Perfusion tomography in early follow-up of acute traumatic subdural hematoma: a case series.

Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.

Tuning electrochemically driven surface transformation in atomically flat LaNiO3 thin films for enhanced water electrolysis.

Structure-activity relationships built on descriptors of bulk and bulk-terminated surfaces are the basis for the rational design of electrocatalysts. However, electrochemically driven surface transformations complicate the identification of such descriptors. Here we demonstrate how the as-prepared surface composition of (001)-terminated LaNiO3 epitaxial thin films dictates the surface transformation and the electrocatalytic activity for the oxygen evolution reaction. Specifically, the Ni termination (in the as-prepared state) is considerably more active than the La termination, with overpotential differences of up to 150 mV. A combined electrochemical, spectroscopic and density-functional theory investigation suggests that this activity trend originates from a thermodynamically stable, disordered NiO2 surface layer that forms during the operation of Ni-terminated surfaces, which is kinetically inaccessible when starting with a La termination. Our work thus demonstrates the tunability of surface transformation pathways by modifying a single atomic layer at the surface and that active surface phases only develop for select as-synthesized surface terminations.

A Novel Functional Electrical Stimulation-Induced Cycling Controller Using Reinforcement Learning to Optimize Online Muscle Activation Pattern.

This study introduces a novel controller based on a Reinforcement Learning (RL) algorithm for real-time adaptation of the stimulation pattern during FES-cycling. Core to our approach is the introduction of an RL agent that interacts with the cycling environment and learns through trial and error how to modulate the electrical charge applied to the stimulated muscle groups according to a predefined policy and while tracking a reference cadence. Instead of a static stimulation pattern to be modified by a control law, we hypothesized that a non-stationary baseline set of parameters would better adjust the amount of injected electrical charge to the time-varying characteristics of the musculature. Overground FES-assisted cycling sessions were performed by a subject with spinal cord injury (SCI AIS-A, T8). For tracking a predefined pedaling cadence, two closed-loop control laws were simultaneously used to modulate the pulse intensity of the stimulation channels responsible for evoking the muscle contractions. First, a Proportional-Integral (PI) controller was used to control the current amplitude of the stimulation channels over an initial parameter setting with predefined pulse amplitude, width and fixed frequency parameters. In parallel, an RL algorithm with a decayed-epsilon-greedy strategy was implemented to randomly explore nine different variations of pulse amplitude and width parameters over the same stimulation setting, aiming to adjust the injected electrical charge according to a predefined policy. The performance of this global control strategy was evaluated in two different RL settings and explored in two different cycling scenarios. The participant was able to pedal overground for distances over 3.5 km, and the results evidenced the RL agent learned to modify the stimulation pattern according to the predefined policy and was simultaneously able to track a predefined pedaling cadence. Despite the simplicity of our approach and the existence of more sophisticated RL algorithms, our method can be used to reduce the time needed to define stimulation patterns. Our results suggest interesting research possibilities to be explored in the future to improve cycling performance since more efficient stimulation cost dynamics can be explored and implemented for the agent to learn.

Development of a High-Power Capacity Open Source Electrical Stimulation System to Enhance Research into FES-Assisted Devices: Validation of FES Cycling.

Since the first Cybathlon 2016, when twelve teams competed in the FES bike race, we have witnessed a global effort towards the development of stimulation and control strategies to improve FES-assisted devices, particularly for cycling, as a means to practice a recreational physical activity. As a result, a set of technical notes and research paved the way for many other studies and the potential behind FES-assisted cycling has been consolidated. However, engineering research needs instrumented devices to support novel developments and enable precise assessment. Therefore, some researchers struggle to develop their own FES-assisted devices or find it challenging to implement their instrumentation using commercial devices, which often limits the implementation of advanced control strategies and the possibility to connect different types of sensor. In this regard, we hypothesize that it would be advantageous for some researchers in our community to enjoy access to an entire open-source FES platform that allows different control strategies to be implemented, offers greater adaptability and power capacity than commercial devices, and can be used to assist different functional activities in addition to cycling. Hence, it appears to be of interest to make our proprietary electrical stimulation system an open-source device and to prove its capabilities by addressing all the aspects necessary to implement a FES cycling system. The high-power capacity stimulation device is based on a constant current topology that allows the creation of biphasic electrical pulses with amplitude, width, and frequency up to 150 mA, 1000 µs, and 100 Hz, respectively. A mobile application (Android) was developed to set and modify the stimulation parameters of up to eight stimulation channels. A proportional-integral controller was implemented for cadence tracking with the aim to improve the overall cycling performance. A volunteer with complete paraplegia participated in the functional testing of the system. He was able to cycle indoors for 45 min, accomplish distances of more than 5 km using a passive cycling trainer, and pedal 2400 m overground in 32 min. The results evidenced the capacity of our FES cycling system to be employed as a cycling tool for individuals with spinal cord injury. The methodological strategies used to improve FES efficiency suggest the possibility of maximizing pedaling duration through more advanced control techniques.

