Usability of a telehealth-nurse supported home-based walking training for peripheral arterial disease - The Keep Pace! pilot study.

Background: Guidelines recommend walking trainings for peripheral arterial disease (PAD) management. Supervised walking training is superior to walking advise to improve the walking distance. Telehealth service with nurse support may close this gap. Patients and methods: This study introduces a telehealth service, "Keep pace!", which has been developed for patients with symptomatic PAD (Fontaine stage IIa and IIb), enabling a structured home-based walking training while monitoring progress via an app collecting unblinded account of steps and walking distance in self-paced 6-minute-walking-tests by geolocation tracking to enhance intrinsic motivation. Supervision by nurses via telephone calls was provided for 8 weeks, followed by 4 weeks of independent walking training. Patient satisfaction, walking distance and health-related quality of life were assessed. Results: 19 patients completed the study. The analysis revealed an overall high satisfaction with the telehealth service (95.4%), including system quality (95.1%), information quality (94.4%), service quality (95.6%), intention to use (92.8%), general satisfaction with the program (98.4%) and health benefits (95.8%). 78.9% asserted that the telehealth service lacking nurse calls would be less efficacious. Pain-free walking distance (76.3±36.8m to 188.4±81.2m, +112.2%, p<0.001) as well as total distance in 6-minute-walking test (308.8±82.6m to 425.9±107.1m, +117.2%, p<0.001) improved significantly. The telehealth service significantly reduced discomfort by better pain control (+15.5%, p=0.015) and social participation (+10.5%, p=0.042). Conclusions: In conclusion, patients were highly satisfied with the telehealth service. The physical well-being of the PAD patients improved significantly post vs. prior the telehealth program.

Development of a Web Exercise Video for Nursing Intervention in Outpatients With Low Back Pain.

The purpose of this study was to develop a Web exercise video for nursing intervention among outpatients with low back pain by applying the analysis-design-development-implementation-evaluation model to promote continuous exercise. During the analysis phase, we assessed the needs for the lower back exercise video as well as details of the current situations of the participants. Additionally, we investigated the intervention methods that the medical practitioners thought would be helpful in promoting lower back exercise. After the design and development phase, a lower back exercise video of 5 minutes 46 seconds was developed. The main contents in the video were the stretching and flexing exercises of the spine and muscles, including "One knee to chest," "Both knees to chest," "Hip bridge," "Prone position to erect spine," "Kneeling back extension," "Kneeling, opposite arm and leg raised," and "Sitting rotation stretch." For the implementation and analysis phase, a pilot test was done. The lower back exercise video was posted on the Web site, and participants watched the video and exercised individually. Participants reported that they were able to use the Web video whenever required, and after following the video a few times, they grew accustomed to the practice and were able to perform it repeatedly to help strengthen the lower back. In the future, experimental research is needed to confirm the effectiveness of exercise using Web video.

Physical activity levels in adults and older adults 3-4 years after pedometer-based walking interventions: Long-term follow-up of participants from two randomised controlled trials in UK primary care.

BACKGROUND: Physical inactivity is an important cause of noncommunicable diseases. Interventions can increase short-term physical activity (PA), but health benefits require maintenance. Few interventions have evaluated PA objectively beyond 12 months. We followed up two pedometer interventions with positive 12-month effects to examine objective PA levels at 3-4 years. METHODS AND FINDINGS: Long-term follow-up of two completed trials: Pedometer And Consultation Evaluation-UP (PACE-UP) 3-arm (postal, nurse support, control) at 3 years and Pedometer Accelerometer Consultation Evaluation-Lift (PACE-Lift) 2-arm (nurse support, control) at 4 years post-baseline. Randomly selected patients from 10 United Kingdom primary care practices were recruited (PACE-UP: 45-75 years, PACE-Lift: 60-75 years). Intervention arms received 12-week walking programmes (pedometer, handbooks, PA diaries) postally (PACE-UP) or with nurse support (PACE-UP, PACE-Lift). Main outcomes were changes in 7-day accelerometer average daily step counts and weekly time in moderate-to-vigorous PA (MVPA) in ≥10-minute bouts in intervention versus control groups, between baseline and 3 years (PACE-UP) and 4 years (PACE-Lift). PACE-UP 3-year follow-up was 67% (681/1,023) (mean age: 59, 64% female), and PACE-Lift 4-year follow-up was 76% (225/298) (mean age: 67, 53% female). PACE-UP 3-year intervention versus control comparisons were as follows: additional steps/day postal +627 (95% CI: 198-1,056), p = 0.004, nurse +670 (95% CI: 237-1,102), p = 0.002; total weekly MVPA in bouts (minutes/week) postal +28 (95% CI: 7-49), p = 0.009, nurse +24 (95% CI: 3-45), p = 0.03. PACE-Lift 4-year intervention versus control comparisons were: +407 (95% CI: -177-992), p = 0.17 steps/day, and +32 (95% CI: 5-60), p = 0.02 minutes/week MVPA in bouts. Neither trial showed sedentary or wear-time differences. Main study limitation was incomplete follow-up; however, results were robust to missing data sensitivity analyses. CONCLUSIONS: Intervention participants followed up from both trials demonstrated higher levels of objectively measured PA at 3-4 years than controls, similar to previously reported 12-month trial effects. Pedometer interventions, delivered by post or with nurse support, can help address the public health physical inactivity challenge. TRIAL REGISTRATIONS: PACE-UP isrctn.com ISRCTN98538934; PACE-Lift isrctn.com ISRCTN42122561.

