John Hodsoll

Prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (STROKE-INF): a prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial

BACKGROUND Post-stroke pneumonia is associated with increased mortality and poor functional outcomes. This study assessed the effectiveness of antibiotic prophylaxis for reducing pneumonia in patients with dysphagia after acute stroke. METHODS We did a prospective, multicentre, cluster-randomised, open-label controlled trial with masked endpoint assessment of patients older than 18 years with dysphagia after new stroke recruited from 48 stroke units in the UK, accredited and included in the UK National Stroke Audit. We excluded patients with contraindications to antibiotics, pre-existing dysphagia, or known infections, or who were not expected to survive beyond 14 days. We randomly assigned the units (1:1) by computer to give either prophylactic antibiotics for 7 days plus standard stroke unit care or standard stroke unit care only to patients clustered in the units within 48 h of stroke onset. We did the randomisation with minimisation to stratify for number of admissions and access to specialist care. Patient and staff who did the assessments and analyses were masked to stroke unit allocation. The primary outcome was post-stroke pneumonia in the first 14 days, assessed with both a criteria-based, hierarchical algorithm and by physician diagnosis in the intention-to-treat population. Safety was also analysed by intention to treat. This trial is closed to new participants and is registered with isrctn.com, number ISRCTN37118456. FINDINGS Between April 21, 2008, and May 17, 2014, we randomly assigned 48 stroke units (and 1224 patients clustered within the units) to the two treatment groups: 24 to antibiotics and 24 to standard care alone (control). 11 units and seven patients withdrew after randomisation before 14 days, leaving 1217 patients in 37 units for the intention-to-treat analysis (615 patients in the antibiotics group, 602 in control). Prophylactic antibiotics did not affect the incidence of algorithm-defined post-stroke pneumonia (71 [13%] of 564 patients in antibiotics group vs 52 [10%] of 524 in control group; marginal adjusted odds ratio [OR] 1·21 [95% CI 0·71-2·08], p=0·489, intraclass correlation coefficient [ICC] 0·06 [95% CI 0·02-0·17]. Algorithm-defined post-stroke pneumonia could not be established in 129 (10%) patients because of missing data. Additionally, we noted no differences in physician-diagnosed post-stroke pneumonia between groups (101 [16%] of 615 patients vs 91 [15%] of 602, adjusted OR 1·01 [95% CI 0·61-1·68], p=0·957, ICC 0·08 [95% CI 0·03-0·21]). The most common adverse events were infections unrelated to post-stroke pneumonia (mainly urinary tract infections), which were less frequent in the antibiotics group (22 [4%] of 615 vs 45 [7%] of 602; OR 0·55 [0·32-0·92], p=0·02). Diarrhoea positive for Clostridium difficile occurred in two patients (<1%) in the antibiotics group and four (<1%) in the control group, and meticillin-resistant Staphylococcus aureus colonisation occurred in 11 patients (2%) in the antibiotics group and 14 (2%) in the control group. INTERPRETATION Antibiotic prophylaxis cannot be recommended for prevention of post-stroke pneumonia in patients with dysphagia after stroke managed in stroke units. FUNDING UK National Institute for Health Research.

Ignoring the elephant in the room: a neural circuit to downregulate salience.

How do we ignore stimuli that are salient but irrelevant when our task is to select a lower salient stimulus? Since bottom–up processes favor high saliency, detection of a low-salient target in the presence of highly salient distractors requires top–down attentional guidance. Previous studies have demonstrated that top–down attention can modulate perceptual processing and also that the control of attention is driven by frontoparietal regions. However, to date, there is no direct evidence on the cause and effect relationship between control regions and perceptual processing. Here, we report the first evidence demonstrating a neural circuit for the downregulation of salient distractors when a low-salient target is selected, combining brain imaging using functional magnetic resonance imaging with brain stimulation by transcranial magnetic stimulation. Using these combined techniques, we were able to identify a cause and effect relationship in the suppression of saliency, based on an interaction between the left intraparietal sulcus (IPS) and a region implicated in visual processing in our task (the left occipital pole). In particular, low-salient stimuli were selected by the left IPS suppressing early visual areas that would otherwise respond to a high-saliency distractor in the task. Apart from providing a first documentation of the neural circuit supporting selection by saliency, these data can be critical for understanding the underlying causes of problems in ignoring irrelevant salience that are found in both acquired and neurodevelopmental disorders (e.g., attention deficit/hyperactivity disorder or autism).

Driving attention with the top down: The relative contribution of target templates to the linear separability effect in the size dimension

Bauer, Jolicoeur, and Cowan (1996a, 1996b, 1998) have shown that visual search for a target among distractors is apparently serial if the target is nonlinearly separable from the distractors in a particular feature space (e.g., color or size). In contrast, if the target is linearly separable from the distractors, search is relatively easy and seemingly spatially parallel. We examined the contribution of top-down knowledge of the target to the linear separability effect on search. Two visual search experiments were conducted using small, medium, or large circles as targets. In the first experiment, participants could use knowledge of the target to guide search, whereas, in the second, the target was unknown on each trial. Search for a medium (nonlinearly separable) target among small or large distractors benefited least from knowledge of the target as compared with search for a small or large target. Thus, the linear separability effect can be determined in part by use of top-down knowledge to facilitate the detection of targets at the ends of a continuum defining the stimuli.

Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial

Background Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce the frequency of both. Objective To test the efficacy of these interventions. Design A pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment. Participants Staff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals. Results For shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%). Conclusions Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment. Trial registration IRSCTN38001825.

Driven to Less Distraction: rTMS of the Right Parietal Cortex Reduces Attentional Capture in Visual Search

In visual search, the presence of a highly salient color singleton can slow or facilitate search for a shape target depending on whether the singleton is a distractor or coincides with the target. This is consistent with an attentional shift (attentional capture) to the salient item. This attentional capture can be driven by bottom-up or top-down processes or both. We investigated the role of the parietal cortex in attentional capture by a singleton using repetitive transcranial magnetic stimulation. Following disruption to the right posterior parietal cortex by sustained transcranial magnetic stimulation, the reaction time (RT) cost of the singleton distractor was reduced. At least part of this lessening of singleton distraction was due to the elimination of priming (top-down) effects between target and distractor singletons on consecutive trials. In Experiment 2, we presented the different conditions in separate blocks meaning any effects of the distractor can most likely be attributed to bottom-up processes. Nevertheless, there was still a decrease in RT interference from the distractor so that a reduction in priming cannot provide a full account of the results. The data are consistent with previous work positing that the right parietal cortex directs attention to salient stimuli (e.g., Constantinidis 2005, Mevorach et al. 2006), while also suggesting a role for the right parietal cortex in the integration of bottom-up salience information with memories for salient features on prior trials.

Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15 521 men

To systematically review and create nomograms of flaccid and erect penile size measurements.

Color grouping in space and time: evidence from negative color-based carryover effects in preview search.

Five experiments addressed the role of color grouping in preview search (D. G. Watson & G. W. Humphreys, 1997). Experiment 1 used opposite color ratios of distractors in preview and second search displays, creating equal numbers of distractors in each color group in the final display. There was selective slowing for new targets carrying the majority color of the old items. This effect held when there was no bias in the preview and only the second search set had an uneven color ratio (Experiment 2). In Experiment 3, participants had foreknowledge of the target color, and effects were shown over and above those due to color biases. Experiment 4 demonstrated negative color carryover even when previews changed color. Experiment 5 showed reduced color carryover effects when previews were presented more briefly. Collectively, the results provide evidence for inhibitory carryover effects in preview search based on feature grouping.

Fractionating the binding process: neuropsychological evidence from reversed search efficiencies.

The authors present neuropsychological evidence distinguishing binding between form, color, and size (cross-domain binding) and binding between form elements. They contrasted conjunctive search with difficult feature search using control participants and patients with unilateral parietal or fronto/temporal lesions. To rule out effects of task difficulty or loss of top-down guidance of search, the authors made conjunction search easier than feature search. Despite this, parietal patients were selectively impaired at detecting conjunction targets in their contralateral field. In contrast, the parietal patients performed like the other participants with form conjunctions, with form conjunctions being easier to detect than difficult feature targets. These data indicate a qualitative difference between binding in the form domain and binding across form, color, and size, consistent with theories that propose distinct binding processes in vision.

Attending but not seeing: The "other race" effect in face and person perception studied through change blindness

We used a change blindness paradigm to examine the “other race” effect in perception. White Caucasian and Indian Asian participants viewed scenes in which White Caucasian and Indian Asian students were present. Changes were made either to the faces of the students, to their bodies or to an independent object in the background. Changes in faces were detected faster than changes in the bodies, which were in turn detected faster than changes in the background. For face detection there was a crossover interaction, with changes in White Caucasian faces detected faster than changes in Indian Asian faces by White Caucasian participants, whilst the opposite result occurred for changes in Indian Asian faces. In contrast, there was no effect of race on the detection of body-part changes or on the detection of changes to background objects. The results suggest that participants of both races attended equally well to subjects from the other race in the scene, but despite this they remained less sensitive to “other race” faces. Change blindness can provide a useful way of analysing attentional and memorial processes in social contexts.

Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence

Our aim was to systematically review the prevalence of body dysmorphic disorder (BDD) in a variety of settings. Weighted prevalence estimate and 95% confidence intervals in each study were calculated. The weighted prevalence of BDD in adults in the community was estimated to be 1.9%; in adolescents 2.2%; in student populations 3.3%; in adult psychiatric inpatients 7.4%; in adolescent psychiatric inpatients 7.4%; in adult psychiatric outpatients 5.8%; in general cosmetic surgery 13.2%; in rhinoplasty surgery 20.1%; in orthognathic surgery 11.2%; in orthodontics/cosmetic dentistry settings 5.2%; in dermatology outpatients 11.3%; in cosmetic dermatology outpatients 9.2%; and in acne dermatology clinics 11.1%. Women outnumbered men in the majority of settings but not in cosmetic or dermatological settings. BDD is common in some psychiatric and cosmetic settings but is poorly identified.