PeRsOnaliSed care Planning for oldER people with frailty (PROSPER): protocol for a randomised controlled trial

BACKGROUND

Frailty is common in older age and is characterised by loss of biological reserves across multiple organ systems. These changes associated with frailty mean older people can be vulnerable to sudden, dramatic changes in health because of relatively small problems. Older people with frailty are at increased risk of adverse outcomes including disability, hospitalisation, and care home admission, with associated reduction in quality of life and increased NHS and social care costs. Personalised Care Planning offers an anticipatory, preventative approach to supporting older adults to live independently for longer, but it has not been robustly evaluated in a population of older adults with frailty.

METHODS

Following an initial feasibility study, this multi-centre, individually randomised controlled trial aims to establish whether personalised care planning for older people improves health-related quality of life. It will recruit 1337 participants from general practices across Yorkshire and Humber and Mid-Mersey in the North of England. Eligible patients will be aged 65 and over with an electronic frailty index score of 0.21 or above, living in their own homes, without severe cognitive impairment and not in receipt of end-of-life care. Following confirmation of eligibility, informed consent and baseline data collection, participants will be individually randomised to the PeRsOnaliSed care Planning for oldER people with frailty (PROSPER) intervention or usual care in a 2.6:1 allocation ratio. Participants will not be blinded to allocation, but data collection and analysis will be blinded. The intervention will be delivered over 12 weeks by a Personal Independence Co-ordinator worker based within a voluntary sector organisation, Age UK. The primary outcomes are health-related quality of life, measured using both the physical and mental components of the Short-Form 12 Item Health Questionnaire at 12 months after randomisation. Secondary outcomes comprise activities of daily living, self-management capabilities and loneliness, admission to care homes, hospitalisations, and health and social care resource use at 12 months post randomisation. Parallel cost-effectiveness and process evaluations will be conducted alongside the trial.

DISCUSSION

The PROSPER study will evaluate the effectiveness and cost-effectiveness of a personalised care planning approach for older people with frailty and inform the process of its implementation.

TRIAL REGISTRATION

ISRCTN16123291 .  Registered on  28 August 2020.

'We just need to find space for them to practice so that we can help to make a stronger society': Perceived barriers and facilitators to employing health psychologists in UK public health and clinical health settings

INTRODUCTION

In recent years, health psychology has received significant attention within the health sector, due to its application to understanding influences on health and well-being and translation of health psychology into interventions to support behaviour change. The number of health psychologists in public health and healthcare settings is growing but remains limited, and is it unclear why. This study aimed to explore the views of potential and current employers of health psychologists, to elucidate barriers and facilitators of employing health psychologists in healthcare settings.

METHODS

Semi-structured interviews were carried out to explore the experiences of working with and/or employing health psychologists. Opportunities and barriers were explored for increasing access to health psychology expertise in the NHS and public health. Interviews were analysed using inductive thematic analysis.

RESULTS

Fifteen participants took part in interviews. Participants were mid-senior-level professionals working in varied healthcare settings and/or academic institutions. The majority had experience of health psychology/working with health psychologists, whilst others had limited experience but an interest in employing health psychologists. Three key themes were identified: (1) the organizational fit of health psychologists, (2) perception of competition for roles and (3) ideas for changing hearts, minds and processes.

CONCLUSION

Barriers exist to employing health psychologists in healthcare settings. These barriers include misunderstandings of the role of health psychologists and the need to preserve other disciplines due to perceived competition. Recommendations for change included showcasing the benefits and skills of health psychologists and having transparent conversations with employees and multi-disciplinary colleagues about roles.

What are lay UK public perceptions of frailty: a scoping review

RATIONALE AND OBJECTIVE

Perceptions of frailty can influence how families cope, quality of life and access to support services. Yet little is known of how lay members of the UK general public perceive frailty. This scoping review aimed to explore how frailty is perceived among the lay public in the United Kingdom.

METHODS

The established scoping review methodology by Arksey and O'Malley was followed and searches were conducted across eight electronic databases and grey literature websites for articles published between 1990 and August 2022. In total, 6,705 articles were identified, of which six were included in the review. Data were analysed using Braun and Clarke's thematic analysis framework.

RESULTS

Three key themes were identified; frailty as a normal part of ageing, perceived consequences of frailty and coping with frailty. Overall, frailty has negative connotations and is perceived as linked to a natural part of the ageing process, increased dependency, loss of identity and social exclusion and stigma. However, it is unclear whether these perceptions have a direct bearing on access to support services for communities.

CONCLUSION AND IMPLICATIONS

This review identifies that it is imperative for health and social care service providers to consider the individual meaning of frailty for older people and families, to understand and integrate their particular needs and preferences when planning and delivering person centred frailty care and support. There is also a need for development of interventions that focus on increasing education and reducing stigma around frailty in order to change frailty perceptions in the UK.

Implementing personalised care planning for older people with frailty: a process evaluation of the PROSPER feasibility trial

Background

Personalised Care Planning (PCP) is a collaborative approach used in the management of chronic conditions. Core components of PCP are shared decision making to achieve joint goal setting and action planning by the clinician and patient. We undertook a process evaluation within the PROSPER feasibility trial to understand how best to implement PCP for older people with frailty in the community.

Methods

The trial was set in two localities in England. We observed training sessions and intervention delivery at three time points during the 12-week intervention period. We interviewed delivery teams before, during and after the intervention period, as well as primary care staff. We interviewed older people who had received, declined or withdrawn from PCP. We explored training of staff delivering PCP, structures, mechanisms and resources needed for delivery, and influences on uptake. We undertook a framework approach to data analysis.

Findings

We observed thirteen training sessions and interviewed seven delivery staff, five primary care staff, and twenty older people, including seven who had declined or withdrawn from the intervention. Delivery teams successfully acquired skills and knowledge, but felt underprepared for working with people with lower levels of frailty. Timing of training was critical and ‘top-ups’ were needed. Engagement with primary care staff was tenuous. Older people with lower frailty were unclear of the intervention purpose and benefits, goal setting and action planning.

Conclusions

PCP has the potential to address the individualised needs of older people with frailty. However, training requires careful tailoring and is ideally on-going. Considerable efforts are required to integrate statutory and voluntary stakeholders, understanding the expectations and contributions of each agency from the outset. In addition, older people with frailty need time and support to adjust to new ways of thinking about their own health now and in the future so they can participate in shared decision making. These key factors will be essential when developing models of care for delivering PCP to support older people with frailty to sustain their independence and quality of life.

Trial registration

ISRCTN 12,363,970 – 08/11/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03426-4.

