Fluid flow structures gut microbiota biofilm communities by distributing public goods.

Bacterial gut commensals experience a biologically and physically complex mucosal environment. While many chemical factors mediate the composition and structure of these microbial communities, less is known about the role of mechanics. Here, we demonstrate that fluid flow impacts the spatial organization and composition of gut biofilm communities by shaping how different species interact metabolically. We first demonstrate that a model community composed of Bacteroides thetaiotaomicron (Bt) and Bacteroides fragilis (Bf), two representative human commensals, can form robust biofilms in flow. We identified dextran as a polysaccharide readily metabolized by Bt but not Bf, but whose fermentation generates a public good enabling Bf growth. By combining simulations with experiments, we demonstrate that in flow, Bt biofilms share dextran metabolic by-products, promoting Bf biofilm formation. By transporting this public good, flow structures the spatial organization of the community, positioning the Bf population downstream from Bt. We show that sufficiently strong flows abolish Bf biofilm formation by limiting the effective public good concentration at the surface. Physical factors such as flow may therefore contribute to the composition of intestinal microbial communities, potentially impacting host health.

The sensorimotor system modulates muscular co-contraction relative to visuomotor feedback responses to regulate movement variability.

The naturally occurring variability in our movements often poses a significant challenge when attempting to produce precise and accurate actions, which is readily evident when playing a game of darts. Two differing, yet potentially complementary, control strategies that the sensorimotor system may use to regulate movement variability are impedance control and feedback control. Greater muscular co-contraction leads to greater impedance that acts to stabilize the hand, while visuomotor feedback responses can be used to rapidly correct for unexpected deviations when reaching toward a target. Here, we examined the independent roles and potential interplay of impedance control and visuomotor feedback control when regulating movement variability. Participants were instructed to perform a precise reaching task by moving a cursor through a narrow visual channel. We manipulated cursor feedback by visually amplifying movement variability and/or delaying the visual feedback of the cursor. We found that participants decreased movement variability by increasing muscular co-contraction, aligned with an impedance control strategy. Participants displayed visuomotor feedback responses during the task but, unexpectedly, there was no modulation between conditions. However, we did find a relationship between muscular co-contraction and visuomotor feedback responses, suggesting that participants modulated impedance control relative to feedback control. Taken together, our results highlight that the sensorimotor system modulates muscular co-contraction, relative to visuomotor feedback responses, to regulate movement variability and produce accurate actions.NEW & NOTEWORTHY The sensorimotor system has the constant challenge of dealing with the naturally occurring variability in our movements. Here, we investigated the potential roles of muscular co-contraction and visuomotor feedback responses to regulate movement variability. When we visually amplified movements, we found that the sensorimotor system primarily uses muscular co-contraction to regulate movement variability. Interestingly, we found that muscular co-contraction was modulated relative to inherent visuomotor feedback responses, suggesting an interplay between impedance and feedback control.

Increasing the gradient of energetic cost does not initiate adaptation in human walking.

When in a new situation, the nervous system may benefit from adapting its control policy. In determining whether or not to initiate this adaptation, the nervous system may rely on some features of the new situation. Here, we tested whether one such feature is salient cost savings. We changed cost saliency by manipulating the gradient of participants' energetic cost landscape during walking. We hypothesized that steeper gradients would cause participants to spontaneously adapt their step frequency to lower costs. To manipulate the gradient, a mechatronic system applied controlled fore-aft forces to the waist of participants as a function of their step frequency as they walked on a treadmill. These forces increased the energetic cost of walking at high step frequencies and reduced it at low step frequencies. We successfully created three cost landscapes of increasing gradients, where the natural variability in participants' step frequency provided cost changes of 3.6% (shallow), 7.2% (intermediate), and 10.2% (steep). Participants did not spontaneously initiate adaptation in response to any of the gradients. Using metronome-guided walking-a previously established protocol for eliciting initiation of adaptation-participants next experienced a step frequency with a lower cost. Participants then adapted by -1.41 ± 0.81 (P = 0.007) normalized units away from their originally preferred step frequency obtaining cost savings of 4.80% ± 3.12%. That participants would adapt under some conditions, but not in response to steeper cost gradients, suggests that the nervous system does not solely rely on the gradient of energetic cost to initiate adaptation in novel situations.NEW & NOTEWORTHY People can adapt to novel conditions but often require cues to initiate the adaptation. Using a mechatronic system to reshape energetic cost gradients during treadmill walking, we tested whether the nervous system can use information present in the cost gradient to spontaneously initiate adaptation. We found that our participants did not spontaneously initiate adaptation even in the steepest gradient. The nervous system does not rely solely on the cost gradient when initiating adaptation.

