Lower Baseline Performance Research Articles

Predicting Working Memory Training Responsiveness in Parkinson’s Disease: Both “System Hardware” and Room for Improvement Are Needed

Background. Patients with Parkinson’s disease (PD) are highly vulnerable to develop cognitive dysfunctions, and the mitigating potential of early cognitive training (CT) is increasingly recognized. Predictors of CT responsiveness, which could help to tailor interventions individually, have rarely been studied in PD. This study aimed to examine individual characteristics of patients with PD associated with responsiveness to targeted working memory training (WMT). Methods. Data of 75 patients with PD (age: 63.99 ± 9.74 years, 93% Hoehn & Yahr stage 2) without cognitive dysfunctions from a randomized controlled trial were analyzed using structural equation modeling. Latent change score models with and without covariates were estimated and compared between the WMT group (n = 37), who participated in a 5-week adaptive WMT, and a waiting list control group (n = 38). Results. Latent change score models yielded adequate model fit (χ2-test p > .05, SRMR ≤ .08, CFI ≥ .95). For the near-transfer working memory composite, lower baseline performance, younger age, higher education, and higher fluid intelligence were found to significantly predict higher latent change scores in the WMT group, but not in the control group. For the far-transfer executive function composite, higher self-efficacy expectancy tended to significantly predict larger latent change scores. Conclusions. The identified associations between individual characteristics and WMT responsiveness indicate that there has to be room for improvement (e.g., lower baseline performance) and also sufficient “hardware” (e.g., younger age, higher intelligence) to benefit in training-related cognitive plasticity. Our findings are discussed within the compensation versus magnification account. They need to be replicated by methodological high-quality research applying advanced statistical methods with larger samples.

Increasing physical literacy in youth: A two-week Sport for Development program for children aged 6-10

Regular physical activity significantly improves health outcomes, yet rates of childhood physical activity remain alarmingly low. Physical literacy has been identified as the foundation for quality physical education, suggesting that sport, education, and public health interventions should seek to increase physical literacy to promote physical activity. A two-week day camp program for children aged 6–10 facing barriers to positive development, was developed and delivered by a Sport for Development facility in Toronto, Canada. Utilizing fundamental movement skills (FMS) as a teaching tool and a pre- and post-assessment, the camp aimed to increase physical literacy and promote engagement in physical activity. Results indicate a significant increase in FMS (t (44) = 4.37, p < .001) as well as improved self-perceptions of physical literacy (t (40) = 14.96, p < .001). The largest FMS increases were found in running and balance and the most significant impacts were among low baseline performers.

Lower cognitive baseline scores predict cognitive training success after 6 months in healthy older adults: Results of an online RCT.

Identifying predictors for general cognitive training (GCT) success in healthy older adults has many potential uses, including aiding intervention and improving individual dementia risk prediction, which are of high importance in health care. However, the factors that predict training improvements and the temporal course of predictors (eg, do the same prognostic factors predict training success after a short training period, such as 6 weeks, as well as after a longer training period, such as 6 months?) are largely unknown. Data (N = 4,184 healthy older individuals) from two arms (GCT vs. control) of a three-arm randomized controlled trial were reanalyzed to investigate predictors of GCT success in five cognitive tasks (grammatical reasoning, spatial working memory, digit vigilance, paired association learning, and verbal learning) at three time points (after 6 weeks, 3 months, and 6 months of training). Possible investigated predictors were sociodemographic variables, depressive symptoms, number of training sessions, cognitive baseline values, and all interaction terms (group*predictor). Being female was predictive for improvement in grammatical reasoning at 6 weeks in the GCT group, and lower cognitive baseline scores were predictive for improvement in spatial working memory and verbal learning at 6 months. Our data indicate that predictors seem to change over time; remarkably, lower baseline performance at study entry is only a significant predictor at 6 months training. Possible reasons for these results are discussed in relation to the compensation hypothesis. J Am Geriatr Soc 68:-, 2020.

