Screening for Body Dysmorphic Disorder in Plastic Surgery Patients.

INTRODUCTION: The Australian medical board, the Australian Health Practitioner Regulation Agency (AHPRA) has recently introduced new regulations mandating providers of cosmetic surgery undertake a clinical screen for body dysmorphic disorder (BDD) in all potential cosmetic surgery patients. The assessment must be conducted by the surgeon using a validated psychological screening tool. The aims of this paper are to discuss the key clinical characteristics of BDD before reviewing currently validated screening tools that would meet this new regulatory requirement, and which may be most applicable to a busy plastic surgery practice. METHODS: A literature search identified 1164 titles, of which 229 titles were retrieved for abstract screening. Six studies were identified that validated BDD screening tools in a setting relevant to cosmetic plastic surgery. RESULTS: Six validated screening were identified: BDD Questionnaire (BDDQ), BDD Questionnaire Dermatology Version (BDDQ-DV), BDD Questionnaire Aesthetic Surgery (BDDQ-AS), Cosmetic Procedure Screening Questionnaire (COPS), Body Dysmorphia Symptom Scale (BDSS) and the BDD Screening Test (BDD-ST). Our group practice has chosen to adopt the BDDQ-AS to meet the AHPRA regulator requirement for BDD screening based on its robust validation and ease of use in clinical practice, consisting of a seven-item self-report questionnaire that can be reliably completed in 1-2 minutes in most cases. CONCLUSION: Of the six screening tools for body dysmorphic disorder available for use in clinical practice that have been validated in a cosmetic population setting, we have chosen to use the BDD Questionnaire Aesthetic Surgery (BDDQ-AS). To date all available validated screening tools are based on the DSM-IV, and further work to develop a validated screening tool based on the revised definition of BDD in the DSM-V is recommended, with a particular focus on items relating to repetitive physical or mental behaviours. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Useful Technique for Templating the Reverse Radial Forearm Flap (RFF) for Thumb Degloving Injuries.

Degloving injuries of the thumb pose a significant challenge as replantation is usually unsuccessful. A 60-year-old man was transferred to "Queen Victoria Hospital NHS Trust" four hours after having his left thumb completely avulsed at metacarpophalangeal level. The anastomosis repeatedly failed during urgent replantation and a distally based pedicled RFF was utilized. To achieve accurate flap design, we used the amputated part as a template for the missing tissue. After a longitudinal cut exposing the inner surface, the thumb was placed flat on top of a clean gauze package which was used as a paper template for the skin paddle; the flap was subsequently sutured without tension. Since the circumferential soft tissue envelope is three-dimensional, accurate designing of the flap on the forearm is vital. We propose a useful technique using the amputated part to enable a precise estimation of the tissue requirements to reduce potential complications related to flap inset.

Les lésions de dégantage du pouce posent un défi significatif dans la mesure où la réimplantation échoue habituellement. Un homme âgé de 60 ans a été transféré à « Queen Victoria Hospital NHS Trust ¼ quatre heures après l'arrachement complet de son pouce au niveau métacarpophalangien. L'anastomose a échoué de manière répétée au cours de la réimplantation en urgence et un RFF pédiculé à base distale a été utilisé. Pour obtenir une forme exacte du lambeau, nous avons utilisé la partie amputée comme modèle pour le tissu manquant. Après une incision longitudinale exposant la surface interne, le pouce a été mis à plat sur un paquet de compresses propres qui a servi de modèle papier pour la palette de peau; le lambeau a ensuite été suturé sans tension. Considérant que l'enveloppe de tissu souple circonférentielle est tridimensionnelle, une détermination précise du lambeau sur l'avant-bras est vitale. Nous proposons une technique utile consistant à utiliser la partie amputée pour avoir une estimation précise des besoins en tissu afin de réduire les complications potentielles liées à l'insertion du lambeau.

Modified Posterior Arm Flap for Axillary Hidradenitis Suppurativa.

