Assessing proprioception in children with upper motor neuron lesions: feasibility, validity, and reliability of the proprioception measurement tool.

Introduction: To investigate the feasibility, discriminative and convergent validity, and reliability of a lower limb sensor-based proprioception measure in children with upper motor neuron (UMN) lesions. Method: We assessed three proprioception modalities (joint movement, joint position, and dynamic position sense) of the lower limbs in 49 children with UMN lesions and 50 typically developing (TD) peers (5-19 years). Forty-three children with UMN lesion had a congenital and six an acquired brain lesion and 82% were able to walk without a walking aid. We evaluated the feasibility, compared the test results between children with UMN lesions and TD peers, and calculated Spearman correlations (rs) between the modalities. We quantified relative reliability with Intra-Class Correlation Coefficients (ICC) and absolute reliability with Smallest Detectable Changes (SDC). Results: Most children with UMN lesions (>88%) found the tests easy to perform. The children with UMN lesions had significantly (p < 0.001) lower proprioceptive function than the TD children. The correlation between the three proprioceptive modalities was moderate to high (0.50 ≤ rs ≤ 0.79). The relative reliability for test-retest and the inter-rater reliability was moderate to high (ICCs = 0.65-0.97), and SDC was between 2° and 15°. Discussion: The three tests are feasible, and discriminative and convergent validity and reliability were confirmed. Further studies should investigate the influence on motor function and performance in children with UMN lesions.

Intramyometrial and intravenous oxytocin compared to intravenous carbetocin for prevention of postpartum hemorrhage in elective cesarean section-A quasi-randomized controlled phase IV non-inferiority interventional trial.

INTRODUCTION: Our objective was to assess non-inferiority of the unique approach used in our institution of combined 10 IU IM (intramyometrial) and 10 IU IV (intravenous) oxytocin to carbetocin IV in preventing severe postpartum blood loss in elective cesarean sections. The design was a prospective controlled phase IV non-inferiority interventional trial. The setting was a tertiary center at University Hospital, Zurich, Switzerland. MATERIAL AND METHODS: The population consisted of 550 women undergoing elective cesarean section after 36 completed weeks of gestation at low risk for postpartum hemorrhage (PPH). Participants were assigned to either combined oxytocin regimen (10 IU IM and 10 IU IV) or carbetocin (100 µg IV). Non-inferiority for oxytocin for severe PPH was assessed with a 0.05 margin using the Newcombe-Wilson score method. The main outcome measures were severe postpartum blood loss defined as delta hemoglobin (∆Hb, Hb prepartum-Hb postpartum) ≥30 g/L. RESULTS: Non-inferiority of combined oxytocin (IM/IV) in preventing severe postpartum blood loss was not shown (17 women in the oxytocin group vs. 7 in the carbetocin group). The number needed to treat when using carbetocin was 28. The risk difference for ∆Hb ≥30 g/L was 0.04 (oxytocin 0.06 vs. 0.03), 95% confidence interval (CI) (0.00-0.08). No significant difference was observed for ∆Hb (median 12 [IQR 7.0-19.0] vs. 11 [5.0-17.0], p = 0.07), estimated blood loss (median 500 [IQR 400-600] vs. 500 [400-575], p = 0.38), or the PPH rate defined as estimated blood loss ≥1000 mL (12[4.5] vs. 5 [2.0], risk difference 0.03, 95% CI (-0.01 to 0.06), p = 0.16). More additional uterotonics were administered in the oxytocin group compared to the carbetocin group (15.2% vs. 5.9%, p = 0.001). Total case costs were non-significantly different in the oxytocin group (US $ 10 146 vs. 9621, mean difference 471.4, CI (-476.5 to 1419.3), p = 0.33). CONCLUSIONS: Combined (IM/IV) oxytocin is not non-inferior to carbetocin regarding severe postpartum blood loss defined as postpartum Hb decrease ≥30 g/L in elective cesarean sections. We recommend carbetocin for use in clinical practice for elective cesarean sections.

Are tactile function and body awareness of the foot related to motor outcomes in children with upper motor neuron lesions?

