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.

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.

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.

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.

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.

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.

Addressing Inequities in Urban Health: Do Decision-Makers Have the Data They Need? Report from the Urban Health Data Special Session at International Conference on Urban Health Dhaka 2015

Rapid and uncontrolled urbanisation across low and middle-income countries is leading to ever expanding numbers of urban poor, defined here as slum dwellers and the homeless. It is estimated that 828 million people are currently living in slum conditions. If governments, donors and NGOs are to respond to these growing inequities they need data that adequately represents the needs of the urban poorest as well as others across the socio-economic spectrum.We report on the findings of a special session held at the International Conference on Urban Health, Dhaka 2015. We present an overview of the need for data on urban health for planning and allocating resources to address urban inequities. Such data needs to provide information on differences between urban and rural areas nationally, between and within urban communities. We discuss the limitations of data most commonly available to national and municipality level government, donor and NGO staff. In particular we assess, with reference to the WHO's Urban HEART tool, the challenges in the design of household surveys in understanding urban health inequities.We then present two novel approaches aimed at improving the information on the health of the urban poorest. The first uses gridded population sampling techniques within the design and implementation of household surveys and the second adapts Urban HEART into a participatory approach which enables slum residents to assess indicators whilst simultaneously planning the response. We argue that if progress is to be made towards inclusive, safe, resilient and sustainable cities, as articulated in Sustainable Development Goal 11, then understanding urban health inequities is a vital pre-requisite to an effective response by governments, donors, NGOs and communities.

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 Resource-Control Account of Sustained Attention

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.

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.

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.

Implicit learning modulates attention capture: evidence from an item-specific proportion congruency manipulation

A host of research has now shown that our explicit goals and intentions can, in large part, overcome the capture of visual attention by objects that differ from their surroundings in terms of size, shape, or color. Surprisingly however, there is little evidence for the role of implicit learning in mitigating capture effects despite the fact that such learning has been shown to strongly affect behavior in a host of other performance domains. Here, we employ a modified attention capture paradigm, based on the work of Theeuwes (1991, 1992), in which participants must search for an odd-shaped target amongst homogeneous distracters. On each trial, there is also a salient, but irrelevant odd-colored distracter. Across the experiments reported, we intermix two search contexts: for one set of distracters (e.g., squares) the shape singleton and color singleton coincide on a majority of trials (high proportion congruent condition), whereas for the other set of distracters (e.g., circles) the shape and color singletons are highly unlikely to coincide (low proportion congruent condition). Crucially, we find that observers learn to allow the capture of attention by the salient distracter to a greater extent in the high, compared to the low proportion congruent condition, albeit only when search is sufficiently difficult. Moreover, this effect of prior experience on search behavior occurs in the absence of awareness of our proportion manipulation. We argue that low-level properties of the search displays recruit representations of prior experience in a rapid, flexible, and implicit manner.

On the link between mind wandering and task performance over time

Here we test the hypothesis that fluctuations in subjective reports of mind wandering over time-on-task are associated with fluctuations in performance over time-on-task. In Study 1, we employed a singleton search task and found that performance did not differ prior to on- and off-task reports, nor did individual differences in mind wandering predict differences in performance (so-called standard analytic methods). Importantly however, we find that fluctuations in mind wandering over time are strongly associated with fluctuations in behavior. In Study 2, we provide a replication of the relation between mind wandering and performance over time found in Study 1, using a Flanker interference task. These data indicate (1) a tight coupling between mind wandering and performance over time and (2) that a temporal-analytic approach can reveal effects of mind wandering on performance in tasks where standard analyses fail to do so. The theoretical and methodological implications of these findings are discussed.

Restless mind, restless body

In the present work, we investigate the hypothesis that failures of task-related executive control that occur during episodes of mind wandering are associated with an increase in extraneous movements (fidgeting). In 2 studies, we assessed mind wandering using thought probes while participants performed the metronome response task (MRT), which required them to synchronize button presses with tones. Participants performed this task while sitting on a Wii Balance Board providing us with an index of fidgeting. Results of Study 1 demonstrate that relative to on-task periods, mind wandering is indeed accompanied by increases in fidgeting, as well as increased response variability in the MRT. In Study 2, we observed that only deep mind wandering was associated with increases in fidgeting, whereas task-related response variability increased even during mild mind wandering. We interpret these findings in the context of current theories of mind wandering and suggest that (a) mind wandering is associated with costs not only to primary-task performance but also to secondary-task goals (e.g., controlling extraneous movements) and (b) these costs may depend on the degree to which task-related executive control processes are disengaged during mind wandering (i.e., depth of mind wandering).

