Haemodynamics and oxygenation in the lower-limb muscles of young ambulatory adults with cerebral palsy.

AIM: To evaluate muscle haemodynamics and oxygen metabolism in adults with cerebral palsy (CP) at rest and during exercise. METHOD: This cross-sectional study included 12 adults with spastic CP (four females, eight males; mean age [SD] 29 years 6 months [7 years 10.8 months]) and 13 typically developing individuals (seven females, six males; mean age [SD] 26 years 6 months [1 year 1.9 months]). Near-infrared spectroscopy was used to assess changes in muscle blood flow (mBF), muscle oxygen consumption (mVO2 ), and muscle oxygen saturation in the vastus lateralis and rectus femoris muscles during three conditions: rest, low load at 20% maximum voluntary contraction (MVC), and high load at 80% MVC. RESULTS: MBF was lower in participants with CP than in typically developing participants at rest (p < 0.001) and at 20% MVC (p = 0.007) in both muscles. Increased load caused a reduction in mBF in typically developing participants and an increase in CP. MVO2 in typically developing participants increased from rest to 20% MVC and was reduced at 80% MVC compared with 20% MVC. In participants with CP, there was no change with load in the rectus femoris muscle; however, there was an increase in the vastus lateralis muscle from rest to 20% MVC, and 80% MVC had a similar value. Muscle saturation was higher in participants with CP across all conditions (vastus lateralis, p < 0.001; rectus femoris, p = 0.0518). INTERPRETATION: Oxidative metabolism in CP is not limited by oxygen delivery (mBF), because high muscle saturation suggests oxygen availability. Adults with CP demonstrate muscular responses to exercise that are inconsistent with typical high-workload activation, probably because of inefficient fibre recruitment and secondary anomalies.

Virtual reality-based training and pre-operative planning for head and neck sentinel lymph node biopsy.

OBJECTIVE: Sentinel lymph node biopsy (SLNB) is crucial for managing head and neck skin cancer. However, variable lymphatic drainage can complicate SLN detection when using Single-Photon Emission Computed Tomography (SPECT) or lymphoscintigraphy. Virtual Reality (VR) can contribute to pre-operative planning by simulating a realistic 3D model, which improves orientation. VR can also facilitate real-patient training outside the operating room. This study explored using a VR platform for pre-operative planning in head and neck skin cancer patients undergoing SLNBs and assessed its value for residential training. MATERIALS AND METHODS: In this prospective technology pilot study, attending surgeons and residents who performed 21 SLNB operations on patients with head and neck skin cancers (81% males, mean age 69.2 ± 11.3) used a VR simulation model based on each patient's pre-operative SPECT scan to examine patient-specific anatomy. After surgery, they completed a questionnaire on the efficiency of the VR simulation as a pre-operative planning tool and training device for residents. RESULTS: The attending surgeons rated the VR model's accuracy at 8.3 ± 1.6 out of 10. Three-quarters (76%) of residents reported increased confidence after using VR. The physicians rated the platform's contribution to residents' training at 7.4 ± 2.1 to 8.9 ± 1.3 out of 10. CONCLUSION: A VR SLNB simulation can accurately portray marked sentinel lymph nodes. It was rated high as a surgical planning and teaching tool among attending surgeons and residents alike and may play a role in pre-operative planning and resident training. Further studies are needed to explore its applications in practice.

Facilitating the Work of Unmanned Aerial Vehicle Operators Using Artificial Intelligence: An Intelligent Filter for Command-and-Control Maps to Reduce Cognitive Workload.

OBJECTIVE: Evaluating the ability of a Gibsonian-inspired artificial intelligence (AI) algorithm to reduce the cognitive workloads of military Unmanned Aerial Vehicle (UAV) operators. BACKGROUND: Military UAV operators use the command-and-control (C2) map for developing mission-relevant situation awareness (SA). Yet C2 maps are overloaded with information, mostly irrelevant to the mission, causing operators to neglect the map altogether. To reduce irrelevant information, an intelligent filtering algorithm was developed. Here we evaluate its effectiveness in reducing operators' cognitive workloads. METHOD: Two-stage operational scenarios were conducted with professional ex-military UAV operators, using two filter protocols and a no-filter control. High-end real-time techniques were used to continuously assess workload from muscle behavior and machine learning models. RESULTS: Lower cognitive workload was found when applying the algorithm's protocols, especially when fatigue started to accumulate (Stage II). However, concerns about the quality of SA arose. CONCLUSION: The algorithm was positively evaluated for its ability to reduce operators' cognitive workloads. More evaluations of operators' SA are required. APPLICATION: The algorithm demonstrates the possibility of integrating AI to improve human performance in complex systems, and can be applied to other domains where spatial-temporal information needs to be contextually filtered in real time.

