Disentangling age and schooling effects on inhibitory control development: An fNIRS investigation.

Children show marked improvements in executive functioning (EF) between 4 and 7 years of age. In many societies, this time period coincides with the start of formal school education, in which children are required to follow rules in a structured environment, drawing heavily on EF processes such as inhibitory control. This study aimed to investigate the longitudinal development of two aspects of inhibitory control, namely response inhibition and response monitoring and their neural correlates. Specifically, we examined how their longitudinal development may differ by schooling experience, and their potential significance in predicting academic outcomes. Longitudinal data were collected in two groups of children at their homes. At T1, all children were roughly 4.5 years of age and neither group had attended formal schooling. One year later at T2, one group (P1, n = 40) had completed one full year of schooling while the other group (KG, n = 40) had stayed in kindergarten. Behavioural and brain activation data (measured with functional near-infrared spectroscopy, fNIRS) in response to a Go/No-Go task and measures of academic achievement were collected. We found that P1 children, compared to KG children, showed a greater change over time in activation related to response monitoring in the bilateral frontal cortex. The change in left frontal activation difference showed a small positive association with math performance. Overall, the school environment is important in shaping the development of the brain functions underlying the monitoring of one own's performance.

Home assessment of visual working memory in pre-schoolers reveals associations between behaviour, brain activation and parent reports of life stress.

Visual working memory (VWM) is reliably predictive of fluid intelligence and academic achievements. The objective of the current study was to investigate individual differences in pre-schoolers' VWM processing by examining the association between behaviour, brain function and parent-reported measures related to the child's environment. We used a portable functional near-infrared spectroscopy system to record from the frontal and parietal cortices of 4.5-year-old children (N = 74) as they completed a colour change-detection VWM task in their homes. Parents were asked to fill in questionnaires on temperament, academic aspirations, home environment and life stress. Children were median-split into a low-performing (LP) and a high-performing (HP) group based on the number of items they could successfully remember during the task. LPs increasingly activated channels in the left frontal and bilateral parietal cortices with increasing load, whereas HPs showed no difference in activation. Our findings suggest that LPs recruited more neural resources than HPs when their VWM capacity was challenged. We employed mediation analyses to examine the association between the difference in activation between the highest and lowest loads and variables from the questionnaires. The difference in activation between loads in the left parietal cortex partially mediated the association between parent-reported stressful life events and VWM performance. Critically, our findings show that the association between VWM capacity, left parietal activation and indicators of life stress is important to understand the nature of individual differences in VWM in pre-school children.

Assessment of interventions to attract and retain health workers in rural Zambia: a discrete choice experiment.

BACKGROUND: Workforce shortages, particularly in rural areas, limit the delivery of health services in Zambia. Policymakers and researchers co-created this study to identify potential non-monetary employment incentives and assess their cost-effectiveness to attract and retain public sector health workers to the rural areas of Zambia. METHODS: The study consisted of two key phases: a discrete choice experiment (DCE), preceded by a qualitative component to inform DCE questionnaire development. Firstly, in qualitative interviews with 25 health workers and focus group discussions (FGDs) with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment (DCE) questionnaire. Secondly, this questionnaire, consisting of hypothetical job "choice sets," was presented to 474 practicing health workers and students. A conditional logit regression model was applied to the data from this DCE questionnaire to estimate preferences for various job attributes. Using administrative data, we estimated the cost of implementing potential attraction and retention strategies per health worker year worked. RESULTS: Although health workers preferred urban jobs to rural jobs (OR 1.39, 95% CI 1.11-1.75), employment incentives influenced health workers' decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job (OR 5.04, 95% CI 4.12-6.18). Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake. CONCLUSIONS: Non-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages. These results can provide valuable insight into the types of job attributes and incentives that are most likely to be effective in attracting and retaining health workers in rural areas.

Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial.

STUDY OBJECTIVE: We assess and compare the analgesic efficacy and safety of subdissociative intravenous-dose ketamine with morphine in emergency department (ED) patients. METHODS: This was a prospective, randomized, double-blind trial evaluating ED patients aged 18 to 55 years and experiencing moderate to severe acute abdominal, flank, or musculoskeletal pain, defined as a numeric rating scale score greater than or equal to 5. Patients were randomized to receive ketamine at 0.3 mg/kg or morphine at 0.1 mg/kg by intravenous push during 3 to 5 minutes. Evaluations occurred at 15, 30, 60, 90, and 120 minutes. Primary outcome was reduction in pain at 30 minutes. Secondary outcome was the incidence of rescue analgesia at 30 and 60 minutes. RESULTS: Forty-five patients per group were enrolled in the study. The primary change in mean pain scores was not significantly different in the ketamine and morphine groups: 8.6 versus 8.5 at baseline (mean difference 0.1; 95% confidence interval -0.46 to 0.77) and 4.1 versus 3.9 at 30 minutes (mean difference 0.2; 95% confidence interval -1.19 to 1.46; P=.97). There was no difference in the incidence of rescue fentanyl analgesia at 30 or 60 minutes. No statistically significant or clinically concerning changes in vital signs were observed. No serious adverse events occurred in either group. Patients in the ketamine group reported increased minor adverse effects at 15 minutes post-drug administration. CONCLUSION: Subdissociative intravenous ketamine administered at 0.3 mg/kg provides analgesic effectiveness and apparent safety comparable to that of intravenous morphine for short-term treatment of acute pain in the ED.

