A randomised controlled trial to compare the clinical and cost-effectiveness of prism glasses, visual search training and standard care in patients with hemianopia following stroke: a protocol

INTRODUCTION

Homonymous hemianopia is a common and disabling visual problem after stroke. Currently, prism glasses and visual scanning training are proposed to improve it. The aim of this trial is to determine the effectiveness of these interventions compared to standard care.

METHODS AND ANALYSIS

The trial will be a multicentre three arm individually randomised controlled trial with independent assessment at 6 week, 12 week and 26 week post-randomisation. Recruitment will occur in hospital, outpatient and primary care settings in UK hospital trusts. A total of 105 patients with homonymous hemianopia and without ocular motility impairment, visual inattention or pre-existent visual field impairment will be randomised to one of three balanced groups. Randomisation lists will be stratified by site and hemianopia level (partial or complete) and created using simple block randomisation by an independent statistician. Allocations will be disclosed to patients by the treating clinician, maintaining blinding for outcome assessment. The primary outcome will be change in visual field assessment from baseline to 26 weeks. Secondary measures will include the Rivermead Mobility Index, Visual Function Questionnaire 25/10, Nottingham Extended Activities of Daily Living, Euro Qual-5D and Short Form-12 questionnaires. Analysis will be by intention to treat.

ETHICS AND DISSEMINATION

This study has been developed and supported by the UK Stroke Research Network Clinical Studies Group working with service users. Multicentre ethical approval was obtained through the North West 6 Research ethics committee (Reference 10/H1003/119). The trial is funded by the UK Stroke Association. Trial Registration: Current Controlled Trials ISRCTN05956042. Dissemination will consider usual scholarly options of conference presentation and journal publication in addition to patient and public dissemination with lay summaries and articles.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN05956042.

Conditions for enhancing the encoding of an elementary motor memory by rTMS

OBJECTIVE

Motor learning results in changes of movement representation in primary motor cortex (M1) a process involving long-term potentiation (LTP). Pairing motor training with repetitive transcranial magnetic stimulation (rTMS) of M1 enhances the formation of a motor memory. Here we determined the effect of pairing M1 stimulation and the execution of training movements at different times and frequencies on the formation of a motor memory.

METHODS

Formation of a motor memory was defined as increases in motor evoked potentials (MEP) of the training agonist (extensor carpi ulnaris muscle, ECU) and increases in peak acceleration of the trained movements that last more than 60min. Training consisted of auditory-paced ballistic wrist extension movements (30min, 0.5Hz) paired with 0.1, 0.25 or 0.5Hz subthreshold rTMS. The rTMS pulse was applied at either the onset, 100ms prior to or 300ms after the onset of training movement related increases in electromyographic (EMG) activity of ECU. This was compared to a Sham condition.

RESULTS

Only 0.1Hz rTMS applied at the onset of the training related increase in ECU-EMG activity resulted in increases in MEP amplitudes and peak acceleration when compared to the Sham.

CONCLUSIONS

The formation of motor memory is enhanced above the naïve level by co-administration of low frequency rTMS at the time of execution of training movements.

SIGNIFICANCE

These results indicate the importance of time and frequency of rTMS in these settings and should be considered in the design of rehabilitation treatment strategies using rTMS.

Electron-phonon coupling on the surface of the topological insulator Bi2Se3 determined from surface-phonon dispersion measurements

In this Letter, we report measurements of the coupling between Dirac fermion quasiparticles (DFQs) and phonons on the (001) surface of the strong topological insulator Bi2Se3. While most contemporary investigations of this coupling have involved examining the temperature dependence of the DFQ self-energy via angle-resolved photoemission spectroscopy measurements, we employ inelastic helium-atom scattering to explore, for the first time, this coupling from the phonon perspective. Using a Hilbert transform, we are able to obtain the imaginary part of the phonon self-energy associated with a dispersive surface-phonon branch identified in our previous work [Phys. Rev. Lett. 107, 186102 (2011)] as having strong interactions with the DFQs. From this imaginary part of the self-energy we obtain a branch-specific electron-phonon coupling constant of 0.43, which is stronger than the values reported from the angle-resolved photoemission spectroscopy measurements.

An experimental study on costal osteochondral graft

OBJECTIVE

To investigate usefulness of osteochondral grafting from the costo-osteochondral junction as a repair technique for articular cartilage defects histologic and biochemical analysis of grafted cartilage in rabbit knees was evaluated up to 48 weeks after transplantation.

