Models of care for chronic kidney disease: A systematic review.

AIM: Chronic kidney disease (CKD) is common and presents an increasing burden to patients and health services. However, the optimal model of care for patients with CKD is unclear. We systematically reviewed the clinical effectiveness of different models of care for the management of CKD. METHODS: A comprehensive search of eight databases was undertaken for articles published from 1992 to 2016. We included randomized controlled trials that assessed any model of care in the management of adults with pre-dialysis CKD, reporting renal, cardiovascular, mortality and other outcomes. Data extraction and quality assessment was carried out independently by two authors. RESULTS: Results were summarized narratively. Nine articles (seven studies) were included. Four models of care were identified: nurse-led, multidisciplinary specialist team, pharmacist-led and self-management. Nurse and pharmacist-led care reported improved rates of prescribing of drugs relevant to CKD. Heterogeneity was high between studies and all studies were at high risk of bias. Nurse-led care and multidisciplinary specialist care were associated with small improvements in blood pressure control. CONCLUSION: Evidence of long term improvements in renal, cardiovascular or mortality endpoints was limited by short follow up. We found little published evidence about the effectiveness of different models of care to guide best practice for service design, although there was some evidence that models of care where health professionals deliver care according to a structured protocol or guideline may improve adherence to treatment targets.

Transcriptional and epigenetic basis for restoration of G6PD enzymatic activity in human G6PD-deficient cells.

HDAC inhibitors (HDACi) increase transcription of some genes through histone hyperacetylation. To test the hypothesis that HDACi-mediated enhanced transcription might be of therapeutic value for inherited enzyme deficiency disorders, we focused on the glycolytic and pentose phosphate pathways (GPPPs). We show that among the 16 genes of the GPPPs, HDACi selectively enhance transcription of glucose 6-phosphate dehydrogenase (G6PD). This requires enhanced recruitment of the generic transcription factor Sp1, with commensurate recruitment of histone acetyltransferases and deacetylases, increased histone acetylation, and polymerase II recruitment to G6PD. These G6PD-selective transcriptional and epigenetic events result in increased G6PD transcription and ultimately restored enzymatic activity in B cells and erythroid precursor cells from patients with G6PD deficiency, a disorder associated with acute or chronic hemolytic anemia. Therefore, restoration of enzymatic activity in G6PD-deficient nucleated cells is feasible through modulation of G6PD transcription. Our findings also suggest that clinical consequences of pathogenic missense mutations in proteins with enzymatic function can be overcome in some cases by enhancement of the transcriptional output of the affected gene.

Looking to the future: predicting renal replacement outcomes in a large community cohort with chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is common and important due to poor outcomes. An ability to stratify CKD care based on outcome risk should improve care for all. Our objective was to develop and validate 5-year outcome prediction tools in a large population-based CKD cohort. Model performance was compared with the recently reported 'kidney failure risk equation' (KFRE) models. METHODS: Those with CKD in the Grampian Laboratory Outcomes Mortality and Morbidity Study-I (3396) and -II (18 687) cohorts were used to develop and validate a renal replacement therapy (RRT) prediction tool. The discrimination, calibration and overall performance were assessed. The net reclassification index compared performance of the developed model and the 3- and 4-variable KFRE model to predict RRT in the validation cohort. RESULTS: The developed model (with measures of age, sex, excretory renal function and proteinuria) performed well with a C-statistic of 0.938 (0.918-0.957) and Hosmer-Lemeshow (HL) χ(2) statistic 4.6. In the validation cohort (18 687), the developed model falsely identified fewer as high risk (414 versus 3278 individuals) compared with the KFRE 3-variable model (measures of age, sex and excretory renal function), but had more false negatives (58 versus 21 individuals). The KFRE 4-variable model could only be applied to 2274 individuals because of a lack of baseline urinary albumin creatinine ratio data, thus limiting its use in routine clinical practice. CONCLUSIONS: CKD outcome prediction tools have been developed by ourselves and others. These tools could be used to stratify care, but identify both false positives and -negatives. Further refinement should optimize the balance between identifying those at increased risk with clinical utility for stratifying care.