Structured Cognitive Training Yields Best Results in Healthy Older Adults, and Their ApoE4 State and Baseline Cognitive Level Predict Training Benefits.

Cognitive training has been shown to improve cognitive functions in healthy older adults. However, little is known about which specific variables are responsible for the improvement. Our aim was to evaluate whether healthy older adults benefit more from a structured cognitive training program than an unstructured brain jogging program and to identify possible predictors for training success, including apolipoprotein E4 (apoE4). In a randomized controlled trial, participants completed either a 6-week structured cognitive training program (n=35) or a 6-week unstructured brain jogging program (n=35). A control group received no training and was not part of the randomization procedure (n=35). Overall, 105 participants were included in the training data analyses, focusing on verbal memory, attention, and executive functions. Data from an additional 45 previously trained, healthy older adults were used for the predictor analysis. A significant Time×Training interaction in favor of the structured cognitive training program was found in verbal memory. Low baseline performance on neuropsychological tests was a significant predictor for benefits in verbal memory, attention, and executive functions. A subgroup analysis (n=35) revealed that only noncarriers of the apoE4 allele showed significant gains in long-term verbal memory and attention. Our results support the greater effectiveness of structured cognitive training on verbal memory compared with brain jogging and no training. The success of this type of training program may be predicted by sociodemographic, cognitive, and genetic variables.

Very long-term outcome in resected and non-resected patients with temporal lobe epilepsy with medial temporal lobe sclerosis: A multiple case-study

PurposeTo investigate the very long-term (i.e., ≥15 years) seizure, cognitive and psycho-social outcomes in resected patients (RP) with TLE compared to control patients not having undergone epilepsy surgery. MethodsWe applied a multiple case-study design including three non-resected patients (NRP) who were compared to a group of six RP. The latter were matched to the NRP according to clinical-demographic data. Outcome measures were various seizure, cognitive, and psycho-social variables. ResultsPatients were 56–72 years old. Seizure and AED outcome was more favourable among RP. RP reported better self-perceived overall health but higher subjective memory complaints. Upon formal neuropsychological testing, RP presented with lower verbal memory scores. Very long-term memory decline was evident in left-sided RP with good baseline memory scores, while RP with lower baseline performance, right-sided RP and NRP remained stable. Seizure-freedom had remarkable effects on the relationship between objective and subjective outcome: seizure-free patients, in general, subjectively reported the best psychosocial and cognitive outcome – irrespective of neuropsychological test results. ConclusionOur study suggests positive effects of TLE surgery in the very long-term course of ≥15 years postoperatively. Long-term seizure-freedom appears to have the strongest impact on patients’ subjectively perceived psycho-social and cognitive outcome and may even outweigh actual memory disturbances and/or decline. Overall, our data do not support the assumption of a generally accelerated cognitive decline in patients with TLE.

Inhospital Exercise Training in Children With Cancer: Does It Work for All?

Purpose: Physical exercise training might counteract the weakening effects of both pediatric cancer and anti-cancer treatment. We aimed to analyze the prevalence of “responders” and “non-responders” to inhospital exercise training in children with cancer and to identify the factors that could influence responsiveness, which might help personalize exercise interventions for this patient population.Methods: We performed an ancillary analysis of the randomized controlled trial “Physical activity in Pediatric Cancer” (NCT01645436), in which 49 children with solid tumors were allocated to an inhospital exercise intervention or control group. The present study focused on the children in the former group (n = 24, 10 ± 4 years), who performed 3 weekly training sessions (aerobic + strength exercises). The intervention lasted 19 ± 8 weeks (i.e., from the start to the end of neoadjuvant chemotherapy treatment). A responder-vs-non-responder analysis was performed for physical capacity-related endpoints (five-repetition maximum strength, functional mobility tests, and cardiorespiratory fitness [CRF]). Only those participants showing improvements in a given test of a magnitude greater than both the random error and the threshold for clinically meaningful changes were considered responders.Results: Most participants improved their performance in the strength tests, with 80, 88, and 93% of total showing a positive response for seated bench press, lateral row, and leg press, respectively (p < 0.001). No significant improvements were observed for the functional mobility tests or CRF (p > 0.05, rate of responsiveness ≤ 50%). No differences between responders and non-responders were observed for sex, age, type of cancer, or treatment (i.e., including or not anthracyclines/radiotherapy). However, significant differences (p < 0.05) were observed between responders and non-responders for baseline performance in all the tests, and a significant (p < 0.05) inverse relationship was found between baseline performance and relative improvement for most endpoints.Conclusions: Although most children improved their muscle strength after the exercise intervention, a considerable individual variability was observed for the training responsiveness of functional mobility and CRF. A lower baseline performance was associated with a higher responsiveness for all the study endpoints, with the fittest children at the start of treatment showing the lowest responses. Efforts to individualize exercise prescription are needed to maximize responsiveness in pediatric cancer patients.

