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Abstract Discriminating between similar figures proves to be a remarkably demanding task due to the limited capacity of our visual cognitive processes. Here we examine how perceptual inference and decision-making are modulated by differences arising from neurodiversity. A large sample of autistic (n = 140) and typical (n = 147) participants completed two forced choice similarity judgement tasks online. Each task consisted of “match” (identical figures) and “mismatch” (subtle differences between figures) conditions. Signal detection theory analyses indicated a response bias by the autism group during conditions of uncertainty. More specifically, autistic participants were more likely to choose the “mismatch” option, thus leading to more hits on the “mismatch” condition, but also more false alarms on the “match” condition. These results suggest differences in response strategies during perceptual decision-making in autism.

Abstract Background A critical challenge in current acute lymphoblastic leukemia (ALL) therapy is treatment intensification in order to reduce the relapse rate in the subset of patients at the highest risk of relapse. The year-long maintenance phase is essential in relapse prevention. The Thiopurine Enhanced ALL Maintenance (TEAM) trial investigates a novel strategy for ALL maintenance. Methods TEAM is a randomized phase 3 sub-protocol to the ALLTogether1 trial, which includes patients 0–45 years of age with newly diagnosed B-cell precursor or T-cell ALL, and stratified to the intermediate risk-high (IR-high) group, in 13 European countries. In the TEAM trial, the traditional methotrexate (MTX)/6-mercaptopurine (6MP) maintenance backbone (control arm) is supplemented with low dose (2.5–12.5 mg/m2/day) oral 6-thioguanine (6TG) (experimental arm), while the starting dose of 6MP is reduced from 75 to 50 mg/m2/day. A total of 778 patients will be included in TEAM during ~ 5 years. The study will close when the last included patient has been followed for 5 years from the end of induction therapy. The primary objective of the study is to significantly improve the disease-free survival (DFS) of IR-high ALL patients by adding 6TG to 6MP/MTX-based maintenance therapy. TEAM has 80% power to detect a 7% increase in 5-year DFS through a 50% reduction in relapse rate. DFS will be evaluated by intention-to-treat analysis. In addition to reducing relapse, TEAM may also reduce hepatotoxicity and hypoglycemia caused by high levels of methylated 6MP metabolites. Methotrexate/6MP metabolites will be monitored and low levels will be reported back to clinicians to identify potentially non-adherent patients. Discussion TEAM provides a novel strategy for maintenance therapy in ALL with the potential of improving DFS through reducing relapse rate. Potential risk factors that have been considered include hepatic sinusoidal obstruction syndrome/nodular regenerative hyperplasia, second cancer, infection, and osteonecrosis. Metabolite monitoring can potentially increase treatment adherence in both treatment arms. Trial registration EudraCT, 2018–001795-38. Registered 2020-05-15, Clinicaltrials.gov , NCT04307576 . Registered 2020-03-13, https://clinicaltrials.gov/ct2/show/NCT04307576

BackgroundWe examined whether information extracted during a visual statistical learning task could be generalised from specific exemplars to semantically similar ones. We then looked at whether performance in autistic people differed to non-autistic people during a visual statistical learning task and specifically examined whether differences in performance between groups occurred when sequential information was presented at a semantic level. We did this by assessing recall performance using a two-alternative forced choice paradigm after presenting participants with a sequence of naturalistic scene images.Methods125 adult participants (61 participants with an autism diagnosis and 64 non-autistic controls) were presented with a fast serial presentation sequence of images and given a cover task to avoid attention being explicitly drawn to patterns in the underlying sequences. This was followed by a two-alternative forced choice task to assess participants' implicit recall. Participants were presented with 1 of 3 unique versions of the task, in which the presentation and assessment of statistical regularities was done at either a low feature-based level or a high semantic-based level.ResultsParticipants were able to generalise statistical information from specific exemplars to semantically similar ones. There was an overall significant reduction in visual statistical learning in the autistic group but we were unable to determine whether group differences occurred specifically in conditions where the learning of semantic information was required.ConclusionsThese results provide evidence that participants are able to extract statistical information that is presented at the level of specific exemplars and generalise it to semantically similar contexts. We also showed a modest but statistically significant reduction in recall performance in the autistic participants relative to the non-autistic participants.