Niraparib Shows Superior Tissue Distribution and Efficacy in a Prostate Cancer Bone Metastasis Model Compared to Other PARP Inhibitors

Prostate cancer patients whose tumors bear deleterious mutations in DNA-repair pathways often respond to poly (ADP-ribose) polymerase (PARP) inhibitors. Studies were conducted to compare the activity of several PARP inhibitors in vitro, and their tissue exposure and in vivo efficacy in mice bearing PC-3M-luc-C6 prostate tumors grown subcutaneously (SC) or in bone. Niraparib, olaparib, rucaparib, and talazoparib were compared in proliferation assays, using several prostate tumor cell lines, and in a cell-free PARP trapping assay. PC-3M-luc-C6 cells were ~12-20-fold more sensitive to PARP inhibition than other prostate tumor lines, suggesting these cells bear a DNA damage repair defect. The tissue exposure and efficacy of these PARP inhibitors were evaluated in vivo in PC-3M-luc-C6 SC and bone metastasis tumor models. A steady-state pharmacokinetic study in PC-3M-luc-C6 tumor-bearing mice demonstrated that all of the PARP inhibitors had favorable SC tumor exposure, but niraparib was differentiated by superior bone marrow exposure compared with the other drugs. In a PC-3M-luc-C6 SC tumor efficacy study, niraparib, olaparib, and talazoparib inhibited tumor growth and increased survival to a similar degree. In contrast, in the PC-3M-luc-C6 bone metastasis model, niraparib showed the most potent inhibition of bone tumor growth compared to the other therapies (67% vs 40-45% on Day 17), and the best survival improvement over vehicle control (hazard ratio [HR] 0.28 vs HR 0.46-0.59) and over other therapies (HR 1.68-2.16). These results demonstrate that niraparib has superior bone marrow exposure and greater inhibition of tumor growth in bone, compared with olaparib, rucaparib, and talazoparib.

Community Ageing Research 75+ (CARE75+) REMOTE study: a remote model of recruitment and assessment of the health, well-being and social circumstances of older people

INTRODUCTION

The Community Ageing Research 75+ (CARE75+) study is a longitudinal cohort study collecting extensive health and social data, with a focus on frailty, independence and quality of life in older age. CARE75+ was the first international experimental frailty research cohort designed using trial within cohorts (TwiCs) methodology, aligning epidemiological research with clinical trial evaluation of interventions to improve the health and well-being of older people. CARE75+ REMOTE is an extension of CARE75+ using a remote model that does not require face-to-face interactions for data collection in the current circumstances of a global pandemic and will provide an efficient, sustainable data collection model.

METHODS AND ANALYSIS

Prospective cohort study using TwiCs. One thousand community-dwelling older people (≥75 years) will be recruited from UK general practices by telephone. Exclusions include: nursing home/care home residents; those with an estimated life expectancy of 3 months or less; and people receiving palliative care.

DATA COLLECTION

Assessments will be conducted by telephone, web-submission or postal questionnaire: baseline, 6 months, 12 months, 18 months, 24 months, 30 months and 36 months. Measures include activities of daily living, mood, health-related quality of life, comorbidities, medications, frailty, informal care, healthcare and social care service use. Consent will be sought for data linkage and invitations to additional studies (sub-studies).

ETHICS AND DISSEMINATION

CARE75+ was approved by the National Research Ethics Service (NRES) Committee Yorkshire and the Humber-Bradford Leeds 10 October 2014 (14/YH/1120). CARE75+ REMOTE (amendment 13) was approved on the 18th November 2020. Consent is sought if an individual is willing to participate and has capacity to provide informed consent. Consultee assent is sought if an individual lacks capacity. Results will be disseminated in peer-reviewed scientific journals and conferences. Results will be summarised and disseminated to study participants via newsletters, local engagement events and on a bespoke website.

TRIAL REGISTRATION NUMBER

ISRCTN16588124.

Strategies to enhance routine physical activity in care home residents: the REACH research programme including a cluster feasibility RCT

Background

Care home residents are mainly inactive, leading to increased dependency and low mood. Although exercise classes may increase activity, a more sustainable model is to engage staff and residents in increasing routine activity.

Objectives

The objectives were to develop and preliminarily test strategies to enhance the routine physical activity of care home residents to improve their physical, psychological and social well-being through five overlapping workstreams.

Design

This trial had a mixed-methods research design to develop and test the feasibility of undertaking an evaluative study consisting of gaining an understanding of the opportunities for and barriers to enhancing physical activity in care homes (workstream 1); testing physical activity assessment instruments (workstream 2); developing an intervention through a process of intervention mapping (workstream 3); refining the provisional intervention in the care home setting and clarifying outcome measurement (workstream 4); and undertaking a cluster randomised feasibility trial of the intervention [introduced via three facilitated workshops at baseline (with physiotherapist input), 2 weeks (with artist input) and 2 months], with embedded process and health economic evaluations (workstream 5).

Setting

The trial was set in 12 residential care homes differing in size, location, ownership and provision in Yorkshire, UK.

Participants

The participants were elderly residents, carers, managers and staff of care homes.

Intervention

The intervention was MoveMore, designed for the whole home, to encourage and support the movement of residents in their daily routines.

Main outcome measures

The main outcome measures related to the feasibility and acceptability of implementing a full-scale trial in terms of recruitment and retention of care homes and residents, intervention delivery, completion and reporting of baseline data and outcomes (including hours of accelerometer wear, hours of sedentary behaviour and hours and type of physical activity), and safety and cost data (workstream 5).

Results

Workstream 1 – through a detailed understanding of life in a care home, a needs assessment was produced, and barriers to and facilitators of activity were identified. Key factors included ethos of care; organisation, management and delivery of care; use of space; and the residents’ daily routines. Workstream 2 – 22 (73.3%) out of 30 residents who wore a hip accelerometer had valid data (≥ 8 hours on ≥ 4 days of the week). Workstream 3 – practical mechanisms for increasing physical activity were developed, informed by an advisory group of stakeholders and outputs from workstreams 1 and 2, framed by the process of intervention mapping. Workstream 4 – action groups were convened in four care homes to refine the intervention, leading to further development of implementation strategies. The intervention, MoveMore, is a whole-home intervention involving engagement with a stakeholder group to implement a cyclical process of change to encourage and support the movement of residents in their daily routines. Workstream 5 – 12 care homes and 153 residents were recruited to the cluster randomised feasibility trial. Recruitment in the care homes varied (40–89%). Five care homes were randomised to the intervention and seven were randomised to usual care. Predetermined progression criteria were recruitment of care homes and residents (green); intervention delivery (amber); and data collection and follow-up – 52% of residents provided usable accelerometer data at 9 months (red), > 75% of residents had reported outcomes at 9 months (green, but self-reported resident outcomes were red), 26% loss of residents to follow-up at 9 months [just missing green criterion (no greater than 25%)] and safety concerns (green).

Limitations

Observations of residents’ movements were not conducted in private spaces. Working with care home residents to identify appropriate outcome measures was challenging. Take-up of the intervention was suboptimal in some sites. It was not possible to make a reliably informed decision on the most appropriate physical activity end point(s) for future use in a definitive trial.