METHODS

Twenty New Zealand White rabbits were used. A costal osteochondral plug was harvested from a middle rib. After trimming, it was transplanted into a cylindrical osteochondral 2.5 mm diameter and 5 mm deep defect created in the knee. The animals were sacrificed at 6, 12, 24, and 48 weeks after transplantation. Defect sites were inspected macroscopically, and then by light microscopy. Samples were evaluated for cell viability using a fluorescent in situ double-staining protocol with confocal laser microscopic analysis. Samples were also processed to assess type I & II collagen and aggrecan mRNA expression using reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

Histologically, bone union was achieved in all plugs. Confocal microscopic analysis revealed chondrocyte viability in the 48-week grafts; the distribution of chondrocytes was similar to surrounding articular cartilage. The expression of type II collagen and aggrecan mRNA in the grafted cartilage was consistent with normal articular cartilage and normal costal cartilage. These results were observed over 6-48 weeks.

CONCLUSIONS

Our study revealed that chondrocytes in the grafted cartilage were viable at least up to 48 weeks and that mRNA expression of type II collagen and aggrecan was also similar to that of normal articular cartilage. These results suggest that costal osteochondral grafting can be a useful alternative in the treatment of osteochondral defects.

Interaction of phonons and dirac fermions on the surface of Bi2Se3: a strong Kohn anomaly

We report the first measurements of phonon dispersion curves on the (001) surface of the strong three-dimensional topological insulator Bi2Se3. The surface phonon measurements were carried out with the aid of coherent helium beam surface scattering techniques. The results reveal a prominent signature of the exotic metallic Dirac fermion quasiparticles, including a strong Kohn anomaly. The signature is manifest in a low energy isotropic convex dispersive surface phonon branch with a frequency maximum of 1.8 THz and having a V-shaped minimum at approximately 2kF that defines the Kohn anomaly. Theoretical analysis attributes this dispersive profile to the renormalization of the surface phonon excitations by the surface Dirac fermions. The contribution of the Dirac fermions to this renormalization is derived in terms of a Coulomb-type perturbation model.

Open Air Laboratories (OPAL): a community-driven research programme

OPAL is an English national programme that takes scientists into the community to investigate environmental issues. Biological monitoring plays a pivotal role covering topics of: i) soil and earthworms; ii) air, lichens and tar spot on sycamore; iii) water and aquatic invertebrates; iv) biodiversity and hedgerows; v) climate, clouds and thermal comfort. Each survey has been developed by an inter-disciplinary team and tested by voluntary, statutory and community sectors. Data are submitted via the web and instantly mapped. Preliminary results are presented, together with a discussion on data quality and uncertainty. Communities also investigate local pollution issues, ranging from nitrogen deposition on heathlands to traffic emissions on roadside vegetation. Over 200,000 people have participated so far, including over 1000 schools and 1000 voluntary groups. Benefits include a substantial, growing database on biodiversity and habitat condition, much from previously unsampled sites particularly in urban areas, and a more engaged public.

Independent measurement of the total active 8B solar neutrino flux using an array of 3He proportional counters at the Sudbury Neutrino Observatory

The Sudbury Neutrino Observatory (SNO) used an array of 3He proportional counters to measure the rate of neutral-current interactions in heavy water and precisely determined the total active (nu_x) 8B solar neutrino flux. This technique is independent of previous methods employed by SNO. The total flux is found to be 5.54_-0.31;+0.33(stat)-0.34+0.36(syst)x10(6) cm(-2) s(-1), in agreement with previous measurements and standard solar models. A global analysis of solar and reactor neutrino results yields Deltam2=7.59_-0.21;+0.19x10(-5) eV2 and theta=34.4_-1.2;+1.3 degrees. The uncertainty on the mixing angle has been reduced from SNO's previous results.

Efficacy, safety and lack of immunogenicity of insulin aspart compared with regular human insulin for women with gestational diabetes mellitus

AIM

The efficacy and safety of insulin aspart (IAsp), a rapid-acting human insulin analogue, were compared with regular human insulin (HI) as the bolus component of basal-bolus therapy for subjects with gestational diabetes mellitus (GDM).

METHODS

In a randomized, parallel-group, open-labelled trial, 27 women with GDM (age 30.7 +/- 6.3 years, HbA(1c) < 7%) were randomized to receive IAsp (5 min before meal) or HI (30 min before meal). The trial period extended from diagnosis of GDM (18-28 weeks) to 6 weeks postpartum.

