Brief opportunistic interventions by general practitioners to promote smoking cessation: A conversation analytic study.

Very brief opportunistic interventions for smoking cessation are effective, cost-saving for health systems, and universally recommended in guidelines. However, evidence suggests that clinicians are reluctant to intervene, citing interactional difficulties. Only one UK study has specifically examined smoking discussions, within naturally occurring primary care consultations. However smoking cessation treatment was not available at the time. We examined existing datasets amounting to 519 video-recordings of GP consultations in England for instances of talk about smoking. We used conversation analytic methods to assess patients' responses to doctors asking about smoking, giving advice on smoking, and offering cessation treatment. In 31 recordings it was apparent that the patient smoked, and, in 25/31 consultations, doctors initiated the topic of smoking. They did so by asking about smoking status, commonly during the history-taking phase of the consultation. In many instances, these questions led to active resistance from patients against being placed in a discreditable category, for example by minimising their smoking. This was more pronounced when GPs pursued efforts to quantify the amount smoked. Thereafter, where doctors returned to the topic of smoking, they did so typically by linking smoking to the patient's medical condition, which likewise led to resistance. Guidance recommends that GPs advise on how best to quit smoking where patients are interested in doing so, but this was only evident in a minority of consultations. Where GPs offered support for cessation, they did so using interactional practices that minimised the need for the patient to respond and thereby accept. Interactional difficulties were found to be common in consultations between GPs and people who smoke when GPs actions aligned with some VBA guidelines. Future research should examine when and how advice on how best to quit, and offers of support, should be delivered within primary care consultations.

Cutaneous afferents from the monkeys fingers: responses to tangential and normal forces.

Control of tangential force plays a key role in everyday manipulations. In anesthetized monkeys, forces tangential to the skin were applied at a range of magnitudes comparable to those used in routine manipulations and in eight different directions. The paradigm used enabled separation of responses to tangential force from responses to the background normal force. For slowly adapting type I (SAI) afferents, tangential force responses ranged from excitatory through no response to suppression, with both a static and dynamic component. For fast adapting type I (FAI) afferents, responses were dynamic and excitatory only. Responses of both afferent types were scaled by tangential force magnitude, elucidating the neural basis for previous human psychophysical scaling data. Most afferents were direction selective with a range of preferred directions and a range in sharpness of tuning. Both the preferred direction and the degree of tuning were independent of the background normal force. Preferred directions were distributed uniformly over 360 degrees for SAI afferents, but for FAI afferents they were biased toward the proximo-ulnar direction. Afferents from all over the glabrous skin of the distal segment of the finger responded; there was no evident relationship between the position of an afferent's receptive field on the finger and its preferred direction or its degree of tuning. Nor were preferred directions biased either toward or away from the receptive field center. In response to the relatively large normal forces, some afferents saturated and others did not, regardless of the positions of their receptive fields. Total afferent response matched human psychophysical scaling functions for normal force.

The AsTex: clinimetric properties of a new tool for evaluating hand sensation following stroke.

OBJECTIVES: To investigate the clinimetric properties and clinical utility of the AsTex((R)), a new clinical tool for evaluation of hand sensation following stroke. DESIGN: The AsTex((R)) was administered on two occasions separated by a week to appraise test-retest reliability, and by three assessors on single occasion to establish inter-rater reliability. Pilot normative values were collected in an age-stratified sample. Clinical utility was evaluated based on ease of administration, ceiling and floor effects, and responsiveness to sensory recovery. PARTICIPANTS: Test-retest (n = 31) and inter-rater (n = 31) reliability and normative values (n = 95) for the AsTex((R)) were established in neurologically normal participants aged 18-85 years. Test-retest reliability was investigated in 22 individuals a mean of 46 months (range 12-125) post stroke and clinical utility was evaluated in an additional 24 subacute stroke participants a mean of 29.4 days (range 12-41) post stroke. MAIN MEASURE: The AsTex((R)). RESULTS: The AsTex((R)) demonstrated excellent test-retest (intraclass correlation coefficient (ICC) = 0.98, 95% confidence interval (95% CI) = 0.97-0.99) and inter-rater reliability (ICC = 0.81, 95% CI = 0.73-0.87) in neurologically normal participants. Test-retest reliability of the AsTex((R)) in individuals following stroke was excellent (ICC = 0.86, 95% CI = 0.68-0.94). The AsTex((R)) was simple to administer, demonstrated small standard error of measurement (0.14 mm), minimal floor and ceiling effects (12.5% and 8.3%) and excellent responsiveness (standardized response mean = 0.57) in subacute stroke participants. CONCLUSION: The AsTex((R)) is a reliable, clinically useful and responsive tool for evaluating hand sensation following stroke.

