Initial Treatment Session Research Articles

Changes in Functional Connectivity Predict Outcome of Repetitive Transcranial Magnetic Stimulation Treatment of Major Depressive Disorder

Repetitive transcranial magnetic stimulation (rTMS) treatment of major depressive disorder (MDD) is associated with changes in brain functional connectivity (FC). These changes may be related to the mechanism of action of rTMS and explain the variability in clinical outcome. We examined changes in electroencephalographic FC during the first rTMS treatment in 109 subjects treated with 10 Hz stimulation to left dorsolateral prefrontal cortex. All subjects subsequently received 30 treatments and clinical response was defined as ≥40% improvement in the inventory of depressive symptomatology-30 SR score at treatment 30. Connectivity change was assessed with coherence, envelope correlation, and a novel measure, alpha spectral correlation (αSC). Machine learning was used to develop predictive models of outcome for each connectivity measure, which were compared with prediction based upon early clinical improvement. Significant connectivity changes were associated with clinical outcome (P < 0.001). Machine learning models based on αSC yielded the most accurate prediction (area under the curve, AUC = 0.83), and performance improved when combined with early clinical improvement measures (AUC = 0.91). The initial rTMS treatment session produced robust changes in FC, which were significant predictors of clinical outcome of a full course of treatment for MDD.

Changes in Functional Connectivity Predict Outcome of Repetitive Transcranial Magnetic Stimulation Treatment of Major Depressive Disorder

Repetitive transcranial magnetic stimulation (rTMS) treatment of major depressive disorder (MDD) is associated with changes in brain functional connectivity (FC). These changes may be related to the mechanism of action of rTMS and explain the variability in clinical outcome. We examined changes in electroencephalographic FC during the first rTMS treatment in 109 subjects treated with 10 Hz stimulation to left dorsolateral prefrontal cortex. All subjects subsequently received 30 treatments and clinical response was defined as ≥40% improvement in the inventory of depressive symptomatology-30 SR score at treatment 30. Connectivity change was assessed with coherence, envelope correlation, and a novel measure, alpha spectral correlation (αSC). Machine learning was used to develop predictive models of outcome for each connectivity measure, which were compared with prediction based upon early clinical improvement. Significant connectivity changes were associated with clinical outcome (P < 0.001). Machine learning models based on αSC yielded the most accurate prediction (area under the curve, AUC = 0.83), and performance improved when combined with early clinical improvement measures (AUC = 0.91). The initial rTMS treatment session produced robust changes in FC, which were significant predictors of clinical outcome of a full course of treatment for MDD.

O16 Shifts in mean peak oscillatory frequency during repetitive transcranial magnetic stimulation (rTMS) treatment of major depressive disorder

Objectives Repetitive Transcranial Magnetic Stimulation (rTMS) is an effective treatment for Major Depressive Disorder (MDD). Efficacy is variable and there are no reliable predictors of treatment outcome. This study aimed to identify a quantitative electroencephalography (qEEG) biomarker of rTMS treatment outcome. Methods 59 subjects with MDD (mean baseline Inventory of Depressive Symptomatology – Self Rated [IDS-SR] score = 52) underwent rTMS treatment applied to left dorsolateral prefrontal cortex (DLPFC). Subjects were examined with a 64 channel TMS-compatible qEEG system before, during, and after the initial treatment session. Changes in primary and secondary mean peak frequencies between 6 and 14 Hz were examined between pre- and post-treatment resting states. Clinical outcome was examined after two and six weeks of treatment, with response defined as a 50% reduction in IDS-SR and remission a final IDS-SR ≤ 11. Results There was a significant association between changes in mean peak frequency and outcome. Early response and six -week remission were associated with acceleration and decreased variance of primary mean peak frequency, and emergence of higher frequency secondary peaks. Changes in mean peak frequency pre- to post- the initial rTMS treatment session predicted six-week clinical outcome. Discussion Changes in mean peak frequency during the initial rTMS treatment session are a promising biomarker of clinical outcome. Conclusions Future studies should examine shifts in frequency in relation to adjustment of rTMS parameters. Significance qEEG studies performed during the initial rTMS treatment session may be a useful method for guiding decisions regarding the duration and parameters used for rTMS treatment.

Factors in Patient Responsiveness to Directional Preference-Matched Treatment of Neck Pain With or Without Upper Extremity Radiation.