Introduction: Somatosensory function can be reduced in children with Upper Motor Neuron (UMN) lesions. Therefore, we investigated relationships between somatosensory functions of the foot and motor outcomes in children with UMN lesions. Method: In this cross-sectional study, we assessed the Tactile Threshold (TT) with monofilaments and body awareness with Tactile Localisation Tasks for spatial-related action (TLTaction) and structural-related perception (TLTperception) body representation at the foot sole. Furthermore, we assessed four motor outcomes: the Selective Control Assessment of the Lower Extremity (SCALE), the modified Timed Up and Go test (mTUG), the Gillette Functional Assessment Questionnaire (FAQ), and the Functional Mobility Scale (FMS). Spearman's correlations (ρ) were applied to assess relationships between the somatosensory function of the foot sole and the applied motor outcomes. Results: Thirty-five children with UMN lesions, on average 11.7 ± 3.4 years old, participated. TLTperception correlated significantly with all lower limb motor outcomes (|ρ|=0.36-0.57; p < 0.05), but TLTaction (|ρ|=0.00-0.27; p = 0.15-0.97, and TT did not (|ρ|=0.01-0.83; p = 0.73-0.94). TLTperception correlated strongly with the Gross Motor Function Classification System (|ρ|=0.62; p = 0.001) in children with cerebral palsy (n = 24). Discussion: Assessing structural body representation of the foot sole should be considered when addressing lower limb motor impairments, including gait, in children with upper motor neuron lesions. Our results suggest that the assessment of tactile function and spatial body representation may be less related to lower limb motor function.

Feasibility, Validity, and Reliability of Lower Limb Tactile and Body Awareness Assessments in Children With Upper Motor Neuron Lesions.

OBJECTIVE: To investigate the feasibility, discriminative and convergent validity, and inter-rater reliability of a lower limb tactile function and 2 body awareness assessments in children with upper motor neuron (UMN) lesions. DESIGN: Cross-sectional psychometric study. SETTING: Pediatric rehabilitation center. PARTICIPANTS: Forty individuals with UMN lesions (mean age 11.7 years, SD 3.4 years; 27 girls) and 40 neurotypically developing children of the same age participated (N=80). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We assessed the tactile threshold (TT) with monofilaments and body awareness with tactile localization tasks (TLTs) for structural (TLTaction) and spatial (TLTperception) body representation at the foot sole. We compared the test outcomes between children with UMN lesions and neurotypically developing children with the Wilcoxon signed-rank test. Furthermore, we quantified the relations between the 3 tests with Spearman correlations (rs) and the interrater reliability with quadratic weighted kappa (κQW). RESULTS: About 80% of the children with UMN lesions perceived the tests easy to perform. The children with UMN lesions had significantly reduced somatosensory function compared with the neurotypically developing children. For the more affected leg, we found good relations between the TT and the TLTaction (rs=0.71; P<.001) and between the 2 TLTs (rs=0.66; P<.001), and a fair relation between the TT and the TLTperception (rs=0.31; P=.06). The inter-rater reliability analyses for the sum scores showed almost perfect agreement for the TT (κQW more affected leg 0.86; less affected leg 0.81), substantial agreement for TLTaction (κQW more affected leg 0.76; less affected leg 0.63), and almost perfect agreement for TLTperception (κQW more affected leg 0.88; less affected leg 0.74). CONCLUSION: The 3 tests are feasible to assess lower limb somatosensory function in children with UMN lesions. Discriminative and convergent validity and reliability of the 3 tests were confirmed. Further studies should investigate responsiveness and association with motor function of these outcome measures.

SERO - A New Mobile App for Suicide Prevention.

Mobile apps indicate a positive effect on suicidal ideation and potential impact on suicide attempts. As part of the SERO suicide prevention program, Lucerne Psychiatry in collaboration with partner organizations aims to reduce suicides and suicide attempts in its service area, and to improve the self-management of suicidal individuals with a mobile app. The concept for such an app was developed in a trialog with health professionals, persons at risk and their relatives and its functions were compared to six known essential app-based strategies for suicide prevention, such as the development of a safety plan, access to support networks and tracking of mood. We present the concept and architecture for the app and discuss potential added value, which may result from the intertwining of the strategies within the app, which will be available in its first version in late 2022.

Digi-Care: Exploring the Impacts of Digitization on Nursing Work in Switzerland.

In this paper we present first findings of the Digi-Care project, a multidisciplinary, multi-stakeholder research project investigating the impacts of digitization on nursing work practices and in particular the transmission of patient care information within and beyond nursing work practices. We completed the initial data collection of the funded 3-year research project and report on a plethora of significant and critical IT-related events. Some of them can be attributed to usability issues.

Psychometric Properties of Lower Limb Somatosensory Function and Body Awareness Outcome Measures in Children with Upper Motor Neuron Lesions: A Systematic Review.

PURPOSE: A systematic review of the psychometric properties and feasibility of outcome measures assessing lower limb somatosensory function and body awareness in children with upper motor neuron lesion. METHODS: We followed the COnsensus-based Standards for the selection of health Measurement INstruments guidelines. Two raters independently judged the quality and risk of bias of each study. Data synthesis was performed, and aspects of feasibility were extracted. RESULTS: Twelve studies investigated eleven somatosensory function measures quantifying four modalities and eight body awareness measures quantifying two modalities. The best evidence synthesis was very low to low for somatosensory function modalities and low for body awareness modalities. Few feasibility aspects were reported (e.g., the percentage or minimum age of participants able to perform the tests). CONCLUSION: Current evidence on the psychometric characteristics of somatosensory function and body awareness outcome measures are relatively sparse. Further research on psychometric properties and practical application is needed.