Identifying Patients With Inflammatory Bowel Disease on Twitter and Learning From Their Personal Experience: Retrospective Cohort Study.

BACKGROUND: Patients use social media as an alternative information source, where they share information and provide social support. Although large amounts of health-related data are posted on Twitter and other social networking platforms each day, research using social media data to understand chronic conditions and patients' lifestyles is limited. OBJECTIVE: In this study, we contributed to closing this gap by providing a framework for identifying patients with inflammatory bowel disease (IBD) on Twitter and learning from their personal experiences. We enabled the analysis of patients' tweets by building a classifier of Twitter users that distinguishes patients from other entities. This study aimed to uncover the potential of using Twitter data to promote the well-being of patients with IBD by relying on the wisdom of the crowd to identify healthy lifestyles. We sought to leverage posts describing patients' daily activities and their influence on their well-being to characterize lifestyle-related treatments. METHODS: In the first stage of the study, a machine learning method combining social network analysis and natural language processing was used to automatically classify users as patients or not. We considered 3 types of features: the user's behavior on Twitter, the content of the user's tweets, and the social structure of the user's network. We compared the performances of several classification algorithms within 2 classification approaches. One classified each tweet and deduced the user's class from their tweet-level classification. The other aggregated tweet-level features to user-level features and classified the users themselves. Different classification algorithms were examined and compared using 4 measures: precision, recall, F1 score, and the area under the receiver operating characteristic curve. In the second stage, a classifier from the first stage was used to collect patients' tweets describing the different lifestyles patients adopt to deal with their disease. Using IBM Watson Service for entity sentiment analysis, we calculated the average sentiment of 420 lifestyle-related words that patients with IBD use when describing their daily routine. RESULTS: Both classification approaches showed promising results. Although the precision rates were slightly higher for the tweet-level approach, the recall and area under the receiver operating characteristic curve of the user-level approach were significantly better. Sentiment analysis of tweets written by patients with IBD identified frequently mentioned lifestyles and their influence on patients' well-being. The findings reinforced what is known about suitable nutrition for IBD as several foods known to cause inflammation were pointed out in negative sentiment, whereas relaxing activities and anti-inflammatory foods surfaced in a positive context. CONCLUSIONS: This study suggests a pipeline for identifying patients with IBD on Twitter and collecting their tweets to analyze the experimental knowledge they share. These methods can be adapted to other diseases and enhance medical research on chronic conditions.

Insights into motor performance deficits after stroke: an automated and refined analysis of the lower-extremity motor coordination test (LEMOCOT).

BACKGROUND: The lower-extremity motor coordination test (LEMOCOT) is a performance-based measure used to assess motor coordination deficits after stroke. We aimed to automatically quantify performance on the LEMOCOT and to extract additional performance parameters based on error analysis in persons with stroke (PwS) and healthy controls. We also aimed to explore whether these parameters provide additional information regarding motor control deficit that is not captured by the traditional LEMOCOT score. In addition, the associations between the LEMOCOT score, parameters of error and performance-based measures of lower-extremity impairment and gait were tested. METHODS: Twenty PwS (age: 62 ± 11.8 years, time after stroke onset: 84 ± 83 days; lower extremity Fugl-Meyer: 30.2 ± 3.7) and 20 healthy controls (age: 42 ± 15.8 years) participated in this cross-sectional exploratory study. Participants were instructed to move their big toe as fast and accurately as possible between targets marked on an electronic mat equipped with force sensors (Zebris FDM-T, 60 Hz). We extracted the contact surface area of each touch, from which the endpoint location, the center of pressure (COP), and the distance between them were computed. In addition, the absolute and variable error were calculated. RESULTS: PwS touched the targets with greater foot surface and demonstrated a greater distance between the endpoint location and the location of the COP. After controlling for the number of in-target touches, greater absolute and variable errors of the endpoint were observed in the paretic leg than in the non-paretic leg and the legs of controls. Also, the COP variable error differentiated between the paretic, non-paretic, and control legs and this parameter was independent of in-target counts. Negative correlations with moderate effect size were found between the Fugl Meyer assessment and the error parameters. CONCLUSIONS: PwS demonstrated lower performance in all outcome measures than did controls. Several parameters of error indicated differences between legs (paretic leg, non-paretic leg and controls) and were independent of in-target touch counts, suggesting they may reflect motor deficits that are not identified by the traditional LEMOCOT score.