Patient-related predictive factors in responsiveness to directional preference therapy for neck pain with or without upper extremity radiation (NP/R) have not been reported. A directional preference is any neck movement that, when performed repeatedly to end range, results in centralization and/or alleviation of NP/R. It was hypothesized that patient compliance with a prescribed, directional preference-matched home exercise program would improve positive responsiveness to NP/R treatment. Patient-related factors thought to affect responsiveness to care were collected retrospectively from charts and de-identified for patients with NP/R who underwent chiropractic treatment at a multispecialty spine clinic from January 2014 through June 2015. Responsiveness was measured by calculating the percentage change in Neck Bournemouth Questionnaire (NBQ) scores over treatment time. Multiple linear regression was used to identify factors associated with positive responsiveness. Mean percentage change in patient NBQ score from initial intake to discharge was 50% (standard deviation: 32%). Of 104 patients meeting study inclusion criteria, 86 (83%) reported experiencing improvement after the first treatment session. Bivariate analysis of patient characteristics by compliance with directional preference-matched exercise indicated that compliant patients (n=95, 91%) demonstrated significantly greater responsiveness to care than did noncompliant patients, at 55% versus 25% change in NBQ score, respectively (P=0.0041). Four factors were statistically significant predictors of patient responsiveness to directional preference therapy for NP/R: patient compliance with directional preference-matched exercise (P=0.0023), patient age (P=0.0029), condition chronicity (P<0.0001), and whether the patient reported improvement of symptoms following initial treatment session (P=0.0003). The results of this study suggest that patient compliance with directional preference exercise is associated with patient responsiveness to conservative treatment of NP/R, as are age, chronicity and report of immediate symptom improvement.

Communication Skills Training for Practitioners to Increase Patient Adherence to Home-Based Rehabilitation for Chronic Low Back Pain: Results of a Cluster Randomized Controlled Trial

ObjectiveTo assess the effect of an intervention designed to enhance physiotherapists' communication skills on patients' adherence to recommendations regarding home-based rehabilitation for chronic low back pain. DesignCluster randomized controlled trial. SettingPublicly funded physiotherapy clinics. ParticipantsA sample (N=308) of physiotherapists (n=53) and patients with chronic low back pain (n=255; 54% female patients; mean age, 45.3y). InterventionsPatients received publicly funded individual physiotherapy care. In the control arm, care was delivered by a physiotherapist who had completed a 1-hour workshop on evidence-based chronic low back pain management. Patients in the experimental arm received care from physiotherapists who had also completed 8 hours of communication skills training. Main Outcome Measures(1) Patient-reported adherence to their physiotherapists' recommendations regarding home-based rehabilitation measured at 1, 4, 12, and 24 weeks after the initial treatment session. (2) Pain and pain-related function measured at baseline and at 4, 12, and 24 weeks. ResultsA linear mixed model analysis revealed that the experimental arm patients' ratings of adherence were higher than those of controls (overall mean difference, .41; 95% confidence interval, .10–.72; d=.28; P=.01). Moderation analyses revealed that men, regardless of the intervention, showed improvements in pain-related function over time. Only women in the experimental arm showed functional improvements; female controls showed little change in function over time. The Communication Style and Exercise Compliance in Physiotherapy intervention did not influence patients' pain, regardless of their sex. ConclusionsCommunication skills training for physiotherapists had short-term positive effects on patient adherence. This training may provide a motivational basis for behavior change and could be a useful component in complex interventions to promote adherence. Communication skills training may also improve some clinical outcomes for women, but not for men.

Electroacupuncture combined with mosapride alleviates symptoms in diabetic patients with gastroparesis.

