Barriers to healthcare access and experiences of stigma: Findings from a coproduced Long Covid case-finding study.

BACKGROUND AND AIM: Long Covid is often stigmatised, particularly in people who are disadvantaged within society. This may prevent them from seeking help and could lead to widening health inequalities. This coproduced study with a Community Advisory Board (CAB) of people with Long Covid aimed to understand healthcare and wider barriers and stigma experienced by people with probable Long Covid. METHODS: An active case finding approach was employed to find adults with probable, but not yet clinically diagnosed, Long Covid in two localities in London (Camden and Merton) and Derbyshire, England. Interviews explored the barriers to care and the stigma faced by participants and were analysed thematically. This study forms part of the STIMULATE-ICP Collaboration. FINDINGS: Twenty-three interviews were completed. Participants reported limited awareness of what Long Covid is and the available pathways to management. There was considerable self-doubt among participants, sometimes reinforced by interactions with healthcare professionals (HCPs). Participants questioned their deservedness in seeking healthcare support for their symptoms. Hesitancy to engage with healthcare services was motivated by fear of needing more investigation and concerns regarding judgement about the ability to carry out caregiving responsibilities. It was also motivated by the complexity of the clinical presentation and fear of all symptoms being attributed to poor mental health. Participants also reported trying to avoid overburdening the health system. These difficulties were compounded by experiences of stigma and discrimination. The emerging themes reaffirmed a framework of epistemic injustice in relation to Long Covid, where creating, interpreting and conveying knowledge has varied credibility based on the teller's identity characteristics and/or the level of their interpretive resources. CONCLUSION: We have codeveloped recommendations based on the findings. These include early signposting to services, dedicating protected time to listening to people with Long Covid, providing a holistic approach in care pathways, and working to mitigate stigma. Regardless of the diagnosis, people experiencing new symptoms must be encouraged to seek timely medical help. Clear public health messaging is needed among communities already disadvantaged by epistemic injustice to raise awareness of Long Covid, and to share stories that encourage seeking care and to illustrate the adverse effects of stigma. PATIENT OR PUBLIC CONTRIBUTION: This study was coproduced with a CAB made up of 23 members including HCPs, people with lived experience of Long Covid and other stakeholders.

Electromyographic activity in the shoulder musculature during resistance training exercises of the ipsilateral upper limb while wearing a shoulder orthosis.

BACKGROUND: Resistance training is usually postponed until 3 months after rotator cuff surgery to prevent the damaging effects of high muscle stress on the repaired tendon. After upper limb immobilization, noninjured muscles as well as the repaired muscles are affected by long-term inactivity. Exercises with minimal cuff activity may be appropriate in the early postoperative period, so we aimed to quantify the effect of resistance exercises on the muscle activity of a semi-immobilized upper limb. METHOD: Fifteen shoulder muscles of the dominant limb of 14 healthy subjects were evaluated by electromyography, with 11 surface electrodes and 4 fine-wire electrodes in the rotator cuff muscles. While wearing an orthosis, the subjects completed resistance tests including elbow and wrist flexion/extension with 3 loads, maximal squeezing, and shoulder adduction against 3 different foams. The peak activity of each muscle was normalized to maximal voluntary contraction (% MVC). RESULTS: Shoulder muscles were activated less than 20% MVC during elbow and wrist flexion/extension with 2-lb (907-g) and 4-lb (1814-g) loads. In the maximal squeezing test, rotator cuff activity exceeded 20% MVC in some cases. During shoulder adduction tests, subscapularis, latissimus dorsi, triceps, and pectoralis major had the highest activation levels; supraspinatus and infraspinatus were minimally activated. CONCLUSION: Supported elbow and wrist flexion/extension in the horizontal plane, with weights of up to 4 lb (1814 g), minimally activates the rotator cuff muscles while potentially preventing muscle disuse of other upper limb musculature. Resisted shoulder adduction cannot be considered safe for all rotator cuff injuries. LEVEL OF EVIDENCE: Basic science study, electromyography

Optimal shoulder immobilization postures following surgical repair of rotator cuff tears: a simulation analysis.

