Utilization and Reporting of Patient-Reported Outcome Measures in Randomized Clinical Trials of Acute Stroke (2010-2020)

BACKGROUND

Patient-reported outcome measures (PROMs) describe health status from the perspective of the patient. There is growing interest in incorporating PROMs into clinical trials, but the extent that such measures are used in contemporary stroke trials is uncertain. We sought to determine how often acute stroke trials included PROMs as outcome measures and assessed the completeness of methodological reporting.

METHODS

We searched MEDLINE for randomized controlled trials published in 9 high-impact journals between 2010 and 2020. Eligible studies were phase 2 or 3 trials that tested therapeutic interventions within 1 month of stroke onset. Using the trial's primary publication and protocol, we abstracted key study characteristics including all primary and secondary outcome measures. We defined PROMs as self-reported measures of quality of life, symptoms, or function collected without interpretation of an external party.

RESULTS

Of 116 trials that met eligibility, 57 (49%) included at least 1 PROM. Of these, 41 trials (35%) included a PROM in its primary publication, while 16 (14%) identified a PROM in its protocol. Only 1 trial used a PROM as a primary outcome. Among the 57 total trials, the most commonly used measures were Euro-QOL (n=41, 72%), Stroke Impact Scale (n=10, 18%), and Short-Form 36 (n=6, 11%). Trials were more likely to include a PROM if they were published after 2016, were phase 3, or included only hemorrhagic stroke. Of the 41 trials that included a PROM in the primary publication, 40 (97%) provided PROM results, but only 9 (22%) found statistically significant differences between treatment groups. Quality of methodological reporting was generally poor.

CONCLUSIONS

Half of contemporary acute stroke trials published in high-impact journals listed at least 1 PROM as a secondary outcome, but they played a minor role in the presentation of the final trial results. Inclusion of PROMs in acute stroke trials requires greater attention during both the design and reporting phases of the trial.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019128727.

Responder analysis confirms results of a stroke transitional care trial but provides more interpretable results

OBJECTIVES

Interpreting between-group differences in patient-reported outcome measures can be challenging. Responder analyses, which compare the proportions of patients who achieve a meaningful clinical change, represent a more interpretable approach. We conducted a secondary responder analysis of the Michigan Stroke Transitions Trial (MISTT).

STUDY DESIGN AND SETTING

The MISTT randomized 265 patients with stroke to three treatment groups: usual care [UC], social work case management [SWCM], or social work case management plus access to a patient-oriented website [SWCM + website]. Two Patient-Reported Outcomes Measurement and Information System (PROMIS) Global-10 subscales (representing physical and mental health) and 5 additional patient-reported outcomes were collected at baseline and 90-days. Responder analyses were conducted using modified Poisson and linear regression using published minimal important differences. Multiple imputation was used to address missing data.

RESULTS

For the PROMIS-10 global physical health subscale, responders were 80% more common in the SWCM + website group compared to the UC group (relative risk = 1.8, 95% confidence interval [CI]: 1.0, 3.1), with a number needed to treat of 7 (95% CI: 3, 112). No significant treatment effects were observed for the PROMIS-10 global mental health subscale.

CONCLUSION

Results of this responder analysis were largely consistent with the original trial analysis but have the advantage of presenting treatment effects using more clinically interpretable number needed to treat metrics.

Abstract 153: Use Of Patient-reported Outcome Measures (PROMS) In The Primary Publications Of Acute Stroke Clinical Trials (2010-2020)

Background: Patient-reported outcome measures (PROMs) describe health status from the perspective of the patient. There is growing interest in the use of PROMs in clinical trials and there have been major efforts to develop PROMs for neurological conditions (e.g., Neuro-QOL, PROMIS). However, the extent to which such measures are used in stroke trials is uncertain. We sought to determine how often contemporary acute stroke trials included PROMs as primary or secondary outcome measures.

