Nonadherence in the era of severe asthma biologics and thermoplasty.

Nonadherence to inhaled preventers impairs asthma control. Electronic monitoring devices (EMDs) can objectively measure adherence. Their use has not been reported in difficult asthma patients potentially suitable for novel therapies, i.e. biologics and bronchial thermoplasty.Consecutive patients with difficult asthma were assessed for eligibility for novel therapies. Medication adherence, defined as taking >75% of prescribed doses, was assessed by EMD and compared with standardised clinician assessment over an 8-week period.Among 69 difficult asthma patients, adherence could not be analysed in 13, due to device incompatibility or malfunction. Nonadherence was confirmed in 20 out of 45 (44.4%) patients. Clinical assessment of nonadherence was insensitive (physician 15%, nurse 28%). Serum eosinophils were higher in nonadherent patients. Including 11 patients with possible nonadherence (device refused or not returned) increased the nonadherence rate to 31 out of 56 (55%) patients. Severe asthma criteria were fulfilled by 59 out of 69 patients. 47 were eligible for novel therapies, with confirmed nonadherence in 16 out of 32 (50%) patients with EMD data; including seven patients with possible nonadherence increased the nonadherence rate to 23 out of 39 (59%).At least half the patients eligible for novel therapies were nonadherent to preventers. Nonadherence was often undetectable by clinical assessments. Preventer adherence must be confirmed objectively before employing novel severe asthma therapies.

Selection of risk factors to be included in the Canadian Food Inspection Agency risk assessment inspection model for food establishments.

The Canadian Food Inspection Agency (CFIA) is developing a risk assessment model for food establishments. Previous research on the significance of food safety risk factors determined by literature review and expert advice served as the bases for the current study, to further refine, discriminate and select the most important criteria to be included in the model. This process considered the availability of data sources, the clarity and measurability of the selected factors, undertook the elimination of lower-rated risk factors and grouped those with similar focus of attention, enabling the selection of a final list of risk factors for the model. A method of assessment for the remaining factors was then proposed to allow the quantification of individual risk factors within the model. From the 155 risk factors initially identified, 17 consolidated factors were kept and will be considered for the development of the risk assessment model.

Febrile neutropenia management in cancer patients receiving anti-cancer agents' treatment: Deepening the search to offer the best care. A critical review follow-up.

INTRODUCTION: Febrile neutropenia is a common complication in cancer patients. Emergency departments are in most countries the unique entry point to tertiary care. However, some challenges restrain emergency department professionals from complying with the protocol. OBJECTIVE: To update the published review in 2018: "Critical review of emergency department management of chemotherapy complications in cancer patients", and explore improvement opportunities. METHODS: MEDLINE, TROVE and SCOPUS databases were used to conduct a broad electronic literature search. Out of 74 articles yielded, nine responding to our questions were selected. CONCLUSIONS: Febrile neutropenia management in cancer patients still represents a challenge for emergency departments that have difficulties to comply with international guidelines. It is critical to identify the best venue and which professionals to manage the target population. Appropriate care pathways and a more efficient tool to classify low and high risk patients, would improve clinical outcomes, while costs would be reduced.

Systematic Assessment for Difficult and Severe Asthma Improves Outcomes and Halves Oral Corticosteroid Burden Independent of Monoclonal Biologic Use.

BACKGROUND: Guidelines endorse systematic assessment for severe asthma, with data indicating benefit across multiple outcome domains. OBJECTIVE: We examined which patients respond to systematic assessment and whether oral corticosteroid burden can be decreased independent of monoclonal biologic use. METHODS: Specialist-referred patients are assessed systematically for difficult asthma at our center. We undertook a responder analysis for improvements in the domains of symptom control, quality of life, exacerbations, and airflow obstruction, assessed 6 months after initial assessment. Multivariate analyses were performed for each domain to identify predictors of response. Changes in oral corticosteroid burden were also measured, stratified by monoclonal biologics commenced during assessment. RESULTS: Among 161 patients assessed systematically, 64% had a reduction in exacerbations, 54% achieved minimum clinically important differences for both symptom control and quality of life, and 40% increased their forced expiratory volume in 1 second by ≥100 mL. Altogether, 87% of patients with asthma improved in at least 1 domain. The most consistent predictor of response across domains was poorer baseline asthma status. There was a substantial reduction in mean chronic oral corticosteroid dose (11-5 mg, n = 46, P < .001), even after excluding 7 patients commenced on monoclonal biologics (11-5.6 mg, n = 39, P < .001). CONCLUSIONS: Almost 90% of patients undergoing systematic assessment for difficult asthma improve significantly in at least 1 key asthma outcome, with few reliable predictors of response. The halving of oral corticosteroid burden during systematic assessment is independent of, and comparable in magnitude with, that achieved by monoclonal biologics.