The present study compared the clinical effectiveness of electroacupuncture (EA), monotherapy and combination therapy involving the administration of EA and mosapride in diabetic patients with severe or mild symptoms suggestive of gastroparesis. A total of 56 patients with type 2 diabetes who had symptoms suggestive of gastroparesis for >3 months were divided into two groups according to the Gastroparesis Cardinal Symptom Index (GCSI) score, including 33 in the mild group (GCSI score <3.5) and 23 in the severe group (GCSI score ≥3.5). Initially, all patients received EA monotherapy for 14 days. An effective response was defined as a reduction of the overall baseline GCSI score by >25% after treatment. The non-responding patients then received a combination treatment with EA and mosapride. Gastric emptying was assessed by the 13C-octanoic acid breath test at the beginning and end of each treatment session. Two patients in the severe group dropped out of the study during the initial treatment session. The results revealed that 34 early-responding patients (30 from the mild group and 4 from the severe group) treated with EA monotherapy, and 20 non-early-responding patients receiving combination therapy with EA and mosapride showed clinically significant improvements. Analysis of data from the mild subgroup demonstrated that EA treatment specifically improved symptoms of nausea, vomiting, stomach fullness, excessive fullness and bloating. There was no statistically significant difference in the gastric half-emptying time among patients prior to and after EA monotherapy. These preliminary results suggested that EA may be an option for improving mild symptoms in patients with diabetic gastroparesis, whereas combination therapy involving EA and pharmaceutics is required in patients with severe symptoms.

Radiofrequency Ablation and Focal Endoscopic Resection in Barrettʼs Esophagus Treatment: A Single-Center Experience

Introduction: Radiofrequency ablation (RFA) or focal endoscopic resection (ER) followed by RFA safely and effectively eradicates the Barrett's esophagus (BE) with or without dysplasia. However, little is known about the total required treatment sessions to achieve a complete cure when comparing both (RFA alone versus ER+RFA) methods. Herein, we report 2-year experience of treating BE with both approaches. Methods: All patients undergoing treatment for BE with RFA or RFA/ER at a tertiary care center between January 2014 and December 2015 were included in the analysis. Patients who got their initial treatment session before 2014 were included after adding those sessions to the overall number of treatment sessions. Patients who underwent APC tissue destruction as a last treatment session for minute Barrett's islands and then followed by their referring physician were considered as a complete cure. Patients who haven't received their last treatment were excluded. (Figure 1) Tables 1 and 2 show patients demographics and the data collected. Initial biopsy results from the referring physician were compared with the biopsy after the last treatment session to evaluate the complete eradication of intestinal metaplasia (CE-IM) and/or Dysplasia/Intramucosal Carcinoma (CE-D/IMC). Subjects were divided into 2 main groups: Dysplasia/IMC and Intestinal Metaplasia (IM). Comparison was made among patients who underwent RFA or RFA/ER in each main group. (Tables 1 + 2)Figure 1Table 1: Patients who had intestinal metapalsia onlyTable 2: Patients who had Dysplasia/IMCResults: 74 patients with a mean age of 66.5±9.4 years (83% males) were included. Median BE length was 3 cm (range 1-15). Ten patients presented as a recurrence after complete eradication from prior therapy at another facility. 1. Dysplasia/IMC Group: 51 patients were identified (24 RFA + 27 RFA/ER). Median number of total required sessions was 2 in RFA group and 4 in RFA/ER group (p = 0001). CE-D/IMC was achieved in 24 (100%) and 25 (92.6%) patients among RFA and RFA/ER groups respectively. ER 2. Intestinal Metaplasia Group: 23 patients were identified (19 RFA + 4 RFA/ER). The median number of total required sessions was 2 and 4 among RFA and RFA/ER groups respectively (p= 0.0165). There was no significant difference in complications among the RFA and RFA/ER patients. Conclusion: RFA and RFA/ER are safe and effective methods for the treatment of BE. However, patients who were treated with RFA/ER required higher number of overall treatment sessions compared to RFA only.

The Techniques for Overcoming Depression Questionnaire: Mokken Scale Analysis, Reliability, and Concurrent Validity in Depressed Cardiac Patients.

The Techniques for Overcoming Depression (TOD) questionnaire assesses the frequency with which patients being treated for depression use cognitive-behavioral techniques in daily life. This study examined its latent structure, reliability and concurrent validity in depressed cardiac patients. The TOD was administered at the initial and final treatment sessions in three trials of cognitive behavior therapy (CBT) (n = 260) for depression in cardiac patients. Mokken scaling was used to determine its dimensionality. The TOD is unidimensional in depressed cardiac patients, both at the initial evaluation (H = .46) and the end of treatment (H = .47). It is sensitive to change and the total score correlates with therapist ratings of the patient's socialization to CBT (r=.40, p<.05), homework adherence (r=0.36, p<0.05), and use of cognitive-behavioral techniques (r=.51, p<.01). TOD scores were associated with post-treatment depression scores in two of the trials (p<.01 in both analyses). The TOD is a unidimensional, reliable, valid, and clinically informative measure of self-reported use of cognitive-behavioral techniques for overcoming depression in cardiac patients. Studies of the TOD in other depressed patient populations are needed.

