Validation of the brain injury associated visual impairment - impact questionnaire (BIVI-IQ)

PURPOSE

The Brain Injury associated Visual Impairment - Impact Questionnaire (BIVI-IQ) was developed to assess the impact of post-stroke visual impairment. The development of the questionnaire used robust methods involving stroke survivors and clinicians. The aim of this study was to assess the validity of the BIVI-IQ in a stroke population.

METHODS

Stroke survivors with visual impairment were recruited from stroke units, outpatient clinics and non-healthcare settings. Participants were asked to complete questionnaire sets on three separate occasions; the BIVI-IQ at each visit with additional questionnaires at baseline and visit 2. Vision assessment and anchor questions from participants and clinicians were collected. The analysis included assessment of missing data, acceptability, Rasch model analysis, test-retest reliability, construct validity (NEI VFQ-25, EQ-5D-5L) and responsiveness to change.

RESULTS

316 stroke survivors completed at least one questionnaire of the 326 recruited. Mean age was 67 years and 64% were male. Adequate fit statistics to the Rasch model were reached (χ2 = 73.12, p = 0.02) with two items removed and thresholds of two adjusted, indicating validity and unidimensionality. Excellent test-retest reliability was demonstrated (ICC = 0.905) with a 3-month interval. Construct validity was demonstrated with a strong significant correlation to the NEI VFQ-25 (r = 0.837, p < 0.01). The BIVI-IQ also demonstrated responsiveness to change with significant differences identified between groups based on participant and clinician anchor questions (X2 = 23.29, p < 0.001; X2 = 24.56, p < 0.001).

CONCLUSION

The BIVI-IQ has been shown to be valid and practical for 'everyday' use by clinicians and researchers to monitor vision-related quality of life in stroke survivors with visual impairment.

Long-term evaluation of clinical success and safety of omadacycline in nontuberculous mycobacteria infections: a retrospective, multicenter cohort of real-world health outcomes

Infections due to nontuberculous mycobacteria (NTM) continue to increase in prevalence, leading to problematic clinical outcomes. Omadacycline (OMC) is an aminomethylcycline antibiotic with FDA orphan drug and fast-track designations for pulmonary NTM infections, including Mycobacteroides abscessus (MAB). This multicenter retrospective study across 16 U.S. medical institutions from January 2020 to March 2023 examined the long-term clinical success, safety, and tolerability of OMC for NTM infections. The cohort included patients aged ≥18 yr, who were clinically evaluable, and` had been treated with OMC for ≥3 mo without a previous diagnosis of cystic fibrosis. The primary outcome was 3 mo clinical success, with secondary outcomes including clinical improvement and mortality at 6- and 12 mo, persistence or reemergence of infection, adverse effects, and reasons for OMC utilization. Seventy-five patients were included in this analysis. Most patients were female (48/75, 64.0%) or Caucasian (58/75, 77.3%), with a median (IQR) age of 59 yr (49-67). Most had NTM pulmonary disease (33/75, 44.0%), skin and soft tissue disease (19/75, 25.3%), or osteomyelitis (10/75, 13.3%), and Mycobacterium abscessus (60/75, 80%) was the most commonly isolated NTM pathogen. The median (IQR) treatment duration was 6 mo (4 - 14), and the most commonly co-administered antibiotic was azithromycin (33/70, 47.1%). Three-month clinical success was observed in 80.0% (60/75) of patients, and AEs attributable to OMC occurred in 32.0% (24/75) of patients, leading to drug discontinuation in 9.3% (7/75).

