Surprising simplicities and syntheses in limbless self-propulsion in sand.

Animals moving on and in fluids and solids move their bodies in diverse ways to generate propulsion and lift forces. In fluids, animals can wiggle, stroke, paddle or slap, whereas on hard frictional terrain, animals largely engage their appendages with the substrate to avoid slip. Granular substrates, such as desert sand, can display complex responses to animal interactions. This complexity has led to locomotor strategies that make use of fluid-like or solid-like features of this substrate, or combinations of the two. Here, we use examples from our work to demonstrate the diverse array of methods used and insights gained in the study of both surface and subsurface limbless locomotion in these habitats. Counterintuitively, these seemingly complex granular environments offer certain experimental, theoretical, robotic and computational advantages for studying terrestrial movement, with the potential for providing broad insights into morphology and locomotor control in fluids and solids, including neuromechanical control templates and morphological and behavioral evolution. In particular, granular media provide an excellent testbed for a locomotion framework called geometric mechanics, which was introduced by particle physicists and control engineers in the last century, and which allows quantitative analysis of alternative locomotor patterns and morphology to test for control templates, optimality and evolutionary alternatives. Thus, we posit that insights gained from movement in granular environments can be translated into principles that have broader applications across taxa, habitats and movement patterns, including those at microscopic scales.

The Optimization of an eHealth Solution (Thought Spot) with Transition-Aged Youth in Postsecondary Settings: Participatory Design Research.

BACKGROUND: Seventy percent of lifetime cases of mental illness emerge before the age of 24 years, but many youth are unable to access the support and services they require in a timely and appropriate way. With most youth using the internet, electronic health (eHealth) interventions are promising tools for reaching this population. Through participatory design research (PDR) engagement methods, Thought Spot, a Web- and mobile-based platform, was redeveloped to facilitate access to mental health services by transition-aged youth (aged 16-29 years) in postsecondary settings. OBJECTIVE: The aim of this study was to describe the process of engaging with postsecondary students through the PDR approaches, with the ultimate goal of optimizing the Thought Spot platform. METHODS: Consistent with the PDR approaches, five student-led workshops, attended by 41 individuals, were facilitated to obtain feedback regarding the platform's usability and functionality and its potential value in a postsecondary setting. Various creative engagement activities were delivered to gather experiences and opinions, including semistructured focus groups, questionnaires, personas, journey mapping, and a world café. Innovative technological features and refinements were also brainstormed during the workshops. RESULTS: By using PDR methods of engagement, participants knew that their ideas and recommendations would be applied. There was also an overall sense of respect and care integrated into each group, which facilitated an exchange of ideas and suggestions. CONCLUSIONS: The process of engaging with students to redesign the Thought Spot platform through PDR has been effective. Findings from these workshops will significantly inform new technological features within the app to enable positive help-seeking behaviors among students. These behaviors will be further explored in the second phase that involves a randomized controlled trial.

Effectiveness of the YourCall™ text message intervention to reduce harmful drinking in patients discharged from trauma wards: protocol for a randomised controlled trial.

BACKGROUND: Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care. METHODS/DESIGN: Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Maori compared with non-Maori). DISCUSSION: If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking. TRIAL REGISTRATION: Universal Trial Number (UTN) U1111-1134-0028. ACTRN12612001220853 . Submitted 8 November 2012 (date of enrolment of first participant); Version 1 registration confirmed 19 November 2012. Retrospectively registered.

Emergence of the advancing neuromechanical phase in a resistive force dominated medium.

