Safety and Feasibility of Cervical and Thoracic Transcutaneous Spinal Cord Stimulation to Improve Hand Motor Function in Children With Chronic Spinal Cord Injury

OBJECTIVE

In adults with cervical spinal cord injury (SCI), transcutaneous spinal stimulation (scTS) has improved upper extremity strength and control. This novel noninvasive neurotherapeutic approach combined with training may modulate the inherent developmental plasticity of children with SCI, providing even greater improvements than training or stimulation alone. Because children with SCI represent a vulnerable population, we first must establish the safety and feasibility of any potential novel therapeutic approach. The objectives of this pilot study were to determine the safety, feasibility, and proof of principle of cervical and thoracic scTS for short-term effect on upper extremity strength in children with SCI.

MATERIALS AND METHODS

In this nonrandomized, within-subject repeated measure design, seven participants with chronic cervical SCI performed upper extremity motor tasks without and with cervical (C3-C4 and C6-C7) and thoracic (T10-T11) site scTS. Safety and feasibility of using cervical and thoracic sites scTS were determined by the frequency count of anticipated and unanticipated risks (eg, pain, numbness). Proof-of-principle concept was tested via change in force production during hand motor tasks.

RESULTS

All seven participants tolerated cervical and thoracic scTS across the three days, with a wide range of stimulation intensities (cervical sites = 20-70 mA and thoracic site = 25-190 mA). Skin redness at the stimulation sites was observed in four of 21 assessments (19%) and dissipated in a few hours. No episode of autonomic dysreflexia was observed or reported. Hemodynamic parameters (systolic blood pressure and heart rate) remained within stable limits (p > 0.05) throughout the assessment time points at baseline, with scTS, and after the experiment. Hand-grip and wrist-extension strength increased (p < 0.05) with scTS.

CONCLUSIONS

We indicated that short-term application of scTS via two cervical and one thoracic site is safe and feasible in children with SCI and resulted in immediate improvements in hand-grip and wrist-extension strength in the presence of scTS.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT04032990.

Influence of spatial-intensity contrast in ultraintense laser-plasma interactions

Increasing the intensity to which high power laser pulses are focused has opened up new research possibilities, including promising new approaches to particle acceleration and phenomena such as high field quantum electrodynamics. Whilst the intensity achievable with a laser pulse of a given power can be increased via tighter focusing, the focal spot profile also plays an important role in the interaction physics. Here we show that the spatial-intensity distribution, and specifically the ratio of the intensity in the peak of the laser focal spot to the halo surrounding it, is important in the interaction of ultraintense laser pulses with solid targets. By comparing proton acceleration measurements from foil targets irradiated with by a near-diffraction-limited wavelength scale focal spot and larger F-number focusing, we find that this spatial-intensity contrast parameter strongly influences laser energy coupling to fast electrons. We find that for multi-petawatt pulses, spatial-intensity contrast is potentially as important as temporal-intensity contrast.

Durability of Improved Trunk Control Following Activity-Based Locomotor Training in Children With Acquired Spinal Cord Injuries

BACKGROUND

A recent study in pediatric spinal cord injury (SCI) demonstrated activity-based locomotor training (ABLT) improved trunk control, measured by the Segmental Assessment of Trunk Control (SATCo). It is not known whether improved trunk control is maintained and, if so, for how long.

OBJECTIVES

The purpose was to determine the durability of improvements in trunk control after ABLT is stopped. We hypothesized that SATCo scores at follow-up would not significantly regress (a) beyond the score measured at discharge and (b) to the initial SATCo pre-ABLT level.

METHODS

Patients were assessed pre ABLT, after completing an episode of care, and upon returning to the clinic 1 or more months without ABLT. Durability is a score change less than 3, which is the measurement error of the SATCo.