Charlson index scores from administrative data and case-note review compared favourably in a renal disease cohort.

BACKGROUND: The Charlson index is a widely used measure of comorbidity. The objective was to compare Charlson index scores calculated using administrative data to those calculated using case-note review (CNR) in relation to all-cause mortality and initiation of renal replacement therapy (RRT) in the Grampian Laboratory Outcomes Mortality and Morbidity Study (GLOMMS-1) chronic kidney disease cohort. METHODS: Modified Charlson index scores were calculated using both data sources in the GLOMMS-1 cohort. Agreement between scores was assessed using the weighted Kappa. The association with outcomes was assessed using Poisson regression, and the performance of each was compared using net reclassification improvement. RESULTS: Of 3382 individuals, median age 78.5 years, 56% female, there was moderate agreement between scores derived from the two data sources (weighted kappa 0.41). Both scores were associated with mortality independent of a number of confounding factors. Administrative data Charlson scores were more strongly associated with death than CNR scores using net reclassification improvement. Neither score was associated with commencing RRT. CONCLUSION: Despite only moderate agreement, modified Charlson index scores from both data sources were associated with mortality. Neither was associated with commencing RRT. Administrative data compared favourably and may be superior to CNR when used in the Charlson index to predict mortality.

Individual differences in visual field shape modulate the effects of attention on the lower visual field advantage in crowding.

It has previously been reported that visual crowding of a target by flankers is stronger in the upper visual field than in the lower, and this finding has been attributed to greater attentional resolution in the lower hemifield (He, Cavanagh, & Intriligator, 1996). Here we show that the upper/lower asymmetry in visual crowding can be explained by natural variations in the borders of each individual's visual field. Specifically, asymmetry in crowding along the vertical meridian can be almost entirely accounted for by replacing the conventional definition of visual field location, in units of degrees of visual angle, with a definition based on the ratio of the extents of an individual's upper and lower visual field. We also show that the upper/lower crowding asymmetry is eliminated when stimulus eccentricity is expressed in units of percentage of visual field extent but is present when the conventional measure of visual angle is used. We further demonstrate that the relationship between visual field extent and perceptual asymmetry is most evident when participants are able to focus their attention on the target location. These results reveal important influences of visual field boundaries on visual perception, even for visual field locations far from those boundaries.

White matter microstructure throughout the brain correlates with visual imagery in grapheme-color synesthesia.

In this study we show, for the first time, a correlation between the neuroanatomy of the synesthetic brain and a metric that measures behavior not exclusive to the synesthetic experience. Grapheme-color synesthetes (n=20), who experience colors triggered by viewing or thinking of specific letters or numbers, showed altered white matter microstructure, as measured using diffusion tensor imaging, compared with carefully matched non-synesthetic controls. Synesthetes had lower fractional anisotropy and higher perpendicular diffusivity when compared to non-synesthetic controls. An analysis of the mode of anisotropy suggested that these differences were likely due to the presence of more crossing pathways in the brains of synesthetes. Additionally, these differences in white matter microstructure correlated negatively, and only for synesthetes, with a measure of the vividness of their visual imagery. Synesthetes who reported the most vivid visual imagery had the lowest fractional anisotropy and highest perpendicular diffusivity. We conclude that synesthetes as a population vary along a continuum while showing categorical differences in neuroanatomy and behavior compared to non-synesthetes.

Definitions of progression in chronic kidney disease--predictors and relationship to renal replacement therapy in a population cohort with a 6 year follow-up.

