Integrating Cardio-Oncology Across the Research Pipeline, Policy, and Practice in Australia-An Australian Cardiovascular Alliance Perspective.

Over 18 million people worldwide were diagnosed with cancer in 2020, including over 150,000 people in Australia. Although improved early detection and treatment have increased the survival rates, cardiotoxic treatment and inadequate management of cardiovascular risk factors have resulted in cardiovascular disease (CVD) being one of the leading causes of non-cancer-related death and disability among cancer survivors. International guidelines outline the standards of care for CVD risk surveillance and management. However, Australian cardio-oncology policies and clinical guidelines are limited. There is increasing growth of cardio-oncology research in Australia and support from leading Australian professional bodies and advocacy and research networks, including the Cardiac Society of Australia and New Zealand, the Clinical Oncology Society of Australia, the National Heart Foundation of Australia, and the Australian Cardiovascular Alliance (ACvA). Thus, opportunities to drive multidisciplinary cardio-oncology initiatives are growing, including grant funding, position statements, and novel research to inform new policies. The ACvA has a unique flagship structure that spans the translational research pipeline from drug discovery to implementation science. This article aims to highlight how multidisciplinary cardio-oncology innovations could intersect with the seven ACvA flagships, and to showcase Australian achievements in cardio-oncology thus far. We summarise eight key priority areas for future cardio-oncology research that emerged. These strategies will strengthen cardio-oncology research and care in Australia, and drive new guidelines, policies, and government initiatives to ensure equity in health outcomes for all cardio-oncology patients.

Integrated Text Messaging (ITM) for people attending cardiac and pulmonary rehabilitation: A multicentre randomised controlled trial.

BACKGROUND: People living with cardiac and respiratory disease require improved post-hospital support that is readily available and efficient. OBJECTIVES: To 1) test the effectiveness of an automated, semi-personalised text message support program on clinical and lifestyle outcomes amongst people attending cardiac and pulmonary rehabilitation. Also, 2) to evaluate the program's acceptability and utility using patient-reported outcome and experience measures. METHODS: Multicentre randomised controlled trial (3:1, intervention:control) amongst cardiac and pulmonary rehabilitation attendees. Control received usual care (no message program). Intervention also received a 6-month text message lifestyle and support program. Primary outcome was 6-minute walk distance (6MWD). Secondary outcomes included clinical measures, lifestyle, patient-reported outcome and experience measures, medication adherence and rehabilitation attendance. RESULTS: A total of 316 participants were recruited. They had a mean age of 66.7 (SD 10.1) years. Sixty percent were male (190/316) and 156 were cardiac rehabilitation participants. The cohort's mean baseline 6MWD was higher in the intervention than the control group. At 6 months, 6MWD improved in both groups; it was significantly greater amongst intervention than control participants (unadjusted mean difference of 43.4 m, 95 % CI 4.3 to 82.4; P = 0.0296). After adjustment for baseline values, there was no significant difference between intervention and control groups for 6MWD (adjusted mean difference 2.2 m, -21.2 to 25.6; P = 0·85), medication adherence, or cardiovascular risk factors. At 6-month follow-up, intervention participants reported significantly lower depression scores (adjusted mean difference -1.3, 95 % CI -2.2 to -0.3; P = 0.0124) and CAT scores (adjusted mean difference -3.9, 95 % CI -6.6 to -1.3; P = 0.0038), and significantly lower anxiety (adjusted mean difference -1.1, 95 %CI -2.1 to 0; P = 0.0456). Most participants (86 %) read most of their messages and strongly/agreed that the intervention was easy to understand (99 %) and useful (86 %). CONCLUSIONS: An educational and supportive text message program for cardiac and pulmonary rehabilitation attendees improved anxiety and depression plus program attendance. The program was acceptable to, and useful for, participants and would be suitable for implementation alongside rehabilitation programs. TRIAL REGISTRATION NUMBER: ACTRN12616001167459.