Steady-state sound propagation through hot exhaust jets in cooler cross-flow: A computational study

An analysis has been carried out to investigate the sound radiation through a heated jet in cooler cross-flow, which is representative of many industrial exhaust systems, using a hybrid steady-state computational fluid dynamics and computational acoustic model. The mean flow and temperature fields are modelled using steady-state computational fluid dynamics, with the turbulence modelled using Reynolds Averaged Navier-Stokes equations. The corresponding mean flow and temperature fields are used in the computational sound propagation model using linearised acoustic wave equation with mean flow based on a scalar flow potential. The results obtained from the computational simulations show that the flow significantly changes the sound propagation path and that the sound levels downstream of the duct outlet are higher than expected from using an acoustic monopole radiation pattern. The dominant mechanism affecting the propagation of sound is the refraction arising from the plume's temperature and velocity gradients. The sound propagation is highly dependent on the proximity from the duct outlet, normalised wavenumber, temperature and the jet to cross-flow mean velocity ratio. This computational study builds upon previous experimental work to analyse the fluid-acoustic interaction for heated jets in cooler cross-flow to understand the complex radiation pattern that leads to higher-than-expected sound levels downstream of the duct outlet.

Trainee Knowledge and Perceptions of Less Than Full Time Training

Background Less than full-time (LTFT) training in Ireland is still unusual. Our aim was to identify perceived barriers to LTFT training amongst paediatric trainees and make recommendations to improve knowledge, uptake, and experience of LTFT training. Methods An email questionnaire was disseminated to RCPI paediatric trainees to assess current awareness of and perceptions of barriers to LTFT training. Results 218 questionnaires were distributed, 59 (29%) responded of whom 50 (85%) were female. 17 planned to apply for LTFT training. Seven had no knowledge of LTFT training. The perceived barriers with the highest rankings (% respondents deeming highest possible relevance) were: LTFT post availability (49%), potential impact on career progression (51%), and availability of only 0.5 whole time equivalency (WTE) - i.e. 19.5 hours/week (54%). Trainees noted lack of flexibility, including availability of the scheme only from July to July, restriction to maximum 2 years. Trainees felt applications would be rejected if they were not a parent. Some reported perceptions from teams that LTFT trainees are less committed and that trainees can find it difficult to integrate. Discussion Training options including >0.5WTE posts should be made available to all trainees, and a cultural shift within training bodies and with trainers should be encouraged to recognise LTFT training as an acceptable pathway for all trainees.

96. Impact of Hospital-Based Pharmacist Discharge Prescription Review on the Appropriateness of Antibiotic Therapy

Background

Inappropriate antibiotic prescribing upon hospital discharge poses an increased risk of excess costs, adverse drug reactions, readmission, and resistance. Despite high rates of antibiotic prescription errors upon discharge, there is no widely accepted antimicrobial stewardship initiative to prevent such errors. This study evaluated the impact of hospital-based clinical pharmacist discharge prescription review on the appropriateness of antibiotic prescriptions.

Methods

This was a retrospective assessment of patients with discharge antibiotic prescriptions for treatment of pneumonia, urinary tract infections, Clostridioides difficile infections, acute skin and skin structure infections (ABSSSI), or Gram-negative bacteremia between January 2019 and July 2020. The two cohorts that were studied were patients on Hospitalist services versus patients on Medicine services, in which only the Medicine services had rounding pharmacists who perform discharge prescription reviews. Outcomes included demographics, appropriateness of therapy, 30-day readmission rates, and error types in discharge prescriptions. Appropriateness of therapy was validated by evidence-based guidelines and three Infectious Diseases-trained pharmacists.

Results

Our study included 300 patients, 150 per cohort. Baseline characteristics were similar between groups, with the exception of increased age (p=0.025) and fewer cases of ABSSSI (p=0.001) in the Hospitalist cohort. A statistically significant higher rate of inappropriateness was seen in the Hospitalist group versus Medicine (pharmacist) group, [69/150 (46% versus 25/150 (17%, respectively (p< 0.00001)]. The difference in appropriateness was mainly driven by pneumonia and UTI prescriptions. Thirty day readmission rates were 17% (26/150) for the Hospitalist cohort versus 11% (16/150) in the Medicine (pharmacist) cohort (p=0.134). The most common prescription error was the duration of therapy.

Conclusion

Appropriateness of antibiotic discharge prescriptions significantly improved in the setting of pharmacist discharge prescription review. This initiative highlights the important role of clinical pharmacists in the setting of outpatient antimicrobial stewardship.