Conclusions

A whole-home intervention was developed that was owned and delivered by staff and was informed by residents and staff. The feasibility of conducting a cluster randomised controlled trial was successfully tested: the target numbers of care homes and residents were recruited, demonstrating that it is possible to recruit care home residents to a cluster randomised trial, although this process was time-consuming and resource heavy. A large data set was collected, which provided a comprehensive picture of the environment, residents and staff in care homes. Extensive quantitative and qualitative work comprehensively explored a neglected area of health and social care research. Completion of ethnographic work in a range of settings enabled the production of an in-depth picture of life in care homes that will be helpful for other researchers considering organisational change in this setting.

Future work

The content and delivery of the intervention requires optimisation and the outcome measurement requires further refinement prior to undertaking a full trial evaluation. Consideration could be given to a recommended, simplified, core outcome set, which would facilitate data collection in this population.

Trial registration

Current Controlled Trials ISRCTN16076575.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grant for Applied Research programme and will be published in full in Programme Grant for Applied Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial)

BACKGROUND

provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence and skills of staff who provide care. This trial assessed the feasibility of undertaking a definitive evaluation of a posture and mobility training programme for care staff.

DESIGN AND SETTING

a cluster randomised controlled feasibility trial with embedded process evaluation. Ten care homes in Yorkshire, United Kingdom, were randomised (1:1) to the skilful care training package (SCTP) or usual care (UC).

PARTICIPANTS

residents who were not independently mobile.

INTERVENTION

SCTP-delivered by physiotherapists to care staff.

OBJECTIVES AND MEASUREMENTS

key objectives informed progression to a definitive trial. Recruitment, retention and intervention uptake were monitored. Data, collected by a blinded researcher, included pain, posture, mobility, hospitalisations and falls. This informed data collection feasibility and participant safety.

RESULTS

a total of 348 residents were screened; 146 were registered (71 UC, 75 SCTP). Forty two were lost by 6 months, largely due to deaths. While data collection from proxy informants was good (>95% expected data), attrition meant that data completion rates did not meet target. Data collection from residents was poor due to high levels of dementia. Intervention uptake was variable-staff attendance at all sessions ranged from 12.5 to 65.8%. There were no safety concerns.

CONCLUSION

care home and resident recruitment are feasible, but refinement of data collection approaches and intervention delivery are needed for this trial and care home research more widely.

Abstract 4128: Niraparib shows superior tissue distribution and efficacy in a prostate bone metastasis model compared with other PARP inhibitors

Patients whose prostate tumors bear deleterious mutations in genes that cause DNA repair defects (DRD), such as breast cancer (BRCA)2, respond to inhibitors of poly (ADP-ribose) [PAR] polymerase (PARP)-1 and PARP-2. Several PARP inhibitors, including niraparib, are in clinical development for the treatment of late stage prostate cancer. Prostate cancer typically metastasizes to bone marrow, and it is possible that efficacy of PARP inhibitors could differ based on their ability to penetrate and inhibit tumor growth in bone. Nonclinical studies were conducted to evaluate activity of PARP inhibitors in vitro, and to compare tissue exposure and efficacy in mice bearing PC-3-luc-C6 prostate tumors grown either subcutaneously (SC) or in bone.

PC-3-luc-C6 cells do not have identifiable mutations in DRD genes, but they were >10-fold more sensitive in vitro to PARP inhibition than other prostate tumor lines. Treatment with niraparib induced a pattern of γ-H2AX and RAD51 staining that indicated the cells are deficient in DNA repair. Niraparib and olaparib exhibited similar potency in a biochemical PARP trapping assay, but in vitro cellular cytotoxicity studies of PC-3-luc-C6 cells demonstrated that niraparib was ~8-fold more potent than olaparib.

A steady state PK study in mice bearing PC-3-luc-C6 SC prostate tumors demonstrated distinct patterns of tissue exposure of PARP inhibitors. For example, niraparib was detected for 12 or 24 hours in all tissues tested, including in plasma, tumor, and bone marrow. In contrast, olaparib was detected for up to 12-24 hours in plasma and tumor, but only transient exposure was observed in bone marrow. Mean AUC24 ratio estimates showed that niraparib had several-fold higher distribution to tumor and bone marrow as compared with olaparib.

Efficacy studies were performed in the PC-3-luc-C6 tumor model, implanted either SC or by intracardiac injection to seed bone metastases. In the soft tissue SC tumor model, efficacy of the PARP inhibitors was similar, increasing lifespan by up to ~30%. However, the PARP inhibitors were differentiated by efficacy in the bone metastasis model. Niraparib significantly inhibited bone tumor growth and prolonged survival by ~30% over control mice, while olaparib did not prolong survival. This result is consistent with the hypothesis that niraparib's superior bone marrow exposure results in greater inhibition of tumor growth in bone. It further suggests that prostate cancer patients may derive greater benefit from PARP inhibitors that can penetrate the bone marrow.

Citation Format: Linda A. Snyder, Rajendra N. Damle, Shefali Patel, Jared Bohrer, Jenny Driscoll, Rebecca Hawkins, Christopher F. Stratton, Carol Manning, Kanaka Tatikola, Volha Tryputsen, Kathryn Packman, Rao Mamidi. Niraparib shows superior tissue distribution and efficacy in a prostate bone metastasis model compared with other PARP inhibitors [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4128.

Abstract 4127: Niraparib is active against prostate xenograft models that are wild type or defective for DNA damage repair genes

Patients with metastatic prostate cancer may respond well to first- and second-generation androgen receptor (AR)-targeted therapies, but all will eventually experience disease progression, indicating a need for alternative therapies. A subset of these patients bears prostate tumors harboring mutations that cause DNA repair defects (DRD). Alterations in DRD genes, such as breast cancer (BRCA)2, render tumors sensitive to drugs that inhibit poly (ADP-ribose) [PAR] polymerase-1 (PARP1), thereby inducing synthetic lethality. Clinical study results of PARP inhibitors tested in late stage prostate cancer have confirmed this hypothesis. However, not all tumors with mutations in DRD genes respond to PARP inhibition, and it is possible that some patients with DRDwt prostate tumors could benefit from treatment.

To better understand the basis for response to PARP inhibition, nonclinical studies evaluated the efficacy of niraparib in genetically-profiled prostate xenograft models and advanced prostate cancer patient-derived xenograft (PDX) models. The models tested included BRCA2 biallelic mutant, ataxia-telangiectasia mutated (ATM) biallelic mutant, BRCA2 monoallelic mutant and DRDwt tumor models.

The two BRCA2 biallelic mutant PDX models showed variable responses to niraparib, with significant tumor growth inhibition (TGI) seen in the LuCaP 174.1 PDX, but more modest TGI observed in LuCaP 96CR. This result is similar to the clinical experience, in which many, but not all, patients with biallelic BRCA2 mutant tumors respond to PARP inhibition. BRCA2 monoallelic mutant models did not respond to PARP inhibition, suggesting that a reduction in functional BRCA2 was insufficient to result in PARP inhibitor sensitivity. In contrast, two ATM biallelic mutant models responded to niraparib treatment with significant TGI and survival benefit. Finally, DRDwt models showed distinct patterns of response to niraparib, in that several models showed significant TGI/prolonged survival, while the majority of DRDwt models did not respond. IHC studies indicate that niraparib treatment in responsive tumor models is associated with increased levels of caspase-3, histone γ-H2AX phosphorylation (indicating increased DNA double-stranded breaks), and reduced cell proliferation. Taken together, these studies support the hypothesis that niraparib can provide clinical benefit to prostate cancer patients whose tumors are DRDmutant. Further research is warranted to understand the efficacy of niraparib in DRDwt prostate tumors.