BACKGROUND: Chronic kidney disease (CKD) is common, important and associated with increased healthcare needs due to CKD progression. Definitions of renal disease progression are multiple, and not always comparable. A measure of 'progression' directly comparable with renal replacement therapy (RRT) initiation would identify 'progressors' in research and for healthcare planning. METHODS: The Grampian Laboratory Outcomes Morbidity and Mortality Study (GLOMMS-I) is a community cohort with CKD from 2003, followed up to June 2009 for (i) RRT initiation and (ii) 'progression': sustained reduction in estimated glomerular filtration rate (eGFR) by 15 mL/min/1.73 m2 (equivalent to CKD stage change), or to <10 mL/min/1.73 m2, whichever occurs first. Predictors were baseline demographics and comorbidity. The use of the Kidney Disease: Improving Global Outcomes-2012 progression definition was also explored. RESULTS: Two thousand two hundred and eighty-nine and 1044 had Stage 3 and 4 CKD, 44% were males. Overall, RRT initiation and progression rates were 0.97 and 3.50 per 100 patient-years (py). Females had significantly lower progression and RRT initiation rates. The progression rate was not dependent on CKD stage [incidence rate ratio (IRR) for Stage 4 (versus Stage 3) 0.9 (95% CI 0.8-1.2)], whereas the RRT initiation rate was [IRR 5.6 (95% CI 3.8-8.2)]. Increased proteinuria was associated with both greater RRT initiation and progression rates. CONCLUSIONS: Progression and RRT initiation rate ratios allow comparison of predictors of these outcomes. Higher rates of both in males suggest that greater RRT initiation rate is biological rather than due to preferential treatment. Similar progression but very different RRT initiation rates in Stage 3 and 4 CKD suggests that CKD stage effect on RRT initiation is a function of endpoint proximity rather than faster renal function deterioration.

Ensemble crowd perception: a viewpoint-invariant mechanism to represent average crowd identity.

Individuals can rapidly and precisely judge the average of a set of similar items, including both low-level (Ariely, 2001) and high-level objects (Haberman & Whitney, 2007). However, to date, it is unclear whether ensemble perception is based on viewpoint-invariant object representations. Here, we tested this question by presenting participants with crowds of sequentially presented faces. The number of faces in each crowd and the viewpoint of each face varied from trial to trial. This design required participants to integrate information from multiple viewpoints into one ensemble percept. Participants reported the mean identity of crowds (e.g., family resemblance) using an adjustable, forward-oriented test face. Our results showed that participants accurately perceived the mean crowd identity even when required to incorporate information across multiple face orientations. Control experiments showed that the precision of ensemble coding was not solely dependent on the length of time participants viewed the crowd. Moreover, control analyses demonstrated that observers did not simply sample a subset of faces in the crowd but rather integrated many faces into their estimates of average crowd identity. These results demonstrate that ensemble perception can operate at the highest levels of object recognition after 3-D viewpoint-invariant faces are represented.

Exploring the edges of visual space: the influence of visual boundaries on peripheral localization.

Previous studies of localization of stationary targets in the peripheral visual field have found either underestimations (foveal biases) or overestimations (peripheral biases) of target eccentricity. In the present study, we help resolve this inconsistency by demonstrating the influence of visual boundaries on the type of localization bias. Using a Goldmann perimeter (an illuminated half-dome), we presented targets at different eccentricities across the visual field and asked participants to judge the target locations. In Experiments 1 and 2, participants reported target locations relative to their perceived visual field extent using either a manual or verbal response, with both response types producing a peripheral bias. This peripheral localization bias was a non-linear scaling of perceived location when the visual field was not bounded by external borders induced by facial features (i.e., the nose and brow), but location scaling was linear when visual boundaries were present. Experiment 3 added an external border (an aperture edge placed in the Goldmann perimeter) that resulted in a foveal bias and linear scaling. Our results show that boundaries that define a spatial region within the visual field determine both the direction of bias in localization errors for stationary objects and the scaling function of perceived location across visual space.

Identifying multimorbidity clusters in an unselected population of hospitalised patients.

