fNIRS is capable of distinguishing laterality of lower body contractions.

The use of functional near-infrared spectroscopy (fNIRS) for brain imaging during human movement continues to increase. This technology measures brain activity non-invasively using near-infrared light, is highly portable, and robust to motion artifact. However, the spatial resolution of fNIRS is lower than that of other imaging modalities. It is unclear whether fNIRS has sufficient spatial resolution to differentiate nearby areas of the cortex, such as the leg areas of the motor cortex. Therefore, the purpose of this study was to determine fNIRS' ability to discern laterality of lower body contractions. Activity in the primary motor cortex was recorded in forty participants (mean = 23.4 years, SD = 4.5, female = 23, male = 17) while performing unilateral lower body contractions. Contractions were performed at 30% of maximal force against a handheld dynamometer. These contractions included knee extension, knee flexion, dorsiflexion, and plantar flexion of the left and right legs. fNIRS signals were recorded and stored for offline processing and analysis. Channels of fNIRS data were grouped into regions of interest, with five tolerance conditions ranging from strict to lenient. Four of five tolerance conditions resulted in significant differences in cortical activation between hemispheres. During right leg contractions, the left hemisphere was more active than the right hemisphere. Similarly, during left leg contractions, the right hemisphere was more active than the left hemisphere. These results suggest that fNIRS has sufficient spatial resolution to distinguish laterality of lower body contractions. This makes fNIRS an attractive technology in research and clinical applications in which laterality of brain activity is required during lower body activity.

Functional near infrared spectroscopy detects cortical activation changes concurrent with memory loss in postmenopausal women with Type II Diabetes.

Older adults with Type II Diabetes Mellitus (DM) experience mild cognitive impairment, specifically in the domain of recall/working memory. No consistent causative structural cortical deficits have been identified in persons with DM (PwDM). Memory deficits may be exacerbated in older adult females, who are at the highest risk of cardiovascular decline due to DM. The focus of the current study was to evaluate functional cortical hemodynamic activity during memory tasks in postmenopausal PwDM. Functional Near Infrared Spectroscopy (fNIRS) was used to monitor oxyhemoglobin (HbO) and deoxyhemoglobin (HbR) during memory-based tasks in a cross-sectional sample of postmenopausal women with DM. Twenty-one community-dwelling DM females (age = 65 ± 6 years) and twenty-one age- and sex-matched healthy controls (age = 66 ± 6 years) were evaluated. Working memory performance (via N-back) was evaluated while study participants donned cortical fNIRS. Health state, metabolic data, and menopausal status data were also collected. Deficits in working memory accuracy were found in the DM group as compared to controls. Differences in HbO responses emerged in the DM group. The DM group exhibited altered PFC activity magnitudes and increased functional cortical activity across ROIs compared to controls. HbO and HbR responses were not associated with worsened health state measures. These data indicate a shift in cortical activity patterns with memory deficits in postmenopausal PwDM. This DM-specific shift of HbO is a novel finding that is unlikely to be detected by fMRI. This underscores the value of using non-MRI-based neuroimaging techniques to evaluate cortical hemodynamic function to detect early mild cognitive impairment.

An Unlikely Cause of a Blunt Pancreatic Injury.

We report the case of a 17-year-old male football player with blunt abdominal trauma. Careful evaluation, including computed tomography and laboratory, revealed a pancreatic body laceration. Pancreatic injuries are relatively uncommon and associated with significant morbidity and mortality and require early diagnosis for optimal management and outcome.

Articular scaling and body mass estimation in platyrrhines and catarrhines: Modern variation and application to fossil anthropoids.