Spatial distribution of interictal spikes fluctuates over time and localizes seizure onset.

The location of interictal spikes is used to aid surgical planning in patients with medically refractory epilepsy; however, their spatial and temporal dynamics are poorly understood. In this study, we analysed the spatial distribution of interictal spikes over time in 20 adult and paediatric patients (12 females, mean age = 34.5 years, range = 5-58) who underwent intracranial EEG evaluation for epilepsy surgery. Interictal spikes were detected in the 24 h surrounding each seizure and spikes were clustered based on spatial location. The temporal dynamics of spike spatial distribution were calculated for each patient and the effects of sleep and seizures on these dynamics were evaluated. Finally, spike location was assessed in relation to seizure onset location. We found that spike spatial distribution fluctuated significantly over time in 14/20 patients (with a significant aggregate effect across patients, Fisher's method: P < 0.001). A median of 12 sequential hours were required to capture 80% of the variability in spike spatial distribution. Sleep and postictal state affected the spike spatial distribution in 8/20 and 4/20 patients, respectively, with a significant aggregate effect (Fisher's method: P < 0.001 for each). There was no evidence of pre-ictal change in the spike spatial distribution for any patient or in aggregate (Fisher's method: P = 0.99). The electrode with the highest spike frequency and the electrode with the largest area of downstream spike propagation both localized the seizure onset zone better than predicted by chance (Wilcoxon signed-rank test: P = 0.005 and P = 0.002, respectively). In conclusion, spikes localize seizure onset. However, temporal fluctuations in spike spatial distribution, particularly in relation to sleep and post-ictal state, can confound localization. An adequate duration of intracranial recording-ideally at least 12 sequential hours-capturing both sleep and wakefulness should be obtained to sufficiently sample the interictal network.

The Outcomes of Nonoperative Management of Patients With Hip and Knee Osteoarthritis Triaged to a Physiotherapy-Led Clinic at Minimum 5-Year Follow-Up and Factors Associated With Progression to Surgery.

BACKGROUND: The purpose of this study is to determine outcomes of a nonoperative treatment service for hip and knee osteoarthritis (OA), the "Joint Clinic," at minimum 5-year follow-up, and investigate factors that may influence progression to joint replacement surgery. METHODS: This is an observational cohort study of 337 patients with hip (n = 151, 45%) or knee OA (n = 186, 55%) seen at the Joint Clinic, at 5-7 years of follow-up. Kaplan-Meier survival curves were used to determine survivorship of the affected joint and Cox regression used to determine factors associated with time to surgery. RESULTS: At mean 6-year follow up, 188 (56%) patients had undergone or were awaiting total joint arthroplasty, 127 (38%) were still being managed nonoperatively, and 22 (7%) had died without having surgery. Patients with hip OA were more likely to have required surgery (111/151, 74%) than patients with knee OA (77/186, 41%) (chi-square = 33.6, P < .001). The 7-year surgery-free survival for hip OA was 23.7% and knee OA 55.9% (P < .001). Factors associated with increased likelihood of surgery were joint affected (hip, hazard ratio [HR] 2.80), Kellgren-Lawrence (KL) grade (KL 3, HR 2.02; KL 4, 4.79), and Oxford Hip/Knee Score (HR 1.34 for each 5 points worse at baseline). CONCLUSION: More than 50% of the patients referred to secondary care with mild-moderate knee OA may not need surgery at 7 years. Patients with hip OA and those with severe radiographic changes are more likely to require surgery and should not be delayed if there is not an adequate response to conservative measures.

Is natural variability in gait sufficient to initiate spontaneous energy optimization in human walking?