Effect of post-stroke spasticity on voluntary movement of the upper limb.

BACKGROUND: Hemiparesis following stroke is often accompanied by spasticity. Spasticity is one factor among the multiple components of the upper motor neuron syndrome that contributes to movement impairment. However, the specific contribution of spasticity is difficult to isolate and quantify. We propose a new method of quantification and evaluation of the impact of spasticity on the quality of movement following stroke. METHODS: Spasticity was assessed using the Tonic Stretch Reflex Threshold (TSRT). TSRT was analyzed in relation to stochastic models of motion to quantify the deviation of the hemiparetic upper limb motion from the normal motion patterns during a reaching task. Specifically, we assessed the impact of spasticity in the elbow flexors on reaching motion patterns using two distinct measures of the 'distance' between pathological and normal movement, (a) the bidirectional Kullback-Liebler divergence (BKLD) and (b) Hellinger's distance (HD). These measures differ in their sensitivity to different confounding variables. Motor impairment was assessed clinically by the Fugl-Meyer assessment scale for the upper extremity (FMA-UE). Forty-two first-event stroke patients in the subacute phase and 13 healthy controls of similar age participated in the study. Elbow motion was analyzed in the context of repeated reach-to-grasp movements towards four differently located targets. Log-BKLD and HD along with movement time, final elbow extension angle, mean elbow velocity, peak elbow velocity, and the number of velocity peaks of the elbow motion were computed. RESULTS: Upper limb kinematics in patients with lower FMA-UE scores (greater impairment) showed greater deviation from normality when the distance between impaired and normal elbow motion was analyzed either with the BKLD or HD measures. The severity of spasticity, reflected by the TSRT, was related to the distance between impaired and normal elbow motion analyzed with either distance measure. Mean elbow velocity differed between targets, however HD was not sensitive to target location. This may point at effects of spasticity on motion quality that go beyond effects on velocity. CONCLUSIONS: The two methods for analyzing pathological movement post-stroke provide new options for studying the relationship between spasticity and movement quality under different spatiotemporal constraints.

Viewpoint Analysis for Maturity Classification of Sweet Peppers.

The effect of camera viewpoint and fruit orientation on the performance of a sweet pepper maturity level classification algorithm was evaluated. Image datasets of sweet peppers harvested from a commercial greenhouse were collected using two different methods, resulting in 789 RGB-Red Green Blue (images acquired in a photocell) and 417 RGB-D-Red Green Blue-Depth (images acquired by a robotic arm in the laboratory), which are published as part of this paper. Maturity level classification was performed using a random forest algorithm. Classifications of maturity level from different camera viewpoints, using a combination of viewpoints, and different fruit orientations on the plant were evaluated and compared to manual classification. Results revealed that: (1) the bottom viewpoint is the best single viewpoint for maturity level classification accuracy; (2) information from two viewpoints increases the classification by 25 and 15 percent compared to a single viewpoint for red and yellow peppers, respectively, and (3) classification performance is highly dependent on the fruit's orientation on the plant.

Making Sense of the Cognitive Task of Medication Reconciliation Using a Card Sorting Task.