Abstract The global prevalence of overweight (including obesity) in children under 5 years of age was 7% in 2012, and it is expected to rise to 11% by the year 2025. The main objective of this study was to fit spatio-temporal quantile interval regression models for childhood overweight (including obesity) in Namibia from 2000 to 2013 using fully Bayesian inference implemented in R-INLA package in R version 3.5.1. All the available Demographic and Health Survey (DHS) datasets for Namibia since 2000 were used in this study. Significant determinants of childhood overweight (including obesity) ranged from socio-demographic factors to child and maternal factors. Child age and preceding birth interval had significant nonlinear effects on childhood overweight (including obesity). Furthermore, we observed significant spatial and temporal effects on childhood overweight (including obesity) in Namibia between 2000 and 2013. To achieve the World Health Organisation (WHO) global nutrition target 2025 in Namibia, the existing scaling-up nutrition programme and childhood malnutrition policy makers in this country may consider interventions based on socio-demographic determinants, and spatio-temporal variations presented in this paper.

This contribution to the Special Issue focuses on how we might incorporate ‘peripheral thinking’ on the EU, with a particular focus on teaching the EU at a ‘new periphery’: in Brexit Britain. First, it considers the challenges of teaching the EU in the context of what now feels like an almost permanent crisis in the EU. It argues in favour of a ‘critical-pluralist’ approach: that is, an approach that fully engages with a ‘peripheral’ (including ‘critical’, ‘normative’ and ‘dissident’) set of ideas as part of a commitment to scholarly pluralism. Second, it suggests--with reference to the recent experience of updating an EU politics textbook--that a ‘question driven approach’ might be one pedagogically practical way of presenting such a plurality to our students. Finally, it turns to consider how such an approach might be realised in the classroom, in the particular context of teaching the EU at the EU’s ‘new periphery’, the United Kingdom. While that context presented various teaching related challenges, Brexit as a case study was usefully deployed in a variety of ways in order to pursue the critical-pluralist approach that is advocated.

Abstract Background During the COVID-19 pandemic, over 99% of adults in Hong Kong use face masks in public. With the limited supply of face masks in the market and the uncertainty about the future development of COVID-19, reusing face masks is a legitimate way to reduce usage. Although this practice is not recommended, reusing face masks is common in Hong Kong. This study aimed to examine the practice of reusing face masks among adults in Hong Kong during the COVID-19 pandemic and its association with their health beliefs toward this health crisis. Methods A cross-sectional descriptive study was conducted. A quota sample of 1000 adults was recruited in Hong Kong in April 2020. Guided by the Health Belief Model, the subjects were invited to answer questions on their practice of reusing face masks and health beliefs toward COVID-19 through telephone interview. Their practice on reuse, storage, and decontamination of used face masks were summarized by descriptive statistics. The difference in health beliefs between the subjects who reused and did not reuse face masks was examined by conducting an independent t test. The association between health beliefs and reuse of face masks was determined by conducting a logistic regression analysis. Results One-third (n = 345, 35.4%) of the subjects reused face masks in an average of 2.5 days. Among them, 207 subjects stored and 115 subjects decontaminated their used face masks by using various methods. The subjects who reused face masks significantly perceived having inadequate face masks (t = 3.905; p

Autism is a developmental condition associated with altered functional connectivity. We propose to re-frame the functional connectivity alterations in terms of gradients that capture the functional hierarchy of cortical processing from sensory to default-mode network regions. We hypothesized that this hierarchy will be altered in ASD. To test that, we compared the scale of gradients in people with autism and healthy controls. The present results do not support our hypothesis. There are two alternative implications: either the processing hierarchies are preserved in autism or the scale of the gradients does not capture them. In the future we will attempt to settle which alternative is more likely.

Introduction: Circulating microparticles (MP) have been described in sickle cell anaemia (SCA); however, their interaction with endothelial markers remains unclear. We investigated the relationship between MP, protein C (PC), free protein S (PS), nitric oxide (NO), endothelin-1 (ET-1) and adrenomedullin (ADM) in a large cohort of paediatric patients. Method: A total of 111 children of African ethnicity with SCA: 51 in steady state; 15 in crises; 30 on hydroxyurea (HU) therapy; 15 on transfusion; 17 controls (HbAA) of similar age/ethnicity. MP were analysed by flow cytometry using: Annexin V (AV), CD61, CD42a, CD62P, CD235a, CD14, CD142 (tissue factor), CD201 (endothelial PC receptor), CD62E, CD36 (TSP-1), CD47 (TSP-1 receptor), CD31 (PECAM), CD144 (VE-cadherin). Protein C, free PS, NO, pro-ADM and C-terminal ET-1 were also measured. Results: Total MP AV was lower in crisis (1.26×106 ml−1; 0.56–2.44×106) and steady state (1.35×106 ml−1; 0.71–3.0×106) compared to transfusion (4.33×106 ml−1; 1.6–9.2×106, p0.9, p