In new walking contexts, the nervous system can adapt preferred gaits to minimize energetic cost. During treadmill walking, this optimization is not usually spontaneous but instead requires experience with the new energetic cost landscape. Experimenters can provide subjects with the needed experience by prescribing new gaits or instructing them to explore new gaits. Yet in familiar walking contexts, people naturally prefer energetically optimal gaits: the nervous system can optimize cost without an experimenter's guidance. Here we test the hypothesis that the natural gait variability of overground walking provides the nervous system with sufficient experience with new cost landscapes to initiate spontaneous minimization of energetic cost. We had subjects walk over paths of varying terrain while wearing knee exoskeletons that penalized walking as a function of step frequency. The exoskeletons created cost landscapes with minima that were, on average, 8% lower than the energetic cost at the initially preferred gaits and achieved at walking speeds and step frequencies that were 4% lower than the initially preferred values. We found that our overground walking trials amplified gait variability by 3.7-fold compared with treadmill walking, resulting in subjects gaining greater experience with new cost landscapes, including frequent experience with gaits at the new energetic minima. However, after 20 min and 2.0 km of walking in the new cost landscapes, we observed no consistent optimization of gait, suggesting that natural gait variability during overground walking is not always sufficient to initiate energetic optimization over the time periods and distances tested in this study. NEW & NOTEWORTHY While the nervous system can continuously optimize gait to minimize energetic cost, what initiates this optimization process during every day walking is unknown. Here we tested the hypothesis that the nervous system leverages the natural variability in gait experienced during overground walking to converge on new energetically optimal gaits created using exoskeletons. Contrary to our hypothesis, we found that participants did not adapt toward optimal gaits: natural variability is not always sufficient to initiate spontaneous energy optimization.

Reproducibility of interictal spike propagation in children with refractory epilepsy.

OBJECTIVE: Interictal spikes are a characteristic feature of invasive electroencephalography (EEG) recordings in children with refractory epilepsy. Spikes frequently co-occur across multiple brain regions with discernable latencies, suggesting that spikes can propagate through distributed neural networks. The purpose of this study was to examine the long-term reproducibility of spike propagation patterns over hours to days of interictal recording. METHODS: Twelve children (mean age 13.1 years) were retrospectively studied. A mean ± standard deviation (SD) of 47.2 ± 40.1 hours of interictal EEG recordings were examined per patient (range 17.5-166.5 hours). Interictal recordings were divided into 30-minute segments. Networks were extracted based on the frequency of spike coactivation between pairs of electrodes. For each 30-minute segment, electrodes were assigned a "Degree Preference (DP)" based on the tendency to appear upstream or downstream within propagation sequences. The consistency of DPs across segments ("DP-Stability") was quantified using the Spearman rank correlation. RESULTS: Regions exhibited highly stable preferences to appear upstream, intermediate, or downstream in spike propagation sequences. Across networks, the mean ± SD DP-Stability was 0.88 ± 0.07, indicating that propagation patterns observed in 30-minute segments were representative of the patterns observed in the full interictal window. At the group level, regions involved in seizure generation appeared more upstream in spike propagation sequences. SIGNIFICANCE: Interictal spike propagation is a highly reproducible output of epileptic networks. These findings shed new light on the spatiotemporal dynamics that may constrain the network mechanisms of refractory epilepsy.

How humans initiate energy optimization and converge on their optimal gaits.

A central principle in motor control is that the coordination strategies learned by our nervous system are often optimal. Here, we combined human experiments with computational reinforcement learning models to study how the nervous system navigates possible movements to arrive at an optimal coordination. Our experiments used robotic exoskeletons to reshape the relationship between how participants walk and how much energy they consume. We found that while some participants used their relatively high natural gait variability to explore the new energetic landscape and spontaneously initiate energy optimization, most participants preferred to exploit their originally preferred, but now suboptimal, gait. We could nevertheless reliably initiate optimization in these exploiters by providing them with the experience of lower cost gaits, suggesting that the nervous system benefits from cues about the relevant dimensions along which to re-optimize its coordination. Once optimization was initiated, we found that the nervous system employed a local search process to converge on the new optimum gait over tens of seconds. Once optimization was completed, the nervous system learned to predict this new optimal gait and rapidly returned to it within a few steps if perturbed away. We then used our data to develop reinforcement learning models that can predict experimental behaviours, and applied these models to inductively reason about how the nervous system optimizes coordination. We conclude that the nervous system optimizes for energy using a prediction of the optimal gait, and then refines this prediction with the cost of each new walking step.

Is innovative workforce planning software the solution to NHS staffing and cost crisis? An exploration of the locum industry.