Undulatory locomotion, a gait in which thrust is produced in the opposite direction of a traveling wave of body bending, is a common mode of propulsion used by animals in fluids, on land, and even within sand. As such, it has been an excellent system for discovery of neuromechanical principles of movement. In nearly all animals studied, the wave of muscle activation progresses faster than the wave of body bending, leading to an advancing phase of activation relative to the curvature toward the tail. This is referred to as "neuromechanical phase lags" (NPL). Several multiparameter neuromechanical models have reproduced this phenomenon, but due to model complexity, the origin of the NPL has proved difficult to identify. Here, we use perhaps the simplest model of undulatory swimming to predict the NPL accurately during sand-swimming by the sandfish lizard, with no fitting parameters. The sinusoidal wave used in sandfish locomotion, the friction-dominated and noninertial granular resistive force environment, and the simplicity of the model allow detailed analysis, and reveal the fundamental mechanism responsible for the phenomenon: the combination of synchronized torques from distant points on the body and local traveling torques. This general mechanism should help explain the NPL in organisms in other environments; we therefore propose that sand-swimming could be an excellent system with which to generate and test other neuromechanical models of movement quantitatively. Such a system can also provide guidance for the design and control of robotic undulatory locomotors in complex environments.

Controlled preparation of wet granular media reveals limits to lizard burial ability.

Many animals move within ground composed of granular media (GM); the resistive properties of such substrates can depend on water content and compaction, but little is known about how such parameters affect locomotion or the physics of drag and penetration. Using apparatus to control compaction of GM, our recent studies of movement in dry GM have revealed locomotion strategies of specialized dry-sand-swimming reptiles. However, these animals represent a small fraction of the diversity and presumed burial strategies of fossorial reptilian fauna. Here we develop a system to create states of wet GM of varying moisture content and compaction in quantities sufficient to study the burial and subsurface locomotion of the Ocellated skink (C. ocellatus), a generalist lizard. X-ray imaging revealed that in wet and dry GM the lizard slowly buried (≈30 s) propagating a wave from head to tail, while moving in a start-stop motion. During forward movement, the head oscillated, and the forelimb on the convex side of the body propelled the animal. Although body kinematics and 'slip' were similar in both substrates, the burial depth was smaller in wet GM. Penetration and drag force experiments on smooth cylinders revealed that wet GM was ≈4× more resistive than dry GM. In total, our measurements indicate that while the rheology of the dry and wet GM differ substantially, the lizard's burial motor pattern is conserved across substrates, while its burial depth is largely constrained by environmental resistance.

Locomotor benefits of being a slender and slick sand swimmer.

Squamates classified as 'subarenaceous' possess the ability to move long distances within dry sand; body elongation among sand and soil burrowers has been hypothesized to enhance subsurface performance. Using X-ray imaging, we performed the first kinematic investigation of the subsurface locomotion of the long, slender shovel-nosed snake (Chionactis occipitalis) and compared its biomechanics with those of the shorter, limbed sandfish lizard (Scincus scincus). The sandfish was previously shown to maximize swimming speed and minimize the mechanical cost of transport during burial. Our measurements revealed that the snake also swims through sand by propagating traveling waves down the body, head to tail. Unlike the sandfish, the snake nearly followed its own tracks, thus swimming in an approximate tube of self-fluidized granular media. We measured deviations from tube movement by introducing a parameter, the local slip angle, ßs, which measures the angle between the direction of movement of each segment and body orientation. The average ßs was smaller for the snake than for the sandfish; granular resistive force theory (RFT) revealed that the curvature utilized by each animal optimized its performance. The snake benefits from its slender body shape (and increased vertebral number), which allows propagation of a higher number of optimal curvature body undulations. The snake's low skin friction also increases performance. The agreement between experiment and RFT combined with the relatively simple properties of the granular 'frictional fluid' make subarenaceous swimming an attractive system to study functional morphology and bauplan evolution.

Development of a text message intervention aimed at reducing alcohol-related harm in patients admitted to hospital as a result of injury.