A National Health and Wellness SMS Text Message Program for Breast Cancer Survivors During COVID-19 (EMPOWER-SMS COVID-19): Mixed Methods Evaluation Using the RE-AIM Framework.

BACKGROUND: COVID-19 lockdowns caused widespread closures of supportive care services for breast cancer survivors in Australia. In a randomized controlled trial, our team's lifestyle-focused, evidence-based SMS text message support program (EMPOWER-SMS COVID-19) was found to be acceptable and useful for breast cancer survivors, and it was ready for rapid widespread delivery. OBJECTIVE: This study aims to evaluate the reach (uptake) of an adapted 3-month lifestyle-focused SMS text message program (EMPOWER-SMS COVID-19) and barriers and enablers to implementation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. METHODS: A mixed methods pre-post study was conducted to evaluate the EMPOWER-SMS COVID-19 program. The study evaluated the following aspects: (1) reach/representativeness, which refers to the proportion of participant enrollment (ie, number enrolled/number that visited the study website) and demographics (eg, age, sex, ethnicity, time since completing treatment, Index of Relative Socio-economic Advantage and Disadvantage [IRSAD; quintile 1, which refers to most disadvantaged areas, to quintile 5, which refers to least disadvantaged areas, and remoteness); (2) effectiveness, in which participant engagement and acceptability were evaluated using SMS text message reply data and a feedback survey (5-point Likert scale and free-text responses); (3) adoption, which corresponds to the proportion of organizations or health professionals who agreed to promote the program; (4) implementation fidelity and maintenance, which evaluated SMS text message delivery data, opt-outs, costs, and adaptations. Quantitative data were summarized using means and SDs or frequencies and percentages, while qualitative data were analyzed thematically. RESULTS: With regard to the reach/representativeness of the program, 841/1340 (62.8%) participants enrolled and provided electronic consent. Participants had a mean age of 58.8 (SD 9.8; range 30-87) years. According to the data collected, most participants identified as female (837/840, 99.6%) and White (736/840, 87.6%) and nearly half (418/841, 49.7%) finished treatment ≤18 months ago. Most resided in major cities (574/838, 68.5%) and 30% (251/838) in IRSAD quintile 1 or 2. In terms of effectiveness, 852 replies were received from 511 unique participants (median 1; range 1-26). The most common replies were participants stating how they heard about the program (467/852, 54.8%) or "thank you" (131/852, 15.4%). None of the replies contained urgent safety concerns. Among participants who provided feedback (449/841, 53.4%), most "(strongly) agreed" the SMS text messages were easy to understand (445/448, 99.3%), useful (373/440, 84.8%), helped participants feel supported (388/448, 86.6%), and motivated participants to be physically active (312/445, 70.1%) and eat healthier (313/457, 68.5%). Free-text responses revealed 5 factors influencing engagement: (1) feeling supported and less alone, (2) motivation and reassurance for health self-management, (3) the variety of information, (4) weblinks to information and resources, and (5) the option to save the SMS text messages. Concerning adoption, 50% (18/36) of organizations/health professionals agreed to promote the program. With regard to implementation/maintenance, SMS text messages were delivered as planned (97.43% [41,257/42,344] of SMS text messages were successfully delivered) with minimal opt-outs (62/838, 7.4%) and low cost (Aus $15.40/participant; Aus $1=US $0.67). No adaptations were made during the intervention period. Postintervention adaptations included adding weblinks and participant-selected customizations. CONCLUSIONS: EMPOWER-SMS COVID-19 was implemented quickly, had a broad reach, and had high engagement and acceptability among socioeconomically diverse participants. The program had high fidelity, low cost, and required minimal staff oversight, which may facilitate future implementation. However, further research is needed to evaluate barriers and enablers to adoption and implementation for health professionals and strategies for long-term maintenance.

Supporting women's health outcomes after breast cancer treatment comparing a text message intervention to usual care: the EMPOWER-SMS randomised clinical trial.