Postpartum hemolytic uremic syndrome in a patient with preexisting hypertension and resolving preeclampsia.

Postpartum hemolytic uremic syndrome (PHUS) is an uncommon and potentially devastating complication of pregnancy. We report a case of PHUS in a patient with chronic hypertension and preceding preeclampsia. Since early and appropriate therapy results in remission in most patients with PHUS, the sometimes subtle differences between this syndrome and preeclampsia are reviewed.

How is tactile information affected by parameters of the population such as non-uniform fiber sensitivity, innervation geometry and response variability?

Analysis of population responses in the tactile system requires a step beyond the isomorphic representations that are commonly presented. Using a simple model based on our data for spheres contacting the fingerpad, we illustrate how the parameters of the population itself have a profound effect on the fidelity of neural representations or codes. The effects of these parameters, such as innervation density, variability of sensitivity, type and covariance of noise are not apparent from single unit responses and, at least at present, require a theoretical or modeling approach of some sort.

Tactile discrimination of edge shape: limits on spatial resolution imposed by parameters of the peripheral neural population.

When the flat faces of a coin are grasped between thumb and index finger, a "curved edge" is felt. Analogous curved edges were generated by our stimuli, which comprised the flat face of segments of annuli applied passively to immobilized fingers. Humans could scale the curvature of the annulus and could discriminate changes in curvature of approximately 20 m(-1). The responses of single slowly adapting type I afferents (SAIs) recorded in anesthetized monkeys could be quantified by the product of two factors: their sensitivity and a spatial profile dependent only on the radius of the annulus. This allowed us to reconstruct realistic SAI population responses that included noise, variation in fiber sensitivity, and varying innervation patterns. The critical question was how relatively small populations ( approximately 70 active fibers) can encode edge curvature with such precision. A template-matching approach was used to establish the accuracy of edge representation in the population. The known large interfiber variability in sensitivity had no effect on curvature resolution. Neural resolution was superior to human performance until large levels of central noise were present showing that, unlike simple detection, spatial processing is limited centrally. In contrast to the behavior of mean response codes, neural resolution improved with increasing covariance in noise. Surprisingly, resolution for any single population varied considerably with small changes in the position of the stimulus relative to the SAI matrix. Overall innervation density was not as critical as the spacing of receptive fields at right angles to the edge.

Tactile discrimination of gaps by slowly adapting afferents: effects of population parameters and anisotropy in the fingerpad.

The aim of this study was to determine the acuity of the peripheral tactile system for gaps and to determine how stimulus orientation may impact on this. We quantified the ability of humans to discriminate small differences in gap width using a forced-choice task. Stimuli were presented passively to the distal fingerpad in a region where the skin ridges all run approximately in the same direction. Two standard gap widths were used (2 and 2.9 mm), and the comparison gap widths were larger than the standard gaps. With the gap axis parallel to the skin ridges, the average difference limen was approximately 0.2 mm for both standards. We examined the effect of stimulus orientation by asking subjects to discriminate between a smooth surface and a grating (ridge width, 1.5 mm; groove width, 0. 75 mm). They were able to discriminate the two surfaces when the axis of the grooves was parallel to the skin ridges, but performance was below threshold in the orthogonal orientation. The underlying neural mechanisms were investigated using the gap stimuli to activate single slowly adapting type I mechanoreceptive afferents (SAIs) innervating the fingerpads of anesthetized monkeys. The edges of the gap produced response peaks, and the gap resulted in a trough in the receptive field profiles. The response magnitude at the peaks was greater, and at the troughs was smaller, for larger gap widths and also when the axis of the gap was parallel to the skin ridges as compared with the orthogonal orientation. Simulated SAI population responses showed that response profiles were distorted by variation in afferent sensitivity and by neural noise. Using signal detection theory, based on a neural measure of the gaps computed over the active population, the acuity of the SAIs under realistic population conditions was compared with human performance. These analyses showed how parameters like afferent sensitivity, the pattern and density of innervation, and noise impact on performance and why their impact is different for the two stimulus orientations investigated. The greatest limitation was imposed by noise that is independent of response magnitude, and this effect was greater for stimuli oriented orthogonal to the skin ridges than for the parallel orientation.

