Association Between 18-FDG Positron Emission Tomography and MRI Biomarkers of Plaque Vulnerability in Patients With Symptomatic Carotid Stenosis

Purpose: Pathologic studies suggest that unstable plaque morphology and inflammation are associated with cerebrovascular events. ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸FDG-PET) is a validated technique for non-invasive imaging of inflammation-related plaque metabolism, and MRI can identify morphologic features of plaque instability. The aim of this study was to investigate the association of selected imaging characteristics of plaque vulnerability measured with MRI and PET in patients with symptomatic carotid stenosis.

Methods: Patients from the BIOVASC study were selected based on the following inclusion criteria: (1) age ≥ 50 years; (2) recent (<30 days) ischaemic stroke (modified Rankin scale ≤3) or motor/speech/vision TIA; (3) ipsilateral internal carotid artery stenosis (≥5 0% lumen-narrowing); (4) carotid PET/CTA and MRI completed. Semi-automated plaque analysis of MRI images was performed to quantify morphologic features of plaque instability. PET images were co-registered with CTA and inflammation-related metabolism expressed as maximum standardised uptake value (SUV_max).

Results: Twenty-five patients met inclusion criteria (72% men, mean age 65 years). MRI-measured plaque volume was greater in men (1,708–1,286 mm³, p = 0.03), patients who qualified with stroke (1,856–1,440 mm³, p = 0.05), and non-statin users (1,325–1,797 mm³, p = 0.03). SUV_max was associated with MRI-measured plaque lipid-rich necrotic core (LRNC) in the corresponding axial slice (r_s = 0.64, p < 0.001) and was inversely associated with whole-plaque fibrous cap thickness (r_s = −0.4, p = 0.02) and calcium volume (r_s = −0.4, p = 0.03).

Conclusion: This study demonstrated novel correlations of non-invasive imaging biomarkers of inflammation-related plaque metabolism with morphological MRI markers of plaque instability. If replicated, our findings may support the application of combined MRI and PET to detect vulnerable plaque in future clinical practise and randomised trials.

Inflammatory cytokines, high-sensitivity C-reactive protein, and risk of one-year vascular events, death, and poor functional outcome after stroke and transient ischemic attack

Background

Inflammation driven by pro-inflammatory cytokines is a new therapeutic target in coronary disease. Few data exist on the association of key upstream cytokines and post-stroke recurrence. In a prospective cohort study, we investigated the association between pivotal cytokines, high-sensitivity C-reactive protein (hsCRP) and one-year outcomes.

Methods

BIO-STROKETIA is a multi-center prospective cohort study of non-severe ischemic stroke (modified Rankin score ≤ 3) and transient ischemic attack. Controls were patients with transient symptoms attending transient ischemic attack clinics with non-ischemic final diagnosis. Exclusion criteria were severe stroke, infection, and other pro-inflammatory disease; hsCRP and cytokines (interleukin (IL) 6, IL-1β, IL-8, IL-10, IL-12, interferon-γ (IFN-γ), tumor-necrosis factor-α (TNF-α)) were measured. The primary outcome was one-year recurrent stroke/coronary events (fatal and non-fatal).

Results

In this study, 680 patients (439 stroke, 241 transient ischemic attack) and 68 controls were included. IL-6, IL-1β, IL-8, IFN-γ, TNF-α, and hsCRP were higher in stroke/transient ischemic attack cases (p ≤ 0.01 for all). On multivariable Cox regression, IL-6, IL-8, and hsCRP independently predicted one-year recurrent vascular events (adjusted hazard ratios (aHR) per-quartile increase IL-6 1.31, confidence interval (CI) 1.02–1.68, p = 0.03; IL-8 1.47, CI 1.15–1.89, p = 0.002; hsCRP 1.28, CI 1.01–1.62, p = 0.04). IL-6 (aHR 1.98, CI 1.26–3.14, p = 0.003) and hsCRP (aHR 1.81, CI 1.20–2.74, p = 0.005) independently predicted one-year fatality. IL-6 and hsCRP (adjusted odds ratio per-unit increase 1.02, CI 1.01–1.04) predicted poor functional outcome, with a trend for IL-1β (p = 0.054).

Conclusion

Baseline inflammatory cytokines independently predicted late recurrence, supporting a rationale for randomized trials of anti-inflammatory agents for prevention after stroke and suggesting that targeted therapy to high-risk patients with high baseline inflammation may be beneficial.

179 Evaluating a Clinical Pharmacist Service in a Residential Care Unit

Background

This study assessed the pharmacist role in an 80 bed residential care unit by: Quantifying the number and type of pharmacist interventions made and their acceptance rate.Assessing impact of pharmacist interventions on patient care.Assessing staff attitudes towards the clinical pharmacist service.

Methods

This was a non-blinded, non-comparative evaluation of the existing clinical pharmacist service in the unit. All residents were included. All pharmacist interventions over a 10-week period were recorded, then graded according to the Eadon scale1 by a consultant gerontologist and an experienced pharmacist to assess their impact on patient care.

