Abstract TP371: Monitoring a Large-scale International Cluster Stroke Trial: Lessons From Head Position in Stroke Trial

Background and Purpose: There is limited evidence on head positioning in acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH). Potential benefits for lying flat (0°) include improved collateral blood flow in AIS and for head up (30°) reduced cerebral oedema in ICH. The Head Positioning in Stroke Trial (HeadPoST) aims to provide reliable evidence on the optimum head position in acute stroke.

Methods: HeadPoST is a prospective, cluster randomised, crossover, blinded outcome assessed, clinical trial with consecutive patient recruitment who were positioned within 24 hours of admission. Hospitals were randomised to service organisation to compare lying flat vs. sitting up (≥30°) head positioning of stroke patients. An innovative centralized remote monitoring system was used to assess data quality across participating countries.

Results: Over a 30 month study period, 10,000+ patients were recruited across 114 hospitals in 9 countries. A web-based monitoring system provided alerts for cross-over time points and achievement of cluster balance. Centralised reports included serious adverse events, protocol deviations, forms completion, data queries, entry delays and data validation, which were distributed to regional co-ordinating centres for action. Details of these procedures are outlined.

Conclusions: Reliable, complete, and high quality data were required for this pragmatic international nursing care clinical trial, which used a novel cluster cross-over design.

Associations with health-related quality of life after intracerebral haemorrhage: pooled analysis of INTERACT studies

BACKGROUND AND PURPOSE

Limited data exist on health-related quality of life (HRQoL) after intracerebral haemorrhage (ICH). We aimed to determine baseline factors associated with HRQoL among participants of the pilot and main phases of the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trials (INTERACT 1 and 2).

METHODS

The INTERACT studies were randomised controlled trials of early intensive blood pressure (BP) lowering in patients with ICH (<6 hours) and elevated systolic BP (150-220 mm Hg). HRQoL was determined using the European Quality of Life Scale (EQ-5D) at 90 days, completed by patients or proxy responders. Binary logistic regression analyses were performed to identify factors associated with poor overall HRQoL.

RESULTS

2756 patients were included. Demographic, clinical and radiological factors associated with lower EQ-5D utility score were age, randomisation outside of China, antithrombotic use, high baseline National Institutes of Health Stroke Scale (NIHSS) score, larger ICH, presence of intraventricular extension and use of proxy responders. High (≥14) NIHSS score, larger ICH and proxy responders were associated with low scores in all five dimensions of the EQ-5D. The NIHSS score had a strong association with poor HRQoL (p<0.001). Female gender and antithrombotic use were associated with decreased scores in dimensions of pain/discomfort and usual activity, respectively.

CONCLUSIONS

Poor HRQoL was associated with age, comorbidities, proxy source of assessment, clinical severity and ICH characteristics. The strongest association was with initial clinical severity defined by high NIHSS score.

TRIAL REGISTRATION NUMBERS

NCT00226096 and NCT00716079; Post-results.

Parallel-Serial Memoing: A Novel Approach to Analyzing Qualitative Data

The mechanisms by which talking therapies exert their beneficial effects are largely unknown. In exploring the process of a talking therapy, motivational interviewing (MI), when used to treat and prevent low mood in stroke survivors, we developed, what we believe to be, a novel approach to analyzing transcripts. We illustrate the method using qualitative data from MI sessions with 10 stroke survivors. The approach, drawing on grounded theory, incorporated processes of parallel and serial memoing among a team of researchers to allow a process of validation. This enabled us to describe session content and to develop theoretical interpretations of what was occurring in and across MI sessions. We found that this process can be used to integrate different perspectives in theory building, allowing for a richer description and more robust theoretical interpretation. Others can use and adapt this approach to develop insights into their own inquiry.

Factors Influencing Engagement, Perceived Usefulness and Behavioral Mechanisms Associated with a Text Message Support Program

INTRODUCTION

Many studies have now demonstrated the efficacy of text messaging in positively changing behaviours. We aimed to identify features and factors that explain the effectiveness of a successful text messaging program in terms of user engagement, perceived usefulness, behavior change and program delivery preferences.

