Brain computer interface training with motor imagery and functional electrical stimulation for patients with severe upper limb paresis after stroke: a randomized controlled pilot trial.

BACKGROUND: Restorative Brain-Computer Interfaces (BCI) that combine motor imagery with visual feedback and functional electrical stimulation (FES) may offer much-needed treatment alternatives for patients with severely impaired upper limb (UL) function after a stroke. OBJECTIVES: This study aimed to examine if BCI-based training, combining motor imagery with FES targeting finger/wrist extensors, is more effective in improving severely impaired UL motor function than conventional therapy in the subacute phase after stroke, and if patients with preserved cortical-spinal tract (CST) integrity benefit more from BCI training. METHODS: Forty patients with severe UL paresis (< 13 on Action Research Arm Test (ARAT) were randomized to either a 12-session BCI training as part of their rehabilitation or conventional UL rehabilitation. BCI sessions were conducted 3-4 times weekly for 3-4 weeks. At baseline, Transcranial Magnetic Stimulation (TMS) was performed to examine CST integrity. The main endpoint was the ARAT at 3 months post-stroke. A binominal logistic regression was conducted to examine the effect of treatment group and CST integrity on achieving meaningful improvement. In the BCI group, electroencephalographic (EEG) data were analyzed to investigate changes in event-related desynchronization (ERD) during the course of therapy. RESULTS: Data from 35 patients (15 in the BCI group and 20 in the control group) were analyzed at 3-month follow-up. Few patients (10/35) improved above the minimally clinically important difference of 6 points on ARAT, 5/15 in the BCI group, 5/20 in control. An independent-samples Mann-Whitney U test revealed no differences between the two groups, p = 0.382. In the logistic regression only CST integrity was a significant predictor for improving UL motor function, p = 0.007. The EEG analysis showed significant changes in ERD of the affected hemisphere and its lateralization only during unaffected UL motor imagery at the end of the therapy. CONCLUSION: This is the first RCT examining BCI training in the subacute phase where only patients with severe UL paresis were included. Though more patients in the BCI group improved relative to the group size, the difference between the groups was not significant. In the present study, preserved CTS integrity was much more vital for UL improvement than which type of intervention the patients received. Larger studies including only patients with some preserved CST integrity should be attempted.

Multimorbidity and determinants for initiating outpatient trajectories: A population-based study.

INTRODUCTION: Individuals with multimorbidity often receive high numbers of hospital outpatient services in concurrent trajectories. Nevertheless, little is known about factors associated with initiating new hospital outpatient trajectories; identified as the continued use of outpatient contacts for the same medical condition. PURPOSE: To investigate whether the number of chronic conditions and sociodemographic characteristics in adults with multimorbidity is associated with entering a hospital outpatient trajectory in this population. METHODS: This population-based register study included all adults in Denmark with multimorbidity on January 1, 2018. The exposures were number of chronic conditions and sociodemographic characteristics, and the outcome was the rate of starting a new outpatient trajectory during 2018. Analyses were stratified by the number of existing outpatient trajectories. We used Poisson regression analysis, and results were expressed as incidence rates and incidence rate ratios with 95% confidence intervals. We followed the individuals during the entire year of 2018, accounting for person-time by hospitalization, emigration, and death. RESULTS: Incidence rates for new outpatient trajectories were highest for individuals with low household income and ≥3 existing trajectories and for individuals with ≥3 chronic conditions and in no already established outpatient trajectory. A high number of chronic conditions and male gender were found to be determinants for initiating a new outpatient trajectory, regardless of the number of existing trajectories. Low educational level was a determinant when combined with 1, 2, and ≥3 existing trajectories, and increasing age, western ethnicity, and unemployment when combined with 0, 1, and 2 existing trajectories. CONCLUSION: A high number of chronic conditions, male gender, high age, low educational level and unemployment were determinants for initiation of an outpatient trajectory. The rate was modified by the existing number of outpatient trajectories. The results may help identify those with multimorbidity at greatest risk of having a new hospital outpatient trajectory initiated.