DO YOUTHS WITH NEUROMOTOR DISORDER AND THEIR THERAPISTS PREFER A MIXED OR VIRTUAL REALITY HEAD-MOUNTED DISPLAY?

OBJECTIVE: To evaluate the usability of 2 head-mounted displays in youths undergoing neurorehabilitation; a mixed reality head-mounted display and a virtual reality head-mounted display. DESIGN: Observational cross-sectional study. PATIENTS: Thirteen youths (age range 7.8-16.5 years) with neuromotor disorder. METHODS: Youths wore a mixed reality or a virtual reality head-mounted display while being verbally guided through a scene with virtual objects. Differences between the 2 systems, regarding usability, user experience, and acceptability, were evaluated using standardized questions for the youths and their therapists. System preferences and symptoms of cybersickness were noted. RESULTS: Both head-mounted displays were easy to mount and adjust to the children's heads, but the mixed reality system was unstable in 40% of the youths. Participants stated that they could move naturally with both devices. Object appearance scored higher with the virtual reality system, while therapists rated youths' movement execution and needed additional support in favour of the mixed reality system. Most youths preferred the virtual reality device, mainly due to the more distinct appearance of objects and the objects' richer colours. Therapists' preferences were balanced. Two children reported minimal signs of cybersickness. CONCLUSION: Youths and therapists accepted both systems well, with advantages regarding usability, user experience, and preference for the virtual reality, and acceptability for the mixed reality head-mounted display.

Decentralized Digital Health Services Caught Between the Pressure for Innovation and the Burden of Regulations.

Multiple challenges await third-party digital health services when trying to enter the health market. Prominent examples of such services are clinical decision support systems provided as external software. Uncertainty about their challenges, technical as well as legal, pose serious hurdles for many innovations to be adopted early on. There are many options and trade-offs to provide digital healthcare solutions as a third-party service. This paper discusses them by referring to a pharmacogenetic decision support service. By providing best-practices, scenario descriptions and templates designed for third-party services with respect to legal and technical issues, obstacles and uncertainties can be reduced, which will have an impact on better diagnoses and treatments in the healthcare system.

Legal Challenges for IT Service Providers in Pharmacogenomics.

IT providers offering services based on genetic data face serious challenges in managing health data in compliance with the General Data Protection Regulation (GDPR). Based on a literature research and our experiences, an overview of GDPR compliant processing of sensitive data is given. The GDPR requirements for processing sensitive data were specified for a use case concerning a service provider of a pharmacogenomic decision support system. Start-ups who want to enter into the health market also have to comply with the Medical Device Regulation (MDR). The associated efforts for legal compliance constitute an impediment for many start-ups. We created a comprehensive overview, which aligned the requirements of the GDPR with the life-cycle of a medical device. This overview shall help start-ups to grasp and overcome the regulatory hurdles faster.

Information Capturing in Pre-Hospital Emergency Medical Settings (EMS).

Emergency medical situations are characterized by high physical, cognitive and mental demands on the paramedics on the ground. Studies suggest that crucial information such as treatments administered to patients is often documented retrospectively, during patient transport or once a patient is handed over to an emergency department. Information access may also be surprisingly difficult (e.g. patient medical history). In this paper, we focus on supporting in situ information capturing and report on a realistic laboratory-based study involving experienced paramedics that we used to explore the specific requirements and constraints of supporting in situ information capturing. Specifically, we focused on ways to use audio and visual data capture methods and how they need to be designed to better support paramedics without interfering with their work. We then use the resulting information centric perspective to argue for a roadmap towards smart emergency medical services.

No Effect of Transcranial Direct Current Stimulation of the Auditory Cortex on Auditory-Evoked Potentials.

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique to change cortical excitability. Its effects are shown for cognitive processing, and behavior in the motor and perceptual domains. However, evidence of tDCS effects in the perceptual domain particularly for auditory processing is rare. Therefore, and in the context of disturbances in auditory processing in psychiatric populations, e.g., in patients with auditory verbal hallucinations, we aimed to investigate the potential modulatory effect of tDCS on the excitability of left posterior temporal cortex in detail. We included 24 healthy participants in a crossover design, applying sham and anodal stimulation in two measurement sessions 1 week apart. Electroencephalography (EEG) was recorded while participants listened to tones before, during, and after stimulation. Amplitudes and latencies of P50, N100, and P200 auditory-evoked potentials (AEP) were compared between anodal and sham stimulation, and between time points before, during, and after tDCS. In contrast to previous studies, results demonstrate no significant differences between stimulation types or time points for any of the investigated AEP amplitudes or latencies. Furthermore, a topographical analysis did not show any topographical differences during peak time periods of the investigated AEP for stimulation types and time points besides a habituation effect. Thus, our results suggest that tDCS modulation of excitability of the left posterior temporal cortex, targeting the auditory cortex, does not have any effect on AEP. This is particularly interesting in the context of tDCS as a potential treatment for changed electrophysiological parameters and symptoms of psychiatric diseases, e.g., lower N100 or auditory verbal hallucinations in schizophrenia.