METHODS

Mixed methods qualitative design combining four data sources; (i) analytic data extracted directly from the software system, (ii) participant survey, (iii) focus groups to identify barriers and enablers to implementation and mechanisms of effect and (iv) recruitment screening logs and text message responses to examine engagement. This evaluation was conducted within the TEXT ME trial-a parallel design, single-blind randomized controlled trial (RCT) of 710 patients with coronary heart disease (CHD). Qualitative data were interpreted using inductive thematic analysis.

RESULTS

307/352 (87% response rate) of recruited patients with CHD completed the program evaluation survey at six months and 25 participated in a focus group. Factors increasing engagement included (i) ability to save and share messages, (ii) having the support of providers and family, (iii) a feeling of support through participation in the program, (iv) the program being initiated close to the time of a cardiovascular event, (v) personalization of the messages, (vi) opportunity for initial face-to-face contact with a provider and (vii) that program and content was perceived to be from a credible source. Clear themes relating to program delivery were that diet and physical activity messages were most valued, four messages per week was ideal and most participants felt program duration should be provided for at least for six months or longer.

CONCLUSIONS

This study provides context and insight into the factors influencing consumer engagement with a text message program aimed at improving health-related behavior. The study suggests program components that may enhance potential success but will require integration at the development stage to optimize up-scaling.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry, ACTRN12611000161921.

Effect of affordable technology on physical activity levels and mobility outcomes in rehabilitation: a protocol for the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial

INTRODUCTION

People with mobility limitations can benefit from rehabilitation programmes that provide a high dose of exercise. However, since providing a high dose of exercise is logistically challenging and resource-intensive, people in rehabilitation spend most of the day inactive. This trial aims to evaluate the effect of the addition of affordable technology to usual care on physical activity and mobility in people with mobility limitations admitted to inpatient aged and neurological rehabilitation units compared to usual care alone.

METHODS AND ANALYSIS

A pragmatic, assessor blinded, parallel-group randomised trial recruiting 300 consenting rehabilitation patients with reduced mobility will be conducted. Participants will be individually randomised to intervention or control groups. The intervention group will receive technology-based exercise to target mobility and physical activity problems for 6 months. The technology will include the use of video and computer games/exercises and tablet applications as well as activity monitors. The control group will not receive any additional intervention and both groups will receive usual inpatient and outpatient rehabilitation care over the 6-month study period. The coprimary outcomes will be objectively assessed physical activity (proportion of the day spent upright) and mobility (Short Physical Performance Battery) at 6 months after randomisation. Secondary outcomes will include: self-reported and objectively assessed physical activity, mobility, cognition, activity performance and participation, utility-based quality of life, balance confidence, technology self-efficacy, falls and service utilisation. Linear models will assess the effect of group allocation for each continuously scored outcome measure with baseline scores entered as a covariate. Fall rates between groups will be compared using negative binomial regression. Primary analyses will be preplanned, conducted while masked to group allocation and use an intention-to-treat approach.

ETHICS AND DISSEMINATION

The protocol has been approved by the relevant Human Research Ethics Committees and the results will be disseminated widely through peer-reviewed publication and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12614000936628. Pre-results.

Motivational Interviewing Post-Stroke: An Analysis of Stroke Survivors' Concerns and Adjustment

Our earlier research demonstrated that participation in four sessions of motivational interviewing (MI) early post-stroke has a positive impact on stroke survivors' mood. However, the theoretical underpinnings of MI in supporting adjustment (rather than its traditional use in supporting behavior change) require clarification. This article describes a content analysis of MI transcripts for 10 participants in our previous study, to identify the focus of discussions (patient "concerns") and potential effective components of our MI approach. Patients' post-stroke concerns were shown in 16 categories, including frustration, family impact, and getting well. There was a pattern of change discourse across sessions: "Sustain talk" (reasons for not changing) reduced from Session 1 onward, "change talk" (intent to change) increased then reduced, and "change expressed" (changes achieved) increased from Sessions 1 to 4. MI facilitates healthy adjustment post-stroke in some patients, in turn affecting mood, but clarification of how this effect is achieved requires further exploration.