Predicting length of stay with assessment of motor and process skills in subjects with acquired brain injury.

BACKGROUND: The Functional Independence Measure (FIM) is a well-established predictor of length of stay (LOS) for rehabilitation. The Assessment of Motor and Process Skills (AMPS) is a more in-depth construct for measuring activities of daily living (ADL) and may therefore be a valuable adjunct when predicting LOS. This paper aimed to investigate AMPS as a candidate predictor of LOS in a statistical model including FIM. METHODS: A cohort study of 647 patients with acquired brain injuries admitted for rehabilitation. LOS was analyzed in a multiple regression model with the motor and process/cognitive domains of AMPS and FIM. RESULTS: Independence in ADL process ability and FIM cognition were associated with 31% (p < 0.001) and 38% (p < 0.001) shorter LOS, respectively, relative to patients needing total assistance. Independence in ADL motor ability was associated with a 26% (p = 0.002) shorter LOS, whereas FIM motor was not a predictor. CONCLUSIONS: The AMPS predicts LOS for rehabilitation at a level that is at least as good as that of FIM. Conducting the AMPS early in the course of inpatient rehabilitation provides clinicians and managers with valuable information for planning LOS.

Estimating Day-to-Day Circadian Rhythm in Patients with Severe Acquired Brain Injury at the Beginning of In-Hospital Rehabilitation.

BACKGROUND: Patients with severe acquired brain injury (sABI) are likely to have a disturbed circadian rhythm in the early phase of neurorehabilitation. Circadian rhythm and sleep play an important role in the rehabilitation of patients with severe acquired brain injury (sABI). Research has also pointed out the importance of investigating novel ways of assessing sleep and circadian rhythm in patients with acquired brain injury. Established methods fail to apply to the heterogeneous and fluctuant biological or behavioral signals of the patients with sABI. Accelerometry (ACC) has proven a useful measure of circadian rhythm in sABI patients. However, ACC is unavailing if patients have limited motor activity due to a low consciousness level or severe paresis. Heart rate (HR) could be a viable alternative. In this study, we aim to present a novel model for the estimation of circadian rhythm and rhythm characteristics in both motor-active and -inactive patients using ACC and HR. Furthermore, we aim to present the results of the model in patients with sABI during their first three weeks of subacute in-hospital neurorehabilitation. METHODS: An explorative observational study. Continuous recordings of ACC and electrocardiography were conducted. The suggested model was applied to examine circadian rhythms. RESULTS: This study has proven the feasibility of a novel model for the analysis of circadian rhythm. Twenty-nine patients were included, 20 motor active and nine motor inactive. Estimates of rhythm characteristics have been presented along with estimates of circadian rhythm presence or absence for both groups. CONCLUSIONS: The model has been successfully applied in a population of patients with sABI. The circadian rhythm of patients undergoing in-hospital neurorehabilitation is fluctuating across time and highly variant between subjects within the first three weeks after admission to sub-acute neurorehabilitation.

Construct and content validity of the Functional Oral Intake Scale; Analyses from a cohort of patients with acquired brain injury.

OBJECTIVE: To investigate the construct validity of the Functional Oral Intake Scale (FOIS) as a proxy measure for dysphagia, through associations with swallowing prerequisites, orofacial functions, age, and diagnosis; and to investigate content validity through distributions of FOIS ratings. METHODS: A cohort of 1,876 patients with severe acquired brain injury. Early Functional Abilities items were applied as measures of swallowing prerequisites and orofacial functions. Clustered logistic regression model with 6,052 cross-sectional observations. RESULTS: Disturbance in swallowing 10.55 OR (95%CI:7.90;14.09), oro-facial stimulation 3.04 OR (95%CI:2.41;3.83), and head control 2.86 OR (95%CI:2.25;3.62) were robustly associated with tube feeding (FOIS 1-3). Disturbance in trunk control, wakefulness, tongue movement/chewing, older age, and a non-stroke diagnosis were also associated with tube feeding. BMI did not attenuate associations in sensitivity analyses. FOIS ratings had greatest density in FOIS level 1 and level 7, with 25% and 40% of registrations, respectively. Level 4 was rated in only 1% of 6,052 registrations. CONCLUSIONS: The FOIS was robustly associated with indicators of dysphagia. However, associations with postural control, wakefulness, age and diagnosis highlights that tube feeding may be attributed to other issues than dysphagia. It should be further investigated whether FOIS level 4 is meaningful in neurorehabilitation.