PURPOSE: The aim of this study is to evaluate the efficacy, feasibility and acceptability of a co-designed lifestyle-focused text message intervention (EMPOWER-SMS) for breast cancer survivors' self-efficacy, quality of life (QOL), mental (anxiety, depression, stress) and physical (endocrine therapy medication adherence, physical activity, BMI) health. METHODS: Single-blind randomised controlled trial (1:1) comparing EMPOWER-SMS to usual care at 6-months (intention-to-treat). SETTING: public Breast Cancer Institute (Sydney, Australia). ELIGIBILITY CRITERIA: adult (> 18 years) females, < 18-months post-active breast cancer treatment (stage I-III), owned a mobile phone, written informed consent. PRIMARY OUTCOME: Self-Efficacy for Managing Chronic Disease Scale at 6 months. Process data: message delivery analytics, cost, and post-intervention survey. RESULTS: Participants (N = 160; mean age ± SD 55.1 ± 11.1 years) were recruited 29th-March-2019 to 7th-May-2020 and randomised (n = 80 EMPOWER-SMS: n = 80 control). Baseline mean self-efficacy was high (I: 7.1 [95%CI 6.6, 7.5], C: 7.4 [7, 7.8]). Six-month follow-up: no significant differences between groups for self-efficacy (I: 7.6 [7.3, 7.9], C: 7.6 [7.3, 7.9], adjusted mean difference 0 (95%CI 0.4, 0.4), QOL, mental health, physical activity, or BMI. Significantly less EMPOWER-SMS participants missed ≥ 1 endocrine therapy medication doses compared to control (I: 3/42[7.1%], C: 8/47[17.0%], Adjusted RR 0.13 [95%CI 0.02, 0.91]). Text messages were delivered successfully (7925/8061, 98.3%), costing $13.62USD/participant. Participants strongly/agreed EMPOWER-SMS was easy-to-understand (64/64; 100%), useful (58/64; 90.6%), motivating for lifestyle change (43/64; 67.2%) and medication adherence (22/46; 47.8%). CONCLUSION: EMPOWER-SMS was feasible, inexpensive, acceptable for delivering health information to breast cancer survivors between medical appointments, with minor improvements in medication adherence. IMPLICATIONS FOR CANCER SURVIVORS: Text messages offer a feasible strategy for continuity-of-care between medical appointments.

Lung Support Service: Implementation of a Nationwide Text Message Support Program for People with Chronic Respiratory Disease during the COVID-19 Pandemic.

BACKGROUND: COVID-19 pandemic lockdowns led to the closure of most in-person pulmonary rehabilitation programs in Australia. Text message programs are effective for delivering health support to aid the self-management of people with chronic diseases. This study aimed to evaluate the implementation of a six-month pre-post text message support program (Texting for Wellness: Lung Support Service), and the enablers and barriers to its adoption and implementation. METHODS: This mixed-methods pre-post study used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate the Texting for Wellness: Lung Support Service, which is an automated six-month text message support program that included evidence-based lifestyle, disease-self management and COVID-19-related information. Reach was measured by the proportion of participant enrolments and demographic characteristics. Adoption enablers and barriers were measured using text message response data and a user feedback survey (five-point Likert scale questions and free-text responses). Implementation was evaluated to determine fidelity including text message delivery data, opt-outs, and intervention costs to promote and deliver the program. RESULTS: In total, 707/1940 (36.4%) participants enrolled and provided e-consent, with a mean age (±standard deviation) of 67.9 (±9.2) years old (range: 23-87 years). Of participants who provided feedback, (326/707) most 'agreed' or 'strongly agreed' that the text messages were easy to understand (98.5%), helpful them to feel supported (92.3%) and helped them to manage their health (88.0%). Factors influencing engagement included a feeling of support and reducing loneliness, and its usefulness for health self-management. Messages were delivered as planned (93.7% successfully delivered) with minimal participant dropouts (92.2% retention rate) and low cost ($AUD24.48/participant for six months). A total of 2263 text message replies were received from 496 unique participants. There were no reported adverse events. CONCLUSION: Texting for Wellness: Lung Support Service was implemented quickly, had a broad reach, with high retention and acceptability among participants. The program was low cost and required minimal staff oversight, which may facilitate future implementation. Further research is needed to evaluate the efficacy of text messaging for the improvement of lung health outcomes and strategies for long-term pulmonary rehabilitation program maintenance.