BACKGROUND: Workforce planning in the British healthcare system (NHS) is associated with significant costs of agency staff employment. The introduction of a novel software (ABG) as a 'people to people economy' (P2PE) platform for temporary staff recruitment offers a potential solution to this problem. Consequently, the focus of this study was twofold - primarily to explore the locum doctor landscape, and secondarily to evaluate the implementation of P2PE in the healthcare industry. METHODS: Documentary analysis was conducted alongside thirteen semi structured interviews across five informant groups: two industry experts, two healthcare consultants, an executive director, two speciality managers and six doctors. RESULTS: We found that locum doctors are indispensable to covering workforce shortages, yet existing planning and recruitment practices were found to be inefficient, inconsistent and lacking transparency. Contrarily, mobile-first solutions such as ABG seem to secure higher convenience, better transparency, cost and time efficiency. We also identified factors facilitating the successful diffusion of ABG; these were in line with classically cited characteristics of innovation such as trialability, observability, and scope for local reinvention. Drawing upon the concept of value-based healthcare coupled with the analysis of our findings led to the development of Information Exchange System (IES) model, a comprehensive framework allowing a thorough comparison of recruitment practices in healthcare. CONCLUSION: IES was used to evaluate ABG and its diffusion against other recruitment methods and ABG was found to outperform its alternatives, thus suggesting its potential to solve the staffing and cost crisis at the chosen hospital.

Contribution of blood oxygen and carbon dioxide sensing to the energetic optimization of human walking.

People can adapt their gait to minimize energetic cost, indicating that walking's neural control has access to ongoing measurements of the body's energy use. In this study we tested the hypothesis that an important source of energetic cost measurements arises from blood gas receptors that are sensitive to O2 and CO2 concentrations. These receptors are known to play a role in regulating other physiological processes related to energy consumption, such as ventilation rate. Given the role of O2 and CO2 in oxidative metabolism, sensing their levels can provide an accurate estimate of the body's total energy use. To test our hypothesis, we simulated an added energetic cost for blood gas receptors that depended on a subject's step frequency and determined if subjects changed their behavior in response to this simulated cost. These energetic costs were simulated by controlling inspired gas concentrations to decrease the circulating levels of O2 and increase CO2 We found this blood gas control to be effective at shifting the step frequency that minimized the ventilation rate and perceived exertion away from the normally preferred frequency, indicating that these receptors provide the nervous system with strong physiological and psychological signals. However, rather than adapt their preferred step frequency toward these lower simulated costs, subjects persevered at their normally preferred frequency even after extensive experience with the new simulated costs. These results suggest that blood gas receptors play a negligible role in sensing energetic cost for the purpose of optimizing gait.NEW & NOTEWORTHY Human gait adaptation implies that the nervous system senses energetic cost, yet this signal is unknown. We tested the hypothesis that the blood gas receptors sense cost for gait optimization by controlling blood O2 and CO2 with step frequency as people walked. At the simulated energetic minimum, ventilation and perceived exertion were lowest, yet subjects preferred walking at their original frequency. This suggests that blood gas receptors are not critical for sensing cost during gait.

Why do undescended testes and posterior urethral valve occur together?

BACKGROUND/AIM: Undescended testis (UDT) occurs in ~2 % of newborn males, and occasionally these infants also have posterior urethral valve (PUV). The cause of this relationship is uncertain. We aimed to review the literature to identify publications documenting co-occurrence of UDT and PUV, and to summarise the theories of co-occurrence. METHODS: A search of the literature (Embase, Medline, Pubmed; 1947-2015) was undertaken to identify publications describing the link between UDT in PUV patients, as well as PUV in UDT patients. Ten publications in English were found with both UDT and PUV: 9 articles describing the frequency of UDT in patients with PUV, and 1 article examining the frequency of PUV in infants with UDT. RESULTS: UDT occurred in 12-17 % of PUV compared with 1-2 % in the control population, consistent with a 10-fold increase. PUV occurred in 1.2 % of UDT patients compared with 0.01 % in the control population, consistent with a 100-fold increase. DISCUSSION: PUV leads to a 10-fold increase in occurrence of UDT, while the presence of UDT causes a 100-fold increase in occurrence of PUV. Four main theories of causation have been proposed, each of which have some merit but little supporting evidence, leaving the cause of simultaneous occurrence of PUV and UDT uncertain.

The cost of moving optimally: kinematic path selection.