BACKGROUND: Screening for alcohol misuse and brief interventions (BIs) for harm in trauma care settings are known to reduce alcohol intake and injury recidivism, but are rarely implemented. We created the content for a mobile phone text message BI service to reduce harmful drinking among patients admitted to hospital following an injury who screen positive for hazardous alcohol use. The aim of this study was to pre-test and refine the text message content using a robust contextualisation process ahead of its formal evaluation in a randomised controlled trial. METHODS: Pre-testing was conducted in two phases. First, in-depth interviews were conducted with 14 trauma inpatients (16-60 years) at Auckland City Hospital and five key informants. Participants were interviewed face-to-face using a semi-structured interview guide. Topics explored included: opinions on text message ideas and wording, which messages did or did not work well and why, interactivity of the intervention, cultural relevance of messages, and tone of the content. In a second phase, consultation was undertaken with Maori (New Zealand's indigenous population) and Pacific groups to explore the relevance and appropriateness of the text message content for Maori and Pacific audiences. RESULTS: Factors identified as important for ensuring the text message content was engaging, relevant, and useful for recipients were: reducing the complexity of message content and structure; increasing the interactive functionality of the text message programme; ensuring an empowering tone to text messages; and optimising the appropriateness and relevance of text messages for Maori and Pacific people. The final version of the intervention (named 'YourCall(™)') had three pathways for people to choose between: 1) text messages in English with Te Reo (Maori language) words of welcome and encouragement, 2) text messages in Te Reo Maori, and 3) text messages in English (with an option to receive a greeting in Samoan, Tongan, Cook Island Maori, Niuean, Tokelauan, Tuvaluan, or Fijian). CONCLUSIONS: We have developed a text message intervention underpinned by established BI evidence and behaviour change theory and refined based on feedback and consultation. The next step is evaluation of the intervention in a randomised-controlled trial.

Environmental interaction influences muscle activation strategy during sand-swimming in the sandfish lizard Scincus scincus.

Animals like the sandfish lizard (Scincus scincus) that live in desert sand locomote on and within a granular medium whose resistance to intrusion is dominated by frictional forces. Recent kinematic studies revealed that the sandfish utilizes a wave of body undulation during swimming. Models predict that a particular combination of wave amplitude and wavelength yields maximum speed for a given frequency, and experiments have suggested that the sandfish targets this kinematic waveform. To investigate the neuromechanical strategy of the sandfish during walking, burial and swimming, here we use high-speed X-ray and visible light imaging with synchronized electromyogram (EMG) recordings of epaxial muscle activity. While moving on the surface, body undulation was not observed and EMG showed no muscle activation. During subsurface sand-swimming, EMG revealed an anterior-to-posterior traveling wave of muscle activation which traveled faster than the kinematic wave. Muscle activation intensity increased as the animal swam deeper into the material but was insensitive to undulation frequency. These findings were in accord with empirical force measurements, which showed that resistance force increased with depth but was independent of speed. The change in EMG intensity with depth indicates that the sandfish targets a kinematic waveform (a template) that models predict maximizes swimming speed and minimizes the mechanical cost of transport as the animal descends into granular media. The differences in the EMG pattern compared with EMG of undulatory swimmers in fluids can be attributed to the friction-dominated intrusion forces of granular media.

Mechanics of undulatory swimming in a frictional fluid.

The sandfish lizard (Scincus scincus) swims within granular media (sand) using axial body undulations to propel itself without the use of limbs. In previous work we predicted average swimming speed by developing a numerical simulation that incorporated experimentally measured biological kinematics into a multibody sandfish model. The model was coupled to an experimentally validated soft sphere discrete element method simulation of the granular medium. In this paper, we use the simulation to study the detailed mechanics of undulatory swimming in a "granular frictional fluid" and compare the predictions to our previously developed resistive force theory (RFT) which models sand-swimming using empirically determined granular drag laws. The simulation reveals that the forward speed of the center of mass (CoM) oscillates about its average speed in antiphase with head drag. The coupling between overall body motion and body deformation results in a non-trivial pattern in the magnitude of lateral displacement of the segments along the body. The actuator torque and segment power are maximal near the center of the body and decrease to zero toward the head and the tail. Approximately 30% of the net swimming power is dissipated in head drag. The power consumption is proportional to the frequency in the biologically relevant range, which confirms that frictional forces dominate during sand-swimming by the sandfish. Comparison of the segmental forces measured in simulation with the force on a laterally oscillating rod reveals that a granular hysteresis effect causes the overestimation of the body thrust forces in the RFT. Our models provide detailed testable predictions for biological locomotion in a granular environment.