Body mass is an important component of any paleobiological reconstruction. Reliable skeletal dimensions for making estimates are desirable but extant primate reference samples with known body masses are rare. We estimated body mass in a sample of extinct platyrrhines and Fayum anthropoids based on four measurements of the articular surfaces of the humerus and femur. Estimates were based on a large extant reference sample of wild-collected individuals with associated body masses, including previously published and new data from extant platyrrhines, cercopithecoids, and hominoids. In general, scaling of joint dimensions is positively allometric relative to expectations of geometric isometry, but negatively allometric relative to expectations of maintaining equivalent joint surface areas. Body mass prediction equations based on articular breadths are reasonably precise, with %SEEs of 17-25%. The breadth of the distal femoral articulation yields the most reliable estimates of body mass because it scales similarly in all major anthropoid taxa. Other joints scale differently in different taxa; therefore, locomotor style and phylogenetic affinity must be considered when calculating body mass estimates from the proximal femur, proximal humerus, and distal humerus. The body mass prediction equations were applied to 36 Old World and New World fossil anthropoid specimens representing 11 taxa, plus two Haitian specimens of uncertain taxonomic affinity. Among the extinct platyrrhines studied, only Cebupithecia is similar to large, extant platyrrhines in having large humeral (especially distal) joints. Our body mass estimates differ from each other and from published estimates based on teeth in ways that reflect known differences in relative sizes of the joints and teeth. We prefer body mass estimators that are biomechanically linked to weight-bearing, and especially those that are relatively insensitive to differences in locomotor style and phylogenetic history. Whenever possible, extant reference samples should be chosen to match target fossils in joint proportionality.

New fossils from Tadkeshwar Mine (Gujarat, India) increase primate diversity from the early Eocene Cambay Shale.

Several new fossil specimens from the Cambay Shale Formation at Tadkeshwar Lignite Mine in Gujarat document the presence of two previously unknown early Eocene primate species from India. A new species of Asiadapis is named based on a jaw fragment preserving premolars similar in morphology to those of A. cambayensis but substantially larger. Also described is an exceptionally preserved edentulous dentary (designated cf. Asiadapis, unnamed sp. nov.) that is slightly larger and much more robust than previously known Cambay Shale primates. Its anatomy most closely resembles that of Eocene adapoids, and the dental formula is the same as in A. cambayensis. A femur and calcaneus are tentatively allocated to the same taxon. Although the dentition is unknown, exquisite preservation of the dentary of cf. Asiadapis sp. nov. enables an assessment of masticatory musculature, function, and gape adaptations, as well as comparison with an equally well-preserved dentary of the asiadapid Marcgodinotius indicus, also from Tadkeshwar. The new M. indicus specimen shows significant gape adaptations but was probably capable of only weak bite force, whereas cf. Asiadapis sp. nov. probably used relatively smaller gapes but could generate relatively greater bite forces.

Single- and dual-energy CT of the abdomen: comparison of radiation dose and image quality of 2nd and 3rd generation dual-source CT.

OBJECTIVES: To compare single-energy (SECT) and dual-energy (DECT) abdominal CT examinations in matched patient cohorts regarding differences in radiation dose and image quality performed with second- and third-generation dual-source CT (DSCT). METHODS: We retrospectively analysed 200 patients (100 male, 100 female; mean age 61.2 ± 13.5 years, mean body mass index 27.5 ± 3.8 kg/m2) equally divided into four groups matched by gender and body mass index, who had undergone portal venous phase abdominal CT with second-generation (group A, 120-kV-SECT; group B, 80/140-kV-DECT) and third-generation DSCT (group C, 100-kV-SECT; group D, 90/150-kV-DECT). The radiation dose was normalised for 40-cm scan length. Dose-independent figure-of-merit (FOM) contrast-to-noise ratios (CNRs) were calculated for various organs and vessels. Subjective overall image quality and reader confidence were assessed. RESULTS: The effective normalised radiation dose was significantly lower (P < 0.001) in groups C (6.2 ± 2.0 mSv) and D (5.3 ± 1.9 mSv, P = 0.103) compared to groups A (8.8 ± 2.3 mSv) and B (9.7 ± 2.4 mSv, P = 0.102). Dose-independent FOM-CNR peaked for liver, kidney, and portal vein measurements (all P ≤ 0.0285) in group D. Subjective image quality and reader confidence were consistently rated as excellent in all groups (all ≥1.53 out of 5). CONCLUSIONS: With both DSCT generations, abdominal DECT can be routinely performed without radiation dose penalty compared to SECT, while third-generation DSCT shows improved dose efficiency. KEY POINTS: • Dual-source CT (DSCT) allows for single- and dual-energy image acquisition. • Dual-energy acquisition does not increase the radiation dose in abdominal DSCT. • Third-generation DSCT shows improved dose efficiency compared to second-generation DSCT. • Dose-independent figure-of-merit image contrast was highest with third-generation dual-energy DSCT. • Third-generation DSCT shows improved dose efficiency for SECT and DECT.

