SummaryBackgroundResults of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.MethodsFOCUS 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.FindingsBetween 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.InterpretationFluoxetine 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.FundingUK Stroke Association and NIHR Health Technology Assessment Programme.

Synchronising movements with events in the surrounding environment is an ubiquitous aspect of everyday behaviour. Often, information about a stream of events is available across sensory modalities. While it is clear that we synchronise more accurately to auditory cues than other modalities, little is known about how the brain combines multisensory signals to produce accurately timed actions. Here, we investigate multisensory integration for sensorimotor synchronisation. We extend the prevailing linear phase correction model for movement synchronisation, describing asynchrony variance in terms of sensory, motor and timekeeper components. Then we assess multisensory cue integration, deriving predictions based on the optimal combination of event time, defined across different sensory modalities. Participants tapped in time with metronomes presented via auditory, visual and tactile modalities, under either unimodal or bimodal presentation conditions. Temporal regularity was manipulated between modalities by applying jitter to one of the metronomes. Results matched the model predictions closely for all except high jitter level conditions in audio-visual and audio-tactile combinations, where a bias for auditory signals was observed. We suggest that, in the production of repetitive timed actions, cues are optimally integrated in terms of both sensory and temporal reliability of events. However, when temporal discrepancy between cues is high they are treated independently, with movements timed to the cue with the highest sensory reliability.

Synchronizing our actions with external events is a task we perform without apparent effort. Its foundation relies on accurate temporal control that is widely accepted to take one of two different modes of implementation: explicit timing for discrete actions and implicit timing for smooth continuous movements. Here we assess synchronisation performance for different types of action and test the degree to which each action supports corrective updating following changes in the environment. Participants performed three different finger actions in time with an auditory pacing stimulus allowing us to assess synchronisation performance. Presenting a single perturbation to the otherwise regular metronome allowed us to examine corrections supported by movements varying in their mode of timing implementation. We find that discrete actions are less variable and support faster error correction. As such, discrete actions may be preferred when engaging in time-critical adaptive behaviour with people and objects in a dynamic environment.

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Many everyday skilled actions depend on moving in time with signals that are embedded in complex auditory streams (e.g. musical performance, dancing or simply holding a conversation). Such behaviour is apparently effortless; however, it is not known how humans combine auditory signals to support movement production and coordination. Here, we test how participants synchronize their movements when there are potentially conflicting auditory targets to guide their actions. Participants tapped their fingers in time with two simultaneously presented metronomes of equal tempo, but differing in phase and temporal regularity. Synchronization therefore depended on integrating the two timing cues into a single-event estimate or treating the cues as independent and thereby selecting one signal over the other. We show that a Bayesian inference process explains the situations in which participants choose to integrate or separate signals, and predicts motor timing errors. Simulations of this causal inference process demonstrate that this model provides a better description of the data than other plausible models. Our findings suggest that humans exploit a Bayesian inference process to control movement timing in situations where the origin of auditory signals needs to be resolved.

Previously, it has been shown that synchronising actions with periodic pacing stimuli are unaffected by ageing. However, synchronisation often requires combining evidence across multiple sources of timing information. We have previously shown the brain integrates multisensory cues to achieve a best estimate of the events in time and subsequently reduces variability in synchronised movements (Elliott et al. in Eur J Neurosci 31(10):1828-1835, 2010). Yet, it is unclear if sensory integration of temporal cues in older adults is degraded and whether this leads to reduced synchronisation performance. Here, we test for age-related changes when synchronising actions to multisensory temporal cues. We compared synchronisation performance between young (N = 15, aged 18-37 years) and older adults (N = 15, aged 63-80 years) using a finger-tapping task to auditory and tactile metronomes presented unimodally and bimodally. We added temporal jitter to the auditory metronome to determine whether participants would integrate auditory and tactile signals, with reduced weighting of the auditory metronome as its reliability decreased under bimodal conditions. We found that older adults matched the performance of young adults when synchronising to an isochronous auditory or tactile metronome. When the temporal regularity of the auditory metronome was reduced, older adults' performance was degraded to a greater extent than the young adults in both unimodal and bimodal conditions. However, proportionally both groups showed similar improvements in synchronisation performance in bimodal conditions compared with the equivalent, auditory-only conditions. We conclude that while older adults become more variable in synchronising to less regular beats, they do not show any deficit in the integration of multisensory temporal cues, suggesting that using multisensory information may help mitigate any deficits in coordinating actions to complex timing cues.

Background Children and young people (CYP) with chronic rheumatic conditions; Juvenile Idiopathic Arthritis, Juvenile Systemic Lupus Erythematosus, Juvenile Dermatomyositis and Juvenile Vasculitis, treated with steroids, have low bone density, increased fracture risk and are likely to have suboptimal peak bone mass. There is currently no evidence base for the management of steroid-induced bone loss in children with rheumatic diseases. Methods We undertook a multi-centre double dummy double-blind randomised placebo controlled trial to investigate whether the bisphosphonate risedronate was superior to alfacalcidol or calcium and vitamin D supplementation in the prevention and treatment of steroid-induced osteopaenia in these children. Patients were stratified and randomised in a 1:1 ratio, into: placebo; alfacalcidol; risedronate. The primary outcome was the change in lumbar spine bone mineral density z score (LSaBMDz) measured by dual energy x-ray absorptiometry at one year. Secondary outcome was fracture rate. Results Two hundred and seventeen patients were recruited to the study. Seventy seven placebo, 71 alfacalcidol, and 69 risedronate. Highly statistically significant differences were observed in the change in LSaBMDz between the placebo and risedronate groups; 0.274, 95% CI (0.061, 0.487) (p < 0.001) and between the risedronate and the alfacalcidol groups; 0.326 95% CI (0.109, 0.543) (p < 0.001). The difference observed between the alfacalcidol and placebo group was not statistically significant. Highly statistically significant differences were seen in the change in Total Body Less Head aBMD-Z Score between the placebo and risedronate groups (p < 0.01) but not between the alfacalcidol and risedronate groups. No significant differences in fracture frequency, adverse or serious adverse reactions were observed between the groups. Conclusions Children and adolescents receiving steroids for rheumatic diseases benefit from prophylactic treatment with bisphosphonates to increase LSaBMD. Alfacalcidol is ineffective.

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