Patient and provider perspectives on eHealth interventions in Canada and Australia: a scoping review.

INTRODUCTION: Despite the promises of universal health care in most developed countries, health inequities remain prevalent within and between rural and remote communities. Remote health technologies are often promoted as solutions to increase health system efficiency, to enhance quality of care, and to decrease gaps in access to care for rural and remote communities. However, there is mixed evidence for these interventions, particularly related to how they are received and perceived by health providers and by patients. Health technologies do not always adequately meet the needs of patients or providers. To examine this, a broad-based scoping review was conducted to provide an overview of patient and provider perspectives of eHealth initiatives in rural communities. The unique objective of this review was to prioritize the voices of patients and providers in discussing the disparities between health interventions and needs of people in rural communities. eHealth initiatives were reviewed for rural communities of Australia and Canada, two countries that have similar geographies and comparable health systems at the local level. METHODS: Searches were performed in PubMed, Scopus, and Web of Science with results limited from 2000 to 2018. Keywords included combinations of 'eHealth', 'telehealth', 'telemedicine', 'electronic health', and 'rural/remote'. Individual patient and provider perspectives on health care were identified, followed by qualitative thematic coding based on the type of intervention, the feedback provided, the affected population, geographic location, and category of individual providing their perspective. Quotes from patients and providers are used to illustrate the identified benefits and disadvantages of eHealth technologies. RESULTS: Based on reviewed literature, 90.1% of articles reported that eHealth interventions were largely positive. Articles noted decreased travel time (18%), time/cost saving (15.1%), and increased access to services (13.9%) as primary benefits to eHealth. The most prevalent disadvantages of eHealth were technological issues (24.5%), lack of face-to-face contact (18.6%), limited training (10.8%), and resource disparities (10.8%). These results show where existing eHealth interventions could improve and can inform policymakers and providers in designing new interventions. Importantly, benefits to eHealth extend beyond geographic access. Patients reported ancillary benefits to eHealth that include reduced anxiety, disruption on family life, and improved recovery time. Providers reported closer connections to colleagues, improved support for complex care, and greater eLearning opportunity. Barriers to eHealth are recognized by patient and providers alike to be largely systemic, where lack of rural high-speed internet and unreliability of installed technologies were significant. CONCLUSION: Regional and national governments are seen as the key players in addressing these technical barriers. This scoping review diverges from many reviews of eHealth with the use of first-person perspectives. It is hoped that this focus will highlight the importance of patient voices in evaluating important healthcare interventions such as eHealth and associated technologies.

Effect of robotic gait training on muscle and bone characteristics in spinal cord transected rats.

Osteoporosis and loss of muscle mass are secondary issues with spinal cord injury. Robotic gait training has provided evidence of increasing bone density and muscle mass, but its effect on bone strength is undetermined. The purpose of this study was to determine the effect of a 6-week robotic locomotion training program on skeletal muscle mass and bone characteristics. Twelve female Sprague-Dawley rats received a mid-thoracic spinal cord transection at 5 days old and at 3 weeks old were assigned to a Control or Trained Group. The Trained Group performed 5-min sessions on the Rat Stepper 5 days a week for 6 weeks with 90% of body weight supported. At the end of the 6 weeks, body mass was obtained and right femurs and four lower extremity muscles were harvested. Femur bone mineral density was measured with DXA and mechanical characteristics of the femur were determined via 3-point bending testing. Independent t-tests, effects sizes and percent differences were computed between the two groups (p < 0.05). The Trained Group had significantly larger normalized femur mass (p = 0.007) and normalized soleus muscle mass (p = 0.033) when compared to the Control Group. There was a medium or large effect size with the Trained Groups' femurs having larger mass, bone mineral density, rupture loads, cortical wall thickness, shaft cross sectional area, soleus mass, normalized gastrocnemius mass, and smaller shaft inner diameters compared to the Control Group. These changes may contribute to decreasing osteoporosis and fracture risk in those with spinal cord injuries.

Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review.