Day-to-day features of soleus stretch reflexes in sub-acute stroke patients.

The aim of the study was to assess the reliability and variability of stretch reflex magnitude (SRmag) in sub-acute stroke patients. For testing, rapid dorsiflexion stretches were induced 24 h apart in 22 patients and 34 controls. SRmag between sessions in patients and controls was not different and the SRmag on the more-affected side was significantly larger than the less-affected, dominant, and non-dominant sides. The SRmag was consistent between sessions. Therefore, patients were not as variable between sessions as we had hypothesized.

Functional Independence: A Comparison of the Changes During Neurorehabilitation Between Patients With Nontraumatic Subarachnoid Hemorrhage and Patients With Intracerebral Hemorrhage or Acute Ischemic Stroke.

OBJECTIVE: To compare the changes in functional independence measured by the FIM after specialized neurorehabilitation between patients with nontraumatic subarachnoid hemorrhage (SAH) and patients with intracerebral hemorrhage (ICH) or acute ischemic stroke (AIS). DESIGN: Historical cohort study comparing changes in functional independence between patients with nontraumatic SAH and those with ICH/AIS, using FIM scores from a local database and clinical information from the Danish National Patient Registry. SETTING: Postacute specialized inpatient neurorehabilitation. PARTICIPANTS: Participants (N=660) comprised patients with a first-time nontraumatic SAH (n=212) and age-matched patients with a first-time ICH/AIS (n=448). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Crude and adjusted comparisons of FIM (total and item by item) measured at baseline and at discharge. RESULTS: Patients with nontraumatic SAH were admitted with a lower functional level compared with patients with ICH/AIS (median total FIM score, 25 [interquartile range (IQR), 18-81] vs 78.5 [IQR, 47-107]), and discharged with a lower functional level (median total FIM score, 98 [IQR, 40-116] vs 110 [IQR, 82.5-119]), although they made more progress during neurorehabilitation (median change in total FIM score, 27 [IQR, 4-60] vs 17 [IQR, 7-35]). Statistically, patients with nontraumatic SAH had significantly better odds for obtaining functional independence than did patients with ICH/AIS in 6 of the 18 FIM items: eating (odds ratio [OR]=3.2; 95% confidence interval [CI], 1.7-5.8); dressing-upper body (OR=2.0; 95% CI, 1.1-3.5); transfer tub/shower (OR=2.0; 95% CI, 1.1-3.6); stair walking (OR=2.2; 95% CI, 1.3-3.7); comprehension (OR=2.3; 95% CI, 1.3-3.9); and expression (OR=3.6; 95% CI, 2.0-6.5). CONCLUSIONS: Patients with nontraumatic SAH made significantly more progress during neurorehabilitation, although they were discharged with a lower level of functional independence compared with patients with ICH/AIS. However, both patients with nontraumatic SAH and those with ICH/AIS improved their functional outcome significantly. Also, patients with nontraumatic SAH admitted with severe functional outcome were shown to be capable of recovering to a moderate level of functional independence.

Return to Work After Severe Traumatic Brain Injury: A Nationwide Follow-up Study.

OBJECTIVE: To determine return to work (RTW) after severe traumatic brain injury (TBI) and to compare long-term labor market attachment (LMA) with the general population. PARTICIPANTS: All persons aged 18 to 64 years who received highly specialized neurorehabilitation after severe TBI between 2004 and 2012 (n = 637) were matched to general population controls on age, sex, preinjury employment status, educational level, and residence (n = 2497). DESIGN: Nationwide follow-up study using weekly records on public assistance benefits. MAIN MEASURES: Both RTW and LMA were defined as having no public assistance benefits except education grants/leave. Stable LMA was defined as weeks with LMA of 75% or more. LMA among persons with severe TBI and controls was compared using multivariable conditional logistic regression. RESULTS: RTW mainly occurred within first 2 years after severe TBI, with 30% of the people attempting RTW and 16% achieving stable LMA within 2 years. The prevalence of people with LMA decreased to 11% from 2½ years to 5 years postinjury. Adjusted odds ratios were 0.01 for LMA up to 2 years postinjury and 0.05 for stable LMA for persons with severe TBI compared with the general population. CONCLUSION: Both RTW and long-term LMA after severe TBI were low in Denmark when compared with the general population and other countries.