Slowly adapting type I afferents from the sides and end of the finger respond to stimuli on the center of the fingerpad.

The central part of the fingerpad in anesthetized monkeys was stimulated by spheres varying in curvature indented into the skin. Responses were recorded from single slowly adapting type I primary afferent fibers (SAIs) innervating the sides and end of the distal segment of the stimulated finger. Although these afferents had receptive field centers that were remote from the stimulus, their responses were substantial. Increasing the curvature of the stimulus resulted in an increased response for most afferents. In general, responses increased most between stimuli with curvatures of 0 (flat) and 80.6 m(-1), with further increases in curvature having progressively smaller effects on the response. We calculated an index of sensitivity to changes in curvature; this index varied widely among the afferents but for most it was less than the index calculated for afferents innervating the fingerpad in the vicinity of the stimulus. Responses of all the SAIs increased when the contact force of the stimulus increased. An index of sensitivity to changes in contact force varied widely among the afferents but in all cases was greater than the index calculated for SAIs from the fingerpad itself. Neither the curvature sensitivity nor the force sensitivity of an afferent was related in any obvious way to the location of its receptive field center on the digit. There was only a minor correspondence between an afferent's sensitivity to force and its sensitivity to curvature. The large number of afferents innervating the border regions of the digit do respond to stimuli contacting the central fingerpad; they convey some information about the curvature of the stimulus and substantial information about contact force.

Effects of nonuniform fiber sensitivity, innervation geometry, and noise on information relayed by a population of slowly adapting type I primary afferents from the fingerpad.

The capacity of a population of primary afferent fibers to signal information about a sphere indenting the fingerpad is limited by factors such as the inhomogeneity of sensitivity among the afferents, the pattern and density of innervation, and the effects of noise (response variability). Using experimental data recorded from single slowly adapting type I afferents (SAIs), we simulated the response of the SAI population to such a stimulus. The human ability to discriminate stimulus curvature, location, and force has been quantified previously. We devised three neural measures, treating them as surrogates for the real neural measures underlying human performance, and explored how population parameters usually overlooked in neural coding studies affect such measures. Variation in sensitivity among SAIs is large; this distorts population response profiles markedly but has no significant impact on the neural measures. Two classes of noise were introduced, one dependent on and the other independent of the level of neural activity. Resolution of the model was compared with discrimination in humans. Correlation of noise among neurons had different effects for the different measures. An increase in correlation decreased resolution in the measure for force but improved resolution in the measure for position. Increasing innervation density (1) always increased resolution for position and (2) increased resolution for force if noise was uncorrelated but had diminishing effects as correlation increased. Correlation and innervation density had complex effects on the measure for curvature, depending on the class of noise. Nonuniformity in the pattern of innervation had negligible effects on resolution.

Direction selectivity of synaptic potentials in simple cells of the cat visual cortex.

