Improvement in children's fine motor skills following a computerized typing intervention

Children spend a large proportion of their school day engaged in tasks that require manual dexterity. If children experience difficulties with their manual dexterity skills it can have a consequential effect on their academic achievement. The first aim of this paper was to explore whether an online interactive typing intervention could improve children’s scores on a standardised measure of manual dexterity. The second aim was to implement a serial reaction time tapping task as an index of children's finger movement learning, and to see whether performance on this task would improve after the intervention. Seventy-eight typically developing children aged between 8 and 10 were tested at their school on the pre-intervention Movement Assessment Battery for Children (2nd edition; MABC-2) and tapping tasks. Twenty-eight of these children volunteered to be randomly allocated to the intervention or control group. Children in the intervention group had a choice of two online games to play at home over a period of four weeks, while the children in the control group were not given these games to play. The intervention and control groups were then re-tested on the MABC-2 manual dexterity and the tapping task. Children in the intervention group significantly improved their manual dexterity scores in the MABC-2 compared to the control group. On average, all children learnt the tapping sequence, however, there were no group differences and no effect of the intervention on the tapping task. These results have important implications for implementing a freely available, easy to administer, fun and interactive intervention to help children improve their manual dexterity skills.

Optimization of foraging and diet by the piscivorous Othos dentex (Serranidae)

The aim of this study was to determine the dietary characteristics and mouth morphology of Othos dentex and to use these data, together with in situ observations of feeding behaviour, to elucidate how foraging and diet are optimized by this piscivorous serranid. Seasonal spear and line fishing over reefs in south-western Australia yielded 426 O. dentex (total length, L_T , 183-605 mm), among which the stomachs of 95 contained food. The food in the stomachs of 76 fish was sufficiently undigested to be seen to contain, almost invariably, a single fish prey, which was typically identifiable to family and often to species. The prey of O. dentex, which were measured (L_T ), represented 10 families, of which the Labridae and Pempheridae constituted nearly two-thirds of the prey volume. Two-way crossed analysis of similarities of volumetric data for stomach contents showed that the dietary compositions of the different length classes of O. dentex in the various seasons were significantly related to length class of prey, but not to prey family, length class within the various prey families or season. Furthermore, an inverse (Q-mode) analysis, including one-way analysis of similarities, showed that the patterns in the prey consumed by the different length classes of O. dentex in the various seasons were related more strongly to length class than prey family. The former trend is exemplified in a shade plot, by a marked diagonality of the length classes of prey with increasing predator size. The ingestion of typically a single teleost prey, whose body size increases as that of O. dentex increases, reduces the frequency required for seeking prey, thus saving energy and reducing the potential for intraspecific competition for food. The ability of O. dentex to ingest large prey is facilitated by its possession of a very large gape, prominent recurved teeth, dorsal and independently-moveable eyes, cryptic colouration and effective ambush behaviour. Othos dentex has thus evolved very cost-effective mechanisms for optimizing its foraging and diet.

Online Control of Prehension Predicts Performance on a Standardized Motor Assessment Test in 8- to 12-Year-Old Children

Goal-directed hand movements are guided by sensory information and may be adjusted 'online,' during the movement. If the target of a movement unexpectedly changes position, trajectory corrections can be initiated in as little as 100 ms in adults. This rapid visual online control is impaired in children with developmental coordination disorder (DCD), and potentially in other neurodevelopmental conditions. We investigated the visual control of hand movements in children in a 'center-out' double-step reaching and grasping task, and examined how parameters of this visuomotor control co-vary with performance on standardized motor tests often used with typically and atypically developing children. Two groups of children aged 8-12 years were asked to reach and grasp an illuminated central ball on a vertically oriented board. On a proportion of trials, and at movement onset, the illumination switched unpredictably to one of four other balls in a center-out configuration (left, right, up, or down). When the target moved, all but one of the children were able to correct their movements before reaching the initial target, at least on some trials, but the latencies to initiate these corrections were longer than those typically reported in the adult literature, ranging from 211 to 581 ms. These later corrections may be due to less developed motor skills in children, or to the increased cognitive and biomechanical complexity of switching movements in four directions. In the first group (n = 187), reaching and grasping parameters significantly predicted standardized movement scores on the MABC-2, most strongly for the aiming and catching component. In the second group (n = 85), these same parameters did not significantly predict scores on the DCDQ'07 parent questionnaire. Our reaching and grasping task provides a sensitive and continuous measure of movement skill that predicts scores on standardized movement tasks used to screen for DCD.