Disclosures

All Authors: No reported disclosures

1082. Real-World Experience with Omadacycline for Nontuberculous Mycobacterial Infections: A Multicenter Evaluation

Background

Nontuberculous mycobacteria (NTM) are resistant to numerous antibiotics and lead to significant morbidity and mortality. Omadacycline (OMC) is an aminomethylcycline antibiotic that is Food and Drug Administration-approved for acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia. Furthermore, OMC has shown in vitro activity against NTM. Given that real-world evidence is lacking, our primary objective was to evaluate the clinical success and tolerability of OMC when used for a variety of NTM infections.

Methods

This was a multicenter, retrospective, observational study conducted from January 2020 to June 2021. We included all patients ≥ 18 years of age that received OMC of any indication for Mycobacterium spp. The primary outcome was clinical success, defined as a lack of all-cause mortality, lack of persistence or re-emergence of infection during or after therapy, and lack of alteration of OMC. Incidence of adverse effects potentially attributable to OMC and reasons for OMC utilization were also analyzed.

Results

A total of 31 patients were included from 12 geographically distinct academic health systems (median age: 57 (IQR, 45-63) years; 45% male; 81% Caucasian). The majority of isolated pathogens were Mycobacterium abscessus complex (84%) and of those with subspeciation performed (54%), the majority (86%) were subsp. abscessus. The primary infections were of pulmonary origin (67%) and the median (IQR) duration of OMC therapy was 5.3 (3.2-9.4) months. Most isolates did not have OMC susceptibility conducted (87%), while the majority did for tigecycline (90%). Clinical success was reported in 81% of the population. Most patients were on combination antimicrobial therapy, and 39% of patients reported an adverse effect while on OMC (58% gastrointestinal distress). The majority of patients were prescribed OMC due to ease of administration (61%) and antimicrobial resistance to previous antibiotics (42%).

Conclusion

OMC may be a potential option for the therapy of NTM infections. Prospective, randomized clinical trials are needed to confirm our preliminary findings.

Disclosures

Julie V. Philley, MD, Paratek Pharmaceuticals (Advisor or Review Panel member)Paratek Pharmaceuticals, Inc. (Consultant) Michael P. Veve, Pharm.D., Cumberland (Grant/Research Support)Paratek Pharmaceuticals (Research Grant or Support) Michael J. Rybak, PharmD, MPH, PhD, Paratek Pharmaceuticals (Research Grant or Support)

47. Transitioning to Batch Dosing of High-Cost Antimicrobials in the Inpatient Setting

Background

Antimicrobial stewardship (AMS) committees ensure appropriate antimicrobial utilization. One stewardship intervention is to evaluate the delivery model of high-cost antimicrobials to better utilize resources and mitigate expenses. We analyzed the total medication waste and costs of high-cost antimicrobials, specifically daptomycin, ertapenem, amphotericin, and micafungin, at our institution and propose innovative cost-savings changes at a systems level.

Methods

This retrospective study consisted of 263 patients. All patients were at least 18 years old who was admitted to our academic institution from January 2020 to April 2021 and received daptomycin, ertapenem, amphotericin, or micafungin. Demographics, daily medication dosage, total doses received, the date and time of the start of the medication, last administered dose, and discontinued order were recorded.

Results

The daptomycin cohort consisted of 143 patients with 46.2% females and average age of 56.3 years. In this group, 145.3 vials were wasted which equated to a loss of &22,630. The ertapenem group had 53 patients with 62.3% females and a mean age of 62.3 years. There were 24 vials wasted with a calculated loss of &1080. The amphotericin cohort had 32 patients with an average age of 52.2 years and 43.8% females. There were 189 vials wasted with a loss of &46,116. The micafungin group had 35 patients with 42.9% females and average age of 60.4 years. This group had 12 vials wasted with a loss of &2052.