INTRODUCTION: Hidradenitis suppurativa (HS) is a chronic, inflammatory condition of the apocrine sweat glands present in 1% to 4% of the adult population, with twice greater prevalence in females. Surgical excision is the criterion-standard treatment for advanced, grade III disease, characterized by extensive and recurrent abscesses and interconnected sinus tracts. Numerous reconstructive methods have been used to cover the resulting defects, including secondary intention healing, use of skin grafts, and a wide range of locoregional flaps. METHODS: The modified posterior arm flap has been developed for reconstruction of axillary defects after radical excision of HS. Based on perforating vessels from the axillary artery first identified by Masquelet, a brachioplasty-like incision is used to keep the donor site closure relatively hidden on the posteromedial aspect of the inner arm. RESULTS: Eight modified posterior arm flaps have been undertaken in 6 patients, all women (mean age, 35 years; range, 22-51 years) from 2014 to 2019. All patients had complete resolution of their HS symptoms with no incidences of recurrence at mean follow-up of 15 months. All reported satisfaction with the aesthetic and functional outcomes of the procedure. DISCUSSION: We present a novel modification of the posterior arm flap for the treatment of advanced axillary HS with good functional and aesthetic outcomes and no incidences of recurrence.

A comparison of the academic impact of plastic surgery units in the United Kingdom and Ireland using bibliometric analysis.

Academic output is just one aspect of a successful career as a plastic surgeon. However, for those with a strong interest in academia, the academic output of a department will likely be a key factor when deciding how to rank jobs. The aim of this study was to quantify and rank the academic output of plastic surgery units across the UK and Ireland. The Institute for Scientific Information (ISI) Web of Science Bibliometric analysis tool was used to collate cumulative (1950-2016), 10 year (2006-2016) and 3 years (2013-2015) research output data for plastic surgery units in the UK and Ireland. Sixty-six plastic surgery units were identified. Departments were ranked for each time period according to the number of papers produced, number of citations (Nc) and h-index (a measure of the impact of scientific output). The top 3 departments for number of papers in the last 10 years were The Royal Free Hospital, London (226) Broomfield Hospital, Chelmsford (218), and Morriston Hospital and Swansea (188). The top 3 for h-number were The Royal Free Hospital (21) Wythenshawe Hospital, Manchester (18) and Morriston Hospital (17). Academic output varies across plastic surgery units in the UK and Ireland. A number of departments have consistently maintained high academic outputs across the years and will be of interest to surgeons hoping to pursue a career in academia.

Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults.