Media multitasking and failures of attention in everyday life

Using a series of online self-report measures, we examine media multitasking, a particularly pervasive form of multitasking, and its relations to three aspects of everyday attention: (1) failures of attention and cognitive errors (2) mind wandering, and (3) attentional control with an emphasis on attentional switching and distractibility. We observed a positive correlation between levels of media multitasking and self-reports of attentional failures, as well as with reports of both spontaneous and deliberate mind wandering. No correlation was observed between media multitasking and self-reported memory failures, lending credence to the hypothesis that media multitasking may be specifically related to problems of inattention, rather than cognitive errors in general. Furthermore, media multitasking was not related with self-reports of difficulties in attention switching or distractibility. We offer a plausible causal structural model assessing both direct and indirect effects among media multitasking, attentional failures, mind wandering, and cognitive errors, with the heuristic goal of constraining and motivating theories of the effects of media multitasking on inattention.

Wound drainage after axillary dissection for carcinoma of the breast

BACKGROUND

Axillary dissection is commonly performed for breast carcinoma. It is uncertain whether insertion of a drain reduces complication rates.

OBJECTIVES

To assess the effects of wound drainage after axillary dissection for breast carcinoma on the incidence of postoperative seroma formation. Secondary outcome measures include the incidence of infection and length of hospital stay.

SEARCH METHODS

We searched the Cochrane Wound and Breast Cancer Group's Specialised Registers (22 February 2013), MEDLINE (1950 to 22 February 2013), EMBASE (1966 to 22 February 2013), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (22 February 2013) for all prospectively registered and ongoing trials (22 February 2013). Reference lists of included studies were handsearched by two independent review authors to look for additional eligible trials.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing wound drainage versus no wound drainage in individuals after axillary dissection for the treatment of breast carcinoma were included. All disease stages were considered. Breast-conserving surgery and mastectomy were considered. Patients undergoing sentinel node biopsy without axillary dissection were not included. No limits were applied to language or study location. Two review authors independently determined the eligibility of each study.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for each included study using a predesigned data extraction proforma and assessed risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Discrepancies were resolved by consensus discussion with a third review author. Dichotomous variables were analysed using a Mantel-Haenszel model to produce odds ratios (ORs). Continuous variables were analysed using an inverse variance model to produce a mean difference (MD).

MAIN RESULTS

Seven RCTs including 960 participants were identified. The quality of trials was generally low, with several studies at risk of selection bias, and no studies used blinding during treatment or outcome assessment. There was a high level of statistical variation between the studies, which therefore reduces the reliability of the evidence. The OR for seroma formation was 0.46 (95% confidence interval (CI) 0.23 to 0.91, P = 0.03) in favour of a reduced incidence of seroma in participants with drains inserted. There was no significant difference in infection rates between drainage and no drainage groups (OR = 0.70; 95% CI 0.44 to 1.12, P = 0.14). The mean difference in length of hospital stay, reported in four trials consisting of 600 participants, was 1.47 days greater in the drained population (95% CI 0.67 to 2.28, P = 0.0003). A mean difference of 0.79 fewer postoperative seroma aspirations was found in the drained population (95% CI 1.23 to 0.35 fewer, P = 0.0004) in two trials including 212 participants. No significant difference in volume of seroma aspirations was reported (MD -19.44, 95% CI -59.45 to 20.57, P = 0.34) in three trials including 519 participants. No significant difference in the incidence of lymphoedema was noted (OR 2.31 favouring no drainage, 95% CI 0.47 to 11.37, P = 0.30), with only six instances reported in three trials of 360 participants, nor was any significant difference in the incidence of haematoma observed (OR 1.68, 95% CI 0.33 to 8.51, P = 0.53), with only five instances reported in two trials of 314 participants.

AUTHORS' CONCLUSIONS

There is limited quality evidence that insertion of a drain following axillary lymphadenectomy reduced the odds of developing a seroma and reduced the number of post-operative seroma aspirations. These benefits should be balanced against an increased length of hospital stay in the drained population.

In pursuit of off-task thought: mind wandering-performance trade-offs while reading aloud and color naming

The present study investigated whether the frequency of probe-caught mind wandering varied by condition and had any impact on performance in both an item-by-item reading aloud task and a blocked version of the classic Stroop task. Across both experiments, mind wandering rates were found to be quite high and were negatively associated with vocal onset latencies and error rates across conditions. Despite this however, we observed poor correspondence between the effects of task demands on mind wandering rates and the effects of mind wandering on primary task performance. We discuss these findings in relation to attentional resource accounts of mind wandering and suggest that individuals can adjust the relative distribution of executive/attentional resources between internal and external goals in a way that maximizes off-task thought while preserving primary task performance.