RESULTS

Both treatment groups maintained good overall glycaemic control during the study (beginning and end of study HbA(1c)< or = 6%). During the meal test, mean glucose at week 6 (IAsp 4.2 +/- 0.57 mmol/l, HI 4.8 +/- 0.86 mmol/l) was slightly lower than at week 0 (IAsp 4.9 +/- 0.59 mmol/l, HI 5.1 +/- 0.36 mmol/l). However, change from baseline values for average glucose (IAsp -1.09 +/- 0.54 mmol/l, HI -0.54 +/- 0.74 mmol/l; P = 0.003) and C-peptide (IAsp -0.50 +/- 0.67 nmol/l, HI -0.30 +/- 0.70 nmol/l; P = 0.027) were significantly lower after IAsp treatment than HI treatment. No major hypoglycaemic events were reported during the study. Cross-reacting insulin antibody binding increased slightly from baseline in both treatments groups (end of study: IAsp 2.1 +/- 5.4%, HI 6.4 +/- 13.9%), whereas antibodies specific to IAsp or HI remained relatively low (< 1% binding).

CONCLUSION

IAsp was more effective than HI in decreasing postprandial glucose concentrations. Duration of IAsp injection 5 min before a meal rather than 30 min prior to meals offers a more convenient therapy for subjects with GDM. Overall safety and effectiveness of IAsp were comparable to HI in pregnant women with GDM.

Comparison of the antibody in lymphocyte supernatant (ALS) and ELISPOT assays for detection of mucosal immune responses to antigens of enterotoxigenic Escherichia coli in challenged and vaccinated volunteers

In the present study we compared the ELISPOT and antibody in lymphocyte supernatants (ALS) assays as surrogate measures of mucosal immunity. In separate studies, 20 inpatient volunteers received oral doses of 6 x 10(8) or 4 x 10(9)cfu of ETEC strain E24377A (LT+, ST+, CS1+, CS3+) and 20 subjects received 1 (n = 9) or 2 (n = 11) oral doses of the attenuated ETEC vaccine, PTL-003 expressing CFA/II (CS1+ and CS3+) (2 x 10(9)cfu/dose). Peripheral blood mononuclear cells (PBMCs) from all subjects were assayed for anti-colonization factor or toxin-specific IgA antibody responses using the ALS and ELISPOT procedures. ALS responses were measured using a standard ELISA, as well as by time-resolved fluorescence (TRF). Following challenge with E24377A, significant anti-CS3, CS1 and LT ALS responses were detected in the lymphocyte supernatants of 75-95% of the subjects. A similar proportion (75%) of subjects mounted an ALS response to CFA/II antigen after vaccination with the PTL-003 vaccine. Inter-assay comparisons between ALS and ELISPOT methods also revealed a high degree of correlation in both immunization groups. ALS sensitivity versus the ELISPOT assay for LT, CS3 and CS1-specific responses following challenge were 95%, 94% and 78%, respectively and 83% for the ALS response to CFA/II antigen after vaccination with PTL-003. Correlation coefficients for the LT and CS3 antigens were 0.94 (p<0.001) and 0.82 (p<0.001), respectively after challenge and 0.78 (p<0.001) after vaccination. The association between ALS and ELISPOT for the CS1 antigen was however, significant only when ALS supernatants were tested by TRF (r = 0.91, p<0.001). These results demonstrate the value and flexibility of the ALS assay as an alternative to ELISPOT for the measurement of mucosal immune responses to ETEC antigens, particularly when the complexities of ELISPOT may make it impractical to perform.

The anatomy of tibial eminence fractures: arthroscopic observations following failed closed reduction

BACKGROUND

Failed manipulative reduction of avulsion fractures of the tibial insertion of the anterior cruciate ligament has been attributed to interposition of soft tissues, particularly the anterior horn of the medial meniscus. The objectives of the present report were (1) to show that the failure to reduce Meyers and McKeever type-III tibial eminence fractures was not due to interposition of soft tissues and (2) to discuss the relevance of the finding that the anterior third of the lateral meniscus was attached to the avulsed anterior cruciate ligament insertion site in all patients studied.

METHODS

Twelve patients who had had a failed manipulative reduction of a type-III tibial eminence fracture underwent arthroscopic reduction and fixation of the avulsed fragment.