Alternative measures reveal different but low estimates of labour market attachment after severe traumatic brain injury: A nationwide cohort study.

OBJECTIVE: To explore if the definition of labour market attachment (LMA) changes LMA proportions after severe traumatic brain injury (TBI). DESIGN: Cohort study with 5-year follow-up. PARTICIPANTS: Patients aged 18-64 years with severe TBI from 2004 to 2012 (n = 637) and matched controls (n = 2497). METHODS: LMA was defined in three ways. All definitions included patients working with no government benefits. Definition 2 included patients receiving unemployment benefits (LMA-unemployment benefits). Definition 3 included patients receiving supplemental benefits/services such as patients involved in work-activation schemes (LMA supplementary benefits). First week of return to work (RTW), stable LMA first year after RTW and weekly LMA prevalence were calculated. Patients and controls were compared using multivariable conditional logistic regression. RESULTS: LMA unemployment benefits had similar proportions to LMA with no benefits. These estimates were lower than LMA supplemental benefits where 52% attempted to RTW and 31% achieved stable LMA within 2 years. The maximal LMA prevalence (LMA supplementary benefits) decreased from 33 to 30% from years 2 to 5. Adjusted odds ratios were 0.05 and 0.06 for years 1 and 2, and 0.07 for stable LMA in patients compared to controls. CONCLUSION: LMA proportions differed depending on the definition. Regardless of definition, LMA proportions following severe TBI were low in Denmark.

Diurnal and day-to-day variation of isometric muscle strength in myasthenia gravis.

INTRODUCTION: In patients with myasthenia gravis (MG), muscle strength is expected to decrease gradually during the day due to physical activities. METHODS: Isometric muscle strength at the shoulder, knee, and ankle was determined in 10 MG patients (MGFA class II-IV) who were receiving usual medical treatment and in 10 control subjects. To determine diurnal and day-to-day variation, muscle strength was measured 4 times during day 1 and once at day 2. RESULTS: Knee extension strength decreased during the day in both patients and controls. Neither diurnal nor day-to-day variation of muscle strength was higher in patients compared with controls. CONCLUSIONS: Patients with mild to moderate MG did not have increased variation of isometric muscle strength during the day or from day-to-day compared with controls. This suggests that isometric muscle performance can be determined with high reproducibility in similar groups of MG patients without regard to time of day.

Tympanic ear thermometer assessment of body temperature among patients with cognitive disturbances. An acceptable and ethically desirable alternative?

AIM: Investigation of a possible relation between body temperature measurements by the current generation of tympanic ear and rectal thermometers. BACKGROUND: In Denmark, a national guideline recommends the rectal measurement. Subsequently, the rectal thermometers and tympanic ear devices are the most frequently used and first choice in Danish hospital wards. Cognitive changes constitute challenges with cooperating in rectal temperature assessments. With regard to diagnosing, ethics, safety and the patients' dignity, the tympanic ear thermometer might comprise a desirable alternative to rectal noninvasive measurement of body temperature during in-hospital-based neurorehabilitation. DESIGN: A prospective, descriptive cohort study. Consecutive inclusion of 27 patients. Linear regression models were used to analyse 284 simultaneous temperature measurements. ETHICS: Ethical approval for this study was granted by the Danish Data Protection Agency, and the study was completed in accordance with the Helsinki Declaration 2008. RESULTS: About 284 simultaneous rectal and ear temperature measurements on 27 patients were analysed. The patient-wise variability of measured temperatures was significantly higher for the ear measurements. Patient-wise linear regressions for the 25 patients with at least three pairs of simultaneous ear and rectal temperature measurements showed large interpatient variability of the association. CONCLUSION: A linear relationship between the rectal body temperature assessment and the temperature assessment employing the tympanic thermometer is weak. Both measuring methods reflect variance in temperature, but ear measurements showed larger variation.