RESULTS

Twenty-eight children (10 females; 4 ± 2.5 years old) completed at least 40 sessions of ABLT and returned for the follow-up 8 ± 7 months (range, 1-38) after the episode of care. Trunk control improved 6 ± 3/20 points with ABLT (p < .0001). At the follow-up, average SATCo score decreased 2 ± 2/20 points, and the follow-up SATCo score was 4 ± 3 points higher than pre ABLT (p < .0001). There was no correlation between the change in SATCo scores and changes in age, weight, height or elapsed time between discharge and follow-up.

CONCLUSION

Improvements in trunk control due to ABLT were maintained, indicating ABLT is neurotherapeutic. Although not achieving complete recovery of trunk control, the immediate effects and sustained improvements provide support for a clinical shift to neurotherapeutic approaches and for continued research to achieve enhanced recovery.

A pilot randomised controlled trial of befriending by volunteers in people with intellectual disability and depressive symptoms

BACKGROUND

People with intellectual disability (ID) are more likely to experience chronic depression compared with the general population, which may be compounded by loneliness and lower levels of social support. Befriending aims to provide social support and promote engagement in community activities. No randomised controlled trials have examined whether befriending improves symptoms of depression and social outcomes in people with ID. The aim of this pilot trial was to assess the feasibility and acceptability of a future larger trial of one-to-one befriending by volunteers in people with ID and depressive symptoms.

METHODS

Participants were adults with mild or moderate ID with a score of 5 or more on the Glasgow Depression Scale for People with Learning Disabilities (GDS-LD). They were randomised to the intervention arm (matched to a volunteer befriender for 6 months) or the control arm (usual care). Volunteers received training and supervision provided by two community befriending schemes. The main outcomes were feasibility of recruitment (minimum target n = 35), retention rate of participants, adherence (minimum 10 meetings), acceptability of the intervention, changes in depressive symptoms (assessed at baseline and 6 months) and feasibility of collecting data for a health economic analysis.

RESULTS

Recruitment was challenging, and only 16 participants with ID and 10 volunteers were recruited. Six participants were matched with a volunteer and no participants dropped out (except for two volunteers). Four participants completed 10 meetings (mean 11.8). Befriending was thought to be acceptable, but modifications were suggested. An exploratory analysis suggested that GDS-LD score was lower in the intervention group compared with the control group after adjusting for baseline scores, but not significant (adjusted mean difference: -4.0; 95% confidence interval: -11.2 to 3.2).

CONCLUSIONS

A large trial would not be feasible based on the recruitment strategies employed in this study. A further feasibility study addressing these challenges or the use of other study designs should be considered.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

The effectiveness of Sufi music for mental health outcomes. A systematic review and meta-analysis of 21 randomised trials

BACKGROUND

There is some evidence that Sufi music therapy might improve physical and mental well-being; however, no systematic review or meta-analysis has pooled and critiqued the evidence. The aim of this systematic review was to evaluate the effects of Sufi music therapy on mental health outcomes.

METHODS

We searched Medline, PsycINFO, the Web of Science, Science Direct, PsycARTICLES, Cochrane Library, SCOPUS, CINAHL Plus, AMED, and ULAKBIM databases, and the reference lists of the studies found. Papers published in academic peer-reviewed journals were included, as well as from other sources such as chapters in edited books, the grey literature, or conference presentations. Articles published up to March 2020 in Turkish and English were included. Our primary outcome of interest was anxiety and secondary outcomes of interest were other mental health outcomes such as depression. To assess the methodological quality of the articles, the Cochrane Risk of Bias Tool was used. The quality of evidence was assessed using the GRADEpro GDT system.

RESULTS

This search yielded 21 clinical trials that were eligible for inclusion. A meta-analysis, using a random effects model, of 18 randomised controlled trials involving 1454 participants showed that Sufi music therapy with makams, compared with treatment as usual (TAU) or a no-music control group, reduced symptoms of anxiety in the short term in patients undergoing an operation or treatments such as chemotherapy or haemodialysis (standardised mean difference SMD= -1.15, 95 % CI, -1.64 to -0.65; very low-quality evidence). The evidence of Sufi music with makam's effect on anxiety is rated as very low. Qualitative synthesis of secondary outcomes revealed significant effects for depression, positive symptoms in schizophrenia, stress, which however were based on fewer studies. Trials were of moderate methodological quality, and there was significant heterogeneity across the studies.