Heart Rate and Blood Pressure Assessment by Physical Therapists in the Outpatient Setting—An Observational Study

Purpose: Although physical therapists (PTs) are equipped and trained with the knowledge of the importance of vital sign assessment and cardiovascular risk factors, there seems to be a discrepancy between the practice guidelines and the actual practice in the clinic. Therefore, the purpose of this study was to observe the frequency with which PTs take and record heart rate (HR) and blood pressure (BP) in the orthopedic outpatient setting during therapy sessions. Methods: Physical therapists from 6 area clinics were observed, including 15 licensed PTs, during 74 patient sessions. The frequency with which the PTs measured patients' BP and HR during initial assessment and/or follow-up treatment sessions was documented. Physical therapist demographics and patient diagnosis, comorbidities, age, and sex were recorded. Results: Of the 74 patient sessions, 15 were initial visits, 54 were follow-up, and 5 were discharge sessions. Although 26% (n = 19) of the patients had hypertension as a comorbidity, initial HR and BP were only taken in 2 sessions, and only once taken after exercise. Conclusions: Within our limited sample, PTs in outpatient settings were not following HR and BP screening or exercise monitoring practice guidelines. This could put patients at risk for cardiovascular incidents during therapy sessions.

Early in-session predictors of response to trauma-focused cognitive therapy for posttraumatic stress disorder

Trauma-focused cognitive behaviour therapy is effective in treating posttraumatic stress disorder but non-response rates range between 25% and 50%. Results of previous research on patient characteristics predicting outcome are inconsistent and mainly focused on demographic and diagnostic variables. This study examined whether behavioural predictors of poor treatment response can be observed in early sessions. It was predicted that greater patient perseveration, lower expression of thoughts and feelings and weaker therapeutic alliance would be associated with poorer outcomes. We also explored the relationships of patient behaviours with therapeutic alliance and the efficiency and competence of treatment delivery. Audio or video recordings of the initial treatment sessions of 58 patients who had shown either good (n = 34) or poor response (n = 24) to cognitive therapy for PTSD (CT-PTSD, Ehlers & Clark, 2000) were blindly coded for patient perseveration, expression of thoughts and feelings, therapeutic alliance, efficiency and competency of treatment delivery and therapist competence. Poor responders showed more perseveration and less expression of thoughts and feelings in the initial session. Patient perseveration and low expression of thoughts and feelings were associated with poorer therapeutic alliance and compromised treatment delivery. Patients with these behavioural characteristics may benefit from additional treatment strategies. Limitations of the study and implications for clinical practice are discussed.

Testing the efficacy of pure versus guided mirror exposure in women with bulimia nervosa: A combination of neuroendocrine and psychological indices

Background and ObjectivesBody exposure improves body image problems in women with eating disorders. However it has almost always been combined with other interventions. Thus, the efficacy of body exposure alone (i.e., pure exposure) remains largely unclear. We aimed to compare the efficacy of two body exposure techniques through psychological and neuroendocrine indices recorded within and between successive sessions. MethodTwenty-nine women with high body dissatisfaction and diagnosis of bulimia nervosa were randomly assigned to one of two treatment groups: Pure Exposure (n = 14) or Guided Exposure (n = 15). Participants received 6 exposure sessions. After each session, changes in thoughts (positive/negative) and body satisfaction were assessed. Also, we assessed the body discomfort experienced by participants within and between sessions. Finally, the changes in salivary cortisol levels within and between the initial and final treatment sessions were measured. ResultsBoth groups showed a reduction in negative thoughts and a progressive increase in positive thoughts throughout the treatment. However, the increase in body satisfaction and the reduction in subjective discomfort within the sessions were greater in the pure exposure group. The cortisol levels during the initial and final treatment sessions decreased in both groups. LimitationsMethodological limitations are reported. ConclusionsThese results suggest that pure and guided exposures are effective interventions for improving thoughts and neuroendocrine responses, although pure exposure increased more body satisfaction feelings in bulimic women. Subjective discomfort also showed different patterns of change within and along sessions for each treatment. Reasons for these results are discussed.