Effects of Low-Dose and Very Low-Dose Ketamine among Patients with Major Depression: a Systematic Review and Meta-Analysis

BACKGROUND

Several recent trials indicate low-dose ketamine produces rapid antidepressant effects. However, uncertainty remains in several areas: dose response, consistency across patient groups, effects on suicidality, and possible biases arising from crossover trials.

METHODS

A systematic search was conducted for relevant randomized trials in Medline, Embase, and PsycINFO databases up to August 2014. The primary endpoints were change in depression scale scores at days 1, 3 and 7, remission, response, suicidality, safety, and tolerability. Data were independently abstracted by 2 reviewers. Where possible, unpublished data were obtained on treatment effects in the first period of crossover trials.

RESULTS

Nine trials were identified, including 201 patients (52% female, mean age 46 years). Six trials assessed low-dose ketamine (0.5 mg/kg i.v.) and 3 tested very low-dose ketamine (one trial assessed 50 mg intra-nasal spray, another assessed 0.1-0.4 mg/kg i.v., and another assessed 0.1-0.5 mg/kg i.v., intramuscular, or s.c.). At day 3, the reduction in depression severity score was less marked in the very low-dose trials (P homogeneity <.05) and among bipolar patients. In analyses excluding the second period of crossover trials, response rates at day 7 were increased with ketamine (relative risk 3.4, 95% CI 1.6-7.1, P=.001), as were remission rates (relative risk 2.6, CI 1.2-5.7, P=.02). The absolute benefits were large, with day 7 remission rates of 24% vs 6% (P=.02). Seven trials provided unpublished data on suicidality item scores, which were reduced on days 1 and 3 (both P<.01) but not day 7.

CONCLUSION

Low-dose ketamine appears more effective than very low dose. There is substantial heterogeneity in clinical response, with remission among one-fifth of patients at 1 week but most others having benefits that are less durable. Larger, longer term parallel group trials are needed to determine if efficacy can be extended and to further assess safety.

Comparison of inherently essential genes of Porphyromonas gingivalis identified in two transposon-sequencing libraries

Porphyromonas gingivalis is a Gram-negative anaerobe and keystone periodontal pathogen. A mariner transposon insertion mutant library has recently been used to define 463 genes as putatively essential for the in vitro growth of P. gingivalis ATCC 33277 in planktonic culture (Library 1). We have independently generated a transposon insertion mutant library (Library 2) for the same P. gingivalis strain and herein compare genes that are putatively essential for in vitro growth in complex media, as defined by both libraries. In all, 281 genes (61%) identified by Library 1 were common to Library 2. Many of these common genes are involved in fundamentally important metabolic pathways, notably pyrimidine cycling as well as lipopolysaccharide, peptidoglycan, pantothenate and coenzyme A biosynthesis, and nicotinate and nicotinamide metabolism. Also in common are genes encoding heat-shock protein homologues, sigma factors, enzymes with proteolytic activity, and the majority of sec-related protein export genes. In addition to facilitating a better understanding of critical physiological processes, transposon-sequencing technology has the potential to identify novel strategies for the control of P. gingivalis infections. Those genes defined as essential by two independently generated TnSeq mutant libraries are likely to represent particularly attractive therapeutic targets.

Monoterpene concentrations in fresh, senescent, and decaying foliage of singleleaf pinyon (Pinus monophylla Torr. & Frem.: Pinaceae) from the western Great Basin

Senescent foliage from pines is potentially a large contributor to the total monoterpene content of the litter layer, and the availability of these compounds as phytotoxins may result from release of these compounds into the vapor phase. In order to determine the fate of several monoterpene hydrocarbons in the natural environment, we examined their concentrations in fresh, senescent, and decaying needles from 32 single-leaf pinyon pine (Pinus monophylla Torr. & Frem.: Pinaceae) trees growing at two different locations. Total monoterpene content was highest in the fresh needles (mean=5.6 ± 2.2 mg/g extracted air dry weight), but also remained relatively high in senescent needles (mean=3.6 ±1.8 mg/g extracted air dry weight), either still attached to the tree or forming the freshest layer of understory litter. Decaying needles within a dark decomposing layer of litter material 5-20 cm from the surface were found to contain much lower amounts of total monoterpenes (average: =0.12 ±0.06 mg/g extracted air dry weight). Further investigation of the fate of these compounds in the pinyon understory is required to determine if these hydrocarbons are indeed exerting phytotoxic characteristics.