Multimorbidity (multiple coexisting chronic health conditions) is common and increasing worldwide, and makes care challenging for both patients and healthcare systems. To ensure care is patient-centred rather than specialty-centred, it is important to know which conditions commonly occur together and identify the corresponding patient profile. To date, no studies have described multimorbidity clusters within an unselected hospital population. Our aim was to identify and characterise multimorbidity clusters, in a large, unselected hospitalised patient population. Linked inpatient hospital episode data were used to identify adults admitted to hospital in Grampian, Scotland in 2014 who had ≥ 2 of 30 chronic conditions diagnosed in the 5 years prior. Cluster analysis (Gower distance and Partitioning around Medoids) was used to identify groups of patients with similar conditions. Clusters of conditions were defined based on clinical review and assessment of prevalence within patient groups and labelled according to the most prevalent condition. Patient profiles for each group were described by age, sex, admission type, deprivation and urban-rural area of residence. 11,389 of 41,545 hospitalised patients (27%) had ≥ 2 conditions. Ten clusters of conditions were identified: hypertension; asthma; alcohol misuse; chronic kidney disease and diabetes; chronic kidney disease; chronic pain; cancer; chronic heart failure; diabetes; hypothyroidism. Age ranged from 51 (alcohol misuse) to 79 (chronic heart failure). Women were a higher proportion in the chronic pain and hypothyroidism clusters. The proportion of patients from the most deprived quintile of the population ranged from 6% (hypertension) to 14% (alcohol misuse). Identifying clusters of conditions in hospital patients is a first step towards identifying opportunities to target patient-centred care towards people with unmet needs, leading to improved outcomes and increased efficiency. Here we have demonstrated the face validity of cluster analysis as an exploratory method for identifying clusters of conditions in hospitalised patients with multimorbidity.

Attentional selection of relative SF mediates global versus local processing: evidence from EEG.

Previous research on functional hemispheric differences in visual processing has associated global perception with low spatial frequency (LSF) processing biases of the right hemisphere (RH) and local perception with high spatial frequency (HSF) processing biases of the left hemisphere (LH). The Double Filtering by Frequency (DFF) theory expanded this hypothesis by proposing that visual attention selects and is directed to relatively LSFs by the RH and relatively HSFs by the LH, suggesting a direct causal relationship between SF selection and global versus local perception. We tested this idea in the current experiment by comparing activity in the EEG recorded at posterior right and posterior left hemisphere sites while participants' attention was directed to global or local levels of processing after selection of relatively LSFs versus HSFs in a previous stimulus. Hemispheric asymmetry in the alpha band (8-12 Hz) during preparation for global versus local processing was modulated by the selected SF. In contrast, preparatory activity associated with selection of SF was not modulated by the previously attended level (global/local). These results support the DFF theory that top-down attentional selection of SF mediates global and local processing.

Reference and point-of-care testing for G6PD deficiency: Blood disorder interference, contrived specimens, and fingerstick equivalence and precision.

Certain clinical indications and treatments such as the use of rasburicase in cancer therapy and 8-aminoquinolines for Plasmodium vivax malaria treatment would benefit from a point-of-care test for glucose-6-phosphate dehydrogenase (G6PD) deficiency. Three studies were conducted to evaluate the performance of one such test: the STANDARD™ G6PD Test (SD BIOSENSOR, South Korea). First, biological interference on the test performance was evaluated in specimens with common blood disorders, including high white blood cell (WBC) counts. Second, the test precision on fingerstick specimens was evaluated against five individuals of each, deficient, intermediate, and normal G6PD activity status. Third, clinical performance of the test was evaluated at three point-of-care settings in the United States. The test performed equivalently to the reference assay in specimens with common blood disorders. High WBC count blood samples resulted in overestimation of G6PD activity in both the reference assay and the STANDARD G6PD Test. The STANDARD G6PD Test showed good precision on multiple fingerstick specimens from the same individual. The same G6PD threshold values (U/g Hb) were applied for a semiquantitative interpretation for fingerstick- and venous-derived results. The sensitivity/specificity values (95% confidence intervals) for the test for G6PD deficiency were 100 (92.3-100.0)/97 (95.2-98.2) and 100 (95.7-100.0)/97.4 (95.7-98.5) for venous and capillary specimens, respectively. The same values for females with intermediate (> 30% to ≤ 70%) G6PD activity were 94.1 (71.3-99.9)/88.2 (83.9-91.7) and 82.4 (56.6-96.2)/87.6(83.3-91.2) for venous and capillary specimens, respectively. The STANDARD G6PD Test enables point-of-care testing for G6PD deficiency.