Results

There were 615 pharmacist interventions. The most common interventions were: Drug Therapy Review, 34% (n=209) Technical Prescription, 26.5% (n=163) Administration, 15.3% (n=94) Drug Interaction, 10.4% (n=64) Medication Reconciliation, 8.5% (n=52)

98% (n=596) of interventions were rated as having significance to patient care, of which: 48.4% (n=298) and 41.8% (n=257) of the interventions rated as ‘significant and resulting in an improvement in the standard of care’1% (n=6) and 0.5% (n=3) rated as ‘very significant and preventing harm’.

There was a statistically significant agreement between the evaluators, κw = 0.231 (95% CI, 0.156 to 0.307), p < .0005. The strength of agreement was fair.

Of interventions requiring acceptance by medical team (n=335), 89.9% (n=301) were accepted.

95% (n=36) of staff who responded agreed or strongly agreed that improved patient safety resulted from the pharmacist’s involvement in multidisciplinary medication reviews.

Over 92% (n=35) agreed or strongly agreed that their experience of the pharmacist was positive.

Conclusion

The pharmacist has an important role in our residential care unit. Their involvement in the medicines optimisation process positively impacts patient outcomes and prevents harm. Staff perceived a positive impact of the clinical pharmacist service provided on patient care and patient safety.

183 Risk of Hypoglycaemia in Older Patients in Residential Care on Oral Hypoglycaemic Medication

Background

Diabetes mellitus (DM) is common in older patients in residential care(RC) with prevalence ranging from 11-36%.Guidlines(1) on glucose targets to avoid the risk of hypoglycaemia or hyperglycaemia respectively in older people recommend avoiding a fasting glucose on treatment of 6mmol/L or a random glucose level higher than 11.0mmol/L. An HbA1c of 53to 59mmol/mol(7-7.5%) should be aimed for although this may need adjusting in RC and StoppFrail guidelines suggest a target of HbA1c of <8%(64mmol/mol). We assessed the prevalence, drug treatment and glycaemic control in 107 older patients in residential care at two sites in Dublin.

Methods

Patients with DM were identified from review of medical notes. Hypoglycaemic treatment whether oral hypoglycemic drugs(OHD) or insulin, capillary blood glucose measurements(CBGM) over the previous 28 day period, HbA1c values and weight change over the previous year respectively were tabulated from patient records.

Results

Sixteen patients (15%) aged 66-93 were documented with DM. Eight (50%) were on no hypoglycaemic treatment in whom OHD had been discontinued in 2 patients over the previous 6 months because of risk of hypoglycaemia.. Six patients (38%) were only on OHD, whilst 2 were on insulin. Of the 6 patients on OHD, CABGM were below 6mmol/L in 3 patients (50%) with no values above 11mmol/L. All 3 patients had lost weight ( 2.5-6.8Kg) over the previous year and HbA1c levels were below 53mmol/mol (7%) in all 3 patients.

Conclusion

Although our numbers are small, 50% of our patients in residential care on OHD are at risk of hypoglycemia possibly related to weight loss. Reducing or discontinuing their OHD may be appropriate.

192 Interleukin-6 and C-Reactive Protein Predict all Cause Death and Poor Functional Outcome after Non-Severe Stroke and Transient Ischaemic Attack

Background

Inflammation plays a role in the development of ischaemic cerebrovascular events. High sensitivity C-reactive protein (CRP) is known to predict recurrent events. Little data exists for more upstream serum markers of inflammation.

Methods

BIO-STROKE and BIO-TIA were multicentre prospective biomarker and imaging studies of patients with non-severe stroke, TIA and controls. Exclusion criteria were malignancy, infection, recent trauma / surgery, recurrent stroke before phlebotomy/MRI.

Serum biomarkers analysed included Interleukin (IL) – 6, CRP, IL-1, IL-8, IL10, IL12p70, IFN and TNF.Plasma CRP and IL-6 were measured by mass spectrometry. Additional biomarkers were measured using ELISA. Follow up was performed at 7, 28, 90 days and 1 year.

Results

680 patients (439 strokes, 241 TIAs) and 68 controls were included in the analysis. The median age was 70 for cases. Carotid stenosis was present in 23.6% of cases. Median CRP was 3.75mg/L, 2.36mg/l and 1.87mg/L in the stroke, TIA and control groups (p=<0.001). Median IL-6 was 5.86pg/ml (stroke), 4.25pg/ml (TIA), 3.06pg/ml (control) (p=<0.001).

On multivariate cox regression analysis baseline IL6 and CRP were independent predictors of all cause death at 1 year with a HR of 1.005 (95% CI 1.002-1.007, p<0.001).and 1.005(95% CI 1.002-1.007, p<0.001) per unit increase. Both IL6 and CRP were associated with vascular death at 1 year. In adjusted analyses, IL6 and CRP were associated with poor functional outcome at 1 year (OR of 1.02(CI 1.01 -1.03) and 1.02(CI 1.01-1.03) per unit increase, for IL6 and CRP respectively).