Global land-use/land-cover (LULC) change projections and historical datasets are typically available at coarse grid resolutions and are often incompatible with modeling applications at local to regional scales. The difficulty of downscaling and reapportioning global gridded LULC change projections to regional boundaries is a barrier to the use of these datasets in a state-and-transition simulation model (STSM) framework. Here we compare three downscaling techniques to transform gridded LULC transitions into spatial scales and thematic LULC classes appropriate for use in a regional STSM. For each downscaling approach, Intergovernmental Panel on Climate Change (IPCC) Representative Concentration Pathway (RCP) LULC projections, at the 0.5 × 0.5 cell resolution, were downscaled to seven Level III ecoregions in the Pacific Northwest, United States. RCP transition values at each cell were downscaled based on the proportional distribution between ecoregions of (1) cell area, (2) land-cover composition derived from remotely-sensed imagery, and (3) historic LULC transition values from a LULC history database. Resulting downscaled LULC transition values were aggregated according to their bounding ecoregion and “cross-walked” to relevant LULC classes. Ecoregion-level LULC transition values were applied in a STSM projecting LULC change between 2005 and 2100. While each downscaling methods had advantages and disadvantages, downscaling using the historical land-use history dataset consistently apportioned RCP LULC transitions in agreement with historical observations. Regardless of the downscaling method, some LULC projections remain improbable and require further investigation.

Coastal environments are highly dynamic, and are characterized by short-term, local-scale variability in atmospheric and oceanic processes. Yet, high-frequency measurements of atmospheric composition, and particularly nitrogen dioxide (NO2) and ozone (O3) dynamics, are scarce over the ocean, introducing uncertainties in satellite retrievals of coastal ocean biogeochemistry and ecology. Combining measurements from different platforms, the Korea-US Ocean Color and Air Quality field campaign provided a unique opportunity to capture, for the first time, the strong spatial dynamics and diurnal variability in total column (TC) NO2 and O3 over the coastal waters of South Korea. Measurements were conducted using a shipboard Pandora Spectrometer Instrument specifically designed to collect accurate, high-frequency observations from a research vessel, and were combined with ground-based observations at coastal land sites, synoptic satellite imagery, and air-mass trajectory simulations to assess source contributions to atmospheric pollution over the coastal ocean. TCO3 showed only small (

Snake bite is a common medical emergency in Papua New Guinea (PNG). The taipan, Oxyuranus scutellatus, inflicts a large number of bites that, in the absence of antivenom therapy, result in high mortality. Parenteral administration of antivenoms manufactured in Australia is the current treatment of choice for these envenomings. However, the price of these products is high and has increased over the last 25 years; consequently the country can no longer afford all the antivenom it needs. This situation prompted an international collaborative project aimed at generating a new, low-cost antivenom against O. scutellatus for PNG.A new monospecific equine whole IgG antivenom, obtained by caprylic acid fractionation of plasma, was prepared by immunising horses with the venom of O. scutellatus from PNG. This antivenom was compared with the currently used F(ab')(2) monospecific taipan antivenom manufactured by CSL Limited, Australia. The comparison included physicochemical properties and the preclinical assessment of the neutralisation of lethal neurotoxicity and the myotoxic, coagulant and phospholipase A(2) activities of the venom of O. scutellatus from PNG. The F(ab')(2) antivenom had a higher protein concentration than whole IgG antivenom. Both antivenoms effectively neutralised, and had similar potency, against the lethal neurotoxic effect (both by intraperitoneal and intravenous routes of injection), myotoxicity, and phospholipase A(2) activity of O. scutellatus venom. However, the whole IgG antivenom showed a higher potency than the F(ab')(2) antivenom in the neutralisation of the coagulant activity of O. scutellatus venom from PNG.The new whole IgG taipan antivenom described in this study compares favourably with the currently used F(ab')(2) antivenom, both in terms of physicochemical characteristics and neutralising potency. Therefore, it should be considered as a promising low-cost candidate for the treatment of envenomings by O. scutellatus in PNG, and is ready to be tested in clinical trials.