Direction selectivity of synaptic potentials in simple cells of the cat visual cortex. J. Neurophysiol. 78: 2772-2789, 1997. The direction selectivity of simple cells in the visual cortex is generated at least in part by nonlinear mechanisms. If a neuron were spatially linear, its responses to moving stimuli could be predicted accurately from linear combinations of its responses to stationary stimuli presented at different positions within the receptive field. In extracellular recordings, this has not been found to be the case. Although the extracellular experiments demonstrate the presence of a nonlinearity, the cellular process underlying the nonlinearity, whether an early synaptic mechanism such as a shunting inhibition or simply the spike threshold at the output, is not known. To differentiate between these possibilities, we have recorded intracellularly from simple cells of the intact cat with the whole cell patch technique. A linear model of direction selectivity was used to analyze the synaptic potentials evoked by stationary sine-wave gratings. The model predicted the responses of cells to moving gratings with considerable accuracy. The degree of direction selectivity and the time course of the responses to moving gratings were both well matched by the model. The direction selectivity of the synaptic potentials was considerably smaller than that of the intracellularly recorded action potential, indicating that a nonlinear mechanism such as threshold enhances the direction selectivity of the cell's output over that of its synaptic inputs. At the input stage, however, the cells apparently sum their synaptic inputs in a highly linear fashion. A more constrained test of linearity of synaptic summation based on principal component analysis was applied to the responses of direction-selective cells to stationary gratings. The analysis confirms that the summation in these cells is highly linear. The principal component analysis is consistent with a model in which direction selectivity in cortical simple cells is generated by only two subunits, each with a different receptive-field position and response time course. The response time course for each of the two subunits is derived for four analyzed cells. Each derived subunit is linear in spatial summation, suggesting that the neurons that comprise each subunit are either geniculate X-cells or receive their primary synaptic input from X-cells. The amplitude of the response of each subunit is linearly related to the contrast of the stimulus. The subunits are nonlinear in the time domain, however: the response to a stationary stimulus whose contrast is modulated sinusoidally in time is nonsinusoidal. The principal component analysis does not exclude models of direction selectivity based on more than two subunits, but such higher-order models would have to include the constraint that the extra subunits form a smooth continuum of interpolation between the properties derived from the two subunit solution.

Cross-reactivity in Histoplasma capsulatum variety capsulatum antigen assays of urine samples from patients with endemic mycoses.

We evaluated cross-reactivity in the antigen assay used for the diagnosis of histoplasmosis by testing urine samples from patients with disseminated fungal infections. The mycoses chosen for this study were selected on the basis of the observation that during clinical testing, cross-reactions may occur between Histoplasma capsulatum var. capsulatum, Paracoccidioides brasiliensis, Blastomyces dermatitidis, Coccidioides immitis, and Penicillium marneffei. We detected antigen in 12 of 19 patients with blastomycosis, 8 of 9 with paracoccidioidomycois, in 17 of 18 with P. marneffei infection, and in one with disseminated H. capsulatum var. duboisii infection. Cross-reactions were not observed in the assays for six patients with disseminated coccidioidomycosis. Cross-reactivity between the agents of other endemic mycoses should be considered in interpreting a positive H. capsulatum var. capsulatum antigen assay. Antigen detection may provide a rapid, provisional diagnosis for patients with serious infections caused by one of these organisms.

Orientation selectivity of thalamic input to simple cells of cat visual cortex.

More than 30 years after Hubel and Wiesel first described orientation selectivity in the mammalian visual cortex, the mechanism that gives rise to this property is still controversial. Hubel and Wiesel proposed a simple model for the origin of orientation tuning, in which the circularly symmetrical receptive fields of neurons in the lateral geniculate nucleus that excite a cortical simple cell are arranged in rows. Since this model was proposed, several experiments and neuronal simulations have suggested that the connectivity between the lateral geniculate nucleus and the cortex is not well organized in an orientation-specific fashion, and that orientation tuning arises instead from extensive interactions within the cortex. To test these models we have recorded visually evoked synaptic potentials in simple cells while cooling the cortex, which largely inactivates the cortical network, but leaves geniculate synaptic input functional. We report that the orientation tuning of these potentials is almost unaffected by cooling the cortex, in agreement with Hubel and Wiesel's original proposal.