On adjusted analysis, when IL6 was analysed as quartiles, there was a strong association with death at 1 year with an OR 1.87 (95% CI 1.19-2.93).CRP, analysed as quartiles, demonstrated an OR for death at 1 year of 1.64 (1.10-2.46).

Conclusion

IL-6 and CRP may be a useful prognostic factor for the prediction of outcome and death after stroke at 1 year follow up.

Falls-Related EvEnts in the first year after StrokE in Ireland: Results of the multi-centre prospective FREESE cohort study

Introduction

Falls are common post-stroke adverse events. This study aimed to describe the first-year falls incidence, circumstances and consequences among persons discharged home after stroke in Ireland, and to examine the association between potential risk factors and recurrent falls.

Patients and methods

Patients with acute stroke and planned home-discharge were recruited consecutively from five hospitals. Variables recorded pre-discharge included: age, stroke severity, co-morbidities, fall history, prescribed medications, hemi-neglect, cognition and functional independence (Barthel index). Falls were recorded with monthly diaries, and 6 and 12-month interviews. The association of pre-discharge factors with recurrent falls (>1 fall) was examined using univariable logistic regression.

Results

A total of 128 participants (mean age = 68.6, SD = 13.3) were recruited; 110 completed the 12-month follow-up. The first-year falls incidence was 44.5% (95% CI = 35.1-53.6) with 25.6% falling repeatedly (95% CI = 18.5-34.4). Fallers experienced 1-18 falls (median = 2) and five reported fractures; 47% of fallers experienced at least one fall outdoors. Only 10% of recurrent fallers had bone health medication prescribed at discharge. Lower Barthel index scores (<75/100, RR = 4.38, 1.64-11.72) and psychotropic medication prescription (RR = 2.10, 1.13-3.91) were associated with recurrent falls.

Discussion

This study presents prospectively collected information about falls circumstances. It was not powered for multivariable analysis of risk factors.

Conclusion

One-quarter of stroke survivors discharged to the community fall repeatedly and mostly indoors in the first year. Specific attention may be required for individuals with poor functional independence or those on psychotropic medication. Future falls-management research in this population should explore falls in younger individuals, outdoor as well as indoor falls and post-stroke bone health status.

First year post-stroke healthcare costs and fall-status among those discharged to the community

INTRODUCTION

Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community.

PATIENTS AND METHODS

Survivors of acute stroke with planned home discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation.

RESULTS

A total of 109 stroke survivors with complete follow-up data (mean age = 68.5 years (SD = 13.5 years)) were included. Fifty-three participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p = 0.02 and p < 0.01, respectively).

DISCUSSION

The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included.

CONCLUSION

This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/tertiary care (including inpatient re-admissions) and allied healthcare. Future research could compare the cost-effectiveness of inpatient versus community-based fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction.

Staying well with bipolar disorder: A qualitative analysis of five-year follow-up interviews with young people

WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Bipolar disorder is a long-term condition which causes ongoing disruptions to the individual's life. Current evidence suggests that a combination of medication in combination with psychotherapy is more effective than medication alone. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: There are few published reports of the effects of interventions (pharmacological or psychotherapeutic) for treatment in bipolar disorder. While both psychotherapies provided a framework for understanding bipolar disorder each had specific strategies that participants identified as effective. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Because bipolar disorder is a long-term condition, its treatment needs to incorporate psychotherapeutic approaches that address the unique nature of its impact on each individual and provide individualized strategies for managing the disorder. Both Interpersonal and Social Rhythm Therapy and Specialist Supportive Care provide strategies that promote personal recovery.

ABSTRACT

Introduction The primary outcomes from this study of psychotherapy for young people with bipolar disorder identified that most participants had continued to remain well. Given that up to 80% of people relapse within 2 years, it was important to establish how these participants described the process of staying well. Aim To examine how participants in a psychotherapy for young people with bipolar disorder study at 5-year follow-up described their experiences of the intervention and its impact on living with the disorder. Methods This qualitative study was conducted 5 years after participants had completed a psychotherapy intervention in a randomized controlled trial for young people with bipolar disorder. Thirty people were recruited into this qualitative study and interviewed regarding their experiences. The data were analysed using an inductive thematic analysis. Findings Three themes were identified from the data: self-awareness in the context of bipolar disorder; understanding my bipolar disorder; and learning to stay well with bipolar disorder. Conclusions Mental health nurses can promote the factors that participants found helpful in learning to stay well self-awareness, understanding the unique characteristics of their disorder, learning to take care of the self and stabilization of social rhythms.

The experience of recurrent fallers in the first year after stroke

PURPOSE

Understanding the experiences of fallers after stroke could inform falls-prevention interventions, which have not yet shown effectiveness in this population. The aim of this study was to explore the experience of recurrent fallers post-stroke in relation to recovery and living with falls.

METHODS

Participants who had more than one fall in the first year after stroke were identified from a prospective cohort study. The methods of grounded theory informed data collection and analysis. Semi-structured interviews were conducted, audio-recorded and transcribed. Coding was conducted and categories were developed inductively.