A controlled examination of two coping skills for daily alcohol use and PTSD symptom severity among dually diagnosed individuals

Investigations of targeted coping skills could help guide initial treatment decisions for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol dependence (AD) who often endorse worse coping skills than those with AD but not PTSD. Although improvement in coping skills is associated with enhanced alcohol use outcomes, no study has evaluated the utility of teaching specific coping skills in the context of comorbid PTSD/AD. We compared the effects of teaching two coping skills (cognitive restructuring [CR] and experiential acceptance [EA]) or an attention control condition on drinking and PTSD symptoms among 78 men and women with comorbid PTSD/AD during a 5-week daily follow-up assessment. Both CR and EA skills were associated with decreased drinking compared to control, and that change in drinking over time did not significantly differ between those who received CR and EA. Individuals who received CR skills, however, consumed less alcohol on a given day than those who received EA skills. Neither CR nor EA was associated with a decrease in PTSD symptom severity. These results provide preliminary support for clinicians to prioritize CR and EA skills during initial treatment sessions when working with individuals with PTSD/AD, and offer ideas for continued investigation and intervention refinement.

Retrospective Cost-Effectiveness Analysis of Treatments for Aphasia: An Approach Using Experimental Data

Evidence supports the effectiveness of speech-language treatment for individuals with aphasia, yet less is known about the cost-effectiveness of such treatments. The purpose of this study was to examine the incremental cost and cost-effectiveness of aphasia treatment using previously published data. The authors completed a retrospective cost-effectiveness analysis using experimental data that they extracted from 19 previously published aphasia treatment studies. Average and incremental cost-effectiveness ratios were calculated based on participants' pre- and posttreatment proficiency scores. The average cost-effectiveness ratio for all sessions was $9.54 for each 1% increase in the outcome of interest. Measures of incremental cost-effectiveness indicated that aphasia treatments resulted in statistically significant improvements up to and including 17 treatment sessions. Increases in proficiency occurred at a cost of approximately $7.00 per 1% increase for the first 3 sessions to more than $20.00 in the 14th session; the ratio was either not statistically significant or dominated (more costly and less effective) in later sessions. This cost-effectiveness analysis demonstrated that initial aphasia treatment sessions resulted in relatively larger and more cost-effective benefits than did later aphasia treatment sessions. The findings reported here are preliminary and have limitations. Prospective studies are needed to examine the cost-effectiveness of speech-language treatment for individuals with aphasia.

Efficacy and Safety of and Patient Satisfaction with Injectable Hyaluronic Acid with 0.3% Lidocaine Hydrochloride for the Treatment of Superficial Perioral Lines or Superficial Lateral Canthal Lines

It is commonly requested that perioral and lateral canthal rhytides, which result from extrinsic and intrinsic factors, be rejuvenated. To valuate the safety and efficacy of and patient satisfaction with injectable hyaluronic acid (HA) with 0.3% lidocaine hydrochloride in reducing superficial, vertical perioral wrinkles and superficial, horizontal, lateral canthal rhytides. This was a two-center, evaluator-masked, 180-day study in which 40 patients with moderate to severe superficial, vertical perioral lines or superficial, horizontal, lateral canthal lines were treated at their baseline visit with up to three 0.9-mL syringes of HA (5.5mg/mL) with 0.3% lidocaine hydrochloride. The investigator and a blinded evaluator assessed patients 7days after treatment and then every 30days after the initial treatment session for 180days. Subjects experienced statistically significant improvement in their superficial, vertical perioral lines and superficial, horizontal, lateral canthal lines and maintained those results for 180 and 120days, respectively. Three patients experienced delayed-onset periocular nodule formation associated with swelling and erythema at sites of injection, which were histologically consistent with a granulomatous reaction to the product. Injectable HA with a particle size of 350μm was efficacious and resulted in high patient improvement scores in improving moderate to severe superficial, vertical perioral lines and superficial, horizontal, lateral canthal lines. Three of the 40 enrolled patients demonstrated granuloma formation.

Clinical comparison between two bleaching techniques: a 180-day follow-up study.