Abstract Background In recent years there has been an increasing problem with Staphylococcus aureus strains that are resistant to treatment with existing antibiotics. An important starting point for the development of new antimicrobial drugs is the identification of "essential" genes that are important for bacterial survival and growth. Results We have developed a robust microarray and PCR-based method, Transposon-Mediated Differential Hybridisation (TMDH), that uses novel bioinformatics to identify transposon inserts in genome-wide libraries. Following a microarray-based screen, genes lacking transposon inserts are re-tested using a PCR and sequencing-based approach. We carried out a TMDH analysis of the S. aureus genome using a large random mariner transposon library of around a million mutants, and identified a total of 351 S. aureus genes important for survival and growth in culture. A comparison with the essential gene list experimentally derived for Bacillus subtilis highlighted interesting differences in both pathways and individual genes. Conclusion We have determined the first comprehensive list of S. aureus essential genes. This should act as a useful starting point for the identification of potential targets for novel antimicrobial compounds. The TMDH methodology we have developed is generic and could be applied to identify essential genes in other bacterial pathogens.

Background: Hip pain is a common chief complaint among sports medicine patients, and there is a wide variety of pathology that may cause pain around the hip joint. Indications: Any patient presenting to a clinic with a complaint of hip and groin pain should undergo a comprehensive physical examination to aid in diagnosis and treatment planning. Technique Description: All patients presenting with hip pain, regardless of the complaint, undergo a screening examination to further identify potential etiology of their pain. Based on the screening examination, as well as a comprehensive history and imaging findings, more specific examination maneuvers may be conducted to further establish an accurate diagnosis and treatment plan. Conclusion: Hip pain presents a diagnostic challenge for sports medicine providers, as there is a wide range of pathology that may manifest as pain around the hip joint. It is vital for all sports providers, regardless of the area of interest, to have the ability to perform a comprehensive physical examination of the hip to obtain an accurate diagnosis and to initiate appropriate treatment plans. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

The Arctic is entering a new ecological state, with alarming consequences for humanity. Animal-borne sensors offer a window into these changes. Although substantial animal tracking data from the Arctic and subarctic exist, most are difficult to discover and access. Here, we present the new Arctic Animal Movement Archive (AAMA), a growing collection of more than 200 standardized terrestrial and marine animal tracking studies from 1991 to the present. The AAMA supports public data discovery, preserves fundamental baseline data for the future, and facilitates efficient, collaborative data analysis. With AAMA-based case studies, we document climatic influences on the migration phenology of eagles, geographic differences in the adaptive response of caribou reproductive phenology to climate change, and species-specific changes in terrestrial mammal movement rates in response to increasing temperature., (Copyright © 2020 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Undergraduate nursing students face challenges that can result in stress leading to impaired performance, physical illness, high turnover and sickness absence (Kinman and Jones 2001). Students therefore require skills and knowledge to help them cope with the challenges of learning professional practice. This paper explores the concept of resilience, with an emphasis on how educational programmes can foster resilient practices among student nurses. Educators can facilitate resilience by incorporating resilience teaching and training that includes, the core concepts of resilience: self-efficacy, reflective ability and self-confidence. Critical appraisal and synthesis of the literature resulted in the identification of three themes: attributes, programmes and transition. The following five key learning and teaching methods were identified as supporting the development of resilience: peer activities; reflective practice; directed study; problem based learning/enquiry based learning and experiential learning Having resilience and resilient qualities is an integral part of nursing, having a positive impact upon the health and well-being of the nurse as practitioner. Resilient qualities and behaviours can be developed through the facilitation of appropriate learning and teaching interventions., Competing Interests: Declaration of competing interest There are no conflicts of interest known to authors., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Safe and effective immobilization of grizzly bears (Ursus arctos) is essential for research and management. Fast induction of anesthesia, maintenance of healthy vital rates, and predictable recoveries are priorities. From September 2010 to May 2012, we investigated these attributes in captive and wild grizzly bears anesthetized with a combination of a reversible α2 agonist (dexmedetomidine [dexM], the dextrorotatory enantiomer of medetomidine) and a nonreversible N-methyl-d-aspartate (NMDA) agonist and tranquilizer (tiletamine and zolazepam [TZ], respectively). A smaller-than-expected dose of the combination (1.23 mg tiletamine, 1.23 mg zolazepam, and 6.04 µg dexmedetomidine per kg bear) produced reliable, fast ataxia (3.7 ± 0.5 min, x̄±SE) and workable anesthesia (8.1 ± 0.6 min) in captive adult grizzly bears. For wild bears darted from a helicopter, a dose of 2.06 mg tiletamine, 2.06 mg zolazepam, and 10.1 µg dexmedetomidine/kg produced ataxia in 2.5 ± 0.3 min and anesthesia in 5.5 ± 1.0 min. Contrary to published accounts of bear anesthesia with medetomidine, tiletamine, and zolazepam, this combination did not cause hypoxemia or hypoventilation, although mild bradycardia (<50 beats per min) occurred in most bears during the active season. With captive bears, effective dose rates during hibernation were approximately half those during the active season. The time to first signs of recovery after the initial injection of dexMTZ was influenced by heart rate (P<0.001) and drug dose (P<0.001). Intravenous (IV) injection of the reversal agent, atipamezole, significantly decreased recovery time (i.e., standing on all four feet and reacting to the surrounding environment) relative to intramuscular injection. Recovery times (25 ± 8 min) following IV injections of the recommended dose of atipamezole (10 µg/µg of dexmedetomidine) and half that dose (5 µg/µg) did not differ. However, we recommend use of the full dose based on the appearance of a more complete recovery. Field trials confirmed that the dexMTZ + atipamezole protocol is safe, reliable, and predictable when administered to wild grizzly bears, especially during helicopter capture operations.