Effects of a Cognitive Training With and Without Additional Physical Activity in Healthy Older Adults: A Follow-Up 1 Year After a Randomized Controlled Trial.

Background: Combining cognitive training (CT) with physical activity (CPT) has been suggested to be most effective in maintaining cognition in healthy older adults, but data are scarce and inconsistent regarding long-term effects (follow-up; FU) and predictors of success.Objective: To investigate the 1-year FU effects of CPT versus CT and CPT plus counseling (CPT+C), and to identify predictors for CPT success at FU.Setting and Participants: We included 55 healthy older participants in the data analyses; 18 participants (CPT group) were used for the predictor analysis.Interventions: In a randomized controlled trial, participants conducted a CT, CPT, or CPT+C for 7 weeks.Outcome Measures: Overall cognition, verbal, figural, and working memory, verbal fluency, attention, planning, and visuo-construction.Results: While within-group comparisons showed cognitive improvements for all types of training, only one significant interaction Group × Time favoring CPT in comparison to CPT+C was found for overall cognition and verbal long-term memory. The most consistent predictor for CPT success (in verbal short-term memory, verbal fluency, attention) was an initial low baseline performance. Lower education predicted working memory gains. Higher levels of insulin-like growth factor 1 (IGF-1) and lower levels of brain-derived neurotrophic factor at baseline (BDNF) predicted alternating letter verbal fluency gains.Discussion: Within-group comparisons indicate that all used training types are helpful to maintain cognition. The fact that cognitive and sociodemographic data as well as nerve growth factors predict long-term benefits of CPT contributes to the understanding of the mechanisms underlying training success and may ultimately help to adapt training to individual profiles.Clinical Trial Registration: WHO ICTRP (http://apps.who.int/trialsearch/), identifier DRKS00005194.

Does payment for performance increase performance inequalities across health providers? A case study of Tanzania.

The impact of payment-for-performance (P4P) schemes in the health sector has been documented, but there has been little attention to the distributional effects of P4P across health facilities. We examined the distribution of P4P payouts over time and assessed whether increased service coverage due to P4P differed across facilities in Tanzania. We used two service outcomes that improved due to P4P [facility-based deliveries and provision of antimalarials during antenatal care (ANC)], to also assess whether incentive design matters for performance inequalities. We used data from 150 facilities from intervention and comparison areas in January 2012 and 13 months later. Our primary data were gathered through facility survey and household survey, while data on performance payouts were obtained from the programme administrator. Descriptive inequality measures were used to examine the distribution of payouts across facility subgroups. Difference-in-differences regression analyses were used to identify P4P differential effects on the two service coverage outcomes across facility subgroups. We found that performance payouts were initially higher among higher-level facilities (hospitals and health centres) compared with dispensaries, among facilities with more medical commodities and among facilities serving wealthier populations, but these inequalities declined over time. P4P had greater effects on coverage of institutional deliveries among facilities with low baseline performance, serving middle wealth populations and located in rural areas. P4P effects on antimalarials provision during ANC was similar across facilities. Performance inequalities were influenced by the design of incentives and a range of facility characteristics; however, the nature of the service being targeted is also likely to have affected provider response. Further research is needed to examine in more detail the effects of incentive design on outcomes and researchers should be encouraged to report on design aspects in their evaluations of P4P and systematically monitor and report subgroup effects across providers.

Inhibitory Mechanisms in Primary Somatosensory Cortex Mediate the Effects of Peripheral Electrical Stimulation on Tactile Spatial Discrimination

Selective afferent activation can be used to improve somatosensory function, possibly by altering cortical inhibitory circuit activity. Peripheral electrical stimulation (PES) is widely used to induce selective afferent activation, and its effect may depend on PES intensity. Therefore, we investigated the effects of high- and low-intensity PES applied to the right index finger on tactile discrimination performance and cortical somatosensory-evoked potential paired-pulse depression (SEP-PPD) in 25 neurologically healthy subjects. In Experiment 1, a grating orientation task (GOT) was performed before and immediately after local high- and low-intensity PES (both delivered as 1-s, 20-Hz trains of 0.2-ms electrical pulses at 5-s intervals). In Experiment 2, PPD of SEP components N20/P25_SEP-PPD, N20_SEP-PPD and P25_SEP-PPD, respectively, were assessed before and immediately after high- and low-intensity PES. Improved GOT discrimination performance after high-intensity PES (reduced discrimination threshold) was associated with lower baseline performance (higher baseline discrimination threshold). Subjects were classified into low and high (baseline) GOT performance groups. Improved GOT discrimination performance in the low GOT performance group was significantly associated with a greater N20_SEP-PPD decrease (weaker PPD). Subjects were also classified into GOT improvement and GOT decrement groups. High-intensity PES decreased N20_SEP-PPD in the GOT improvement group but increased N20_SEP-PPD in the GOT decrement group. Furthermore, a greater decrease in GOT discrimination threshold was significantly associated with a greater N20_SEP-PPD decrease in the GOT improvement group. These results suggest that high-intensity PES can improve somatosensory perception in subjects with low baseline function by modulating cortical inhibitory circuits in primary somatosensory cortex.

Does audit and feedback improve the adoption of recommended practices? Evidence from a longitudinal observational study of an emerging clinical network in Kenya

BackgroundAudit and feedback (A&F) is widely used in healthcare but there are few examples of how to deploy it at scale in low-income countries. Establishing the Clinical Information Network (CIN)...

3-hydroxyanthranilic acid 3,4-dioxygenase mediates hippocampal dysfunction during chronic inflammation

Inflammation disrupts balance of the tryptophan-kynurenine pathway (KP) in the brain towards production of neurotoxic metabolites, particularly in the hippocampus. Quinolinic acid is the neurotoxic metabolite most often implicated in mediating the deleterious effects of neuroinflammation, but only indirect evidence implicates quinolinic acid as a mechanistic factor driving the disruption of hippocampal- dependent tasks due to inflammation. Here, 3-hydroxyanthralinic acid 3,4-dioxygenase (HAAO) knockout mice or WT mice were administered M. bovis, BCG intraperitoneally to induce chronic inflammation, and hippocampal-dependent cognitive tasks were measured 7–9 days post challenge. No difference in spontaneous locomotor activity in the open field was apparent between groups, although BCG reduced the duration of time spent in the central area of the open field in WT but not HAAO KO mice. BCG impaired Y- maze working memory and novel place preference in WT mice, and while HAAO KO mice exhibited a lower baseline performance on these hippocampal-dependent tasks, no BCG-induced deficit was observed. Novel object recognition was disrupted in both WT and HAAO KO mice. These are the first data to provide direct evidence that inflammation-induced increases in quinolinic acid are responsible for hippocampal dysfunction in cognitive performance.

Effects of prior testing lasting a full year in NCANDA adolescents: Contributions from age, sex, socioeconomic status, ethnicity, site, family history of alcohol or drug abuse, and baseline performance

Longitudinal study provides a robust method for tracking developmental trajectories. Yet inherent problems of retesting pose challenges in distinguishing biological developmental change from prior testing experience. We examined factors potentially influencing change scores on 16 neuropsychological test composites over 1year in 568 adolescents in the National Consortium on Alcohol and NeuroDevelopment in Adolescence (NCANDA) project. The twice-minus-once-tested method revealed that performance gain was mainly attributable to testing experience (practice) with little contribution from predicted developmental effects. Group mean practice slopes for 13 composites indicated that 60% to ∼100% variance was attributable to test experience; General Ability accuracy showed the least practice effect (29%). Lower baseline performance, especially in younger participants, was a strong predictor of greater gain. Contributions from age, sex, ethnicity, examination site, socioeconomic status, or family history of alcohol/substance abuse were nil to small, even where statistically significant. Recognizing that a substantial proportion of change in longitudinal testing, even over 1-year, is attributable to testing experience indicates caution against assuming that performance gain observed during periods of maturation necessarily reflects development. Estimates of testing experience, a form of learning, may be a relevant metric for detecting interim influences, such as alcohol use or traumatic episodes, on behavior.

Cognitive function did not improve after initiation of natalizumab treatment in relapsing-remitting multiple sclerosis. A prospective one-year dual control group study

BackgroundCognitive impairment in multiple sclerosis (MS) is common and has severe implications. Natalizumab (NZ) has documented effects on relapse rate and radiological disease activity in relapsing-remitting MS (RRMS) but studies regarding its specific effects on cognitive functioning are few. Previous studies have reported improvement, however, often lacking relevant control groups. The objective of the present study was to evaluate the cognitive effects of NZ treatment, compared to patients on stable first-line treatment and healthy control subjects. MethodsMS patients starting NZ (MS-NZ), MS controls with stable interferon beta therapy (MS-C) and healthy control subjects (HC) were evaluated twice with one year interval, using a cognitive test battery covering six cognitive domains. The effects of NZ on levels of self-reported depression, fatigue, daytime sleepiness and perceived health were also examined. ResultsMS patients (MS-NZ and MS-C) had significantly lower baseline cognitive performance compared to HC (global score, p=0.002), but there were no significant differences between MS-NZ and MS-C. At follow-up, both MS-NZ and MS-C had improved significantly in four and five cognitive domains, respectively, and in global score (p=0.013 and p<0.001, respectively). HC improved significantly in three cognitive domains but not in global score. A regression analysis including baseline cognitive z-score and z-score change showed that participants with lower baseline scores had a significantly greater improvement, compared to those with better initial performance (p=0.021). There were no significant changes in depression, fatigue, daytime sleepiness or perceived health in MS-NZ or MS-C. ConclusionsInitiation of NZ therapy did not result in true cognitive improvement over one year. Presumably, the increased test performance in both MS groups was artificial and due to retest effects that were stronger in patients with lower baseline performance. Adequate control groups are essential when evaluating cognitive functioning in intervention trials among RRMS patients.

Cathodal transcranial direct current stimulation over posterior parietal cortex enhances distinct aspects of visual working memory

In this study, we investigated the effects of tDCS over the posterior parietal cortex (PPC) during a visual working memory (WM) task, which probes different sources of response error underlying the precision of WM recall. In two separate experiments, we demonstrated that tDCS enhanced WM precision when applied bilaterally over the PPC, independent of electrode configuration. In a third experiment, we demonstrated with unilateral electrode configuration over the right PPC, that only cathodal tDCS enhanced WM precision and only when baseline performance was low. Looking at the effects on underlying sources of error, we found that cathodal stimulation enhanced the probability of correct target response across all participants by reducing feature-misbinding. Only for low-baseline performers, cathodal stimulation also reduced variability of recall. We conclude that cathodal- but not anodal tDCS can improve WM precision by preventing feature-misbinding and hereby enhancing attentional selection. For low-baseline performers, cathodal tDCS also protects the memory trace. Furthermore, stimulation over bilateral PPC is more potent than unilateral cathodal tDCS in enhancing general WM precision.

Locomotor sequence learning in visually guided walking.

Voluntary limb modifications must be integrated with basic walking patterns during visually guided walking. In this study we tested whether voluntary gait modifications can become more automatic with practice. We challenged walking control by presenting visual stepping targets that instructed subjects to modify step length from one trial to the next. Our sequence learning paradigm is derived from the serial reaction-time (SRT) task that has been used in upper limb studies. Both random and ordered sequences of step lengths were used to measure sequence-specific and sequence-nonspecific learning during walking. In addition, we determined how age (i.e., healthy young adults vs. children) and biomechanical factors (i.e., walking speed) affected the rate and magnitude of locomotor sequence learning. The results showed that healthy young adults (age 24 ± 5 yr,n= 20) could learn a specific sequence of step lengths over 300 training steps. Younger children (age 6-10 yr,n= 8) had lower baseline performance, but their magnitude and rate of sequence learning were the same compared with those of older children (11-16 yr,n= 10) and healthy adults. In addition, learning capacity may be more limited at faster walking speeds. To our knowledge, this is the first study to demonstrate that spatial sequence learning can be integrated with a highly automatic task such as walking. These findings suggest that adults and children use implicit knowledge about the sequence to plan and execute leg movement during visually guided walking.

Supplemental Material for Multi-Domain Training Enhances Attentional Control

Multi-domain training potentially increases the likelihood of overlap in processing components with transfer tasks and everyday life, and hence is a promising training approach for older adults. To empirically test this, 84 healthy older adults aged 64 to 75 years were randomly assigned to one of three single-domain training conditions (inhibition, visuomotor function, spatial navigation) or to the simultaneous training of all three cognitive functions (multi-domain training condition). All participants trained on an iPad at home for 50 training sessions. Before and after the training, and at a 6-month follow-up measurement, cognitive functioning and training transfer were assessed with a neuropsychological test battery including tests targeting the trained functions (near transfer) and transfer to executive functions (far transfer: attentional control, working memory, speed). Participants in all four training groups showed a linear increase in training performance over the 50 training sessions. Using a latent difference score model, the multi-domain training group, compared with the single-domain training groups, showed more improvement on the far transfer attentional control composite. Individuals with initially lower baseline performance showed higher training-related improvements, indicating that training compensated for lower initial cognitive performance. At the 6-month follow-up, performance on the cognitive test battery remained stable. This is one of the first studies to investigate systematically multi-domain training including comparable single-domain training conditions. Our findings suggest that multi-domain training enhances attentional control involved in handling several different tasks at the same time, an aspect in everyday life that is particularly challenging for older people.

Priming in word stem completion tasks: comparison with previous results in word fragment completion tasks.

This study investigates priming in an implicit word stem completion (WSC) task by analyzing the effect of linguistic stimuli characteristics on said task. A total of 305 participants performed a WSC task in two phases (study and test). The test phase included 63 unique-solution stems and 63 multiple-solution stems. Analysis revealed that priming (mean = 0.22) was stronger in the case of multiple-solution stems, indicating that they were not a homogeneous group of stimuli. Thus, further analyses were performed only for the data of the unique-solution stems. Correlations between priming and familiarity, frequency of use, and baseline completion were significant. The less familiar words, which were less frequent, had higher priming values. At the same time, the stems with lower baseline completion generated more priming. A regression analysis showed that baseline completion was the only significant predictor of priming, suggesting that the previous processing of the stimuli had a greater impact on the stimuli with low baseline performance. At the same time, baseline completion showed significant positive correlations with familiarity and frequency of use, and a negative correlation with length. When baseline completion was the dependent variable in the regression analysis, the significant variables in the regression were familiarity and length. These results were compared with those obtained in a study using word fragment completion (WFC) by Soler et al. (2009), in which the same words and procedure were employed. Analysis showed that the variables that correlated with priming were the same as in the WSC task, and that completion baseline was the variable that showed the greatest predictive power of priming. This coincidence of results obtained with WFC and WSC tasks highlights the importance of controlling the characteristics of the stimuli used when exploring the nature of priming.

