Improving Brain–Machine Interface Performance by Decoding Intended Future Movements

Objective. A brain–machine interface (BMI) records neural signals in real time from a subject\u27s brain, interprets them as motor commands, and reroutes them to a device such as a robotic arm, so as to restore lost motor function. Our objective here is to improve BMI performance by minimizing the deleterious effects of delay in the BMI control loop. We mitigate the effects of delay by decoding the subject\u27s intended movements a short time lead in the future. Approach. We use the decoded, intended future movements of the subject as the control signal that drives the movement of our BMI. This should allow the user\u27s intended trajectory to be implemented more quickly by the BMI, reducing the amount of delay in the system. In our experiment, a monkey (Macaca mulatta) uses a future prediction BMI to control a simulated arm to hit targets on a screen. Main Results. Results from experiments with BMIs possessing different system delays (100, 200 and 300 ms) show that the monkey can make significantly straighter, faster and smoother movements when the decoder predicts the user\u27s future intent. We also characterize how BMI performance changes as a function of delay, and explore offline how the accuracy of future prediction decoders varies at different time leads. Significance. This study is the first to characterize the effects of control delays in a BMI and to show that decoding the user\u27s future intent can compensate for the negative effect of control delay on BMI performance

Development and evaluation of an interactive booklet for use in primary care consultations with children with respiratory tract infections

Respiratory tract infections are the most common reason for children to consult, and be prescribed antibiotics, in primary care. Parental anxiety and misinformation can contribute to increased consulting which, combined with perceived expectations for antibiotics, can increase prescribing. Clinicians are exhorted to rationalise antibiotic prescribing, but lack evidence-based tools to achieve this. Patient education using printed materials presented by a healthcare professional has been shown to reduce reconsulting and antibiotic prescribing. I developed an interactive booklet on respiratory tract infections in children for use in primary care consultations, and training in its use. The booklet aims to address unrealistic expectations about symptom duration and antibiotic effectiveness, and increase parental empowerment by prompting clinicians to address parental concerns and expectations, and providing information about treatment options, and features that should prompt reconsultation. Booklet development was guided by behaviour change theories and guidance on developing patient materials. It involved summarising relevant scientific evidence and consulting with parents and clinicians through focus groups, and other professionals (graphic designer and a literacy expert). The intervention (booklet and training in its use) was compared with usual care in a cluster randomised controlled trial. 83 practices were randomised and 61 recruited 557 children with an acute RTI. Reconsulting, antibiotic prescribing, and parental satisfaction, enablement, and other outcomes were assessed via a telephone interview at two-weeks. Use of the intervention resulted in a non-statistically significant reduction in reconsulting, a statistically significant and clinically meaningful reduction in antibiotic prescribing (OR 0.27,95% CI 0.14 to 0.60), and no statistically significant difference in enablement, satisfaction, reassurance, or consulting over the following year. There was no statistically significant difference in total cost between study arms. Changes in clinicians' beliefs about the importance of rationalising prescribing, and using the booklet as an aide-memoir, and to support a non-prescribing approach, appear to be responsible for the reduction in prescribing

Dermatology life quality index (DLQI) as a psoriasis referral triage tool

Most primary care psoriasis referrals in the UK are triaged as ‘routine’, in part because of the prioritisation of skin cancer. As a result, patients with severe psoriasis may wait several months to be seen, enduring quality of life (QoL) impairment that could have been reduced. Furthermore some patients may spontaneously improve by the time they are seen by a specialist, making the appointment unnecessary at that time. Therefore, following approval from the local ethics committee, we conducted a prospective study to evaluate the usefulness of Dermatology Life Quality Index (DLQI) scores in triaging patients with psoriasis referred to our dermatology secondary health care services

The management of acne vulgaris in primary care: a cohort study of consulting and prescribing patterns using CPRD

Background Effective management of acne vulgaris in primary care involves support (usually provided over a number of consultations) and prescribing effective treatments. However, consulting and prescribing patterns for acne in primary care are not well described. Objective To describe the rate of primary care consultations and follow-up consultations; prescribing patterns, including overall use of acne related medications (ARM) and initial and follow-up prescribing, for acne vulgaris in the UK. Methods UK primary care acne consultations and prescriptions for ARMs were identified in the Clinical Practice Research Datalink (CPRD). Annual consultation rates (between 2004 and 2013) by age and gender, new consultations and consultations in the subsequent year; prescribing trends, prescribing during a new consultation and over the subsequent 90 days and year were calculated, using number of registered patients as the denominator. Results 65.9% of patients who had a new acne consultation had no further acne consultations in the subsequent year. 26.6%, 25.2%, 23.5% and 2.8% of patients were prescribed no ARM, an oral antibiotic, a topical antibiotic, or an oral plus topical antibiotic respectively during a new acne consultation. 59.9% and 38.5% of patients prescribed an ARM received no further ARM prescriptions in the following 90 days and one year respectively, despite most prescriptions being for 2 months or less. Prescribing rates for lymecycline and topical combined clindamycin/benzoyl peroxide increased substantially between 2004 and 2013. There were no important changes in consultation rates between 2004 and 2013. Conclusion These data suggest that patients with acne are receiving sub-optimal initial choice of ARMs, longitudinal care and prescribing