Selective serotonin reuptake inhibitors for stroke recovery

CLINICAL QUESTION

Are selective serotonin reuptake inhibitors (SSRIs) associated with better recovery after stroke?

BOTTOM LINE

SSRIs may be associated with improved recovery after stroke, even in persons without depression. However, much of the evidence is of poor quality. Large, high-quality trials are needed to evaluate the validity of the current evidence and improve precision of estimates of any treatment benefits.

Regulon controlled by the GppX hybrid two component system in Porphyromonas gingivalis

The periodontal pathogen Porphyromonas gingivalis experiences a number of environmental conditions in the oral cavity, and must monitor and respond to a variety of environmental cues. However, the organism possesses only five full two-component systems, one of which is the hybrid system GppX. To investigate the regulon controlled by GppX we performed RNA-Seq on a ΔGppX mutant. Fifty-three genes were upregulated and 37 genes were downregulated in the ΔGppX mutant. Pathway analyses revealed no systemic function for GppX under nutrient-replete conditions; however, over 40% of the differentially abundant genes were annotated as encoding hypothetical proteins indicating a novel role for GppX. Abundance of small RNA was, in general, not affected by the absence of GppX. To further define the role of GppX with respect to regulation of a hypothetical protein observed with the greatest significant relative abundance change relative to a wild-type control, PGN_0151, we constructed a series of strains in which the ΔgppX mutation was complemented with a GppX protein containing specific domain and phosphotransfer mutations. The transmembrane domains, the DNA-binding domain and the phosphotransfer residues were all required for regulation of PGN_0151. In addition, binding of GppX to the PGN_0151 promoter regions was confirmed by an electrophoretic mobility shift assay. Both the ΔGppX mutant and a ΔPGN_0151 mutant were deficient in monospecies biofilm formation, suggesting a role for the GppX-PGN_0151 regulon in colonization and survival of the organism.

Depression screening in stroke: a comparison of alternative measures with the structured diagnostic interview for the diagnostic and statistical manual of mental disorders, fourth edition (major depressive episode) as criterion standard

BACKGROUND AND PURPOSE

Screening tools for depression and psychological distress commonly used in medical settings have not been well validated in stroke populations. We aimed to determine the accuracy of common screening tools for depression or distress in detecting caseness for a major depressive episode compared with a clinician-administered structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders Fourth Edition as the gold standard.

METHODS

Seventy-two participants ≥3 weeks poststroke underwent a diagnostic interview for major depressive episode and completed the Patient Health Questionnaire-2 and -9, Hospital Anxiety and Depression Scale, Beck Depression Inventory-II, Distress Thermometer, and Kessler-10. Internal consistency, sensitivity, specificity, likelihood ratios, and posttest probabilities were calculated. Each measure was validated against the gold standard using receiver operating characteristic curves with comparison of the area under the curve for all measures.

RESULTS

Internal consistency ranged from acceptable to excellent for all measures (Cronbach α=0.78-0.94). Areas under the curve (95% CI) for the Patient Health Questionnaire-2, Patient Health Questionnaire-9, Hospital Anxiety and Depression Scale depression and total score, Beck Depression Inventory-II, and Kessler-10 ranged from 0.80 (0.69-0.89) for the Kessler-10 to 0.89 (0.79-0.95) for the Beck Depression Inventory-II with no significant differences between measures. The Distress Thermometer had an area under the curve (95% CI) of 0.73 (0.61-0.83), significantly smaller than the Beck Depression Inventory-II (P<0.05).

CONCLUSIONS

Apart from the Distress Thermometer, selected scales performed adequately in a stroke population with no significant difference between measures. The Patient Health Questionnaire-2 would be the most useful single screen given free availability and the shortest number of items.

Abstract 2637: Being Depression Free Helps Return To Work In Younger (<65 Years) Stroke Survivors: Results From The Psychosocial Outcomes In Stroke (POISE) Study

Background: Each year approximately 12,000 Australians of working age survive a stroke. An ability to participate in paid employment has been identified by younger stroke survivors as having important psychological and economic consequences.