Let's just ask them. Perspectives on urban dwelling and air quality: A cross-sectional survey of 3,222 children, young people and parents.

This research aimed to capture and synthesise the views of children, young people, parents and expectant parents (CYPP) about the cities where they live, with a specific focus on air pollution (AP), in order to support the generation of evidence-informed policy that reflects CYPP's perspectives, ultimately contributing to the development of child-centered, healthier, sustainable cities. The Children, Cities and Climate (CCC) project used targeted social media adverts to recruit CYPP to complete an online survey with a combination of open and closed questions in order to collect perceptions about air quality in their home cities, the main sources of AP, and how they would improve their cities. The survey was completed by 3,222 CYPP in 59 of the most polluted cities in 14 countries. Nearly two in five (39%) CYPP cited AP as one of the worst things about their city, with motor transport perceived as the main contributor. CYPP reported differing views on whether their cities were becoming better (43%) or worse (34%) places to live (33% reported it was 'staying the same'). Numerous specific ideas to improve cities and urban air quality emerged, alongside an emphasis on also addressing structural barriers to change. A clear set of principles that should guide how city leaders act was also described, including the need to engage with young people meaningfully. CYPPs articulated good and bad experiences of urban living and perceived AP and traffic as pressing concerns. They provided a clear set of suggestions for improving their cities. Further efforts to engage young people on these issues are warranted.

Mild traumatic brain injury: improving quality of care in the paediatric emergency department setting.

AIM: Traumatic brain injury (TBI) in childhood can impose a significant threat to life and longer-term disability. This study investigated the extent to which the documentation of key indicators of healthcare quality in the emergency department (ED) setting was consistent with clinical guidelines for the management of children with mild TBI (MTBI). METHODS: The clinical records of a random sample of 60 children (stratified by ethnicity and age group), who were seen and discharged from a large metropolitan paediatric hospital ED following a head injury, were systematically reviewed to examine the processes of care and follow-up. RESULTS: Based on the documentation in clinical records, processes designed to identify and manage potentially life-threatening acute complications (e.g. computed tomography scanning to identify intracranial haemorrhage) were consistent with best practice standards. However gaps existed between current and best practice for some aspects of care that could minimise risks of longer-term disability from MTBI. For example, relevant clinical criteria were well documented, but this information did not appear to be applied systematically to identify and to follow up children with definite or possible MTBI. CONCLUSION: The apparent absence of a systematic approach to the diagnosis and follow-up of MTBI in children presenting to ED suggests a missed opportunity to minimise the risk of disability following these injuries. Greater attention to an integrated care pathway that improves the identification, documentation, and follow-up of children with MTBI presenting to ED is required.

A health sector response to the commercial determinants of health.

AIM: To develop and apply a theoretical framework to assess the rigour of a district health organisation's response to the commercial determinants of health (CDoH). METHODS: The multi-method study incorporated literature reviews of CDoH strategies and ways in which organisations can respond; policy document review; and 12 qualitative, semi-structured, key informant interviews. RESULTS: A theoretical framework was developed summarising CDoH and potential responses. The organisation has relevant policies, including those concerning corporate relationships and conflict of interest; however, there are opportunities to strengthen policy content and processes. Key themes were identified based on key informants' perceptions: 1) disconnect between community impacts of harmful commodities and awareness/action on CDoH drivers of these impacts; 2) power imbalance between harmful commodity industries and communities; and 3) need for a robust, values-based, Tiriti-aligned response to CDoH. CONCLUSIONS: The health sector has an important role to play in redressing the power imbalance between harmful commodity industries and communities. Responses include: raising awareness about CDoH; strengthening policies related to interactions with corporations, and in particular considering alignment of values; supporting community actions; and advocating for legislative changes which restrict the power of harmful industries and support healthy environments and communities.