Knowledge and predictors of dysplasia surveillance performance in inflammatory bowel diseases in Australia.

BACKGROUND: Dysplasia surveillance is recognized as an integral component in the management of inflammatory bowel diseases (IBDs). The adherence to surveillance guidelines is variable, and understanding of quality indicators and predictors of behavior is currently limited. OBJECTIVE: To perform a nationwide evaluation of the quality of IBD surveillance practiced by Australian endoscopists and to determine the predictors of quality practice. DESIGN: Cross-sectional nationwide survey. SETTING: Survey distributed through the gastroenterology and colorectal surgery societies covering knowledge and practice of IBD surveillance. MAIN OUTCOME MEASUREMENTS: Adherence to indicators of high-quality surveillance and median score of IBD surveillance guideline knowledge. RESULTS: A total of 264 responses were received, comprising 240 respondents who perform surveillance screening (218 gastroenterologists, 46 colorectal surgeons). Gastroenterologists were significantly more likely to undertake surveillance (P < .001), adhere to guidelines (P = .02), use advanced imaging modalities (P = .04), and have greater surveillance knowledge than colorectal surgeons (P < .001). Knowledge score and gastroenterologists were independent predictors of dysplasia screening (odds ratio [OR] 1.66; 95% confidence interval [CI], 1.41-1.96 and OR 11.2; 95% CI, 4.53-27.87), guideline adherence (OR 1.15; 95% CI, 1.01-1.31 and OR 2.42; 95% CI, 1.11-5.30), and advanced endoscopic imaging technique use (OR 1.19; 95% CI, 1.05-1.35 and OR 2.2; 95% CI, 1.02-4.74). LIMITATIONS: Potential responder bias results appear, however, aligned with those of previous studies. CONCLUSIONS: IBD dysplasia surveillance in Australia is being performed at a high standard. Gastroenterology specialization and knowledge score have been demonstrated to be strong predictors of high-quality surveillance practice. This is the first study to determine predictors of screening behavior and quantify surveillance quality. These results further emphasize that gastroenterologists should play a key role in IBD surveillance.

Convergent evolution of anthropoid-like adaptations in Eocene adapiform primates.

Adapiform or 'adapoid' primates first appear in the fossil record in the earliest Eocene epoch ( approximately 55 million years (Myr) ago), and were common components of Palaeogene primate communities in Europe, Asia and North America. Adapiforms are commonly referred to as the 'lemur-like' primates of the Eocene epoch, and recent phylogenetic analyses have placed adapiforms as stem members of Strepsirrhini, a primate suborder whose crown clade includes lemurs, lorises and galagos. An alternative view is that adapiforms are stem anthropoids. This debate has recently been rekindled by the description of a largely complete skeleton of the adapiform Darwinius, from the middle Eocene of Europe, which has been widely publicised as an important 'link' in the early evolution of Anthropoidea. Here we describe the complete dentition and jaw of a large-bodied adapiform (Afradapis gen. nov.) from the earliest late Eocene of Egypt ( approximately 37 Myr ago) that exhibits a striking series of derived dental and gnathic features that also occur in younger anthropoid primates-notably the earliest catarrhine ancestors of Old World monkeys and apes. Phylogenetic analysis of 360 morphological features scored across 117 living and extinct primates (including all candidate stem anthropoids) does not place adapiforms as haplorhines (that is, members of a Tarsius-Anthropoidea clade) or as stem anthropoids, but rather as sister taxa of crown Strepsirrhini; Afradapis and Darwinius are placed in a geographically widespread clade of caenopithecine adapiforms that left no known descendants. The specialized morphological features that these adapiforms share with anthropoids are therefore most parsimoniously interpreted as evolutionary convergences. As the largest non-anthropoid primate ever documented in Afro-Arabia, Afradapis nevertheless provides surprising new evidence for prosimian diversity in the Eocene of Africa, and raises the possibility that ecological competition between adapiforms and higher primates might have played an important role during the early evolution of stem and crown Anthropoidea in Afro-Arabia.