Identification and selection of food safety-related risk factors to be included in the Canadian Food Inspection Agency's Establishment-based Risk Assessment model for Hatcheries.

Towards the continuous improvement of its inspection system, the Canadian Food Inspection Agency (CFIA) is developing an Establishment-based Risk Assessment model for Hatcheries to allocate inspection resources based on the food safety risk associated with the Canadian hatcheries falling under its jurisdiction. The objectives of the current study were to identify and select critical food safety-related risk factors that would be included in this model, with a main focus on Salmonella. A literature review was used to develop a comprehensive list of risk factors that could potentially contribute to the food safety risk attributed to Canadian hatcheries operating in all production streams (breeders, layers, broilers, turkeys, waterfowl and game birds). The development of this list used a selection process that was conducted according to the availability of data sources, the clarity of definition and the measurability of the selected risk factors. A panel of experts reviewed and adjusted the identified risk factors. A final list of 29 risk factors was generated; 20 originated from the scientific literature and nine from the expert panel. Risk factors were grouped in three clusters according to whether they pertained to the inherent risk (nine factors identified), risk mitigation (nine factors identified) or compliance of a hatchery with its preventive control plan and regulatory requirements (11 factors identified). Criteria for assessing each risk factor were defined based on common practices used in the Canadian hatchery industry. This comprehensive list of risk factors and criteria represents useful information to support the design and implementation of a Canadian risk assessment model for hatcheries, but could also be used by like-minded food safety authorities.

Older adults' responses to emotional stimuli: a cautionary note.

Thirty younger (mean age = 21 years) and 30 older (mean age = 73 years) adults were compared to determine if they had similar affective experiences to eight emotion films previously validated with young adults (Gross & Levenson, 1995). Participants rated their emotions, and heart rate was collected during two films of each emotion: amusement, anger, sadness, and fear. Older and younger adults were generally similar in their physiological and subjective responses to films, but with a few exceptions. Older adults reported more intense anger in response to one film and more intense nontarget negative emotions for both anger films compared with young adults. Some older adults also reported a negative response compared with young adults to one of the films designed to elicit amusement. Thus it is inappropriate to assume that emotional stimuli produce the same response across the adult life span.

Source attribution at the food sub-product level for the development of the Canadian Food Inspection Agency risk assessment model.

Decreasing the health burden caused by foodborne pathogens is challenging and it depends on the identification of the most significant hazards and food sources causing illnesses, so adequate mitigation strategies can be implemented. In this regard, the Canadian Food Inspection Agency (CFIA) has developed the Establishment-based Risk Assessment (ERA) model, so that a more effective and efficient allocation of resources can be assigned to the highest food safety risk areas. To assess risk, the model considers the type of food sub-products being manufactured by establishments and its scope is limited to the 17 most important foodborne pathogens representing the highest level of food safety risk. However, the information on source attribution at the sub-product level based on a structured approach is limited. To overcome this challenge, an expert elicitation was conducted in 2016 to estimate the relative contribution and associated certainty of each sub-product for 31 pathogen-commodity combinations to the total Canadian health burden associated with foodborne illnesses (expressed in DALYs). These DALYs represent 78% of the total Canadian health burden associated with federally-regulated food commodities considered within the model. A total of 49 Canadian experts recruited using a "snow ball" sampling strategy participated in the study by completing an electronic survey. Results of the elicitation displayed variable levels of health burden allocation between the pathogens and the different commodity sub-products. Assessment of the certainty levels showed some combinations being evaluated with more confidence (e.g., Campylobacter and eggs/poultry sub-products) than others, where a bimodal distribution of certainty was observed (e.g., Toxoplasma in pork sub-products). Furthermore, no participant raised concerns on the food classification scheme, suggesting their agreement with the proposed sub-products categorization of the elicitation. Relative contribution estimates will be included in the CFIA ERA model and used to enhance its applicability for risk prioritization and effective resource allocation during food establishment inspections. While substantial uncertainty around the central tendency estimates was found, these estimates provide a good basis for regulatory oversight and public health policy.