External Validation of a Dynamic Prediction Model for Upper Limb Function After Stroke.

Objective: To externally validate the dynamic prediction model for prediction of upper limb (UL) function 6 months after stroke. The dynamic prediction model has been developed and cross-validated on data from 4 Dutch studies. Design: Data from a prospective Danish cohort study were used to assess prediction accuracy. Setting: A Danish neurorehabilitation hospital. Participants: In this external validation study, follow-up data for 80 patients in the subacute phase after stroke (N=80), mean age 64 (SD11), 43% women, could be obtained. They were assessed at 2 weeks, 3 months, and 6 months after stroke with the Action Research Arm Test (ARAT), Fugl-Meyer Motor Assessment upper limb (FMA), and Shoulder Abduction (SA) Finger Extension (FE), (SAFE) test. Intervention: Not applicable. Main Outcome Measures: Prediction accuracy at 6 months was examined for 3 categories of ARAT (0-57 points): mild (48-57), moderate (23-47), and severe (0-22). Two individual predictions of ARAT scores at ±6 months post-stroke were computed based on, respectively, baseline (2 weeks) and 3 months ARAT, FE, SA values. The absolute individual differences between observed and predicted ARAT scores were summarized. Results: The prediction model performed best for patients with relatively good UL motor function, with an absolute error median (IQR) of 3 (2-9), and worst for patients with severe UL impairment, with a median (IQR) of 30 (3-39) at baseline. In general, prediction accuracy substantially improved when data obtained 3 months after stroke was included compared with baseline at 2 weeks after stroke. Conclusion: We found limited clinical usability due to the lack of prediction accuracy 2 weeks after stroke and for patients with severe UL impairments. The dynamic prediction model could probably be refined with data from biomarkers.

The Effect of Coordinating the Outpatient Treatment across Medical Specialities for Patients With Multimorbidity.

Introduction: Patients with multimorbidity attend multiple outpatient clinics. We assessed the effects on hospital use of scheduling several outpatient appointments to same-day visits in a multidisciplinary outpatient pathway (MOP). Methods: This study used a quasi-experimental design. Eligible patients had multimorbidity, were aged ≥18 years and attended ≥2 outpatient clinics in five different specialties. Patients were identified through forthcoming appointments from August 2018 to March 2020 and divided into intervention group (alignment of appointments) and comparison group (no alignment). We used patient questionnaires and paired analyses to study care integration and treatment burden. Using negative binomial regression, we estimated healthcare utilisation as incidence rates ratios (IRRs) at one year before and one year after baseline for both groups and compared IRR ratios (IRRRs). Results: Intervention patients had a 19% reduction in hospital visits (IRRR: 0.81, 95% CI: 0.70-0.96) and a 17% reduction in blood samples (IRRR: 0.83, 0.73-0.96) compared to comparison patients. No effects were found for care integration, treatment burden, outpatient contacts, terminated outpatient trajectories, hospital admissions, days of admission or GP contacts. Conclusion: The MOP seemed to reduce the number of hospital visits and blood samples. These results should be further investigated in studies exploring the coordination of outpatient care for multimorbidity. Research question: Can an intervention of coordinating outpatient appointments to same-day visits combined with a multidisciplinary conference influence the utilisation of healthcare services and the patient-assessed integration of healthcare services and treatment burden among patients with multimorbidity?

Serum neurofilament light chain, inflammatory markers, and kynurenine metabolites in patients with persistent post-concussion symptoms: A cohort study.

