Psychological Stress Management and Stress Reduction Strategies for Stroke Survivors: A Scoping Review.

BACKGROUND: Stroke can be a life-changing event, with survivors frequently experiencing some level of disability, reduced independence, and an abrupt lifestyle change. Not surprisingly, many stroke survivors report elevated levels of stress during the recovery process, which has been associated with worse outcomes. PURPOSE: Given the multiple roles of stress in the etiology of stroke recovery outcomes, we aimed to scope the existing literature on stress management interventions that have been trialed in stroke survivors. METHODS: We performed a database search for intervention studies conducted in stroke survivors which reported the effects on stress, resilience, or coping outcome. Medline (OVID), Embase (OVID), CINAHL (EBSCO), Cochrane Library, and PsycInfo (OVID) were searched from database inception until March 11, 2019, and updated on September 1, 2020. RESULTS: Twenty-four studies met the inclusion criteria. There was significant variation in the range of trialed interventions, as well as the outcome measures used to assess stress. Overall, just over half (13/24) of the included studies reported a benefit in terms of stress reduction. Acceptability and feasibility were considered in 71% (17/24) and costs were considered in 17% (4/24) of studies. The management of stress was rarely linked to the prevention of symptoms of stress-related disorders. The overall evidence base of included studies is weak. However, an increase in the number of studies over time suggests a growing interest in this subject. CONCLUSIONS: Further research is required to identify optimum stress management interventions in stroke survivors, including whether the management of stress can ameliorate the negative impacts of stress on health.

Evaluation of a Virtual Reality Platform to Train Stress Management Skills for a Defense Workforce: Multisite, Mixed Methods Feasibility Study.

BACKGROUND: Psychological stress-related injuries within first-responder organizations have created a need for the implementation of effective stress management training. Most stress management training solutions have limitations associated with scaled adoption within the workforce. For instance, those that are effective in civilian populations often do not align with the human performance culture embedded within first-responder organizations. Programs involving expert-led instructions that are high in quality are often expensive. OBJECTIVE: This study sought to evaluate a tailored stress management training platform within the existing training schedule of the Australian Defense Force (ADF). The platform, known as Performance Edge (PE), is a novel virtual reality (VR) and biofeedback-enabled stress management skills training platform. Focusing on practical training of well-established skills and strategies, the platform was designed to take advantage of VR technology to generate an immersive and private training environment. This study aimed to assess the feasibility of delivering the VR platform within the existing group-based training context and intended training population. In this setting, the study further aimed to collect data on critical predictors of user acceptance and technology adoption in education, including perceived usability, usefulness, and engagement, while also assessing training impacts. METHODS: This study used a mixed methods, multisite approach to collect observational, self-reported, and biometric data from both training staff and trainers within a real-world "on-base" training context in the ADF. Validated scales include the Presence Questionnaire and User Engagement Scale for perceived usefulness, usability, and engagement, as well as the State Mindfulness Scale and Relaxation Inventory, to gain insights into immediate training impacts for specific training modules. Additional surveys were specifically developed to assess implementation feedback, intention to use skills, and perceived training impact and value. RESULTS: PE training was delivered to 189 ADF trainees over 372 training sessions. The platform was easy to use at an individual level and was feasible to deliver in a classroom setting. Trainee feedback consistently showed high levels of engagement and a sense of presence with the training content and environment. PE is overall perceived as an effective and useful training tool. Self-report and objective indices confirmed knowledge improvement, increased skill confidence, and increased competency after training. Specific training elements resulted in increased state mindfulness, increased physical relaxation, and reduced breathing rate. The ability to practice cognitive strategies in a diverse, private, and immersive training environment while in a group setting was highlighted as particularly valuable. CONCLUSIONS: This study found the VR-based platform (PE) to be a feasible stress management training solution for group-based training delivery in a defense population. Furthermore, the intended end users, both trainers and trainees, perceive the platform to be usable, useful, engaging, and effective for training, suggesting end-user acceptance and potential for technology adoption.

Correction: Evaluation of a Virtual Reality Platform to Train Stress Management Skills for a Defense Workforce: Multisite, Mixed Methods Feasibility Study.

[This corrects the article DOI: 10.2196/46368.].

Impact assessment of the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery.