RESULTS

Nine stroke survivors aged 53-85 were interviewed 18-22 months post-discharge. Participants had experienced between 2 and 9 falls and one participant suffered a fracture. Three inter-linked categories were identified: (i) Judging the importance of falls by exploring cause and consequence, (ii) getting back up, and (iii) being careful.

CONCLUSIONS

Stroke survivors' assessment of their own falls-risk and their individual priorities contribute to their decisions around activity participation. "Being careful" could be described as a form of self-managing falls-risk. The inclusion of self-management principles, peer-educators, and education to rise from the floor in falls-management programmes warrants investigation. Not all falls were considered equally important by participants. This could be considered when defining falls-related outcomes. Implications for Rehabilitation Healthcare professionals may be able to offer an increased sense of control to stroke survivors through education about how to avoid particular causes and consequences of falls. Falls-related advice should be specific, relevant to the individual, and respectful of their sense of identity. Being able to rise from the floor appears to be important for coping with falls and falls-risk. Professionals should be cognisant of the potential differences of opinion between stroke survivors and their families around management of falls-risk.

Validation of two risk-prediction models for recurrent falls in the first year after stroke: a prospective cohort study

Background

several multivariable models have been derived to predict post-stroke falls. These require validation before integration into clinical practice. The aim of this study was to externally validate two prediction models for recurrent falls in the first year post-stroke using an Irish prospective cohort study.

Methodology

stroke patients with planned home-discharges from five hospitals were recruited. Falls were recorded with monthly diaries and interviews 6 and 12 months post-discharge. Predictors for falls included in two risk-prediction models were assessed at discharge. Participants were classified into risk groups using these models. Model 1, incorporating inpatient falls history and balance, had a 6-month outcome. Model 2, incorporating inpatient near-falls history and upper limb function, had a 12-month outcome. Measures of calibration, discrimination (area under the curve (AUC)) and clinical utility (sensitivity/specificity) were calculated.

Results

128 participants (mean age = 68.6 years, SD = 13.3) were recruited. The fall status of 117 and 110 participants was available at 6 and 12 months, respectively. Seventeen and 28 participants experienced recurrent falls by these respective time points. Model 1 achieved an AUC = 0.56 (95% CI 0.46-0.67), sensitivity = 18.8% and specificity = 93.6%. Model 2 achieved AUC = 0.55 (95% CI 0.44-0.66), sensitivity = 51.9% and specificity = 58.7%. Model 1 showed no significant difference between predicted and observed events (risk ratio (RR) = 0.87, 95% CI 0.16-4.62). In contrast, model 2 significantly over-predicted fall events in the validation cohort (RR = 1.61, 95% CI 1.04-2.48).

Conclusions

both models showed poor discrimination for predicting recurrent falls. A further large prospective cohort study would be required to derive a clinically useful falls-risk prediction model for a similar population.

Establishing routines to cope with the loneliness associated with widowhood: a narrative analysis

WHAT IS KNOWN ON THE SUBJECT?: Loneliness in older adults has been identified as an important public health issue in many countries. Widowhood is a time when many older people experience loneliness. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Little is known about strategies that are effective in mitigating experiences of loneliness and this paper explores this with older people who have been through the process. The narratives of the older people in this study described a trajectory in which loneliness was experienced as both a loss of spouse and a loss of routines that enabled them to maintain connections with others. This trajectory moved onto the establishment of new routines that enabled connections to be developed. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Loneliness is strongly associated with depression and anxiety in the elderly and mental health nurses should be encouraged to screen for loneliness when undertaking assessments. Interventions that facilitate the development of meaningful routines could be integrated into mental health nursing care of older people.

ABSTRACT

Background Loneliness in older people is a public health concern in many Western countries. While not necessarily a symptom of mental disorder, it is often associated with depression and anxiety. Widowhood is a transition period during which many older people experience acute loneliness but over time develops strategies to manage it. Little is known about effective strategies that older people have used to manage the experience. The strategies older people used to manage this was the focus of this paper. Aim The aim was to examine older widows' experiences of loneliness. Design The design of this study was a qualitative narrative analysis with thematic analysis and the participants were 40 older widow/widowers aged between 70 and 97 years. Findings The study found that the participants negotiated the experience of loneliness following widowhood from an acute phase of experiencing an absence and the associated loss of routine connection to the establishment of new routines that provided new connections and a new sense of identity as an individual rather than a couple. Conclusions It is important for mental health nurses to screen for loneliness and be able to facilitate interventions that may alleviate the experience of loneliness.