Local or global? Attentional selection of spatial frequencies binds shapes to hierarchical levels.

Contrary to the traditional view that shapes and their hierarchical level (local or global) are a priori integrated in perception, recent evidence suggests that the identity of a shape and its level are encoded independently, implying the need for shape-level binding to account for normal perception. What is the binding mechanism in this case? Using hierarchically arranged letter shapes, we obtained evidence that the left hemisphere has a preference for binding shapes to the local level, whereas the right hemisphere has a preference for binding shapes to the global level. More important, binding is modulated by attentional selection of higher or lower spatial frequencies. Attention to higher spatial frequencies facilitated subsequent binding by the left hemisphere of elements to the local level, whereas attention to lower spatial frequencies facilitated subsequent binding by the right hemisphere of elements to the global level.

Implicit representation and explicit detection of features in patients with hemispatial neglect.

Despite profound inattention to the side of space opposite a brain lesion in patients with unilateral neglect, priming studies demonstrate that undetected stimuli are capable of influencing subsequent behaviour. However, the nature of implicit processing of neglected stimuli is poorly understood. In the current study, we examined implicit processing in five patients with neglect using both visual search and priming methods. A psychophysical staircase method varying time of presentation was first used to establish a high (75%) and low (25%) detection probability for targets in both a feature and a conjunction search array. The arrays were then used in a priming task to examine how a difference in the level of overt detection of a feature or a conjunction presented in neglected space influenced subsequent discrimination speed to a single probe presented at fixation. The results showed that priming effects with feature primes were independent of their explicit detection rates (high versus low), but priming effects with conjunction primes reflected the pattern of explicit detection. These findings are discussed as they relate to availability versus accessibility of neglected stimuli.

Maternal and neonatal risk factors for childhood type 1 diabetes: a matched case-control study.

BACKGROUND: An interaction between genetic susceptibility and environmental factors is thought to be involved in the aetiology of type 1 diabetes. The aim of this study was to investigate maternal and neonatal risk factors for type 1 diabetes in children under 15 years old in Grampian, Scotland. METHODS: A matched case-control study was conducted by record linkage. Cases (n = 361) were children born in Aberdeen Maternity Hospital from 1972 to 2002, inclusive, who developed type 1 diabetes, identified from the Scottish Study Group for the Care of Diabetes in the Young Register. Controls (n = 1083) were randomly selected from the Aberdeen Maternity Neonatal Databank, matched by year of birth. Exposure data were obtained from the Aberdeen Maternity Neonatal Databank. Conditional logistic regression was used to evaluate the association between various maternal and neonatal factors and the risk of type 1 diabetes. RESULTS: There was no evidence of statistically significant associations between type 1 diabetes and maternal age, maternal body mass index, previous abortions, pre-eclampsia, amniocentesis, maternal deprivation, use of syntocinon, mode of delivery, antepartum haemorrhage, baby's sex, gestational age at birth, birth order, birth weight, jaundice, phototherapy, breast feeding, admission to neonatal unit and Apgar score (P > 0.05). A significantly decreased risk of type 1 diabetes was observed in children whose mothers smoked at the booking appointment compared to those whose mothers did not, with an adjusted OR of 0.67, 95% CI (0.46, 0.99). CONCLUSIONS: This case-control study found limited evidence of a reduced risk of the development of type 1 diabetes in children whose mothers smoked, compared to children whose mothers did not. No evidence was found of a significant association between other maternal and neonatal factors and childhood type 1 diabetes.