The aim of this clinical study was to compare tooth shade, color rebound, and tooth sensitivity after using either a combined bleaching technique (CBT) or a deep bleaching technique (DBT) to lighten stained teeth. CBT is a two-stage bleaching process consisting of an initial in-office bleaching treatment session using 35% hydrogen peroxide (HP) followed by a 7-day at-home bleaching session with 6% HP. DBT involves a 7-day at-home bleaching session with 6% HP prior to the initiation of a two-stage CBT process. Thirty-six volunteers were recruited in this split-mouth design randomized clinical trial. Tooth shade was objectively evaluated by using a spectrophotom-eter and shade guide tabs. Tooth and gingival tissue sensitivity were self-evaluated by recording any tooth or gingival sensitivity on a daily basis. Both CBT and DBT presented satisfactory whitening effects. Although DBT resulted in a better shade change, the two bleaching techniques had a similar rebound effect. CBT was associated with a lower frequency of tooth sensitivity, but both bleaching techniques can be considered safe from a clinical standpoint. The results indicate that CBT might potentially be preferred to whiten teeth, thus promoting the shade change, and avoiding gingival and tooth sensitivity.

High power laser therapy treatment compared to simple segmental physical rehabilitation in whiplash injuries (1� and 2� grade of the Quebec Task Force classification) involving muscles and ligaments

whiplash is a frequent post traumatic pathology caused by muscle, tendon and capsular elements over stretching. The authors conducted a short term prospective randomised study to test the effectiveness of a multi wave High Power Laser Therapy (HPLT) versus conventional simple segmental physical rehabilitation (PT) included in Italian tariff nomenclature performance physiotherapy Study Design: prospective randomised study (Level II). the authors identified 135 homogeneous patients with whiplash grade 1 - 2 of the Quebec Task Force classification (QTFC). INAIL, the Italian National Workers Insurance, based in Milan, was reliable source for identifying patients. All patients with whiplash injuries grade 1 or 2 QTFC, were eligible for the study, starting from April 28 2010 to September 30 2010. Patients referred to a Coordinator (C.M.) who applied the inclusion and exclusion criteria. Patients who agreed to participate were randomly assigned to one of the two treatment groups. Dates for initial treatment session were arranged, including cervical spine X-ray, and assessment. Each patient gave informed consent for participation and agreed to adopt only the study treatment for 6 weeks. Group A (84 patients) was treated with High Power Laser Therapy (HPLT), Group B (51 patients) received conventional simple segmental physical rehabilitation (PT). During the treatment period, no other electro-medical therapy, analgesics or anti-inflammatory drugs were allowed. All patients were assessed at baseline (T0) and at the end of the treatment period (T1) using a Visual Analogical Scale (VAS), (T2) the date of return to work was registered afterwards. there was a reduction in VAS pain scores at T1. Group A (VAS = 20) Group B (VAS = 34,8) (p =0.0048). Laser treatment allowed quick recovery and return to work (T2). Group A after 48 days against 66 days of Group B (p=0.0005). results suggest that High Power Laser Therapy - is an effective treatment in patients with whiplash injury, compared to conventional simple segmental physical rehabilitation.

Time to Treatment Among Veterans of Conflicts in Iraq and Afghanistan With Psychiatric Diagnoses

Early mental health treatment after military deployment may reduce chronic mental health problems. The authors described time to, and predictors of time to, initiation of a first primary care visit, a first mental health outpatient visit, and minimally adequate mental health care (eight or more outpatient visits within 12 months) among veterans with psychiatric diagnoses. The authors conducted a retrospective cohort analysis of medical records of veterans of the conflicts in Iraq and Afghanistan who enrolled in Veterans Affairs (VA) health care, had a psychiatric diagnosis, and had used primary or mental health outpatient care between October 7, 2001, and September 30, 2011 (N=314,717). The median time from the end of the last deployment to engagement in mental health care was over two years. More than three years postdeployment, 75% of the veterans in the VA system for at least one year had not engaged in minimally adequate mental health care. There was a median lag of nearly 7.5 years between initial mental health treatment session and initiation of minimally adequate mental health care. Men waited nearly two years longer than women to initiate minimally adequate mental health care. Younger age and minority racial or ethnic status were also associated with greater time to initial mental health outpatient visit and to minimally adequate mental health care. Delays in initiating and completing minimally adequate mental health care by veterans using VA services highlight the importance of attending to the timing of care, particularly among newly returning veterans.