BACKGROUND: There is a high incidence of retear following surgical repair of rotator cuff tears. Postoperative shoulder immobilization is commonly prescribed to protect the repair; but there is no consensus on the best immobilization postures. METHODS: A generic musculoskeletal model of the shoulder was used to simulate postoperative immobilization of full thickness rotator cuff tears involving the supraspinatus only and the supraspinatus concomitantly with the infraspinatus or subscapularis. Optimal immobilization postures, which simultaneously minimized the stresses in the repaired tendons and the angle of humerus elevation, were obtained. RESULTS: For isolated supraspinatus tears, elevation of the humerus in planes close to the scapular plane was suggested. When the infraspinatus was also involved, planes posterior to the scapular plane were suggested; while, if the subscapularis was also involved, planes anterior to the scapular plane and internal rotation were suggested. The required thoracohumeral elevation angles ranged from 58° to 109°, depending on the tear length and the muscles involved. The optimal postures reduced the stresses in the repaired tendons by between 29% and 90%. CONCLUSION: Prescription of immobilization posture for a patient should be based on the conditions of the tear repaired. Appropriate choice of immobilization posture will reduce the stress in the repair, and as such has the potential to reduce retear rates.

Electromyographic activity in the immobilized shoulder musculature during ipsilateral elbow, wrist, and finger movements while wearing a shoulder orthosis.

BACKGROUND: Shoulder immobilization after rotator cuff surgery is usually prescribed to protect the repaired tendons; however, shoulder orthoses often also immobilize the elbow and wrist joints. There is insufficient evidence to support that elbow and wrist movements can affect repair integrity by highly activating the rotator cuff muscles. The aim of this study was to quantify the electromyographic activity of immobilized shoulder muscles during elbow, wrist, and finger movements. METHODS: Fifteen shoulder muscles of the dominant limb of 14 healthy subjects were evaluated by use of electromyography with 11 surface electrodes and 4 fine-wire electrodes in the rotator cuff muscles. While wearing a custom orthosis, the subjects completed tests involving elbow, wrist, and finger movements of the ipsilateral limb. The peak activity of each muscle was normalized to maximum voluntary contraction (percent MVC) and averaged across the subjects. RESULTS: Rotator cuff muscles were activated to less than 10% MVC in both slow and fast elbow flexions. The mean peak activations of all muscles during wrist and finger movements were less than 5% MVC. In daily activities such as writing, typing, clicking a computer mouse, and holding a box or bag, rotator cuff muscle activity did not exceed 11% MVC, but sudden movements such as grasping a bottle could show higher levels of activity, which in some individuals exceeded 20% MVC. CONCLUSION: Elbow, wrist, and finger movements could minimally activate the rotator cuff muscles when the shoulder is immobilized with an orthosis.

Long Covid active case finding study protocol: A co-produced community-based pilot within the STIMULATE-ICP study (Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways).

BACKGROUND AND AIM: Long Covid is a significant public health concern with potentially negative implications for health inequalities. We know that those who are already socially disadvantaged in society are more exposed to COVID-19, experience the worst health outcomes and are more likely to suffer economically. We also know that these groups are more likely to experience stigma and have negative healthcare experiences even before the pandemic. However, little is known about disadvantaged groups' experiences of Long Covid, and preliminary evidence suggests they may be under-represented in those who access formal care. We will conduct a pilot study in a defined geographical area in London, United Kingdom to test the feasibility of a community-based approach of identifying Long Covid cases that have not been clinically diagnosed and have not been referred to Long Covid specialist services. We will explore the barriers to accessing recognition, care, and support, as well as experiences of stigma and perceived discrimination. METHODS: This protocol and study materials were co-produced with a Community Advisory Board (CAB) made up primarily of people living with Long Covid. Working with voluntary organisations, a study leaflet will be distributed in the local community to highlight Long Covid symptoms and invite those experiencing them to participate in the study if they are not formally diagnosed. Potential participants will be assessed according to the study's inclusion criteria and offered the opportunity to participate if they fit them. Awareness of Long Covid and associated symptoms, experiences of trying to access care, as well as stigma and discrimination will be explored through qualitative interviews with participants. Upon completion of the interviews, participants will be offered a referral to the local social prescribing team to receive support that is personalised to them potentially including, but not restricted to, liaising with their primary care provider and the regional Long Covid clinic.