Management of behavioural and psychological symptoms of dementia by an aroma-massage with acupressure treatment protocol: A randomised clinical trial.

AIMS AND OBJECTIVES: This study evaluates the clinical effectiveness of a multicomponent aroma-massage with an acupressure treatment protocol and compared it to cognitive training for the management of behavioural and psychological symptoms of dementia. BACKGROUND: Pharmacological interventions have been unsatisfactory in managing behavioural and psychological symptoms of dementia; thus, complementary and alternative medicine has been extensively researched to identify an adjunct safe and cost-effective intervention. DESIGN: This randomised clinical trial utilised a three-arm parallel group design. Cognitive training was used as a conventional intervention to manage behavioural and psychological symptoms of dementia, whereas exercise was considered "treatment as usual" in this study; both were used as comparisons with the experimental protocol. There were three treatment groups: Group 1: aroma-massage with acupressure + exercise, Group 2: cognitive training + exercise and Group 3: aroma-massage with acupressure + cognitive training. METHOD: Sixty older adults were recruited and randomly assigned to the three groups (20 each). Using the 29-item Chinese Version of the Cohen-Mansfield Agitation Inventory, Neuropsychiatric Inventory, Mini-mental State Examination and Barthel Index-20, the outcome measures were assessed at preintervention, postintervention and the 3-month follow-up to assess behaviour, Activities of Daily Living, cognition, and behavioural and psychological symptoms of dementia severity and distress. Multiple comparisons performed through repeated measures were analysed to detect between-group differences and within-subject differences, as well as the interaction effects between groups and times. RESULTS: The Group 1 and 3 participants showed a significant reduction in the severity and distress caused by behavioural and psychological symptoms of dementia, whereas Group 2 did not demonstrate similar effects. CONCLUSIONS: This clinical study suggests that aroma-massage with acupressure is as effective as cognitive training and can enhance cognitive training in reducing the severity and distress of behavioural and psychological symptoms of dementia. RELEVANCE TO CLINICAL PRACTICE: Aroma-massage with acupressure may serve as an adjunct therapy to reduce behavioural and psychological symptoms of dementia. This therapy is safe, cost-effective and can be implemented by caregivers and family members who are not professionally trained.

The effects of a nurse-supervised home exercise programme on improving patients' perceptions of the benefits and barriers to exercise: A randomised controlled trial.