BACKGROUND: Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Although history-taking and visual inspection of a suspicious lesion by a clinician are usually the first in a series of 'tests' to diagnose skin cancer, dermoscopy has become an important tool to assist diagnosis by specialist clinicians and is increasingly used in primary care settings. Dermoscopy is a magnification technique using visible light that allows more detailed examination of the skin compared to examination by the naked eye alone. Establishing the additive value of dermoscopy over and above visual inspection alone across a range of observers and settings is critical to understanding its contribution for the diagnosis of melanoma and to future understanding of the potential role of the growing number of other high-resolution image analysis techniques. OBJECTIVES: To determine the diagnostic accuracy of dermoscopy alone, or when added to visual inspection of a skin lesion, for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in-person), or based on remote (image-based), assessment. SEARCH METHODS: We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA: Studies of any design that evaluated dermoscopy in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. Data on the accuracy of visual inspection, to allow comparisons of tests, was included only if reported in the included studies of dermoscopy. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated accuracy using hierarchical summary receiver operating characteristic (SROC),methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; observer expertise; and dermoscopy training. MAIN RESULTS: We included a total of 104 study publications reporting on 103 study cohorts with 42,788 lesions (including 5700 cases), providing 354 datasets for dermoscopy. The risk of bias was mainly low for the index test and reference standard domains and mainly high or unclear for participant selection and participant flow. Concerns regarding the applicability of study findings were largely scored as 'high' concern in three of four domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The accuracy of dermoscopy for the detection of invasive melanoma or atypical intraepidermal melanocytic variants was reported in 86 datasets; 26 for evaluations conducted in person (dermoscopy added to visual inspection), and 60 for image-based evaluations (diagnosis based on interpretation of dermoscopic images). Analyses of studies by prior testing revealed no obvious effect on accuracy; analyses were hampered by the lack of studies in primary care, lack of relevant information and the restricted inclusion of lesions selected for biopsy or excision. Accuracy was higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio (RDOR) 4.6, 95% confidence interval (CI) 2.4 to 9.0; P < 0.001).We compared accuracy for (a), in-person evaluations of dermoscopy (26 evaluations; 23,169 lesions and 1664 melanomas),versus visual inspection alone (13 evaluations; 6740 lesions and 459 melanomas), and for (b), image-based evaluations of dermoscopy (60 evaluations; 13,475 lesions and 2851 melanomas),versus image-based visual inspection (11 evaluations; 1740 lesions and 305 melanomas). For both comparisons, meta-analysis found dermoscopy to be more accurate than visual inspection alone, with RDORs of (a), 4.7 (95% CI 3.0 to 7.5; P < 0.001), and (b), 5.6 (95% CI 3.7 to 8.5; P < 0.001). For a), the predicted difference in sensitivity at a fixed specificity of 80% was 16% (95% CI 8% to 23%; 92% for dermoscopy + visual inspection versus 76% for visual inspection), and predicted difference in specificity at a fixed sensitivity of 80% was 20% (95% CI 7% to 33%; 95% for dermoscopy + visual inspection versus 75% for visual inspection). For b) the predicted differences in sensitivity was 34% (95% CI 24% to 46%; 81% for dermoscopy versus 47% for visual inspection), at a fixed specificity of 80%, and predicted difference in specificity was 40% (95% CI 27% to 57%; 82% for dermoscopy versus 42% for visual inspection), at a fixed sensitivity of 80%.Using the median prevalence of disease in each set of studies ((a), 12% for in-person and (b), 24% for image-based), for a hypothetical population of 1000 lesions, an increase in sensitivity of (a), 16% (in-person), and (b), 34% (image-based), from using dermoscopy at a fixed specificity of 80% equates to a reduction in the number of melanomas missed of (a), 19 and (b), 81 with (a), 176 and (b), 152 false positive results. An increase in specificity of (a), 20% (in-person), and (b), 40% (image-based), at a fixed sensitivity of 80% equates to a reduction in the number of unnecessary excisions from using dermoscopy of (a), 176 and (b), 304 with (a), 24 and (b), 48 melanomas missed.The use of a named or published algorithm to assist dermoscopy interpretation (as opposed to no reported algorithm or reported use of pattern analysis), had no significant impact on accuracy either for in-person (RDOR 1.4, 95% CI 0.34 to 5.6; P = 0.17), or image-based (RDOR 1.4, 95% CI 0.60 to 3.3; P = 0.22), evaluations. This result was supported by subgroup analysis according to algorithm used. We observed higher accuracy for observers reported as having high experience and for those classed as 'expert consultants' in comparison to those considered to have less experience in dermoscopy, particularly for image-based evaluations. Evidence for the effect of dermoscopy training on test accuracy was very limited but suggested associated improvements in sensitivity. AUTHORS' CONCLUSIONS: Despite the observed limitations in the evidence base, dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants, particularly in referred populations and in the hands of experienced users. Data to support its use in primary care are limited, however, it may assist in triaging suspicious lesions for urgent referral when employed by suitably trained clinicians. Formal algorithms may be of most use for dermoscopy training purposes and for less expert observers, however reliable data comparing approaches using dermoscopy in person are lacking.

Visual inspection for diagnosing cutaneous melanoma in adults.