Sedimentary talc in Neoproterozoic carbonate successions

Mineralogical, petrographic and sedimentological observations document early diagenetic talc in carbonate-dominated successions deposited on two early Neoproterozoic (~ 800–700 million years old) platform margins. In the Akademikerbreen Group, Svalbard, talc occurs as nodules that pre-date microspar cements that fill molar tooth structures and primary porosity in stromatolitic carbonates. In the upper Fifteenmile Group of the Ogilvie Mountains, NW Canada, the talc is present as nodules, coated grains, rip-up clasts and massive beds that are several meters thick. To gain insight into the chemistry required to form early diagenetic talc, we conducted precipitation experiments at 25 °C with low-SO4 synthetic seawater solutions at varying pH, Mg2+ and SiO2(aq). Our experiments reveal a sharp and reproducible pH boundary (at ~ 8.7) only above which does poorly crystalline Mg-silicate precipitate; increasing Mg2+ and/or SiO2(aq) alone is insufficient to produce the material. The strong pH control can be explained by Mg-silica complexing activated by the deprotonation of silicic acid above ~ 8.6–8.7. FT-IR, TEM and XRD of the synthetic precipitates reveal a talc-like 2:1 trioctahedral structure with short-range stacking order. Hydrothermal experiments simulating burial diagenesis show that dehydration of the precipitate drives a transition to kerolite (hydrated talc) and eventually to talc. This formation pathway imparts extensive layer stacking disorder to the synthetic talc end-product that is identical to Neoproterozoic occurrences. Early diagenetic talc in Neoproterozoic carbonate platform successions appears to reflect a unique combination of low Al concentrations (and, by inference, low siliciclastic input), near modern marine salinity and Mg2+, elevated SiO2(aq), and pH > ~ 8.7. Because the talc occurs in close association with microbially influenced sediments, we suggest that soluble species requirements were most easily met through microbial influences on pore water chemistry, specifically pH and alkalinity increases driven by anaerobic Fe respiration.Organismic and Evolutionary Biolog

Prospective Phase II trial of drug-eluting bead chemoembolization for liver transplant candidates with hepatocellular carcinoma and marginal hepatic reserve.

Purpose: To determine whether chemoembolization using drug-eluting beads (DEB-TACE) is safe and effective for liver transplantation candidates with liver-limited hepatocellular carcinoma (HCC) without vascular invasion and baseline hepatic dysfunction. Materials and methods: Seventeen adult liver transplantation candidates (median age 66 years, range 58-73 years; 13 men) with HCC were treated with DEB-TACE as a part of Stage 1 of a prospective single-institution Phase II trial. All patients had marginal hepatic reserve based on at least one of the following criteria: ascites (n=14), bilirubin between 3 and 6 mg/dL (n=5), AST 5-10 times upper normal limit (n=1), INR between 1.6 and 2.5 (n=4), portal vein thrombosis (n=2), and/or portosystemic shunt (n=2). Primary study objectives were safety and best observed radiographic response. Results: Thirty-seven DEB-TACE procedures were performed. Objective response rate and disease control rate were 63% and 88%, respectively. HCC progression was observed in 12 patients. Median time to progression was 5.6 months (range 0.9-13.6 months). Within 1 month following DEB-TACE, 13 patients (76%) developed grade 3 or 4 AE attributable to the procedure. Four patients (all within Milan Criteria) were transplanted (2.7-6.9 months after DEB-TACE), and 12 patients died (1.8-32 months after DEB-TACE). All deaths were due to liver failure that was either unrelated to HCC (n=5), in the setting of metastatic HCC (n=5), or in the setting of locally advanced HCC (n=2). Mortality rate at 1 month was 0%. Conclusions: DEB-TACE achieves tumor responses but carries a high risk of hepatotoxicity for liver transplant candidates with HCC and marginal hepatic reserve

An illness-focused interactive booklet to optimise management and medication for childhood fever and infections in out-of-hours primary care: study protocol for a cluster randomised trial

Background Fever is the most common reason for a child to be taken to a general practitioner (GP), especially during out-of-hours care. It is mostly caused by self-limiting infections. However, antibiotic prescription rates remain high, especially during out-of-hours care. Anxiety and lack of knowledge among parents, and perceived pressure to prescribe antibiotics amongst GPs, are important determinants of excessive antibiotic prescriptions. An illness-focused interactive booklet has the potential to improve this by providing parents with information about fever self-management strategies. The aim of this study is to develop and determine the effectiveness of an interactive booklet on management of children presenting with fever at Dutch GP out-of-hours cooperatives. Methods/design We are conducting a cluster randomised controlled trial (RCT) with 20 GP out-of-hours cooperatives randomised to 1 of 2 arms: GP access to the illness-focused interactive booklet or care as usual. GPs working at intervention sites will have access to the booklet, which was developed in a multistage process. It consists of a traffic light system for parents on how to respond to fever-related symptoms, as well as information on natural course of infections, benefits and harms of (antibiotic) medications, self-management strategies and ‘safety net’ instructions. Children < 12 years of age with parent-reported or physician-measured fever are eligible for inclusion. The primary outcome is antibiotic prescribing during the initial consultation. Secondary outcomes are (intention to) (re)consult, antibiotic prescriptions during re-consultations, referrals, parental satisfaction and reassurance. In 6 months, 20,000 children will be recruited to find a difference in antibiotic prescribing rates of 25% in the control group and 19% in the intervention group. Statistical analysis will be performed using descriptive statistics and by fitting two-level (GP out-of-hours cooperative and patient) random intercept logistic regression models. Discussion This will be the first and largest cluster RCT evaluating the effectiveness of an illness-focused interactive booklet during GP out-of-hours consultations with febrile children receiving antibiotic prescriptions. It is hypothesised that use of the booklet will result in a reduced number of antibiotic prescriptions, improved parental satisfaction and reduced intention to re-consult

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Purpose: To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations. Methods: Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong. Results: Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients’ perspective: the GPs considered patients’ experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients’ perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of “wrong decisions” and concerning the negotiation of responsibilities. Conclusion: Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs’ management decisions. GPs consider a holistic understanding of illness and the patients’ own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the health care systems’ organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients’ social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations