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Background Incidence of acute kidney injury (AKI) is known to peak in winter months. This is likely influenced by seasonality of commonly associated acute illnesses. We set out to assess seasonal mortality trends for patients who develop AKI across the English National Health Service (NHS) and to better understand associations with patient ‘case-mix’. Methods The study cohort included all hospitalised adult patients in England who triggered a biochemical AKI alert in 2017. We modelled the impact of season on 30-day mortality using multivariable logistic regression; adjusting for age, sex, ethnicity, index of multiple deprivation (IMD), primary diagnosis, comorbidity (RCCI), elective/emergency admission, peak AKI stage and community/hospital acquired AKI. Seasonal odds ratios for AKI mortality were then calculated and compared across individual NHS hospital trusts. Results The crude 30-day mortality for hospitalised AKI patients was 33% higher in winter compared to summer. Case-mix adjustment for a wide range of clinical and demographic factors did not fully explain excess winter mortality. The adjusted odds ratio of patients dying in winter vs. summer was 1.25 (1.22–1.29), this was higher than for Autumn and Spring vs. Summer, 1.09 (1.06–1.12) and 1.07 (1.04–1.11) respectively and varied across different NHS trusts (9 out of 90 centres outliers). Conclusion We have demonstrated an excess winter mortality risk for hospitalised patients with AKI across the English NHS, which could not be fully explained by seasonal variation in patient case-mix. Whilst the explanation for worse winter outcomes is not clear, unaccounted differences including ‘winter-pressures’ merit further investigation.

According to predictive processing theories, vision is facilitated by predictions derived from our internal models of what the world should look like. However, the contents of these models and how they vary across people remains unclear. Here, we use drawing to directly access the contents of the internal models of individual participants. Participants were first asked to draw typical versions of scene categories, as descriptors of their internal models. These drawings were converted into standardized 3d renders, which we used as stimuli in subsequent scene categorization experiments. Across two experiments, participants’ scene categorization was more accurate for renders tailored to their own drawings compared to renders based on others’ drawings or copies of scene photographs, suggesting that scene perception is determined by a match with idiosyncratic internal models. These results demonstrate that visual perception can only be fully understood through the lens of our personally unique models of the world.

Recognizing facial expressions is dependent on multiple brain networks specialized for different cognitive functions. In the current study participants (N=20) were scanned using functional magnetic resonance imaging (fMRI) while they performed a covert facial expression naming task. Immediately prior to scanning thetaburst transcranial magnetic stimulation (TMS) was delivered over the right lateral prefrontal cortex (PFC), or the vertex control site. A group whole-brain analysis revealed that TMS induced opposite effects in the neural responses across different brain networks. Stimulation of the right PFC (compared to stimulation of the vertex) decreased neural activity in the left lateral PFC but increased neural activity in three nodes of the default mode network (DMN): the right superior frontal gyrus (SFG), right angular gyrus and the bilateral middle cingulate gyrus. A region of interest (ROI) analysis showed that TMS delivered over the right PFC reduced neural activity across all functionally localised face areas (including in the PFC) compared to TMS delivered over the vertex. These results causally demonstrate that visually recognizing facial expressions is dependent on the dynamic interaction of the face processing network and the DMN. Our study also demonstrates the utility of combined TMS / fMRI studies for revealing the dynamic interactions between different functional brain networks.

Models of human cortex propose the existence of neuroanatomical pathways specialised for different behavioural functions. These pathways include a ventral pathway for object recognition, a dorsal pathway for performing visually guided physical actions and a recently proposed third pathway for social perception. In the current study we tested the hypothesis that different categories of moving stimuli are differentially processed across the dorsal and third pathways according to their behavioural implications. Human participants (N=30) were scanned with functional magnetic resonance imaging (fMRI) while viewing moving and static stimuli from five categories (faces, bodies, scenes, objects, and scrambled objects). Whole brain group analyses showed that moving bodies and moving objects increased neural responses in bilateral V5/MT+ and intraparietal sulcus (IPS), parts of the dorsal pathway. In addition, moving faces and moving bodies increased neural responses in bilateral V5/MT+ and the right posterior superior temporal sulcus (rpSTS), parts of the third pathway. This pattern of results was also supported by a separate region of interest (ROI) analysis showing that moving stimuli produced more robust neural responses for all visual object categories, particularly in lateral and dorsal brain areas. Our results suggest that dynamic naturalistic stimuli from different categories are routed along specific visual pathways that process their unique behavioural implications.

Hemispheric differences speak to the functional organisation of the human brain. A new study causally demonstrates such differences are present in bilateral motion-selective areas that are early in the visual cortical hierarchy.

Neuroimaging studies identify multiple face-selective areas in the human brain. In the current study, we compared the functional response of the face area in the lateral prefrontal cortex to that of other face-selective areas. In Experiment 1, participants (n = 32) were scanned viewing videos containing faces, bodies, scenes, objects, and scrambled objects. We identified a face-selective area in the right inferior frontal gyrus (rIFG). In Experiment 2, participants (n = 24) viewed the same videos or static images. Results showed that the rIFG, right posterior superior temporal sulcus (rpSTS), and right occipital face area (rOFA) exhibited a greater response to moving than static faces. In Experiment 3, participants (n = 18) viewed face videos in the contralateral and ipsilateral visual fields. Results showed that the rIFG and rpSTS showed no visual field bias, while the rOFA and right fusiform face area (rFFA) showed a contralateral bias. These experiments suggest two conclusions; firstly, in all three experiments, the face area in the IFG was not as reliably identified as face areas in the occipitotemporal cortex. Secondly, the similarity of the response profiles in the IFG and pSTS suggests the areas may perform similar cognitive functions, a conclusion consistent with prior neuroanatomical and functional connectivity evidence.

Existing models propose that primate visual cortex is divided into two functionally distinct pathways. The ventral pathway computes the identity of an object; the dorsal pathway computes the location of an object, and the actions related to that object. Despite remaining influential, the two visual pathways model requires revision. Both human and non-human primate studies reveal the existence of a third visual pathway on the lateral brain surface. This third pathway projects from early visual cortex, via motion-selective areas, into the superior temporal sulcus (STS). Studies demonstrating that the STS computes the actions of moving faces and bodies (e.g., expressions, eye-gaze, audio-visual integration, intention, and mood) show that the third visual pathway is specialized for the dynamic aspects of social perception.

To investigate the functional connections between the core components of the face processing network we tested Herschel, an acquired prosopagnosic patient with a right ventral occipitotemporal lesion. In Experiment 1 Herschel, and control participants, were scanned with functional magnetic resonance imaging (fMRI) while viewing videos of moving faces or static images taken from the videos. In Experiment 2 participants viewed videos of actors making facial expressions or static images taken from the videos. In Experiment 3, participants viewed videos of moving faces presented in the left or right visual field. Results showed the neural response in Herschel’s right occipital face area (OFA) was impaired for moving and static faces (Experiment 1), moving expressions (Experiment 2) and moving faces in the left visual field (Experiment 3). The response in Herschel’s right fusiform face area (FFA) to moving and static faces was impaired in Experiment 1 only, in Experiments 2 and 3 Herschel’s FFA response was not significantly different from controls. By contrast, the response in Herschel’s right posterior superior temporal sulcus (rpSTS) to moving and static faces and expressions (Experiments 1 and 2) and the visual field response (Experiment 3) was not significantly different from control participants. Our results demonstrate there are cortico-cortical inputs to the pSTS from early visual cortex that are independent of the OFA, a conclusion inconsistent with established models of face processing.

Background Neuroimaging studies suggest that facial expression recognition is processed in the bilateral posterior superior temporal sulcus (pSTS). Our recent repetitive transcranial magnetic stimulation (rTMS) study demonstrates that the bilateral pSTS is causally involved in expression recognition, although involvement of the right pSTS is greater than involvement of the left pSTS. Objective /Hypothesis: In this study, we used a dual-site TMS to investigate whether the left pSTS is functionally connected to the right pSTS during expression recognition. We predicted that if this connection exists, simultaneous TMS disruption of the bilateral pSTS would impair expression recognition to a greater extent than unilateral stimulation of the right pSTS alone. Methods Participants attended two TMS sessions. In Session 1, participants performed an expression recognition task while rTMS was delivered to the face-sensitive right pSTS (experimental site), object-sensitive right lateral occipital complex (control site) or no rTMS was delivered (behavioural control). In Session 2, the same experimental design was used, except that continuous theta-burst stimulation (cTBS) was delivered to the left pSTS immediately before behavioural testing commenced. Session order was counter-balanced across participants. Results In Session 1, rTMS to the rpSTS impaired performance accuracy compared to the control conditions. Crucially in Session 2, the size of this impairment effect doubled after cTBS was delivered to the left pSTS. Conclusions Our results provide evidence for a causal functional connection between the left and right pSTS during expression recognition. In addition, this study further demonstrates the utility of the dual-site TMS for investigating causal functional links between brain regions., Highlights • Dual-site TMS was used to test causal functional connectivity between left and right pSTS during expression recognition. • rTMS impaired facial expression recognition when delivered to the right pSTS during a facial expression recognition task. • cTBS delivered to the left pSTS prior to the task doubled the impairment effect of rTMS to the right pSTS during the task. • The results demonstrate causal functional connectivity between the left and right pSTS during expression recognition. • The results also demonstrate the utility of dual-site TMS for investigating interregional causal functional connectivity.

Faces are rich sources of social information that simultaneously convey someone’s identity, attentional focus, and emotional state. Humans process this wealth of socially relevant information in a network of face-selective regions distributed across the brain. This chapter reviews studies that have used transcranial magnetic stimulation (TMS) to study the cognitive operations and functional connections of the face network. TMS has been used to disrupt brain areas contributing to the processing of facial identity, facial expression, eye-gaze direction, head direction, trustworthiness, and the auditory-visual integration of speech. TMS has also been combined with neuroimaging to map how transient disruption of a targeted face area impacts connectivity across the face network. I also review chronometric TMS studies that have established when faces are processed across different brain areas down to a millisecond resolution.

BACKGROUND AND AIMS Alport Syndrome (AS) is the second most common genetic kidney disease and results from mutations in COL4A3, A4 or A5 genes. It is characterized by glomerulonephritis, CKD, hearing loss, and ocular lens defects. Estimated incidence is ∼ 1 in 50 000 live births with prevalence of 1 in 5000–10 000. About 80% patients reach ESKD by age 35 years. The UK Alport Registry, part of the National Registry of Rare Kidney Diseases (RaDaR), performs on-going collection of longitudinal data of AS patients. The aims of this study were to characterize demographic and lab data of AS patients and determine the proportion of AS patients at risk for rapid kidney function decline. METHOD Eligible patients had a clinical, histological or genetic diagnosis of ‘Alport syndrome’ or ‘thin basement membrane nephropathy’ by their physician and provided informed consent. Some data were entered manually, but most routine test results were collected by automatic link between RaDaR and renal IT systems. eGFR was calculated using CKD-EPI Cr equation without race adjustment (2021) or Schwartz equation for subjects ≤16 years of age at time of Cr measurement. For eGFR slope calculations, a minimum of four measurements over at least 2 years were required to be included in this analysis; subjects were censored if they reached ESKD, defined as maintenance dialysis, transplant, or ≥ 2 consecutive eGFR measurements of RESULTS Between 4 January 2013 and 29 November 2021, 887 patients were recruited. See Table 1 for summary of data stratified by age groups. Overall, 52% male versus 48% female, and in those with genotyping data, 54% had X-linked AS with a mean age of 25.8 years at diagnosis and a mean age of proteinuria onset of 29.6 years. Clinically meaningful Stage 2 CKD was already present at time of diagnosis (mean eGFR 72.7 mL/min/1.73 m2) in many of those ≥ 18 years of age. A total of 43% of this AS cohort have reached ESKD, at a mean age of 32.8 years. While 37% were on ACEi and 20% on ARB medications, only 4% were on dual RAAS blockade therapy. About 50% had documentation of eGFR loss ≥4 mL/min/1.73 m2 per year, 29% had UPCR > 2 g/g, and 50% of those age ≥ 18 years had reached ESKD. The proportion of patients with ≥1 risk factor for rapid progression of kidney failure (defined as eGFR decline ≥ 4 mL/min/1.73 m2 per year, UPCR > 2 g/g, UACR > 1 g/g or male 18–23 yrs with eGFR < 90 mL/min/1.73 m2 based on ATHENA natural history study) was 41%. CONCLUSION Demographic and genetic characteristics of AS patients in the RaDaR registry are generally comparable with previously reported data. Approximately 50% had eGFR decline ≥ 4 mL/min/1.73 m2 per year and 41% of patients had exhibited ≥ 1 risk factor for future rapid progression of kidney disease. Results should be interpreted with caution, however, in light of the considerable amount of missing data in a number of the analyses. On-going data collection in this open cohort should allow for further insights on the natural history over time as well as identify AS patients for potential enrollment into clinical trials.

Single case studies of neuropsychological patients have been used to constrain neural models of cognitive function. In this tradition Rossion reports how studies of acquired prosopagnosic patient P.S. informed his model of the face processing network (Rossion, 2022). Rossion discusses the role of the occipital face area (OFA) and what he argues are conclusions that are inconsistent with our transcranial magnetic stimulation (TMS) studies. I address these differences here.

Humans process faces by using a network of face-selective regions distributed across the brain. Neuropsychological patient studies demonstrate that focal damage to nodes in this network can impair face recognition, but such patients are rare. We approximated the effects of damage to the face network in neurologically normal human participants by using theta burst transcranial magnetic stimulation (TBS). Multi-echo functional magnetic resonance imaging (fMRI) resting-state data were collected pre- and post-TBS delivery over the face-selective right superior temporal sulcus (rpSTS), or a control site in the right motor cortex. Results showed that TBS delivered over the rpSTS reduced resting-state connectivity across the extended face processing network. This connectivity reduction was observed not only between the rpSTS and other face-selective areas, but also between nonstimulated face-selective areas across the ventral, medial, and lateral brain surfaces (e.g., between the right amygdala and bilateral fusiform face areas and occipital face areas). TBS delivered over the motor cortex did not produce significant changes in resting-state connectivity across the face processing network. These results demonstrate that, even without task-induced fMRI signal changes, disrupting a single node in a brain network can decrease the functional connectivity between nodes in that network that have not been directly stimulated., Author Summary Human behavior is dependent on brain networks that perform different cognitive functions. We combined theta burst transcranial magnetic stimulation (TBS) with resting-state fMRI to study the face processing network. Disruption of the face-selective right posterior superior temporal sulcus (rpSTS) reduced fMRI connectivity across the face network. This impairment in connectivity was observed not only between the rpSTS and other face-selective areas, but also between nonstimulated face-selective areas on the ventral and medial brain surfaces (e.g., between the right amygdala and bilateral fusiform face areas and occipital face areas). Thus, combined TBS/fMRI can be used to approximate and measure the effects of focal brain damage on brain networks, and suggests such an approach may be useful for mapping intrinsic network organization.

Background and Aims Acute kidney injury (AKI) is a common and serious condition associated with longer length of hospital stay (LOS) for affected patients; leading to increased morbidity, emotional distress and higher healthcare costs. Implementation of AKI care quality improvement interventions have consistently been shown to reduce patient LOS, suggesting its measurement may serve as a valuable AKI care quality indicator for hospitals. In this study, we set out to explore, for the first time, unwarranted centre variation in case-mix adjusted LOS for patients who develop hospital acquired AKI (HA-AKI) across England. Method Analysis was undertaken using a routinely collected national database of patients with biochemically detected AKI, linked with hospitals administrative data. 250,504 HA-AKI episodes were studied in total, across 103 hospitals between 01/01/2017 – 31/12/2018. LOS was defined as the number of days between first AKI alert and discharge. A negative binomial model was used to generate predicted LOS for patients with HA-AKI at each hospital trust using age, sex, diagnosis group, comorbidity score, AKI severity, admission method, month of AKI alert and critical care attendance. Variation in “observed LOS – predicted LOS” values across centres were then compared using a funnel plot. Additional analyses were undertaken to investigate potential associations between centre LOS and readmission rates as well as variation in LOS amongst patients in the most common diagnosis groups. Results The overall median LOS following HA-AKI alert was 8 days (Interquartile range, 3-17). There was significant variation seen in “observed - predicted LOS” values across hospitals, with 55/103 trusts classed as outliers (99.8% control limits). When analysis was limited to patients with more severe AKI (stages 2 or 3) at presentation this number fell to 10/103 (99.8% control limits). Risk factors for longer LOS included male sex, advancing age, higher comorbidity score, more severe AKI at presentation, emergency admission and critical care attendance. Patients admitted due to fracture neck of femur were at highest risk of longer LOS and exhibited considerably more variation in “observed - predicted LOS” values compared to patients with congestive heart failure, pneumonia or septicaemia. Just over 1/5 of patients with HA-AKI went on to have an emergency re-admission within 30 days of discharge, with no association observed between a trusts “observed – predicted LOS” values and readmission rates (Figure). Conclusion There was considerable centre-variation in LOS for patients with HA-AKI across England. Further interrogation of patient and centre-level factors underlying the observed variation is now necessary to better understand why this variation exists and to inform development of future targeted quality improvement interventions to address this.

Background and Aims Routine monitoring of outcomes for patients with Acute Kidney Injury (AKI) is necessary to drive quality improvement in AKI care. In this study, we describe development of a case-mix adjusted 30-day mortality indicator for patients with hospital acquired AKI (H-AKI), to facilitate identification of unwarranted variation in outcomes across hospitals in England. Method We utilised a routinely collected national dataset of biochemically defined AKI cases, linked with hospitals administrative and mortality data. 250,504 H-AKI episodes were studied in total, across 103 hospitals between January 2017 - December 2018. Standardised mortality ratios were calculated for each hospital using logistic regression; adjusting for age, sex, primary diagnosis, comorbidity score, AKI severity, month of AKI, and admission method. Results Mean 30-day mortality rate was high at 28.6% and varied considerably between hospitals (22.3%-35.5%), with 23/103 trusts classed as outliers (95% control limits). Patients with H-AKI had mortality rates more than 5 times higher than the overall hospitalized population in 90/136 diagnosis groups and over 10 times higher in 60/136 groups. Increasing age, male sex, deprivation, higher comorbidity burden, more severe AKI stage at detection, emergency admission and admission during winter months were all associated with a higher risk of death Presentation at hospitals with on-site specialist nephrology services and Asian or Black ethnicity, however, were linked to a lower risk of death. Conclusion This is the largest multi-centre analysis of mortality for patients with biochemically ascertained H-AKI to date, once again highlighting development of AKI as an important patient safety concern across hospital settings. Centres identified as having poor outcomes will need to carefully interrogate their AKI care pathways to understand and explore reasons underlying the observed variation to guide future quality improvement interventions.

To understand the behaviour and intentions of other people we use visual cues generated by the movements and actions of their faces and bodies. These include facial expressions, eye-gaze, body movements and the audio-visual integration of speech. Explaining the neural processes that enable us to see, process and respond to these signals is a fundamental aim of psychology. In pursuit of this goal, we recently proposed the existence of a visual pathway specialised for social perception. This pathway projects from V1 into the posterior banks of the superior temporal sulcus (STS), via the motion-selective area V5/MT. In response, Weiner and Gomez have raised salient questions about the third pathway, which I welcome the opportunity to address here.

Human visual cortex contains three scene-selective regions in the lateral, medial and ventral cortex, termed the occipital place area (OPA), medial place area (MPA) and parahippocampal place area (PPA). Using functional magnetic resonance imaging (fMRI), all three regions respond more strongly when viewing visual scenes compared with isolated objects or faces. To determine how these regions are functionally and causally connected, we applied transcranial magnetic stimulation to OPA and measured fMRI responses before and after stimulation, using a theta-burst paradigm (TBS). To test for stimulus category-selectivity, we presented a range of visual categories (scenes, buildings, objects, faces). To test for specificity of any effects to TBS of OPA we employed two control conditions: Sham, with no TBS stimulation, and an active TBS-control with TBS to a proximal face-selective cortical region (occipital face area, or OFA). We predicted that TBS to OPA (but not OFA) would lead to decreased responses to scenes and buildings (but not other categories) in other scene-selective cortical regions. Across both ROI and whole-volume analyses, we observed decreased responses to scenes in PPA as a result of TBS. However, these effects were neither category specific, with decreased responses to all stimulus categories, nor limited to scene-selective regions, with decreases also observed in face-selective fusiform face area (FFA). Furthermore, similar effects were observed with TBS to OFA, thus effects were not specific to the stimulation site in the lateral occipital cortex. Whilst these data are suggestive of a causal, but non-specific relationship between lateral occipital and ventral temporal cortex, we discuss several factors that could have underpinned this result, such as the differences between TBS and online TMS, the role of anatomical distance between stimulated regions and how TMS effects are operationalised. Furthermore, our findings highlight the importance of active control conditions in brain stimulation experiments to accurately assess functional and causal connectivity between specific brain regions.

Background Routine monitoring of outcomes for patients with acute kidney injury (AKI) is important to drive ongoing quality improvement in patient care. In this study we describe the development of a case mix-adjusted 30-day mortality indicator for patients with post-hospitalization AKI (PH-AKI) across England to facilitate identification of any unwarranted centre variation in outcomes. Methods We utilized a routinely collected national dataset of biochemically detected AKI cases linked with national hospitals administrative and mortality data. A total of 250 504 PH-AKI episodes were studied across 103 National Health Service hospital trusts between January 2017 and December 2018. Standardized mortality ratios (SMRs) were calculated for each trust using logistic regression, adjusting for age, sex, primary diagnosis, comorbidity score, AKI severity, month of AKI and admission method. Results The mean 30-day mortality rate was high, at 28.6%. SMRs for 23/103 trusts were classed as outliers, 12 above and 11 below the 95% confidence limits. Patients with PH-AKI had mortality rates >5 times higher than the overall hospitalized population in 90/136 diagnosis groups and >10 times higher in 60/136 groups. Presentation at trusts with a co-located specialist nephrology service was associated with a lower mortality risk, as was South Asian or Black ethnicity. Deprivation, however, was associated with higher mortality. Conclusions This is the largest multicentre analysis of mortality for patients with biochemically ascertained PH-AKI to date, demonstrating once again the considerable risk associated with developing even mild elevations in serum creatinine. Mortality rates varied considerably across centres and those identified as outliers will now need to carefully interrogate local care pathways to understand and address the reasons for this, with national policy required to tackle the identified health disparities.

The development of the use of transcranial magnetic stimulation (TMS) in the study of psychological functions has entered a new phase of sophistication. This is largely due to an increasing physiological knowledge of its effects and to its being used in combination with other experimental techniques. This review presents the current state of our understanding of the mechanisms of TMS in the context of designing and interpreting psychological experiments. We discuss the major conceptual advances in behavioral studies using TMS. There are meaningful physiological and technical achievements to review, as well as a wealth of new perceptual and cognitive experiments. In doing so we summarize the different uses and challenges of TMS in mental chronometry, perception, awareness, learning, and memory.

Cultural confusion is a common experience among children in foster care. But it can be especially severe for Muslims when their faith, traditional values and way of life are disrespected and when this is exacerbated by removal from familiar home environments. This article describes the experiences of young people affected by this and critically examines how their situation matches the definitions of good practice in agencies and professionals seeking to help them. Four issues emerged: the child’s confusion surrounding separation and moving to somewhere strange; identifying the right placement; intervening in a way that offers children future choices; and the ever-present risk of discrimination. In each of these situations, well-meaning and firmly established fostering practices can be insensitive to the needs and wishes of Muslim children. This confounds their understanding of their self, depresses their sense of social belonging and demands they adjust in order to survive. The article makes recommendations to support Muslim adolescents entering care and to improve the practice of the professionals and agencies responsible for them. The dearth of specialist therapeutic services is highlighted, along with suggestions for future research.

Introduction:\ud Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) practice has been shown to be variable and sub-optimal. This paper describes the development of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). ReSPECT is a process which encourages shared understanding of a patient’s condition and what outcomes they value and fear, before recording clinical recommendations about cardiopulmonary-resuscitation (CPR) within a broader plan for emergency care and treatment.\ud \ud Methods:\ud ReSPECT was developed iteratively, with integral stakeholder engagement, informed by the Knowledge-to-Action cycle. Mixed methods included: synthesis of existing literature; a national online consultation exercise; cognitive interviews with users; a patient-public involvement (PPI) workshop and a usability pilot, to ensure acceptability by both patients and professionals.\ud \ud Results:\ud The majority (89%) of consultation respondents supported the concept of emergency care and treatment plans. Key features identified in the evaluation and incorporated into ReSPECT were: The importance of discussions between patient and clinician to inform realistic treatment preferences and clarity in the resulting recommendations recorded by the clinician on the form. The process is compliant with UK mental capacity laws. Documentation should be recognised across all health and care settings. There should be opportunity for timely review based on individual need.\ud \ud Conclusion:\ud ReSPECT is designed to facilitate discussions about a person’s preferences to inform emergency care and treatment plans (including CPR) for use across all health and care settings. It has been developed iteratively with a range of stakeholders. Further research will be needed to assess the influence of ReSPECT on patient-centred decisions, experience and health outcomes.

Faces are rich sources of social information that simultaneously convey someone’s identity, attentional focus, and emotional state. Humans process this wealth of socially relevant information in a network of face-selective regions distributed across the brain. In this chapter I review studies that have used transcranial magnetic stimulation (TMS) to study the cognitive operations and functional connections of this network. TMS has disrupted brain areas contributing to the processing of facial identity, facial expression, eye-gaze direction, head direction, trustworthiness and the auditory-visual integration of speech. TMS can also be combined with neuroimaging techniques to study how transient focal disruption of a targeted face area impacts connections across the extended face network. I also review chronometric TMS studies that have established when faces are processed across different brain areas down to a millisecond resolution.

Making new acquaintances necessitates learning to recognise previously unfamiliar faces. In the current study, we investigated this process by staging real-world social interactions between actors and the participants. Participants (N=22) completed a face-matching behavioural task in which they matched photographs of the actors (whom they had yet to meet), or faces similar to the actors (henceforth called foils). Participants were then scanned using functional magnetic resonance imaging (fMRI) while viewing photographs of actors and foils. Immediately after exiting the scanner, participants met the actors for the first time and interacted with them for ten minutes. On subsequent days, participants completed a second behavioural experiment and then a second fMRI scan. Prior to each session, actors again interacted with the participants for ten minutes. Behavioural results showed that social interactions improved performance accuracy when matching actor photographs, but not foil photographs. The fMRI analysis focused on face-selective areas in the right hemisphere, including the fusiform face area (FFA), occipital face area (OFA), posterior superior temporal sulcus (pSTS) and amygdala, as well as the right hippocampus. Results showed a greater response to actor photographs than foil photographs across all regions of interest after social interactions had occurred. Our results demonstrate that short social interactions were sufficient to learn and discriminate previously unfamiliar individuals. Moreover, these learning effects were present in brain areas involved in face processing and memory.

Neuroimaging studies show that ventral face-selective regions, including the fusiform face area (FFA) and occipital face area (OFA), preferentially respond to faces presented in the contralateral visual field (VF). In the current study we measured the VF response of the face-selective posterior superior temporal sulcus (pSTS). Across 3 functional magnetic resonance imaging experiments, participants viewed face videos presented in different parts of the VF. Consistent with prior results, we observed a contralateral VF bias in bilateral FFA, right OFA (rOFA), and bilateral human motion-selective area MT+. Intriguingly, this contralateral VF bias was absent in the bilateral pSTS. We then delivered transcranial magnetic stimulation (TMS) over right pSTS (rpSTS) and rOFA, while participants matched facial expressions in both hemifields. TMS delivered over the rpSTS disrupted performance in both hemifields, but TMS delivered over the rOFA disrupted performance in the contralateral hemifield only. These converging results demonstrate that the contralateral bias for faces observed in ventral face-selective areas is absent in the pSTS. This difference in VF response is consistent with face processing models proposing 2 functionally distinct pathways. It further suggests that these models should account for differences in interhemispheric connections between the face-selective areas across these 2 pathways.

The human brain contains areas that respond selectively to faces, bodies and scenes. Neuroimaging studies have shown that a subset of these areas preferentially respond more to moving than static stimuli, but the reasons for this functional dissociation remain unclear. In the present study, we simultaneously mapped the responses to motion in face-, body- and scene-selective areas in the right hemisphere using moving and static stimuli. Participants (N = 22) were scanned using functional magnetic resonance imaging (fMRI) while viewing videos containing bodies, faces, objects, scenes or scrambled objects, and static pictures from the beginning, middle and end of each video. Results demonstrated that lateral areas, including face-selective areas in the posterior and anterior superior temporal sulcus (STS), the extrastriate body area (EBA) and the occipital place area (OPA) responded more to moving than static stimuli. By contrast, there was no difference between the response to moving and static stimuli in ventral and medial category-selective areas, including the fusiform face area (FFA), occipital face area (OFA), amygdala, fusiform body area (FBA), retrosplenial complex (RSC) and parahippocampal place area (PPA). This functional dissociation between lateral and ventral/medial brain areas that respond selectively to different visual categories suggests that face-, body- and scene-selective networks may be functionally organized along a common dimension.

The Resuscitation Council (UK), the British Cardiovascular Society (including the British Heart Rhythm Society and the British Society for Heart Failure) and the National Council for Palliative Care recognise the importance of providing clear and consistent guidance on management of cardiovascular implanted electronic devices (CIEDs) towards the end of life, during cardiorespiratory arrest and after death. This document has been developed to provide guidance for the full range of healthcare professionals who may encounter people with CIEDs in the situations described and for healthcare managers and commissioners. The authors recognise that some patients and people close to patients may also wish to refer to this document. It is intended as an initial step to help to ensure that people who have CIEDs, or are considering implantation of one, receive explanation of and understand the practical implications and decisions that this entails; to promote a good standard of care and service provision for people in the UK with CIEDs in the circumstances described; to offer relevant ethical and legal guidance on this topic; to offer guidance on the delivery of services in relation to deactivation of CIEDs where appropriate; to offer guidance on whether any special measures are needed when a person with a CIED receives cardiopulmonary resuscitation; and to offer guidance on the actions needed when a person with a CIED dies.

Kidney disease is a recognised risk factor for poor COVID-19 outcomes. Up to 30 June 2020, the UK Renal Registry (UKRR) collected data for 2,385 in-centre haemodialysis (ICHD) patients with COVID-19 in England and Wales. Overall unadjusted survival at 1 week after date of positive COVID-19 test was 87.5% (95% CI 86.1–88.8%); mortality increased with age, treatment vintage and there was borderline evidence of Asian ethnicity (HR 1.16, 95% CI 0.94–1.44) being associated with higher mortality. Compared to the general population, the relative risk of mortality for ICHD patients with COVID-19 was 45.4 and highest in younger adults. This retrospective cohort study based on UKRR data supports efforts to protect this vulnerable patient group.

Prior studies demonstrate that a face-responsive region in the posterior superior temporal sulcus (pSTS) is involved in facial expression recognition. Although this region can be identified in both hemispheres, studies more commonly report it in the right hemisphere. However, the extent to which expression recognition is lateralised in pSTS remains unclear. In the current study, we used transcranial magnetic stimulation (TMS) to systematically compare the causal contribution of the right pSTS (rpSTS) with the left pSTS (lpSTS) during facial expression recognition. TMS was delivered over the functionally localised rpSTS, lpSTS and the control vertex site while participants (N = 30) performed an expression matching task and a control object matching task. TMS delivered over the rpSTS impaired expression recognition more than TMS delivered over the lpSTS. Crucially, TMS delivered over the rpSTS and lpSTS impaired task performance more than TMS delivered over the control site. TMS had no effect on the control task. This causally demonstrates that while task disruption was greater in the rpSTS, both the rpSTS and the lpSTS were engaged in facial expression recognition. Our results indicate that cognitive functions that are seemingly lateralised in neuroimaging studies, still rely on computations performed in both hemispheres for optimum task performance.

Discussions and decisions about whether or not cardiopulmonary resuscitation (CPR) should be attempted are challenging for patients and clinicians. Misunderstandings, poor decision making, and communication failures are common and have led to complaints, litigation, and adverse media reports. This chapter considers why decisions and recommendations about CPR and other potentially life-sustaining treatments are an important part of advance care planning (ACP), and are needed in other contexts as well. It summarizes what is needed to achieve high-quality, person-centred planning that is both ethical and lawful, and considers current efforts to develop a scheme that will encourage and support clinicians and their patients in that endeavour.

The UK Renal Association clinical practice guidelines include clinical performance measures for biochemical variables in dialysis patients. The UK Renal Registry(UKRR) annually audits dialysis centre performance against these measures as part of its role in promoting continuous quality improvement.Cross sectional performance analyses were undertaken to compare dialysis centre achievement of clinical audit measures for prevalent haemodialysis (HD) and peritoneal dialysis (PD) cohorts in 2013. The biochemical variables studied were phosphate, adjusted calcium, parathyroid hormone and bicarbonate.In addition, longitudinal analyses were performed (2002–2013) to show changes in achievement of clinical performance measures over time.Fifty-seven percent of HD and 62% of PD patients achieved a phosphate within the range recommended by the RA clinical practice guidelines. Seventy-eight percent of HD and of PD patients had adjusted calcium between 2.2–2.5 mmol/L. Fifty-seven percent of HD and 63% of PD patients had parathyroid hormone between 16–72 pmol/L. Fifty-nine percent of HD and 79% of PD patients achieved the audit measure for bicarbonate. There was significant inter-centre variation for all variables studied.The UKRR consistently demonstrates significant inter-centre variation in achievement of biochemical clinical audit measures. Understanding the causes of this variation is an important part of improving the care of dialysis patients in the UK.

Dialysis access should be timely, minimize complications and maintain functionality. The aim of the second combined vascular and peritoneal dialysis access audit was to examine practice patterns with respect to dialysis access and highlight variations in practice between renal centres.The UK Renal Registry collected centre-specific information on incident vascular and peritoneal dialysis access outcome measures in patients from England, Wales and Northern Ireland (EWNI), including patient demographics, dialysis access type (at start of dialysis and three months after start of dialysis), surgical assessment and access functionality. Centres who had reported data on incident PD patients for the previous 2012 audit were additionally asked to provide one year follow up data for this group. The findings were compared to the audit measures stated in Renal Association clinical practice guidelines for dialysis access.Fifty-seven centres in EWNI (representing 92% of all centres) returned data on first access from 3,663 incident HD patients and 1,022 incident PD patients. A strong relationship was seen between surgical assessment and the likelihood of starting HD with an arteriovenous fistula (AVF). Twenty-four centres were at least two standard deviations below the 65% target for incident patients starting haemodialysis on AVF and only eight centres (14%) were within two standard deviations of the 85% target for prevalent haemodialysis patients on AVF.There was wide practice variation across the UK in provision of both HD and PD access which requires further exploration.

Trichinellosis, also known as trichinosis and trichiniasis, is a rare infection caused by the ingestion of raw or undercooked meat containing viable encysted larvae of the parasitic roundworm Trichinella species1-3. Previously quite common, the Centers for Disease Control and Prevention currently report only a few trichinellosis cases annually in the United States2,4. The scarcity of present-day cases is largely attributed to increased federal legislation over the past several decades that led to many public health measures to educate people regarding techniques for safe food preparation2,4-6. Trichinellosis usually presents acutely with circumorbital edema, fever, myalgia, and abdominal discomfort. We report a case in a fifty-seven-year-old woman who presented atypically with a soft-tissue mass in the forearm. Clinical presentation, diagnosis, prevention, and treatment of this rare infection are discussed. The patient was informed that data concerning her case would be submitted for publication, and she provided consent. A fifty-seven-year-old woman presented to the orthopaedic oncology service for evaluation of a painless mass in the left forearm, which had been slowly enlarging over several years. The patient's rheumatoid arthritis had caused finger deformities and diffuse rheumatoid nodules. At the time of presentation, the rheumatoid arthritis was being treated with abatacept, a T-cell costimulation modulator, but in the past it had been treated with other disease-modifying antirheumatic drugs. Additionally, she had a twenty-year history of anterior interosseous nerve syndrome of the right forearm, and a one-year history of anterior interosseous nerve syndrome of the left forearm, although the cause of these bilateral syndromes was unknown. Physical examination demonstrated a firm, fixed, painless mass on the volar side of the left forearm, proximal to the wrist crease. The patient had an absence of flexor pollicus longus and flexor digitorium profundus function …

Institute of Cognitive Neuroscience and Department ofPsychology, University College London, Alexandra House,17 Queen Square, London WC1N 3AR, UKSummaryFaces contain structural information, for identifying individ-uals, as well as changeable information, which can conveyemotion and direct attention. Neuroimaging studies revealbrain regions thatexhibit preferentialresponses toinvariant[1, 2] or changeable [3–5] facial aspects but the functionalconnections between these regions are unknown. We ad-dressed this issue by causally disrupting two face-selectiveregions with thetaburst transcranial magnetic stimulation(TBS) and measuring the effects of this disruption in localand remote face-selective regions with functional magneticresonance imaging (fMRI). Participants were scanned, overtwo sessions, while viewing dynamic or static faces and ob-jects. During these sessions, TBS was delivered over theright occipital face area (rOFA) or right posterior superiortemporal sulcus (rpSTS). Disruption of the rOFA reducedthe neural response to both static and dynamic faces inthe downstream face-selective region in the fusiform gyrus.In contrast, the response to dynamic and static faces wasdoubly dissociated in the rpSTS. Namely, disruption of therOFA reduced the response to static but not dynamic faces,while disruption of the rpSTS itself reduced the response todynamic but not static faces. These results suggest thatdynamic and static facial aspects are processed via dis-sociable cortical pathways that begin in early visual cortex,a conclusion inconsistent with current models of faceperception [6–9].ResultsInfluential models of face perception [6–8] propose that twofunctionally distinct cortical pathways process different facialaspects. The ventral pathway, which includes the fusiformface area (FFA) [10], preferentially responds to invariant facialaspects, such as individual identity. The lateral pathway,which includes the posterior superior temporal sulcus(pSTS) [3], preferentially responds to changeable facial as-pects, such as emotional expression and eye-gaze direction[4]. Crucially, despite functional differences, both pathwaysare believed to begin in the same face-selective region, theoccipital face area (OFA) [7–9, 11]. In the present study wecausally tested the hypothesis that the OFA is the solegateway for the face perception network using a ‘‘virtual’’lesion approach.Toexaminehowface-selectiveregionsarefunctionallycon-nected,thetabursttranscranialmagneticstimulation(TBS)[12]was used to transiently disrupt the brains of neurologicallyhealthy participants. The effects of this disruption were thenmeasuredinlocalandremoteface-selectiveregionswithfunc-tionalmagneticresonanceimaging (fMRI).Wereasonedthat ifthe OFA is the sole source of dynamic and static face informa-tion for the FFA and pSTS, then disrupting the OFA wouldreduce the neural response to dynamic and static faces inboth the FFA and pSTS. However, if a separate pathwayconveying only dynamic face information exists to the pSTS,independently of the OFA, then disruption of the OFA wouldhave relatively little impact on the response to dynamic facesin the pSTS (see Figure 1).Participants completed two scanning sessions, performedon separate days, while viewing face and object stimulithat were either dynamic or static (see Figure 2). Scanningwas performed before and after TBS was delivered over thefunctionally localized right OFA (rOFA) or right posterior supe-rior temporal sulcus (rpSTS). We then measured what ef-fect TBS disruption had on the neural response in both thestimulated regions (rOFA and rpSTS), as well as in the rightFFA (rFFA), a face-selective region on the ventral corticalsurface that cannot be directly stimulated by TBS. The magni-tuderesponsesfromeachface-selectiveROIaswellasfortheright extrastriate body area (rEBA) and right lateral occipitalarea (rLO) are shown in full in Figures S1 and S2 availableonline.ROI AnalysisTo understand what effect TBS stimulation had on the threeface-selective regions, we calculated the size of the TBSdisruptive effect in the rpSTS, rOFA, and rFFA. This wasdone by subtracting the BOLD responses for each stimuluscategory (dynamic faces, static faces, dynamic objects, staticobjects) after TBS stimulation of the rOFA and rpSTS from thepre-TMS baseline response in each ROI (see Figure 3).Thedatawerethenentered intoa2(TMS: TBStorOFA;TBSto rpSTS) by 2 (motion: dynamic, static) by 2 (stimulus: faces,objects) by 3 (ROI: rFFA, rpSTS; rOFA) repeated-measuresANOVA. Results showed a main effect of stimulus (F (1,14) =7.3, p = 0.017) as well as interactions between motion andTMS (F (1,14) = 4.2, p = 0.048) and between motion, stimulus,and TMS (F (1,14) = 3.6, p = 0.041). Crucially, there was alsoa significant interaction between ROI, motion, stimulus, andTMS(F(2,28)=3,p=0.043).Nootherinteractionsapproachedsignificance.Separate ANOVAs performed in each of the face-selectiveROIs (reported in full in Supplemental Information) demon-strated that TBS stimulation of the rOFA and rpSTS induceda double dissociation between the response to dynamic andstatic faces in the rpSTS (Figure 3). The response to staticfaces in the rpSTS was reduced by stimulation of the rOFAbut not of the rpSTS, while the response to dynamic faces inthe rpSTS was reduced by stimulation of the rpSTS but notof the rOFA. This result is consistent with the hypothesis thatdynamic face information can reach the rpSTS independently

Neuroimaging studies have identified a face-selective region in the right posterior superior temporal sulcus (rpSTS) that responds more strongly during facial expression recognition tasks than during facial identity recognition tasks, but precisely when the rpSTS begins to causally contribute to expression recognition is unclear. The present study addressed this issue using transcranial magnetic stimulation (TMS). In Experiment 1, repetitive TMS delivered over the rpSTS of human participants, at a frequency of 10 Hz for 500 ms, selectively impaired a facial expression task but had no effect on a matched facial identity task. In Experiment 2, participants performed the expression task only while double-pulse TMS (dTMS) was delivered over the rpSTS or over the right occipital face area (rOFA), a face-selective region in lateral occipital cortex, at different latencies up to 210 ms after stimulus onset. Task performance was selectively impaired when dTMS was delivered over the rpSTS at 60-100 ms and 100-140 ms. dTMS delivered over the rOFA impaired task performance at 60-100 ms only. These results demonstrate that the rpSTS causally contributes to expression recognition and that it does so over a longer time-scale than the rOFA. This difference in the length of the TMS induced impairment between the rpSTS and the rOFA suggests that the neural computations that contribute to facial expression recognition in each region are functionally distinct.

Nonhuman primate neuroanatomical studies have identified a cortical pathway from the superior temporal sulcus (STS) projecting into dorsal subregions of the amygdala, but whether this same pathway exists in humans is unknown. Here, we addressed this question by combining theta burst transcranial magnetic stimulation (TBS) with fMRI to test the prediction that the STS and amygdala are functionally connected during face perception. Human participants (N= 17) were scanned, over two sessions, while viewing 3 s video clips of moving faces, bodies, and objects. During these sessions, TBS was delivered over the face-selective right posterior STS (rpSTS) or over the vertex control site. A region-of-interest analysis revealed results consistent with our hypothesis. Namely, TBS delivered over the rpSTS reduced the neural response to faces (but not to bodies or objects) in the rpSTS, right anterior STS (raSTS), and right amygdala, compared with TBS delivered over the vertex. By contrast, TBS delivered over the rpSTS did not significantly reduce the neural response to faces in the right fusiform face area or right occipital face area. This pattern of results is consistent with the existence of a cortico-amygdala pathway in humans for processing face information projecting from the rpSTS, via the raSTS, into the amygdala. This conclusion is consistent with nonhuman primate neuroanatomy and with existing face perception models.SIGNIFICANCE STATEMENTNeuroimaging studies have identified multiple face-selective regions in the brain, but the functional connections between these regions are unknown. In the present study, participants were scanned with fMRI while viewing movie clips of faces, bodies, and objects before and after transient disruption of the face-selective right posterior superior temporal sulcus (rpSTS). Results showed that TBS disruption reduced the neural response to faces, but not to bodies or objects, in the rpSTS, right anterior STS (raSTS), and right amygdala. These results are consistent with the existence of a cortico-amygdala pathway in humans for processing face information projecting from the rpSTS, via the raSTS, into the amygdala. This conclusion is consistent with nonhuman primate neuroanatomy and with existing face perception models.

Dialysis access should be timely, minimise complications and maintain functionality. Good functional access is required for renal replacement therapy (RRT) to be successful. The aim of the combined vascular and peritoneal dialysis access audit was to examine practice patterns with respect to dialysis access and highlight variations in practice between renal centres.The UK Renal Registry collected centre-specific information on vascular and peritoneal access outcome measures including patient demographics, dialysis access type (at start of dialysis and three months after start of dialysis), surgical assessment and access functionality. The combined access audit covered incident haemodialysis (HD) and peritoneal dialysis (PD) patients in 2012 from England, Northern Ireland and Wales. Centres who had reported data on incident PD patients for the previous audit in 2011 were additionally asked to provide one year follow up data for this group.Fifty-one centres in England, Wales and Northern Ireland (representing 82% of all centres) returned data on first access from 3,720 incident HD patients and 1,018 incident PD patients. A strong relationship was seen between surgical assessment and the likelihood of starting HD with an arteriovenous fistula (AVF). Type of first access was related to the length of time known to renal services with higher numbers of AVFs and PD catheters used in patients known to renal services for at least one year. Three month and one year outcomes of HD and PD access were poorly reported.This audit provides information on important patient related outcome measures with the potential to lead to an improvement in access provision. This represents an important advance, however data collection remains suboptimal. There is wide practice variation across the England, Wales and Northern Ireland in provision of both HD and PD access which requires further exploration.