Antidepressants Trial in Parkinson's Disease (ADepT-PD): protocol for a randomised placebo-controlled trial on the effectiveness of escitalopram and nortriptyline on depressive symptoms in Parkinson's disease

BACKGROUND

Depressive symptoms are common in patients with Parkinson's disease and depression is a significant predictor of functional impairment, reduced quality of life and general well-being in Parkinson's disease. Despite the high prevalence of depression, evidence on the effectiveness and tolerability of antidepressants in this population is limited. The primary aim of this trial is to establish the clinical and cost effectiveness of escitalopram and nortriptyline for the treatment of depression in Parkinson's disease.

METHODS

This is a multi-centre, double-blind, randomised placebo-controlled trial in 408 people with Parkinson's disease with subsyndromal depression, major depressive disorder or persistent depressive disorder and a Beck Depression Inventory-II (BDI-II) score of 14 or above. Participants will be randomised into one of three groups, receiving either escitalopram, nortriptyline or placebo for 12 months. Trial participation is face-to-face, hybrid or remote. The primary outcome measure is the BDI-II score following 8 weeks of treatment. Secondary outcomes will be collected at baseline, 8, 26 and 52 weeks and following withdrawal, including severity of anxiety and depression scores as well as Parkinson's disease motor severity, and ratings of non-motor symptoms, cognitive function, health-related quality of life, levodopa-equivalence dose, changes in medication, overall clinical effectiveness, capability, health and social care resource use, carer health-related quality of life, adverse effects and number of dropouts.

DISCUSSION

This trial aims to determine the effectiveness of escitalopram and nortriptyline for reducing depressive symptoms in Parkinson's disease over 8 weeks, to provide information on the effect of these medications on anxiety and other non-motor symptoms in PD and on impact on patients and caregivers, and to examine their effect on change in motor severity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03652870 Date of registration - 29^th August 2018.

Printing bone in a gel: using nanocomposite bioink to print functionalised bone scaffolds

Free-form printing offers a novel biofabrication approach to generate complex shapes by depositing hydrogel materials within a temporary supportive environment. However, printed hydrogels typically lack the requisite mechanical properties and functionality of the desired tissue, limiting application and, more importantly, safety and efficacy of the implant. The study authors have developed an innovative nanoclay-based bioink to print high shape fidelity functional constructs for potential skeletal application. Laponite® (LAP) nanoclay was combined with gellan gum (GG) to generate a printable hydrogel that was highly stable in vitro, displayed limited swelling ability compared with the silicate-free control and remained stable over time. An agarose fluid gel was found to provide the requisite support for the deposition of the material ink and preservation of the printed structure before crosslinking. Printed C2C12 myoblasts remained viable and displayed extensive proliferation over 21 days in culture. Cell-laden scaffolds demonstrated functionality within 1 day of culture in vitro and that was preserved over 3 weeks. Analysis of absorption and release mechanisms from LAP-GG using model proteins (lysozyme and bovine serum albumin) demonstrated the retention capability of the clay-based materials for compound localisation and absence of burst release. Vascular endothelial growth factor ​was loaded within the agarose fluid gel and absorbed by the material ink via absorption during deposition. The 3D-printed constructs were implanted on the chorioallantoic membrane of a 10-day-old developing chick. Extensive and preferential vasculature infiltration was observed in LAP-GG-loaded vascular endothelial growth factor constructs compared with controls (p<0.01 and p<0.0001) after only 7 days of incubation. The current studies demonstrate, for the first time, the application of innovative LAP-GG 3D constructs in the generation of growth factor-loaded 3D constructs for potential application in skeletal tissue repair.

Investigating the intra- and inter-rater reliability of a panel of subjective and objective burn scar measurement tools

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Subjective scar measures have poor reliability unless repeated by more than one assessor.

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Objective scar measures have been demonstrated to have good to excellent reliability.

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Physical symptoms of scars such as pain and itch were found to be more important to patients compared to surface, area and colour although this finding was not sustained when corrected for multiple comparisons.

Background

Research into the treatment of hypertrophic burn scar is hampered by the variability and subjectivity of existing outcome measures. This study aims to measure the inter- and intra-rater reliability of a panel of subjective and objective burn scar measurement tools.