OBJECTIVE: To explore cognitive strategies clinicians apply while performing a medication reconciliation task, handling incomplete and conflicting information. BACKGROUND: Medication reconciliation is a method clinicians apply to find and resolve inconsistencies in patients' medications and medical conditions lists. The cognitive strategies clinicians use during reconciliation are unclear. Controlled lab experiments can explore how clinicians make sense of uncertain, missing, or conflicting information and therefore support the development of a human performance model. We hypothesize that clinicians apply varied cognitive strategies to handle this task and that profession and experience affect these strategies. METHOD: 130 clinicians participated in a tablet-based experiment conducted in a large American teaching hospital. They were asked to simulate medication reconciliation using a card sorting task (CaST) to organize medication and medical condition lists of a specific clinical case. Later on, they were presented with new information and were asked to add it to their arrangements. We quantitatively and qualitatively analyzed the ways clinicians arranged patient information. RESULTS: Four distinct cognitive strategies were identified ("Conditions first": n = 76 clinicians, "Medications first": n = 7, "Crossover": n = 17, and "Alternating": n = 10). The strategy clinicians applied was affected by their experience (p = .02) but not by their profession. At the appearance of new information, clinicians moved medication cards more frequently (75.2 movements vs. 49.6 movements, p < .001), suggesting that they match medications to medical conditions. CONCLUSION: Clinicians apply various cognitive strategies while reconciling medications and medical conditions. APPLICATION: Clinical information systems should support multiple cognitive strategies, allowing flexibility in organizing information.

Imaging blood-brain barrier dysfunction as a biomarker for epileptogenesis.

A biomarker that will enable the identification of patients at high-risk for developing post-injury epilepsy is critically required. Microvascular pathology and related blood-brain barrier dysfunction and neuroinflammation were shown to be associated with epileptogenesis after injury. Here we used prospective, longitudinal magnetic resonance imaging to quantitatively follow blood-brain barrier pathology in rats following status epilepticus, late electrocorticography to identify epileptic animals and post-mortem immunohistochemistry to confirm blood-brain barrier dysfunction and neuroinflammation. Finally, to test the pharmacodynamic relevance of the proposed biomarker, two anti-epileptogenic interventions were used; isoflurane anaesthesia and losartan. Our results show that early blood-brain barrier pathology in the piriform network is a sensitive and specific predictor (area under the curve of 0.96, P < 0.0001) for epilepsy, while diffused pathology is associated with a lower risk. Early treatments with either isoflurane anaesthesia or losartan prevented early microvascular damage and late epilepsy. We suggest quantitative assessment of blood-brain barrier pathology as a clinically relevant predictive, diagnostic and pharmaco!dynamics biomarker for acquired epilepsy.

Development of automatic body condition scoring using a low-cost 3-dimensional Kinect camera.

Body condition scoring (BCS) is a farm-management tool for estimating dairy cows' energy reserves. Today, BCS is performed manually by experts. This paper presents a 3-dimensional algorithm that provides a topographical understanding of the cow's body to estimate BCS. An automatic BCS system consisting of a Kinect camera (Microsoft Corp., Redmond, WA) triggered by a passive infrared motion detector was designed and implemented. Image processing and regression algorithms were developed and included the following steps: (1) image restoration, the removal of noise; (2) object recognition and separation, identification and separation of the cows; (3) movie and image selection, selection of movies and frames that include the relevant data; (4) image rotation, alignment of the cow parallel to the x-axis; and (5) image cropping and normalization, removal of irrelevant data, setting the image size to 150×200 pixels, and normalizing image values. All steps were performed automatically, including image selection and classification. Fourteen individual features per cow, derived from the cows' topography, were automatically extracted from the movies and from the farm's herd-management records. These features appear to be measurable in a commercial farm. Manual BCS was performed by a trained expert and compared with the output of the training set. A regression model was developed, correlating the features with the manual BCS references. Data were acquired for 4 d, resulting in a database of 422 movies of 101 cows. Movies containing cows' back ends were automatically selected (389 movies). The data were divided into a training set of 81 cows and a test set of 20 cows; both sets included the identical full range of BCS classes. Accuracy tests gave a mean absolute error of 0.26, median absolute error of 0.19, and coefficient of determination of 0.75, with 100% correct classification within 1 step and 91% correct classification within a half step for BCS classes. Results indicated good repeatability, with all standard deviations under 0.33. The algorithm is independent of the background and requires 10 cows for training with approximately 30 movies of 4 s each.

Differences in microRNA detection levels are technology and sequence dependent.