A small proportion of health care users are recognized to use a significantly higher proportion of health system resources, largely due to systemic, inequitable access and disproportionate health burdens. These high-resource health system users are routinely characterized as older, with multiple comorbidities, and reduced access to adequate health care. Geographic trends also emerge, with more rural and isolated regions demonstrating higher rates of high-resource use than others. Despite known geographical discrepancies in health care access and outcomes, health policy and research initiatives remain focused on urban population centers. To alleviate mounting health system pressure from high-resource users, their characteristics must be better understood within the context in which i arises. To examine this, a scoping review was conducted to provide an overview of characteristics of high-resource users in rural and remote communities in Canada and Australia. In total, 21 papers were included in the review. Using qualitative thematic coding, primary findings characterized rural high-resource users as those of an older age; with increased comorbid conditions and condition severity; lower socioeconomic status; and elevated risk behaviors.

Relationship Between Ground Reaction Force Characteristics and Bone Mineral Density of the Hip and Spine in Male Runners.

The purpose of this study was to determine the relationship between running ground reaction force (GRF) characteristics and hip and lumbar spine bone mineral density (BMD) values in male runners. Individuals who ran at least 48.3 km per week and were injury-free were recruited. Kistler force plates collected running vertical and anteroposterior GRF data. A Hologic Discovery W bone densitometer measured lumbar spine and five regional hip BMD values. Only runners who consistently used a rear foot strike pattern were included (n = 32). Pearson correlation coefficients were calculated between BMD values and various GRF values and step-wise multiple regression was run to predict BMD values from the various GRF values. The vertical impact force was significantly correlated with the lumbar spine and four of the five hip BMD values (r > 0.374, p < 0.035). Both the peak early loading rate (ELR) and average ELR were significantly correlated with the lumbar spine and Ward's triangle BMD (r > 0.430, p < 0.014), while the average active loading rate was correlated only with the Ward's triangle BMD (r = 0.438, p = 0.012). Multiple regression revealed the peak impact force was the predictor for every hip region BMD other than the trochanter and the average ELR as a predictor for the lumbar spine BMD. The peak braking force was negatively correlated with the Ward's triangle BMD (r = -0.414, p = 0.019). It appears that the large forces and loading rates associated with rear foot striking may be advantageous and predictive for BMD at the hip and spine.

Sustainability of critical power determined by a 3-minute all-out test in elite cyclists.

Critical power (CP) is a theoretical workload representative of an athlete's maximal sustainable pace. Recent research has validated a 3-minute all-out test on a cycle ergometer for determining CP; however, few studies have investigated the sustainability of CP using this test. The purpose of this study was to determine the sustainability of CP established during the 3-minute test and the determinants of sustainability. A group of elite cyclists (N = 21) performed a VO2max test, 3-minute all-out test, and a time to exhaustion (TTE) trial at CP on 3 different days separated by at least 24 hours. Expired gases were collected during all trials and analyzed for VO2 and VCO2. Heart rate was measured by telemetry. Multiple regression was used to determine predictors of sustainability with significance predetermined at p < 0.05. VO2max was measured at 58.9 ± 5.6 ml·kg(-1)·min(-1), ventilation breakpoint at 44.9 ± 5.7 ml·kg(-1)·min(-1) (75% VO2max), and maximum heart rate at 179 ± 10 b·min(-1). Peak power (PP) in the 3-minute all-out test was measured at 738 ± 170 W, and CP was determined at 305 ± 32 W or 79% of VO2max. The VO2 at CP was 55.4 ± 6.9 ml·kg(-1)·min(-1), representing 94% of measured VO2max. The mean TTE at CP was 14.79 ± 8.38 minutes. The difference score of PP - CP significantly predicted TTE (r = 0.65, p < 0.05). No other measured variables contributed to this prediction. Based on sustainability, these data suggest that the 3-minute all-out test may overestimate CP in elite cyclists, which could lead to overtraining if CP determined with this test is used to identify training intensities.

What a Pandemic Has Taught Us About the Potential for Innovation in Rural Health: Commencing an Ethnography in Canada, the United States, Sweden, and Australia.