Given documented social dominance and intraspecific predation in bear populations, the ideal despotic distribution model and sex hypothesis of sexual segregation predict adult female grizzly bears (Ursus arctos) will avoid areas occupied by adult males to reduce risk of infanticide. Under ideal despotic distribution, juveniles should similarly avoid adult males to reduce predation risk. Den-site selection and use is an important component of grizzly bear ecology and may be influenced by multiple factors, including risk from conspecifics. To test the role of predation risk and the sex hypothesis of sexual segregation, we compared adult female (n = 142), adult male (n = 36), and juvenile (n = 35) den locations in Denali National Park and Preserve, Alaska, USA. We measured elevation, aspect, slope, and dominant land cover for each den site, and used maximum entropy modeling to determine which variables best predicted den sites. We identified the global model as the best-fitting model for adult female (area under curve (AUC) = 0.926) and elevation as the best predictive variable for adult male (AUC = 0.880) den sites. The model containing land cover and elevation best-predicted juvenile (AUC = 0.841) den sites. Adult females spatially segregated from adult males, with dens characterized by higher elevations (mean= 1,412 m, SE = 52) and steeper slopes (mean = 21.9°, SE = 1.1) than adult male (elevation: mean = 1,209 m, SE = 76; slope: mean = 15.6°, SE = 1.9) den sites. Juveniles used a broad range of landscape attributes but did not avoid adult male denning areas. Observed spatial segregation by adult females supports the sex hypothesis of sexual segregation and we suggest is a mechanism to reduce risk of infanticide. Den site selection of adult males is likely related to distribution of food resources during spring.

Sequential analysis of pacemaker diagnostics has been used to help manage the treatment and pacemaker program in patients who have sick sinus syndrome with documented paroxysmal atrial fibrillation. One hundred consecutive patients were followed for an average of 18 months. Knowledge of the atrial fibrillation burden led to major changes in medical management for half of the patients and changes to pacemaker programming for all. At the end of the study, 48 patients were free of arrhythmia with pacing although 14 required antiarrhythmic medication. We advocate using pacemaker diagnostics to improve patient management.

The onset of schizophrenia for the first time in late life has been considered rare, and the nosology of the late-onset functional psychoses remains contentious. However, it is clear that a significant proportion of individuals with a diagnosis of schizophrenia do have the first onset of the illness in late and very late life. The clinical presentation of such patients shows some differences from patients with early-onset disease, particularly in having a lower prevalence of premorbid dysfunction, negative symptoms and formal thought disorder. The longitudinal course is variable, possibly a reflection of aetiological heterogeneity. Atypical antipsychotic agents would appear to have significant benefits in the treatment of this group of patients, given the particular vulnerability of the elderly to extrapyramidal adverse effects, notably tardive dyskinesia.