A Web-Based Alcohol Risk Communication Tool: Development and Pretesting Study.

BACKGROUND: Alcohol use is a major public health concern associated with an increased risk of morbidity and mortality. Health professionals in primary care commonly see patients with a range of alcohol-related risks and problems, providing an ideal opportunity for screening and brief intervention (BI). OBJECTIVE: This study aimed to develop a prototype for a Web-based tool for use by primary care health professionals (eg, doctors and nurses) to communicate alcohol harm risk to their patients and to engage with them regarding ways this risk could be reduced. METHODS: Following conceptualization and development of prototype wireframes, formative work and pretesting were undertaken. For the formative work, focus groups and key informant interviews were conducted with potential end users of the risk communication tool, including health professionals and consumers. The focus groups and interviews explored perceptions of alcohol risk communication and obtained feedback on the initial prototype. For pretesting, participants (primary care doctors and nurses) completed a Web-based survey followed by a period of pretesting before completion of a follow-up survey. The study was designed to gain feedback on the tool's performance in real-world settings as well as its relevance, ease of use, and any suggested refinements. RESULTS: In the formative work stage, 11 key informants and 7 consumers participated in either focus groups or individual interviews. Participants were very positive about the prototype and believed that it would be useful and acceptable in practice. Key informants identified that the key point of difference with the tool was that it provided all the pieces in 1 place (ie, assessment, interpretation, and resources to support change). Participants provided feedback on how the tool could be improved, and these suggestions were incorporated into the prototype where possible. In the pretesting stage, 7 people (5 doctors and 2 primary care nurses) completed the pretesting. Participants reported that the tool provided a useful framework for an intervention, that it would be acceptable to patients, that it was easy to use, that they would be likely to use it in practice, and that there were no technical issues. CONCLUSIONS: The alcohol risk communication tool was found to be acceptable and has the potential to increase the confidence of health professionals in assessing risk and providing BI.

Effect of a text message intervention on alcohol-related harms and behaviours: secondary outcomes of a randomised controlled trial.

OBJECTIVE: Mobile Health approaches show promise as a delivery mode for alcohol screening and brief intervention. The 'YourCall' trial evaluated the effect of a low-intensity mobile phone text message brief intervention compared with usual care on hazardous drinking and alcohol-related harms among injured adults. This paper extends our previously published primary outcome analysis which revealed a significant reduction in hazardous drinking associated with the intervention at 3 months, with the effect maintained across 12 months follow-up. The objective of the current study was to evaluate the effect of the intervention on alcohol-related harms and troubles and help-seeking behaviours (secondary outcomes) at 12-months follow-up. RESULTS: A parallel two-group, single-blind, randomised controlled trial was conducted in 598 injured inpatients aged 16-69 years identified as having medium-risk hazardous drinking. Logistic regression models applied to 12-month follow-up data showed no significant differences between intervention and control groups in self-reported alcohol-related harms and troubles and help-seeking behaviours. Although this text message intervention led to a significant reduction in hazardous alcohol consumption (previously published primary outcome), changes in self-reported alcohol-related harms and troubles and help seeking behaviours at 12-months follow up (secondary outcomes) were small and non-significant. TRIAL REGISTRATION: ACTRN12612001220853. Retrospectively registered 19 November 2012.

Using Exploratory Trials to Identify Relevant Contexts and Mechanisms in Complex Electronic Health Interventions: Evaluating the Electronic Patient-Reported Outcome Tool.