The COVID-19 pandemic coincided with a multi-national federally funded research project examining the potential for health and care services in small rural areas to identify and implement innovations in service delivery. The project has a strong focus on electronic health (eHealth) but covers other areas of innovation as well. The project has been designed as an ethnography to prelude a realist evaluation, asking the question under what conditions can local health and care services take responsibility for designing and implementing new service models that meet local needs? The project had already engaged with several health care practitioners and research students based in Canada, Sweden, Australia, and the United States. Our attention is particularly on rural communities with fewer than 5,000 residents and which are relatively isolated from larger service centres. Between March and September 2020, the project team undertook ethnographic and auto-ethnographic research in their own communities to investigate what the service model responses to the pandemic were, and the extent to which local service managers were able to customize their responses to suit the needs of their communities. An initial program theory drawn from the extant literature suggested that "successful" response to the pandemic would depend on a level of local autonomy, "absorptive capacity,*" strong service-community connections, an "anti-fragile†" approach to implementing change, and a realistic recognition of the historical barriers to implementing eHealth and other innovations in these types of rural communities. The field research in 2020 has refined the theory by focusing even more attention on absorptive capacity and community connections, and by suggesting that some level of ignorance of the barriers to innovation may be beneficial. The research also emphasized the role and power of external actors to the community which had not been well-explored in the literature. This paper will summarize both what the field research revealed about the capacity to respond well to the COVID-19 challenge and highlight the gaps in innovative strategies at a managerial level required for rapid response to system stress. *Absorptive Capacity is defined as the ability of an organization (community, clinic, hospital) to adapt to change. Organizations with flexible capacity can incorporate change in a productive fashion, while those with rigid capacity take longer to adapt, and may do so inappropriately. †Antifragility is defined as an entities' ability to gain stability through stress. Biological examples include building muscle through consistent use, and bones becoming stronger through subtle stress. Antifragility has been used as a guiding principle in programme implementation in the past.

Lower Extremity Joint Kinematics of Shod, Barefoot, and Simulated Barefoot Treadmill Running.

Barefoot running is considered to decrease injury risk, but is not always practical, particularly while running on a fitness center treadmill. The purpose of this study was to compare the kinematics of shod, barefoot, and simulated barefoot running. Twelve subjects (age = 21.1 ± 1.2 years) who regularly run on a treadmill for fitness participated in the study. After a warm up, each runner ran on a Biodex RTM 400 treadmill set at 7.4 mph (approximately 3.3 m/s) in their own shoes, barefoot, and while running "like they were barefoot" in their own shoes. Sixteen reflective markers were affixed to each subject to use PlugInGait (Vicon) to determine three-dimensional body landmark coordinates and to compute lower extremity joint angles. Values at touchdown and during stance were averaged over ten strides for analysis. Repeated measures ANOVA was implemented to determine differences based on running condition (p < 0.05) and post hoc testing was performed with an adjustment for multiple comparisons (p<0.05/3). At touchdown, ankle angle values significantly differed based on condition (6.2 ± 5.9° vs. -4.0 ± 12.0° vs, -0.2 ± 13.3°; p = 0.004 for shod, barefoot and simulated barefoot running, respectively) indicating that when simulating barefoot running the subjects altered their foot strike pattern. Stride frequency differed between shod and barefoot running (1.415±0.068 Hz vs. 1.457±0.065 Hz; p = 0.001) but the simulated barefoot condition did not differ from the shod condition. The runners were able to simulate an important element of barefoot running, but they did not completely mimic their barefoot running pattern.

Comparison of the basal cell-specific markers, 34betaE12 and p63, in the diagnosis of prostate cancer.