AIMS AND OBJECTIVES: To explore the effects of a home exercise programme on patients' perceptions of the barriers and benefits to exercise and adherence to the programme. BACKGROUND: Great efforts have been made to encourage dialysis patients to participate in rehabilitation regimens. The promotion of exercise in this population is still limited. DESIGN: This was a post hoc analysis of a randomised, two-group parallel study. METHODS: A total of 113 adult patients recruited from the haemodialysis units were randomised into two groups on a 1:1 ratio. Both groups received in-centre group exercise training weekly for 6 weeks. The intervention group patients were provided with an additional individualised nurse-led home exercise prescription and behavioural support for 12 weeks. The patients' perceptions of the barriers and benefits to exercise, adherence to the home exercise prescription and their exercise level at weeks 6 and 12 were evaluated. RESULTS: There was a significant between-group difference in the score on patient perceptions of the barriers and benefits to exercise, with the intervention group reporting a greater reduction in perceived barriers to exercise. Significant group differences were noted in exercise level upon the completion of the programme, with the intervention group reporting higher such levels. The average adherence rate to the negotiated exercise plans was 78.9%. The intervention group of patients did better at meeting or exceeding the minimum exercise goal than did the control group. CONCLUSION: Home exercise prescriptions and behavioural support provided by trained nurses are effective at helping patients to remove barriers to engaging in exercise training. RELEVANCE TO CLINICAL PRACTICE: Physical exercise in a clinical arena should not be considered the exclusive domain of physical therapists; the team could collaborate with nurses to play a core role in making physical exercise for patients an essential practice of care in a multidisciplinary team.

Home-Based Exercise in Older Adults Recently Discharged From the Hospital for Cardiovascular Disease in China: Randomized Clinical Trial.

BACKGROUND: Exercise is important for fitness and recovery of older adults after hospitalization for treatment of cardiovascular disease. Home-based, nurse-led exercise programs may be beneficial. OBJECTIVE: The aim of this study was to test the effects of a low-intensity, home-based exercise protocol led by an advanced practice nurse on health-related quality of life (HRQOL), physical fitness, and left ventricular ejection fraction (LVEF) in older adults after hospital discharge with a cardiovascular disease diagnosis. METHODS: The study was randomized and single blinded. Seventy-seven older adults (≥75 years old, mean = 80.68 years old) were included; 32 subjects in the intervention and 29 in the control group completed the study. The low-intensity, home-based exercise protocol is composed of 14-type joint exercises and walking for 12 weeks. The main outcome measures were assessments on the Medical Outcomes Study Short-Form-36, the Senior Fitness Test, and LVEF at baseline and 12 weeks after hospital discharge. RESULTS: After 12 weeks, the intervention group showed significant improvements in HRQOL (physical functioning, role-physical, bodily pain, and vitality; p < .05) as well as on the Senior Fitness Test (chair stands, arm curls, Timed Up and Go, and 6-minute walk distance; p < .05); there was no significant improvement in LVEF (p = .56). CONCLUSIONS: The low-intensity, home-based exercise led by an advanced practice nurse was effective in improving HRQOL and physical fitness. Adherence was high, and there were no adverse events related to exercise.

Psychological responses and adherence to exercise in heart failure.

PURPOSE: The purpose of this study was to describe psychological effects and exercise adherence during a multicomponent exercise training intervention. METHODS: A sample of 42 patients with heart failure were randomized into an exercise (INV) group (n = 22) and an attention control (AC) group (n = 20). The exercise protocol included two 12-week phases, a structured phase and a self-managed phase. The psychological responses assessed were mood states and exercise self-efficacy. To meet the second purpose of the study, the exercise group was dichotomized based on the number of sessions completed to create two adherence subgroups. FINDINGS: Results indicate self-efficacy improved for the INV group and was maintained during the self-management phase. The adherence subgroups demonstrated different patterns for weekly exercise. Depression and confusion scores improved for the high-adherence group in contrast to worsening for the low-adherence group. CONCLUSIONS: Results suggest a need for further study of the psychological responses of exercise adherence for patients with heart failure. CLINICAL RELEVANCE: The study indicates the importance of continuous assessment of exercise participation and longer term adherence support for patients with heart failure.

The role of the nurse in pulmonary rehabilitation.

Pulmonary rehabilitation can help patients with chronic obstructive pulmonary disease improve their exercise tolerance and quality of life. Care packages can be devised and managed by respiratory nurses.

Wii-hab for pre-frail older adults.

