Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. Findings Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. Funding UK Stroke Association and NIHR Health Technology Assessment Programme

Advancing coastal risk reduction science and implementation by accounting for climate, ecosystems and people

Climate change and population growth are degrading coastal ecosystems and increasing risks to communities and infrastructure. Reliance on seawalls and other types of hardened shorelines is unsustainable in an era of rising seas, given the costs to build and maintain these structures and their unintended consequences on ecosystems. This is especially true for communities that depend on coastal and marine ecosystems for livelihoods and sustenance. Protecting and restoring coral reefs and coastal forests can be lower cost, sustainable alternatives for shoreline protection. However, decision-makers often lack basic information about where and under what conditions ecosystems reduce risk to coastal hazards and who would benefit. To better understand where to prioritize ecosystems for coastal protection, we assessed risk reduction provided by coral reefs, mangroves, and seagrass along the entire coast of The Bahamas, under current and future climate scenarios. Modeled results show that the population most exposed to coastal hazards would more than double with future sea-level rise and more than triple if ecosystems were lost or degraded. We also found that ecosystem-based risk reduction differs across islands due to variation in a suite of ecological, physical, and social variables. On some populated islands, like Grand Bahama and Abaco, habitats provide protection to disproportionately large numbers of people compared to the rest of the country. Risk reduction provided by ecosystems is also evident for several sparsely populated, remote coastal communities, in some cases with large elderly populations. The results from our analyses were critical for engaging policy-makers in discussions about employing natural and nature-based features for coastal resilience. After hurricanes Joaquin and Matthew hit The Bahamas in 2016 and 2017, our assessment of coastal risk reduction and the multiple benefits provided by coastal ecosystems helped pave the way for an innovative loan from the Inter-American Development Bank to the Government of The Bahamas to invest in mangrove restoration for coastal resilience. This work serves as an example for other regions and investors aiming to use assessments of ecosystem services to inform financing of natural and nature-based approaches for coastal resilience and climate adaptation

Children and the coronavirus disease 2019 pandemic: a Caribbean perspective

This study aims to assess coronavirus disease 2019 (COVID-19) surveillance methods, health resources, vaccination coverage and income stratification and quantify burdens of disease and death in children and adolescents in the Caribbean. The investigation was a descriptive, cross-sectional study that included 15 Caribbean countries/territories and utilized surveys and secondary data sources. Quarantine and isolation measures were robust and surveillance strategies were similar. Pediatric specialists were available across the region, but few had designated pediatric hospitals or high-dependency units. There were more cases in children on islands with larger populations. Compared to high-income countries/territories, upper and lower middle-income countries/territories had higher disease burdens, fewer doctors and nurses per 1 000 population, lower bed capacities, and lower vaccination coverage. Child and adolescent cases ranged from 0.60% to 16.9%, compared with a global case rate of 20.2% in 2021. By August 2021 there were 33 deaths among children from Haiti, Jamaica, Trinidad and Tobago, and Barbados. The respective case fatality rates for 09-year-olds and 1019-year-olds were 2.80 and 0.70 in Haiti, 0.10 and 0.20 in Jamaica, and 0.00 and 0.14 in Trinidad, compared with 0.17 and 0.1 globally. Overall COVID-19 incidence and mortality in children were consistent with global estimates. Limited resources have been offset by availability of pediatricians across the region, and minimally direct effects on children. Prioritization of admission of specific at-risk groups, training of first responders and vaccination campaigns targeting pregnant women and vulnerable children and adolescents could benefit countries with low vaccine coverage rates and limited resources

RASP: Optimal Single Puncta Detection in Complex Cellular Backgrounds

Super-resolution and single-molecule microscopy are increasingly applied to complex biological systems. A major challenge of this approach is that fluorescent puncta must be detected in the low signal, high noise, heterogeneous background environments of cells and tissue. We present RASP, Radiality Analysis of Single Puncta, a bioimaging-segmentation method that solves this problem. RASP removes false positive puncta that other analysis methods detect, and detects features over a broad range of spatial scales: from single proteins to complex cell phenotypes. RASP outperforms the state-of-the-art in precision and speed, using image gradients to separate Gaussian-shaped objects from background. We demonstrate RASP's power by showing it can extract spatial correlations between microglia, neurons, and alpha-synuclein oligomers in the human brain. This sensitive, computationally efficient approach enables fluorescent puncta and cellular features to be distinguished in cellular and tissue environments with a sensitivity down to the level of the single protein. Python and MATLAB codes, enabling users to perform this RASP analysis on their own data, are provided as supplementary files and links to third-party repositories.Aligning Science Across Parkinson's [ASAP-000509

