Conducted at the BioMag laboratory at the Helsinki University Hospital, a new patient study could open a new opportunity to rehabilitate patients with spinal cord damage. Dr Anastasia Shulga, a medical doctor specialising in neurology, led a study in which two patients with spinal cord injuries received a form of treatment that combined transcranial magnetic stimulation with simultaneous peripheral nerve stimulation given repeatedly for nearly six months. This was the first time that attempts were made to rehabilitate patients paralysed as a result of a spinal cord injury through long-term stimulation treatment of this type.

Both patients who participated in the study had spinal cord injuries caused by trauma. One patient was paraplegic, paralysed from the knees down, and the other was tetraplegic, with some voluntary movement of the hands but no capacity to grasp. Both patients had been injured more than two years ago and had received conventional rehabilitation treatments throughout their recovery, and continued to do so during the stimulation treatment.

After approximately six months of the stimulation treatment, the paraplegic patient could bend both ankles, and the tetraplegic could grasp an object.

‘We observed strengthened neural connections and partial restoration of movement to muscles which the patients were previously entirely unable to use,’ explains Anastasia Shulga.

The movement restored during the treatment was still present a month after the stimulation treatment had ended. One of the patients is participating in a further study in which stimulation is given more extensively and for an even longer period.

Dr. Jyrki Makela, head of the BioMag laboratory, points out that rehabilitation of patients with chronic spinal cord injuries is highly challenging, and new treatment methods are sorely needed:

‘This is a case study with two patients only, but we think the results are promising. Further study is needed to confirm whether long-term paired associative stimulation can be used in rehabilitation after spinal cord injury by itself and, possibly, in combination with other therapeutic strategies.’

Helsinki University www.helsinki.fi/en/news/repeated-stimulation-treatment-can-restore-movement-to-paralysed-muscles

The first recommendations on multimodality imaging assessment of prosthetic heart valves have been published.
The novel document was produced by the European Association of Cardiovascular Imaging (EACVI), a registered branch of the European Society of Cardiology (ESC). They are endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging.
‘Prosthetic heart valves are the best treatment for the majority of patients with severe symptomatic valvular heart disease,’ said first author Professor Patrizio Lancellotti. ‘Heart valve disease is one of the most common types of cardiovascular disease and affects around 3-6% of the population over 65 years.’
Heart valve replacement is performed using mechanical or biological prostheses. It is estimated that by 2050, some 850 000 prosthetic heart valves will be implanted every year in western countries.
Dysfunction of prosthetic heart valves is rare but can be life threatening. When it does occur, it is crucial to determine the cause as this will define what treatment is needed. The paper published provides the first recommendations on how to use multimodality imaging to detect and diagnose prosthetic heart valve complications.
When prosthetic heart valve complications are suspected, the authors recommend:
First-line imaging with 2D transthoracic echocardiography (TTE); 2D and 3D TTE and transesophageal echocardiography (TOE) for complete evaluation; Cinefluoroscopy to evaluate disc mobility and valve ring structure; Cardiac computed tomography (CT) to visualize calcification, degeneration, pannus, thrombus; Cardiac magnetic resonance imaging (CMR) to assess cardiac and valvular function; Nuclear imaging, especially when infective endocarditis is suspected.
‘In this paper we have underlined the incremental value of all imaging modalities to evaluate prosthetic heart valves,’ said Professor Lancellotti. ‘Echocardiography should be used in the first instance to detect any dysfunction. Non-echo imaging modalities can be performed afterwards if more information is needed to establish the cause and extent of complications.’
He concluded: ‘We have introduced new algorithms to help clinicians diagnose and quantify prosthetic heart valve dysfunction. They are easy to use and we hope will improve assessment and subsequent management of patients so that when complications do occur, better outcomes can be achieved.’

European Society of Cardiology http://tinyurl.com/go9gwgq

A study led by investigators from the Ragon Institute of MGH, MIT and Harvard finds evidence that antibody protection may help control infection with the bacteria that causes tuberculosis (TB). In their study the research team describes finding consistent differences in both the structure and function of antibodies targeting the TB bacteria between individuals with active TB disease and those with latent TB, which neither produces symptoms nor can be transmitted. The findings may lead to better ways of distinguishing between active and latent disease and to a more effective vaccine against a disease that kills more than 1.5 million people each year.

‘Ending tuberculosis by 2030 is one of the targets of the World Health Organization’s newly adopted Sustainable Developmental Goals,’ says Lenette Lu, MD, PhD, of the Ragon Institute and the Massachusetts General Hospital (MGH) Department of Medicine. ‘A more effective vaccine against TB could substantially contribute towards that goal, impacting the nearly one in three people worldwide who are infected and addressing the leading killer of individuals infected with HIV.’

The only currently available preventive against infection with the TB bacteria – the BCG vaccine – has been available since the 1920s; but its effectiveness against pulmonary TB, the most common form of the disease, has always been uncertain. BCG is believed to work by stimulating cellular immunity, which is carried out by specialized immune cells including T cells and the macrophages that are directly infected by TB bacteria. Previous investigations into a possible role for antibodies in the immune response to TB have had conflicting results, but the Ragon team – led by Galit Alter, PhD, of MGH Department of Medicine and Sarah Fortune, MD, of the Harvard T.H. Chan School of Public Health – used a novel approach.