Methods: We searched MEDLINE for completed RCTs published in one of nine major journals between 2010 and 2020. Eligible studies were phase 2 or 3 trials undertaken to test therapeutic interventions within one month of stroke onset. For each trial we accessed the primary publication as well as the published protocol and supplement when available. We abstracted key trial characteristics including all primary and secondary efficacy outcome measures. We defined PROMs using online databases (qolid.org) with the focus on self-reported measures of quality of life, symptoms, and function collected without interpretation of an external party.

Results: 115 trials met eligibility criteria. Only one trial used a PROM for its primary outcome measure (visual analogue pain scale), but 40 trials (35%) listed at least one PROM as a secondary outcome measure in its primary publication. An additional 15 trials (13%) listed at least one PROM in their protocol. Among the 55 trials that defined at least one PROM as a secondary outcome measure, the most commonly used measure was Euro-QOL (n=42, 76%) followed by SIS-16 (n=9, 16%), SF-36 (n=7, 13%), and the stroke-specific QOL scale (n=5, 9%). Other PROMs included various measures of anxiety and depression (n=9, 16%). Only one study used a Neuro-QOL based measure. Of the 41 trials that listed a PROM as a primary or secondary outcome in the primary publication, 39 (95%) provided PROM results, but of these only 7 (18%) found statistically significant treatment differences.

Conclusions: While about half of acute stroke trials listed at least one PROM as a secondary outcome, they played a minor role in the presentation of trial results. Inclusion of PROMs in acute stroke trials requires greater attention during both the design and reporting phases of the trial.

Abstract TP11: Acute Stroke Randomized Clinical Trials: What Factors Help Trials Achieve Their Intended Sample Size?

Background: We performed a systematic review of acute stroke trials to determine features associated with premature termination of trial enrollment.

Methods: MEDLINE was searched for stroke RCTs between 1/1/2013-6/11/2020. Included studies were Phase 2 or 3, had a preplanned sample size ≥100, had time to treatment within 24 hours of onset for TIA, ischemic stroke, or ICH, and were published in a major clinical journal (BMJ, Circulation, Stroke, Neurology, JAMA, JAMA Neurology, Lancet, Lancet Neurology, NEJM). Studies were deemed prematurely terminated if authors reported early termination. Study variables and inclusion criteria are listed in Table 1. Complex trials required specialized training and expertise, high degree of monitoring, or procedural intervention. Univariate Chi-square tests/Fisher’s exact test were used to determine characteristics associated with early termination, and multivariable lasso logistic regression was used to select the most important predictors.

Results: Of 1,219 studies assessed, 69 trials met eligibility criteria for inclusion (Table 1); 34 (49%) were prematurely terminated. In univariate analysis, variables associated with premature termination were complexity of treatment, industry involvement, exclusion of older patients, and presence of a futility stopping rule. In lasso regression, complex treatment trials (OR 3.77, 95% CI 1.30-10.97, versus moderate or simple trials combined), presence of a futility rule (OR 3.56, 95% CI 1.02-12.40 versus no rule), and geographic region (North America OR 1.97, 95% CI 0.57-6.81 versus all other regions combined) were selected as important factors.

Conclusion: Half of acute stroke trials were terminated prematurely. Broadening inclusion/exclusion criteria and simplifying the complexity of trials may decrease the likelihood of unplanned premature termination, whereas planned futility analyses may appropriately terminate trials early, saving money and resources.

Early Termination of Acute Stroke Randomized Controlled Trials Published Between 2013 and 2020: A Systematic Review

BACKGROUND

Termination of a clinical trial before the maximum planned sample size is accrued can occur for multiple valid reasons but has implications for the interpretation of results. We undertook a systematic review of contemporary acute stroke trials to document the prevalence of and reasons for early termination.

METHODS

We searched MEDLINE for randomized controlled trials of acute stroke therapies published between 2013 and 2020 in 9 major clinical journals. Manuscripts describing the primary results of phase 2 and phase 3 trials of acute stroke care were included. Data on study characteristics and adherence to CONSORT reporting guidelines were abstracted and summarized using descriptive statistics. Where feasible, we compared treatment effect sizes between trials terminated early and those not terminated early.