Leveraging electronic health record data to inform hospital resource management : A systematic data mining approach.

Early identification of resource needs is instrumental in promoting efficient hospital resource management. Hospital information systems, and electronic health records (EHR) in particular, collect valuable demographic and clinical patient data from the moment patients are admitted, which can help predict expected resource needs in early stages of patient episodes. To this end, this article proposes a data mining methodology to systematically obtain predictions for relevant managerial variables by leveraging structured EHR data. Specifically, these managerial variables are: i) Diagnosis categories, ii) procedure codes, iii) diagnosis-related groups (DRGs), iv) outlier episodes and v) length of stay (LOS). The proposed methodology approaches the problem in four stages: Feature set construction, feature selection, prediction model development, and model performance evaluation. We tested this approach with an EHR dataset of 5,089 inpatient episodes and compared different classification and regression models (for categorical and continuous variables, respectively), performed temporal analysis of model performance, analyzed the impact of training set homogeneity on performance and assessed the contribution of different EHR data elements for model predictive power. Overall, our results indicate that inpatient EHR data can effectively be leveraged to inform resource management on multiple perspectives. Logistic regression (combined with minimal redundancy maximum relevance feature selection) and bagged decision trees yielded best results for predicting categorical and numerical managerial variables, respectively. Furthermore, our temporal analysis indicated that, while DRG classes are more difficult to predict, several diagnosis categories, procedure codes and LOS amongst shorter-stay patients can be predicted with higher confidence in early stages of patient stay. Lastly, value of information analysis indicated that diagnoses, medication and structured assessment forms were the most valuable EHR data elements in predicting managerial variables of interest through a data mining approach.

Endoscopic resection of sellar and suprasellar epidermoid cyst: report of two cases and review of literature.

INTRODUCTION: Epidermoid cysts (EC) are lesions developing from neuroectodermal epithelial cells. They represent 1-2% of all intracranial tumors and are usually found in cerebellopontine angle and parasellar regions. To the best of our knowledge, only 27 cases have been reported of EC in sellar and suprasellar region. In 12 cases out of the 27, surgery was done by craniotomy means. The 7 most recent manuscripts (with 15 patients described) share in common the use of endoscopic endonasal approach (EEA) to perform surgical removal. RESULTS: In this paper, we report the safe removal of epidermoid cysts arising from the pituitary using an EEA in two patients, which should be the sixth such description in literature. In both cases, resection and evolution was favourable. DISCUSSION: Surgical resection is the treatment standard for epidermoid cysts, with total resection including the cyst wall to prevent recurrence when possible. The degree of resection obtained is limited by adherence to nearby neural and vascular structures. The advent of EEA approaches has allowed safe maximal resection especially in midline lesions nearby sellar and suprasellar compartiments.

Telehealth Opportunities in the COVID-19 Pandemic Early Days: What Happened, Did Not Happen, Should Have Happened, and Must Happen in the Near Future?

The objective of this communication is to offer a better understanding of the value of telemedicine in health care, particularly its role in creating opportunities for continuity of care to patients in a complex and novel setting as were the circumstances of the early COVID-19 pandemic times. Crisis time is also a time for opportunities. With regard to telehealth, all players (providers, staff, and patients) should be informed about its benefits and should also become familiar with the use of the various telehealth options and this will only be achieved through large information campaigns necessary enriched by local teaching and training programs in both public and private institutions. The final aim is to launch the debate and foster ideas useful throughout the pandemic. This article covers the experiences of physicians as well as health professionals in the Iberian Peninsula (Spain and Portugal), to provide a clearer idea of what has happened and how we can improve it with the possibilities provided by telemedicine, while at the same time to put in evidence that public health systems need to be rethought to provide solutions to situations such as that we are experiencing.

Overview of FES-Assisted Cycling Approaches and Their Benefits on Functional Rehabilitation and Muscle Atrophy.