Citation Format: Linda A. Snyder, Krista Menard, Georges Habineza Ndikuyeze, Holly M. Nguyen, Anna Hughes, Lorraine Angelillo, Gerald Chu, Jenny Driscoll, Rebecca Hawkins, Eva Corey. Niraparib is active against prostate xenograft models that are wild type or defective for DNA damage repair genes [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4127.

Normative Estimates and Agreement Between 2 Measures of Health-Related Quality of Life in Older People With Frailty: Findings From the Community Ageing Research 75+ Cohort

BACKGROUND

Previous studies have summarized evidence on health-related quality of life for older people, identifying a range of measures that have been validated, but have not sought to present results by degree of frailty. Furthermore, previous studies did not typically use quality-of-life measures that generate an overall health utility score. Health utility scores are a necessary component of quality-adjusted life-year calculations used to estimate the cost-effectiveness of interventions.

METHODS

We calculated normative estimates in mean and standard deviation for EQ-5D-5L, short-form 36-item health questionnaire in frailty (SF-36), and short-form 6-dimension (SF-6D) for a range of established frailty models. We compared response distributions across dimensions of the measures and investigated agreement using Bland-Altman and interclass correlation techniques.

RESULTS

The EQ-5D-5L, SF-36, and SF-6D scores decrease and their variability increases with advancing frailty. There is strong agreement between the EQ-5D-5L and SF-6D across the spectrum of frailty. Agreement is lower for people who are most frail, indicating that different components of the 2 instruments may have greater relevance for people with advancing frailty in later life. There is a greater risk of ceiling effects using the EQ-5D-5L rather than the SF-6D.

CONCLUSIONS

We recommend the SF-36/SF-6D as an appropriate measure of health-related quality of life for clinical trials if fit older people are the planned target. In trials of interventions involving older people with increasing frailty, we recommend that both the EQ-5D-5L and SF36/SF6D are included, and are used in sensitivity analyses as part of cost-effectiveness evaluation.

Study protocol for a cluster randomised controlled feasibility trial evaluating personalised care planning for older people with frailty: PROSPER V2 27/11/18

Background

Frailty is characterised by increased vulnerability to falls, disability, hospitalisation and care home admission. However, it is relatively reversible in the early stages. Older people living with frailty often have multiple health and social issues which are difficult to address but could benefit from proactive, person-centred care. Personalised care planning aims to improve outcomes through better self-management, care coordination and access to community resources.

Methods

This feasibility cluster randomised controlled trial aims to recruit 400 participants from 11 general practice clusters across Bradford and Leeds in the north of England. Eligible patients will be aged over 65 with an electronic frailty index score of 0.21 (identified via their electronic health record), living in their own homes, without severe cognitive impairment and not in receipt of end of life care. After screening for eligible patients, a restricted 1:1 cluster-level randomisation will be used to allocate practices to the PROSPER intervention, which will be delivered over 12 weeks by a personal independence co-ordinator worker, or usual care. Following initial consent, participants will complete a baseline questionnaire in their own home including measures of health-related quality of life, activities of daily living, depression and health and social care resource use. Follow-up will be at six and 12 months. Feasibility outcomes relate to progression criteria based around recruitment, intervention delivery, retention and follow-up. An embedded process evaluation will contribute to iterative intervention optimisation and logic model development by examining staff training, intervention implementation and contextual factors influencing delivery and uptake of the intervention.

Discussion

Whilst personalised care planning can improve outcomes in long-term conditions, implementation in routine settings is poor. We will evaluate the feasibility of conducting a cluster randomised controlled trial of personalised care planning in a community population based on frailty status. Key objectives will be to test fidelity of trial design, gather data to refine sample size calculation for the planned definitive trial, optimise data collection processes and optimise the intervention including training and delivery.

Trial registration

ISRCTN12363970 – 08/11/18.

Reduced Global Efficiency and Random Network Features in Patients with Relapsing-Remitting Multiple Sclerosis with Cognitive Impairment

BACKGROUND AND PURPOSE

Graph theory uses structural similarity to analyze cortical structural connectivity. We used a voxel-based definition of cortical covariance networks to quantify and assess the relationship of network characteristics to cognition in a cohort of patients with relapsing-remitting MS with and without cognitive impairment.

MATERIALS AND METHODS

We compared subject-specific structural gray matter network properties of 18 healthy controls, 25 patients with MS with cognitive impairment, and 55 patients with MS without cognitive impairment. Network parameters were compared, and predictive value for cognition was assessed, adjusting for confounders (sex, education, gray matter volume, network size and degree, and T1 and T2 lesion load). Backward stepwise multivariable regression quantified predictive factors for 5 neurocognitive domain test scores.

RESULTS

Greater path length (r = -0.28, P < .0057) and lower normalized path length (r = 0.36, P < .0004) demonstrated a correlation with average cognition when comparing healthy controls with patients with MS. Similarly, MS with cognitive impairment demonstrated a correlation between lower normalized path length (r = 0.40, P < .001) and reduced average cognition. Increased normalized path length was associated with better performance for processing (P < .001), learning (P < .001), and executive domain function (P = .0235), while reduced path length was associated with better executive (P = .0031) and visual domains. Normalized path length improved prediction for processing (R ² = 43.6%, G² = 20.9; P < .0001) and learning (R ² = 40.4%, G² = 26.1; P < .0001) over a null model comprising confounders. Similarly, higher normalized path length improved prediction of average z scores (G² = 21.3; P < .0001) and, combined with WM volume, explained 52% of average cognition variance.

CONCLUSIONS

Patients with MS and cognitive impairment demonstrate more random network features and reduced global efficiency, impacting multiple cognitive domains. A model of normalized path length with normal-appearing white matter volume improved average cognitive z score prediction, explaining 52% of variance.

102 Process Evaluation Exploring the Delivery and Uptake of Posture and Mobility Training for Staff in Care Homes

Introduction

Provision of care for care home residents with complex needs is challenging. Physiotherapists can play a major role in enhancing the confidence, skills and abilities of care home staff. The Skilful Care Training Package (SCTP) aims to provide staff with an understanding of good posture and training in skilled facilitation of movement. This process evaluation explored barriers and facilitators to delivery and uptake of the SCTP within the context of a feasibility cluster randomised controlled trial (cRCT) in 10 care homes.

Methods

A mixed methods process evaluation, incorporating non-participant observations and interviews, conducted in the five care homes receiving the SCTP intervention. Interviews were audio recorded and transcribed verbatim; resident conversations were captured via a Dictaphone and/or field-notes. Data analysis used the Framework approach.