BACKGROUND: Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. History-taking and visual inspection of a suspicious lesion by a clinician is usually the first in a series of 'tests' to diagnose skin cancer. Establishing the accuracy of visual inspection alone is critical to understating the potential contribution of additional tests to assist in the diagnosis of melanoma. OBJECTIVES: To determine the diagnostic accuracy of visual inspection for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with limited prior testing and in those referred for further evaluation of a suspicious lesion. Studies were separated according to whether the diagnosis was recorded face-to-face (in-person) or based on remote (image-based) assessment. SEARCH METHODS: We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA: Test accuracy studies of any design that evaluated visual inspection in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. We excluded studies reporting data for 'clinical diagnosis' where dermoscopy may or may not have been used. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities per algorithm and threshold using the bivariate hierarchical model. We investigated the impact of: in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; and observer expertise. MAIN RESULTS: We included 49 publications reporting on a total of 51 study cohorts with 34,351 lesions (including 2499 cases), providing 134 datasets for visual inspection. Across almost all study quality domains, the majority of study reports provided insufficient information to allow us to judge the risk of bias, while in three of four domains that we assessed we scored concerns regarding applicability of study findings as 'high'. Selective participant recruitment, lack of detail regarding the threshold for deciding on a positive test result, and lack of detail on observer expertise were particularly problematic.Attempts to analyse studies by degree of prior testing were hampered by a lack of relevant information and by the restricted inclusion of lesions selected for biopsy or excision. Accuracy was generally much higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio of 8.54, 95% CI 2.89 to 25.3, P < 0.001). Meta-analysis of in-person evaluations that could be clearly placed on the clinical pathway showed a general trade-off between sensitivity and specificity, with the highest sensitivity (92.4%, 95% CI 26.2% to 99.8%) and lowest specificity (79.7%, 95% CI 73.7% to 84.7%) observed in participants with limited prior testing (n = 3 datasets). Summary sensitivities were lower for those referred for specialist assessment but with much higher specificities (e.g. sensitivity 76.7%, 95% CI 61.7% to 87.1%) and specificity 95.7%, 95% CI 89.7% to 98.3%) for lesions selected for excision, n = 8 datasets). These differences may be related to differences in the spectrum of included lesions, differences in the definition of a positive test result, or to variations in observer expertise. We did not find clear evidence that accuracy is improved by the use of any algorithm to assist diagnosis in all settings. Attempts to examine the effect of observer expertise in melanoma diagnosis were hindered due to poor reporting. AUTHORS' CONCLUSIONS: Visual inspection is a fundamental component of the assessment of a suspicious skin lesion; however, the evidence suggests that melanomas will be missed if visual inspection is used on its own. The evidence to support its accuracy in the range of settings in which it is used is flawed and very poorly reported. Although published algorithms do not appear to improve accuracy, there is insufficient evidence to suggest that the 'no algorithm' approach should be preferred in all settings. Despite the volume of research evaluating visual inspection, further prospective evaluation of the potential added value of using established algorithms according to the prior testing or diagnostic difficulty of lesions may be warranted.

An imagery-induced reversal of intertrial priming in visual search.

Maljkovic and Nakayama (1994) found that pop-out search performance is more efficient when a singleton target feature repeats rather than switches from 1 trial to the next-an effect known as priming of pop-out (PoP). They also reported findings indicating that the PoP effect is strongly automatic, as it was unaffected by knowledge of the upcoming target color. In the present study, we examined the impact of visual imagery on the PoP effect. Participants were instructed to imagine a target color that was opposite that of the preceding trial (e.g., if the prior target was red, then imagine green). Under these conditions, responses were faster for targets that matched the imagined color than for targets that matched the previous target color, reversing the typical PoP effect. There was no such reversal of the PoP effect for participants asked to verbalize rather than imagine an upcoming target color. In Experiment 3, we explored whether the PoP effect was indeed eliminated in the prior experiments, or instead obscured by the opposing visual imagery effect. Two conditions were compared, 1 in which a PoP effect could oppose the visual imagery effect, and another in which no such effect was possible, allowing inferences about whether a PoP effect was present. The results indicated that the PoP effect was present, but obscured by the larger visual imagery strategy effect that pushed performance in the opposite direction. Overall, the results suggest that the PoP effect is sensitive to top-down strategies that involve visual representations. (PsycINFO Database Record