Conclusion

Each antimicrobial has a specific formulation protocol. Daptomycin and ertapenem formulation occurs in the early morning. Amphotericin formulation occurs 2 hours prior to medication use. Micafungin formulation occurs at the time the order label prints. These medications were more often administered in the late morning to early afternoon timeframe. The order to discontinue the medications also occurred at the same interval. One reason could be due to decisions made on morning rounds from primary teams and specialty input. These orders would then be placed after rounds. A cost-saving method would be to batch and change the formulation time for all antimicrobials to later in the afternoon, which would not only prevent waste, but also allow the AMS team to effectively audit appropriate antimicrobial use.

Disclosures

All Authors: No reported disclosures

Sound propagation through elevated, heated jets in cooler cross-flow: An experimental study

Sound propagation through hot exhaust plumes with cooler cross-winds is present in many real world systems. One particular example is the sound propagation from exhaust stacks attached to open cycle gas turbine power stations. The research presented in this paper investigates the sound propagation from a reduced-scale exhaust stack, with a cross-flow from experiments conducted in a wind tunnel. Experimental measurements of the flow and temperature fields provide insight into the complex sound radiation characteristics. Results from the acoustic measurements show the change in the sound directivity arising from the inclusion of the hot exhaust plume, leading to non-axisymmetric sound directivity and a concentration of sound downwind of the exhaust stack outlet. In certain cross-flow conditions, the hot exhaust plume can increase the sound observed downwind by up to 11 dB when compared to the scenario of sound propagation from an exhaust stack in the absence of a heated jet or cross-flow. This paper describes the acoustic directivity at various radial distances from the exhaust stack, acoustic frequencies, jet temperatures, and cross-flow free-stream velocity. The results from this paper emphasise the importance of taking into consideration the hot exhaust plume with cooler cross-flow when estimating sound levels downwind of the stack.

Preliminary, Real-world, Multicenter Experience With Omadacycline for Mycobacterium abscessus Infections

Twelve patients were treated with omadacycline (OMC) as part of a multidrug regimen for Mycobacterium abscessus. The majority of infections were of pulmonary origin (7/12; 58.3%). The median (interquartile range) duration of OMC was 6.2 (4.2-11.0) months. Clinical success occurred in 9/12 (75.0%) patients. Three patients experienced a possible adverse effect while on therapy.

256. Serratia Marcescens Bacteremia and Endocarditis: A Treatment Assessment from an Academic Medical Center

Background

Serratia Marcescens (SM) is often an opportunist that has been associated as a cause of healthcare-associated infection and in some people who inject drugs (PWID). Decisions about the treatment of SM infections are difficult given the small clinical studies available and concerns for multidrug resistance. SM has the ability to produce inducible AmpC b-lactamase and may acquire extended-spectrum b-lactamase (ESBL). Evidence-based guidance is lacking in terms of identifying preferred antimicrobial therapy of SM bacteremia and endocarditis. Compared to other reports, our hospital has one of the largest SM data sets to compare.

Methods

This observation study included adult patients admitted to our hospital (2016–2019) with SM bloodstream infections, including endocarditis. Patients were excluded from the analysis, if they had a concomitant infection with another gram-negative organism. Our evaluation was designed to: compare outcomes associated with different antibiotic regimens, evaluate how care differed in PWID patients versus others, and identify factors associated with obtaining infectious diseases expert consultations (ID Consult).

Results

Forty-three patients met study inclusion/exclusion. Twenty-eight patients (65.1%) had ID Consults. Twenty-four (55.8%) were PWID. Endocarditis was diagnosed in 30.2% of patients. The most common regimen was cefepime +/- aminoglycoside, followed by a carbapenem +/- aminoglycoside. Combination therapy was only recommended during ID Consult. Piperacillin-tazobactam was used in 11.6% of patients. No regimen displayed an efficacy or safety advantage over another. Most patients (90.7%) cleared their blood stream within 48 hours of antibiotic start. Phenotypic susceptibility testing did not identify either ESBL or AmpC production in any of the isolates, including recurrences. Multi-drug resistance was not appreciated. Significant factors associated with obtaining ID Consult were: PWID (p=0.004), endocarditis (p=0.0002), sepsis (p=0.022), surgical intervention (p=0.003).