A Qualitative Study Exploring Feasibility and Acceptability of Acupuncture, Yoga, and Mindfulness Meditation for Managing Weight After Breast Cancer.

INTRODUCTION: Weight gain is common after breast cancer. Yoga, mindfulness meditation, and acupuncture may assist with managing weight. However, evidence on effectiveness is limited. This study assessed the feasibility and acceptability of recruiting for and implementing a randomized controlled trial (RCT) evaluating these interventions as adjuncts to lifestyle interventions (diet and exercise) for weight management in women with breast cancer. METHODS: Qualitative study involving virtual focus groups or semi-structured interviews. Participants were recruited via email invitation from a breast cancer consumer organization and breast cancer center in Australia. Eligible participants had received treatment for breast cancer, and were fluent in English. A purposive sample of culturally and linguistically diverse (CALD) participants was also recruited. Focus groups and interviews were audio-recorded, transcribed verbatim and analyzed using thematic analysis with the constant comparison method. RESULTS: Emails were sent to 1415 women of which 37 provided data in 5 focus groups and 1 semi-structured interview, including 1 focus group (n = 6) with only women from CALD backgrounds. Yoga and mindfulness meditation were perceived as feasible and acceptable for weight management, but acupuncture was seen to be too invasive to be acceptable. A focus on wellness rather than weight reduction, flexible program delivery, trusted advice, consideration of participant burden and benefit, and peer-support were key factors perceived to increase feasibility and acceptability. CONCLUSIONS: Yoga and mindfulness meditation are acceptable and useful adjuncts to lifestyle interventions for weight management after breast cancer. This research places end-users at the forefront of trial design, and will inform future trials using these interventions for weight management and improving health and wellbeing after breast cancer.

Electronic Health Interventions for Patients With Breast Cancer: Systematic Review and Meta-Analyses.

PURPOSE: Ongoing supportive care using electronic health (eHealth) interventions has the potential to provide remote support and improve health outcomes for patients with breast cancer. This study aimed to evaluate the effectiveness of eHealth interventions on patient-reported outcomes (quality of life [QOL], self-efficacy, and mental or physical health) for patients during and after breast cancer treatment and patient-reported experience measures (acceptability and engagement). METHODS: Systematic review with meta-analyses (random-effects model) of randomized controlled trials was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Nine databases were searched using a prespecified search strategy. Patient-directed eHealth interventions for adult patients during or after active breast cancer treatment measuring QOL, self-efficacy, and mental (depressive, anxiety, and distress symptoms) or physical (physical activity, nutrition, and fatigue) health outcomes were included. Data from eligible full-text articles were independently extracted by six observers. RESULTS: Thirty-two unique studies (4,790 patients) were included. All were health self-management interventions, and most were multicomponent (videos, forums, and electronic reminder systems) websites. Meta-analyses revealed a significant effect of eHealth interventions on QOL (standardized mean difference [SMD], 0.20 [95% CI, 0.03 to 0.36]), self-efficacy (SMD, 0.45 [95% CI, 0.24 to 0.65]), distress (SMD, -0.41 [95% CI,-0.63 to -0.20]), and fatigue (SMD, -0.37 [95% CI, -0.61 to -0.13]). Twenty-five studies (78.1%) measured patient-reported experience measures. Acceptability (n = 9) was high, with high ratings for satisfaction (range, 71%-100%), usefulness (range, 71%-95%), and ease-of-use (range, 73%-92%). Engagement (n = 25) decreased over time, but disease-focused information and interactive support were most engaging. CONCLUSION: eHealth interventions may provide an acceptable and effective strategy for improving QOL, distress, self-efficacy, and fatigue among patients with breast cancer.