Sentinel node biopsy status is strongly predictive of survival in cutaneous melanoma: Extended follow-up of Oxford patients from 1998 to 2014.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) is widely used as a key investigatory tool for cutaneous melanoma, with results incorporated into the latest AJCC staging guidelines. We present the results of our extended follow-up of sentinel lymph node biopsy for melanoma over a sixteen-year period. METHODS: Data were collected prospectively from June 1998 to December 2014 from a single tertiary skin cancer referral centre. Chi-squared analysis was used to analyse patient demographics and primary tumour pathology. Survival analysis was conducted using Cox regression models and Kaplan-Meier survival curves. RESULTS: Over a sixteen-year period 1527 patients underwent SLNB in 1609 basins, with 2876 nodes harvested. 347 patients (23%) had a positive biopsy. The most common primary tumour sites for males was the back (32%); women had a significantly higher number of melanomas occurring on the lower and upper limbs (45% and 26% respectively) [all p < 0.0001, Chi-squared]. Mean follow-up time was 4.9 years. Patients with a positive SLNB at diagnosis were significantly more likely to die from melanoma (subhazard ratio 5.59, p = 0.000, 95% CI 3.59-8.69). Breslow thickness and ulceration were also significant predictors of melanoma-specific mortality. For patients with a primary Breslow >4.0 mm ten-year disease free survival was 52% for SLNB negative and 26% for SLNB positive patients. For Breslow thicknesses of 2.01-4 mm these values were 66% and 32% respectively. CONCLUSIONS: Sentinel lymph node biopsy status is strongly predictive of survival across all thicknesses of primary cutaneous melanoma.

On the preservation of vigilant attention to semantic information in healthy aging.

Despite decades of research on younger adults, little is known about the way in which vigilant attention is affected by healthy aging, and the small body of work that does exist has yielded mixed findings. Prior examinations of aging and vigilant attention have focused almost exclusively on sensory/perceptual tasks despite the fact that many real-world vigilance tasks are semantic in nature and it has been shown that older adults exhibit memory and attention deficits in semantic tasks in other domains. Here, we present the first empirical investigation of vigilant attention to verbal stimuli in healthy normal aging. In Experiment 1 we find that older adults are just as able as younger adults to identify critical targets defined by category membership (both overall and over time). In Experiment 2, we increase the difficulty of the task by changing the target category from one block to the next, but again find no age-group effects in accuracy. Response time data, however, show that older adults respond more slowly and subjective ratings indicate that older adults experience higher workload and arousal compared to their younger counterparts. The practical as well as theoretical implications of these findings are discussed.

Disrupting monotony while increasing demand: benefits of rest and intervening tasks on vigilance.

In the experiments presented here, we examined the impact of intervening tasks on the vigilance decrement. In Experiment 1 participants either (a) continuously performed a visuospatial vigilance task, (b) received a rest break, or (c) temporarily performed a different, demanding visuospatial task in the middle of the vigil. Both taking a rest break and performing the intervening task were found to alleviate the vigilance decrement in response times. Target detection accuracy was equivalent across groups. In Experiment 2 we obtained subjective ratings of task demand, boredom, motivation, and mind wandering for both the vigilance task and intervening task administered in Experiment 1. The intervening task was rated as more demanding in terms of mental demand, physical demand, temporal demand, own performance, effort, and frustration. In addition, participants also reported being more bored, less motivated, and reported mind wandering more frequently when completing the vigil. Disruptions to task monotony (even if cognitively demanding), can alleviate the vigilance decrement. The implications of this finding with respect to current theoretical accounts of the vigilance decrement are discussed.

When should axillary drains be removed? A meta-analysis of time-limited versus volume controlled strategies for timing of drain removal following axillary lymphadenectomy.