Carotid endarterectomy in the elderly: risk factors, intraoperative carotid hemodynamics and short-term complications: a UK tertiary center retrospective analysis

This retrospective analysis aims to demonstrate the safety of carotid endarterectomy (CE) in patients >75 years with particular attention paid to intraoperative hemodynamics. Four hundred and ninety-six consecutive patients with >70% symptomatic and asymptomatic stenosis who underwent CE were prospectively assessed and divided into those <75 years (n = 408; mean 64 years) and those >75 years (n = 88; mean 78 years). Associated risk factors, hemodynamic parameters, surgical techniques and 30-day perioperative complications were compared. Carotid artery stump pressures of <25 mmHg (13 versus 29%) and middle cerebral artery velocities of <20 cm/sec (46 versus 29%) were more common in those >75 years (P = 0.0001 and P <0.005, respectively). However, there was no difference in the frequency of intraluminal shunt (34% in both groups) or synthetic patch usage (primary patching: 12.5%, older group versus 11%, younger group; secondary patching: 34% in both groups), and no difference in the combined 30-day stroke and death rates (3.4%, >75 years versus 1.1%, <75 years; P = 0.425). CE in this cohort of patients >75 years was not associated with increased morbidity or mortality. Altered intraoperative hemodynamics were not associated with increased use of shunting or patching. This analysis supports CE as a safe procedure in the elderly.

Revisiting the time course of inter-trial feature priming in singleton search

Current theories of the locus of inter-trial priming effects in efficient visual search posit an early perceptual component that reflects the short-term influence of a memory trace for low-level stimulus attributes. Despite the fact that this memory trace is hypothesized to be short term, and should therefore have a diminishing influence on performance over time, there has been relatively little study of the effect of time alone on singleton priming effects. The present series of experiments addresses this issue by systematically examining the effect of time on the priming of pop-out (PoP) effect. In Experiment 1, we show that the PoP effect does indeed diminish with increases in the RSI between trials, and does so in accord with a power-law function. In Experiment 2, we show that temporal discriminability of trial n - 1 from the trial that precedes it does not contribute to PoP effects. The results of Experiment 3 revealed two key results: (1) the PoP effect survives an equivalent number of intervening trials across very different RSI conditions; and (2) the cumulative target repetition benefit does depend on the RSI between trials. Together, the results favor neither a simple passive decay nor a strong episodic retrieval account of the PoP effect.

Context-specific control and the Stroop negative priming effect

The present study highlights the utility of context-specific learning for different probe types in accounting for the commonly observed dependence of negative priming on probe selection. Using a Stroop priming procedure, Experiments 1a and 1b offered a demonstration that Stroop priming effects can differ qualitatively for selection and no-selection probes when probe selection is manipulated between subjects, but not when it is manipulated randomly from trial to trial within subject (see also Moore, 1994). In Experiments 2 and 3, selection and no-selection probes served as two contexts that varied randomly from trial to trial, but for which proportion repeated was manipulated separately. A context-specific proportion repeated effect was observed in Experiment 2, characterized by modest quantitative shifts in the repetition effects as a function of the context-specific proportion repeated manipulation. However, with a longer intertrial interval in Experiment 3, a context-specific proportion repeated manipulation that focused on the no-selection probes changed the repetition effect qualitatively, from negative priming when the proportion repeated was .25 to positive priming when the proportion repeated was .75. The results are discussed with reference to the role of rapid, context-specific learning processes in the integration of prior experiences with current perception and action.

Measurement of auditory brainstem responses evoked by electrical stimulation with a cochlear implant

Auditory brainstem responses evoked by electrical stimulation with a Nucleus/Cochlear implant can be measured if care is taken to prevent stimulus artefacts. A simple procedure is described which relies upon a passive LCR filter to prevent the radiofrequency carrier from entering the input of the recording amplifier. The filter simply prevents saturation of the amplifier by the carrier.

Polarity order of biphasic square pulse electric current stimulation of human cochlear nerve: observations with transtympanic electrodes

Eighteen totally deaf human cochleae were stimulated with biphasic square pulses of current through transtympanic needle electrodes. The thresholds of the 2 polarity orders, + - and - +, were compared for various pulse durations. For a pulse duration of 500 microseconds the polarity order - + had the lower threshold. For pulse durations of 2 ms and longer, the polarity order + - had the lower threshold. A discussion is given of the significance of the results for finding out the site of cochlear nerve excitation by the stimuli.