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.

Penile purpura as a manifestation of lichen sclerosus et atrophicus.

Heightened public and professional awareness of the sexual abuse of children demands that physicians be able to distinguish lesions associated with sexual abuse from those caused by primary skin disorders. Purpura is an occasional manifestation of pediatric lichen sclerosus et atrophicus (LSA), especially when the vulva is affected. We report a 12-year-old boy with penile purpura that occasioned a consideration of sexual abuse but proved to be due to LSA.

Distribution of serum antibodies to wheat gliadin and bovine milk in atopic and non-atopic healthy adults.

Sera from 262 blood donors were tested against wheat gliadin and bovine milk antigens employing an ELISA system. 9.2% of the sera clearly contained antibodies, predominantly IgG but also including IgA and occasional IgM, reactive with either gliadin (11/262) or milk (13/262). There was no overlap between the gliadin and milk groups, and only one of these sera was also IgE-RAST-positive against wheat or milk. Five of 48 sera with raised IgE levels (greater than or equal to 100 iu/ml) were ELISA-positive against either gliadin or milk, a frequency comparable with that overall in this normal adult population. Six of these 48 sera with raised IgE levels were IgE-RAST-positive against wheat or milk, of which only one was ELISA-positive. These results have indicated that nearly 10% of normal adults have serum IgG/A/M antibodies to milk or gliadin, but that this population is separate from individuals (2.3%) who may be IgE-RAST-positive to the same dietary antigens.

Phase behavior of synthetic phosphatidylglycerols and binary mixtures with phosphatidylcholines in the presence and absence of calcium ions.

Using differential thermal analysis, scanning calorimetry and light scattering, transition temperatures and enthalpy data for the gel to liquid crystalline phase transitions of five synthetic phosphatidylglycerol sodium salts (PG-Na+) were measured. The values obtained were almost identical with literature values for the corresponding phosphatidylcholines (PC). However, transition temperatures for the fully protonated forms of the saturated phosphatidylglycerols (PG-H+) were approximately 20 degrees C higher. For binary mixtures of PG-Na+ and PC in which the acyl chains of the two species were identical, the width of the thermal transition for the phase change was not appreciably greater than that observed with either of the two components alone. In contrast, mixing of PG-Na+ and PC with different chain lengths increases the transition width. In the presence of Ca2+, narrow transitions were also observed with mixtures of PG and PC when the chain length of the PG-Ca2+ was equal to or two carbons shorter than the PC but the transition width was clearly increased when the chain length of the PG-Ca2+ was two carbons longer than the PC. Mixing lipids with greater differences in chain length or mixing saturated lipids with unsaturated lipids in the presence of Ca2+ produced two minima in the thermograms, clearly indicative of phase separation. In sum, these results provide evidence for a high degree of miscibility of the phosphoglycerol and phosphocholine head groups, either in the presence or absence of Ca2+, such that the characteristic phase behavior of each mixture is determined primarily by differences in the hydrocarbon chain structure.

Effects of a polyoxyethylene detergent (Brij 58) on platelet aggregation, release and clotting activity.

Low concentrations of a polyoxyethylene detergent, Brij 58, inhibited the secondary phase of platelet aggregation induced by ADP in human citrated platelet-rich plasma but had no effect on primary aggregation. Thrombin-induced aggregation of washed human platelets suspended in Tyrode's buffer was inhibited after incubation of cells with 4.10(-6) M detergent. Efflux of [14C]serotonin, 45Ca2+ and labile aorta contracting substance (thromboxane A2) and development of prothrombin-converting activity (platelet factor 3) were abolished concomitantly. Aggregation of washed platelets either by sodium arachidonate or by collagen was also inhibited by the same concentration of Brij 58 which inhibited thrombin aggregation. This concentration did not itself produce any release of a cytoplasmic marker, lactate dehydrogenase, from platelets. Higher concentrations of Brij 58, exceeding 4.10(-5) M, lysed the cells liberating lactate dehydrogenase, serotonin and Ca2+. When albumin was included as a platelet stabilizer in the suspending medium the concentration of detergent required for the inhibitory effects was increased ten-fold. This could be attributed to competitive binding of the detergent to albumin, demonstrated with [14C]acetylated Brij 58. A variety of other polyoxyethylene detergents, at concentrations from 8.10(-4) to 5.10(-3) M, also inhibited platelet aggregation induced by thrombin. It is concluded that low concentrations of Brij 58 stabilize the platelets against the action of aggregating agents, while higher concentrations produce membrane destabilization and cell lysis.

