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As the variety of specific treatments in a disease area increases, there may be a growing interest in employing treatment sequencing within health economic models. The aim of this review was to identify and thematically analyze patterns regarding the approaches to modeling treatment sequencing in National Institute for Health and Care Excellence (NICE) appraisals.
Methods
A review of NICE technology appraisals (TAs) published between 1 January 2020 and 13 March 2023 was conducted.
Results
A total of twenty-four TAs incorporating treatment sequencing were included, most commonly in autoimmune and oncology indications. Primary justifications for companies employing treatment sequencing were precedence and alignment with clinical practice, whilst lack of appropriate clinical data was cited to justify its exclusion. Relatedly, External Assessment Groups commonly criticized treatment sequences for oversimplifying clinical practice. Notably, almost half of identified TAs assumed that the relative efficacy of an intervention was maintained regardless of disease severity or position within the treatment sequence.
Conclusion
A substantial proportion of TAs employed treatment sequencing, but it is challenging to determine the impact of current approaches on the overall uncertainty associated with any health economic model. The challenges identified in this review could be used to inform future formal guidance and associated methodology for the implementation of treatment sequencing modeling, which could improve the comparability and reliability of models and their results.
To explain human social sophistication, and proximal phylogenetic steps leading to it, Dunbar claims that mentalising expands to increasingly high levels of recursion. However, the evidential basis for this claim is weak, exposing both a limitation in Dunbar’s account and in the field’s current understanding of social sophistication.
Facial expression has evolved as a solution to the primate group living problem. A growing body of empirical evidence suggests that the evolution of facial expression has been driven by the need to bond. Dunbar’s theories of group cohesion are therefore key to understanding primate (including human) facial expression.
Echocardiography is the preferred method for the visual assessment of bubble load in divers. This study evaluates the feasibility of a microteaching program for training combat medics to perform ultrasound measurements using echocardiography for self-monitoring decompression stress on the waterside.
Materials and Method:
A microteaching was provided to combat medics of the Netherlands Armed Forces. Participants used a handheld ultrasound device connected to a tablet. After two minutes practice time, medics performed and recorded videos on randomly assigned partners while being assessed by an anesthesiologist. Three outcomes were measured: (1) observer-assessed performance adapted from Objective Structured Assessment of Technical Skills (OSATS); (2) self-perceived procedure experience; and (3) video recording quality on a five-point scale.
Results:
All 21 combat medics completed the microteaching program. Three out of 21 video recordings were lost due to technical issues. All participants successfully obtained at least a partial cardiac view (median time: 61 seconds). Performance scores indicated near-competence across preparation, time-motion, and procedural flow. Image quality ratings by two reviewers showed near-perfect intra-rater agreement (κ = 0.904 and κ = 0.960) but substantial inter-rater variability (κ = 0.671); the assessor’s median scores were 2.75 and 3.0 out of 5.0, respectively. Most recordings received average scores of 3.0 or higher.
Conclusion:
This study demonstrates that combat medics, following a brief microteaching session, were able to acquire cardiac ultrasound images partially suitable for assessing vascular gas emboli (VGE). These findings support microteaching as a feasible first step in echocardiography training for combat medics in austere environments.
Specialised forms of social cognition enable primates to manage the stresses of group living by allowing for flexible and intentional communication. This is used to increase the predictability of conspecifics’ behaviour for both signallers and receivers. Intentional communication helps to overcome the stimulus-driven processing that may occur due to stress, enhancing attention allocation in receivers.
The current manuscript rightly points out that non-human primates evolved complex social cognitive skills to maintain weaker social ties. However, these capacities are likely more expansive than currently proposed: research shows that apes behave more socially to those with whom they experience similar things, suggesting that they possess some precursor of humans’ capacity to bond through shared experiences.
Dunbar explains primates group cohesion through cognitive and structural mechanisms like grooming and social cognition. We extend this by highlighting collective social niche construction, where emergent social properties arise from feedback loops, selection pressures, and self-organisation. Adaptive social networks evolve through multilevel selection, cultural transmission, and ontogenetic changes, shaping survival, cognition, and collective intelligence across species.
Primate species deploy a suite of behavioural and cognitive adaptations to offset the costs of group-living. Dunbar uses species-level comparisons to posit a series of cumulative steps that describe large-scale phylogenetic patterns in the evolution of sociality. Here, we highlight the value of population-level variation within species for empirically testing the predicted socio-ecological correlations that underpin Dunbar’s hypothesis.