Early Childhood Dental Problems

Investigations into the wider bioecological understanding of dental problems in early childhood are limited in national surveys. Classification tree analysis (CTA) was used to explore multilevel interactions among key aspects of child and primary caregiver (PCG) psychosocial and physical health affecting dental problems in preschool children. Data were derived from the Growing Up in Ireland study, a nationally representative sample of 9-mo-olds (N = 11,134) in 2007/2008 followed up at age 3 y (N = 9,793) in 2010/2011. Analysis included PCG reports of children’s dental problems, general health, temperament, emotional and behavioral difficulties, and their own general health, stress and depression, relationship, and sociodemographic variables. Misclassification costs were specified for the model by applying a higher penalty for misclassifying those with a dental problem (minority class). Logistic regression analyses were carried out for comparison. Dental problems were reported among 302 infants (2.7%) at 9 mo of age and 493 children (5.0%) at 3 y. CTA identified infant temperament (Infant Characteristics Questionnaire unpredictable) as the primary predictor of dental problems at 9 mo and child global health at 3 y of age. First-level predictors were PCG depression score and use of a soother at 9 mo and PCG ethnicity and unscheduled hospital visits at 3 y of age. Regression analyses results supported the most important predictors at 9 mo and 3 y of age. The CTA model for 9-mo-old infants had a specificity of 90.4%, sensitivity of 31.2%, and overall accuracy of 88.8% while that for 3-y-olds had a specificity of 58.5%, sensitivity of 66%, and overall accuracy of 59%. Key aspects of infant/child and PCG health, as well as psychosocial characteristics associated with reported dental problems, should be considered in future multidisciplinary approaches to child health.

Knowledge Transfer Statement: The results of this data analysis should help raise awareness among clinicians of how primary caregiver and child psychosocial and general health factors are associated with early childhood dental problems, even before the primary dentition is complete. Classification tree analysis visually demonstrates how factors such as infant temperament (9 mo) and child global health (3 y) can interact at multiple levels and affect different subgroups of the child population. Future intervention strategies for oral health should involve consideration of the psychological and general health characteristics of the young child and PCG at both the patient and population levels. This knowledge could assist decision makers adopt an integrated multidisciplinary approach in formulating a coherent oral health policy for preschool children.

Culture-negative Bartonella endocarditis in a patient with renal failure: the value of molecular methods in diagnosis

Members of the genus Bartonella are increasingly recognised as a cause of culture-negative endocarditis, particularly in those patients with underlying risk factors (e.g., homelessness and alcoholism (B. quintana) or valvulopathy and cat ownership (B. henselae). The aortic and mitral-valves are most commonly involved. Here, a case is reported of culture-negative right-sided endocarditis, without any of the above risk factors, due to Bartonella sp. in a 69-year-old man who presented with acute renal failure. The diagnosis was made using a broad-range 16S rRNA polymerase chain reaction (PCR) technique and direct automated sequencing on a peripheral blood sample, which was subsequently confirmed serologically. A review of the literature on Bartonella endocarditis is also presented. Molecular laboratory methods using peripheral blood or blood cultures may be very useful in the diagnosis of causal agents in culture-negative endocarditis and add further support to the recently inclusion of molecular (PCR) diagnosis, as a major Duke's criterion, for the diagnosis of infective endocarditis.

The Role the Frailty Syndrome Can Play in Advocacy and Resource Allocation for Our Ageing Population - Findings in a Dublin Day Hospital

Frail individuals are at higher risk of adverse outcomes, and need identification and priority access to Comprehensive Geriatric Assessment (CGA). We prospectively collected data on new referrals to our day hospital. Levels of frailty were measured with the SHARE Frailty Instrument for Primary Care (SHARE-FI). Of 257 patients assessed (90 men, 167 women), 110 (43%) were non-frail, 66 (26%) pre-frail and 81 (32%) frail. Mean age was 82 years for the non-frail, 83 for the pre-frail and 84 for the frail. Forty-one percent of the frail reported two or more falls in the preceding year, compared to 38% of the pre-frail and 21% of the non-frail (P for trend = 0.003). Of 27 patients who were referred for ongoing multidisciplinary assessment and rehabilitation, 16 (59%) were frail. The frailty syndrome has the potential to become an advocacy tool for older people and help target effective, but finite, CGA resources.

Social rhythm interventions for bipolar disorder: a systematic review and rationale for practice

INTRODUCTION

Three interconnected pathways to relapse have been identified as stressful life events, medication non-adherence and disruptions in social rhythms (daily activity and routine). The role of medication and stressful life events is generally better understood than the role of social rhythms. There is no previous review of interventions that target social rhythms.

AIM

To identify the evidence for the effectiveness of interventions that target social rhythms for improving mood symptoms.

METHOD

A quantitative systematic review was conducted. Results Seven studies were included in the review: four reporting interpersonal and social rhythm therapy (IPSRT) interventions and three sleep/light interventions.

DISCUSSION

The results suggest that IPSRT may have a potential benefit in improving mood symptoms and relapse, but it is not clear whether this is of greater benefit than an intensive supportive care intervention of similar duration. The sleep/light interventions demonstrated rapid mood improvements; however, it was not clear how long this improvement was sustained.

IMPLICATIONS FOR PRACTICE

Attention to social rhythms and the implementation of interventions that target these could be useful for mental health nursing practice may provide people with BD a clinically effective adjunctive intervention to medication.