PURPOSE: To examine the effectiveness of a novel intervention aimed at decreasing indices related to frailty through systematic, Progressive Functional Rehabilitation (PFR). METHODS: Pre-frail volunteers were recruited to participate in a 15 week exercise intervention or control group. Those who met study criteria and consented were randomized into one of three groups: control, seated exercise, or Wii(®) -fit. Test measures were completed before and after the 15 week intervention period on all participants. Measures included: Senior Fitness Test, Body Weight, Balance Efficacy Scale, CHAMPS, Late-Life Function and Disability Index, MOS SF-36. Attendance was also recorded. RESULTS: There were improvements on several of the measures included in the Senior Fitness Test including chair stands, arm curls, step 2, six minute walk, sit and reach, and the timed up and go. A few participants did lose weight. All of the differences reflected improved physical functional status in the seated exercise or Wii-fit groups compared with the control group. DISCUSSION: Increased physical activity was beneficial for all who participated. There were improvements in physical performance scores on several of the measures on the senior fitness test in both the seated exercise and Wii-fit groups. Participants in the Wii-fit group also showed improvement in their reported caloric expenditure and balance confidence. CONCLUSION: This pilot study suggests a rehabilitation effect that was similar to the effect of community based senior fitness classes. A home video game console system with weight vest could be an effective alternative for pre-frail senior adults to group exercise classes.

Stress incontinence and pelvic floor exercises in pregnancy.

This literature review is a critique of the research looking at the impact of pelvic floor exercises during pregnancy on urinary stress incontinence in postnatal women. Seven studies were selected for review following a database search on the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Medline and the British Nursing Index (BNI). The research produced mixed findings. Four of the seven studies demonstrated a significant improvement in urinary stress incontinence in postnatal women following pelvic floor muscle exercise during pregnancy. However, the studies that spanned a longer time period found no long-term effectiveness. More research is needed for a more conclusive picture as to whether antenatal pelvic floor exercises can improve stress incontinence in the postpartum period.

The Impact of a Nurse-Led Exercise Activity for Cancer-Related Fatigue in Patients With Leukemia.

Many patients with leukemia experience cancer-related fatigue (CRF). However, when patients are admitted for treatment with chemotherapy, clinicians often overlook CRF and interventions that can help to manage it. The purpose of this four-week intervention was to determine whether a nurse-led exercise activity would reduce CRF and increase physical activity compared to current practice. The results suggest that nurse-led exercise programs can immediately decrease CRF and increase activity in admitted patients with leukemia receiving chemotherapy. Including patients in nurse-led exercise activities can support active participation in their own care during and after hospitalization.

Effectiveness of Web-based versus face-to-face delivery of education in prescription of falls-prevention exercise to health professionals: randomized trial.

BACKGROUND: Exercise is an effective intervention for the prevention of falls; however, some forms of exercises have been shown to be more effective than others. There is a need to identify effective and efficient methods for training health professionals in exercise prescription for falls prevention. OBJECTIVE: The objective of our study was to compare two approaches for training clinicians in prescribing exercise to prevent falls. METHODS: This study was a head-to-head randomized trial design. Participants were physiotherapists, occupational therapists, nurses, and exercise physiologists working in Victoria, Australia. Participants randomly assigned to one group received face-to-face traditional education using a 1-day seminar format with additional video and written support material. The other participants received Web-based delivery of the equivalent educational material over a 4-week period with remote tutor facilitation. Outcomes were measured across levels 1 to 3 of Kirkpatrick's hierarchy of educational outcomes, including attendance, adherence, satisfaction, knowledge, and self-reported change in practice. RESULTS: Of the 166 participants initially recruited, there was gradual attrition from randomization to participation in the trial (n = 67 Web-based, n = 68 face-to-face), to completion of the educational content (n = 44 Web-based, n = 50 face-to-face), to completion of the posteducation examinations (n = 43 Web-based, n = 49 face-to-face). Participant satisfaction was not significantly different between the intervention groups: mean (SD) satisfaction with content and relevance of course material was 25.73 (5.14) in the Web-based and 26.11 (5.41) in the face-to-face group; linear regression P = .75; and mean (SD) satisfaction with course facilitation and support was 11.61 (2.00) in the Web-based and 12.08 (1.54) in the face-to-face group; linear regression P = .25. Knowledge test results were comparable between the Web-based and face-to-face groups: median (interquartile range [IQR]) for the Web-based group was 90.00 (70.89-90.67) and for the face-to-face group was 80.56 (70.67-90.00); rank sum P = .07. The median (IQR) scores for the exercise assignment were also comparable: Web-based, 78.6 (68.5-85.1), and face-to-face, 78.6 (70.8-86.9); rank sum P = .61. No significant difference was identified in Kirkpatrick's hierarchy domain change in practice: mean (SD) Web-based, 21.75 (4.40), and face-to-face, 21.88 (3.24); linear regression P = .89. CONCLUSION: Web-based and face-to-face approaches to the delivery of education to clinicians on the subject of exercise prescription for falls prevention produced equivalent results in all of the outcome domains. Practical considerations should arguably drive choice of delivery method, which may favor Web-based provision for its ability to overcome access issues for health professionals in regional and remote settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number: ACTRN12610000135011; http://www.anzctr.org.au/ACTRN12610000135011.aspx (Archived by WebCite at http://www.webcitation.org/63MicDjPV).