RESULTS

A number of consistent findings were noted. The avulsed intercondylar eminence was displaced superiorly into the intercondylar notch. Attached to this fragment was not only the anterior cruciate ligament, but also, in all cases, the anterior horn of the lateral meniscus. The anterior third of the lateral meniscus had been torn from its tibial attachment and displaced together with the osseous fragment into the intercondylar notch. No interposition of bone or soft tissue was observed. Reduction of the osseous fragment was facilitated by traction on, or sutures passed around, the anterior horn of the lateral meniscus. Standard fixation methods were utilized.

CONCLUSIONS

The concept that avulsion fractures of the tibial insertion of the anterior cruciate ligament cannot be reduced by manipulation because of soft-tissue interposition was not supported by the findings of the present study. The attachment of the anterior horn of the lateral meniscus to the avulsed tibial insertion of the anterior cruciate ligament may not be an irrelevant incidental finding. The observation that the displaced osseous fragment was attached simultaneously to the anterior cruciate ligament and to the anterior horn of the lateral meniscus, both pulling in different directions, may explain why type-III tibial eminence fractures are irreducible by manipulation.

Mycobacterium paratuberculosis heat shock protein 70 as a tool in control of paratuberculosis

Paratuberculosis in cattle is a chronic intestinal disease in which a distinctive cellular reactivity of a Th1-type preceeds the phase in which antibody titers are easily detectable and the animal becomes clinically ill. During infection with Mycobacterium avium ssp. paratuberculosis (M.a.p), a decrease in CD4 T-helper cells has been observed in the clinical phase. Our ultimate aim is to elicit a cytotoxic reaction against infected macrophages, using recombinant Hsp70 (rHsp70) of M.a.p. as a tool to shuttle antigen into the MHC class I antigen presentation pathway. To investigate the mechanism of rHsp70 as a carrier for antigen into the cell, we studied the interaction between APC and Fitc-labelled rHsp70, using FACS analysis and confocal microscopy. Interaction of rHsp70 with the cell surface of bovine APC, presumably via a receptor, was shown on monocytes, monocyte derived macrophages and dendritic cell (DC). The interaction is detectable on the complete population of freshly derived monocytes, although peak intensity of fluorescence is lower on these cells than on macrophages and DCs. DCs show interaction on a high percentage of the cells, with high intensity, while in the case of macrophages only a subpopulation interacts with rHsp70. Efficient uptake of rHsp70 as compared to OVA is shown. Preincubation of DC with unlabelled rHsp70 leads to a decreased interaction with rHsp70-FITC. DC interacting with rHsp70 in addition showed high expression of MHC I, MHC II, Myd-1 (CD172a) and CD40. Further research will focus on loading of the rHsp70 with M.a.p. antigen for presentation in MHC class I.

Characterization of humoral and cellular immune responses elicited by meningococcal carriage

In order to study the immune response elicited by asymptomatic carriage of Neisseria meningitidis, samples of serum, peripheral blood mononuclear cells (PBMCs), and saliva were collected from a cohort of more than 200 undergraduate students in Nottingham, United Kingdom, who were subject to high rates of acquisition and carriage of meningococci. Serum immunoglobulin G levels were elevated following increases in the rate of carriage, and these responses were specific for the colonizing strains. In order to investigate T-cell responses, PBMCs from 15 individuals were stimulated with a whole-cell lysate of the H44/76 meningococcal strain (B:15:P1.7,16), stained to detect cell surface markers and intracellular cytokines, and examined by flow cytometry. The cells were analyzed for expression of CD69 (to indicate activation), gamma interferon (IFN-gamma) (a representative T-helper 1 subset [Th1]-associated cytokine), and interleukin-5 (IL-5) (a Th2-associated cytokine). Following a brief meningococcal stimulation, the numbers of CD69(+) IFN-gamma(+) CD56/16(+) NK cells were much higher than cytokine-positive CD4(+) events. Both IFN-gamma(+) and IL-5(+) events were detected among the CD69(+) CD4(+) population, leading to the conclusion that an unbiased T-helper subset response was elicited by meningococcal carriage.

Foreign-body synovitis mimicking septic arthritis of the knee

Three cases are presented of recurrent synovitis of the knee in children caused by the presence of foreign material. There was no clear history of trauma. Arthroscopy is a useful method providing early diagnosis and simultaneous treatment of this condition.