Methods

Three independent assessors evaluated 55 scar and normal skin sites using subjective (modified Vancouver Scar Scale [mVSS] & Patient and Observer Scar Assessment Scale [POSAS]) and objective tools. The intra-class correlation coefficient was utilised to measure reliability (acceptable when >0.70). Patient satisfaction with the different tools and scar parameter importance were assessed via questionnaires.

Results

The inter-rater reliabilities of the mVSS and POSAS were below the acceptable limit. For erythema and pigmentation, all of the Scanoskin and DSM II measures (except the b* value) had acceptable to excellent intra and inter-rater reliability. The Dermascan ultrasound (dermal thickness, intensity) had excellent intra- and inter-rater reliability (>0.90). The Cutometer R0 (firmness) had acceptable reliability but not R2 (gross elasticity). All objective measurement tools had good overall satisfaction scores. Patients rated scar related pain and itch as more important compared to appearance although this finding was not sustained when corrected for multiple comparisons.

Conclusion

The objective scar measures demonstrated acceptable to excellent intra- and inter-rater reliability and performed better than the subjective scar scales.

Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer

AIM

To develop a management strategy (rehabilitation programme) for erectile dysfunction (ED) after radiotherapy (RT) or androgen deprivation therapy (ADT) for prostate cancer that is suitable for use in a UK NHS healthcare context.

METHODS

PubMed literature searches of ED management in this patient group together with a survey of 28 experts in the management of treatment-induced ED from across the UK were conducted.

RESULTS

Data from 19 articles and completed questionnaires were collated. The findings discussed in this article confirm that RT/ADT for prostate cancer can significantly impair erectile function. While many men achieve erections through PDE5-I use, others need combined management incorporating exercise and lifestyle modifications, psychosexual counselling and other erectile aids. This article offers a comprehensive treatment algorithm to manage patients with ED associated with RT/ADT.

CONCLUSION

Based on published research literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for ED after RT/ADT. In addition to implementing the algorithm, understanding the rationale for the type and timing of ED management strategies is crucial for clinicians, men and their partners.

Development of UK recommendations on treatment for post-surgical erectile dysfunction

AIM

To develop a management strategy (rehabilitation programme) for postsurgical erectile dysfunction (ED) among men experiencing ED associated with treatment of prostate, bladder or rectal cancer that is suitable for use in a UK NHS healthcare context.

METHODS

PubMed literature searches of ED management together with a survey of 13 experts in the management of ED from across the UK were conducted.

RESULTS

Data from 37 articles and completed questionnaires were collated. The results discussed in this study demonstrate improved objective and subjective clinical outcomes for physical parameters, sexual satisfaction, and rates of both spontaneous erections and those associated with ED treatment strategies.

CONCLUSION

Based on the literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for postsurgical ED.

Effect of plasma surface modification on the biocompatibility of UHMWPE

In this paper active screen plasma nitriding (ASPN) is used to chemically modify the surface of UHMWPE. This is an unexplored and new area of research. ASPN allows the homogeneous treatment of any shape or surface at low temperature; therefore, it was thought that ASPN would be an effective technique to modify organic polymer surfaces. ASPN experiments were carried out at 120 °C using a dc plasma nitriding unit with a 25% N(2) and 75% H(2) atmosphere at 2.5 mbar of pressure. UHMWPE samples treated for different time periods were characterized by nanoindentation, FTIR, XPS, interferometry and SEM. A 3T3 fibroblast cell line was used for in vitro cell culture experiments. Nanoindentation of UHMWPE showed that hardness and elastic modulus increased with ASPN treatment compared to the untreated material. FTIR spectra did not show significant differences between the untreated and treated samples; however, some changes were observed at 30 min of treatment in the range of 1500-1700 cm(-1) associated mainly with the presence of N-H groups. XPS studies showed that nitrogen was present on the surface and its amount increased with treatment time. Interferometry showed that no significant changes were observed on the surfaces after the treatment. Finally, cell culture experiments and SEM showed that fibroblasts attached and proliferated to a greater extent on the plasma-treated surfaces leading to the conclusion that ASPN surface treatment can potentially significantly improve the biocompatibility behaviour of polymeric materials.