Antithrombotic Treatment at Onset of Stroke with Atrial Fibrillation, Functional Outcome, and Fatality: A Systematic Review and Meta-Analysis

Background

In atrial fibrillation–associated stroke, conflicting data exist regarding association between therapeutic vitamin K-antagonist anticoagulation (International Normalized Ratio 2–3) and early death and functional outcome, and few data exist relating to late outcome in ischemic and haemorrhagic atrial fibrillation–stroke.

Aim

We performed a systematic review and meta-analysis of oral anticoagulation at stroke onset, death and functional outcome.

Methods

We performed a systematic review, searching multiple sources. Studies were included if outcomes in atrial fibrillation–associated stroke were reported stratified by pre-stroke antithrombotic status, with documented International Normalized Ratio at onset. Outcomes were survival and good functional outcome (modified Rankin score 0–2) at discharge/30 days, and at one-year.

Results

Of eight studies (3552 patients) in ischemic stroke, International Normalized Ratio ≥ 2 compared with other treatments (International Normalized Ratio < 2, antiplatelet, or no anti-thrombotic) was associated with good outcome [pooled odds ratio 1·9 (95% confidence interval) 1·5–2·5, P < 0·001] and improved survival at 30 days discharge (pooled odds ratio for death 0·4, confidence interval 0·2–0·5, P < 0·001). The net benefit remained after inclusion of haemorrhagic stroke (odds ratio for good outcome 1·89, confidence interval 1·45–2·46, P < 0·001). At one-year, improved functional outcome for International Normalized Ratio ≥ 2 (pooled odds ratio 1·7, confidence interval 1·0–2·7, P = 0·04) and survival (odds ratio for death 0·5, confidence interval 0·4–0·8, P = 0·001) were also observed.

Conclusions

Therapeutic International Normalized Ratio at stroke onset was associated with early and late improved survival and functional recovery suggesting sustained benefit for warfarin anticoagulation for stroke outcome in atrial fibrillation patients. Long-term outcome data following stroke in patients taking new oral anticoagulants is required.

Clinical guideline adherence by physiotherapists working in acute stroke care

The publication of the Irish Clinical Guidelines for Stroke in 2009 provided healthcare professionals with an essential tool for improving stroke services. The aim of this study was to identify the degree to which Senior Physiotherapists in acute stroke care adhered to the Irish Clinical Guidelines for Stroke. This was a cross-sectional study, a postal or online survey was distributed to 31 Senior Physiotherapists working in acute stroke care, 23 responded, achieving a 74% response rate. There was excellent compliance with guidelines for the completion and documentation of full assessment within 5 working days of admission 19 respondents (82.6%), and the involvement of the patient in goal setting 19 (82.6%). Poor compliance was reported in relation to the provision of early assessment 10 (43.5%) and adequate rehabilitation intensity 9 (39%). The main barriers to compliance in these areas were organisational in nature.

Serum lipids associated with inflammation-related PET-FDG uptake in symptomatic carotid plaque

OBJECTIVE

We hypothesized that serum lipids, which experimental data suggest may be key initiators of carotid plaque inflammation, would be associated with plaque inflammation on (18)fluorodeoxyglucose (FDG)-PET in patients with acutely symptomatic carotid stenosis.

METHODS

In this cohort study, consecutive patients with acute symptomatic internal carotid artery (ICA) stenosis (≥50%) underwent carotid PET-CT. We quantified plaque FDG uptake as follows: (1) average maximum standardized uptake values (SUVmax) across 10 regions of interest (ROI); (2) highest single ROI SUV measure (SUVROImax); (3) averaged mean SUV across 10 ROIs (SUVmean).

RESULTS

Sixty-one patients were included. Plaque inflammatory FDG SUVmax was associated with increasing tertiles of low-density lipoprotein (LDL) (trend p = 0.004), total cholesterol (p = 0.009), and triglycerides (p = 0.01), and with lower high-density lipoprotein (HDL) (p = 0.005). When analyzed as a continuous variable, LDL was associated with symptomatic ICA SUVmean (Spearman rho 0.44, p = 0.009), SUVROImax (rho 0.33, p = 0.01), and SUVmax (rho 0.35, p = 0.06). Total cholesterol was associated with SUVmean (rho 0.33, p = 0.009), with trends for SUVmax (rho 0.24, p = 0.059) and SUVROImax (rho 0.23, p = 0.08). Triglycerides were associated with SUVmax (rho 0.32, p = 0.01) and SUVROImax (rho 0.35, p = 0.005). HDL was associated with lower SUVmax (rho -0.37, p = 0.004) and SUVROImax (rho -0.44, p = 0.0004). On multivariable linear regression analysis adjusting for age, sex, degree of carotid stenosis, statins, and smoking, LDL (p = 0.008) and total cholesterol (p = 0.04) were independently associated with SUVmax.

CONCLUSION

Serum LDL and total cholesterol were associated with acutely symptomatic carotid plaque FDG uptake, supporting experimental data suggesting lipids may promote plaque inflammation, mediating rupture and clinical events.

