologists in training. The majority had a positive attitude towards EBM, but at the moment only approximately 50% of their clinical practice was thought to be evidence-based. The most important barrier to practicing EBM in pediatric oncology was a lack of time. However, only a minority of the respondents thought that more time was an appropriate method to facilitate the use of EBM in pediatric oncology. The majority of pediatric oncologists and pediatric oncologists in training would prefer to be able to use EBM summaries, guidelines and protocols. CONCLUSIONS: Despite the positive attitude of the majority of pediatric oncologists and pediatric oncologists in training towards EBM, only half of clinical practice is currently believed to be evidence-based. By using EBM summaries, guidelines and protocols as time-saving methods the use of EBM in pediatric oncology practice may be improved.

Pharmacokinetics of aprepitant after single and multiple oral doses in healthy volunteers.

Aprepitant is the first NK1 receptor antagonist approved for use with corticosteroids and 5HT3 receptor antagonists to prevent chemotherapy-induced nausea and vomiting (CINV). The effective dose to prevent CINV is a 125-mg capsule on day 1 followed by an 80-mg capsule on days 2 and 3. Study 1 evaluated the bioavailability of the capsules and estimated the effect of food. The mean (95% confidence interval [CI]) bioavailabilities of 125-mg and 80-mg final market composition (FMC) capsules, as assessed by simultaneous administration of stable isotope-labeled intravenous (i.v.) aprepitant (2 mg) and FMC capsules, were 0.59 (0.53, 0.65) and 0.67 (0.62, 0.73), respectively. The geometric mean (90% CI) area under the plasma concentration time curve (AUC) ratios (fed/fasted) were 1.2 (1.10, 1.30) and 1.09 (1.00, 1.18) for the 125-mg and 80-mg capsule, respectively, demonstrating that aprepitant can be administered independently of food. Study 2 defined the pharmacokinetics of aprepitant administered following the 3-day regimen recommended to prevent CINV (125 mg/80 mg/80 mg). Consistent daily plasma exposures of aprepitant were obtained following this regimen, which was generally well tolerated.

Diclofenac systemic exposure is not increased when topical diclofenac is applied to ultraviolet-induced erythema.

OBJECTIVES: Diclofenac is a non-steroidal anti-inflammatory drug used for a variety of painful and inflammatory conditions. A new low-dose, topical-gel form of diclofenac sodium (diclofenac-Na) has been developed for pain relief and redness reduction after sunburn. The objective was to compare exposure to oral diclofenac-Na with the systemic exposure to diclofenac after application of the new topical diclofenac-Na 0.1% Emulgel gel (diclofenac-Na gel) to normal skin and to that with ultraviolet-induced erythema relative. METHODS: This study was an open, single-centre, three-period, non-randomised trial in 18 healthy Caucasian subjects. During the first period, 12.5 g gel (12.5 mg diclofenac-Na) was applied twice on a single day to normal skin. During the second period, a 25-mg diclofenac-Na, enteric-coated tablet was given orally three times in a single day. During the third period, the diclofenac-Na gel was applied, as in the first period, but during the early phase of an erythema induced by three times the ultraviolet minimal erythema dose, i.e. a first-degree sunburn associated with pain. During each period, venous blood samples were collected over 24 h and urine was collected over 72 h after first administration for the determination of diclofenac in plasma and urine and of 4'-OH-diclofenac in urine. RESULTS: The systemic exposure after topical application of 25 mg diclofenac-Na on sunburned skin was less than 3% that of 75 mg oral diclofenac-Na and was not increased to that measured on normal skin. CONCLUSION: The diclofenac-Na 0.1% Emulgel gel can be applied safely to sunburned skin (superficial sunburn, i.e. first degree) as well as to normal skin.