Results

Fourteen staff training sessions were observed. Interviews with 22 staff and four trainers, and 13 conversations with residents were completed. Five factors influenced delivery and uptake of the SCTP:Organisational factors: strategies to publicise and facilitate access to training improved attendance; a convenient training location and trainer flexibility encouraged attendance and staff engagement.Intervention delivery: a practical participatory element to the training was highly valued; adapting the training to meet the needs of the homes was well-received.Engagement and interaction: relating training to workplace and residents’ experiences engaged staff; high levels of engagement and positive interaction within the training sessions were reported; challenges relating to staff hierarchy affected training delivery in some homes.Intervention content: posture and mobility elements were seen as important; however, some repetition with prior training was highlighted.Training impact: there were indications that staff adopted SCTP techniques. Staff reported an increase in their wellbeing and confidence in movement facilitation; cascade training was reported in some homes.

Conclusions

Training was well-received, and feedback on its impact was largely positive. Practical elements were viewed favourably over classroom-based learning. Intervention content should be revised to optimise focus and avoid overlap with other training.

101 A Posture and Mobility Training Package for Care Home Staff: Results of A Cluster Randomised Controlled Feasibility Trial

Introduction

Provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve physical well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence, skills and abilities of care home staff. This trial assessed the feasibility of undertaking a definitive evaluation of the Skilful Care Training Package (SCTP) - a posture and mobility training programme developed by physiotherapists for care home staff.

Methods

A parallel-group, cluster randomised controlled feasibility trial was undertaken in ten care homes in Yorkshire. Five were randomised to receive SCTP, five to usual care. SCTP was delivered by specialist physiotherapists, with the intention of training all direct care staff. Following consent, data were collected from and about residents with restricted mobility (those fulfilling the eligibility criteria) at baseline, three and six months post-randomisation by blinded researchers. Outcome measurement included resident mobility, posture, pain and quality of life. The feasibility of recruitment, retention, data collection and intervention delivery was assessed.

Results

All residents (348) at participating homes were screened for eligibility. 250 were eligible and 146 took part. Follow-up was balanced between arms, with an overall loss-to-follow-up rate of 28.8% at six months. Where residents were available for six-month follow-up, proxy data provision was excellent (97.1% - 100% of expected data). Difficulty collecting data directly from residents was experienced (43.3% of expected data) due to high levels of cognitive impairment. Staff attendance at training met or was close to pre-specified criteria for acceptability in three homes, with 63.0%, 63.6% and 65.8% direct care staff attending all sessions, and &gt;85% attending at least one session across all three homes. However attendance fell short of acceptability in two homes, with only 21.4% and 12.5% staff attending all sessions.

Conclusions

It is feasible to recruit and follow-up residents in a randomised trial comparing SCTP and usual care. Proxy data collection is a successful method, but collection of data from residents is difficult. Intervention delivery success was variable, illustrating heterogeneity between care homes. Future research will be informed by learning from those homes with greater intervention compliance. Work should be undertaken to investigate how best to collect meaningful data from residents.

Abstract 2134: Niraparib combined with abiraterone acetate inhibits the growth of BRCA2wt prostate tumors

Patients with metastatic prostate cancer may initially respond well to first- and second-generation androgen receptor (AR)-targeted therapies, but many will experience disease progression, indicating a need for alternative therapies. A subset of these patients bears prostate tumors that harbor deleterious mutations in DNA damage repair (DDR) pathway genes, such as BRCA2. These DDR mutations render the tumors sensitive to drugs that inhibit poly (ADP-ribose) [PAR] polymerase-1 (PARP1), inducing synthetic lethality. Studies indicate that there are interactions between AR signaling pathways and DDR pathways in prostate cancer cells, supporting the hypothesis that dual AR/PARP inhibition could inhibit prostate tumor growth more potently than single agents, regardless of the DDR status of the tumor. This hypothesis was tested using well-known human and mouse prostate tumor models that are sensitive to androgen deprivation. Genotyping of the models confirmed that none of them carried homozygous pathogenic mutations in DDR genes, including BRCA1, BRCA2, and ATM. When the cell lines were incubated in vitro with niraparib, a potent and highly selective PARP1/2 inhibitor, PAR formation was significantly inhibited, and there was induction of γH2AX in treated cells, indicating the drug induced DNA double-stranded breaks. In addition, the cytotoxicity IC50 values for niraparib were in the range of 1-10 µM, as expected for cells that are DDRwt. In vivo efficacy studies demonstrated that the VCaP and Myc-CaP tumor models were insensitive or modestly sensitive to single agent treatment with niraparib or abiraterone acetate (AA). In contrast, the combination treatment of niraparib plus AA significantly reduced tumor growth and increased survival (p&lt;0.05) as compared with control or single agent arms. Studies are ongoing to understand the mechanisms of tumor growth control mediated by the combination of these two agents. The results support the hypothesis that prostate tumors may respond to a combination treatment with niraparib, a PARP inhibitor, and AA, an androgen synthesis inhibitor, even in the absence of DDR anomalies. A Phase 3 study is planned to evaluate this hypothesis and the safety and efficacy of this combination in humans.

Citation Format: Rajendra N. Damle, Rebecca Hawkins, Jennifer Hosbach, Georges Habineza Ndikuyeze, Jenny Driscoll, Natalie L. Fulton, David Derosa, Anna Hughes, Gerald Chu, Karl Calara-Nielsen, Denis Smirnov, Dong Shen, Linda A. Snyder. Niraparib combined with abiraterone acetate inhibits the growth of BRCA2wt prostate tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2134.

Community ageing research 75+ study (CARE75+): an experimental ageing and frailty research cohort

INTRODUCTION

The Community Ageing Research 75+ Study (CARE75+) is a longitudinal cohort study collecting an extensive range of health, social and economic data, with a focus on frailty, independence and quality of life in older age. CARE75+ is the first international experimental frailty research cohort designed using Trial within Cohorts (TwiCs) methodology, to align applied epidemiological research with clinical trial evaluation of interventions to improve the health and well-being of older people living with frailty.

METHODS AND ANALYSIS

Prospective cohort study using a TwiCs design. One thousand community-dwelling older people (≥75 years) will be recruited from UK general practices. Nursing home residents, those with an estimated life expectancy of 3 months or less and people receiving palliative care will be excluded. Data collection assessments will be face to face in the person's home at baseline, 6 months, 12 months, 24 months and 48 months, including assessments of frailty, cognition, mood, health-related quality of life, comorbidity, medications, resilience, loneliness, pain and self-efficacy. A modified protocol for follow-up by telephone or web based will be offered at 6 months. Consent will be sought for data linkage and invitations to additional studies, including intervention studies using the TwiCs design. A blood sample biobank will be established for future basic science studies.

ETHICS AND DISSEMINATION

CARE75+ was approved by the NRES Committee Yorkshire and the Humber-Bradford Leeds 10 October 2014 (14/YH/1120). Formal written consent is sought if an individual is willing to participate and has capacity to provide informed consent. Consultee assent is sought if an individual lacks capacity.Study results will be disseminated in peer-reviewed scientific journals and scientific conferences. Key study results will be summarised and disseminated to all study participants via newsletters, local older people's publications and local engagement events. Results will be reported on a bespoke CARE75+ website.