CONCLUSION

Sufi music may reduce anxiety of patients undergoing medical procedures like haemodialysis, coronary artery surgery, angiography, colonoscopy, bone marrow aspiration and biopsy procedures. Evidence from single studies suggests effects on depression and stress as well. However, due to methodological limitations of the studies, further, higher quality studies are required in other cultures.

Basal ganglia echogenicity in preterm infants: A case series

BACKGROUND

Damage to the basal ganglia and thalamus (BGT) can be caused by multiple perinatal factors and may be associated with movement disorders, cognitive delay and visual difficulties. Changes in BGT structure, seen as echogenicity on ultrasound, are difficult to objectively quantify. The aetiology, clinical relevance and developmental outcomes of BGT echogenicity are poorly understood. We aimed to gain a better understanding of the natural history of BGT echogenicity in a preterm population.

METHODS

Retrospective review of clinical course, neuroimaging and development in infants born <32weeks gestation over 5 years with evidence of BGT echogenicity.

RESULTS

BGT echogenicity was reported in 18/650 infants (2.7%). Echogenicity appeared at a median of 8 days (2-45 days) and resolved on pre-discharge ultrasound in 50%. Thirteen infants had a term corrected MRI brain with abnormal BGT signal seen in 3 infants (23%). All 3 infants had persisting echogenicity on discharge ultrasound. No infant with echogenicity resolution on ultrasound had changes on term MRI. 14 infants had developmental progress available at 1 year corrected. Abnormal development was reported in four children of whom one had BGT changes on term MRI. Two children with persistent BGT changes but an otherwise normal MRI had reported normal neurodevelopment.

CONCLUSION

BGT echogenicity is relatively common on routine ultrasound and resolves in the majority of infants by term corrected. This review suggests that at term corrected, normal cranial ultrasound may obviate the need for MRI where no other concerns exist. BGT echogenicity did not appear to independently influence neurodevelopment.

FC16-04 - The clinical effectiveness of individual cognitive behaviour therapy for depressed older people in primary care and the use of a talking control (TC)

Objective

To determine the clinical effectiveness of Cognitive Behaviour Therapy (CBT) delivered in primary care for older people with depression and evaluation of a talking control (TC).

Methods

A single-blind, randomized, controlled trial with 4- and 10-month follow-up. 204 people, aged 65 years or more, with a Geriatric Mental State diagnosis of depression were recruited from primary care. The interventions were: treatment as usual (TAU), TAU plus TC, or TAU plus CBT. The TC and CBT were offered over 4 months. The TC was to control for common effects in therapy. The Beck Depression Inventory-II (BDI-II) was the main outcome. Subsidiary measures were the Beck Anxiety Inventory, Social Functioning Questionnaire, and Euroqol. Intention to treat analysis (ITT) and Compliance Average Causal Effect (CACE) analyses was employed. The Cognitive therapy scale (CTS) evaluated common and specific factors in therapy.

Results

A mean of 7 sessions of TC or CBT were delivered. ITT analysis found improvements of −3.07 (95% confidence interval [CI], −5.73 to −0.42) and −3.65 (95% CI, −6.18 to −1.12) in BDI-II scores in favour of CBT vs TAU and TC respectively. CACE analysis found a benefit of 0.4 points (95% CI, 0.01 to 0.72) per therapy session of CBT over TC. Ratings for CBT on the CTS were high (mean [SD], 54.2 [4.1]) and showed no difference for nonspecific, but significant differences for specific factors in therapy.

Conclusion

CBT is an effective treatment for depressed older people. Improvement appears to be associated with specific factors in CBT.