RESULTS

Of 96 randomized controlled trials, 39 (41%) were terminated early, 84 (88%) had a data and safety monitoring board, and 57 (59%) reported a prespecified statistical stopping rule. Among the 39 trials terminated early, 10 were discontinued for benefit, 10 due to logistical issues, 8 for futility, 6 because of newly available evidence, 1 for harm, and 4 for other or a combination of reasons. The median percentage of the maximum planned sample size accrued among trials terminated early was 63% (range, 8%-89%). Only 55% of trials (53 of 96) reported whether interim efficacy analyses were conducted, as recommended by the CONSORT guidelines. When 10 endovascular therapy trials were compared according to early termination status, the effect sizes of trials terminated early for benefit were only modestly larger than those not terminated early.

CONCLUSIONS

The high prevalence of early termination in combination with the wide variety of reasons underscores the necessity of meticulous trial planning and adherence to methodological and reporting guidelines for early termination. Registration: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42019128727.

Changes in PHQ-9 depression scores in acute stroke patients shortly after returning home

Introduction

Post-stroke depression is a disabling condition that occurs in approximately one-third of stroke survivors. There is limited information on changes in depressive symptoms shortly after stroke survivors return home. To identify factors associated with changes in post-stroke depressive symptoms during the early recovery period, we conducted a secondary analysis of patients enrolled in a clinical trial conducted during the transition period shortly after patients returned home (MISTT).

Methods

The Michigan Stroke Transitions Trial (MISTT) tested the efficacy of social worker case management and access to online information to improve patient-reported outcomes following an acute stroke. Patient Health Questionnaire-9 (PHQ-9) scores were collected via telephone interviews conducted at 7 and 90 days post-discharge; higher scores indicate more depressive symptoms. Generalized estimating equations were used to identify independent predictors of baseline PHQ-9 score at 7 days and of changes over time to 90 days.

Results

Of 265 patients, 193 and 185 completed the PHQ-9 survey at 7 and 90 days, respectively. The mean PHQ-9 score was 5.9 at 7 days and 5.1 at 90 days. Older age, being unmarried, and having moderate stroke severity (versus mild) were significantly associated with lower 7-day PHQ-9 scores (indicating fewer depressive symptoms). However, at 90 days, both unmarried patients and those with moderate or high stroke severity had significant increases in depressive symptoms over time.

Conclusions

In stroke patients who recently returned home, both marital status and stroke severity were associated with depressive symptom scores; however, the relationships were complex. Being unmarried and having higher stroke severity was associated with fewer depressive symptoms at baseline, but both factors were associated with worsening depressive symptoms over time. Identifying risk factors for changes in depressive symptoms may help guide effective management strategies during the early recovery period.

Reporting of Results by Sex in Randomized Controlled Trials of Acute Stroke Therapies (2010-2020)

Background and Purpose

When reporting primary results from randomized controlled trials, recommendations include reporting results by sex. We reviewed the reporting of results by sex in contemporary acute stroke randomized controlled trials.

Methods

We searched MEDLINE for articles reporting the primary results of phase 2 or 3 stroke randomized controlled trials published between 2010 and June 2020 in one of nine major clinical journals. Eligible trials were restricted to those with a therapeutic intervention initiated within one month of stroke onset. Of primary interest was the reporting of results by sex for the primary outcome. We performed bivariate analyses using Fisher exact tests to identify study-level factors associated with reporting by sex and investigated temporal trends using an exact test for trend.

Results

Of the 115 studies identified, primary results were reported by sex in 37% (n=42). Reporting varied significantly by journal, with the New England Journal of Medicine (61%) and Lancet journals (40%) having the highest rates (P=0.03). Reporting also differed significantly by geographic region (21% Europe versus 48% Americas, P=0.03), trial phase (13% phase 2 versus 40% phase 3, P=0.05), and sample size (24% <250 participants versus 61% >750 participants, P<0.01). Although not statistically significant (P=0.11), there was a temporal trend in favor of greater reporting among later publications (25% 2010–2012 versus 48% 2019–2020).

Conclusions

Although reporting of primary trial results by sex improved from 2010 to 2020, the prevalence of reporting in major journals is still low. Further efforts are required to encourage journals and authors to comply with current reporting recommendations.