Thirst-Dependent Activity of the Insular Cortex Reflects its Emotion-Related Subdivision: A Cerebral Blood Flow Study.

Recent studies investigating neural correlates of human thirst have identified various subcortical and telencephalic brain areas. The experience of thirst represents a homeostatic emotion and a state that slowly evolves over time. Therefore, the present study aims at systematically examining cerebral perfusion during the parametric progression of thirst. We measured subjective thirst ratings, serum parameters and cerebral blood flow in 20 healthy subjects across four different thirst stages: intense thirst, moderate thirst, subjective satiation and physiological satiation. Imaging data revealed dehydration-related perfusion differences in previously identified brain areas, such as the anterior cingulate cortex, the middle temporal gyrus and the insular cortex. However, significant differences across all four thirst stages (including the moderate thirst level), were exclusively found in the posterior insular cortex. The subjective thirst ratings over the different thirst stages, however, were associated with perfusion differences in the right anterior insula. These findings add to our understanding of the insular cortex as a key player in human thirst - both on the level of physiological dehydration and the level of the subjective thirst experience.

Rivalry of homeostatic and sensory-evoked emotions: Dehydration attenuates olfactory disgust and its neural correlates.

Neural correlates have been described for emotions evoked by states of homeostatic imbalance (e.g. thirst, hunger, and breathlessness) and for emotions induced by external sensory stimulation (such as fear and disgust). However, the neurobiological mechanisms of their interaction, when they are experienced simultaneously, are still unknown. We investigated the interaction on the neurobiological and the perceptional level using subjective ratings, serum parameters, and functional magnetic resonance imaging (fMRI) in a situation of emotional rivalry, when both a homeostatic and a sensory-evoked emotion were experienced at the same time. Twenty highly dehydrated male subjects rated a disgusting odor as significantly less repulsive when they were thirsty. On the neurobiological level, we found that this reduction in subjective disgust during thirst was accompanied by a significantly reduced neural activity in the insular cortex, a brain area known to be considerably involved in processing of disgust. Furthermore, during the experience of disgust in the satiated condition, we observed a significant functional connectivity between brain areas responding to the disgusting odor, which was absent during the stimulation in the thirsty condition. These results suggest interference of conflicting emotions: an acute homeostatic imbalance can attenuate the experience of another emotion evoked by the sensory perception of a potentially harmful external agent. This finding offers novel insights with regard to the behavioral relevance of biologically different types of emotions, indicating that some types of emotions are more imperative for behavior than others. As a general principle, this modulatory effect during the conflict of homeostatic and sensory-evoked emotions may function to safeguard survival.

First clinical trial of tomographic neurofeedback in attention-deficit/hyperactivity disorder: evaluation of voluntary cortical control.

OBJECTIVE: Tomographic neurofeedback (tNF) training was evaluated as a treatment for attention-deficit/hyperactivity disorder (ADHD). To investigate the specificity of the treatment, outcomes were related to learning during tNF. METHODS: Thirteen children with ADHD trained over 36 lessons to regulate their brain activity in the anterior cingulate cortex (ACC) using both theta-beta frequency and slow cortical potential (SCP) protocols. Thirty-channel electroencephalogram (EEG) was used to calculate low-resolution electromagnetic tNF and to assess the course of the training. Pre- and post-assessments included questionnaires, tests of attention, EEG recordings, and cognitive event-related potentials. RESULTS: Despite behavioural improvement and EEG artefact reduction, only partial learning was found for ACC parameters. Successful regulation was observed only for a simple feedback variant of SCP training, but with ACC-specific effects. Over training, resting EEG analysis indicated individual frequency normalisation rather than unidirectional changes across subjects. CONCLUSIONS: These results indicate that clinical improvement after ACC-tNF training can parallel artefact reduction without substantial learning of improved cortical control. However, individual normalisation of resting EEG activity and partial SCP control proved possible in this specific brain region affected in ADHD using tNF. Further studies are needed to clarify which critical aspects mediate region-specific learning in neurofeedback. SIGNIFICANCE: This study is the first to systematically investigate tNF in children suffering from a psychiatric disorder.