Objective: To describe the complete range of factors which doctors recognise as changing their clinical practice and provide a measure of how often education is involved in change., Design: Interviews using the critical incident technique., Setting: Primary and secondary care., Subjects: Random sample of 50 general practitioners and 50 consultants., Main Outcome Measures: Categories of reasons for change in clinical practice., Results: Doctors described 361 changes in clinical practice, with an average of 3.0 reasons per change. The three most frequently mentioned reasons were organisational factors, education, and contact with professionals, together accounting for 47.9% of the total number of reasons for change. Education accounted for one sixth (16.9%) of the reasons for change and was involved in one third (37.1%) of the changes. Education was seldom mentioned as a reason for change in referral practice but was more often mentioned in management and prescribing changes. Consultants were influenced by medical journals and scientific conferences, while general practitioners were more influenced by medical newspapers and postgraduate meetings., Conclusions: Education is involved in about a third of changes in clinical practice. The wide range of other factors affecting changes in practice need to be taken into account in providing and evaluating education. The role of education in the numerous changes in clinical practice that currently have no educational component should also be considered.

There is a paucity of knowledge regarding teenage health even though it features as one of the priority areas in the government's health plans. There have been few reports of adolescent contacts with primary care teams, although there are impressions of a suboptimal service. As a prelude to understanding more about communication between general practitioners and teenage patients, this study aimed to look at the time spent on teenage consultations, which can be used as one method of describing the quality of care provided to teenage patients. Nine-hundred consultations involving six doctors in one surgery were timed over a 3 month period by one observer using a validated method. One-hundred and nineteen consultations with patients aged 11-19 were compared with the 781 consultations for other age groups and showed a statistically significant mean shortfall of nearly 2 minutes (23%). This trend was confirmed for all six doctors, despite a broad range of average consulting times. The study also demonstrated some other characteristics of teenage consultations. Several implications of these results are discussed as well as possible reasons for these findings. The study emphasizes the need for further research in this area.

The role of the general practitioner in the detection and management of Chlamydia trachomatis infections of the cervix is uncertain. The management by the primary care team of women presenting with lower genital tract symptoms has therefore been studied in one suburban practice. Of 386 women presenting with lower genital tract symptoms over the two year study period 25 (6%) had a positive cervical MicroTrak (Syva) test for Chlamydia trachomatis. Twenty four of these chlamydia positive patients were given their results and treatment by the practice. Twenty two women returned for a follow-up MicroTrak test after treatment and two of these patients (9%) had a positive test following treatment. A review of the patients' notes indicated that contact tracing had been discussed with 22 of the 25 chlamydia positive patients. The results of the management of chlamydial cervicitis by this primary health care team are acceptable when compared with studies from hospital clinics. Provided the primary care team has access to facilities for the diagnosis of C trachomatis and can follow up non-attenders to ensure they receive their results, provide information about contact tracing and follow up positive patients then chlamydial cervicitis can be managed in general practice.

A survey of the involvement in and attitudes towards continuing medical education of 101 general practitioners achieved a 95% response rate. Ninety per cent of the 96 doctors worked in practices which held meetings the content of which was organized by representatives of pharmaceutical companies but only 46% worked in practices which organized their own educational meetings. Seventy six per cent attended meetings away from their practice which were organized by drug companies and 75% had attended at some time continuing medical education activities organized by a local postgraduate centre. The promotional aspects of the drug company organized meetings were disliked by a majority of respondents (58%); more of the trainers (62%) and more of those who had entered general practice within the last seven years (71%) disliked this aspect. Nonetheless the educational content of both meetings held in the practice and those held elsewhere was the aspect most liked by over half of the respondents (59% and 53% respectively). Only 16% of all respondents thought that visits by representatives from pharmaceutical companies were educationally valuable and 37% thought that educational events organized by these companies were of value. Surprisingly 60% of those who worked in practices which held meetings organized by drug company representatives thought them to be of little or no educational value. There is clearly a need for practice based continuing medical education but the current level of dependence on drug companies for organizing these meetings must be questioned. Alternative strategies for the provision of independent non-sponsored educational activities should be sought.

To study continuing medical education 96 out of 101 general practitioners chosen at random from the list held by a family practitioner committee were interviewed. The results provided little evidence of regular attendance at local postgraduate centre meetings, though practice based educational meetings were common. Thirty one of the general practitioners worked in practices that held one or more practice based educational meetings each month at which the doctors provided the main educational content. Performance review was undertaken in the practices of 51 of the general practitioners, and 80 of the doctors recognised its value. The general practitioners considered that the most valuable educational activities occurred within the practice, the most valued being contact with partners. They asked for increased contact with hospital doctors. The development of general practitioners' continuing medical education should be based on the content of the individual general practitioner's day to day work and entail contact with his or her professional colleagues.