Exploring the lived experience of Long Covid in black and minority ethnic groups in the UK: Protocol for qualitative interviews and art-based methods.

Some people experience prolonged symptoms following an acute COVID-19 infection including fatigue, chest pain and breathlessness, headache and cognitive impairment. When symptoms persist for over 12 weeks following the initial infection, and are not explained by an alternative diagnosis, the term post-COVID-19 syndrome is used, or the patient-defined term of Long Covid. Understanding the lived experiences of Long Covid is crucial to supporting its management. However, research on patient experiences of Long Covid is currently not ethnically diverse enough. The study aim is to explore the lived experience of Long Covid, using qualitative interviews and art-based methods, among people from ethnically diverse backgrounds (in the UK), to better understand wider systems of support and healthcare support needs. Co-created artwork will be used to build on the interview findings. A purposive sampling strategy will be used to gain diverse experiences of Long Covid, sampling by demographics, geographic locations and experiences of Long Covid. Individuals (aged >18 years) from Black and ethnic minority backgrounds, who self-report Long Covid symptoms, will be invited to take part in a semi-structured interview. Interviews will be analysed thematically. A sub-sample of participants will be invited to co-create visual artwork to further explore shared narratives of Long Covid, enhance storytelling and increase understanding about the condition. A patient advisory group, representing diversity in ethnicity and experiences of Long Covid, will inform all research stages. Stakeholder workshops with healthcare professionals and persons, systems or networks important to people's management of Long Covid, will advise on the integration of findings to inform management of Long Covid. The study will use patient narratives from people from diverse ethnic backgrounds, to raise awareness of Long Covid and help inform management of Long Covid and how wider social systems and networks may inform better healthcare service access and experiences.

Integral-based filtering of continuous glucose sensor measurements for glycaemic control in critical care.

Hyperglycaemia is prevalent in critical illness and increases the risk of further complications and mortality, while tight control can reduce mortality up to 43%. Adaptive control methods are capable of highly accurate, targeted blood glucose regulation using limited numbers of manual measurements due to patient discomfort and labour intensity. Therefore, the option to obtain greater data density using emerging continuous glucose sensing devices is attractive. However, the few such systems currently available can have errors in excess of 20-30%. In contrast, typical bedside testing kits have errors of approximately 7-10%. Despite greater measurement frequency larger errors significantly impact the resulting glucose and patient specific parameter estimates, and thus the control actions determined creating an important safety and performance issue. This paper models the impact of the continuous glucose monitoring system (CGMS, Medtronic, Northridge, CA) on model-based parameter identification and glucose prediction. An integral-based fitting and filtering method is developed to reduce the effect of these errors. A noise model is developed based on CGMS data reported in the literature, and is slightly conservative with a mean Clarke Error Grid (CEG) correlation of R=0.81 (range: 0.68-0.88) as compared to a reported value of R=0.82 in a critical care study. Using 17 virtual patient profiles developed from retrospective clinical data, this noise model was used to test the methods developed. Monte-Carlo simulation for each patient resulted in an average absolute 1-h glucose prediction error of 6.20% (range: 4.97-8.06%) with an average standard deviation per patient of 5.22% (range: 3.26-8.55%). Note that all the methods and results are generalizable to similar applications outside of critical care, such as less acute wards and eventually ambulatory individuals. Clinically, the results show one possible computational method for managing the larger errors encountered in emerging continuous blood glucose sensors, thus enabling their more effective use in clinical glucose regulation studies.

2014: A Record-Breaking Year for West Nile Virus Positive Mosquito Pools in Harris County and the City of Houston, Texas.