It is currently unclear whether the brain plans movement kinematics explicitly or whether movement paths arise implicitly through optimization of a cost function that takes into account control and/or dynamic variables. Several cost functions are proposed in the literature that are very different in nature (e.g., control effort, torque change, and jerk), yet each can predict common movement characteristics. We set out to disentangle predictions of the different variables using a combination of modeling and empirical studies. Subjects performed goal-directed arm movements in a force field (FF) in combination with visual perturbations of seen hand position. This FF was designed to have distinct optimal movements for muscle-input and dynamic costs while leaving kinematic cost unchanged. Visual perturbations in turn changed the kinematic cost but left the dynamic and muscle-input costs unchanged. An optimally controlled, physiologically realistic arm model was used to predict movements under the various cost variables. Experimental results were not consistent with a cost function containing any of the control and dynamic costs investigated. Movement patterns of all experimental conditions were adequately predicted by a kinematic cost function comprising both visually and somatosensory perceived jerk. The present study provides clear behavioral evidence that the brain solves kinematic and mechanical redundancy in separate steps: in a first step, movement kinematics are planned; and in a second, separate step, muscle activation patterns are generated.

Bimanual proprioception: are two hands better than one?

Information about the position of an object that is held in both hands, such as a golf club or a tennis racquet, is transmitted to the human central nervous system from peripheral sensors in both left and right arms. How does the brain combine these two sources of information? Using a robot to move participant's passive limbs, we performed psychophysical estimates of proprioceptive function for each limb independently and again when subjects grasped the robot handle with both arms. We compared empirical estimates of bimanual proprioception to several models from the sensory integration literature: some that propose a combination of signals from the left and right arms (such as a Bayesian maximum-likelihood estimate), and some that propose using unimanual signals alone. Our results are consistent with the hypothesis that the nervous system both has knowledge of and uses the limb with the best proprioceptive acuity for bimanual proprioception. Surprisingly, a Bayesian model that postulates optimal combination of sensory signals could not predict empirically observed bimanual acuity. These findings suggest that while the central nervous system seems to have information about the relative sensory acuity of each limb, it uses this information in a rather rudimentary fashion, essentially ignoring information from the less reliable limb.

Bacteroides thetaiotaomicron metabolic activity decreases with polysaccharide molecular weight.

The human colon hosts hundreds of commensal bacterial species, many of which ferment complex dietary carbohydrates. To transform these fibers into metabolically accessible compounds, microbes often express a series of dedicated enzymes homologous to the starch utilization system (Sus) encoded in polysaccharide utilization loci (PULs). The genome of Bacteroides thetaiotaomicron (Bt), a common member of the human gut microbiota, encodes nearly 100 PULs, conferring a strong metabolic versatility. While the structures and functions of individual enzymes within the PULs have been investigated, little is known about how polysaccharide complexity impacts the function of Sus-like systems. We here show that the activity of Sus-like systems depends on polysaccharide size, ultimately impacting bacterial growth. We demonstrate the effect of size-dependent metabolism in the context of dextran metabolism driven by the specific utilization system PUL48. We find that as the molecular weight of dextran increases, Bt growth rate decreases and lag time increases. At the enzymatic level, the dextranase BT3087, a glycoside hydrolase (GH) belonging to the GH family 66, is the main GH for dextran utilization, and BT3087 and BT3088 contribute to Bt dextran metabolism in a size-dependent manner. Finally, we show that the polysaccharide size-dependent metabolism of Bt impacts its metabolic output in a way that modulates the composition of a producer-consumer community it forms with Bacteroides fragilis. Altogether, our results expose an overlooked aspect of Bt metabolism that can impact the composition and diversity of microbiota. IMPORTANCE: Polysaccharides are complex molecules that are commonly found in our diet. While humans lack the ability to degrade many polysaccharides, their intestinal microbiota contain bacterial commensals that are versatile polysaccharide utilizers. The gut commensal Bacteroides thetaiotaomicron dedicates roughly 20% of their genomes to the expression of polysaccharide utilization loci for the broad range utilization of polysaccharides. Although it is known that different polysaccharide utilization loci are dedicated to the degradation of specific polysaccharides with unique glycosidic linkages and monosaccharide compositions, it is often overlooked that specific polysaccharides may also exist in various molecular weights. These different physical attributes may impact their processability by starch utilization system-like systems, leading to differing growth rates and nutrient-sharing properties at the community level. Therefore, understanding how molecular weight impacts utilization by gut microbe may lead to the potential design of novel precision prebiotics.