TRIAL REGISTRATION NUMBER

ISRCTN16588124;Results stage.

PATCH: posture and mobility training for care staff versus usual care in care homes: study protocol for a randomised controlled trial

BACKGROUND

Residents of care homes have high levels of disability and poor mobility, but the promotion of health and wellbeing within care homes is poorly realised. Residents spend the majority of their time sedentary which leads to increased dependency and, coupled with poor postural management, can have many adverse outcomes including pressure sores, pain and reduced social interaction. The intervention being tested in this project (the Skilful Care Training Package) aims to increase the awareness and skills of care staff in relation to poor posture in the older, less mobile adult and highlight the benefits of activity, and how to skilfully assist activity, in this group to enable mobility and reduce falls risk. Feasibility work will be undertaken to inform the design of a definitive cluster randomised controlled trial.

METHODS

This is a cluster randomised controlled feasibility trial, aiming to recruit at least 12-15 residents at each of 10 care homes across Yorkshire. Care homes will be randomly allocated on a 1:1 basis to receive either the Skilful Care Training Package alongside usual care or to continue to provide usual care alone. Assessments will be undertaken by blinded researchers with participating residents at baseline (before care home randomisation) and at three and six months post randomisation. Data relating to changes in physical activity, mobility, posture, mood and quality of life will be collected. Data at the level of the home will also be collected and will include staff experience of care and changes in the numbers and types of adverse events residents experience (for example, hospital admissions, falls). Details of NHS service usage will be collected to inform the economic analysis. An embedded process evaluation will explore intervention delivery and its acceptability to staff and residents.

DISCUSSION

Participant uptake, engagement and retention are key feasibility outcomes. Exploration of barriers and facilitators to intervention delivery will inform intervention optimisation. Study results will inform progression to a definitive trial and add to the body of evidence for good practice in care home research.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN50080330 . Registered on 27 March 2017.

Disciplinary power and the process of training informal carers on stroke units

This article examines the process of training informal carers on stroke units using the lens of power. Care is usually assumed as a kinship obligation but the state has long had an interest in framing the carer and caring work. Training carers in healthcare settings raises questions about the power of the state and healthcare professionals as its agents to shape expectations and practices related to the caring role. Drawing on Foucault's notion of disciplinary power, we show how disciplinary forms of power exercised in interactions between healthcare professionals and carers shape the engagement and resistance of carers in the process of training. Interview and observational field note extracts are drawn from a multi-sited study of a training programme on stroke units targeting family carers of people with stroke to consider the consequences of subjecting caring to this intervention. We found that the process of training informal carers on stroke units was not simply a matter of transferring skills from professional to lay person, but entailed disciplinary forms of power intended to shape the conduct of the carer. We interrogate the extent to which a specific kind of carer is produced through such an approach, and the wider implications for the participation of carers in training in healthcare settings and the empowerment of carers.

A randomized, double-blind phase II study evaluating cediranib versus cediranib and saracatinib in patients with relapsed metastatic clear-cell renal cancer (COSAK)

BACKGROUND

Preclinical work suggests SRC proteins have a role in the development of resistance to vascular endothelial growth factor (VEGF) targeted therapy in metastatic clear-cell renal cancer (mRCC). This hypothesis was tested in this trial using the SRC inhibitor saracatinib and the VEGF inhibitor cediranib.

PATIENTS AND METHODS

Patients with disease progression after ≥1 VEGF-targeted therapy were eligible to participate in this double-blind, randomized (1:1) phase II study. The study compared the combination cediranib 30 mg once daily (o.d.) and saracatinib 175 mg o.d. (CS) (n = 69) or cediranib 45 mg o.d. and placebo o.d. (C) (n = 69). Archived tissue was used for biomarker analysis [SRC, focal adhesion kinase (FAK), von Hippel-Lindau, protein tyrosine phosphatase 1b and hypoxia-inducible factor 2α : n = 86]. The primary end point was progression-free survival (PFS) by RECIST v1.1.

RESULTS

Between 2010 and 2012, 138 patients were randomized across 16 UK sites. The characteristics of the two groups were well balanced. Partial responses were seen in 13.0% for C and 14.5% for CS (P > 0.05). There was no significant difference in PFS [5.4 months (3.6-7.3 months) for C and 3.9 (2.4-5.3 months) for CS; hazard ratio (HR) 1.18 (0.94-1.48)] or overall survival (OS) [14.2 months (11.2-16.8 months) for C and 10.0 (6.7-13.2 months) for CS; HR 1.28 (1.00-1.63)]. There was no significant difference in the frequency of key adverse events, dose reductions or drug discontinuations. None of the biomarkers were prognostic for PFS or OS. FAK overexpression correlated with an OS benefit [HR 2.29 (1.09-4.82), P > 0.05], but not PFS, for CS.

CONCLUSIONS

Saracatinib did not increase the efficacy of a VEGF-targeted therapy (cediranib) in this setting. Biomarker analysis did not identify consistent predictive biomarkers.

CLINICALTRIALSGOV

NCT00942877.

Treatment patterns and clinical outcomes in patients with renal cell carcinoma in the UK: insights from the RECCORD registry

BACKGROUND

The aim of the RECCORD registry was to gather real-world UK data on the use of targeted therapies in renal cell carcinoma (RCC) and assess clinical outcomes. Here, demographic and outcome data are presented with the treatment patterns and demographic profile of patients on the registry.

PATIENTS AND METHODS

Patients were retrospectively identified at seven UK hospitals with large cancer centres in England (5), Scotland (1) and Wales (1). Anonymised data were collected through an online registry covering demographics, treatments and outcomes. Five hundred and fourteen UK adult patients with metastatic RCC were included in the study for analysis. Patients were included if they were treated for metastatic RCC at one of the seven centres, and started systemic anti-cancer treatment from March 2009 to November 2012 inclusive. In addition to demographic factors, the principal outcome measures were overall survival (OS), time to disease progression and toxicity.

RESULTS

The majority of first-line treatment was with sunitinib; first-line use of pazopanib increased as the study progressed. 15.8% of patients received second-line treatment, half of whom were prescribed everolimus. Median OS (from initiation of first-line treatment) was 23.9 months (95% confidence interval [CI] 18.6-29.1 months), similar to that reported for clinical trials of targeted RCC therapies [Ljungberg B, Campbell SC, Choi HY et al. The epidemiology of renal cell carcinoma. Eur Urol 2011; 60: 615-621; Abe H, Kamai T. Recent advances in the treatment of metastatic renal cell carcinoma. Int J Urol 2013; 20: 944-955; Motzer RJ, Hutson TE, Tomczak P et al. Overall survival and updated results for sunitinib compared with interferon alfa in patients with metastatic renal cell carcinoma. J Clin Oncol 2009; 27: 3584-3590]. OS was significantly longer for those who received second-line treatment after disease progression (33.0 months; 95% CI 30.8-35.2 months) than those who did not (20.9 months; 95% CI 16.4-25.3 months; P = 0.008).