BACKGROUND: Despite numerous studies over the past few decades, the optimum strategy for deciding when to remove drains following axillary lymphadenectomy remains unknown. This meta-analysis aims to compare time-limited and volume-controlled strategies for drain removal. METHODS: A total of 584 titles were identified following a systematic literature search of EMBASE, MEDLINE, Cinahl and the Cochrane library; 6 titles met our eligibility criteria. Data were extracted and independently verified by two authors. Time-limited drain removal was defined as drain removal at <5 days; volume-controlled strategies ranged from <20 ml/24 h to <50 ml/24 h. RESULTS: In all the studies, the time-limited approach resulted in earlier drain removal. Development of a seroma is 2.54 times more likely with early drain removal (Mantel-Haenszel Fixed Odds Ratio (OR) 2.54, p < 0.00001). However, there is no difference in infection rates between early and late drain removal (OR = 1.07, p = 0.76). CONCLUSIONS: This meta-analysis demonstrates that a strategy of early drain removal following axillary lymphadenectomy is safe, with no difference in infection rates; however, the incidence of seroma is significantly higher, which may necessitate more demanding outpatient care. There is a need for further well-designed clinical trials to address the clinical equipoise in this common area of surgical practice.

Negative priming 1985 to 2015: a measure of inhibition, the emergence of alternative accounts, and the multiple process challenge.

In this article, three generations of authors describe the background to the original article; the subsequent emergence of vigorous debates concerning what negative priming actually reflects, where radically different accounts based on memory retrieval were proposed; and a re-casting of the conceptual issues underlying studies of negative priming. What started as a simple observation (slowed reaction times) and mechanism (distractor inhibition) appears now to be best explained by a multiple mechanism account involving both episodic binding and retrieval processes as well as an inhibitory process. Emerging evidence from converging techniques such as functional magnetic resonance imaging (fMRI), and especially electroencephalography (EEG), is beginning to identify these different processes. The past 30 years of negative priming experiments has revealed the dynamic and complex cognitive processes that mediate what appear to be apparently simple behavioural effects.

A critical examination of the evidence for sensitivity loss in modern vigilance tasks.

It is well known that when human observers must monitor for rare but critical events, probability of detection tends to wane over time, a phenomenon known as the "vigilance decrement." Over 60 years of empirical study on this topic has culminated in the general consensus that performance suffers due to a loss in observers' ability to distinguish signal from noise (a loss in sensitivity) provided that the task loads memory and stimuli are presented at a relatively high rate. We challenge this assertion on 2 fronts: First, we contend on a theoretical level that the metrics employed to measure observer sensitivity in modern vigilance tasks (derived from signal detection theory) are inappropriate and largely uninterpretable. This contention is supported by an evaluation of recent empirical work in the vigilance domain. Second, we present the results of an experiment that demonstrates that shifts in response bias (the observer's "willingness to respond") over time can masquerade as a loss in sensitivity. Consequently, the basic underlying cause of the vigilance decrement is actually unclear, and may simply reflect a shift in response criterion rather than sensitivity. The theoretical, as well as practical implications of these conclusions are discussed with respect to sustained attention in general, and vigilance in particular.

A resource-control account of sustained attention: evidence from mind-wandering and vigilance paradigms.

Staying attentive is challenging enough when carrying out everyday tasks, such as reading or sitting through a lecture, and failures to do so can be frustrating and inconvenient. However, such lapses may even be life threatening, for example, if a pilot fails to monitor an oil-pressure gauge or if a long-haul truck driver fails to notice a car in his or her blind spot. Here, we explore two explanations of sustained-attention lapses. By one account, task monotony leads to an increasing preoccupation with internal thought (i.e., mind wandering). By another, task demands result in the depletion of information-processing resources that are needed to perform the task. A review of the sustained-attention literature suggests that neither theory, on its own, adequately explains the full range of findings. We propose a novel framework to explain why attention lapses as a function of time-on-task by combining aspects of two different theories of mind wandering: attentional resource (Smallwood & Schooler, 2006) and control failure (McVay & Kane, 2010). We then use our "resource-control" theory to explain performance decrements in sustained-attention tasks. We end by making some explicit predictions regarding mind wandering in general and sustained-attention performance in particular.

Reducing the vigilance decrement: The effects of perceptual variability.