Alginate therapy is effective treatment for GERD symptoms: a systematic review and meta-analysis

In patients with gastroesophageal reflux disease (GERD) and erosive esophagitis, treatment with proton pump inhibitors (PPIs) is highly effective. However, in some patients, especially those with nonerosive reflux disease or atypical GERD symptoms, acid-suppressive therapy with PPIs is not as successful. Alginates are medications that work through an alternative mechanism by displacing the postprandial gastric acid pocket. This study performed a systematic review and meta-analysis to examine the benefit of alginate-containing compounds in the treatment of patients with symptoms of GERD. PubMed/MEDLINE, Embase, and the Cochrane library electronic databases were searched through October 2015 for randomized controlled trials comparing alginate-containing compounds to placebo, antacids, histamine-2 receptor antagonists (H2RAs), or PPIs for the treatment of GERD symptoms. Additional studies were identified through a bibliography review. Non-English studies and those with pediatric patients were excluded. Meta-analyses were performed using random-effect models to calculate odds ratios (OR). Heterogeneity between studies was estimated using the I2 statistic. Analyses were stratified by type of comparator. The search strategy yielded 665 studies and 15 (2.3%) met inclusion criteria. Fourteen were included in the meta-analysis (N = 2095 subjects). Alginate-based therapies increased the odds of resolution of GERD symptoms when compared to placebo or antacids (OR: 4.42; 95% CI 2.45-7.97) with a moderate degree of heterogeneity between studies (I2 = 71%, P = .001). Compared to PPIs or H2RAs, alginates appear less effective but the pooled estimate was not statistically significant (OR: 0.58; 95% CI 0.27-1.22). Alginates are more effective than placebo or antacids for treating GERD symptoms.

Alginate therapy is effective treatment for gastroesophageal reflux disease symptoms: a systematic review and meta-analysis

In patients with gastroesophageal reflux disease (GERD) and erosive esophagitis, treatment with proton pump inhibitors (PPIs) is highly effective. However, in some patients, especially those with non-erosive reflux disease or atypical GERD symptoms, acid suppressive therapy with PPIs is not as successful. Alginates are medications that work through an alternative mechanism by displacing the post-prandial gastric acid pocket. We performed a systematic review and meta-analysis to examine the benefit of alginate-containing compounds in the treatment of patients with symptoms of GERD.PubMed/MEDLINE, Embase and the Cochrane library electronic databases were searched through October 2015 for randomized controlled trials comparing alginate-containing compounds to placebo, antacids, histamine-2 receptor antagonists (H2RAs) or PPIs for the treatment of GERD symptoms. Additional studies were identified through bibliography review. Non-English studies and those with pediatric patients were excluded. Meta-analyses were performed using random-effects models to calculate odds ratios (OR). Heterogeneity between studies was estimated using the I2 statistic. Analyses were stratified by type of comparator. The search strategy yielded 665 studies and 15 (2.3%) met inclusion criteria. Fourteen were included in the meta-analysis (N = 2095 subjects). Alginate-based therapies increased the odds of resolution of GERD symptoms when compared to placebo or antacids (OR: 4.42; 95% CI 2.45-7.97) with a moderate degree of heterogeneity between studies (I2 = 71%, P = .001). Compared to PPIs or H2RAs, alginates appear less effective but the pooled estimate was not statistically significant (OR: 0.58; 95% CI 0.27-1.22). Alginates are more effective than placebo or antacids for treating GERD symptoms.

Use of Population-based Data to Demonstrate How Waitlist-based Metrics Overestimate Geographic Disparities in Access to Liver Transplant Care

Liver allocation policies are evaluated by how they impact waitlisted patients, without considering broader outcomes for all patients with end-stage liver disease (ESLD) not on the waitlist. We conducted a retrospective cohort study using two nationally representative databases: HealthCore (2006-2014) and five-state Medicaid (California, Florida, New York, Ohio and Pennsylvania; 2002-2009). United Network for Organ Sharing (UNOS) linkages enabled ascertainment of waitlist- and transplant-related outcomes. We included patients aged 18-75 with ESLD (decompensated cirrhosis or hepatocellular carcinoma) using validated International Classification of Diseases, Ninth Revision (ICD-9)-based algorithms. Among 16 824 ESLD HealthCore patients, 3-year incidences of waitlisting and transplantation were 15.8% (95% confidence interval [CI] : 15.0-16.6%) and 8.1% (7.5-8.8%), respectively. Among 67 706 ESLD Medicaid patients, 3-year incidences of waitlisting and transplantation were 10.0% (9.7-10.4%) and 6.7% (6.5-7.0%), respectively. In HealthCore, the absolute ranges in states' waitlist mortality and transplant rates were larger than corresponding ranges among all ESLD patients (waitlist mortality: 13.6-38.5%, ESLD 3-year mortality: 48.9-62.0%; waitlist transplant rates: 36.3-72.7%, ESLD transplant rates: 4.8-13.4%). States' waitlist mortality and ESLD population mortality were not positively correlated: ρ = -0.06, p-value = 0.83 (HealthCore); ρ = -0.87, p-value = 0.05 (Medicaid). Waitlist and ESLD transplant rates were weakly positively correlated in Medicaid (ρ = 0.36, p-value = 0.55) but were positively correlated in HealthCore (ρ = 0.73, p-value = 0.001). Compared to population-based metrics, waitlist-based metrics overestimate geographic disparities in access to liver transplantation.

Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis

Despite their clinical efficacy, concerns about calcineurin inhibitor (CNI) toxicity make alternative regimens that reduce CNI exposure attractive for renal transplant recipients. In this systematic review and meta-analysis, we assessed four CNI immunosuppression strategies (minimization, conversion, withdrawal, and avoidance) designed to reduce CNI exposure and assessed the impact of each on patient and allograft survival, acute rejection and renal function. We evaluated 92 comparisons from 88 randomized controlled trials and found moderate- to high-strength evidence suggesting that minimization strategies result in better clinical outcomes compared with standard-dose regimens; moderate-strength evidence indicating that conversion to a mammalian target of rapamycin inhibitor or belatacept was associated with improved renal function but increased rejection risk; and moderate- to high-strength evidence suggesting planned CNI withdrawal could result in improved renal function despite an association with increased rejection risk. The evidence base for avoidance studies was insufficient to draw meaningful conclusions. The applicability of the review is limited by the large number of studies examining cyclosporine-based strategies and low-risk populations. Additional research is needed with tacrolimus-based regimens and higher risk populations. Moreover, research is necessary to clarify the effect of induction and adjunctive agents in alternative immunosuppression strategies and should include more comprehensive and consistent reporting of patient-centered outcomes.

Increasing the Number of Organ Transplants in the United States by Optimizing Donor Authorization Rates

While recent policies have focused on allocating organs to patients most in need and lessening geographic disparities, the only mechanism to increase the actual number of transplants is to maximize the potential organ supply. We conducted a retrospective cohort study using OPTN data on all "eligible deaths" from 1/1/08 to 11/1/13 to evaluate variability in donor service area (DSA)-level donor authorization rates, and to quantify the potential gains associated with increasing authorization rates. Despite adjustments for donor demographics (age, race/ethnicity, cause of death) and geographic factors (rural/urban status of donor hospital, statewide participation in deceased-donor registries) among 52 571 eligible deaths, there was significant variability (p < 0.001) in donor authorization rates across the 58 DSAs. Overall DSA-level adjusted authorization rates ranged from 63.5% to 89.5% (median: 72.7%). An additional 773-1623 eligible deaths could have been authorized, yielding 2679-5710 total organs, if the DSAs with authorization rates below the median and 75th percentile, respectively, implemented interventions to perform at the level of the corresponding reference DSA. Opportunities exist within the current organ acquisition framework to markedly improve DSA-level donor authorization rates. Such initiatives would mitigate waitlist mortality while increasing the number of transplants.