Central nervous system diseases include brain or spinal cord impairments and may result in movement disorders almost always manifested by paralyzed muscles with preserved innervations and therefore susceptible to be activated by electrical stimulation. Functional electrical stimulation (FES)-assisted cycling is an approach mainly used for rehabilitation purposes contributing, among other effects, to restore muscle trophism. FES-assisted cycling has also been adapted for mobile devices adding a leisure and recreational benefit to the physical training. In October 2016, our teams (Freewheels and EMA-trike) took part in FES-bike discipline at the Cybathlon competition, presenting technologies that allow pilots with spinal cord injury to use their paralyzed lower limb muscles to propel a tricycle. Among the many benefits observed and reported in our study cases for the pilots during preparation period, we achieved a muscle remodeling in response to FES-assisted cycling that is discussed in this chapter. Then, we have organized some sections to explore how FES-assisted cycling could contribute to functional rehabilitation by means of changes in the skeletal muscle disuse atrophy.

Mediating Effects of Parents' Coping Strategies on the Relationship Between Parents' Emotional Intelligence and Sideline Verbal Behaviors in Youth Soccer.

The overall purpose of this study was to examine the mediating effects of parents' coping strategies on the relationship between parents' emotional intelligence and sideline verbal behaviors during their children's soccer games. Participants were 232 parents (120 mothers and 110 fathers) of youth soccer players age 9-13 years. Observations in situ were carried out at 30 soccer games during a soccer tournament. At the end of the game, parents were approached and asked to complete the Emotional Intelligence Scale and the Brief COPE scale. Structural-equation-modeling analyses revealed that adaptive and maladaptive coping mediated the relationship between regulation of emotion and parents' praise/encouragement, and negative and derogatory comments during the game. In addition, game result moderated the relationships between emotional intelligence, coping strategies, and parent behaviors. Emotional regulation and adaptive coping may promote desirable parent sideline behaviors and reduce undesirable behaviors.

Manchester Triage System version II and resource utilisation in the emergency department.

Emergency department (ED) triage systems aim to direct the best clinical assistance to those who are in the greatest urgency and guarantee that resources are efficiently applied. The study's purpose was to determine whether the Manchester Triage System (MTS) second version is a useful instrument for determining the risk of hospital admission, intrahospital death and resource utilisation in ED and to compare it with the MTS first version. This was a prospective study of patients that attended the ED at a large hospital. It comprised a total of 25,218 cases that were triaged between 11 July and 13 October 2011. The MTS codes were grouped into two clusters: red and orange into a 'high acuity/priority' (HP) cluster, and yellow, green and blue into a 'low acuity/priority' cluster. The risk of hospital admission in the HP cluster was 4.86 times that of the LP cluster for both admission route and ages. The percentage of patient hospital admission between medical and surgical specialties, in high and low priority clusters, was similar. We found the risk of death in the HP cluster to be 5.58 times that of the risk of the low acuity/priority cluster. The MTS had an inconsistent association relative to the utilisation of x-ray, while it seemed to portray a consistent association between ECG and laboratory utilisation and MTS cluster. There were no differences between medical and surgical specialities risk of admission. This suggests that improvements were made in the second version of MTS, particularly in the discriminators of patients triaged to surgical specialties, because this was not true for the first version of MTS.

Application of the participatory design in the testing of a baropodometric insole prototype for weight-bearing asymmetry after a stroke: A qualitative study.

Introduction: Currently studies indicate the need to incorporate the user`s perspective in the testing of new assistive technologies. The objective of this paper is to test a baropodometric insole prototype for monitoring and treatment weight-bearing asymmetry, according to the Participatory Design. Methods: We used a qualitative case study approach during the testing phase of the baropodometric insole prototype. The focus group approach addressed topics related to the experience and accessibility of the potential user in conjunction with professionals, researchers, and physiotherapy students. Facilitators, barriers, and requirements for the device were collected through audio recordings of the discussions during and after prototype testing. Results: Key steps in the prototype testing process were divided into (1) Test of the prototype according to the Participatory Design, divided into Who, When, How, and Why the potential user was involved in the study; and (2) Facilitators, barriers and requirements to improve the prototype. Conclusions: The baropodometric insole prototype can be seen as a promising device for monitoring and treating weight-bearing asymmetry.

Pathophysiology-Based Management of Secondary Injuries and Insults in TBI.

Traumatic Brain Injury (TBI) remains a leading cause of morbidity and mortality among all ages; despite the advances, understanding pathophysiological responses after TBI is still complex, involving multiple mechanisms. Previous reviews have focused on potential targets; however, the research on potential targets has continuously grown in the last five years, bringing even more alternatives and elucidating previous mechanisms. Knowing the key and updated pathophysiology concepts is vital for adequate management and better outcomes. This article reviews the underlying molecular mechanisms, the latest updates, and future directions for pathophysiology-based TBI management.