Methods: The POISE study (Psychosocial Outcome In StrokE 1 ) is the largest cohort of young (<65 years of age) stroke survivors. Consecutive participants <65 years of age were recruited within 28 days of stroke from hospitals and stroke units in the greater Sydney metropolitan region, NSW Australia. Stroke was defined according to WHO standard criteria. A range of validated demographic, clinical, mental health, cognitive and disability measures including return to paid employment were obtained over the 12 months following stroke. Multivariate logistic regression was used to determine factors associated with returning to paid employment within 12 months of stroke.

Results: Among 441 participants, 218 were in paid full-time and 53 in paid part-time work immediately before their stroke, of whom 202 returned to paid part- or full-time work within 12 months of their stroke. Being free of depression at 28-days was the only independent predictor of return to work (OR 2.6, 95% CI 1.1 to 6.5) following adjustment for age, sex, and history of depression before stroke (C statistic 0.73).

Conclusion: Three quarters of previously employed participants returned to paid employment within 12 months of stroke, with those not depressed most likely to return. Depression is potentially modifiable and early management of depressive symptoms may increase the proportion of those able to return to paid employment. 1 Hackett M, Glozier N, Jan S, Lindley R. Psychosocial Outcomes In StrokE: the POISE observational stroke study protocol. BMC Neurology 2009, 9:24

Design and rationale of the tobacco, exercise and diet messages (TEXT ME) trial of a text message-based intervention for ongoing prevention of cardiovascular disease in people with coronary disease: a randomised controlled trial protocol

Background Although supporting lifestyle change is an effective way of preventing further events in people with cardiovascular disease, providing access to such interventions is a major challenge. This study aims to investigate whether simple reminders about behaviour change sent via mobile phone text message decrease cardiovascular risk. Methods and analysis Randomised controlled trial with 6 months of follow-up to evaluate the feasibility, acceptability and effect on cardiovascular risk of repeated lifestyle reminders sent via mobile phone text messages compared to usual care. A total of 720 patients with coronary artery disease will be randomised to either standard care or the TEXT ME intervention. The intervention group will receive multiple weekly text messages that provide information, motivation, support to quit smoking (if relevant) and recommendations for healthy diets and exercise. The primary end point is a change in plasma low-density lipoprotein cholesterol at 6 months. Secondary end points include a change in systolic blood pressure, smoking status, quality of life, medication adherence, waist circumference, physical activity levels, nutritional status and mood at 6 months. Process outcomes related to acceptability and feasibility of TEXT ME will also be collected. Ethics and dissemination Primary ethics approval was received from Western Sydney Local Health Network Human Research Ethics Committee-Westmead. Results will be disseminated via the usual scientific forums including peer-reviewed publications and presentations at international conferences. Clinical trials registration number ACTRN12611000161921.

Ethnicity and functional outcome after stroke

BACKGROUND AND PURPOSE

There is limited information on the influence of ethnicity on functional outcome after stroke. We examined functional outcomes among European New Zealanders, Māori, Pacific, and Asian people 6 months after stroke in a population-based context.

METHODS

This was a prospective incidence and 6-month outcomes study of all new stroke patients (excluding subarachnoid hemorrhage) that occurred over 1 year in a defined geographical area in Auckland, New Zealand, during 2002 to 2003. Ethnicity was self-defined. Outcome measures included the Frenchay Activities Index, 36-item Short Form questionnaire, independence, death, composite of death and dependence, and living situation.

RESULTS

Functional measures were available in 1127 patients 6 months after stroke. Frenchay Activities Index scores were associated with ethnicity on both univariable and multivariable analysis, with Asian and Pacific people having worse scores. Physical Component Summary score of the 36-item Short Form was associated with ethnicity on univariable (scores for Pacific, Māori, and Asian people were higher than those for Europeans) but not multivariable analysis. Asian people were less likely to be dead compared to Europeans, and Pacific people were more likely to be dependent on others for help than Europeans. Pacific people were more likely to be dead or dependent than Europeans. Asian and Pacific people were more likely to be living at home than Europeans.

CONCLUSIONS

Ethnicity was associated independently with functional outcomes. The association was attenuated when adjusted for stroke severity and other covariates. The direction of the relationship was not consistent between measures for individual ethnic groups.