Sulfhydryl analogues of adenosine diphosphate: chemical synthesis and activity as platelet-aggregating agents.

2-Thioadenosine 5'-diphosphate (2-SH ADP), 2,2'-dithiobisadenosine 5'-diphosphate (2,2'-(S-ADP)2), 8-thioadenosine 5' diphosphate (8-SH ADP), and 6-mercaptopurine riboside 5'-disphosphate (6-MPRDP) were synthesized as potential affinity labels for ADP receptors on the blood-platelet membrane. The mean relative activities of these compounds in aggregating human platelets suspended in homologous plasma were 155% (2,2'-(S-ADP)2), 74% (2-SH ADP), 0.65% (8-SH ADP), and 0.08% (6-MPRDP). The mean relative activities against washed platelets were 249% (2,2"-(S-ADP)2) and 115% (2-SH ADP), whereas no aggregation occurred with 8-SH ADP or 6-MPRDP. The last two compounds were found to be weak inhibitors of ADP-induced aggregation. Therefore, thio-substitution at postition 2 followed by oxidation to a disulfide appears to be the most promising approach to further studies of affinity labelling of membrane ADP-receptors.

13C nuclear magnetic resonance spectra of 1,2-dioctadec-cis-enoyl-sn-glycero-3-phosphorylcholines.

The 13C NMR spectra of all sixteen 1,2-dioctade-cis-enoyl-sn-glycero-3-phosphorylcholines have been obtained. Resonance lines of the olefinic, methylene, methyl and carboxyl carbon nuclei are sufficiently characteristic to permit unequivocal designation of double bond position for each isomer. Two resonances of the sn-glycero-3-phosphorylcholine structure have been reassigned.

Hydrocarbon chain packing and molecular motion in phospholipid bilayers formed from unsaturated lecithins. Synthesis and properties of sixteen positional isomers of 1,2-dioctadecenoyl-sn-glycero-3-phosphorylcholine.

Isomers of cis-octadecenoic acid, with the double bond in each position in the hydrocarbon chain, were used to synthesize the corresponding 1,2-diacyl-sn-glycero-3phosphorylcholines (lecithins). Differential thermal analysis of the lecithins, as a function of water content, permitted evaluation of the limiting transition temperature (Tc) of each isomer. Values of Tc plotted against double bond position fell on a smooth curve with a minimum at minus 22 degrees for the dioctadec-9'-enoyl compound. The presence of a "pretransition" endotherm in differential thermal analysis of 1,2-dioctadec-15'-and 1,2-dioctadec-16'-enoyl-sn-glycero-3-phosphorylcholine implies the existence of two beta crystalline forms. This was not observed with any of the other lecithins. Enthalpy and entropy data were then obtained from differential scanning calorimetry measurements. Values of delta H were lower (7.6 plus or minus 0.1 kcal mol- minus 1) when the center of unsaturation was near the middle of the hydrocarbon chain than they were (9.6 kcal mol- minus 1) when the center of unsaturation was close to either end of the chain. However, values of delta S showed no consistent variation with double bond position. Four positional isomers of 1-octadec-cis-enoyl-2-octadecanoyl-sn-glycero-3-phosphorylcholine were synthesized. With the double bond near the middle of the chain or close to the terminal group, the Tc values of the mixed acid lecithins were higher than those of the corresponding dioctadecenoyl lecithins. 13-C nuclear magnetic resonance relaxation measurements were used to obtain information about chain motion of selected 1,2-dioctadec-cis-enoyl-sn-glycero-3-phosphorylcholines at a temperature (52 degrees) above the Tc values. Spin-lattice relaxation times of the resolved resonances indicated that location of double bonds near the middle, as compared to either end, of the hydrocarbon chain favors enhanced molecular motion along the length of the chins and especially at the terminal methyl end. In the gel state, the minimum interaction potential energy of hydrocarbon chains in bilayers formed from dioctadecenoyl lipids appears to be minimized by localization of the double bond near the middle of the chains. It is suggested that in the case of homogeneous chains the double bond primarily affects the cooperativity of interactions and has very little steric effect on van der Waals' contacts. By contrast, in bilayers of mixed lecithins, with heterogeneous chains, the steric effect may become dominant, depending on double bond position. These differences in chain packing in the gel state are promulgated beyond the phase transition to the liquid crystalline state as an enhancement of chain motion as the temperature rises above Tc.