Conclusion

We could not identify an advantage with any particular antibiotic treatment regimen in this study. Induction of AmpC or selection of ESBL organisms was not displayed by any of the organisms.

Disclosures

All Authors: No reported disclosures

1290. Real-World Experience with Omadacycline for Nontuberculous Mycobacterial and Gram-Negative Infections: A Multicenter Evaluation

Background

Omadacycline (OMC) is an aminomethylcycline antibiotic in the tetracycline class that has been Food and Drug Administration-approved for acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia. OMC has been shown to have potent in vitro activity against a broad-spectrum of Gram-positive and Gram-negative organisms, as well as Nontuberculous Mycobacteria (NTM). Due to it’s unique activity and availability as an oral agent, off-label use of OMC has been increasing. We evaluated the real-world effectiveness and safety of OMC for a variety of infections.

Methods

This was a multicenter, retrospective, observational study that was conducted from January 2020 to June 2020. We included all patients ≥ 18 years of age that received OMC for ≥ 72 hours for any indication and/or pathogen. The primary outcome was clinical success, defined as a lack of 30-day (non-NTM) or 90-day (NTM) mortality or microbiologic recurrence and absence of therapy escalation or alteration. Reasons for OMC utilization and incidence of potential adverse effects attributable to OMC were also analyzed.

Results

A total of 18 patients were included from six geographically distinct academic health systems (median age: 56 (IQR, 49-60.5) years; 61% male; 72% Caucasian). The majority of OMC use was in NTM (61%; 100% Mycobacterium abscessus) and in Acinetobacter baumannii (22%) for bone/joint (39%) and respiratory tract (33%) infections. OMC was used primarily in the outpatient setting alone (83%) and most isolates did not have OMC susceptibility conducted (89%). Clinical success was reported in 83% of the total population (71% non-NTM and 91% NTM). The majority of patients were prescribed OMC due to antimicrobial resistance to previous antibiotic(s) (61%) and/or due to OMC’s availability as an oral agent (44%). Three patients experienced side effects while on therapy (serum creatinine elevation, AST/ALT increase, and gastrointestinal distress).

Conclusion

OMC appears to be effective and well-tolerated for a variety of infections caused by various pathogens, including M. abscessus and A. baumannii.

Disclosures

Michael J. Rybak, PharmD, MPH, PhD, Paratek (Grant/Research Support)

Observed psychopathology in offspring of parents with major depressive disorder, bipolar disorder and schizophrenia

BACKGROUND

Children of parents with mood and psychotic disorders are at elevated risk for a range of behavioral and emotional problems. However, as the usual reporter of psychopathology in children is the parent, reports of early problems in children of parents with mood and psychotic disorders may be biased by the parents' own experience of mental illness and their mental state.

METHODS

Independent observers rated psychopathology using the Test Observation Form in 378 children and youth between the ages of 4 and 24 (mean = 11.01, s.d. = 4.40) who had a parent with major depressive disorder, bipolar disorder, schizophrenia, or no history of mood and psychotic disorders.

RESULTS

Observed attentional problems were elevated in offspring of parents with major depressive disorder, bipolar disorder and schizophrenia (effect sizes ranging between 0.31 and 0.56). Oppositional behavior and language/thought problems showed variable degrees of elevation (effect sizes 0.17 to 0.57) across the three high-risk groups, with the greatest difficulties observed in offspring of parents with bipolar disorder. Observed anxiety was increased in offspring of parents with major depressive disorder and bipolar disorder (effect sizes 0.19 and 0.25 respectively) but not in offspring of parents with schizophrenia.

CONCLUSIONS

Our results suggest that externalizing problems and cognitive and language difficulties may represent a general manifestation of familial risk for mood and psychotic disorders, while anxiety may be a specific marker of liability for mood disorders. Observer assessment may improve early identification of risk and selection of youth who may benefit from targeted prevention.

African Enculturation and Performance on the African Neuropsychological Battery

Objective

To test a core assumption of the African Neuropsychology Battery (ANB) that greater African enculturation is associated with better performance.