Minimal benefit of earlier-than-recommended repeat colonoscopy among US Medicare enrollees following a negative colonoscopy

BACKGROUND

A large proportion of US Medicare beneficiaries undergo earlier-than-recommended follow-up colonoscopies after negative screening colonoscopy. Such practice entails substantial cost and added risk.

AIMS

To compare the risk of colorectal cancer (CRC) associated with varying follow-up colonoscopy intervals following a negative colonoscopy, and to determine whether the potential benefit of a shorter colonoscopy follow-up interval would differ by gender.

METHODS

We conducted a weighted cohort study using the Surveillance, Epidemiology and End Results-Medicare linked database (1991-2006) among 932,370 Medicare enrollees who are representative of the entire US elderly population. We compared the cumulative incidence of CRC among patients who underwent follow-up colonoscopies at different intervals following a negative colonoscopy. The primary outcome was incident CRC.

RESULTS

The eligible study cohort (n = 480,864) included 106,924 patients who underwent ≥1 colonoscopy. Men were more likely to require polypectomy during their initial colonoscopy than women. Compared to the recommended 9-10 year follow-up colonoscopy interval, an interval of 5-6 years was associated with the largest CRC cumulative risk reduction [i.e. 0.17% (95% CI: 0.009-0.32%)]. The magnitude of risk reduction associated with shorter colonoscopy follow-up intervals was not significantly different between men and women.

CONCLUSIONS

Among elderly individuals who undergo a negative colonoscopy, the magnitude of reduction in the cumulative CRC risk afforded by earlier-than-recommended follow-up colonoscopy is quite small, and probably cannot justify the risk and cost of increased colonoscopy frequency. In addition, there are insufficient differences between men and women to warrant gender-specific recommendations.

Evaluating a systematic voiding programme for patients with urinary incontinence after stroke in secondary care using soft systems analysis and Normalisation Process Theory: findings from the ICONS case study phase

BACKGROUND

Urinary incontinence (UI) affects between 40 and 60% of people in hospital after stroke, but is often poorly managed in stroke units.

OBJECTIVES

To inform an exploratory trial by three methods: identifying the organisational context for embedding the SVP; exploring health professionals' views around embedding the SVP and measuring presence/absence of UI and frequency of UI episodes at baseline and six weeks post-stroke.

DESIGN

A mixed methods single case study included analysis of organisational context using interviews with clinical leaders analysed with soft systems methodology, a process evaluation using interviews with staff delivering the intervention and analysed with Normalisation Process Theory, and outcome evaluation using data from patients receiving the SVP and analysed using descriptive statistics.

SETTING

An 18 bed acute stroke unit in a large Foundation Trust (a 'not for profit' privately controlled entity not accountable to the UK Department of Health) serving a population of 370,000.

PARTICIPANTS

Health professionals and clinical leaders with a role in either delivering the SVP or linking with it in any capacity were recruited following informed consent. Patients were recruited meeting the following inclusion criteria: aged 18 or over with a diagnosis of stroke; urinary incontinence (UI) as defined by the International Continence Society; conscious; medically stable as judged by the clinical team and with incontinence classified as stress, urge, mixed or 'functional'. All patients admitted to the unit during the intervention period were screened for eligibility; informed consent to collect baseline and outcome data was sought from all eligible patients.

RESULTS

Organisational context: 18 health professionals took part in four group interviews. Findings suggest an environment not conducive to therapeutic continence management and a focus on containment of UI. Embedding the SVP into practice: 21 nursing staff took part in six group interviews. Initial confusion gave way to embedding of processes facilitated by new routines and procedures. Patient outcome: 43 patients were recruited; 28 of these commenced the SVP. Of these, 6/28 (21%) were continent at six weeks post-stroke or discharge.