Digital vaccine passports and digital health diplomacy: an online model WHO simulation.

In the wake of Coronavirus disease 2019 (COVID-19), several nations have sought to implement digital vaccine passports (DVPs) to enable the resumption of international travel. Comprising a minimum dataset for each unique individual, DVPs have the makings of a global electronic health record, broaching key issues involved in building a global digital health ecosystem. Debate simulations offer a safe, interactive space to foster participatory policy discussions for advancing digital health diplomacy. This study used an online simulation of a Model World Health Assembly to critically analyze the sociotechnical issues associated with the global implementation of DVPs, and to generate useful insights and questions about the role of diplomacy in global digital health. The debate arguments addressed and provided insights into the technological, scientific, ethical, legal, policy, and societal aspects of DVPs. Reflecting on the simulation, we discuss its opportunities and challenges for the digitalization, decolonization, decentralization, and democratization of participatory policymaking.

Chronic stroke survivors' perspective on the use of serious games to motivate upper limb rehabilitation - a qualitative study.

Upper limb paresis occurs quite commonly after stroke and may result in the affected limb's disuse or learned non-use. As a result, its cortical representation may be suppressed, further inhibiting its spontaneous utilization, resulting in motor function deterioration, increase in spasticity, joint stiffness and pain.The aim of this work was to involve stroke survivors in a qualitative study within a user centred design process to better understand the perspectives of stroke survivors on virtual reality - based serious games (SG) for upper limb rehabilitation during the chronic phase and use those insights to design a VR-based serious games which promotes activation of the affected cortical area.A qualitative research method was performed using a multi professional focus group discussion, including a representative group of stroke survivors.With the insights of this work, the authors initiated the design of a VR-based SG prototype for upper limb rehabilitation with two modes, one version to be played with any arm to pick a virtual hammer and hit targeted objects, and other version, a mirror version based on mirror therapy.

Maximal respiratory pressures: Measurements at functional residual capacity in individuals with different health conditions using a digital manometer.

BACKGROUND: Measuring maximal respiratory pressure is a widely used method of investigating the strength of inspiratory and expiratory muscles. OBJECTIVES: To compare inspiratory pressures obtained at functional residual capacity (FRC) with measures at residual volume (RV), and expiratory pressures obtained at FRC with measures at total lung capacity (TLC) in individuals with different health conditions: post-COVID-19, COPD, idiopathic pulmonary fibrosis (IPF), heart failure (CHF), and stroke; and to compare the mean differences between measurements at FRC and RV/TLC among the groups. METHODS: Inspiratory and expiratory pressures were obtained randomly at different lung volumes. Mixed factorial analysis of covariance with repeated measures was used to compare measurements at different lung volumes within and among groups. RESULTS: Seventy-five individuals were included in the final analyses (15 individuals with each health condition). Maximal inspiratory pressures at FRC were lower than RV [mean difference (95% CI): 11.3 (5.8, 16.8); 8.4 (2.3, 14.5); 11.1 (5.5, 16.7); 12.8 (7.1, 18.4); 8.0 (2.6, 13.4) for COVID-19, COPD, IPF, CHF, and stroke, respectively] and maximal expiratory pressures at FRC were lower than TLC [mean difference (95% CI): 51.9 (37.4, 55.5); 60.9 (44.2, 77.7); 62.9 (48.1, 77.8); 58.0 (43.9, 73.8); 57.2 (42.9, 71.6) for COVID-19, COPD, IPF, CHF, and stroke, respectively]. All mean differences were similar among groups. CONCLUSION: Although inspiratory and expiratory pressures at FRC were lower than measures obtained at RV/TLC for the five groups of health conditions, the mean differences between measurements at different lung volumes were similar among groups, which raises the discussion about the influence of the viscoelastic properties of the lungs on maximal respiratory pressure.

Lessons learned from investigating patients' and physiotherapists' perspectives on the design of a telerehabilitation platform.