Control of position and movement is simplified by combined muscle spindle and Golgi tendon organ feedback.

Whereas muscle spindles play a prominent role in current theories of human motor control, Golgi tendon organs (GTO) and their associated tendons are often neglected. This is surprising since there is ample evidence that both tendons and GTOs contribute importantly to neuromusculoskeletal dynamics. Using detailed musculoskeletal models, we provide evidence that simple feedback using muscle spindles alone results in very poor control of joint position and movement since muscle spindles cannot sense changes in tendon length that occur with changes in muscle force. We propose that a combination of spindle and GTO afferents can provide an estimate of muscle-tendon complex length, which can be effectively used for low-level feedback during both postural and movement tasks. The feasibility of the proposed scheme was tested using detailed musculoskeletal models of the human arm. Responses to transient and static perturbations were simulated using a 1-degree-of-freedom (DOF) model of the arm and showed that the combined feedback enabled the system to respond faster, reach steady state faster, and achieve smaller static position errors. Finally, we incorporated the proposed scheme in an optimally controlled 2-DOF model of the arm for fast point-to-point shoulder and elbow movements. Simulations showed that the proposed feedback could be easily incorporated in the optimal control framework without complicating the computation of the optimal control solution, yet greatly enhancing the system's response to perturbations. The theoretical analyses in this study might furthermore provide insight about the strong physiological couplings found between muscle spindle and GTO afferents in the human nervous system.

Delivery of Topical Drugs to the Olfactory Cleft.

Olfactory dysfunction affects approximately 20% of the population globally, with incidence increasing over the age of 60. The pathophysiology is complex, not yet fully understood, and depends on many factors, including the underlying cause. Despite this, the present literature on olfaction is limited due to significant heterogeneity in methodological approaches. This has resulted in limited effective treatments available for olfactory dysfunction. Medications for olfactory dysfunction can be administered locally (directly to the olfactory epithelium) or systemically (orally or intravenously). Currently, there are various methods for local drug delivery to the olfactory epithelium (nasal drops, nasal sprays, atomisers, pressured meter-dosed inhalers, rinses, and exhalation delivery systems). The aims of this review are to summarise the different methods of drug delivery to the olfactory cleft, evaluate the current literature to assess which method is the most effective in delivering drugs to the olfactory epithelium, and review the medications currently available to treat olfactory dysfunction topically. Going forward, further research is required to better establish effective methods of drug delivery to the olfactory epithelium to treat smell disorders.

A comprehensive wireless neurological and cardiopulmonary monitoring platform for pediatrics.

Neurodevelopment in the first 10 years of life is a critical time window during which milestones that define an individual's functional potential are achieved. Comprehensive multimodal neurodevelopmental monitoring is particularly crucial for socioeconomically disadvantaged, marginalized, historically underserved and underrepresented communities as well as medically underserved areas. Solutions designed for use outside the traditional clinical environment represent an opportunity for addressing such health inequalities. In this work, we present an experimental platform, ANNE EEG, which adds 16-channel cerebral activity monitoring to the existing, USA FDA-cleared ANNE wireless monitoring platform which provides continuous electrocardiography, respiratory rate, pulse oximetry, motion, and temperature measurements. The system features low-cost consumables, real-time control and streaming with widely available mobile devices, and fully wearable operation to allow a child to remain in their naturalistic environment. This multi-center pilot study successfully collected ANNE EEG recordings from 91 neonatal and pediatric patients at academic quaternary pediatric care centers and in LMIC settings. We demonstrate the practicality and feasibility to conduct electroencephalography studies with high levels of accuracy, validated via both quantitative and qualitative metrics, compared against gold standard systems. An overwhelming majority of parents surveyed during studies indicated not only an overall preference for the wireless system, but also that its use would improve their children's physical and emotional health. Our findings demonstrate the potential for the ANNE system to perform multimodal monitoring to screen for a variety of neurologic diseases that have the potential to negatively impact neurodevelopment.

Can proprioceptive training improve motor learning?