BACKGROUND: Research impact is an emerging measure of research achievement alongside traditional academic outputs such as publications. We present the results of applying the Framework to Assess the Impact from Translational health research (FAIT) to the Centre for Research Excellence (CRE) in Stroke Rehabilitation and Brain Recovery (CRE-Stroke, 2014-2019) and report on the feasibility and lessons from the application of FAIT to a CRE rather than a discrete research project. METHODS: Data were gathered via online surveys, in-depth interviews, document analysis and review of relevant websites/databases to report on the three major FAIT methods: the modified Payback Framework, an assessment of costs against monetized consequences, and a narrative account of the impact generated from CRE-Stroke activities. FAIT was applied during the last 4 years of CRE-Stroke operation. RESULTS: With an economic investment of AU$ 3.9 million over 5 years, CRE-Stroke delivered a return on investment that included AU$ 18.8 million in leveraged grants, fellowships and consultancies. Collectively, CRE-Stroke members produced 354 publications that were accessed 470,000 times and cited over 7220 times. CRE-Stroke supported 26 PhDs, 39 postdocs and seven novice clinician researchers. There were 59 capacity-building events benefiting 744 individuals including policy-makers and consumers. CRE-Stroke created research infrastructure (including a research register of stroke survivors and a brain biobank), and its global leadership produced international consensus recommendations to influence the stroke research landscape worldwide. Members contributed to the Australian Living Stroke Guidelines: four researchers' outputs were directly referenced. Based only on the consequences that could be monetized, CRE-Stroke returned AU$ 4.82 for every dollar invested in the CRE. CONCLUSION: This case example in the developing field of impact assessment illustrates how researchers can use evidence to demonstrate and report the impact of and returns on research investment. The prospective application of FAIT by a dedicated research impact team demonstrated impact in broad categories of knowledge-gain, capacity-building, new infrastructure, input to policy and economic benefits. The methods can be used by other research teams to provide comprehensive evidence to governments and other research funders about what has been generated from their research investment but requires dedicated resources to complete.

Comparing approaches for selection, development, and deployment of extended reality (XR) teaching applications: A case study at The University of Newcastle Australia.

The use of extended reality (XR) technology in education offers many advantages for transferring knowledge and practical skills training at the higher education level. As a result, many Universities over the past 5 + years have undertaken pilot programs to both develop XR content and assess how to best implement it within existing teaching and learning systems. Unfortunately, very few of these efforts have included structured evaluation or documentation. As such, limited published evidence exists to inform processes and approaches that may assist or hinder broad scale implementation. This leads many Universities to unnecessarily commit significant time and resources to testing identical or similar approaches, resulting in repeated identification of the same or similar challenges. In response to this situation, The University of Newcastle, Australia decided to systematically document the approach for selection, development and implementation of four new virtual-reality (VR) teaching applications. The current paper contains a detailed intrinsic case study, outlining the process and critical elements that shaped the selection of suitable teaching content, software development, hardware solutions and implementation. Details are provided on how decisions were made, what components were considered helpful, challenges identified, and important lessons outlined. These findings will be useful to organisations and individuals as they look to develop pathways and processes to integrate XR technology, particularly within their existing training and educational frameworks. Supplementary Information: The online version contains supplementary material available at 10.1007/s10639-022-11364-2.

What do stroke survivors' value about participating in research and what are the most important research problems related to stroke or transient ischemic attack (TIA)? A survey.

BACKGROUND: Recruitment to stroke clinical trials is challenging, but consumer registers can facilitate participation. Researchers need to understand the key factors that facilitate trial involvement and improve consumer partnerships to identify what research topics important to stroke and transient ischemic attack (TIA) survivors and their carers. We aimed to examine i) the experience of being involved in a stroke research register, and ii) the priorities for stroke research from the perspective of stroke survivors. METHODS: Online and paper-based surveys were sent directly to members of a stroke register and disseminated online. Multiple choice questions were reported as counts and percentages and open-ended questions were thematically analysed using Braun and Clarke's 6-stage process. RESULTS: Of 445 survey respondents, 154 (38%) were a member of the Stroke Research Register. The most frequently reported reason for research participation was to help others in the future. Respondents reported they were less likely to take part in research if the research question was not relevant to them, if transport was an issue, or because they lacked time. The most important research problems reported were targeting specific impairments including recovery of movement, fatigue, and aphasia, improvement of mental health services, and increased support for carers. CONCLUSIONS: Recruitment to trials may be improved by research registers if an inclusive research culture is fostered, in which consumers feel valued as members of a community, have direct and timely access to research findings and the opportunity to be meaningfully involved in research around the problems that consumers find most important.

Implementing a protocol for a research impact assessment of the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery.