BACKGROUND: Designing appropriate studies for evaluating complex interventions, such as electronic health solutions to support integrated care, remains a methodological challenge. With the many moving parts of complex interventions, it is not always clear how program activities are connected to anticipated and unanticipated outcomes. Exploratory trials can be used to uncover determinants (or mechanisms) to inform content theory that underpins complex interventions before designing a full evaluation plan. OBJECTIVE: A multimethod exploratory trial of the electronic patient-reported outcome (ePRO) tool was conducted to uncover contexts, processes and outcome variables, and the mechanisms that link these variables before full-scale evaluation. ePRO is a mobile app and portal designed to support goal-oriented care in interdisciplinary primary health care practices (clinical-level integration). This paper offers evaluation findings and methodological insight on how to use exploratory trial data to identify relevant context, process, and outcome variables, as well as central (necessary to achieving outcomes) versus peripheral (less critical and potentially context dependent) mechanisms at play. METHODS: The 4-month trial was conducted in 2 primary health care practices in Toronto, Canada. The patients were randomized into control and intervention groups and compared pre and post on quality of life and activation outcome measures. Semistructured interviews were conducted with providers and patients in the intervention group. Narrative analysis was used to uncover dominant mechanisms that inform the intervention's content theory (how context and process variables are linked to outcomes). RESULTS: Overall, 7 providers, 1 administrator, and 16 patients (7-control, 9-intervention) participated in the study. This study uncovered many complex and nuanced context, process, and outcome variables at play in the intervention. Narrative analysis of patient and provider interviews revealed dominant story lines that help to tease apart central and peripheral mechanisms driving the intervention. Provider and patient story lines centered around fitting the new intervention into everyday work and life of patients and providers and meaningfulness of the intervention. These themes were moderated by patient-provider relationships going into and throughout the intervention, their comfort with technology, and the research process. CONCLUSIONS: Identifying dominant story lines using narrative analysis helps to identify the most relevant context and process variables likely to influence study outcomes. Normalization process theory emerges as a useful theory to uncover underlying mechanisms because of its emphasis on the social production and normalization of technological, processual, and social aspects of work; all found to be critical to our intervention. The number of complex, overlapping influencing variables suggests that complex interventions such as ePRO require us to pay careful attention to central versus peripheral mechanisms that will influence study outcomes. The narrative methods presented here are shown to be useful in uncovering these mechanisms and help to guide subsequent larger evaluation studies.

Determination of a lorazepam dose threshold for using the osmol gap to monitor for propylene glycol toxicity.

STUDY OBJECTIVE: To determine a threshold dose for parenteral lorazepam when screening for propylene glycol toxicity with the osmol gap, and to characterize which osmol gap values are more predictive of toxic propylene glycol concentrations and resultant clinical toxicity. DESIGN: Prospective, two-phase observational study. SETTING: Thirty-two bed, multidisciplinary intensive care unit. PATIENTS: Thirty-five adult patients receiving any dose of parenteral lorazepam (phase 1), and 14 patients receiving lorazepam in doses of 1 mg/kg/day or higher (phase 2). MEASUREMENTS AND MAIN RESULTS: Serum osmolality was measured every other day during lorazepam therapy, and the osmol gap (measured osmolality minus calculated osmolarity) was determined. A serum propylene glycol concentration was obtained when the osmol gap first exceeded 10. In phase 1, 35 patients were monitored for 186 patient-days. Ten patients (29%) developed an osmol gap greater than 10; only one (10%) of these patients had propylene glycol concentrations greater than 18 mg/dl. In phase 2, 14 patients received lorazepam at a median dose of 631 mg (interquartile range [IQR] 437-972 mg) over a median of 5.5 days (IQR 4-8.75 days). Nine patients (64%) had propylene glycol concentrations greater than 18 mg/dl; six (67%) of these nine developed transient acute kidney injury, metabolic acidosis, or both. The correlation between osmol gap and propylene glycol concentration was 0.44 (p=0.006). An osmol gap of 10 or greater had a likelihood ratio of 4.4 to predict a propylene glycol concentration greater than 18 mg/dl. An osmol gap of 12 or greater had a likelihood ratio of 2.7 to predict the development of possible propylene glycol clinical toxicity. CONCLUSION: Screening for propylene glycol toxicity with the osmol gap may be helpful for patients receiving intravenous lorazepam in doses of 1 mg/kg/day or higher. An osmol gap of 10 or greater was predictive of elevated propylene glycol concentrations, and values of 12 or greater were predictive of clinical changes suggestive of propylene glycol toxicity.