Recent work has investigated the link between motor learning and sensory function in arm movement control. A number of findings are consistent with the idea that motor learning is associated with systematic changes to proprioception (Haith A, Jackson C, Mial R, Vijayakumar S. Adv Neural Inf Process Syst 21: 593-600, 2008; Ostry DJ, Darainy M, Mattar AA, Wong J, Gribble PL. J Neurosci 30: 5384-5393, 2010; Vahdat S, Darainy M, Milner TE, Ostry DJ. J Neurosci 31: 16907-16915, 2011). Here, we tested whether motor learning could be improved by providing subjects with proprioceptive training on a desired hand trajectory. Subjects were instructed to reproduce both the time-varying position and velocity of novel, complex hand trajectories. Subjects underwent 3 days of training with 90 movement trials per day. Active movement trials were interleaved with demonstration trials. For control subjects, these interleaved demonstration trials consisted of visual demonstration alone. A second group of subjects received visual and proprioceptive demonstration simultaneously; this group was presented with the same visual stimulus, but, in addition, their limb was moved through the target trajectory by a robot using servo control. Subjects who experienced the additional proprioceptive demonstration of the desired trajectory showed greater improvements during training movements than control subjects who only received visual information. This benefit of adding proprioceptive training was seen in both movement speed and position error. Interestingly, additional control subjects who received proprioceptive guidance while actively moving their arm during demonstration trials did not show the same improvement in positional accuracy. These findings support the idea that the addition of proprioceptive training can augment motor learning, and that this benefit is greatest when the subject passively experiences the goal movement.

Rare case of sudden onset sensorineural hearing loss in a patient diagnosed with sarcoidosis.

We report the case of a woman in her 30s who was referred to the ear, nose and throat department with sudden onset left-sided sensorineural hearing loss (SNHL), left anterior uveitis and erythematous lower limb lesions with bilateral pitting oedema. Based on her symptoms, an underlying inflammatory systemic disease was suspected. Autoantibodies were negative but an X-ray and high-resolution CT scan of the chest were suggestive of sarcoidosis, which was confirmed on endoscopic bronchial biopsy. Following treatment with a course of oral steroids, the patient's hearing has improved but she still suffers from episodes of uveitis. While immune-mediated inner ear disorders are a recognised cause of SNHL, sarcoidosis is a very rare cause. This case demonstrates the importance of screening for systemic autoimmune aetiology in SNHL and highlights the importance of an effective multidisciplinary team in the diagnosis and management of these patients.

Improving nutritional assessment in acute medical admissions at a district general hospital.

BACKGROUND: Malnutrition adversely affects clinical outcomes, necessitating a prompt and accurate assessment of nutritional status on admission. A variety of tools exist to aid nutritional assessment, of which the malnutrition universal screening tool (MUST) is recommended, but remains difficult to implement in practice. OBJECTIVE: The aim of this audit was to improve the utilisation of the malnutrition universal screening tool (MUST) in the Acute Medical Unit (AMU) at Queen Elizabeth Hospital, King's Lynn. Specifically, patients should have a completed and accurate MUST score within 6 hours of arrival to AMU and high-risk patients (MUST score ≥2) should be referred to dieticians within 48 hours of admission. The first cycle was conducted by March 2019 and the second cycle was completed 1 year later to allow assessment of interventions actioned after the first cycle. METHODS: We conducted a two-cycle audit evaluating the MUST completion and dietician referral rate of high-risk patients (defined as MUST ≥2) on the Acute Medical Unit in a district general hospital, with the standards of 80% and 100% respectively. A questionnaire was distributed after the first cycle exploring nurses' current experience and competence in using MUST. RESULTS: In the first cycle, MUST scores were calculated correctly in 111/150 patients (74%) and 1/9 (11%) high-risk patients were referred to dieticians. After interventions, MUST scores were calculated correctly in 77/101 patients (76%) and 2/4 high-risk patients (50%) were referred to dieticians. The nurses (n = 19) who took part in the questionnaire felt confident in MUST completion, but the average score in an objective assessment was 67%. CONCLUSIONS: As per the literature, the first cycle demonstrated the under-utilisation of MUST in clinical practice. In response, we proposed additional face-to-face training for existing staff, the inclusion of an e-learning module within the staff's induction, and provision of ward MUST 'troubleshooting' booklets. MUST utilisation rates improved upon re-auditing, but not to target standards. We will need to consider potential barriers to sustainable change and implement interventions such as identification of nursing champions to overcome them.