The first year in formal schooling improves working memory and academic abilities.

Neurocognition and academic abilities during the period of 4 and 7 years of age are impacted by both the transition from kindergarten to primary school and age-related developmental processes. Here, we used a school cut-off design to tease apart the impact of formal schooling from age, on working memory (WM) function, vocabulary, and numeracy scores. We compared two groups of children with similar age, across two years: first-graders (FG), who were enrolled into primary school the year that they became eligible and kindergarteners (KG), who were deferred school entry until the following year. All children completed a change detection task while brain activation was recorded using portable functional near-infrared spectroscopy, a vocabulary assessment, and a numeracy screener. Our results revealed that FG children showed greater improvement in WM performance and greater engagement of a left-lateralized fronto-parietal network compared to KG children. Further, they also showed higher gains in vocabulary and non-symbolic numeracy scores. This improvement in vocabulary and non-symbolic numeracy scores following a year in primary school was predicted by WM function. Our findings contribute to a growing body of literature examining neurocognitive and academic benefits conferred to children following exposure to formal schooling.

Analysis of policy interventions to attract and retain nurse midwives in rural areas of Malawi: A discrete choice experiment.

BACKGROUND: Inadequate and unequal distribution of health workers are significant barriers to provision of health services in Malawi, and challenges retaining health workers in rural areas have limited scale-up initiatives. This study therefore aims to estimate cost-effectiveness of monetary and non-monetary strategies in attracting and retaining nurse midwife technicians (NMTs) to rural areas of Malawi. METHODS: The study uses a discrete choice experiment (DCE) methodology to investigate importance of job characteristics, probability of uptake, and intervention costs. Interviews and focus groups were conducted with NMTs and students to identify recruitment and retention motivating factors. Through policymaker consultations, qualitative findings were used to identify job attributes for the DCE questionnaire, administered to 472 respondents. A conditional logit regression model was developed to produce probability of choosing a job with different attributes and an uptake rate was calculated to estimate the percentage of health workers that would prefer jobs with specific intervention packages. Attributes were costed per health worker year. RESULTS: Qualitative results highlighted housing, facility quality, management, and workload as important factors in job selection. Respondents were 2.04 times as likely to choose a rural job if superior housing was provided compared to no housing (CI 1.71-2.44, p<0.01), and 1.70 times as likely to choose a rural job with advanced facility quality (CI 1.47-1.96, p<0.01). At base level 43.9% of respondents would choose a rural job. This increased to 61.5% if superior housing was provided, and 72.5% if all facility-level improvements were provided, compared to an urban job without these improvements. Facility-level interventions had the lowest cost per health worker year. CONCLUSIONS: Our results indicate housing and facility-level improvements have the greatest impact on rural job choice, while also creating longer-term improvements to health workers' living and working environments. These results provide practical evidence for policymakers to support development of workforce recruitment and retention strategies.

Time to Blood Pressure Control Before Thrombolytic Therapy in Patients With Acute Ischemic Stroke: Comparison of Labetalol, Nicardipine, and Hydralazine.

BACKGROUND: Elevated blood pressure is common in patients with acute ischemic stroke. Thrombolytic therapy is contraindicated in patients with a systolic blood pressure greater than 185 mmHg or diastolic blood pressure greater than 110 mmHg. Elevated blood pressure can lead to a delay in thrombolytic therapy, which is associated with increased morbidity. There is currently insufficient evidence to support the use of a specific antihypertensive agent in this setting. OBJECTIVE: This study aimed to compare the effects of labetalol, nicardipine, or hydralazine on time to target blood pressure before alteplase administration in patients with acute ischemic stroke. METHODS: A retrospective chart review was conducted to identify patients who received labetalol, nicardipine, or hydralazine to treat elevated blood pressure (systolic blood pressure > 185 or diastolic blood pressure > 110) before intravenous alteplase therapy for ischemic stroke. Data collection included time to blood pressure control, door-to-needle time, total dose administered, and use of additional antihypertensive agent(s). RESULTS: Most patients in this study received labetalol (25/29). Median time to blood pressure control was 10, 22, and 15 minutes in the labetalol, nicardipine, and hydralazine groups, respectively. Among patients who received labetalol, the average time to blood pressure control was 10 minutes longer in those who received 10 mg initially versus those who received 20 mg. Patients who required higher total doses of labetalol tended to achieve blood pressure control more slowly, had longer door-to-needle times, and required additional antihypertensive agents. CONCLUSIONS: Adequate initial dosing of antihypertensive treatment has the potential to reduce time to blood pressure control and possibly time to alteplase therapy. The optimal antihypertensive regimen for controlling blood pressure before alteplase therapy remains unclear.