Supporting breast cancer survivors via text messages: reach, acceptability, and utility of EMPOWER-SMS.

PURPOSE: This study aims to evaluate the reach, usefulness, acceptability, and factors influencing engagement with a lifestyle-focused text message intervention to support women's mental and physical health after breast cancer treatment. METHODS: This study uses a mixed-methods process evaluation nested in the EMPOWER-SMS randomised controlled trial (n = 160; intervention n = 80, wait-list control n = 80). Data sources included screening logs, text message delivery software analytics, intervention feedback survey, and focus groups (n = 16), which were summarised thematically based on the framework approach. RESULTS: A total of 387 women met the inclusion criteria (meanage ± SD = 59.3 ± 11.6 years). Participants who declined (n = 227) were significantly older than those who enrolled (n = 160; 62.2 ± 11.1 vs 55.1 ± 11.1 years, respectively, p < 0.001). Most intervention participants (64/80; 80%) completed the end-of-study survey, reporting the messages were easy to understand (64/64; 100%), useful (58/64; 91%), and motivating (43/64; 67%). The focus groups (n = 16) revealed five factors influencing engagement: (i) feelings of support/continued care, (ii) convenience/flexibility of message delivery, (iii) weblinks, (iv) information from a credible source, and (v) options to save or share messages. CONCLUSION: A lifestyle-focused text message program was acceptable and useful for women after breast cancer treatment. However, text messaging may be a barrier for women aged over 68 years. Suggestions for program improvements included delivering the program to patients with other cancers, during all stages of treatment, and including more weblinks in text messages. Implications for Cancer Survivors Text message programs offer a low-cost way to deliver post-treatment health support to breast cancer survivors in a non-invasive way. Text messages can improve patient-health professional communication and were found to be acceptable and useful.

How Helpful and What Is the Quality of Digital Sources of Healthy Lifestyle Information Used by Australian Adolescents? A Mixed Methods Study.

To evaluate the digital platforms most used by adolescents for healthy lifestyle information, perceived helpfulness of platform information, helpfulness for positive behaviour changes, and quality of platforms' lifestyle health information. Mixed-methods study including a cross-sectional online survey and content analysis. Eligible participants were 13-18-years; living in Australia; and had searched online for healthy lifestyle behaviour (nutrition, physical activity, weight management, sleep) information in the previous three months. Survey items examined the use of digital platforms, self-perceived helpfulness, usefulness for positive behaviour, and popular content. Data were analysed using descriptive statistics and ordinal logistic regression models. Content analysis was performed on popular digital content to evaluate expertise, objectivity, transparency, popularity, and relevance. In total, 297 participants completed the survey (62.3% female; 15.8 [SD1.5] years). Seventy-eight percent and 77% of participants reported using websites and social media, respectively, for seeking healthy lifestyle information. Websites and social media were rated as somewhat helpful by 43% and 46% of participants, respectively. Sixty-six percent and 53% of participants agreed/strongly agreed smartphone apps and social media were helpful for positive behaviour change, respectively. Helpfulness did not differ by age or gender. We evaluated 582 popular digital content; 38% were produced by a commercial company. Only 7% of content was from health organisations, 10% from health professionals and only 10% of content was objective, and 14% was transparent. Adolescents extensively utilise websites and social media for health information, yet popular content has limited objectivity and transparency. Governments and health organisations should consider creating age-appropriate digital information for healthy lifestyle behaviours.

Development and plasticity of complex movement representations.