Maximum ingested food size in captive anthropoids.

OBJECTIVES: Maximum ingested food size (Vb ) is an empirically tested performance variable that can shed light on feeding energetics and adaptation in the masticatory system. Until now, this variable had been tested in strepsirrhines alone among primates. Here, we present the first data on Vb in a broad sample of anthropoid primates and describe scaling patterns. MATERIALS AND METHODS: Vb data on anthropoids were collected under captive conditions at the Philadelphia Zoo and compared with published data on strepsirrhines. Data on Vb were scaled against individual body mass and were compared with experimentally determined toughness and stiffness values for the test foods. RESULTS: Unlike in strepsirrhines, where essentially Vb scales isometrically with body mass, Vb in anthropoids scales with negative allometry. There is a significant effect of food material properties on Vb , although bite size in anthropoids varies less based on food properties than in strepsirrhines. Large folivorous strepsirrhines follow the anthropoid trend in bite size scaling, but large frugivorous ones take especially large bites. DISCUSSION: Negative scaling of bite size in the anthropoids sampled could be due to reduced adaptation for gape. Some early anthropoids likely evolved adaptations for maximizing mechanical advantage and fatigue resistance in the chewing muscles, resulting in reduced gape. This might have channeled them toward smaller bites of more-resistant foods and away from taking large bites. This might also be the case for some folivorous strepsirrhines.

Craniomandibular signals of diet in adapids.

OBJECTIVES: The craniomandibular morphology of the adapid primates of Europe, especially Adapis and Leptadapis (sensu lato), suggests that they possessed enormous jaw adductor muscles. The goal of this study is to estimate jaw adductor muscle mass, physiological cross-sectional area (PCSA), and fiber length in adapid primates from the Eocene of Europe. We also estimated muscle leverage, bite force, and gape parameters. MATERIALS AND METHODS: We use bony morphology and osteological correlates of soft tissues in a sample of extant strepsirrhines to estimate these soft-tissue and performance variables in Adapis and Leptadapis. RESULTS: Our results suggest that, compared to a broad sample of extant strepsirrhines, Adapis and Leptadapis had relatively great jaw adductor muscle mass, PCSA, and bite force. They had moderately great jaw adductor leverage but no sign of adaptation for wide gapes. There is no support for the hypothesis that either adapid was a gouger. DISCUSSION: Our estimates support the inference that Adapis and Leptadapis were primarily folivorous, perhaps also consuming small to medium-sized tough fruits, nuts, and seeds. Explanations for the likely extreme development of the jaw adductor muscles in adapids remain speculative. These include (1) foods that were generally tougher and/or of higher yield strength than those eaten by strepsirrhines today, (2) using the muscles "in shifts" to avoid muscle fatigue in the context of an obdurate diet, and (3) potential constraints on reshaping of the skull for more efficient food processing.

Comparing apples and oranges-the influence of food mechanical properties on ingestive bite sizes in lemurs.

Previously we found that Maximum Ingested Bite Size (Vb )-the largest piece of food that an animal will ingest whole without biting first-scales isometrically with body size in 17 species of strepsirrhines at the Duke Lemur Center (DLC). However, because this earlier study focused on only three food types (two with similar mechanical properties), it did not yield results that were easily applied to describing the broad diets of these taxa. Expressing Vb in terms of food mechanical properties allows us to compare data across food types, including foods of wild lemurs, to better understand dietary adaptations in lemurs. To this end, we quantified Vb in five species of lemurs at the DLC representing large and small frugivores and folivores using ten types of food that vary widely in stiffness and toughness to determine how these properties relate to bite sizes. We found that although most species take smaller bites of stiffer foods, this negative relationship was not statistically significant across the whole sample. However, there is a significant relationship between bite size and toughness. All three of the more frugivorous taxa in our sample take significantly smaller bites of tougher foods. However, the two more folivorous lemurs do not. They take small bites for all foods. This suggests that the species most adapted to the consumption of tough foods do not modulate their ingestive sizes to accommodate larger pieces of weak foods.