Experiences With the Levonorgestrel Intrauterine System Among Clients, Providers, and Key Opinion Leaders: A Mixed-Methods Study in Nigeria.

BACKGROUND: The levonorgestrel intrauterine system (LNG IUS) is one of the most effective contraceptive methods, and it has noncontraceptive health benefits, including treatment for women with heavy menstrual bleeding. In 2016, Marie Stopes International Organisation Nigeria (MSION) expanded LNG IUS provision through training and support to 9 mobile outreach teams, 105 social franchise clinics, and 20 public-sector providers in 17 states. Information about the LNG IUS was added to awareness-raising materials, and community mobilizers provided information on the LNG IUS alongside other voluntary family planning methods. METHODS: In 2016, Marie Stopes International, MSION, and FHI 360 examined clients' and providers' experiences with the LNG IUS to assess the potential for further scale-up of the method as part of a comprehensive approach to family planning in Nigeria. A mixed-methods approach was used including analysis of routine service data, supplemental data specific to LNG IUS clients, and in-depth interviews with LNG IUS clients, providers, and key opinion leaders. RESULTS: Just under 1,000 LNG IUS were inserted from September 2016 to December 2017 in 16 states in channels supported by MSION, representing 0.4% of all long-acting and reversible contraceptive (LARC) services provided by the participating providers during this time frame. The vast majority (82%) of LARCs provided were implants. A small pool of providers was responsible for providing almost half of the LNG IUS services. Common reasons for women choosing the LNG IUS were reduced menstrual bleeding (61%), long-acting duration (52%), effectiveness (49%), and discreetness (42%). Almost 80% of the users first heard about the method from a provider. Almost all users and providers reported positive experiences with the method, noting the noncontraceptive benefits and fewer side effects compared with other methods. All providers who were interviewed said they would continue offering the LNG IUS. Several key opinion leaders mentioned a total market approach incorporating both public and private sectors would be needed to successfully scale up the LNG IUS. CONCLUSION: Reduced menstrual bleeding and fewer side effects compared with other methods were identified as important attributes of the LNG IUS by clients, providers, and key opinion leaders. Challenges to uptake of the LNG IUS include difficulty with introducing a new method within a busy service delivery infrastructure and limited awareness and demand-generation activities on the LNG IUS specifically. A comprehensive product introduction approach with coordinated demand- and supply-side activities may be required for this method to reach its full potential.

Youth Voucher Program in Madagascar Increases Access to Voluntary Family Planning and STI Services for Young People.

BACKGROUND: Young people often express a preference for seeking family planning information and services from the private sector. However, in many Marie Stopes International (MSI) social franchise networks, the proportion of young clients, and particularly those under 20 years of age, remains low. Marie Stopes Madagascar (MSM) piloted a youth voucher program that joins a supply-side intervention-youth-friendly social franchisee training and quality monitoring-with a corresponding demand-side-component, free vouchers that reduce financial barriers to family planning access for young people. METHODS: Young people identified by MSM's community health educators (CHEs) received a free voucher redeemable at a BlueStar social franchisee for a package of voluntary family planning and sexually transmitted infection (STI) information and services. BlueStar social franchisees-private providers accredited by MSM-are reimbursed for the cost of providing these services. We reviewed service statistics data from the first 18 months of the youth voucher program, from July 2013 to December 2014, as well as client demographic profile data from July 2015.Findings: Between July 2013 and December 2014, 58,417 vouchers were distributed to young people by CHEs through a range of community mobilization efforts, of which 43,352 (74%) were redeemed for family planning and STI services. Most clients (78.5%) chose a long-acting reversible contraceptive (LARC), and just over half (51%) of young people benefited from STI counseling as part of their voucher service. Most (78%) services were provided in the Analamanga region (the capital and its surroundings), which was expected given the population density in this region and the high concentration of BlueStar franchisees. The client profile data snapshot from July 2015 revealed that 69% of voucher clients had never previously used a contraceptive method, and 96% of clients were aged 20 or younger, suggesting that the voucher program is successfully reaching the intended target group. CONCLUSION: MSM's youth voucher program has revealed a high demand for voluntary family planning services, especially among youth under 20 years old, and MSM has since integrated the youth voucher beyond the initial pilot locations. MSM's experience indicates that youth vouchers are a novel and effective means of increasing young people's access to voluntary family planning services in Madagascar, and this model could potentially be replicated or adapted in other contexts where young people are faced with barriers to accessing quality information and services.

Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda.

From 2001 to 2011, modern contraceptive prevalence in Uganda increased from 18% to 26%. However, modern method use, in particular use of long-acting reversible contraceptives (LARCs) and permanent methods (PMs), remained low. In the 2011 Uganda Demographic and Health Survey, only 1 of 5 married women used a LARC or PM even though 34% indicated an unmet need for contraception. Between 2011 and 2014, a social franchise and family planning voucher program, supporting 400 private facilities to provide family planning counseling and broaden contraceptive choice by adding LARCs and PMs to the service mix, offered a voucher to enable poor women to access family planning services at franchised facilities. This study analyzes service trends and voucher client demographics and estimates the contribution of the program to increasing contraceptive prevalence in Uganda, using the Impact 2 model developed by Marie Stopes International. Between March 2011 and December 2014, 330,826 women received a family planning service using the voucher, of which 70% of voucher clients chose an implant and 25% chose an intrauterine device. The median age of voucher users was 28 years; 79% had no education or only a primary education; and 48% reported they were unemployed or a housewife. We estimated that by 2014, 280,000 of the approximately 8,600,000 women of reproductive age in Uganda were using a contraceptive method provided by the program and that 120,000 of the clients were "additional users" of contraception, contributing 1.4 percentage points to the national modern contraceptive prevalence rate. The combination of family planning vouchers and a franchise-based quality improvement initiative can leverage existing private health infrastructure to substantially expand family planning access and choice for disadvantaged populations and potentially improve contraceptive prevalence when scaled nationally.

Increasing Access to Family Planning Choices Through Public-Sector Social Franchising: The Experience of Marie Stopes International in Mali.

BACKGROUND: Mali has one of the world's lowest contraceptive use rates and a high rate of unmet need for family planning. In order to increase access to and choice of quality family planning services, Marie Stopes International (MSI) Mali introduced social franchising in public-sector community health centers (referred to as CSCOMs in Mali) in 3 regions under the MSI brand BlueStar. PROGRAM DESCRIPTION: Potential franchisees are generally identified from CSCOMs who have worked with MSI outreach teams; once accredited as franchisees, CSCOMs receive training, supervision, family planning consumables and commodities, and support for awareness raising and demand creation. To ensure availability and affordability of services, franchisees are committed to providing a wide range of contraceptive methods at low fixed prices. METHODS AND RESULTS: The performance of the BlueStar network from inception in March 2012 until December 2015 was examined using information from routine monitoring data, clinical quality audits, and client exit interviews. During this period, the network grew from 70 to 135 franchisees; an estimated 123,428 clients received voluntary family planning services, most commonly long-acting reversible methods of contraception. Franchisee efficiency and clinical quality of services increased over time, and client satisfaction with services remained high. One-quarter of clients in 2015 were under 20 years old, and three-quarters were adopters of family planning (that is, they had not been using a modern method during the 3 months prior to their visit). CONCLUSION: Applying a social franchising support package, originally developed for for-profit private-sector providers, to public-sector facilities in Mali has increased access, choice, and use of family planning in 3 regions of Mali. The experience of BlueStar Mali suggests that interventions that support quality supply of services, while simultaneously addressing demand-side barriers such as service pricing, can successfully create demand for a broad range of family planning services, even in settings with low contraceptive prevalence.

The effect of ankle bracing on landing biomechanics in female netballers.

