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

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

Objective: Pilot trial comparing 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/week over 6- weeks. Arm b (visual search training) for minimum 30 minutes, 5 days/week over 6-weeks. Arm c (standard care-information only).Inclusion criteria: Adult stroke survivors (>18 years), stable hemianopia, visual acuity better than 0.5logMAR, refractive error within 5Dioptres, 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-randomisation at baseline and 6, 12, 26 weeks. Randomisation: Randomisation block lists stratified by site and partial/complete hemianopia. Blinding: Allocations disclosed to patients. Primary outcome assessor blind to treatment allocation. Results: 87 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 (SD19) to 68.4 (SD20)) Compared to Fresnel prisms (68.5 (SD16.4) to 68.2 (18.4): 7% difference) and standard care (63.7 (SD19.4) to 59.8 (SD22.7): 10% difference), p=0.05. 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

Motor‐evoked potentials reveal a motor‐cortical readout of evidence accumulation for sensorimotor decisions

Many everyday activities require time-pressured sensorimotor decision making. Traditionally, perception, decision, and action processes were considered to occur in series, but this idea has been successfully challenged, particularly by neurophysiological work in animals. However, the generality of parallel processing requires further elucidation. Here, we investigate whether the accumulation of a decision can be observed intrahemispherically within human motor cortex. Participants categorized faces as male or female, with task difficulty manipulated using morphed stimuli. Transcranial magnetic stimulation, applied during the reaction-time interval, produced motor-evoked potentials (MEPs) in two hand muscles that were the major contributors when generating the required pinch/grip movements. Smoothing MEPs using a Gaussian kernel allowed us to recover a continuous time-varying MEP average, comparable to an EEG component, permitting precise localization of the time at which the motor plan for the responding muscle became dominant. We demonstrate decision-related activity in the motor cortex during this perceptual discrimination task, suggesting ongoing evidence accumulation within the motor system even for two independent actions represented within one hemisphere

Difficulties in evaluating public engagement initiatives: reflections on an evaluation of the UK GM Nation? public debate about transgenic crops

In the realm of risk management, and policy-making more generally, “public engagement” is often advocated as an antidote to pathologies associated with traditional methods of policy-making, and associated deficit-model-driven communication strategies. The actual benefits of public engagement are, however, difficult to establish without thorough evaluation of specific engagement processes. Unfortunately, rigorous evaluation is difficult, and, perhaps for this reason, it has rarely been undertaken. In this paper we highlight a number of these difficulties in the light of our experiences in evaluating a major engagement initiative, namely the GM Nation? publice debate on the possible commercialization of transgenic crops, which took place in Britain in 2003. The difficulties we identify seem likely to be relevant to many, if not most, engagement evaluations. They are concerned with both theoretical/normative (how one should evaluate) and practical (how one does evaluate) issues. We suggest a number of possible solutions to these evaluation difficulties

Does stroke location predict walk speed response to gait rehabilitation?

Objectives Recovery of independent ambulation after stroke is a major goal. However, which rehabilitation regimen best benefits each individual is unknown and decisions are currently made on a subjective basis. Predictors of response to specific therapies would guide the type of therapy most appropriate for each patient. Although lesion topography is a strong predictor of upper limb response, walking involves more distributed functions. Earlier studies that assessed the cortico-spinal tract (CST) were negative, suggesting other structures may be important. Experimental Design: The relationship between lesion topography and response of walking speed to standard rehabilitation was assessed in 50 adult-onset patients using both volumetric measurement of CST lesion load and voxel-based lesion–symptom mapping (VLSM) to assess non-CST structures. Two functional mobility scales, the functional ambulation category (FAC) and the modified rivermead mobility index (MRMI) were also administered. Performance measures were obtained both at entry into the study (3–42 days post-stroke) and at the end of a 6-week course of therapy. Baseline score, age, time since stroke onset and white matter hyperintensities score were included as nuisance covariates in regression models. Principal Observations: CST damage independently predicted response to therapy for FAC and MRMI, but not for walk speed. However, using VLSM the latter was predicted by damage to the putamen, insula, external capsule and neighbouring white matter. Conclusions Walk speed response to rehabilitation was affected by damage involving the putamen and neighbouring structures but not the CST, while the latter had modest but significant impact on everyday functions of general mobility and gait

Analysis of a normative framework for evaluating public engagement exercises: reliability, validity and limitations

Over recent years, many policy-makers and academics have come to the view that involving the public in policy setting and decision-making (or “public engagement”) is desirable. The theorized benefits of engagement (over traditional approaches) include the attainment of more satisfactory and easier decisions, greater trust in decision-makers, and the enhancement of public and organizational knowledge. Empirical support for these advantages is, however, scant. Engagement processes are rarely evaluated, and when they are, the quality of evidence is generally poor. The absence of standard effectiveness criteria, and instruments to measure performance against these, hinders evaluation, comparison, generalization and the accumulation of knowledge. In this paper one normative framework for evaluating engagement processes is considered. This framework was operationalized and used as part of the evaluation of a recent major UK public engagement initiative: the 2003 GM Nation? debate. The evaluation criteria and processes are described, and their validity and limitations are analyzed. Results suggest the chosen evaluation criteria have some validity, though they do not exhaustively cover all appropriate criteria by which engagement exercises ought to be evaluated. The paper concludes with suggestions on how to improve the framework

UC-15 Malware Analysis Using Reverse Engineering

The motivation for this project is driven by evaluation of the different tools on the market that allow for breaking down executables or binary files, and understanding what the malware is doing. By reverse-engineering the malware, we can understand its impact and how to protect against it. Our focus is to understand where different tools are stronger than others, as well as understand the evolving landscape of malware and security overall. For this capstone project, we utilized two different tools and many sample malware files. The methods used to debug the malware are detailed in our milestone two report and will be expanded upon in our final presentation. At this point, we\u27ve found the tool WinDbg to be the most versatile for binary and executable debugging. We also evaluated IDA Pro, and understand the many ways in which its graphical display of data and relationships, equips a researcher with the necessary tools and information to walk through an executable. Our focus in milestone 3 is to expand our documentation and guide on malware debugging to the point that it provides a user the full breadth of information and steps needed to start from scratch and end with a broken apart piece of malware. We provided much of this as part of the milestone 2 presentation and report, but we will continue to build on it so it\u27s a useful how-to guide for anyone trying to debug a piece of malicious code.Advisors(s): Dr. Ying Xie [email protected](s): SecurityIT 498