In the 14 years since the emergence of West Nile virus (WNV) in Harris County and the city of Houston, Texas, the number of mosquitoes infected with the virus has fluctuated with several high and low count years. During this 14-year period, mosquito surveillance operational areas in Harris County were expanded from 248 to 268 and the distribution of the virus activity in mosquitoes varied from year to year. Operational areas with WNV infected mosquitoes increased from 137 in 2002 to 197 in 2006, decreased to 71 areas in 2007, and to an all-time low of 18 in 2008. The number increased to 78 areas in 2009, 96 in 2010, 133 in 2011, and 177 in 2012, but fell to 73 in 2013. However, 234 areas were confirmed in 2014, and only 138 in 2015. The WNV transmission was high in 2002 with 227 WNV positive mosquito pools. The number of positive mosquitoes remained elevated for a number of years and then declined from 2007 to 2010. Three record high years for WNV activity were: 2005, 2006, and 2011 with 698, 838, and 605 confirmed positive mosquito pools, respectively. Viral activity declined in 2012, followed by a marked decline in 2013 with only 147 WNV positive mosquito pools. In 2014, a record-breaking number of 1,286 WNV positive mosquito pools were confirmed in Harris County and the city of Houston, the most ever in a single season, while 406 were confirmed in 2015.

Optimal technique for maximal forward rotating vaults in men's gymnastics.

In vaulting a gymnast must generate sufficient linear and angular momentum during the approach and table contact to complete the rotational requirements in the post-flight phase. This study investigated the optimization of table touchdown conditions and table contact technique for the maximization of rotation potential for forwards rotating vaults. A planar seven-segment torque-driven computer simulation model of the contact phase in vaulting was evaluated by varying joint torque activation time histories to match three performances of a handspring double somersault vault by an elite gymnast. The closest matching simulation was used as a starting point to maximize post-flight rotation potential (the product of angular momentum and flight time) for a forwards rotating vault. It was found that the maximized rotation potential was sufficient to produce a handspring double piked somersault vault. The corresponding optimal touchdown configuration exhibited hip flexion in contrast to the hyperextended configuration required for maximal height. Increasing touchdown velocity and angular momentum lead to additional post-flight rotation potential. By increasing the horizontal velocity at table touchdown, within limits obtained from recorded performances, the handspring double somersault tucked with one and a half twists, and the handspring triple somersault tucked became theoretically possible.

Can one angle be simply subtracted from another to determine range of motion in three-dimensional motion analysis?

To determine the range of motion of a joint between an initial orientation and a final orientation, it is convenient to subtract initial joint angles from final joint angles, a method referred to as the vectorial approach. However, for three-dimensional movements, the vectorial approach is not mathematically correct. To determine the joint range of motion, the rotation matrix between the two orientations should be calculated, and angles describing the range of motion should be extracted from this matrix, a method referred to as the matrical approach. As the matrical approach is less straightforward to implement, it is of interest to identify situations in which the vectorial approach leads to insubstantial errors. In this study, the vectorial approach was compared to the matrical approach, and theoretical justification was given for situations in which the vectorial approach can reasonably be used. The main findings are that the vectorial approach can be used if (1) the motion is planar (Woltring HJ. 1994. 3-D attitude representation of human joints: a standardization proposal. J Biomech 27(12): 1399-1414), (2) the angles between the final and the initial orientation are small (Woltring HJ. 1991. Representation and calculation of 3-D joint movement. Hum Mov Sci 10(5): 603-616), (3) the angles between the initial orientation of the distal segment and the proximal segment are small and finally (4) when only one large angle occurs between the initial orientation of the distal segment and the proximal segment and the angle sequence is chosen in such a way that this large angle occurs on the first axis of rotation. These findings provide specific criteria to consider when choosing the angle sequence to use for movement analysis.

The influence of touchdown conditions and contact phase technique on post-flight height in the straight handspring somersault vault.

In vaulting the gymnast must generate sufficient linear and angular momentum during the approach and table contact in order to complete the rotational requirements in the post-flight phase. This study investigated the effects of touchdown conditions and contact technique on peak post-flight height of a straight handspring somersault vault. A planar seven-segment torque-driven computer simulation model of the contact phase in vaulting was evaluated by varying joint torque activation time histories to match three performances of a straight handspring somersault vault by an elite gymnast. The closest matching simulation was used as a starting point to optimise peak post-flight height of the mass centre for a straight handspring somersault. It was found that optimising either the touchdown conditions or the contact technique increased post-flight height by 0.1m whereas optimising both together increased post-flight height by 0.4m above that of a simulation matching the recorded performance. Thus touchdown technique and contact technique make similar contributions to post-flight height in the straight handspring somersault vault. Increasing touchdown velocity and angular momentum lead to additional post-flight height although there was a critical value of vertical touchdown velocity beyond which post-flight height decreased.