OBJECTIVES: Investigate the impact of lace-up ankle braces on landing biomechanics. DESIGN: Within-subject repeated measures. Participants completed a drop jump, drop land, and netball-specific task in braced and unbraced conditions. SETTING: Biomechanical research laboratory. PARTICIPANTS: Twenty female high school netballers. MAIN OUTCOME MEASURES: Leg, knee, and ankle stiffness, knee/ankle stiffness ratio, knee and ankle sagittal excursion, peak vertical ground reaction force, time-to-peak vertical ground reaction force, and loading rate. RESULTS: In the brace condition leg stiffness increased bilaterally during the drop land (ES = 0.21, 0.22), ankle stiffness increased bilaterally during the drop jump (ES = 0.37, 0.29) and drop land (ES = 0.40, 0.60), and knee/ankle stiffness ratio decreased in all three tasks (ES = -0.22 to -0.45). Ankle sagittal excursion decreased bilaterally during the drop jump (ES = -0.35, -0.53) and drop land (ES = -0.23, -0.46), and decreased in the lead limb during the netball jump (ES = -0.36). Knee excursion decreased bilaterally during the drop jump (ES = -0.36, -0.40) and in the lead limb during netball task (ES = -0.59). Lead limb TTP was greater during the netball jump (ES = 0.41). CONCLUSIONS: Lace-up ankle braces may increase leg and joint stiffness and reduce joint excursion during landing but do not appear to affect landing forces. The observed effect on landing biomechanics may predispose young netballers to injury.

Dementia does not explain correlation between age and scores on Boston Naming Test.

The major purpose of this study was to determine if the correlation between age and performance on the Boston Naming Test that has been reported by some investigators results from inclusion of people in the early stages of dementia in those samples. The correlation between age and naming score was -.36 in 125 carefully evaluated nondemented individuals aged 60-88 years who were enrolled in the control group at an Alzheimer's Disease Research Center between 1985 and 1998. All participants remained undemented for at least 2 years after testing. The magnitude of the correlation between naming scores and age was similar to that found in unscreened samples. Increased confrontation naming difficulty appears to occur with normal aging.

Establishing and Scaling-Up Clinical Social Franchise Networks: Lessons Learned From Marie Stopes International and Population Services International.

In many low- and middle-income countries, a majority of people seek health care from the private sector. However, fragmentation, poor economies of scale, inadequate financing, political opposition, a bias toward curative services, and weak regulatory and quality control systems pose serious challenges for the private sector. Social franchising addresses a number of these challenges by organizing small, independent health care businesses into quality-assured networks. Global franchisors Marie Stopes International (MSI) and Population Services International (PSI) have rapidly scaled their family planning social franchising programs in recent years, jointly delivering over 10.8 million couple-years of protection (CYPs) in 2014-up 26% from 8.6 million CYPs just 1 year prior. Drawing on experience across MSI's 17 and PSI's 25 social franchise networks across Africa, Asia, and Latin America and the Caribbean, this article documents the organizations' operational approaches, challenges faced, and solutions implemented. The organizations provide intensive capacity building and support for private-sector providers, including clinical training, branding, monitoring quality of franchised services, and commodity support. In addition, franchising programs engage providers and clients through behavior change communication (BCC) and demand generation activities to raise awareness and to attract clients, and they implement initiatives to ensure services are affordable for the lowest-income clients. Social franchise programs offer the private sector a collective platform to better engage government in health policy advocacy and for integrating into new public health care financing and procurement mechanisms. The future of social franchising will require developing approaches to scale-up and sustain the model cost-effectively, selectively integrating other health services into the franchise package, and being responsive to evolving health care financing approaches with the potential to contribute to universal health coverage.

Neuropatía periférica producida por taxanos y calidad de vida global en pacientes con cáncer de mama / Peripheral neuropathy caused by taxanes and overall quality of life in breast cancer patients

OBJETIVO: determinar la incidencia y evolución de la neuropatía periférica inducida por taxanos (NPIT) en pacientes con cáncer de mama y valorar la influencia de la NPIT en la calidad de vida global (CV). MÉTODO: estudio descriptivo longitudinal prospectivo realizado en el Servicio de Oncología del Hospital Clínic de Barcelona (julio 2015-abril 2016). Se incluyeron mujeres diagnosticadas de cáncer de mama en su primera línea de tratamiento con quimioterapia (paclitaxel o docetaxel) en quienes se evaluó la neurotoxicidad y la calidad de vida mediante tres cuestionarios autoinformados validados al inicio, a las 6 y 12 semanas y un mes tras finalizar el tratamiento. RESULTADOS: participaron 33 pacientes de las cuales el 84,4% había desarrollado algún grado de NP al final del seguimiento. La neurotoxicidad empeoró de manera estadísticamente significativa con la acumulación de dosis hasta el final del tratamiento y se mantuvo estable un mes tras la última administración (p< 0,001). La neuropatía sensitiva aumentó de manera estadísticamente significativa a lo largo del seguimiento (p< 0,001). La afectación de la sensibilidad motora también, salvo en la última medición (p< 0,005). Se observó una correlación positiva entre la neurotoxicidad y deterioro de la CV (r= 0,609 (p< 0,0001)) CONCLUSIONES: la NPIT es un efecto secundario con una alta incidencia en la población de mujeres con cáncer de mama estudiada y provoca un efecto negativo en la CV percibida de las pacientes. Las enfermeras oncológicas son profesionales clave en la prevención y el manejo de este efecto secundario