Application of an Advanced Image-Based Virtual Monoenergetic Reconstruction of Dual Source Dual-Energy CT Data at Low keV Increases Image Quality for Routine Pancreas Imaging.

PURPOSE: To compare image quality on contrast-enhanced dual-energy computed tomography (DECT) during the pancreatic parenchymal phase of pancreatic masses between linearly-blended simulated 120 kVp images (routine) and advanced image-based virtual monoenergetic reconstructions at 55 keV. METHODS: This was a retrospective evaluation of 24 nonconsecutive adults found to have a focal pancreatic mass on a multiphasic abdominal dual-source DECT (12 adenocarcinoma, 5 neuroendocrine, 7 cystic tumors). For pancreatic-parenchymal phase images, subjects had routine and 55 keV images reconstructed at the time of clinical evaluation. Quantitative evaluation by contrast-to-noise ratio and qualitative evaluations of image quality by (1) direct comparison of image pairs (preference) and (2) blinded assessment of image quality measures based on Likert scores were performed. RESULTS: Mean patient weight was 205.8 ± 26.6 lbs. Mean pancreatic lesion contrast-to-noise ratio was significantly higher at 55 keV (6.8 ± 4.1) compared to the routine image series (5.8 ± 3.8; P = 0.0002). All 3 readers preferred the 55-keV images over routine blended images in 70.1% to 95.8% of cases. No significant differences were observed for subjective sharpness of the mass, visualization of internal mass structures, or image noise. CONCLUSIONS: Use of a single advanced image-based virtual monoenergetic reconstruction at 55 keV in pancreatic DECT showed improved objective image quality and reader preference compared to routine images. As this image reconstruction can be incorporated into the scan protocol, this technique should be considered for routine clinical use.

Oldest known cranium of a juvenile New World monkey (Early Miocene, Patagonia, Argentina): implications for the taxonomy and the molar eruption pattern of early platyrrhines.

A juvenile cranium of Homunculus patagonicus Ameghino, 1891a from the late Early Miocene of Santa Cruz Province (Argentina) provides the first evidence of developing cranial anatomy for any fossil platyrrhine. The specimen preserves the rostral part of the cranium with deciduous and permanent alveoli and teeth. The dental eruption sequence in the new specimen and a reassessment of eruption patterns in living and fossil platyrrhines suggest that the ancestral platyrrhine pattern of tooth replacement was for the permanent incisors to erupt before M(1), not an accelerated molar eruption (before the incisors) as recently proposed. Two genera and species of Santacrucian monkeys are now generally recognized: H. patagonicus Ameghino, 1891a and Killikaike blakei Tejedor et al., 2006. Taxonomic allocation of Santacrucian monkeys to these species encounters two obstacles: 1) the (now lost) holotype and a recently proposed neotype of H. patagonicus are mandibles from different localities and different geologic members of the Santa Cruz Formation, separated by approximately 0.7 million years, whereas the holotype of K. blakei is a rostral part of a cranium without a mandible; 2) no Santacrucian monkey with associated cranium and mandible has ever been found. Bearing in mind these uncertainties, our examination of the new specimen as well as other cranial specimens of Santacrucian monkeys establishes the overall dental and cranial similarity between the holotype of Killikaike blakei, adult cranial material previously referred to H. patagonicus, and the new juvenile specimen. This leads us to conclude that Killikaike blakei is a junior subjective synonym of H. patagonicus.

Body size and premolar evolution in the early-middle eocene euprimates of Wyoming.