BACKGROUND: There is growing recognition that the wider benefits of research (economic, social and health impacts) should be assessed and valued alongside traditional research performance metrics such as peer-reviewed papers. Translation of findings into policy and practice needs to accelerate and pathways to impact need to be better understood. This research protocol outlines a mixed methods study to apply the Framework to Assess the Impact from Translational health research (FAIT) to the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery (CRE-Stroke). FAIT is purpose-designed to encourage research translation and assess research impact but lacks validation. METHODS/DESIGN: Phase 1 involves application of the FAIT-modified programme logic model to each CRE-Stroke research stream including identifying process, output and impact metrics, as well as end users of the research. A scoping review will inform potential impacts anticipated from CRE-Stroke. In Phase 2, audit and feedback on achievements against plans will track and encourage research translation. Logic models will be updated to account for changes in the research pathways over time. In Phase 3, three proven methods for measuring research impact - Payback, economic assessment and narratives - will be applied to each research stream and the data triangulated and reported in Phase 4. The feasibility of applying FAIT will also be assessed as part of Phase 3. DISCUSSION: Use of prospective, comprehensive research impact frameworks for large interdisciplinary programmes of research is rare. FAIT's application to CRE-Stroke will provide opportunity for the impact of CRE-Stroke to be assessed and a range of impacts beyond standard academic achievements to be reliably reported. The feasibility of FAIT's application will also be assessed and, if necessary, refined. The usefulness of FAIT for encouraging research translation will also be described and may prove useful for other programmes looking to implement a research impact framework.

Alteration of transcriptional networks in the entorhinal cortex after maternal immune activation and adolescent cannabinoid exposure.

Maternal immune activation (MIA) and adolescent cannabinoid exposure (ACE) have both been identified as major environmental risk factors for schizophrenia. We examined the effects of these two risk factors alone, and in combination, on gene expression during late adolescence. Pregnant rats were exposed to the viral infection mimic polyriboinosinic-polyribocytidylic acid (poly I:C) on gestational day (GD) 15. Adolescent offspring received daily injections of the cannabinoid HU210 for 14days starting on postnatal day (PND) 35. Gene expression was examined in the left entorhinal cortex (EC) using mRNA microarrays. We found prenatal treatment with poly I:C alone, or HU210 alone, produced relatively minor changes in gene expression. However, following combined treatments, offspring displayed significant changes in transcription. This dramatic and persistent alteration of transcriptional networks enriched with genes involved in neurotransmission, cellular signalling and schizophrenia, was associated with a corresponding perturbation in the expression of small non-coding microRNA (miRNA). These results suggest that a combination of environmental exposures during development leads to significant genomic remodeling that disrupts maturation of the EC and its associated circuitry with important implications as the potential antecedents of memory and learning deficits in schizophrenia and other neuropsychiatric disorders.

Quantitative assessment of microglial morphology and density reveals remarkable consistency in the distribution and morphology of cells within the healthy prefrontal cortex of the rat.

BACKGROUND: Microglial morphology within the healthy brain has been the subject of a number of observational studies. These have suggested that microglia may consist of separate classes, which possess substantially different morphological features. Critically, there have been no systematic quantitative studies of microglial morphology within the healthy brain. METHODS: We examined microglial cells within the adult rat prefrontal cortex. At high magnification, digital reconstructions of cells labelled with the microglial-specific marker ionized calcium-binding adapter molecule-1 (Iba-1) were made in each of the cortical layers. These reconstructions were subsequently analyzed to determine the convex hull area of the cells, their somal perimeter, the length of processes, the number of processes, the extent of process branching and the volume of processes. We additionally examined whether cells' morphological features were associated with cell size or numerical density. RESULTS: Our analysis indicated that while there was substantial variability in the size of cells within the prefrontal cortex, cellular morphology was extremely consistent within each of the cortical layers. CONCLUSIONS: Our results provide quantitative confirmation that microglia are largely homogenous in the uninjured rodent prefrontal cortex.

Clinical staging: a necessary step in the development of improved animal models of mood disturbance?

Recently, it has been suggested that the clinical staging approach be considered a serious alternative framework for conceptualising mood related psychopathology. The fundamental difference between clinical staging and the now dominant categorical diagnostic framework is that the entire illness trajectory becomes relevant, as opposed to simply the end-stage. The concept of disease trajectory has significant implications for animal models of psychopathology, and particularly for animal models of depression. This article will introduce and discuss the implications of the clinical staging approach for those undertaking research using animal models of mood disturbance.

Chronic stress induces prolonged suppression of the P2X7 receptor within multiple regions of the hippocampus: a cumulative threshold spectra analysis.

A number of studies have identified that mutations in the P2X7 receptor occur with a significantly higher incidence in individuals with major depression. Consistent with these findings, a number of preclinical studies have identified that mice in which the P2X7 receptor has been deleted exhibit a higher level of resilience-like behaviour to acutely aversive situations. At present, however, no studies have examined changes in P2X7 receptor expression in otherwise healthy animals exposed to persistently stressful situations. This is significant as several lines of evidence have demonstrated that it is exposure to persistently aversive, rather than acutely aversive, situations that is associated with the emergence of mood disturbance. Accordingly, the objective of the current study was to examine whether chronic exposure to restraint stress was associated with alterations in the expression of P2X7 within the hippocampal formation. The study involved three principal groups: acute stress (1 session), chronic stress (21 sessions, 1 per day) and a chronic stress with recovery group (21 sessions, 1 per day followed by 7days of no stress) and appropriate control groups. The results of the analysis indicate that all forms of stress, regardless of the duration, provoked a reduction in P2X7 receptor expression. Comparative analysis on normalised data indicated that the magnitude of the P2X7 reduction was significantly greater in the chronic stress relative to the acute stress group. We additionally found that there was a gradual rebound in P2X7 expression, in two of nine regions examined, in animals that were allowed to recover for 7days following the final stress session. Collectively, these findings provide the first evidence that exposure to chronic restraint stress produces a pronounced and relatively persistent suppression of the P2X7 receptor within the hippocampus.