OBJECTIVE: to determine the incidence and evolution of taxane-induced peripheral neuropathy (TIPN) in breast cancer patients, and to assess the influence of TIPN on overall quality of life (QoL). METHOD: a prospective longitudinal descriptive study conducted at the Oncology Unit of the Hospital Clínic de Barcelona (July, 2015- April, 2016). The study included women with diagnosis of breast cancer, on their first line of treatment with chemotherapy (paclitaxel or docetaxel); neurotoxicity and quality of life were evaluated through three self-reported questionnaires validated at baseline, at 6 and 12 weeks, and one month after completing treatment. RESULTS: the study included 33 patients; 84.4% of them had developed some degree of PN at the end of follow-up. There was a statistically significant worsening in neurotoxicity with dose accumulation until the end of the treatment, and it remained stable one month after the last administration (p< 0.001). There was a statistically significant increase in sensitive neuropathy throughout follow-up (p< 0.001); also in terms of involvement in motor sensitivity, except in the final measurement (p< 0-005). A positive correlation was observed between neurotoxicity and QoL deterioration (r= 0.609 (p < 0.0001)). CONCLUSIONS: TIPN is a side effect with high incidence among the population studied of women with breast cancer, and it causes a negative impact on patient-perceived QoL. Oncology nurses are the key professionals for the prevention and management of this side effect

Postnatal quality of life: a pilot study using the Mother-Generated Index.

BACKGROUND: Although postnatal morbidity has been well documented in recent years, postnatal quality of life has not been addressed. A newly derived subjective measurement of postnatal quality of life (the Mother-Generated Index) combines a quantitative and qualitative evaluation. AIMS: This part of our pilot study aimed to compare the aspects of their lives nominated by women with low and high quality of life (Primary Index) scores, and to examine the respective importance of these areas. METHODS: The Mother-Generated Index was tested using the Edinburgh Postnatal Depression Scale, Short Form 12, and an established maternal and neonatal physical morbidity index as validators. Four health visitors administered these at 6-8 weeks and 8 months postpartum to 103 women by structured face-to-face interviews between June 2000 and March 2001. Data were entered into Epi-Info, and exported to Microsoft Excel and SPSS for analysis. RESULTS: A wide variety of quality of life aspects were reported, including emotional, social and financial concerns. Tiredness was prevalent in all groups, but other physical problems were rare at 8 months. Mothers with low quality of life (Primary Index) scores at 6-8 weeks and 8 months commonly reported having less personal time. Low scoring areas, which health professionals might consider in greatest need of attention, were often not the ones mothers deemed most important. LIMITATIONS: The study involved only 103 participants, and did not assess the degree of support experienced by the mothers. CONCLUSIONS: The Mother-Generated Index helps mothers to identify the areas of their lives which are of most concern to them. This pilot suggests that mothers with high and low quality of life scores have markedly divergent experiences.

Noun and verb retrieval in healthy aging.

This study tests the hypothesis that retrieval of object and action names declines at different rates with age. Uncued and cued performance on the Boston Naming Test (BNT) and the Action Naming Test (ANT) were examined for 171 individuals from 50 to 88 years old. To control for differences in item difficulty, a subset of items from each of the two tests was selected for which uncued performance was equivalent in individuals in their 50s. With this matched set of items, differences in action and object naming were tested in the 60s and 70+ age groups. Although age-related decline in name retrieval was observed for both the BNT and the ANT subsets, no differences between object and action retrieval were found. Our results, thus, do not confirm previous studies reporting that object names and action names are differentially retrieved with aging. We discuss these new findings in relation to evidence of dissociations in object and action naming in brain-damaged individuals.