The mammalian motor cortex is topographically organized into representations of discrete body parts (motor maps). Studies in adult rats using long-duration intracortical microstimulation (LD-ICMS) reveal that forelimb motor cortex is functionally organized into several spatially distinct areas encoding complex, multijoint movement sequences: elevate, advance, grasp, and retract. The topographical arrangement of complex movements during development and the influence of skilled learning are unknown. Here, we determined the emergence and topography of complex forelimb movement representations in rats between postnatal days (PND) 13 and 60. We further investigated the expression of the maps for complex movements under conditions of reduced cortical inhibition and whether skilled forelimb motor training could alter their developing topography. We report that simple forelimb movements are first evoked at PND 25 and are confined to the caudal forelimb area (CFA), whereas complex movements first reliably appear at PND 30 and are observed in both the caudal and rostral forelimb areas (RFA). During development, the topography of complex movement representations undergoes reorganization with "grasp" and "elevate" movements predominantly observed in the RFA and all four complex movements observed in CFA. Under reduced cortical inhibition, simple and complex movements were first observed in the CFA on PND 15 and 20, respectively, and the topography is altered relative to a saline control. Further, skilled motor learning was associated with increases in "grasp" and "retract" representations specific to the trained limb. Our results demonstrate that early-life motor experience during development can modify the topography of complex forelimb movement representations.NEW & NOTEWORTHY The motor cortex is topographically organized into maps of different body parts. We used to think that the function of motor cortex was to drive individual muscles, but more recently we have learned that it is also organized to make complex movements. However, the development and plasticity of those complex movements is completely unknown. In this paper, the emergence and topography of complex movement representation, as well as their plasticity during development, is detailed.

Junk Food on Demand: A Cross-Sectional Analysis of the Nutritional Quality of Popular Online Food Delivery Outlets in Australia and New Zealand.

The demand for convenience and the increasing role of digital technology in everyday life has fueled the use of online food delivery services (OFD's), of which young people are the largest users globally. OFD's are disrupting traditional food environments, yet research evaluating the public health implications of such services is lacking. We evaluated the characteristics and nutritional quality of popular food outlets on a market-leading platform (UberEATS®) in a cross-sectional observational study conducted in two international cities: Sydney (Australia) and Auckland (New Zealand). A systematic search using publicly available population-level data was used to identify geographical areas with above-average concentrations (>30%) of young people (15-34-years). A standardized data extraction protocol was used to identify the ten most popular food outlets within each area. The nutritional quality of food outlets was assessed using the Food Environment Score (FES) (range: -10 'unhealthiest' to 10 'healthiest'). Additionally, the most popular menu items from each food outlet were classified as discretionary or core foods/beverages according to the Australian Dietary Guidelines. The majority of popular food outlets were classified as 'unhealthy' (FES range -10 to -5; 73.5%, 789/1074) and were predominately takeaway franchise stores (59.6%, 470/789, e.g., McDonald's®). 85.9% of all popular menu items were discretionary (n = 4958/5769). This study highlights the pervasion and accessibility of discretionary foods on OFD's. This study demonstrated that the most popular food outlets on the market-leading online food delivery service are unhealthy and popular menu items are mostly discretionary foods; facilitating the purchase of foods of poor nutritional quality. Consideration of OFD's in public health nutrition strategies and policies in critical.

Text Message Behavioral Intervention for Teens on Eating, Physical Activity and Social Wellbeing (TEXTBITES): Protocol for a Randomized Controlled Trial.

BACKGROUND: Obesity is among the most significant health challenges facing today's adolescents. Weight gain during adolescence is related to cardiovascular disease, type 2 diabetes, and some cancers in later life. Presently, adolescents living in Australia have limited access to age-appropriate obesity prevention services. OBJECTIVE: This study aims to investigate whether a two-way text message program, with optional telephone health counseling, improves body mass index (BMI) z score and lifestyle outcomes in adolescents who are overweight. METHODS: This study will be a single-blind randomized controlled trial (N=150) comparing a two-way text message intervention, with optional telephone health counseling, to usual care in adolescents (13-18 years old, inclusive) who are overweight (recruited from a pediatric weight management clinic and the broader community in Sydney, Australia). The intervention group will receive a six-month text message program, which consists of two-way, semipersonalized, lifestyle-focused text messages (four messages/week) in addition to usual care. The control group will be assigned to receive usual care. The study also includes a follow-up at 12-months. The primary outcome is a change in BMI z score at six months. Secondary outcomes are changes in waist-to-height ratio, diet, physical and sedentary activity levels, sleep quality, quality of life, self-esteem, self-efficacy, social support, and eating disorder and depression symptoms. Also, we will examine acceptability, utility, and engagement with the program through a study-specific process evaluation questionnaire, semi-structured telephone interviews, and an analysis of health counselor communication logs. The analyses will be performed by the intention-to-treat principle to assess differences between intervention and control groups. RESULTS: The study opened for recruitment in December 2019. Data collection is expected to be completed by December 2021, and the results for the primary outcome are expected to be published in early 2022. CONCLUSIONS: This study will test the effectiveness of an interactive two-way text message program compared to usual care in improving BMI z score and lifestyle outcomes in adolescents with overweight. This interactive, innovative, and scalable project also aims to inform future practice and community initiatives to promote obesity prevention behaviors for adolescents. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619000389101; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377158&isReview=true. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/16481.