BACKGROUND: Concussion leads to persistent post-concussion symptoms (PPCS) in up to one-third of those affected. While previous research has linked the initial trauma to elevated serum levels of neurofilament light chain (NFL), inflammatory markers, and neurotoxic metabolites within the kynurenine pathway, few studies have explored their relevance in PPCS. This study aims to investigate these biomarkers in PPCS patients, elucidating their relevance in the prolonged phase of concussion. METHODS: Serum samples from 86 PPCS individuals aged 18-30 years, 2-6 months post-trauma were analyzed, with 54 providing follow-up samples after seven months. NFL was measured using single-molecule array (Simoa) technology, 13 inflammatory markers via a Luminex immunoassay, and five kynurenine metabolites using liquid chromatography-mass spectrometry. A control group of 120 healthy anonymous blood donors was recruited for comparison. RESULTS: No significant NFL differences were found in PPCS participants compared with healthy individuals (p = 0.22). Intriguingly, a subset (9.3%) of PPCS participants initially exhibited abnormally high NFL levels (>9.7 pg/mL), which normalized upon follow-up (p = 0.032). Additionally, serum levels of the inflammatory markers, monocyte chemoattractant protein-1 (MCP-1/CCL2), and eotaxin-1/CCL11 were 25-40% lower than in healthy individuals (p ≤ 0.001). As hypothesized, PPCS participants exhibited a 22% reduction in the ratio of kynurenic acid to quinolinic acid (neuroprotective index) (p < 0.0001), indicating a shift towards the formation of neurotoxic metabolites. CONCLUSION: NFL may serve as a biomarker to monitor recovery, and future studies should investigate the potential therapeutic benefits of modulating the kynurenine pathway to improve PPCS.

Subacute prognosis of oral nutrition (SPOON): Development of a multivariable prognostic model for complete oral intake in tube-fed subjects with acquired brain injury.

BACKGROUND & AIMS: Enteral feeding is very common following an acquired brain injury. However, no prognostic models for oral food intake have been developed for subacute rehabilitation. The aim of this study was to develop a prognostic model and online tool, coined "subacute prognosis of oral nutrition" (SPOON), for complete oral intake in tube-fed subjects with acquired brain injury. METHODS: The model was developed using routinely gathered clinical data from a cohort of 1233 adult patients who were tube-fed at admission for sub-acute inpatient rehabilitation. Candidate predictors were included based on scientific evidence and their availability in the medical records within the first days following admission. The outcome was time until achieving complete oral food intake without any tube-feeding supplements. Time until complete oral intake was analyzed by discrete time-to-event analysis with logit-link and presented as daily odds ratios (OR) with 95% confidence intervals (CI). RESULTS: The following predictors of complete oral intake were included in the model: age, diagnosis, cuffed tracheostomy tube, days from injury to admission for rehabilitation, and the Early Functional Abilities (EFA) sum score. Multiple adjusted analyses were performed stratified by cuffed tracheostomy tube status. Some of the strongest predictors of complete oral intake were age 18-40 years, OR 1.99 (95%CI: 1.53; 2.59); 0-2 weeks since injury, OR 3.75 (95%CI: 2.72; 5.16); and EFA 61-100 (slight/no disturbance in function), OR 5.81 (95%CI: 4.47; 7.55). The online prognostic tool SPOON was evaluated in a usability study. Based on feedback from clinicians, the tool was further refined to enable extraction of data for prediction directly from medical records. CONCLUSIONS: The objective of SPOON is to complement the planning of rehabilitation initiatives and inform discussions to determine if a percutaneous endoscopic gastrostomy (PEG) tube should be inserted. SPOON is being implemented locally, but external validation based on appropriate data modeling is warranted before further clinical implementation.

Exploring Physical Activity During the Discharge Transition Phase in People With Acquired Brain Injury-An Observational Study.