The longer we are required to monitor for rare but critical events, the accuracy and speed with which we detect such events tend to suffer (the 'vigilance decrement') with more difficult tasks yielding larger decrements. Here, we present a striking example of a situation in which increasing the difficulty and complexity of a novel vigilance task actually decreases the vigilance decrement. In a 'Stable' condition participants monitored for the same critical target throughout the task, whereas in a 'Variable' condition, participants monitored for many possible instantiations of the critical target. Despite the fact that the Variable condition was objectively more difficult, the vigilance decrement was significantly reduced in response times relative to the Stable condition. We discuss these findings in light of 'overload' and 'underload' theories of the vigilance decrement and suggest that perceptual variability may provide bottom-up support for the maintenance of attentional resource allocation to an external task.

Media multitasking and behavioral measures of sustained attention.

In a series of four studies, self-reported media multitasking (using the media multitasking index; MMI) and general sustained-attention ability, through performance on three sustained-attention tasks: the metronome response task (MRT), the sustained-attention-to-response task (SART), and a vigilance task (here, a modified version of the SART). In Study 1, we found that higher reports of media multitasking were associated with increased response variability (i.e., poor performance) on the MRT. However, in Study 2, no association between reported media multitasking and performance on the SART was observed. These findings were replicated in Studies 3a and 3b, in which we again assessed the relation between media multitasking and performance on both the MRT and SART in two large online samples. Finally, in Study 4, using a large online sample, we tested whether media multitasking was associated with performance on a vigilance task. Although standard vigilance decrements were observed in both sensitivity (A') and response times, media multitasking was not associated with the size of these decrements, nor was media multitasking associated with overall performance, in terms of either sensitivity or response times. Taken together, the results of the studies reported here failed to demonstrate a relation between habitual engagement in media multitasking in everyday life and a general deficit in sustained-attention processes.

The more your mind wanders, the smaller your attentional blink: an individual differences study.

The present studies investigate the hypothesis that individuals who frequently report experiencing episodes of mind wandering do so because they under-invest attentional/executive resources in the external environment. Here we examined whether self-reported instances of mind wandering predict the magnitude of the "attentional blink" (AB) in a rapid serial visual presentation (RSVP) task, since a prominent view is that the AB derives from an over-investment of attention in the information stream. Study 1 demonstrates that subjective reports of mind wandering in a sustained attention task have a negative predictive relation with respect to the magnitude of the AB measured in a subsequent RSVP task. In addition, using the Spontaneous and Deliberate Mind Wandering Questionnaire in Study 2, we were again able to show that trait-level mind wandering in everyday life negatively predicts AB magnitude. We suggest that mind wandering may be the behavioural outcome of an adaptive cognitive style intended to maximize the efficient processing of dynamic and temporally unpredictable events.

Wound drainage following groin dissection for malignant disease in adults.

BACKGROUND: Groin dissection is commonly performed for the treatment of a variety of cancers, including melanoma, and squamous cell carcinoma of the skin, penis or vulva. It is uncertain whether insertion of a drain reduces complication rates, and, if used, the optimum time for drain removal after surgery is also unknown. OBJECTIVES: To assess the current level of evidence to determine whether placement of a drain is beneficial after groin dissection in terms of reducing seroma, haematoma, wound dehiscence and wound infection rates, and to determine the optimal type and duration of drainage following groin dissection if it is shown to be beneficial. SEARCH METHODS: In September 2014 we searched the following electronic databases using a pre-designed search strategy: the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library). In November 2013 we searched Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting. SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) comparing wound drainage with no wound drainage in individuals undergoing groin dissection, where the most superior node excised was Cloquet's node (the most superior inguinal lymph node). No limits were applied to language of publication or trial location. Two review authors independently determined the eligibility of each trial. DATA COLLECTION AND ANALYSIS: Two review authors, working independently, screened studies identified from the search; there were no disagreements. MAIN RESULTS: We did not identify any RCTs that met the inclusion criteria for the review. AUTHORS' CONCLUSIONS: There is a need for high quality RCTs to guide clinical practice in this under-researched area.