Sex Disparities in Enrollment in Recent Randomized Clinical Trials of Acute Stroke: A Meta-analysis

Importance

The underenrollment of women in randomized clinical trials represents a threat to the validity of the evidence supporting clinical guidelines and potential disparities in access to novel treatments.

Objective

To determine whether women were underenrolled in contemporary randomized clinical trials of acute stroke therapies published in 9 major journals after accounting for their representation in underlying stroke populations.

Data Sources

MEDLINE was searched for acute stroke therapeutic trials published between January 1, 2010, and June 11, 2020.

Study Selection

Eligible articles reported the results of a phase 2 or 3 randomized clinical trial that enrolled patients with stroke and/or transient ischemic attack and examined a therapeutic intervention initiated within 1 month of onset.

Data Extraction

Data extraction was performed by 2 independent authors in duplicate. Individual trials were matched to estimates of the proportion of women in underlying stroke populations using the Global Burden of Disease database.

Main Outcomes and Measures

The primary outcome was the enrollment disparity difference (EDD), the absolute difference between the proportion of trial participants who were women and the proportion of strokes in the underlying disease populations that occurred in women. Random-effects meta-analyses of the EDD were performed, and multivariable metaregression was used to explore the associations of trial eligibility criteria with disparity estimates.

Results

The search returned 1529 results, and 115 trials (7.5%) met inclusion criteria. Of 121 105 randomized patients for whom sex was reported, 52 522 (43.4%) were women. The random-effects summary EDD was -0.053 (95% CI, -0.065 to -0.040), indicating that women were underenrolled by 5.3 percentage points. This disparity persisted across virtually all geographic regions, intervention types, and stroke types, apart from subarachnoid hemorrhage (0.117 [95% CI, 0.084 to 0.150]). When subarachnoid hemorrhage trials were excluded, the summary EDD was -0.067 (95% CI, -0.078 to -0.057). In the multivariable metaregression analysis, an upper age limit of 80 years as an eligibility criterion was associated with a 6-percentage point decrease in the enrollment of women.

Conclusions and Relevance

Further research is needed to understand the causes of the underenrollment of women in acute stroke trials. However, to maximize representation, investigators should avoid imposing age limits on enrollment.

Benefits and Risks of Dual Versus Single Antiplatelet Therapy for Secondary Stroke Prevention: A Systematic Review for the 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

BACKGROUND

Dual antiplatelet therapy (DAPT) after ischemic stroke or transient ischemic attack may reduce recurrent stroke but also increase severe bleeding compared with single antiplatelet therapy (SAPT). The American Heart Association/American Stroke Association convened an evidence review committee to perform a systematic review and meta-analysis of the benefits and risks of DAPT compared with SAPT for secondary ischemic stroke prevention.

METHODS

The Medline, Embase, and Cochrane databases were searched on December 5, 2019, to identify phase III or IV randomized controlled trials (n≥100) from December 1999 to December 2019. We calculated unadjusted relative risks (RRs) and performed meta-analyses of studies based on the duration of treatment (short [≤90 days] versus long [>90 days]).

RESULTS

Three short-duration randomized controlled trials were identified that enrolled mostly patients with minor stroke or high risk transient ischemic attack. In these trials, DAPT, compared with SAPT, was associated with a lower 90-day risk of recurrent ischemic stroke (pooled RR, 0.68 [95% CI, 0.55-0.83], I ²=37.1%). There was no significant increase in major bleeding with DAPT in short-duration trials (pooled RR, 1.88 [95% CI, 0.93-3.83], I ²=8.9%). In 2 long-duration treatment randomized controlled trials (mean treatment duration, 18-40 months), DAPT was not associated with a significant reduction in recurrent ischemic stroke (pooled RR, 0.89 [95% CI, 0.79-1.02], I ²=1.4%), but was associated with a higher risk of major bleeding (pooled RR, 2.42 [95% CI, 1.37-4.30], I ²=75.5%).