Where does attention go when it moves? Spatial properties and locus of the attentional repulsion effect.

Reliable effects of spatial attention on perceptual measures have been well documented, yet little is known about how attention affects perception of space per se. The present study examined the effects of involuntary shifts of spatial attention on perceived location using a paradigm developed by S. Suzuki and P. Cavanagh (1997) that produces an attentional repulsion effect (ARE). The ARE refers to the illusory displacement of two vernier lines away from briefly presented cues. In Experiment 1, we show that the magnitude of the ARE depends on cue-target distance, indicating that the effects of attention on perceived location are not uniform across the visual field. Experiments 2 and 3 tested whether repulsion occurs away from cue center of mass or from cue contour. Perceived repulsion always occurred away from the cues' center of mass, regardless of the arrangement of the cue contours relative to the vernier lines. Moreover, the magnitude of the ARE varied with shifts in the position of the cues' center of mass. These experiments suggest that the onset of the cue produces a shift of attention to its center of mass rather than to the salient luminance contours that define it, and that this mechanism underlies the ARE.

Urban-rural and socioeconomic status: Impact on multimorbidity prevalence in hospitalized patients.

OBJECTIVE: The aim of this study was to describe multimorbidity prevalence in hospitalized adults, by urban-rural area of residence and socioeconomic status (SES). METHODS: Linked hospital episode data were used. Adults (≥18 years) admitted to hospital as an inpatient during 2014 in Grampian, Scotland, were included. Conditions were identified from admissions during the 5 years prior to the first admission in 2014. Multimorbidity was defined as ≥2 conditions and measured using Tonelli et al. based on International Classification of Diseases-10 coding (preselected list of 30 conditions). We used proportions and 95% confidence intervals (CIs) to summarize the prevalence of multimorbidity by age group, sex, urban-rural category and deprivation. The association between multimorbidity and patient characteristics was assessed using the χ 2 test. RESULTS: Forty one thousand five hundred and forty-five patients were included (median age 62, 52.6% female). Overall, 27.4% (95% CI 27.0, 27.8) of patients were multimorbid. Multimorbidity prevalence was 28.8% (95% CI 28.1, 29.5) in large urban versus 22.0% (95% CI 20.9, 23.3) in remote rural areas and 28.7% (95% CI 27.2, 30.3) in the most deprived versus 26.0% (95% CI 25.2, 26.9) in the least deprived areas. This effect was consistent in all age groups, but not statistically significant in the age group 18-29 years. Multimorbidity increased with age but was similar for males and females. CONCLUSION: Given the scarcity of research into the effect of urban-rural area and SES on multimorbidity prevalence among hospitalized patients, these findings should inform future research into new models of care, including the consideration of urban-rural area and SES.

The attentional repulsion effect and relative size judgments.

Rapid shifts of involuntary attention have been shown to induce mislocalizations of nearby objects. One pattern of mislocalization, termed the Attentional Repulsion Effect (ARE), occurs when the onset of peripheral pre-cues lead to perceived shifts of subsequently presented stimuli away from the cued location. While the standard ARE configuration utilizes vernier lines, to date, all previous ARE studies have only assessed distortions along one direction and tested one spatial dimension (i.e., position or shape). The present study assessed the magnitude of the ARE using a novel stimulus configuration. Across three experiments participants judged which of two rectangles on the left or right side of the display appeared wider or taller. Pre-cues were used in Experiments 1 and 2. Results show equivalent perceived expansions in the width and height of the pre-cued rectangle in addition to baseline asymmetries in left/right relative size under no-cue conditions. Altering cue locations led to shifts in the perceived location of the same rectangles, demonstrating distortions in perceived shape and location using the same stimuli and cues. Experiment 3 demonstrates that rectangles are perceived as larger in the periphery compared to fixation, suggesting that eye movements cannot account for results from Experiments 1 and 2. The results support the hypothesis that the ARE reflects a localized, symmetrical warping of visual space that impacts multiple aspects of spatial and object perception.