An online positive parenting skills programme for paediatric traumatic brain injury: feasibility and parental satisfaction

We examined the feasibility of and parental satisfaction with a training programme for parents with children who had suffered traumatic brain injury (TBI). Families who did not have a home computer and/or webcam were loaned the necessary equipment. Skype was used for videoconferencing. After the initial treatment session in the family's home, the remaining nine sessions were conducted online. Each session had two parts: (1) a self-guided web session with information about a particular skill; (2) a videoconference session with the therapist. Three of the 20 families (15%) dropped out prior to the final 6-month follow-up visit. Of the remaining 17 families, 13 (65% of those enrolled) completed 9-14 sessions. Almost all of the caregivers (87%) said that the Skype sessions were helpful compared to a conventional office visit. Almost all parents were satisfied with the programme and the technology that was used. Parental satisfaction with the programme was not influenced by prior computer ownership or comfort with technology. The programme appears to be feasible for a wide range of parents of children with TBI and provides an alternative to conventional office-based sessions that may not be accessible to all families.

Preventing cognitive decline in older African Americans with mild cognitive impairment: Design and methods of a randomized clinical trial

Mild Cognitive Impairment (MCI) affects 25% of older African Americans and predicts progression to Alzheimer's disease. An extensive epidemiologic literature suggests that cognitive, physical, and/or social activities may prevent cognitive decline. We describe the methods of a randomized clinical trial to test the efficacy of Behavior Activation to prevent cognitive decline in older African Americans with the amnestic multiple domain subtype of MCI. Community Health Workers deliver 6 initial in-home treatment sessions over 2–3months and then 6 subsequent in-home booster sessions using language, materials, and concepts that are culturally relevant to older African Americans during this 24month clinical trial. We are randomizing 200 subjects who are recruited from churches, senior centers, and medical clinics to Behavior Activation or Supportive Therapy, which controls for attention. The primary outcome is episodic memory as measured by the Hopkins Verbal Learning Test—Revised at baseline and at months 3, 12, 18, and 24. The secondary outcomes are general and domain-specific neuropsychological function, activities of daily living, depression, and quality-of-life. The negative results of recent clinical trials of drug treatments for MCI and Alzheimer's disease suggest that behavioral interventions may provide an alternative treatment approach to preserve cognition in an aging society.

Abstract 48: High Risk of Symptomatic Vasospasm in Unaffected Arteries in Subarachnoid Hemorrhage Patients Receiving Targeted Endovascular Treatment for Focal Symptomatic Vasospasm

Background: Targeted treatment (angioplasty and/or vasodilators) limited to symptomatic artery offers effective and sustained clinical benefit in patients with cerebral vasospasm and cerebral ischemia. However, there is controversy whether arteries that are not symptomatic within the same patients should be treated in the same session (global treatment). Objective: To determine the rates of occurrence of symptomatic vasospasm on previously asymptomatic arterial distributions among patients with subarachnoid hemorrhage who underwent targeted endovascular treatment for symptomatic focal vasospasm. Methods: We retrospectively identified all patients with aneurysmal subarachnoid hemorrhage and selected those who had developed focal symptomatic vasospasm and received targeted treatment with either angioplasty with or without intra-arterial (IA) vasodilators or IA vasodilators alone, in two academic institutions from June 2006- April 2010. We ascertained any new occurrence of ischemic symptoms requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the duration of hospitalization. Blinded reviewer quantitatively graded cerebral vasospasm (50%) in all major arteries on the angiogram acquired for each patient at the time of targeted treatment. Results: Out of the total of 127 patients with aneurysmal subarachnoid hemorrhage, 48 patients developed focal symptomatic vasospasm. Of the 48 patients, 43 received endovascular treatment and 5 patients were treated with medical management for mild angiographic changes. Of the 43 who received targeted endovascular treatment for vasospasm, 17 (40 %) were treated with angioplasty with or without IA vasodilators, and 26 (60%) were treated with IA vasodilators alone. In subsequent days, 13 out of the 43 patients (30%) developed vasospasm associated ischemic symptoms in previously asymptomatic vascular distributions requiring treatment with angioplasty and/ or IA vasodilators. Severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment did not predict the new occurrence of ischemic symptoms requiring endovascular treatment. Conclusions: The high risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global treatment during the initial treatment session for symptomatic vasospasm treatment in preventing subsequent occurrence of ischemic symptoms in previously asymptomatic arteries.