CONCLUSIONS

DAPT was more effective than SAPT for prevention of secondary ischemic stroke when initiated early after the onset of minor stroke/high-risk transient ischemic attack and treatment duration was <90 days. However, when the treatment duration was longer and initiated later after stroke or transient ischemic attack onset, DAPT was not more effective than SAPT for ischemic stroke prevention and it increased the risk of bleeding.

Abstract P199: Predictors of Early Change in PHQ-9 Depression Scores Following Acute Stroke: A Secondary Analysis of the Michigan Stroke Transitions Trial

Introduction: Predictors of changes in depression in the early transitional period following an acute stroke are not well understood. We conducted a secondary analysis of patients enrolled in the Michigan Stroke Transitions Trial (MISTT) to characterize factors associated with changes in depressive symptoms from 7 to 90 days after returning home.

Methods: MISTT was an open, parallel, randomized clinical trial testing the efficacy of social worker case management alone or in conjunction with a website to improve outcomes following acute stroke. Patient-reported outcomes including PHQ-9 were collected via telephone interviews conducted 7 and 90 days after patients returned home. PHQ-9 score ranges from 0-27 with higher scores indicating more severe symptoms. Key demographic variables were extracted from medical records. Multivariable linear regression was used to identify independent predictors of change in PHQ-9 score from 7 to 90 days using the GLM procedure in SAS. All analyses were adjusted for baseline (7-day) PHQ-9 score and pre-specified confounders (Table). We accounted for missing data using inverse probability weighting.

Results: Of 265 patients enrolled in MISTT, 164 had PHQ-9 scores available at both 7 and 90 days and were included in the analysis. The mean PHQ-9 score was 5.4 at 7 days and 4.9 at 90 days. The mean within person change from 7 to 90 days was -0.5. In the final model, being unmarried (versus married), and moderate or severe stroke severity (versus mild) were associated with an increase in depressive symptoms (Table). As expected, 7-day PHQ-9 score was a strong predictor of 90-day score. Accounting for missing data did not meaningfully change model results.

Conclusions: Increases in PHQ-9 scores following stroke hospitalization were seen in unmarried patients and those with greater stroke severity. Identifying factors associated with worsening symptoms over time may help guide clinical management during the early transition period.

Abstract MP30: Reporting of Sex-Specific Results in Randomized Clinical Trials of Acute Stroke (2010-2020)

Introduction: When reporting primary results, it is recommended that RCTs report sex-specific outcomes. We reviewed the reporting of sex-specific outcomes in contemporary acute stroke RCTs.

Methods: We searched MEDLINE for manuscripts published between 2010 and June 2020 in one of nine major clinical journals reporting the primary results of phase 2 or 3 stroke RCTs. Eligible trials tested a therapeutic intervention initiated within one month of stroke onset. Reporting of sex-specific primary results was the outcome of interest. We also investigated whether the trial formally tested for an interaction between sex and treatment and if that interaction test was statistically significant. We performed bivariate analyses using Fisher’s exact tests to identify study-level factors associated with sex-specific reporting including journal, geographic region, trial phase, sample size, stroke type, trial type (e.g. thrombolytic, EVT, secondary prevention), and industry funding. Temporal trends using two-year time periods were also explored.

Results: Of the 115 studies identified, sex-specific primary outcome data were reported in 37% (n=42). Reporting varied significantly by journal, with NEJM (61%) and Lancet journals (40%) having the highest rates (p=0.03) (Table). Reporting also differed by geographic region (p=0.03), trial phase (p=0.05), and sample size (p<0.01). Reporting did not vary significantly by stroke type, trial type, or industry involvement. While not significant, there was a positive temporal trend in favor of greater reporting in later publications (p=0.09). Of the 29 trials that formally tested for an interaction between sex and treatment, only one significant interaction was found.

Conclusions: Although reporting of sex-specific outcomes improved from 2010 to 2020, the prevalence of reporting in major journals is still low. Further efforts are required to ensure that journals and authors comply with reporting guidelines.