Effect of a text message intervention to reduce hazardous drinking among injured patients discharged from a trauma ward: a randomized controlled trial.

Screening and brief intervention for hazardous alcohol use in trauma care settings is known to reduce alcohol intake and injury recidivism, but is often not implemented due to resource constraints. Brief interventions delivered by mobile phone could overcome this challenge. This study aimed to evaluate the effect of a mobile phone text message intervention (YourCallTM) on hazardous drinkers admitted for an injury. The parallel two-group, single-blind, randomised controlled trial enrolled 598 injured patients aged 16-69 years identified as medium-risk drinkers at recruitment. The intervention group (n = 299) received 16 text messages incorporating brief intervention principles in the 4 weeks following discharge from hospital. Controls (n = 299) received usual care and one text message acknowledging participation in the trial. The primary outcome was the difference in hazardous alcohol use (assessed using AUDIT-C) between study groups at 3 months, with the maintenance of effect examined at 6 and 12 months' follow-up. Data were analysed using a mixed-effects model for repeated measures. Both groups had similar baseline features. Compared to controls, hazardous drinking was significantly lower in the intervention group at 3 months and maintained over the 12-month follow-up period (least squares mean difference in AUDIT-C scores: -0.322; 95% CI: -0.636, -0.008; p = 0.04). The intervention effect was similar among Maori (New Zealand's indigenous population) and non-Maori (interaction p = 0.59), and among younger (16-29 years) and older (30-69 years) patients (p = 0.77). The effectiveness of this intervention reflects the potential of low cost, scalable mobile health technologies to overcome common barriers in implementing alcohol harm reduction strategies following injury.

Mobile Web-Based Follow-up for Postoperative ACL Reconstruction: A Single-Center Experience.

BACKGROUND: The initial 6 weeks after surgery has been identified as an area for improvement in patient care. During this period, the persistence of symptoms that go unchecked can lead to unscheduled emergency room and clinic visits, calls to surgeons' offices, and readmissions. PURPOSE: To analyze postoperative data from a previous study examining postoperative outcomes in 2 patient populations following breast reconstruction and anterior cruciate ligament (ACL) reconstruction with use of a patient-centered mobile application. Here, the authors establish whether this method of follow-up can provide useful insight specific to the orthopaedic patient population, and they determine whether the mobile platform has the potential to modify their postoperative treatment. In addition, the authors examine its utility for orthopaedic physicians and patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eligible patients undergoing ACL reconstruction from 2 surgeons were consecutively recruited to use a mobile smartphone application that allowed physicians to monitor their recovery at home. Data from 32 patients were collected via the application and analyzed to evaluate recovery trends during the first 6 postoperative weeks. Following completion of the study, patients and physicians were interviewed on their experience. RESULTS: Data collected from each question in the mobile application provided insightful trends on daily real-time indicators of postoperative recovery. The application identified 1 patient who required in-person reassessment to rule out a possible infection, following surgeon review of an uploaded image. It was estimated that the majority of patients could have avoided follow-up at 2 and 6 weeks, owing to the application's efficacy. Participants described their satisfaction with the device as excellent (43%), good (40%), fair (10%), and poor (7%), and 94% (n = 30) of patients reported that they would respond to questions using a similar application in the future. Both physicians rated their experience as positive and identified useful traits in the web portal. CONCLUSION: This system can accurately assess patient recovery; it has the potential to change how postoperative orthopaedic patients are followed, and it is well received by patients and physicians. Recognition of the study's limitations and employment of user feedback to improve the current application are essential before a formal randomized controlled trial is conducted.