Identification and quantification of small RNAs are challenging because of their short length, high sequence similarities within microRNA (miRNA) families, and the existence of miRNA isoforms and O-methyl 3' modifications. In this study, the detection performance of three high-throughput commercial platforms, Agilent and Affymetrix microarrays and Illumina next-generation sequencing, was systematically and comprehensively compared. The ability to detect miRNAs was shown to depend strongly on the platform and on miRNA modifications and sequence. Using synthetic transcripts, including mature, precursor, and O-methyl-modified miRNAs spiked into human RNA, a large intensity variation in all spiked-in miRNAs and a reduced capacity in detecting O-methyl-modified miRNAs were observed between the tested platforms. In addition, endogenous human miRNA expression levels were assessed across the platforms. Detected miRNA expression levels were not consistent between platforms. Although biases in miRNA detection were previously described, here the end-point result, i.e., detection intensity, of these biases was investigated on multiple platforms in a controlled fashion. A detailed exploration of a large number of attributes, including base composition, sequence structure, and isoform miRNA attributes, suggests their impact on miRNA expression detection level. This study provides a basis for understanding the attributes that should be considered to adjust platform-dependent detection biases.

Comparison of proactive and reactive interaction modes in a mobile robotic telecare study.

Mobile robotic telepresence systems require that information about the environment, the task, and the robot be presented to a remotely located user (operator) who controls the robot for a specific task. In this study, two interaction modes, proactive and reactive, that differ in the way the user receives information from the robot, were compared in an experimental system simulating a healthcare setting. The users controlled a mobile telepresence robot that delivered and received items (medication, food, or drink), and also obtained metrics (vital signs) from a simulated patient while the users performed a secondary healthcare-related task (they compiled health records which were displayed to them on the screen and answered related questions). The effect of the two interaction modes on overall performance and user perception was evaluated through a within-participant study design conducted with 50 participants belonging to two different types of populations (with and without a technological background). Efficiency, effectiveness, understanding, satisfaction, and situation awareness were defined as the dependent variables measured both objectively and subjectively. The proactive mode increased user performance, and understanding of the system and reduced the workload compared to the reactive mode. However, several of the users valued the option of increased user control experienced in the reactive mode. We, therefore, proposed design suggestions to highlight some of the benefits of factoring the reactive mode into the design as a hybrid mode.

Virtual Reality-Enhanced Assessment of the Anterior Glottic Angle Using Cadaveric Models: A Proof-of-Concept Study.

OBJECTIVES: Vocal fold paralysis (VFP) is a complex disorder that affects voice, speech, swallowing, and overall quality of life. Current evaluation methods for determining the position of paralyzed vocal folds lack the objectivity required for personalized interventions and research on innovative treatments for VFP. This study was designed to validate the accuracy and reproducibility of a virtual reality (VR)-based platform to measure the anterior glottic angle (AGA), a critical component in determining the position of a paralyzed vocal fold. STUDY DESIGN: Retrospective. METHODS: A retrospective analysis of computed tomography (CT) scans of 39 adult patients was conducted to measure the AGA shortly after death. Two measurement methods were used: 2-dimensional (2D)-CT for direct measurements on 2D images and a 3-dimensional (3D)-VR method utilizing a dedicated platform to create a 3D VR model of the larynx. The AGA measurements conducted by two senior otolaryngologists using the 3D-VR method were compared to the 2D-CT measurements made by one of these same otolaryngologists. RESULTS: The mean AGA measured by the 3D-VR method was found to be 32.936 ± 6.486° (n = 39), and the measurements were highly correlated (r = 0.9670, P < 0.0001). By contrast, the 2D-CT method without VR yielded a significantly lower mean angle of 23.754° (n = 35) with a higher standard deviation of 10.365°. The 3D-VR method demonstrated excellent reliability for AGA measurements (intraclass correlation coefficient of 0.954). CONCLUSION: The findings underscore the potential value of using a VR-based platform to improve reproducibility and reduce the variability in measurements of AGA in cases of VFP.

Virtual Reality Helps Describe the Progression of Thyroid Cartilage Calcification.