CONCLUSIONS

RECCORD is a large 'real-world' database assessing metastatic RCC treatment patterns and outcomes. Treatment patterns changed over time as targeted therapies were approved and became widely available; survival data in RECCORD are consistent with those reported for systemic treatments in clinical trials. Kaplan-Meier analysis of results demonstrated that receiving second-line therapy was a major prognostic factor for longer OS.

Abstract 2470: Anti-leukemic activity and tolerability of anti-human CD47 monoclonal antibodies

CD47 is a ubiquitously expressed cell surface Ig superfamily member. CD47 mediates a variety of biological processes, including leukocyte adhesion/migration, T-cell activation, apoptosis, and phagocytosis due to physical interaction with various proteins (integrins, thrombospondin-1, and signal regulatory protein alpha [SIRPα]). The CD47-SIRPα interaction negatively regulates phagocytosis.

Enhanced CD47 expression has been described on hematological and solid cancers, suggesting that CD47 may mediate cancer cell escape from immune surveillance (e.g., by macrophages or neutrophils). Published studies demonstrated that anti-CD47 antibodies induced phagocytosis or apoptosis of cancer cells in vitro and mediated in vivo anti-tumor efficacy.

Hypothesizing that blocking the CD47-SIRPα interaction will lead to phagocytosis and elimination of tumor cells, we generated 23 unique anti-CD47 monoclonal antibodies (mAbs), which potently block the CD47-SIRPα interaction. Upon further functional testing and optimization, three candidates emerged with nanomolar affinity to human and cynomolgus monkey CD47 and lack of hemagglutination and platelet aggregation activity: C47B157, C47B161 and C47B222 (human CD47 KD 3.53, 2.87, and 1.12 nM, respectively). To further characterize these antibodies and to better understand the contribution of merely blocking the CD47-SIRPα interaction to in vitro and in vivo anti-tumor activity, the mAbs were cloned into an effector function silent (IgG2sigma) and competent (IgG1) Fc backbone. In vitro ADCP assays demonstrated that IgG1 C47B157, C47B161, and C47B222 enhanced phagocytosis 4-fold over PBS control, while the IgG2sigma mAbs did not enhance phagocytosis. Subsequently, the anti-tumor activity was characterized in three human acute myeloid leukemia (AML) xenograft models (HL60/NSG, MV4-11/NSG, and Kasumi-3/NSG mice). At 10mg/kg C47B157, C47B161, and C47B222 completely suppressed growth of leukemia cells across all models in peripheral blood as IgG1 (0.74-2.78%) vs. control (23.2-88.5%) at time of control sacrifice. As IgG2sigma, C47B222 caused greatest suppression at 10 mg/kg in all models (1.6-2.2%). Additional in vivo studies with either AML cell lines or AML patient-derived primary cells revealed that although IgG2sigma C47B222 reduced disease outgrowth in peripheral blood and distinct organs (e.g., spleen), merely blocking the CD47-SIRPα interaction did not yield a survival advantage. In non-human primates, a single dose of IgG1 C47B222 caused ∼40% decrease in red blood cell count, hematocrit and hemoglobin at 1 mg/kg. In contrast, IgG2sigma C47B222 had minimal impact on red cell indices at 1 and 10 mg/kg.

In conclusion, the findings suggest that efficacy and tolerability of anti-CD47 mAbs are Fc effector function dependent. The need to balance efficacy and tolerability raise questions on the feasibility of targeting CD47 in the development of cancer therapeutics.

Citation Format: E. Christine Pietsch, Jianying Dong, Xiaochun Zhang, Diana Chin, Rebecca Hawkins, Thai Dinh, Mimi Zhou, Brandy Strake, Ping-Hua Feng, Meredith Rocca, Cedric Dos Santos, Xiaochuan Shan, Gwenn Danet-Desnoyers, Elizabeth Kaiser, Hillary Quinn, Jeffrey A. Nemeth, Ricardo Attar. Anti-leukemic activity and tolerability of anti-human CD47 monoclonal antibodies. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2470. doi:10.1158/1538-7445.AM2015-2470

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Development and evaluation of tools and an intervention to improve patient- and carer-centred outcomes in Longer-Term Stroke care and exploration of adjustment post stroke: the LoTS care research programme

Background

Evidence-based care pathways are required to support stroke patients and their carers in the longer term.

Aims

The twofold aim of this programme of four interlinking projects was to enhance the care of stroke survivors and their carers in the first year after stroke and gain insights into the process of adjustment.

Methods and results

We updated and further refined a purposely developed system of care (project 1) predicated on a patient-centred structured assessment designed to address areas of importance to patients and carers. The structured assessment is linked to evidence-based treatment algorithms, which we updated using a structured protocol: reviewing available guidelines, Cochrane reviews and randomised trials. A pragmatic cluster randomised controlled trial evaluation of the clinical effectiveness and cost-effectiveness of this system of care was undertaken in 29 community-based UK stroke care co-ordinator services (project 2). In total, 15 services provided the system of care and 14 continued with usual practice. The primary objective was to determine whether the intervention improved patient psychological outcomes (General Health Questionnaire-12) at 6 months; secondary objectives included functional outcomes for patients, outcomes for carers and cost-effectiveness, as measured through self-completed postal questionnaires at 6 and 12 months. A total of 800 patients and 208 carers were recruited; numbers of participants and their baseline characteristics were well balanced between intervention and control services. There was no evidence of statistically significant differences in primary or secondary end points or adverse events between the two groups, nor evidence of cost-effectiveness. Intervention compliance was high, indicating that this is an appropriate approach to implement evidence into clinical practice. A 22-item Longer-term Unmet Needs after Stroke (LUNS) questionnaire was developed and robustly tested (project 3). A pack including the LUNS questionnaire and outcome assessments of mood and social activity was posted to participants 3 or 6 months after stroke to assess acceptability and validity. The LUNS questionnaire was re-sent 1 week after return of the first pack to assess test–retest reliability. In total, 850 patients were recruited and the acceptability, validity and test–retest reliability of the LUNS questionnaire as a screening tool for post-stroke unmet need were confirmed. This tool is now available for clinical use. An in-depth qualitative investigation was undertaken with 22 patients (and carers) at least 1 year after stroke (project 4) to gain further insights into the experience of adjustment. This included initial semistructured interviews, limited observations and solicited diaries with a follow-up interview 3–4 months after the initial interview and highlighted a range of different trajectories for post-stroke recovery.

Conclusions

The programme has been completed as planned, including one of the largest ever stroke rehabilitation trials. This work highlights that successfully addressing the needs of a heterogeneous post-stroke population remains problematic. Future work could explore stratifying patients and targeting services towards patients (and carers) with specific needs, leading to a more specialised bespoke service. The newly developed LUNS questionnaire and the qualitative work will help inform such services.