Measuring multimorbidity in hospitalised patients using linked hospital episode data: comparison of two measures.

INTRODUCTION: Multimorbidity is a complex and growing health challenge. There is no accepted "gold standard" multimorbidity measure for hospital resource planning, and few studies have compared measures in hospitalised patients. AIM: To evaluate operationalisation of two multimorbidity measures in routine hospital episode data in NHS Grampian, Scotland. METHODS: Linked hospital episode data (Scottish Morbidity Record (SMR)) for the years 2009-2016 were used. Adults admitted to hospital as a general/acute inpatient during 2014 were included. Conditions (ICD-10) were identified from general/acute (SMR01) and psychiatric (SMR04) admissions during the five years prior to first admission in 2014. Two count-based multimorbidity measures were used (Charlson Comorbidity Index and Tonelli et al.), and multimorbidity was defined as ≥2 conditions. Kappa statistics assessed agreement. The association between multimorbidity and length of stay, readmission and mortality was assessed using logistic and negative binomial regression as appropriate. RESULTS: In 41,545 adults (median age 62 years, 52.6% female), multimorbidity prevalence was 15.1% (95% CI 14.8%, 15.5%) using Charlson and 27.4% (27.0%, 27.8%) using Tonelli - agreement 85.1% (Kappa 0.57). Multimorbidity prevalence, using both measures, increased with age. Multimorbidity was higher in males (16.5%) than females (13.9%) using the Charlson measure, but similar across genders when measured with Tonelli. After adjusting for covariates, multimorbidity remained associated with longer length of stay (Charlson IRR 1.1 (1.0, 1.2); Tonelli IRR 1.1 (1.0, 1.2)) and readmission (Charlson OR 2.1 (1.9, 2.2); Tonelli OR 2.1 (2.0, 2.2)). Multimorbidity had a stronger association with mortality when measured using Charlson (OR 2.7 (2.5, 2.9)), than using Tonelli (OR 1.8 (1.7, 2.0)). CONCLUSIONS: Multimorbidity measures operationalised in hospital episode data identified those at risk of poor outcomes and such operationalised tools will be useful for future multimorbidity research and use in secondary care data systems. Multimorbidity measures are not interchangeable, and the choice of measure should depend on the purpose. HIGHLIGHTS: Operationalisation of two count-based multimorbidity measures using linked electronic hospital episode data was evaluated (Charlson and Tonelli).First study to compare the Tonelli measure with another measure for investigating multimorbidity in hospitalised patients.Multimorbidity prevalence differed depending on measure used, but both multimorbidity measures identified those at risk of poor outcomes.Operationalised multimorbidity tools have uses for future multimorbidity research and use in secondary care data systems.Multimorbidity measures are not interchangeable, and choice of measure should depend on purpose.

Different effects of voluntary and involuntary attention on EEG activity in the gamma band.

Previous studies have shown that EEG activity in the gamma range can be modulated by attention. Here, we compared this activity for voluntary and involuntary spatial attention in a spatial-cueing paradigm with faces as targets. The stimuli and trial timing were kept constant across attention conditions with only the predictive value of the cue changing. Gamma-band response was linked to voluntary shifts of attention, but not to the involuntary capture of attention. The presence of increased gamma responses for the voluntary allocation of attention, and its absence in cases of involuntary capture suggests that the neural mechanisms governing these two types of attention are different. Moreover, these data allow a description of the temporal dynamics contributing to the dissociation between voluntary and involuntary attention. The distribution of this correlate of voluntary attention is consistent with a top-down process involving contralateral anterior and posterior regions.