St Andrew's COVID-19 surgery safety (StACS) study: The Burns Centre experience

Background

The COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has the potential to significantly impact burns patients both directly through infective complications of an immunocompromised cohort, and indirectly through disruption of care pathways and resource limitations. The pandemic presents new challenges that must be overcome to maintain patient safety; in particular, the potential increased risks of surgical intervention, anaesthesia and ventilation. This study comprehensively reviews the measures implemented to adapt referral pathways and mitigate the risk posed by COVID-19 during the height of the pandemic, within a large Burns Centre.

Methods

A prospective cohort study was designed to assess patients treated at the Burns Centre during the UK COVID-19 pandemic peak (April–May 2020), following implementation of new safety measures. All patients were analysed for 30-day mortality. In addition, a prospective controlled cohort study was undertaken on all inpatients and a random sample of outpatients with telephone follow-up at 30 days. These patients were divided into three groups (operative inpatients, non-operative inpatients, outpatients). COVID-19 related data collected included test results, contact with proven cases, isolation status and symptoms. The implemented departmental service COVID-19 safety adaptations are described.

Results

Of 323 patients treated at the Burns Centre during the study period, no 30-day COVID-19 related deaths occurred (0/323). Of the 80 patients analysed in the prospective controlled cohort section of the study, 51 underwent COVID-19 testing, 3.9% (2/51) were positive. Both cases were in the operative group, however in comparison to the non-operative and outpatient groups, there was no significant increase in COVID-19 incidence in operative patients.

Conclusions

We found no COVID-19 related mortality during the study period. With appropriate precautions, burns patients were not exposed to an increased COVID-19 risk. Similarly, burns patients undergoing operative management were not at a significantly increased risk of contracting COVID-19 in comparison to non-operative groups.

Sex differences in IV thrombolysis treatment for acute ischemic stroke

Objective

A prior meta-analysis of reports published between 2000 and 2008 found that women were 30% less likely to receive IV recombinant tissue plasminogen activator (rtPA) treatment for stroke than men; we updated this meta-analysis to determine if this sex difference persisted.

Methods

We identified studies that reported sex-specific IV rtPA treatment rates for acute ischemic stroke published between 2008 and 2018. Eligible studies included representative populations of patients with ischemic stroke from hospital-based, registry-based, or administrative data. Random effects odds ratios (ORs) were generated to quantify sex differences.

Results

Twenty-four eligible studies were identified during this 10-year period. The summary unadjusted OR based on 17 studies with data on all ischemic stroke patients was 0.87 (95% confidence interval [CI], 0.82–0.93), indicating that women had 13% lower odds of receiving IV rtPA treatment than men. However, substantial between-study variability existed. Lower treatment odds in women were also observed in 7 studies that provided data on the subgroup of patients eligible for IV rtPA treatment, although the summary OR of 0.95 (95% CI, 0.88–1.02) was not statistically significant. Examination of time trends across 33 studies published between 2000 and 2018 found evidence that the sex difference had narrowed in more recent years.

Conclusions

Although there is considerable variability in the findings of individual studies, pooled data from recent studies show that women with acute stroke are less likely to be treated with IV thrombolysis compared with men. However, the size of this difference has narrowed compared to studies published before 2008.

Abstract TP324: Early Termination of Acute Stroke Randomized Controlled Trials Published Between 2013 and 2018: A Systematic Review

Introduction: A priori sample size determination is an essential step in designing randomized controlled trials (RCTs). Failure to reach pre-planned sample size introduces risk of both falsely negative and spuriously positive findings. We undertook a systematic review of contemporary acute stroke trials to document the prevalence and reasons for termination of trials prior to completion of enrollment.

Methods: We searched MEDLINE for RCTs of acute stroke therapy published between 2013 and 2018 in 9 major journals. Manuscripts describing the final primary results of phase 3 and large phase 2 trials of any therapeutic intervention were eligible for inclusion. Study characteristics, including the presence of a data monitoring committee (DMC) and stopping rules, risk-of-bias assessment, funding sources and conflicts of interest, were abstracted from published manuscripts and trial protocols by two independent reviewers. The prevalence of and reasons for early termination were quantified. Multivariable logistic regression was used to identify study-level predictors of early termination.