Dunbar presents an intriguing analysis of variance in primate group sizes, and social glue’s (grooming) relationship to cognitive evolution. This focus on primates with consistent and stable grouping excludes perspectives on the evolution of grouping beyond predation and competition. The analysis raises important questions about variation, dynamic sizes, and the conservation implications of variance for primate population extinction vulnerabilities.
Paraxerus cepapi is an arboreal tree squirrel that occurs in the Savanna biome of Africa, and information on its parasite diversity is limited and mostly qualitative. The aim of the study was to record the diversity and abundance of ecto- and helminth parasites associated with P. cepapi across its distribution in South Africa. P. cepapi individuals (n = 94) were opportunistically obtained from eight localities during 2020 to 2024. In total, 21 parasite species (19 ectoparasites and two nematodes) and one tick species group were identified. This included lice, ticks, fleas, a mesostigmatic mite, chiggers, nematodes and cestodes. Nematodes were the most prevalent (93·67%), followed by lice (80·85%). Syphatineria cepapi was recorded in 92·41% of P. cepapi, while an unknown Strongyloides species, resembling S. robustus, was recorded in 21·52% of squirrels. The lice species displayed variation in parasitope preference, while chiggers were primarily recorded in the ears. This study provides new country records for the lice species Werneckia paraxeri and Enderleinellus heliosciuri, for the chigger species Microtrombicula polymorpha, and for the nematode S. cf. robustus. New locality records were documented for the nematode S. cepapi in South Africa, and P. cepapi is a new host record for the eight chigger species and S. cf. robustus. It is evident that P. cepapi in South Africa hosts a considerably larger diversity of parasite taxa than previously recorded. Nematode counts were related to host length. These findings warrant future studies on the parasite diversity of P. cepapi in Africa.
Human social networks are far larger than those of nonhuman primates. Maintaining cohesion in large networks requires a robust mechanism that can accommodate the dense webs of connections within communities. A parsimonious account of how humans achieve social cohesion is mental abstraction, which enables individuals to construct fuzzy network representations that facilitate information flow tracking and mitigate conflict.
Drawing on our previous work on human trust networks, we provide further evidence of how group structure can foster group cohesion. But this work also raises doubts about two central tenets of the target paper: (1) the role assigned to cognitive abilities in group cohesion and stabilization; and (2) the emphasis on group size as the critical variable.
Cyantraniliprole is a widely used insecticide that disrupts calcium homeostasis by binding to ryanodine receptors (RyRs) in the sarcoplasmic reticulum. Insects have a type of RyR with a 47% sequence homology to mammalian RyRs. Due to the high homology and strong affinity of cyantraniliprole for insect RyRs, concerns have been raised about potential adverse effects in mammals. This study aimed to evaluate the effects of cyantraniliprole on the liver and kidneys of male Wistar rat offspring exposed to a dose of 10 mg/kg during gestation and lactation. Thirty-three 80-day-old pregnant Wistar rats were randomly assigned to either a control group or a cyantraniliprole group (10 mg/kg). The treatment period lasted from the 5th gestational day to the 21st lactational day. The offspring were euthanized on postnatal day 55 (puberty) or 90 (adulthood). Blood samples were collected for biochemical assays, and liver and kidney samples were collected for histopathological analysis, oxidative stress biomarkers, and inflammatory profile assessment. The results indicated that exposure to cyantraniliprole caused vacuolation and vascular congestion in the pubertal and adult offspring, as well as significant morphological changes in the liver and kidneys. There was an increase in catalase and glutathione S-transferase activity in response to oxidative stress induced by the insecticide in the liver, with elevated levels of thiobarbituric acid reactive substances in the liver of adult animals and increased myeloperoxidase activity in pubertal animals. These findings suggest that exposure to cyantraniliprole induces significant damage to the organs involved in metabolism and excretion.
Saturated fatty acids, particularly palmitic acid (PA), promote inflammation and contribute to chronic diseases such as type 2 diabetes and cardiovascular disease. PA induces interleukin-1 beta (IL-1β) production in lipopolysaccharide (LPS)-primed macrophages via NLRP3 inflammasome activation; but the underlying mechanism remains unclear. This study investigates whether PA-induced IL-1β production involves cytosolic potassium (K+) depletion. In LPS-primed macrophages, treatment with PA conjugated to bovine serum albumin (PA-BSA) significantly reduced cytosolic K+ levels and increased IL-1β production 2.4-fold. Stearic acid-BSA produced similar effects, whereas BSA-bound oleic, linoleic and docosahexaenoic acids had minimal impact. Voltage-gated potassium (Kv) channel blockers, 4-aminopyridine and tetraethylammonium chloride, attenuated PA-BSA-induced K+ efflux and IL-1β production in LPS-primed macrophages, implicating Kv channels as key mediators. These findings reveal a novel inflammatory pathway in which PA-BSA promotes IL-1β production via Kv channel-dependent K+ efflux, highlighting a mechanistic link between saturated fatty acid exposure and inflammatory signalling.