OBJECTIVES: Thyroid cartilage (TC) calcifications may impact surgical planning and clinical management. However, few studies to date have implemented virtual reality (VR) to evaluate these calcifications. This study assessed the feasibility of evaluating TC calcifications in various regions and measuring their volumes through VR models generated from computed tomography scans. We also investigated age and gender-related differences in calcification patterns. METHODS: Ninety-two participants were categorized into younger, middle-aged, and older age groups. Calcification patterns (degree in Hounsfield units and volume of calcification in cm3) in different TC regions were identified by VR analysis, which enabled comparisons between age groups and genders. RESULTS: Significant differences in calcification patterns were observed between males and females, particularly in the middle right, middle left, bottom left, and vertex regions. Age-related differences in the vertex region showed increased calcification in the older age group. CONCLUSION: This study points to the contribution of VR in the evaluation of complex anatomical structures. The findings revealed significant gender and age patterns in TC calcification. These insights can inform surgical planning and highlight the potential of using VR to gain a better understanding of TC calcification clinically.

What are IBD Patients Talking About on Twitter? Using Natural Language Understanding to Investigate Patients' Tweets.

This research aims to investigate what patients with inflammatory bowel disease (IBD) are talking about on Twitter and learn from the experimental knowledge they share online. The study presents a framework for analyzing patients' tweets and comparing their content to tweets of the general population. We started by constructing two datasets of tweets-a dataset of patients' tweets and a control dataset for comparison. Then, we thematically classified the tweets and obtained a subset of tweets related to health and nutrition. We used a Dirichlet regression to compare the thematic segmentations of the two groups. We continued by extracting keywords from the filtered tweets and applying entity sentiment analysis to determine the patients' sentiments towards the extracted keywords. Finally, we detected emotions within the tweets and used a Wilcoxon test to compare the emotions conveyed in each group. We found statistically significant differences between the patients' thematic segmentations and those of the control group and observed significant differences in the emotions each group expressed while talking about health. Not only do patients talk more about health in comparison to the general Twitter population, but they also address the subject with negative sentiments and express more negative emotions. The personal information IBD patients share on Twitter can be used to derive complementary knowledge about the disease and provide an additional foundation to existing medical research on IBD. The four stages of the study are also feasible to extend to other chronic conditions.

Older adults and stroke survivors are steadier when gazing down.

BACKGROUND: Advanced age and brain damage have been reported to increase the propensity to gaze down while walking, a behavior that is thought to enhance stability through anticipatory stepping control. Recently, downward gazing (DWG) has been shown to enhance postural steadiness in healthy adults, suggesting that it can also support stability through a feedback control mechanism. These results have been speculated to be the consequence of the altered visual flow when gazing down. The main objective of this cross-sectional, exploratory study was to investigate whether DWG also enhances postural control in older adults and stroke survivors, and whether such effect is altered with aging and brain damage. METHODS: Posturography of older adults and stroke survivors, performing a total of 500 trials, was tested under varying gaze conditions and compared with a cohort of healthy young adults (375 trials). To test the involvement of the visual system we performed spectral analysis and compared the changes in the relative power between gaze conditions. RESULTS: Reduction in postural sway was observed when participants gazed down 1 and 3 meters ahead whereas DWG towards the toes decreased steadiness. These effects were unmodulated by age but were modulated by stroke. The relative power in the spectral band associated with visual feedback was significantly reduced when visual input was unavailable (eyes-closed condition) but was unaffected by the different DWG conditions. CONCLUSIONS: Like young adults, older adults and stroke survivors better control their postural sway when gazing down a few steps ahead, but extreme DWG can impair this ability, especially in people with stroke.

Three-dimensional reconstruction of computed tomography colonography discloses anatomic features associated with colonoscopy failure.

Objectives: Three-dimensional virtual reality (3D VR) permits precise reconstruction of computed tomography (CT) images, and these allow precise measurements of colonic anatomical parameters. Colonoscopy proves challenging in a subset of patients, and thus CT colonoscopy (CTC) is often required to visualize the entire colon. The aim of the study was to determine whether 3D reconstructions of the colon could help identify and quantify the key anatomical features leading to colonoscopy failure. Design: Retrospective observational study. Methods: Using 3D VR technology, we reconstructed and compared the length of various colonic segments and number of bends and colonic width in 10 cases of CTC in technically failed prior colonoscopies to 10 cases of CTC performed for non-technically failure indications. Results: We found significant elongation of the sigmoid colon (71 ± 23 cm versus 35 ± 9; p = 0.01) and of pancolonic length (216 ± 38 cm versus 158 ± 20 cm; p = 0.001) in cases of technically failed colonoscopy. There was also a significant increase in the number of colonic angles (17.7 ± 3.2 versus 12.7 ± 2.4; p = 0.008) in failed colonoscopy cases. Conclusion: Increased sigmoid and pancolonic length and more colonic bends are novel factors associated with technical failure of colonoscopy.