Results: Of 756 hits, 60 were eligible for inclusion, 21 (35%) of which were terminated early. Among the trials stopped early, 10 (48%) reported stopping for benefit or newly available evidence while 11 (52%) were terminated for futility; 20 (95%) reported a DMC and 17 (81%) reported the use of a pre-specified statistical stopping rule. Factors associated with early termination included study location in North America, larger planned sample size, and industry funding (Table). Study location in North America and larger planned sample size retained statistical significance in a multivariable model.

Conclusions: One in three contemporary stroke trials were terminated prior to completion of enrollment. Reasons for termination were evenly split between benefit and futility. Further study is needed to understand the reasons for and impact of early termination on study results.

Abstract WP336: Global Variation in the Representation of Women in Contemporary Acute Stroke Trials

Introduction: Women have historically been underrepresented in RCTs of cardiovascular disease. We undertook a review of acute stroke RCTs to determine whether women were equitably represented and whether any sex disparity varied across geographic region.

Methods: We searched for papers describing primary results of acute stroke RCTs published 2013-2018 in 9 major journals and abstracted the proportion of trial participants that were women (PPW). We then searched for incidence studies from the geographic regions in which trial enrollment took place and estimated the proportion of incident strokes occurring in women (PSW) in each region (i.e., North America, Europe, Asia Pacific, Multiple Regions). We quantified the representation of women using the enrollment disparity difference (EDD) calculated as the absolute difference between the two proportions (i.e., PSW - PPW). An EDD greater than 0 indicated a disparity in favor of men. We pooled EDDs from individual RCTs using random effects meta-analysis to estimate overall and region-specific disparities.

Results: Among 60 trials the PPW ranged from 33.8% to 56.9% (median 44.7%). The overall pooled EDD was 0.07 (95% CI=0.06-0.08, Q p<0.001, I 2 =85.8%) (Figure), indicating that 7% more men were included in the trials, relative to the underlying incidence. A statistically significant EDD existed in all regions; the magnitude was largest for RCTs with enrollment from Asia Pacific (EDD=0.11, 95% CI=0.10-0.13) and Multiple Regions (EDD=0.10, 95% CI=0.08-0.12) and smallest among North American and European trials (EDD 0.04 and 0.06, respectively). All region-specific summary estimates showed significant between study heterogeneity apart from Asia (Q p=0.102, I 2 =38.4%).

Conclusions: Women were underrepresented globally in contemporary acute stroke RCTs; the magnitude of the disparity differed between regions. Future research should focus on trial eligibility criteria that may contribute to this disparity.

Mycetoma of the calf

Actinomycetous infections typically involve either the head and neck or the extremities following a traumatic implantation. Classic clinical associations are draining sinus tracts. This case report describes the pathologic and MR findings of a relatively acute mycetomatous process involving the soft tissues. Pathologic findings in this case included an occasional granule composed of gram positive, thin branching elements. These and other findings were consistent with actinomycetes bacterium infection. The discussion centers around the use of MR, both with and without gadolinium, in evaluating this type of granulomatous infection. Infiltration of the adjacent subcutaneous tissues was easier to appreciate on both the T1-weighted images without gadolinium and the T1-weighted images with gadolinium when compared to the T2-weighted images. Signal characteristics as described in this case report may suggest a granulomatous process.

Influence of social partner on interactions of toddlers with disabilities: comparison of interactions with mothers and familiar playmates

The social exchanges of young children with developmental disabilities over time with two different social partners and the nature of these exchanges were compared. Thirty-three toddlers with developmental disabilities were video-taped for 15 minutes with each partner at two different data points. Data were transcribed and coded using a modification of Vandell and Wilson's (1979) coding system. Results showed that more of the observation time was spent socially with mothers than with peers, and the number of turns per exchange was longer with mothers. In contrast, toddlers initiated more social exchanges with peers than with mothers. There were similarities in the content of the social exchanges with both partners. There were few changes over time, although exchanges consisted of more purely social behaviors at Time 2. Results were interpreted with respect to implications for early intervention.