Cost-effectiveness of exercise on prescription with telephone support among women in general practice over 2 years.

AIM: To assess the cost-effectiveness of exercise on prescription with ongoing support in general practice. METHODS: Prospective cost-effectiveness study undertaken as part of the 2-year Women's lifestyle study randomised controlled trial involving 1089 'less-active' women aged 40-74. The 'enhanced Green Prescription' intervention included written exercise prescription and brief advice from a primary care nurse, face-to-face follow-up at 6 months, and 9 months of telephone support. The primary outcome was incremental cost of moving one 'less-active' person into the 'active' category over 24 months. Direct costs of programme delivery were recorded. Other (indirect) costs covered in the analyses included participant costs of exercise, costs of primary and secondary healthcare utilisation, allied health therapies and time off work (lost productivity). Cost-effectiveness ratios were calculated with and without including indirect costs. RESULTS: Follow-up rates were 93% at 12 months and 89% at 24 months. Significant improvements in physical activity were found at 12 and 24 months (p<0.01). The exercise programme cost was New Zealand dollars (NZ$) 93.68 (€45.90) per participant. There was no significant difference in indirect costs over the course of the trial between the two groups (rate ratios: 0.99 (95% CI 0.81 to 1.2) at 12 months and 1.01 (95% CI 0.83 to 1.23) at 24 months, p=0.9). Cost-effectiveness ratios using programme costs were NZ$687 (€331) per person made 'active' and sustained at 12 months and NZ$1407 (€678) per person made 'active' and sustained at 24 months. CONCLUSIONS: This nurse-delivered programme with ongoing support is very cost-effective and compares favourably with other primary care and community-based physical activity interventions internationally.

Incentives and barriers to lifestyle interventions for people with severe mental illness: a narrative synthesis of quantitative, qualitative and mixed methods studies.

AIM: To examine the evidence for incentives and barriers to lifestyle interventions for people with severe mental illness. BACKGROUND: People with severe mental illnesses, particularly those with schizophrenia, have poorer physical health than the general population with increased mortality and morbidity rates. Social and lifestyle factors are reported to contribute to this health inequality, though antipsychotic therapy poses additional risk to long-term physical health. Many behavioural lifestyle interventions including smoking cessation, exercise programmes and weight-management programmes have been delivered to this population with promising results. Surprisingly little attention has been given to factors that may facilitate or prevent engagement with these interventions in this population. DATA SOURCES: Eight electronic databases were searched [1985-March 2009] along with the Cochrane Library and Google Scholar. Electronic 'hand' searches of key journals and explosion of references were undertaken. REVIEW METHODS: A narrative synthesis of qualitative, quantitative and mixed-methods studies was undertaken. RESULTS: No studies were identified that specifically explored the incentives and barriers to participation in lifestyle intervention for this population. Existing literature report some possible incentives and barriers including: illness symptoms, treatment effects, lack of support and negative staff attitudes as possible barriers; and symptom reduction, peer and staff support, knowledge, personal attributes and participation of staff as possible incentives. CONCLUSIONS: Healthcare professionals, in particular nurses, should consider issues that may hinder or encourage individuals in this clinical group to participate in lifestyle interventions if the full benefits are to be achieved. Further research is needed to explore possible incentives and barriers from the service users' own perspective.

Assisted Walking Program on Walking Ability in In-Hospital Geriatric Patients: A Randomized Trial.