Objective: To explore physical activity trajectories during the discharge transition phase after in-hospital rehabilitation after acquired brain injury (ABI). Design: A cross-sectional observational study. Setting: Transition from an in-hospital rehabilitation center to community-based living. Participants: Independently walking patients with ABI (n=10) who were ready for discharge. Interventions: Not applicable. Main Outcome Measures: Two weeks of physically active time continuously monitored with an accelerometer and classified by a machine learning algorithm summed as daily average and total active time for each participant and classified into standing, walking, running, bike riding, stair climbing, ambulation, and sedentary time. Physical activity trajectories showing the total daily active time for all participants were inspected before and after discharge, and the average active time per participant was plotted against self-reported scores of potentially explanatory factors. Results: Average total physically active time was 5:49 hours (range 4:26-7:13 hours). Average daily physically active time for participants appeared to be related to functional independence measure sub scores, fatigue, and pre-morbid physical activity level. Individual physical activity trajectories showed a decreased walking activity after discharge, which increased again after 1-2 days. Conclusions: Daily total physically active time among participants was higher than expected. Factors expectedly related to physical activity trajectories in the discharge transition phase were explored and showed some relation to functional scores.

Effect of telemonitoring on readmissions for acute exacerbation of chronic obstructive pulmonary disease: A randomized clinical trial.

INTRODUCTION: Acute exacerbations of chronic obstructive pulmonary disease are associated with high morbidity and mortality. Telemonitoring may reduce the frequency of hospitalization. The aim of this study was to investigate the effect of telemonitoring on hospitalization rates for acute exacerbations of chronic obstructive pulmonary disease. METHODS: Patients were recruited during hospitalization and equally randomized to telemonitoring or usual care. Telemonitoring participants recorded symptoms and monitored oxygen saturation, heart rate, peak expiratory flow, and body weight. Alerts were generated if readings breached thresholds. Acute exacerbations of chronic obstructive pulmonary disease hospitalizations during the 6 months intervention were compared using logistic regression, and time to first hospitalization was assessed using Cox proportional hazard modeling. The incidence rates for acute exacerbations of chronic obstructive pulmonary disease hospitalization were compared using a negative binomial regression model with between-group comparisons expressed as incidence rate ratios. The telemonitoring group was used as reference. RESULTS: A total of 222 patients were randomized. 37/112 (33%) in the control group and 31/110 (28%) in the telemonitoring group experienced acute exacerbations of chronic obstructive pulmonary disease hospitalization during the intervention period, odds ratio of 1.26, confidence interval 0.71-2.23, p = 0.4. No difference was seen in time to first hospitalization, hazard ratio 1.23, CI 0.77-1.99, p = 0.4. The number of hospitalizations in the intervention period was 66 in the control group and 42 in the telemonitoring group, with incidence rate ratio 1.42, confidence interval 1.04-1.95, p = 0.03. Adjustment for dyspnea score, smoking, and cohabitation status did not change the results, incidence rate ratio 1.44, confidence interval 1.05-1.99, p = 0.02. DISCUSSION: Patients who received telemonitoring experienced significantly fewer acute exacerbations of chronic obstructive pulmonary disease hospitalizations, although the overall risk of having at least one hospitalization and the time to first hospitalization was similar between the two groups.

The Danish Atrial Fibrillation Registry: A Multidisciplinary National Pragmatic Initiative for Monitoring and Supporting Quality of Care Based on Data Retrieved from Administrative Registries.

Aim: The Danish Atrial Fibrillation (AF) Registry monitors and supports improvement of quality of care for all AF patients in Denmark. This report describes the registry's administrative and organizational structure, data sources, data flow, data analyses, annual reporting, and feedback between the registry, clinicians, and the administrative system. We also report the selection process of the quality indicators and the temporal trends in results from 2017-2021. Methods and Results: The Danish AF Registry aims for complete registration and monitoring of care for all patients diagnosed with AF in Denmark. Administrative registries provide data on contacts to general practice, contacts to private cardiology practice, hospital contacts, medication prescriptions, updated vital status information, and biochemical test results. The Danish Stroke Registry provides information on stroke events. From 2017 to 2021, the proportion with a reported echocardiography among incident AF patients increased from 39.9% (95% CI: 39.3-40.6) to 82.6% (95% CI: 82.1-83.1). The initiation of oral anticoagulant therapy among patients with incident AF and a CHA2DS2-VASc score of ≥1 in men and ≥2 in women increased from 85.3% (95% CI: 84.6-85.9) to 90.4% (95% CI: 89.9-91.0). The 1-year and 2-year persistence increased from 85.2% (95% CI: 84.5-85.9) to 88.7% (95% CI: 88.0-89.3), and from 85.4% (95% CI: 84.7-86.2) to 88.2% (95% CI: 87.5-88.8), respectively. The 1-year risk of ischemic stroke among prevalent patients with AF decreased from 0.88% (95% CI: 0.83-0.93) to 0.71% (95% CI: 0.66-0.75). Variation in clinical performance between the five administrative Danish regions was reduced. Conclusion: Continuous nationwide monitoring of quality indicators for AF originating from administrative registries is feasible and supportive of improvements of quality of care.