Tactile resolution: peripheral neural mechanisms underlying the human capacity to determine positions of objects contacting the fingerpad.

We measured the ability of humans to discriminate the positions of spherical objects passively contacting the fingerpad. The discrimination threshold averaged 0.55 mm for a moderately curved sphere (radius 5.80 mm) and decreased to 0.38 mm for a more curved sphere (radius 1.92 mm); since the receptor density is about 1 per mm2, these values are substantially smaller than those predicted by the sampling theorem (referred to as hyperacuity). To elucidate the underlying neural mechanisms, responses to the same spheres and random sequences of stimuli were recorded from single Merkel afferents (SAIs) and Meissner afferents (RAs) in anesthetized monkeys. For multiple applications of identical stimuli, coefficients of variation of responses were around 3%. Profiles of responses across the SAI population were "hill-shaped." A change in position of the stimulus on the skin resulted in a matching shift of the profile, evident over the whole profile for the more curved sphere but ony at the skirts for the less curved sphere. The shift in response profiles, relative to the standard deviations, increased as the change in position increased, and was more reliable for the more curved sphere. Responses were measured over four time frames: 0.2, 0.3, 0.5, and 1.0 sec. Although responses increased with an increase in integration time, so, too, did their standard deviations, so that signal-to-noise ratios or the resolution in the SAI population was bout the same at 0.2 sec as at 1.0 sec. Only half the RAs responded; responses were small, but signalled reliable information about the position of the stimulus.

Representation of curved surfaces in responses of mechanoreceptive afferent fibers innervating the monkey's fingerpad.

The aim was to elucidate how the population of digital nerve afferents signals information about the shape of objects in contact with the fingerpads during fine manipulations. Responses were recorded from single mechanoreceptive afferent fibers in median nerves of anesthetized monkeys. Seven spherical surfaces were used, varying from a highly curved surface (radius, 1.44 mm; curvature, 694 m-1) to a flat surface (radius, infinity; curvature, 0 m-1). These were applied to the fibers' receptive fields, which were located on the central portion of a fingerpad. When the objects were located at the centers of the receptive fields, the responses of the slowly adapting fibers (SAIs) increased as the curvature of the surface increased and as the contact force increased. All SAIs behaved in the same way, differing only by a scaling factor (the sensitivity of the individual afferent). Responses of the rapidly adapting afferents were small and did not vary systematically with the stimulus parameters, and most Pacinians did not respond at all. Stimuli were applied at different positions in the receptive fields of SAIs to define the response profiles of the afferents (response as a function of position on the fingerpad). All SAIs had similarly shaped profiles for the same surface curvature and the shape differed for different curvatures. These profiles reflected the shape of the stimulus. An increase in contact force scaled these profiles upward. Thus, the population of digital nerve fibers signals unambiguous information about the shape and contact force of curved surfaces contacting the fingerpad.

Linearity of summation of synaptic potentials underlying direction selectivity in simple cells of the cat visual cortex.

Intracellular recordings from simple cells of the cat visual cortex were used to test linear models for the generation of selectivity for the direction of visual motion. Direction selectivity has been thought to arise in part from nonlinear processes, as suggested by previous experiments that were based on extracellular recordings of action potentials. In intracellular recordings, however, the fluctuations in membrane potential evoked by moving stimuli were accurately predicted by the linear summation of responses to stationary stimuli. Nonlinear mechanisms were not required.

Magnitude estimation of contact force when objects with different shapes are applied passively to the fingerpad.

Stimuli with spherically curved surfaces were presented passively to the fingerpads of human subjects. There were 28 stimuli, consisting of all combinations of 4 different curvatures and 7 different contact forces; these were presented in random order. Subjects scaled their perceived magnitude of the contact force using magnitude estimation. Perceived force increased markedly with an increase in experimentally applied contact force. An increase in curvature resulted in a slight increase in perceived contact force. Thus, when humans are passively presented with objects changing in both shape and contact force, they are able to extract information about the force. Because of the passive nature of the task, all such information must be conveyed to the brain by the cutaneous mechanoreceptors.