Dunbar suggests structural, behavioral, and cognitive mechanisms to mitigate the costs of living in large groups. While we generally concur with the notion of group size effects on female productivity, we call for a more explicit treatment of how functional support alleviates social costs and disagree with the outright dismissal of ecological drivers and phylogenetic inertia.
Body-focused repetitive behaviors (BFRBs) include activities like hair pulling and skin-picking that can lead to functional impairment. The neurocognitive underpinnings of BFRBs remain unclear, with inconsistent findings across domains.
Methods:
This online study aimed to investigate the neuropsychological capacities of individuals with self-reported BFRBs. We administered the Go/No-Go test to assess inhibitory control and attention and the Verbal Learning and Memory Test to evaluate learning, recall, and memory confidence. From the 2,129 participants who entered the survey, 412 individuals with self-reported BFRBs and 412 matched controls from the general population were included. Drop-out was high.
Results:
Individuals with BFRBs showed no inhibitory deficits on the Go/No-Go test but made fewer hits on the Go trials compared to controls, indicating attentional lapses. Regarding memory, only immediate recall was worse in the BFRB sample. Controls were biased toward being more confident. When we divided the sample by impairment (>1 SD below the mean of controls), a minority of the BFRB group showed deficits in attention and immediate recall.
Conclusions:
Our findings suggest that neurocognitive deficits are not prevalent in BFRB, affecting less than 20% of our sample. Yet, attentional problems in a subgroup of individuals with BFRB highlights the need to study heterogeneity within BFRBs. Potential moderators such as motivation, stress, and self-stigma remain to be explored. Our findings must be interpreted with caution given the study’s limited generalizability due to its online format, high drop-out rate, and absence of independent diagnostic confirmation.
Dunbar exclusively sees groups as arising through the aggregate relationships between individuals and thereby makes the serious omission of not considering the capacity of those individuals to categorize one another as ingroup versus outgroup members.
Agitation is one of the most distressing behavioral symptoms among hospice-eligible patients with dementia. It compromises patient comfort, increases caregiver burden, and undermines the quality of end-of-life care. Although pharmacologic treatments are frequently used, evidence guiding their safe and effective use in this population remains limited.
Objective
To identify and synthesize existing randomized controlled trials (RCTs) that evaluated interventions for agitation in hospice-eligible patients with dementia, and to assess the quality and relevance of current evidence.
Methods
A narrative review was conducted using systematic search strategies to identify RCTs published between 1990 and 2024 across 8 databases. Studies were included if they (1) focused on hospice-eligible patients with dementia, (2) targeted agitation as a major outcome, and (3) used an RCT design. Studies lacking eligibility criteria, non-RCTs, and non-English articles were excluded.
Results
Of 44 articles screened, only 3 met the inclusion criteria: 2 studies tested nonpharmacological interventions (Namaste and Balancing Arousal Controls Excesses) and 1 tested a pharmacological intervention (sertraline). Results from the nonpharmacological interventions were mixed, and the pharmacologic trial showed no difference between treatment and placebo. Common limitations included small sample sizes, lack of racial and gender diversity, and absence of home-based hospice settings.
Significance of results
There is a critical gap in high-quality and generalizable evidence to guide agitation management at the end of life for patients with dementia. Addressing this gap is essential to improving not only symptom control but also to preserving dignity and reducing caregiver distress in hospice care. Future trials must include diverse populations, incorporate home-based hospice settings, and rigorously evaluate both pharmacologic and nonpharmacologic interventions to support compassionate, patient-centered care.
This review highlights urgent gaps in research and care delivery, underscoring the need for inclusive and scalable intervention designs to address agitation at the end of life.
The paper of Dunbar (2025) on social stress is a strong demonstration that stress in itself can have a purely cognitive origin. The paper shows that the cognitive system can have profound impacts on the hypothalamus. As detailed in my commentary, this opens up new avenues of how to interpret psychiatric conditions, placebo, and other associations between perceptions and vegetative functions in the brain.
Grooming is one strong mechanism allowing primate groups to grow larger and more cohesive, but a reduction in reactive aggression responses can be expected to have contributed to this trend too. There is indeed a partial overlap between the neurobiology of grooming and the neurobiology of reactive aggression.