OBJECTIVES: The main aim of this study was to evaluate if an individualized assisted walking program (IAWP) for hospitalized older patients could improve walking ability compared with usual geriatric care and rehabilitation. DESIGN: A randomized controlled trial with an active control group, open labeled with parallel assignment was conducted between October 2018 and January 2020. SETTING: Geriatric ward. PARTICIPANTS: A total of 387 hospitalized patients (≥65 years) were randomly assigned to an intervention or control (usual-care) group. INTERVENTION: The control group received usual hospital care. The intervention group received also an IAWP. MEASUREMENTS: The primary endpoint was change in walking ability from hospital admission (considering both current and pre-admission status) to discharge, as assessed with the Braden Activity subscale measures. The secondary endpoint was the occurrence of in-hospital adverse events, such as complications of mobility, pressure ulcers, falls, pain and mortality, and the length of hospital stay. Intention-to-treat and per-protocol analyses were performed. RESULTS: Baseline characteristics were similar between intervention and control groups. The intervention group, relative to the control group, had significantly improved walking ability at discharge (P < .001). There were no statistically significant differences between the groups in terms of in-hospital adverse events. No adverse effects were detected. CONCLUSION: In in-hospital patients aged 65 and older, an IAWP improves walking ability at discharge.

Effectiveness of Rehabilitation Nursing versus Usual Therapist-Led Treatment in Patients with Acute Ischemic Stroke: A Randomized Non-Inferiority Trial.

PURPOSE: To determine the effectiveness of rehabilitation nursing program interventions in patients with acute ischemic stroke. PATIENTS AND METHODS: An assessment-blinded randomized controlled trial was conducted at a tertiary referral hospital in China. Eligible patients were stratified according to their weighted corticospinal tract lesion load and then randomly assigned to an experimental group (n = 121) or a control group (n = 103). The experimental group received rehabilitation nursing from well-trained, qualified nurses (30 minutes per session, two sessions per day for seven consecutive days). The control group received therapist-led rehabilitation with the same timing and frequency. Comparative analysis of the primary outcomes was performed to determine non-inferiority with a predetermined non-inferiority margin. The primary outcomes were the Motor Assessment Scale, Fugl-Meyer Assessment, and the Action Research Arm Test assessed at baseline and after seven days of treatment. The secondary outcomes were the modified Barthel Index, the National Institutes of Health Stroke Scale, and the modified Rankin Scale, evaluated before and after the intervention and at 4 and 12 weeks of follow-up. RESULTS: Two hundred participants completed the trial. In both groups, all outcomes improved significantly after seven days and at follow-ups. The rehabilitation nursing program was non-inferior to therapist-led treatment with lower 95% confidence limits beyond the margins for primary outcomes (P < 0.001). CONCLUSION: Both treatments had comparable effects; however, no definite conclusion could be drawn. Adequately powered studies are required.

Design of Exercise Nursing Program for Pelvic Floor Muscle Function Recovery at 42 Days Postpartum.

In order to explore the effect of exercise nursing intervention for pelvic floor muscle function recovery at 42 days postpartum, this paper conducts experimental research through controlled experiments, combines statistical methods to carry out digital processing, and sets a single variable of nursing intervention to provide a basis for experimental control, and statistical test results are used for effect evaluation. It has been discovered via experimental study that pelvic floor muscle function recovery exercise training for normal delivery women may enhance the mother's compliance with the pelvic floor muscle function exercise. Moreover, it can reduce the occurrence of urinary incontinence and pelvic organ prolapse, improve the postpartum pelvic floor function of postpartum women, improve the quality of life, and have a significant recovery effect. In addition, it is a simple, noninvasive, and highly safe continuation nursing measure, which can effectively improve the quality of obstetric care and has strong clinical use value.

Exercise and the cardiac patient-success is just steps away.

Physical activity is an essential lifestyle intervention for the patient with existing cardiovascular disease. National guidelines describe the importance of and define the minimal doses of daily physical activity including walking 10,000 steps a day (equivalent to 5 miles) or performing 30 minutes of moderate-intensity aerobic activity most days of the week in 10- to 15-minute bouts. However, cardiac patients are often fearful that increasing physical activity would be detrimental and cause chest pain or myocardial infarction. Research has shown that cardiac patients can perform a walking program safely. Patient education; development of a realistic plan; measurement of the frequency, intensity, duration, and type of physical activity attained; and consistent follow-up over time are key strategies. This article provides important information for healthcare providers to plan a safe and efficacious walking plan to increase physical activity in the cardiac patient.