The basal cell-specific cytokeratin antibody (34betaE12) is widely used to aid in the diagnosis of cancer in challenging prostate needle biopsies (NBX) and transurethral resections of the prostate (TURP). Because prostate carcinoma (PCa) lacks basal cells, the absence of basal cell as determined by 34betaE12 can aid in the confirmation of a histologically suspicious lesion. However, false-negative staining occurs because of patchy cytoplasmic staining, making a definitive diagnosis difficult. A recently identified basal cell marker p63, a p53 homologue, stains basal cell nuclei but not secretory cells. The aim of this study is to determine if the p63 antibody offers any clinically useful advantage over 34betaE12 in the diagnosis of challenging atypical prostate lesions. Ninety-four cases, comprised of 25 consecutive prostate NBX and 2 TURP with an atypical suspicious focus, 55 NBX cases of histologically unequivocal PCa and 12 TURP specimen removed for benign prostate hyperplasia, were stained with the monoclonal antibodies 34betaE12 and 4A4 anti-p63. Basal cell staining intensity, percentage basal cell-positive glands in benign, malignant, and atypical foci, and number of benign glands not staining were evaluated for 34betaE12 and p63 stains. A total of 67 prostate NBX cases, including one TURP, were diagnosed with PCa, 1 atypical small acinar proliferation, 10 benign, and 4 cases excluded because of lost tissue on step sections. None of the 67 PCa NBX cases demonstrated 34betaE12 or p63 immunoreactivity (100% specific). Whereas 57 of 108 (53%) prostate NBX cores from 78 cases demonstrated a similar percentage of basal cell staining for both antibodies, 45 of 108 (41%) NBX cores demonstrated a higher percentage of p63 basal cell staining in benign glands. Only 6 of 108 NBX (6%) cores had a higher percentage of basal cell staining with 34betaE12 (Wilcoxon signed rank test, p <0.0001). Lack of basal cell staining in more than two benign glands occurred in 25 of 108 (23%) and 10 of 108 (9%) prostate NBX cores stained with 34betaE12 and p63, respectively. In the vast majority of atypical cases, both 34betaE12 and p63 staining differences were not clinically significant, except in 2 of 27 (7%) cases p63 offered diagnostic utility beyond the 34betaE12 immunostain. p63 in these cases demonstrated discontinuous but strong staining in atypical glands and adjacent benign glands, whereas 34betaE12 failed to stain optimally in this critical area. For 12 TURP cases the mean percentage basal cell positivity in benign glands was 75% and 95% for 34betaE12 and p63, respectively (p = 0.006). Lack of basal cell staining in more than two glands occurred in 12 of 12 (100%) and 2 of 12 (17%) TURP specimens stained with 34betaE12 and p63, respectively (p <0.0001). In summary, 34betaE12 and p63 are highly specific for basal cells and therefore are negative in areas of PCa. p63 is more sensitive than 34betaE12 in staining benign basal cells, particularly for TURP specimens, offering slight advantage over 34betaE12 in diagnostically challenging cases. p63 may be used as an alternative to 34betaE12 stain for difficult prostate lesions.

Usefulness of basal cell cocktail (34betaE12 + p63) in the diagnosis of atypical prostate glandular proliferations.

We evaluated the diagnostic usefulness of the 34betaE12-p63 cocktail, compared with 34betaE12 and p63 used alone, in 34 prostate needle biopsy (NBXs) and 3 transurethral resection specimens containing atypical glandular proliferations and in 18 NBXs containing unequivocal prostate carcinoma (PCa). Staining intensity; percentage of basal cells staining in benign, atypical, and malignant glands; number of benign glands lacking basal cell staining; and staining variance were analyzed. All NBXs with unequivocal PCa were negative with all 3 markers. Diagnoses were as follows for the atypical cases after staining for the 3 markers: PCa, 9; postatrophic hyperplasia, 12; high-grade prostatic intraepithelial neoplasia (HGPIN), 5; atypical adenomatous hyperplasia, 6; benign atypical proliferations, 4; and HGPIN with adjacent small atypical acinar proliferation suggestive of PCa, 1. The cocktail demonstrated consistently strong staining intensity and improved basal cell staining in morphologically benign and benign atypical glands compared with p63 and 34betaE12 alone; it had the smallest staining variance compared with 34betaE12 (F < 0.0001) and p63 (F = 0.31), although its advantage for resolving individual atypical cases was limited compared with 34betaE12 and p63 alone. Of 37 atypical cases, 1 (3%) additionally was resolved as benign using the cocktail and p63. Because the diagnosis of PCa is supported by lack of basal cell staining, the immunohistochemical analysis with highest possible sensitivity and lowest possible variability is critical to ensure that a negative reaction is true. The cocktail provides a simple, cost-effective improvement in basal cell immunohistochemical analysis of difficult prostate lesions.