The Development of the DEMoBinc. Toolkit and the Results of Reliability Testing

Aims:

To develop a toolkit to assess the quality of institutionalised care, in both hospital and community settings, for individuals with long-term mental illness.

Methods:

The toolkit was developed by the UK research teams. Items were included to assess the six domains (Living Environment; Therapeutic Environment; Treatments and Interventions; Self-management and Autonomy; Social Policy, Citizenship and Advocacy; Clinical Governance) and three cross-cutting themes (Social Inclusion; Human Rights; Recovery-based Model) which emerged from the international literature review, Delphi exercises and cross-country care standards. Following translation and piloting in each country, the toolkit was refined and tested for reliability in 20 units in each country (a total of 200 units).

Results:

Test-retest reliability was assessed using intra-class correlations and Cohen's Kappa coefficients. Factors with low reliability or extreme response biases were dropped. Remaining items were subjected to an exploratory factor analysis to test the allocation of items to domains and cross-cutting themes and improve their internal consistency. Correlations between domains were explored to determine whether or not domains could be combined.

In the next phase of the study,the toolkit domain ratings will be analysed for associations with standardised assessments of service users' quality of life, autonomy and markers of recovery to investigate whether the toolkit can provide a proxy measurement of the institution's promotion of human rights and recovery.

High order mode structure of intense light fields generated via a laser-driven relativistic plasma aperture

The spatio-temporal and polarisation properties of intense light is important in wide-ranging topics at the forefront of extreme light-matter interactions, including ultrafast laser-driven particle acceleration, attosecond pulse generation, plasma photonics, high-field physics and laboratory astrophysics. Here, we experimentally demonstrate modifications to the polarisation and temporal properties of intense light measured at the rear of an ultrathin target foil irradiated by a relativistically intense laser pulse. The changes are shown to result from a superposition of coherent radiation, generated by a directly accelerated bipolar electron distribution, and the light transmitted due to the onset of relativistic self-induced transparency. Simulations show that the generated light has a high-order transverse electromagnetic mode structure in both the first and second laser harmonics that can evolve on intra-pulse time-scales. The mode structure and polarisation state vary with the interaction parameters, opening up the possibility of developing this approach to achieve dynamic control of structured light fields at ultrahigh intensities.

Depression and self-harm from adolescence to young adulthood in sexual minorities compared with heterosexuals in the UK: a population-based cohort study

Background

There are few population-based cohort studies of the emergence, development, and persistence of mental health problems in sexual minorities compared with heterosexuals. We compared trajectories of depressive symptoms in sexual-minority adolescents and heterosexual adolescents from when they were aged 10 to 21 years, and examined self-harm at ages 16 and 21 years.

Methods

The study included 4828 adolescents born between April 1, 1991, and Dec 31, 1992, from the Avon Longitudinal Study of Parents and Children birth cohort (Bristol, UK) who reported their sexual orientation when aged 16 years. Depressive symptoms were assessed with the short Mood and Feelings Questionnaire at seven timepoints between ages 10 and 21 years. A self-harm questionnaire was completed at ages 16 and 21 years. Analyses were linear multilevel models with growth curves (depressive symptoms), logistic multilevel models (self-harm in the previous year at ages 16 and 21 years), and multinomial regression (lifetime self-harm with and without suicidal intent at age 21 years).

Findings

At age 10, depressive symptoms were higher in sexual minorities than in heterosexuals and increased with age to a larger extent. Depressive symptoms increased at each timepoint by 0·31 points in hetereosexuals, and by 0·49 points in sexual minorities. Sexual-minority adolescents were more likely than heterosexual adolescents to report self-harm in the previous year at ages 16 and 21 years, with no evidence that this estimate decreased with age. At aged 21, sexual minorities were more likely to report lifetime self-harm (ie, on at least one previous occasion) with suicidal intent than heterosexuals.

Interpretation

Mental health disparities between heterosexuals and sexual minorities are present early in adolescence and increase throughout the school years, persisting to young adulthood. Prevention of these mental health problems and early intervention must be a priority.