RASP: Optimal Single Puncta Detection in Complex Cellular Backgrounds

Publication status: PublishedSuper-resolution and single-molecule microscopy are increasingly applied to complex biological systems. A major challenge of this approach is that fluorescent puncta must be detected in the low signal, high noise, heterogeneous background environments of cells and tissue. We present RASP, Radiality Analysis of Single Puncta, a bioimaging-segmentation method that solves this problem. RASP removes false positive puncta that other analysis methods detect, and detects features over a broad range of spatial scales: from single proteins to complex cell phenotypes. RASP outperforms the state-of-the-art in precision and speed, using image gradients to separate Gaussian-shaped objects from background. We demonstrate RASP's power by showing it can extract spatial correlations between microglia, neurons, and alpha-synuclein oligomers in the human brain. This sensitive, computationally efficient approach enables fluorescent puncta and cellular features to be distinguished in cellular and tissue environments with a sensitivity down to the level of the single protein. Python and MATLAB codes, enabling users to perform this RASP analysis on their own data, are provided as supplementary files and links to third-party repositories.Aligning Science Across Parkinson's [ASAP-000509

RASP: Optimal single puncta detection in complex cellular backgrounds.

Super-resolution and single-molecule microscopies have been increasingly applied to complex biological systems. A major challenge of these approaches is that fluorescent puncta must be detected in the low signal, high noise, heterogeneous background environments of cells and tissue. We present RASP, Radiality Analysis of Single Puncta, a bioimaging-segmentation method that solves this problem. RASP removes false-positive puncta that other analysis methods detect and detects features over a broad range of spatial scales: from single proteins to complex cell phenotypes. RASP outperforms the state-of-the-art methods in precision and speed using image gradients to separate Gaussian-shaped objects from the background. We demonstrate RASP's power by showing that it can extract spatial correlations between microglia, neurons, and α-synuclein oligomers in the human brain. This sensitive, computationally efficient approach enables fluorescent puncta and cellular features to be distinguished in cellular and tissue environments, with sensitivity down to the level of the single protein. Python and MATLAB codes, enabling users to perform this RASP analysis on their own data, are provided as Supporting Information and links to third-party repositories

Feasibility of reporting results of large randomised controlled trials to participants:experience from the Fluoxetine or Control under supervision (FOCUS) trial

Objectives Informing research participants of the results of studies in which they took part is viewed as an ethical imperative. However, there is little guidance in the literature about how to do this. The Fluoxetine Or Control Under Supervision trial randomised 3127 patients with a recent acute stroke to 6 months of fluoxetine or placebo and was published in the Lancet on 5 December 2018. The trial team decided to inform the participants of the results at exactly the same time as the Lancet publication, and also whether they had been allocated fluoxetine or placebo. In this report, we describe how we informed participants of the results.Design In the 6-month and 12-month follow-up questionnaires, we invited participants to provide an email address if they wished to be informed of the results of the trial. We re-opened our trial telephone helpline between 5 December 2018 and 31 March 2019.Setting UK stroke services.Participants 3127 participants were randomised. 2847 returned 6-month follow-up forms and 2703 returned 12-month follow-up forms; the remaining participants had died (380), withdrawn consent or did not respond.Results Of those returning follow-up questionnaires, a total of 1845 email addresses were provided and a further 50 people requested results to be sent by post. Results were sent to all email and postal addresses provided; 309 emails were returned unrecognised. Seventeen people replied, of whom three called the helpline and the rest responded by email.Conclusion It is feasible to disseminate results of large trials to research participants, though only around 60% of those randomised wanted to receive the results. The system we developed was efficient and required very little resource, and could be replicated by trialists in the future.Trial registration number ISRCTN83290762; Post-results