CONCLUSION

It was possible to embed the SVP into practice despite an organisational context not conducive to therapeutic continence care. Recommendations are made for introducing the SVP in a trial context.

Biology of the harlequin fish Othos dentex (Serranidae), with particular emphasis on sexual pattern and other reproductive characteristics

Key biological characteristics of the harlequin fish Othos dentex, a representative of a monospecific genus of the Anthiinae (Serranidae), were determined from samples collected around reefs on the south coast of Western Australia. The females of this relatively long-lived species (maximum recorded age in this study = 37 years) attained only a slightly greater maximum total length and age than males and neither the length nor the age-frequency distributions showed a conspicuous sex-based bimodality. Furthermore, gonads from a wide size and age range of O. dentex were shown by histology, at several locations along their length, to always comprise exclusively either ovarian or testicular tissues. Thus, O. dentex is a gonochorist, a sexual pattern only previously recorded definitively for one other anthiine serranid, i.e. Epinephelides armatus, which also occurs in south-western Australia. Similar to E. armatus, O. dentex possesses 'solid' testes with a central sperm duct, thereby differing in structure from those typically found in serranids, in which there is a central membrane-bound 'ovarian' lumen and peripherally located sperm sinuses. The gonadal characteristics and sexual pattern of these two gonochoristic anthiines are not consistent with a recent proposal for the trends exhibited by the evolution of gonochorism and protogyny within the Serranidae. Othos dentex has indeterminate fecundity and a protracted spawning period (7 months) and, on the basis of underwater observations and a low gonado-somatic index (I(G)) for males, is a pair spawner, which is unusual for a gonochorist of a serranid or member of a related family. While the large spots on the lower half of the body of O. dentex are shown quantitatively to be similarly yellow in juveniles and adult females, they then become blue in males at maturity and this intensifies during the spawning period, when they presumably play an important role in agonistic interactions among males and courtship with females. The attainment of maturity and rapid growth by O. dentex early in life may reflect selection pressures to reduce predation mortality during that period. Total mortality in the population is moderately low during later life, implying that the current fishing pressure on O. dentex is relatively light.

The liver is populated by a broad spectrum of markers for macrophages. In alcoholic hepatitis the macrophages are M1 and M2

Background

Liver cell injury in alcoholic hepatitis (AH) is in part, due to macrophage generated proinflammatory cytokines i.e., M1, M2a, M2b, and M2c might be involved in ALD. The T cell response to chemokines and cytokines differs not only when M1 and M2 macrophages are compared but even when individual M2 subtypes are profiled.

Purpose

In AH, M1 monocytes in the blood show increased sensitivity in the TNF-α response to LPS. Immunohistochemistry (IHC) studies showed that the liver sinusoids in ALD are abundantly populated by CD163 expressing type 2 macrophages. In this report, we profile many of the molecules associated with M1 and M2 macrophages in livers with AH using IHC.

Methods

Using immunofluorescent antibody-labeling, we profiled the receptors, cytokines and chemokines observed in M1, M2a, M2b, and M2c macrophages in liver biopsies from patients with AH.

Results

The increased CD 163 expression found in previous studies was confirmed as well an additional macrophage phenotypic marker CD206, suggesting that AH pathogenesis at least partially involves M2a and M2c macrophages. TGF-β was found to be robustly over expressed by liver sinusoidal macrophages. Macrophage expression of the phenotypic markers TLR-2, TLR-4 and TLR-8 – found in both M1 and M2 macrophages – as well as the chemokines CCL-1 and CCL-18 was found. However, IRF-4, which is related to IL-4 production and M2a polarization as well as the cytokines CCL-1 and Il-1β and the chemokine CXCL-1 were also observed, suggesting that M2a and M2b also play a role in AH pathogenesis.