Texting during stair negotiation and implications for fall risk.

BACKGROUND/AIM: Walking requires the integration of the sensory and motor systems. Cognitive distractions have been shown to interfere with negotiation of complex walking environments, especially in populations at greater risk for falls (e.g. the elderly). With the pervasiveness of mobile messaging and the recent introduction of augmented reality mobile gaming, it is increasingly important to understand how distraction associated with the simultaneous use of a mobile device impacts navigation of the complex walking environments experienced in daily life. In this study, we investigated how gait kinematics were altered when participants performed a texting task during step negotiation. METHODS: Twenty participants (13 female, 7 males) performed a series of walking trials involving a step-deck obstacle, consisting of at least 3 texting trials and 3 non-texting trials. RESULTS: When texting, participants ascended more slowly and demonstrated reduced dual-step foot toe clearance. Participants similarly descended more slowly when texting and demonstrated reduced single-step foot heel clearance as well as reduced dual-step foot fore-aft heel clearance. CONCLUSION: These data support the conclusion that texting during stair negotiation results in changes to gait kinematics that may increase the potential for gait disruptions, falls, and injury. Further research should examine the effect texting has on performing other common complex locomotor tasks, actual fall risk, and the patterns of resulting injury rate and severity when negotiating complex environments.

Improving Patient Experience and Primary Care Quality for Patients With Complex Chronic Disease Using the Electronic Patient-Reported Outcomes Tool: Adopting Qualitative Methods Into a User-Centered Design Approach.

BACKGROUND: Many mHealth technologies do not meet the needs of patients with complex chronic disease and disabilities (CCDDs) who are among the highest users of health systems worldwide. Furthermore, many of the development methodologies used in the creation of mHealth and eHealth technologies lack the ability to embrace users with CCDD in the specification process. This paper describes how we adopted and modified development techniques to create the electronic Patient-Reported Outcomes (ePRO) tool, a patient-centered mHealth solution to help improve primary health care for patients experiencing CCDD. OBJECTIVE: This paper describes the design and development approach, specifically the process of incorporating qualitative research methods into user-centered design approaches to create the ePRO tool. Key lessons learned are offered as a guide for other eHealth and mHealth research and technology developers working with complex patient populations and their primary health care providers. METHODS: Guided by user-centered design principles, interpretive descriptive qualitative research methods were adopted to capture user experiences through interviews and working groups. Consistent with interpretive descriptive methods, an iterative analysis technique was used to generate findings, which were then organized in relation to the tool design and function to help systematically inform modifications to the tool. User feedback captured and analyzed through this method was used to challenge the design and inform the iterative development of the tool. RESULTS: Interviews with primary health care providers (n=7) and content experts (n=6), and four focus groups with patients and carers (n=14) along with a PICK analysis-Possible, Implementable, (to be) Challenged, (to be) Killed-guided development of the first prototype. The initial prototype was presented in three design working groups with patients/carers (n=5), providers (n=6), and experts (n=5). Working group findings were broken down into categories of what works and what does not work to inform modifications to the prototype. This latter phase led to a major shift in the purpose and design of the prototype, validating the importance of using iterative codesign processes. CONCLUSIONS: Interpretive descriptive methods allow for an understanding of user experiences of patients with CCDD, their carers, and primary care providers. Qualitative methods help to capture and interpret user needs, and identify contextual barriers and enablers to tool adoption, informing a redesign to better suit the needs of this diverse user group. This study illustrates the value of adopting interpretive descriptive methods into user-centered mHealth tool design and can also serve to inform the design of other eHealth technologies. Our approach is particularly useful in requirements determination when developing for a complex user group and their health care providers.