'Not to Be Harsh but Try Less to Relate to 'the Teens' and You'll Relate to Them More': Co-Designing Obesity Prevention Text Messages with Adolescents.

Text messages remain a preferred way for adolescents to communicate, and recent evidence suggests adolescents would like access to digital healthcare options. However, there is limited evidence for text messages to engage adolescent populations in obesity prevention behaviors. We aimed to co-design a bank of text messages that are evidence-based, acceptable, and engaging for adolescents. An established iterative mixed methods process, consisting of three phases, was used to develop the text message program. The first bank of 145 text messages was drafted based on current evidence, behavior change techniques, and input from researchers and health professionals. A survey was then administered to adolescents and professionals for review of text message content, usefulness, understanding, and age-appropriateness. An adolescent research assistant collaborated with the research team on all three phases. Forty participants (25 adolescents and 15 professionals) reviewed the initial bank of 145 text messages. On average, all reviewers agreed the text messages were easy to understand (13.6/15) and useful (13.1/15). In total, 107 text messages were included in the final text message bank to support behavior change and prevent obesity. This study may guide other researchers or health professionals who are seeking to engage adolescents in the co-design of health promotion or intervention content. Effectiveness of the text message program will be tested in a randomized controlled trial.

HCN channels segregate stimulation-evoked movement responses in neocortex and allow for coordinated forelimb movements in rodents.

KEY POINTS: The present study tested whether HCN channels contribute to the organization of motor cortex and to skilled motor behaviour during a forelimb reaching task. Experimental reductions in HCN channel signalling increase the representation of complex multiple forelimb movements in motor cortex as assessed by intracortical microstimulation. Global HCN1KO mice exhibit reduced reaching accuracy and atypical movements during a single-pellet reaching task relative to wild-type controls. Acute pharmacological inhibition of HCN channels in forelimb motor cortex decreases reaching accuracy and increases atypical movements during forelimb reaching. ABSTRACT: The mechanisms by which distinct movements of a forelimb are generated from the same area of motor cortex have remained elusive. Here we examined a role for HCN channels, given their ability to alter synaptic integration, in the expression of forelimb movement responses during intracortical microstimulation (ICMS) and movements of the forelimb on a skilled reaching task. We used short-duration high-resolution ICMS to evoke forelimb movements following pharmacological (ZD7288), experimental (electrically induced cortical seizures) or genetic approaches that we confirmed with whole-cell patch clamp to substantially reduce Ih current. We observed significant increases in the number of multiple movement responses evoked at single sites in motor maps to all three experimental manipulations in rats or mice. Global HCN1 knockout mice were less successful and exhibited atypical movements on a skilled-motor learning task relative to wild-type controls. Furthermore, in reaching-proficient rats, reaching accuracy was reduced and forelimb movements were altered during infusion of ZD7288 within motor cortex. Thus, HCN channels play a critical role in the separation of overlapping movement responses and allow for successful reaching behaviours. These data provide a novel mechanism for the encoding of multiple movement responses within shared networks of motor cortex. This mechanism supports a viewpoint of primary motor cortex as a site of dynamic integration for behavioural output.