Preparation of macroporous calcium phosphate cement tissue engineering scaffold

Unlike sintered hydroxyapatite there is evidence to suggest that calcium phosphate cement (CPC) is actively remodelled in vivo and because CPC is formed by a low-temperature process, thermally unstable compounds such as proteins may be incorporated into the matrix of the cement which can then be released after implantation. The efficacy of a macroporous CPC as a bone tissue engineering scaffold has been reported; however, there have been few previous studies on the effect of macroporosity on the mechanical properties of the CPC. This study reports a novel method for the formation of macroporous CPC scaffolds, which has two main advantages over the previously reported manufacturing route: the cement matrix is considerably denser than CPC formed from slurry systems and the scaffold is formed at temperatures below room temperature. A mixture of frozen sodium phosphate solution particles and CPC powder were compacted at 106 MPa and the sodium phosphate was allowed to melt and simultaneously set the cement. The effect of the amount of porogen used during processing on the porosity, pore size distribution and compressive strength of the scaffold was investigated. It was found that macroporous CPC could reliably be fabricated using cement:ice ratios as low as 5:2.

Multideterminant role of calcium in hippocampal synaptic plasticity

Hippocampal CA1 cells possess several varieties of long-lasting synaptic plasticity: two different forms of long-term potentiation (LTP) and at least one form of long-term depression (LTD). All forms of synaptic plasticity are induced by afferent activation, all involve Ca2+ influx, all can be blocked by Ca2+ chelators, and all activate Ca(2+)-dependent mechanisms. The question arises as how different physiological responses can be initiated by activation of the same second messenger. We consider two hypotheses which could account for these phenomena: voltage-dependent differences in cytosolic Ca2+ concentration acting upon Ca2+ substrates of differing Ca2+ affinities and compartmentalization of the Ca2+ and its substrates.

Training and testing determinants of short-term associative suppression of phototaxic behavior in Hermissenda

Hermissenda crassicornis shows both short- and long-term retention of conditioning following light-rotation pairings. Previous research has shown that prolonged training (50 trials per session, three consecutive daily sessions) produces a suppression of phototaxis lasting for days. This long-term retention reflects associative learning processes, with little or no contribution of nonassociative learning. In contrast, both associative learning and nonassociative behavioral modification contribute to short-term retention following a single session of five pairing trials. In this paper, we describe important associative and nonassociative determinants of short-term changes in phototaxis. In Experiment 1, animals received successive hourly tests for phototaxis in either a horizontal or a vertical orientation. Repeated testing resulted in decreased phototaxis which was especially pronounced for animals tested horizontally. Experiments 2-4 demonstrated that both repeated handling of animals and repeated periods of dark adaptation prior to each phototaxic test contributed to the development of phototaxic suppression with repeated testing. These nonassociative influences on phototaxis interacted with the gravitational orientation employed during behavioral testing, being most pronounced for testing in the horizontal orientation. An implication of these findings is that attempts to demonstrate short-term pairing-specific suppression will be most successful when nonassociative contributions are minimized (by testing animals vertically). Experiment 5 tested this prediction. We also tested the influence of training light intensity and the stimulus specificity of conditioned suppression. Animals received either five paired or five random presentations of light and rotation. Training light intensity was either moderate or bright. Following training, animals were tested for either suppression of phototaxis or suppression of negative geotaxis, using either a horizontal or a vertical testing orientation. Consistent with previous results, horizontally tested animals exhibited pronounced nonassociative suppression following training. The use of a bright training light also produced nonassociative suppression. However, when trained with a light of moderate intensity and tested vertically, Hermissenda showed associative suppression of phototaxis (significant paired--random difference) but not geotaxis (no paired--random difference). In a final experiment we observed that the longer the period of dark adaptation (prior to testing) the longer the phototaxic latency.(ABSTRACT TRUNCATED AT 400 WORDS)

Systemic acyclovir in pregnancy: a case report

Disseminated herpes simplex infection in pregnancy presents serious risk to mother and fetus. Although an uncommon problem, the high maternal and fetal mortality and morbidity accompanying disseminated herpes infection warrants aggressive new treatment. Specific antiviral chemotherapy is now possible for selected cases. The present report describes the use of acyclovir during the third trimester for disseminated herpes simplex infection. The treatment protocol used and pregnancy outcome are described for this case. Acyclovir therapy and potential toxicities are described.