In addition to binding to their target pathogens and marking them for destruction by the immune system, antibodies also directly stimulate pathogen-killing cells of the innate immune system by binding to a cell-surface protein called the Fc receptor. The Ragon team profiled TB-specific antibodies from 22 individuals with latent TB and 20 with active TB for 70 different features associated with Fc-mediated antibody function. They first identified nine characteristics that differentiated between antibodies of the two groups of participants, and further investigation identified the biomarker that best distinguished between them.

A key regulator of Fc-mediated immune function is the addition to antibodies of compounds called glycans, made up of sugar molecules; and distinct differences in glycosylation patterns were found to clearly distinguish latent TB antibodies from active TB antibodies. To confirm these results in the initial group of participants, who were from South Africa, the team conducted a similar analysis of antibodies from 20 individuals from Texas and Mexico – half with latent and half with active TB – and had the same results. Further experiments revealed that application of latent TB antibodies to TB-infected human macrophages not only increased the activation of several antimicrobial processes but also reduced the survival of the TB bacteria.

Co-lead author Amy Chung, PhD, now at the Peter Doherty Institute for Infection and Immunity in Melbourne, Australia – a joint venture between The University of Melbourne and The Royal Melbourne Hospital – explains, ‘This is a completely new area of immune research in tuberculosis, since these antibodies don’t just recognize the infection, they also recruit immune cells to target it. People with latent infection have inactive disease for a reason, and if antibodies are playing a role in controlling the infection, the mechanism they use could be harnessed for future vaccine development.’

Alter, an associate professor of Medicine at Harvard Medical School, adds, ‘The diagnostic potential of these findings should not be overlooked. The detection of Fc-related modifications of TB-specific antibodies could be easily translated into a rapid, inexpensive point-of-care diagnostic that could have enormous public health impact, particularly in those parts of the globe where TB is endemic.’

Massachusetts General Hospitalwww.massgeneral.org/about/pressrelease.aspx?id=1992

It’s a Catch-22 with potentially deadly consequences: People trying to overcome addiction can’t get treatment for their pain, because the most powerful pain medicines also carry an addiction risk.
And so their pain continues to get in the way of their addiction recovery – or they seek pain relief in the same addictive substances they’re trying to avoid.

But a new study shows the potential for patients to break out of that cycle through a non-drug approach that combines behavioural therapy and social support to help them manage their pain. The low-cost approach, grounded in psychological theories of pain, could help address the nation’s epidemic of addictions to opioid painkillers and illicit drugs.

Veterans who received this pain-focused care while also being treated for addiction found that the intensity of their pain decreased, their ability to function increased, and their alcohol use went down, compared to veterans who received a less-focused approach. However, the two groups had similar rates of drug use.

Just 10 weekly sessions of the approach, called ImPAT for Improving Pain during Addiction Treatment, had an effect that lasted up to a year in 55 veterans who took part, according to the new results published by a team from the VA Ann Arbor Healthcare System’s Center for Clinical Management Research and University of Michigan Medical School’s Addiction Center.

The researchers have already launched a follow-up study in a larger group of 480 non-veterans in a residential addiction treatment program. And the study’s authors note that the ImPAT approach has the potential to be easily and inexpensively adopted by addiction treatment centers and groups worldwide, through team members trained in standard psychological techniques.

Addiction treatment programs often have patients who suffer from chronic pain, but offer few options to treat them, Ilgen says.’These results highlight the need for addiction treatment programs to offer a multifaceted approach that doesn’t only address substance use but also the other factors that might be driving substance use, including pain,’ says Mark Ilgen, Ph.D., the study’s lead author and a VA and U-M psychologist specializing in addiction research. ‘We’ve shown that it’s possible to improve pain outcomes in people with addiction, and even have some spillover effects on their substance use.’

To make matters worse, ‘Past studies of psychosocial approaches for pain have often excluded people with drug or alcohol problems, addiction treatment programs do not usually have providers trained in pain care, and many pain specialists will not treat people who also have addiction. So patients are caught in the middle.’

All 129 patients in the study, most of them men in their 40s and 50s, were receiving outpatient addiction treatment in a CBT-based, non-abstinence setting at the Ann Arbor VA. Half were randomly assigned to ImPAT sessions, the other half to support groups of peers, led by a therapist, where pain and addiction could be discussed.

ImPAT combines elements of cognitive behavioural therapy with another psychosocial approach called acceptance and commitment therapy.

While the two approaches aren’t usually used together, they are often used in pain treatment settings – but those clinics and programs don’t often accept people who also acknowledge they have addiction issues. Ilgen and his colleagues hope their results will help bring the techniques into addiction treatment settings, where the cognitive behavioural therapy approach is often used.

The ImPAT technique seeks to use integrated approaches both to help patients focus less on their pain and more on other aspects of life. This includes techniques to help people adapt to their pain, find ways to distract themselves from their pain, and think of ways to function in the face of pain.

‘We want to take the focus off pain and put it onto functioning, and finding pleasurable ways to spend time,’ Ilgen says. ‘There’s also a strong link between depression and pain. Pain is responsive to mood, and mood is responsive to social support.’

University of Michigan www.uofmhealth.org/news/archive/201607/treating-pain-without-feeding-addiction-study-shows-promise