Lower baseline performance but greater plasticity of working memory for carriers of the val allele of the COMT Val¹⁵⁸Met polymorphism.

Little is known about genetic contributions to individual differences in cognitive plasticity. Given that the neurotransmitter dopamine is critical for cognition and associated with cognitive plasticity, we investigated the effects of 3 polymorphisms of dopamine-related genes (LMX1A, DRD2, COMT) on baseline performance and plasticity of working memory (WM), perceptual speed, and reasoning. One hundred one younger and 103 older adults underwent approximately 100 days of cognitive training, and extensive testing before and after training. We analyzed the baseline and posttest data using latent change score models. For working memory, carriers of the val allele of the COMT polymorphism had lower baseline performance and larger performance gains from training than carriers of the met allele. There was no significant effect of the other genes or on other cognitive domains. We relate this result to available evidence indicating that met carriers perform better than val carriers in WM tasks taxing maintenance, whereas val carriers perform better at updating tasks. We suggest that val carriers may show larger training gains because updating operations carry greater potential for plasticity than maintenance operations.

Neurocognitive effects of acute choline supplementation in low, medium and high performer healthy volunteers

Novel pharmacological treatments targeting alpha 7 nicotinic acetylcholine receptor (α7 nAChR) hypofunction in schizophrenia have shown mixed success in ameliorating cognitive impairments associated with this disorder. Choline, a selective agonist at α7 receptors is increased with oral administration of cytidine 5′-diphosphocholine (CDP-choline), the cognitive effects of which were assessed in healthy volunteers. Using the CogState test battery, behavioral performance in schizophrenia-relevant cognitive domains was assessed in 24 male participants following a single low (500mg) and moderate (1000mg) dose of CDP-choline. Relative to placebo, CDP-choline improved processing speed, working memory, verbal learning, verbal memory, and executive function in low baseline performers, while exerting no effects in medium baseline performers, and diminishing cognition in high baseline performers. Dose effects varied with cognitive domain but were evident with both the 500mg and 1000mg doses. These preliminary findings of cognitive enhancement in relatively impaired performers are consistent with the α7 receptor mechanism and support further trials with CDP-choline as a potential pro-cognitive strategy for cognitive impairment in schizophrenia.

Assessing the quality of care in a new nation: South Sudan's first national health facility assessment.

We adapted a rapid quality of care monitoring method to a fragile state with two aims: to assess the delivery of child health services in South Sudan at the time of independence and to strengthen local capacity to perform regular rapid health facility assessments. Using a two-stage lot quality assurance sampling (LQAS) design, we conducted a national cross-sectional survey among 156 randomly selected health facilities in 10 states. In each of these facilities, we obtained information on a range of access, input, process and performance indicators during structured interviews and observations. Quality of care was poor with all states failing to achieve the 80% target for 14 of 19 indicators. For example, only 12% of facilities were classified as acceptable for their adequate utilisation by the population for sick-child consultations, 16% for staffing, 3% for having infection control supplies available and 0% for having all child care guidelines. Health worker performance was categorised as acceptable in only 6% of cases related to sick-child assessments, 38% related to medical treatment for the given diagnosis and 33% related to patient counselling on how to administer the prescribed drugs. Best performance was recorded for availability of in-service training and supervision, for seven and ten states, respectively. Despite ongoing instability, the Ministry of Health developed capacity to use LQAS for measuring quality of care nationally and state-by-state, which will support efficient and equitable resource allocation. Overall, our data revealed a desperate need for improving the quality of care in all states.