Plaque Inflammation and Unstable Morphology Are Associated With Early Stroke Recurrence in Symptomatic Carotid Stenosis

Background and Purpose—

Although symptomatic carotid stenosis is associated with 3-fold increased risk of early stroke recurrence, the pathophysiologic mechanisms of high early stroke risk have not been established. We aimed to investigate the relationship between early stroke recurrence after initial symptoms and histological features of plaque inflammation and instability in resected carotid plaque.

Methods—

Carotid endarterectomy tissue from consecutive patients with ipsilateral stenosis ≥50% and recent symptoms were analyzed using a validated histopathologic algorithm (Oxford Plaque Study [OPS] system). Nonprocedural stroke recurrence before carotid endarterectomy was ascertained at 7, 28, and 90 days after initial symptoms.

Results—

Among 44 patients meeting eligibility criteria, 27.3% (12/44) had stroke recurrence after initial stroke/transient ischemic attack but before carotid endarterectomy. Compared with patients without recurrence, stroke recurrence was associated with dense macrophage infiltration (OPS grade ≥3; 91.7% versus 37.5%; P =0.002), extensive (>25%) fibrous cap disruption (90.9% versus 37%; P =0.004), neovascularization (OPS grade ≥2; 83.3% versus 43.8%; P =0.04), and low plaque fibrous content (OPS grade <2; 50% versus 6.3%; P =0.003). Early recurrence rates were 82.3% (confidence interval, 49.2%–98.8%) in patients with extensive plaque macrophage infiltration (OPS grade ≥3) compared with 22.2% (confidence interval, 3.5%–83.4%) in those with OPS grade <3 (log-rank P =0.009). On multivariable Cox regression, including OPS macrophage grade (≥3 or <3), age, and severity of stenosis (50%–69% or ≥70%), plaque inflammation was the only variable independently predicting stroke recurrence (adjusted hazard ratio, 9; confidence interval, 1.1–70.6; P =0.04).

Conclusions—

Plaque inflammation and other vulnerability features were associated with highest risk of stroke recurrence and may represent therapeutic targets for future stroke prevention trials.

Abstract W P351: Plasma Interleukin-6 and C-reactive Protein Are Associated With Acute Diffusion Hyperintensity After Transient Ischemic Attack

Background: In suspected TIA, DWI hyperintensity confirms the diagnosis of brain ischemia and identifies those with 3-fold risk of early recurrent stroke. However, immediate MRI is expensive and may not be available in many healthcare settings. A simple validated blood test to objectively support the diagnosis of cerebral ischaemia after transient symptoms might have utility in clinical practice. We hypothesised that blood markers of inflammation may be associated with abnormal DWI following TIA.

Methods: BIO-TIA was a multi-centre prospective study of consecutive patients with clinically-defined TIA, confirmed by a stroke physician. Phlebotomy and stroke protocol MRI were performed within 72 hours of symptoms. Patients with malignancy, active infection, trauma, surgery, definite transient non-ischaemic symptoms or recurrent stroke before phlebotomy/MRI were excluded. Plasma high-sensitivity CRP and interleukin-6 (IL-6) were measured by mass spectrometry.

Results: In 201 included patients, mean age was 68 years (59% male). Carotid stenosis was present in 26.4% and atrial fibrillation in 29.1%. Mean ABCD2 score was 4.2 (SD 1.3). Acute DWI hyperintensity was observed in 37.8% (76/201). Median hsCRP was 1.78mg/L in DWI-negative, compared with 3.01mg/L in DWI-positive TIA (p=0.04). Median IL-6 was 3.76pg/ml (DWI-negative) versus 4.91pg/ml (DWI-positive) (p=0.04). When the highest quartiles of CRP and IL-6 distributions were compared with quartiles 1-3, the prevalence of DWI hyperintensity was 61.5% (Q4) versus 32.9% (Q1-3) for CRP (p=0.001), and 56.4% (Q4) versus 34.9% [Q1-3) for IL-6 (p=0.02). Thresholds of 4.78mg/L for CRP or 6.21pg/ml for IL-6 had at least 80% specificity for identification of abnormal DWI signal. IL-6 was associated with CRP (rho 0.58), age (rho 0.36), and ABCD2 score (rho 0.18) and carotid stenosis (p≤0.01 for all), but not statin use.

Conclusion: Our preliminary findings require validation, but suggest that inexpensive, rapidly-measured blood markers are associated with acute DWI hyperintensity after TIA. If validated, blood markers may have utility to support the diagnosis of cerebral ischemia or select patients for early MRI.

Assessment and management of transient ischaemic attack — the role of the TIA clinic

BACKGROUND

As the risk of early stroke following transient ischaemic attack (TIA) is increasingly recognised, the management of patients presenting with symptoms suggestive of TIA presents a clinical challenge.

METHODS

Analysis of prospectively collected data on patients referred to a TIA clinic in St. Vincent's University Hospital, between January 2003 and July 2004.