Trial registration

Current Controlled Trials ISRCTN67932305.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. The Bradford Teaching Hospitals NHS Foundation Trust received additional funding for project 2 in the submitted work from the Stroke Association, reference number TSA 2006/15. The initial development work for the LUNS tool and the Longer-Term Stroke care (LoTS care) trial carried out before the start of the programme grant was funded by the Stroke Association, reference number TSADRC 2006/01.

Introducing structured caregiver training in stroke care: findings from the TRACS process evaluation study

OBJECTIVE

To evaluate the process of implementation of the modified London Stroke Carers Training Course (LSCTC) in the Training Caregivers After Stroke (TRACS) cluster randomised trial and contribute to the interpretation of the TRACS trial results. The LSCTC was a structured competency-based training programme designed to help develop the knowledge and skills (eg, patient handling or transfer skills) essential for the day-to-day management of disabled survivors of stroke. The LSCTC comprised 14 components, 6 were mandatory (and delivered to all) and 8 non-mandatory, to be delivered based on individual assessment of caregiver need.

DESIGN

Process evaluation using non-participant observation, documentary analysis and semistructured interviews.

PARTICIPANTS

Patients with stroke (n=38), caregivers (n=38), stroke unit staff (n=53).

SETTINGS

10 of the 36 stroke units participating in the TRACS trial in four English regions (Yorkshire, North West, South East and South West, Peninsula).

RESULTS

Preparatory cascade training on delivery of the LSCTC did not reach all staff and did not lead to multidisciplinary team (MDT) wide understanding of, engagement with or commitment to the LSCTC. Although senior therapists in most intervention units observed developed ownership of the LSCTC, MDT working led to separation rather than integration of delivery of LSCTC elements. Organisational features of stroke units and professionals' patient-focused practices limited the involvement of caregivers. Caregivers were often invited to observe therapy or care being provided by professionals but had few opportunities to make sense of, or to develop knowledge and stroke-specific skills provided by the LSCTC. Where provided, caregiver training came very late in the inpatient stay. Assessment and development of caregiver competence was not commonly observed.

CONCLUSIONS

Contextual factors including service improvement pressures and staff perceptions of the necessity for and work required in caregiver training impacted negatively on implementation of the caregiver training intervention. Structured caregiver training programmes such as the LSCTC are unlikely to be practical in settings with short inpatient stays. Stroke units where early supported discharge is in place potentially offer a more effective vehicle for introducing competency based caregiver training.

LINKED TRACS CLUSTER RANDOMISED CONTROLLED TRIAL NUMBER

ISRCTN49208824.

Implementing a training intervention to support caregivers after stroke: a process evaluation examining the initiation and embedding of programme change

BACKGROUND

Medical Research Council (MRC) guidance identifies implementation as a key element of the development and evaluation process for complex healthcare interventions. Implementation is itself a complex process involving the mobilization of human, material, and organizational resources to change practice within settings that have pre-existing structures, historical patterns of relationships, and routinized ways of working. Process evaluations enable researchers and clinicians to understand how implementation proceeds and what factors impact on intended program change. A qualitative process evaluation of the pragmatic cluster randomized controlled trial; Training Caregivers after Stroke was conducted to examine how professionals were engaged in the work of delivering training; how they reached and involved caregivers for whom the intervention was most appropriate; how did those on whom training was targeted experience and respond to it. Normalization Process Theory, which focuses attention on implementing and embedding program change, was used as a sensitizing framework to examine selected findings.

RESULTS

Contextual factors including organizational history and team relationships, external policy, and service development initiatives, impinged on implementation of the caregiver training program in unintended ways that could not have been predicted through focus on mechanisms of individual and collective action at unit level. Factors that facilitated or impeded the effectiveness of the cascade training model used, whether and how stroke unit teams made sense of and engaged individually and collectively with a complex caregiver training intervention, and what impact these factors had on embedding the intervention in routine stroke unit practice were identified.

CONCLUSIONS

Where implementation of complex interventions depends on multiple providers, time needs to be invested in reaching agreement on who will take responsibility for delivery of specific components and in determining how implementation and its effectiveness will be monitored. This goes beyond concern with intervention fidelity; explicit consideration also needs to be given to the implementation process in terms of how program change can be effected at organizational, practice, and service delivery levels. Normalization Process Theory's constructs help identify vulnerable features of implementation processes in respect of the work involved in embedding complex interventions.

Proteinuria in metastatic pheochromocytoma is associated with an increased risk of Acute Respiratory Distress Syndrome, spontaneously or after therapy with 131I-meta-iodobenzylguanidine (131I-MIBG)

Acute Respiratory Distress Syndrome (ARDS) has been reported rarely in pheochromocytoma, occurring spontaneously or after therapy with 131I-meta-iodobenzylguanidine (131I-MIBG). Our objective was to determine whether proteinuria is associated with an increased risk of ARDS. This was a retrospective analysis of a prospective cohort study of 64 patients with metastatic pheochromocytoma or paraganglioma treated with 131I-MIBG on institutional protocols. Proteinuria was defined as at least one urinalysis positive for at least trace protein within 1 month prior to 131I-MIBG or within 1 month prior to spontaneous ARDS. Proportions were compared using Fisher's exact test. Urinalyses within the defined time period were available for 48 patients, 8 of whom had proteinuria. Of the 8 patients with proteinuria, 5 developed ARDS: 3 within 10 days following 131I-MIBG, two 6 months following 131I-MIBG. Both patients who developed ARDS 6 months after 131I-MIBG had proteinuria within 1 month before apparently spontaneous ARDS. None of the 40 patients whose urinalyses were all negative for protein developed ARDS. None of the 16 patients with missing urinalyses developed ARDS. Patients with antecedent proteinuria were more likely to develop ARDS than those without proteinuria (63% vs. 0%; p<0.0001). The following variables were not significantly associated with ARDS: 131I-MIBG activities administered, number of 131I-MIBG administrations, age, hypertension, or secretion of catecholamines or metanephrines. In patients with metastatic pheochromocytoma or paraganglioma, proteinuria is associated with ARDS and urine protein should be examined prior to administering 131I-MIBG.

Interdisciplinary health research: perspectives from a process evaluation research team

BACKGROUND

Interdisciplinary health research (IDHR) is increasingly encouraged and is often a specific requirement for research grants provided by health research funding councils worldwide. There is consensus that research expertise and scholarship from a diverse range of disciplines are necessary to examine questions relating to complex health and social concerns for which single disciplinary approaches have been found inadequate.

METHODS

This paper reports on the experiences of an interdisciplinary process evaluation research team working in the field of stroke care.

RESULTS

Realising the perceived benefits is less than straightforward; setting up and conducting IDHR can present researchers with a range of challenges at a strategic, practical and individual level. We identify how differences in disciplinary perspectives and skills impacted on our research practice.

CONCLUSIONS

Whilst initially challenging, our different approaches to the research problem and the methods to address it, expanded conceptual and methodological understanding and proved of benefit for the research team and the study outputs.