The earliest euprimates to arrive in North America were larger-bodied notharctids and smaller-bodied omomyids. Through the Eocene, notharctids generally continued to increase in body size, whereas omomyids generally radiated within small- and increasingly mid-sized niches in the middle Eocene. This study examines the influence of changing body size and diet on the evolution of the lower fourth premolar in Eocene euprimates. The P4 displays considerable morphological variability in these taxa. Despite the fact that most studies of primate dental morphology have focused on the molars, P4 can also provide important paleoecological insights. We analyzed the P4 from 177 euprimate specimens, representing 35 species (11 notharctids and 24 omomyids), in three time bins of approximately equal duration: early Wasatchian, late Wasatchian, and Bridgerian. Two-dimensional surface landmarks were collected from lingual photographs, capturing important variation in cusp position and tooth shape. Disparity metrics were calculated and compared for the three time bins. In the early Eocene, notharctids have a more molarized P4 than omomyids. During the Bridgerian, expanding body size range of omomyids was accompanied by a significant increase in P4 disparity and convergent evolution of the semimolariform condition in the largest omomyines. P4 morphology relates to diet in early euprimates, although patterns vary between families.

Contact with primary care: the experience of people with intellectual disabilities.

BACKGROUND: People with intellectual disabilities experience disparities in their health and health care. Annual health checks are intended to counter such disparity by improving access to primary health care. However, little is known about their experience of having a health check or other types of contact with primary care services. MATERIALS AND METHODS: The findings of two studies which used focus groups were combined. 102 people with intellectual disabilities participated in the focus groups. RESULTS: Participants' experiences of primary care services generally, and health checks in particular, were positive. However, unanimity was rare on any of the topics discussed and a number of areas of dissatisfaction emerged. CONCLUSIONS: Further studies with larger and more representative samples are necessary as feedback from people with intellectual disabilities about their experience of contact with primary care staff might help to enhance GP knowledge about their health requirements.

Impaired Neurovascular Coupling and Increased Functional Connectivity in the Frontal Cortex Predict Age-Related Cognitive Dysfunction.

Impaired cerebrovascular function contributes to the genesis of age-related cognitive decline. In this study, the hypothesis is tested that impairments in neurovascular coupling (NVC) responses and brain network function predict cognitive dysfunction in older adults. Cerebromicrovascular and working memory function of healthy young (n = 21, 33.2±7.0 years) and aged (n = 30, 75.9±6.9 years) participants are assessed. To determine NVC responses and functional connectivity (FC) during a working memory (n-back) paradigm, oxy- and deoxyhemoglobin concentration changes from the frontal cortex using functional near-infrared spectroscopy are recorded. NVC responses are significantly impaired during the 2-back task in aged participants, while the frontal networks are characterized by higher local and global connection strength, and dynamic FC (p < 0.05). Both impaired NVC and increased FC correlate with age-related decline in accuracy during the 2-back task. These findings suggest that task-related brain states in older adults require stronger functional connections to compensate for the attenuated NVC responses associated with working memory load.

A fossil primate of uncertain affinities from the earliest late Eocene of Egypt.

Paleontological work carried out over the last 3 decades has established that three major primate groups were present in the Eocene of Africa-anthropoids, adapiforms, and advanced strepsirrhines. Here we describe isolated teeth of a previously undocumented primate from the earliest late Eocene ( approximately 37 Ma) of northern Egypt, Nosmips aenigmaticus, whose phylogenetic placement within Primates is unclear. Nosmips is smaller than the sympatric adapiform Afradapis but is considerably larger than other primate taxa known from the same paleocommunity. The species bears an odd mosaic of dental features, combining enlarged, elongate, and molariform premolars with simple upper molars that lack hypocones. Phylogenetic analysis across a series of different assumption sets variously places Nosmips as a stem anthropoid, a nonadapiform stem strepsirrhine, or even among adapiforms. This phylogenetic instability suggests to us that Nosmips likely represents a highly specialized member of a previously undocumented, and presumably quite ancient, endemic African primate lineage, the subordinal affinities of which have been obscured by its striking dental autapomorphies. Discriminant functions based on measurements of lower molar size and topography reliably classify extant prosimian primates into their correct dietary groups and identify Nosmips and Afradapis as omnivores and folivores, respectively. Although Nosmips currently defies classification, this strange and unexpected fossil primate nevertheless provides additional evidence for high primate diversity in northern Africa approximately 37 million years ago and further underscores the fact that our understanding of early primate evolution on that continent remains highly incomplete.

Ultrasound triage of ocular blast injury in the military emergency department.