Conclusion

Livers with AH show robust macrophage over expression of TGF-β, a growth factor more commonly associated with M2 type macrophages and mostly known for its fibrogenetic properties. However, our immunoprofiling of macrophage over expression also shows that AH is driven by receptors, interferons, and cytokines that are commonly associated not just with M2 macrophages, but with M1 as well. Thus, a complex interplay between different types of macrophages expressing a diverse array of molecules and receptors is involved in AH.

Waitlist survival of patients with primary sclerosing cholangitis in the model for end-stage liver disease era

The ability of the Model for End-Stage Liver Disease (MELD) score to capture the urgency of transplantation may not be generalizable to patients with primary sclerosing cholangitis (PSC) because these patients face unique risks of death or removal from the liver transplant waitlist due to disease-specific complications (eg, repeated bouts of bacterial cholangitis and cholangiocarcinoma). We constructed Cox regression models to determine whether disease-based differences exist in waitlist mortality before liver transplantation. We compared the times to death or withdrawal from the waitlist due to clinical deterioration among patients with or without PSC in the United States after the implementation of the MELD allocation score. Over an 8-year period, 14,073 non-PSC patients (20.5%) and 432 PSC patients (13.6%) died or were removed (P < 0.0001). The adjusted hazard ratio (HR) for PSC was 0.72 [95% confidence interval (CI) = 0.66-0.79], which indicated that these patients had a lower time-dependent risk of death or removal from the waitlist in comparison with patients without PSC. This difference was explained in part by the groups' different probabilities of portal hypertension complications at listing because adjustments for these intermediate endpoints moved the HR closer to the null (0.84, 95% CI = 0.74-0.97). In comparison with patients with other forms of end-stage liver disease, patients with PSC are less likely to die or be removed from the waitlist because of clinical deterioration; therefore, the prevailing practice in some centers and regions of preemptively referring PSC patients for living donor transplantation or exception points should be reconsidered.

Treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 March 2007 and 5 March 2007 respectively), CINAHL (January 1982 to January 2007), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Twelve trials with a total of 724 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. BEHAVIOURAL INTERVENTIONS: Three trials assessed behavioural interventions, such as timed voiding and pelvic floor muscle training. All had small sample sizes and confidence intervals were wide. SPECIALISED PROFESSIONAL INPUT INTERVENTIONS: Two trials assessed variants of professional input interventions. Results tended to favour the intervention groups: in a small trial in early rehabilitation, fewer people had incontinence at discharge from hospital after structured assessment and management than in a control group (1/21 vs. 10/13; RR 0.06, 95% CI 0.01 to 0.43); in the second trial, assessment and management by Continence Nurse Advisors was associated with fewer participants having urinary symptoms (48/89 vs. 38/54; RR 0.77, 95% CI 0.59 to 0.99) and statistically significantly more being satisfied with care. COMPLEMENTARY THERAPY INTERVENTIONS: Three small trials all reported fewer participants with incontinence after acupuncture therapy (overall RR 0.44; 95% 0.23 to 0.86), but there were particular concerns about study quality. PHARMACOTHERAPY AND HORMONAL INTERVENTIONS: There were three small trials that included groups allocated meclofenoxate, oxybutinin or oestrogen. There were no apparent differences other than in the trial of meclofenoxate where fewer participants had urinary symptoms in the active group than in the control group (9/40 vs. 27/40; RR 0.33, 95% CI 0.18 to 0.62).

AUTHORS' CONCLUSIONS

Data from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke.

Repetitive task training for improving functional ability after stroke

BACKGROUND

The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation.

OBJECTIVES

To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice.

SEARCH STRATEGY

We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors.

SELECTION CRITERIA

Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information.

MAIN RESULTS

Fourteen trials with 17 intervention-control pairs and 659 participants were included.

PRIMARY OUTCOMES

results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach.

SECONDARY OUTCOMES

results were statistically significant for activities of daily living (SMD 0.29, 95% CI 0.07 to 0.51), but not for quality of life or impairment measures. There was no evidence of adverse effects. Follow-up measures were not significant for any outcome at six or twelve months. Treatment effects were not modified by intervention amount or timing, but were modified by intervention type for lower limbs.

AUTHORS' CONCLUSIONS

Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.