ENHANCE proof-of-concept three-arm randomized trial: effects of reaching training of the hemiparetic upper limb restricted to the spasticity-free elbow range.

Post-stroke motor recovery processes remain unknown. Timescales and patterns of upper-limb (UL) recovery suggest a major impact of biological factors, with modest contributions from rehabilitation. We assessed a novel impairment-based training motivated by motor control theory where reaching occurs within the spasticity-free elbow range. Patients with subacute stroke (≤ 6 month; n = 46) and elbow flexor spasticity were randomly allocated to a 10-day UL training protocol, either personalized by restricting reaching to the spasticity-free elbow range defined by the tonic stretch reflex threshold (TSRT) or non-personalized (non-restricted) and with/without anodal transcranial direct current stimulation. Outcomes assessed before, after, and 1 month post-intervention were elbow flexor TSRT angle and reach-to-grasp arm kinematics (primary) and stretch reflex velocity sensitivity, clinical impairment, and activity (secondary). Results were analyzed for 3 groups as well as those of the effects of impairment-based training. Clinical measures improved in both groups. Spasticity-free range training resulted in faster and smoother reaches, smaller (i.e., better) arm-plane path length, and closer-to-normal shoulder/elbow movement patterns. Non-personalized training improved clinical scores without improving arm kinematics, suggesting that clinical measures do not account for movement quality. Impairment-based training within a spasticity-free elbow range is promising since it may improve clinical scores together with arm movement quality.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique Identifier: NCT02725853; Initial registration date: 01/04/2016.

Virtual reality utilization for left atrial appendage occluder device size prediction.

Aim: To explore the feasibility and accuracy of virtual reality (VR) derived from cardiac computed angiography (CCTA) data to predict left atrial appendage occlusion (LAAO) device size. Method: Retrospective data of patients who underwent LAAO according to clinical indication were reviewed; all patients underwent a pre-procedural CCTA. Measurements of the left atrial appendage (LAA) orifice diameters by CCTA, VR, and transesophageal echocardiography (TEE) (acquired during the procedure) were compared to the implanted device size. The LAA perimeter was calculated using the Ramanujan approximation. Statistical analyses included Lin's Concordance Correlation Coefficient (ρ c ), the mean difference, and the mean square error (MSE). Results: The sample was composed of 20 patients (mean age 75.7 ± 7.5 years, 60% males) who underwent successful LAAO insertion (ACP™ N = 8, Watchman™ N = 12). The CCTA, VR, and TEE maximal diameter ρ c was 0.52, 0.78 and 0.60, respectively with mean differences of +0.92 ± 4.0 mm, -1.12 ± 2.3 mm, and -3.45 ± 2.69 mm, respectively. The CCTA, VR, and TEE perimeter calculations ρ c were 0.49, 0.54, and 0.39 respectively with mean differences of +4.69 ± 11.5 mm, -9.88 ± 8.0 mm, and -16.79 ± 7.8 respectively. Discussion: A VR visualization of the LAA ostium in different perspectives allows for a better understanding of its funnel-shaped structure. VR measurement of the maximal ostium diameter had the strongest correlation with the diameter of the inserted device. VR may thus provide new imaging possibilities for the evaluation of complex pre-procedural structures such as the LAA.

Do first opinions affect second opinions?

BACKGROUND: Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians. OBJECTIVE: To evaluate whether physicians' judgment is affected by another medical opinion given to a patient. DESIGN: Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician's opinion was (study group), and the other group was not told what it was (control group). PARTICIPANTS: A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population). MEASUREMENTS: Scoring was by choice of less or more interventional treatment in the scenarios. We used χ(2) tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician's responses. RESULTS: Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) =4.6, p=0.03; OR=1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p=0.039; scenario 2, p<0.001; scenario 3, p=0.033; scenario 6, p<0.001). These effects were insignificant among the neurologists [F (1,158) =0.44, p=0.51; OR=1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) =0.752, p=0.473; neurologists: F (2,154) =1.951, p=0.146]. CONCLUSIONS: The exploratory survey showed that in some cases physicians' judgments may be affected by other physicians' opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.