Interdisciplinary intervention (GAIN) for adults with post-concussion symptoms: a study protocol for a stepped-wedge cluster randomised trial.

BACKGROUND: Persistent post-concussion symptoms (PCS) are associated with prolonged disability, reduced health-related quality of life and reduced workability. At present, no strong evidence for treatments for people with persistent PCS exists. Our research group developed a novel intervention, "Get going After concussIoN (GAIN)", that incorporates multiple evidence-based strategies including prescribed exercise, cognitive behavioural therapy, and gradual return to activity advice. In a previous randomised trial, GAIN provided in a hospital setting was effective in reducing symptoms in 15-30-year-olds with PCS 2-6 months post-injury. In the current study, we describe the protocol for a trial designed to test the effectiveness of GAIN in a larger municipality setting. Additionally, we test the intervention within a broader age group and evaluate a broader range of outcomes. The primary hypothesis is that participants allocated to enhanced usual care plus GAIN report a higher reduction in PCS 3 months post-intervention compared to participants allocated to enhanced usual care only. METHODS: The study is a stepped-wedge cluster-randomised trial with five clusters. The 8-week interdisciplinary GAIN program will be rolled out to clusters in 3-month intervals. Power calculation yield at least 180 participants to be enrolled. Primary outcome is mean change in PCS measured by the Rivermead Post-Concussion Symptoms Questionnaire from enrolment to 3 months after end of treatment. Secondary outcomes include participation in and satisfaction with everyday activities, labour market attachment and other behavioural measures. Self-reported outcomes are measured at baseline, by end of treatment and at 3, 6, and 18 months after end of treatment. Registry-based outcomes are measured up to 36 months after concussion. DISCUSSION: The trial will provide important information concerning the effectiveness of the GAIN intervention in a municipality setting. Furthermore, it will provide knowledge of possible barriers and facilitators that may be relevant for future implementation of GAIN in different settings. TRIAL REGISTRATION: The current GAIN trial is registered in ClinicalTrials.gov (study identifier: NCT04798885 ) on 20 October 2020.

Shoulder function after constraint-induced movement therapy assessed with 3D kinematics and clinical and patient reported outcomes: A prospective cohort study.

INTRODUCTION: We hypothesised that reduced shoulder function post stroke improves during constraint-induced movement therapy and that improvement in scapula upward rotation measured with three-dimensional kinematics is associated with improvements in clinical and patient reported outcomes. METHODS: Thirty-seven patients were tested pre and post constraint-induced movement therapy and again at three-month follow-up. Kinematic outcome measures - with scapula upward rotation as the primary outcome - during tasks 5 (ReachLow) and 6 (ReachHigh) from the Wolf Motor Function Test were included together with clinical and patient reported outcomes. Changes in outcome measures were analysed with linear mixed models and logistic regression analysis. FINDINGS: Scapula upward rotation was reduced from 16.2° pre intervention through 15.9° post intervention to 15.6° at three-month follow-up during ReachHigh. Statistically significant reductions of <2° were also found for shoulder flexion during ReachLow and trunk lateral flexion during ReachHigh. The clinical and patient reported outcomes showed improvements post constraint-induced movement therapy, and at follow-up, the outcomes resembled post values. INTERPRETATION: The minimal improvements in selected 3D kinematic measures of upper extremity movements did not reflect any clinically meaningful changes. Therefore, the clinical and patient reported improvements could not be related to restitution of shoulder function.