INTRODUCTION: Ultrasound (US) provides rapid effective assessment of the globe. In Afghanistan, ocular blast injuries are common. We present a case series demonstrating the value of US in this context. METHODS: 29 patients with suspected blast eye injury had both computed tomography (CT) of the head and ocular US as part of their standard care in a military hospital in Afghanistan. The US images were assessed by blinded consultants (emergency department and radiology) and compared with the CT reports. RESULTS: 18 patients had an intraocular injury on either CT or US. CT identified 11 injuries. US detected 18, including all 11 detected by CT. Inter-rater agreement was high (28/29). DISCUSSION: This series suggests that US may be as good as CT at detecting ocular blast injuries. However, inability to follow up local national patients meant that the clinical relevance of these findings cannot be quantified. US is likely to have a role on deployed operations in triaging possible ocular injuries. CONCLUSIONS: US is an easy, cheap alternative to CT for the assessment of blast injury to the eye. It appears to have identified all injuries detected by CT in this series and can be accurately interpreted by emergency physicians.

Targeted support and telecare in staffed housing for people with intellectual disabilities: impact on staffing levels and objective lifestyle indicators.

BACKGROUND: Increased provision of out-of-family residential support is required because of demographic changes within the intellectual disabilities population. Residential support now has to be provided in a climate requiring both financial constraint and high quality service outcomes. The aim was to evaluate the quality of life consequences of living with less intensive staff support, resulting from the introduction of more targeted staff allocation coupled with telecare. METHODS: The study comprised 91 participants who lived in 33 settings. The targeted support/telecare intervention was implemented at staggered intervals in 25 of these settings (63 participants). Data on a range of participant and setting descriptors, quality of care, and a range of objective lifestyle indicators were collected at four points in time over 2 years. Impact of the intervention was evaluated using within-group comparisons over time. RESULTS: Comparison between pre- and post-intervention showed that staffing levels were significantly reduced by 23%, whereas they were constant in the absence of intervention. One health indicator improved in the absence of intervention and another improved following intervention. There were no significant changes in any other lifestyle indicators (safety, money, social and community activity, independence or choice). CONCLUSIONS: A combination of targeted support and telecare had no adverse short-term affect on participants' quality of life, but reduced staff input so it seems that they have a role to play in the strategic development of out-of-family placements for adults with intellectual disabilities. Further research is needed to explore in more detail how efficiency is achieved in practice.

A retrospective cohort study of three wound catheter infusion analgesia regimes after midline laparotomy.

BACKGROUND: Local anesthetic wound infusion catheters are increasingly used postmidline laparotomy to reduce pain and opioid use, however there is little evidence to support any particular infusion regime. METHODS: A retrospective cohort study was undertaken of patients after midline laparotomy who had bilateral local anesthetic wound infusion catheters surgically placed. Patients were recruited into 3 cohorts: ropivacaine 0.2% 5-8 mL/hour continuous wound infusion, 10 mL programmed intermittent bolus 2 hourly, 20 mL programmed intermittent bolus 4 hourly. The primary outcome was the maximum daily Numerical Rating Pain Score with movement (dynamic pain score) recorded during first 96 hours postprocedure. Secondary outcomes included the maximum daily resting pain score and opioid utilization. RESULTS: In three cohorts of 70 patients (n=210), the maximum daily dynamic pain score in the intermittent bolus 2-hourly and 4-hourly cohorts was lower when compared with the continuous infusion group over the first 4 postoperative days. The mean difference in maximum daily pain score with respect to the continuous infusion regime was 0.8 (95% CI 0.2 to 1.4) for the intermittent bolus 2-hourly group and 0.6 (95% CI 0.0 to 1.2) for the 4-hourly group. Generalized estimating equation modeling indicates the reduction in dynamic pain score is greatest with the intermittent bolus 2-hourly regime over the first 72 hours postprocedure. The 2-hourly intermittent bolus regime was also associated with lower opioid utilization and local anesthetic exposure. CONCLUSIONS: Intermittent wound infusion catheter infusion regimes were associated with lower maximum daily dynamic pain scores, although the magnitude of this change may be of limited clinical significance.