Prevention and treatment of urinary incontinence after stroke in adults

BACKGROUND

Urinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and around 15% remaining incontinent at one year.

OBJECTIVES

To determine the optimal methods for prevention and treatment of urinary incontinence after stroke in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 December 2004 and 26 October 2004, respectively), CINAHL (January 1982 to November 2004), national and international trial databases for unpublished data, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.

MAIN RESULTS

Seven trials with a total of 399 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. No two trials addressed the same comparison. Four trials tested an intervention against usual care, including acupuncture, timed voiding, and two types of specialist professional intervention. One cross-over trial tested an intervention (oestrogen) against placebo. One trial tested a specific intervention (oxybutynin) against another intervention (timed voiding), and one trial tested a combined intervention (sensory-motor biofeedback plus timed voiding) against a single component intervention (timed voiding alone). Reported data were insufficient to evaluate acupuncture or timed voiding versus usual care, oxybutynin versus timed voiding, or sensory motor biofeedback plus timed voiding versus usual care. Evidence from a single small trial suggested that structured assessment and management of care in early rehabilitation may reduce the number of people with incontinence at hospital discharge (1/21 versus 10/13; RR 0.06, 95% CI 0.01 to 0.43), and have other benefits. Evidence from another trial suggested that assessment and management of care by Continence Nurse Practitioners in a community setting may reduce the number of urinary symptoms (48/89 versus 38/54; RR 0.77, 95% CI 0.59 to 0.99), and increase satisfaction with care.

AUTHORS' CONCLUSIONS

There was suggestive evidence that specialist professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence after stroke. Data from trials of other physical, behavioural, complementary and anticholinergic drug interventions are insufficient to guide continence care of adults after stroke.

In what sense is implicit memory "episodic"? The effect of reinstating environmental context

We consider three aspects of the term episodic. Previous literature shows implicit memory does not make conscious autobiographical reference but does code an item's intrinsic context (e.g., perceptual detail). Here, we consider extrinsic context--namely, that not directly processed as part of item identification and not overtly relevant to the task. Study-test mismatch in environmental context (outdoors vs. indoors) reduced memory in an explicit stem-cued recall task but had no effect on repetition priming in an implicit stem completion task. This was true even for very low frequency words. We support the view that implicit memory reflects traces within perceptual (or semantic) knowledge-based systems that are instance specific but do not code the full spatiotemporal context information necessary to support conscious recollection. We also interpret our results as consistent with differences in environmental context specificity between free recall and recognition.

Are metal mining effluent regulations adequate: identification of a novel bleached fish syndrome in association with iron-ore mining effluents in Labrador, Newfoundland

Water quality guidelines for industrial effluents are in place in many countries but they have generally evolved within a limited ecotoxicological framework. Effluents from iron-ore mines have traditionally been viewed by regulatory bodies as posing little or no risk to the aquatic environment. However, it was recently reported that lake trout taken from a large iron-ore contaminated Lake in Labrador (Wabush Lake) had elevated levels of DNA oxidative damage and were markedly depleted in levels of vitamin A (Payne et al., 1998) in comparison with fish from a Lake (Shabogamo Lake) receiving lesser levels of effluents. Through further observations, it has now been established that the lake trout in Wabush Lake are commonly affected with a marked skin bleaching syndrome in comparison with fish in Shabogamo Lake and a nearby Lake (Ashuanipi) which does not receive effluents. To the authors' knowledge such a syndrome which is characterized by marked reduction in skin pigmentation and overall increase in skin whitening has not been reported before in any fish population in association with contamination. Preliminary information for liver histopathological and blood cell differences have also been obtained in fish in Wabush Lake in comparison with Ashuanipi Lake. It has also been observed through studies on phosphatidyl liposomes that iron-ore leachate contains redox-active material (iron but possibly other transition metals) that has considerable potential for causing oxidative damage to cellular constituents. Using the weight of evidence approach it is indicated that iron-ore effluents may pose more of a risk to the aquatic environment than traditionally considered by regulatory agencies.