Method

Subjects were 27 African immigrants to the U.S. [mean age = 39 (SD = 11.5), mean education = 16.3 years (SD = 2.9)], 32 African-Americans [mean age = 34.0 (SD = 11.2), mean education = 16.2 (SD = 2.5)], and 21 U.S. Caucasians [mean age = 45.7 (SD = 13.8), mean education = 17.2 (SD = 2.3)]. All subjects completed a questionnaire on familiarity with elements of African culture. The ANB was administered one-on-one, by trained technicians, in English, in a single session. ANB tests measured visuospatial perception, naming, memory, and abstract reasoning utilizing content drawn from sub-Saharan African cultures.

Results

Groups differed significantly in age (p < .05), but not education or gender, and age was used as a covariate in subsequent group comparisons. African immigrants showed highest African enculturation, followed by African Americans, and Caucasians [F(2, 74) = 36.16, p < .000], with all groups differing significantly from one another in post-hoc comparisons (p < .02). African enculturation correlated significantly only with ability to identify pictures of African fruits (Pearson r = .58, p < .001) and objects (r = .25, p < .03). Analysis of Covariance followed by Bonferroni post-hoc comparisons confirmed that African immigrants were superior to Caucasians (p < .001) and African-Americans (p < .001) in identifying fruits, with the latter two groups not differing significantly from one another. African immigrants were superior to Caucasians in object identification (p < .05), but did not differ significantly from African-Americans.

Conclusions

African enculturation influences performance on some ANB tests and results support the potential of the ANB to assess performance in a less culturally-biased manner in African immigrants.

A pilot randomized controlled trial comparing effectiveness of prism glasses, visual search training and standard care in hemianopia

OBJECTIVE

Pilot trial to compare prism therapy and visual search training, for homonymous hemianopia, to standard care (information only).

METHODS

Prospective, multicentre, parallel, single-blind, three-arm RCT across fifteen UK acute stroke units.

PARTICIPANTS

Stroke survivors with homonymous hemianopia.

INTERVENTIONS

Arm a (Fresnel prisms) for minimum 2 hours, 5 days per week over 6 weeks. Arm b (visual search training) for minimum 30 minutes, 5 days per week over 6 weeks. Arm c (standard care-information only).

INCLUSION CRITERIA

Adult stroke survivors (>18 years), stable hemianopia, visual acuity better than 0.5 logMAR, refractive error within ±5 dioptres, ability to read/understand English and provide consent.

OUTCOMES

Primary outcomes were change in visual field area from baseline to 26 weeks and calculation of sample size for a definitive trial. Secondary measures included Rivermead Mobility Index, Visual Function Questionnaire 25/10, Nottingham Extended Activities of Daily Living, Euro Qual, Short Form-12 questionnaires and Radner reading ability. Measures were post-randomization at baseline and 6, 12 and 26 weeks.

RANDOMIZATION

Randomization block lists stratified by site and partial/complete hemianopia.

BLINDING

Allocations disclosed to patients. Primary outcome assessor blind to treatment allocation.

RESULTS

Eighty-seven patients were recruited: 27-Fresnel prisms, 30-visual search training and 30-standard care; 69% male; mean age 69 years (SD 12). At 26 weeks, full results for 24, 24 and 22 patients, respectively, were compared to baseline. Sample size calculation for a definitive trial determined as 269 participants per arm for a 200 degree² visual field area change at 90% power. Non-significant relative change in area of visual field was 5%, 8% and 3.5%, respectively, for the three groups. Visual Function Questionnaire responses improved significantly from baseline to 26 weeks with visual search training (60 [SD 19] to 68.4 [SD 20]) compared to Fresnel prisms (68.5 [SD 16.4] to 68.2 [18.4]: 7% difference) and standard care (63.7 [SD 19.4] to 59.8 [SD 22.7]: 10% difference), P=.05. Related adverse events were common with Fresnel prisms (69.2%; typically headaches).

CONCLUSIONS

No significant change occurred for area of visual field area across arms over follow-up. Visual search training had significant improvement in vision-related quality of life. Prism therapy produced adverse events in 69%. Visual search training results warrant further investigation.

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.