RESULTS

One-hundred-and-seventeen (117) patients (mean age 75.5 years) were assessed. The majority (79%) were referred from Accident and Emergency and 61% were seen within one week of referral. Seventy-two patients (62%) had a final diagnosis of cerebrovascular disease (56 TIA, 16 completed strokes), of whom five (7%) and four (5.5%) had severe (> 70%) and moderate (> 50%) symptomatic carotid artery stenosis, respectively, whilst seven patients (10%) had newly diagnosed atrial fibrillation, five of whom were anticoagulated. Non-cerebrovascular diagnoses were made in twenty-seven patients (24%).

CONCLUSION

A TIA clinic, in co-ordination with Accident and Emergency Services, provides a safe and efficient alternative to hospital admission for patients with TIA symptoms and a low early stroke risk.

The process of change in psychotherapy for depression: helping clients to reformulate the problem

There is increasing interest in mental health nurses delivering structured short-term evidence-based psychotherapies such as cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT); however, while there is evidence of the efficacy of psychotherapy for depression, there is limited understanding of the treatment processes. Data were drawn from audio tapes of CBT and IPT sessions for treatment of depression. The transcripts of the initial, middle and final psychotherapy sessions of 40 clients were analysed. A thematic analysis was conducted to identify what was occurring in the sessions, how the client was describing psychotherapy and how the client was describing improvement or lack of improvement in depressive symptoms. There were differences in descriptions of therapy and the experience of depression between clients who responded and those who did not respond to therapy that were related to improvement in symptoms but not to the specific therapy. These differences were in the client's engagement with the language of therapy, sense of optimism about the particular model of psychotherapy, ability to examine their own role in the problem and desire to engage with new ways of being in their lives. Clients who responded to CBT or IPT had flexibility to develop new ways of thinking and acting, the ability to accept responsibility for their role in the identified problem and were willing to risk change.

'Not another UTI ... '

Malaria includes a global disease burden with approximately 300-500 million cases worldwide annually. Varied symptomatology creates a diagnostic challenge. This is a case report of a stroke rehabilitation facility resident who developed Plasmodium ovale infection, several months post-exposure. Physicians should maintain a broad list of differential diagnoses, thinking beyond the range of common diagnoses.

Nurse-led delivery of specialist supportive care for bipolar disorder: a randomized controlled trial

The aim of the study is (1) to assess the feasibility of delivering nurse-led specialist supportive care as an adjunct to usual care in the clinical setting; (2) to examine the relationship between the delivery of specialist supportive care and improved self-efficacy and functioning and reduced depressive symptoms. A randomized controlled trial of the clinical effectiveness of specialist supportive care as an adjunct to usual care was conducted in community mental health services at one site. Participants were randomized to either usual care or usual care and the adjunctive intervention. Self-report measures of depression, general functioning and self-efficacy were completed by participants in both groups at baseline and 9 months. The intervention was delivered parallel to usual treatment arrangements. While recruitment numbers were sufficient, a low rate of engagement meant we were unable to show significant differences in depressive symptoms or self-efficacy between the usual care group and the specialist supportive care plus usual care group. This study demonstrated that it was difficult to engage patients with bipolar disorder in specialist supportive care when they were currently in a mood episode and under the care of community mental health services.

Feeling out of control: a qualitative analysis of the impact of bipolar disorder

Bipolar disorder is a chronic and recurrent disorder with fluctuating symptoms. Few patients with bipolar disorder experience a simple trajectory of clear-cut episodes, with recovery typically occurring slowly over time. The chronic and disabling course of the disorder has a marked impact on the person's functioning and relationships with others. The objectives of this study were to investigate the impact of bipolar disorder on the lives of people diagnosed with this disorder. The method used was a general inductive qualitative approach. Twenty-one participants were interviewed between 2008 and 2009 about how they had experienced the impact of bipolar disorder. The interviews were audio-taped and transcribed. The core theme that emerged was the participants were feeling out of control. Their own reactions and the reactions of others to the symptoms of bipolar disorder contributed to this core theme. The core theme was constituted by feeling overwhelmed, a loss of autonomy and felling flawed. Mental health nurses can help facilitate a sense of personal control for people with bipolar disorder by exploring what the symptoms mean for that person and implementing strategies to manage the symptoms, address social stigma and facilitate active involvement in treatment.

Models of care delivery in mental health nursing practice: a mixed method study

The aim of this study was to identify the conceptual models that underpin mental health nursing care in clinical settings. This study is a modification of a previous study which evaluated the influence of implicit models of mental disorder on processes of decision making within community-based teams. Participants completed questionnaires in response to a scenario. A range of explanatory conceptual models were identified in respect to aetiology, treatment and recovery. In a forced choice the participants ranked a medical model of care above other models as underpinning care delivery. The content analysis found that the participants used a psychodynamic framework for understanding the causes of mental distress but described the nursing interventions in terms of supporting a medical model of care. Nursing care is dominated by a medical model which constrains mental health nursing. This potentially creates tension between what nurses believe to be the problem and the responses available for nurses in their clinical setting. A range of psychosocial approaches to mental health care delivery have been developed, but there seems to be problems with their implementation in practice. Further research is required to explore how broader therapeutic interventions can be implemented by nurses within multidisciplinary systems of mental health care delivery.