PURPOSE: Home self-rehabilitation exercises for musculoskeletal conditions are a valuable complement to rehabilitation plans. Telerehabilitation systems using artificial intelligence can provide reliable solutions and empower patients by providing them with guidance and motivating them to engage in rehabilitation plans and activities. This study aims to understand the patient's and physiotherapist's perspective on the requirements of effective face-to-face physiotherapy sessions to inspire the design of a telerehabilitation platform to be used in home settings. METHODS: The authors used an ethnography-informed approach through observation and semi-structured interviews with patients (n = 13) and physiotherapists (n = 10) in two outpatient rehabilitation clinics. The AEIOU framework was used to structure and analyse the observation. Thematic analysis was used to code and analyse the data collected from the observations and the interviews. RESULTS: Patients' and physiotherapists' perspectives emphasise the need for exercise instruction clarity, evolution monitoring, and feedback. In the absence of the physiotherapist, in home settings, patients feel insecure and fear execution difficulties and limited exercise instructions, while physiotherapists struggle with controlling patients' home exercise performance. Telerehabilitation is seen as an opportunity to move further into home self-rehabilitation programs. CONCLUSIONS: Besides home exercise monitoring and guidance, telerehabilitation platforms must allow personalization and effective communication between patients and physiotherapists.

This work makes three important contributions, in which it extends existing research:Presents insights into the requirements of effective remote physiotherapy sessions;Highlights the challenges and concerns of patients and physiotherapists regarding telerehabilitation;Provides guidance for developing telerehabilitation platforms.

Evaluating the ability of an artificial-intelligence cloud-based platform designed to provide information prior to locoregional therapy for breast cancer in improving patient's satisfaction with therapy: The CINDERELLA trial.

BACKGROUND: Breast cancer therapy improved significantly, allowing for different surgical approaches for the same disease stage, therefore offering patients different aesthetic outcomes with similar locoregional control. The purpose of the CINDERELLA trial is to evaluate an artificial-intelligence (AI) cloud-based platform (CINDERELLA platform) vs the standard approach for patient education prior to therapy. METHODS: A prospective randomized international multicentre trial comparing two methods for patient education prior to therapy. After institutional ethics approval and a written informed consent, patients planned for locoregional treatment will be randomized to the intervention (CINDERELLA platform) or controls. The patients in the intervention arm will use the newly designed web-application (CINDERELLA platform, CINDERELLA APProach) to access the information related to surgery and/or radiotherapy. Using an AI system, the platform will provide the patient with a picture of her own aesthetic outcome resulting from the surgical procedure she chooses, and an objective evaluation of this aesthetic outcome (e.g., good/fair). The control group will have access to the standard approach. The primary objectives of the trial will be i) to examine the differences between the treatment arms with regards to patients' pre-treatment expectations and the final aesthetic outcomes and ii) in the experimental arm only, the agreement of the pre-treatment AI-evaluation (output) and patient's post-therapy self-evaluation. DISCUSSION: The project aims to develop an easy-to-use cost-effective AI-powered tool that improves shared decision-making processes. We assume that the CINDERELLA APProach will lead to higher satisfaction, better psychosocial status, and wellbeing of breast cancer patients, and reduce the need for additional surgeries to improve aesthetic outcome.

"Digital Health Diplomacy" in Global Digital Health? A call for critique and discourse.

Actualizing the vision of Global Digital Health is a central issue on the Global Health Diplomacy agenda. The COVID-reinforced need for accelerated digital health progress will require political structures and processes to build a foundation for Global Digital Health. Simultaneously, Global Health Diplomacy uses digital technologies in its enactment. Both phenomena have driven interest in the term "Digital Health Diplomacy." A review of the literature revealed 2 emerging but distinct definitions that have been published very recently, each with its associated discourse and practice. This multiplicity of ideas demonstrates the myriad ways in which global digital and political systems are becoming increasingly entangled. Untangling these, this paper proposes and discusses 3 dimensions of Digital Health Diplomacy: "Diplomacy for digital health," "Digital health for diplomacy," and "Digital health in diplomacy." It calls upon digital health professionals, diplomats, political and social scientists, epidemiologists, and clinicians to discuss, critique, and advance this emerging domain.

Clinical Applications of Artificial Intelligence-An Updated Overview.

Artificial intelligence has the potential to revolutionize modern society in all its aspects. Encouraged by the variety and vast amount of data that can be gathered from patients (e.g., medical images, text, and electronic health records), researchers have recently increased their interest in developing AI solutions for clinical care. Moreover, a diverse repertoire of methods can be chosen towards creating performant models for use in medical applications, ranging from disease prediction, diagnosis, and prognosis to opting for the most appropriate treatment for an individual patient. In this respect, the present paper aims to review the advancements reported at the convergence of AI and clinical care. Thus, this work presents AI clinical applications in a comprehensive manner, discussing the recent literature studies classified according to medical specialties. In addition, the challenges and limitations hindering AI integration in the clinical setting are further pointed out.