Medical Student Experiences of Engaging in a Psychological Flexibility Skill Training App for Burnout and Well-being: Pilot Feasibility Study.

BACKGROUND: Medical students are at higher risk of burnout than the general population. Interventions that facilitate adaptive coping behaviors (eg, Psychological Flexibility) in the context of inherent stressors associated with medical training could mitigate burnout risk and improve well-being. Delivering these interventions using smartphone apps offers advantages such as accessibility, scalability, mitigation of time and stigma barriers, and facilitation of individual tailoring (individualization). There is a need for feasibility trials with medical students in this emerging field. Formal evaluations of user experiences of app-based psychological skill training are required to identify barriers to and facilitators of engagement and optimize intervention development before implementation in efficacy trials and real-world settings. OBJECTIVE: This study aimed to assess the feasibility of delivering an individualized Psychological Flexibility skill training intervention (Acceptance and Commitment Training [ACTraining]) to medical students using an app-based delivery format. We further aimed to explore how formal evaluation of user experiences might inform and guide the development of this app before implementation in an efficacy trial and future research involving app-delivered psychological skill training for medical students. METHODS: This single-arm study was an early-phase feasibility trial of a stand-alone ACTraining app conducted with a sample of Australian medical students (n=11). We collected app usability and user experience data across a broad range of domains (eg, perceived helpfulness and relevance, learning experiences, and self-efficacy) using self-report questionnaires (quantitative and qualitative) and behavioral engagement outcomes. RESULTS: Behavioral engagement data demonstrated that the app delivered the assessment procedures and individualized ACTraining intervention to medical students as intended. The subjective feedback provided by students who actively engaged with the app was generally positive across several indicators, including usability, perceived relevance and helpfulness, accessibility, maintenance of privacy, and opportunity for self-reflection. Disengagement from the app was an identified challenge throughout the trial. Participant feedback identified several factors that may have affected engagement, such as time, expectations regarding app interface functioning, and individual differences in confidence and self-efficacy when implementing skills. CONCLUSIONS: This study reports user experience data that have been largely absent from the literature on digital psychological interventions for medical students. Our findings demonstrate the preliminary feasibility of an app-delivered ACTraining intervention for medical student well-being and burnout and support the value of future assessment of the efficacy of this approach with larger samples. We consider subjective feedback from medical students in relation to observed engagement and propose how this information might be used to inform the development of this app and future research in this nascent field.

Evaluation of an App-Delivered Psychological Flexibility Skill Training Intervention for Medical Student Burnout and Well-being: Randomized Controlled Trial.

BACKGROUND: Physician burnout is a common problem, with onset frequently occurring during undergraduate education. Early intervention strategies that train medical students in psychological flexibility skills could support well-being and mitigate burnout risks associated with unmodifiable career stressors. There is a need for randomized controlled trials to assess effectiveness. As psychological flexibility varies contextually and among individuals, tailoring interventions may improve outcomes. Smartphone apps can facilitate individualization and accessibility, and the evaluation of this approach is an identified research priority. OBJECTIVE: This study aimed to evaluate the effectiveness of a stand-alone app-delivered Acceptance and Commitment Training intervention for improving medical students' self-reported burnout, well-being, psychological flexibility, and psychological distress outcomes. We aimed to explore whether an individualized app would demonstrate benefits over a nonindividualized version. METHODS: This parallel randomized controlled trial was conducted with a sample of medical students from 2 Australian universities (N=143). Participants were randomly allocated to 1 of 3 intervention arms (individualized, nonindividualized, and waitlist) using a 1:1:1 allocation ratio. Individualized and nonindividualized participants were blinded to group allocation. The 5-week intervention included an introductory module (stage 1) and on-demand access to short skill training activities (stage 2), which students accessed at their own pace. Stage 2 was either nonindividualized or individualized to meet students' identified psychological flexibility training needs. RESULTS: The mean differences in change from baseline between the intervention groups and the waitlist group were not statistically significant for burnout outcomes: exhaustion (primary; individualized: -0.52, 95% CI -3.70 to 2.65, P=.75; nonindividualized: 1.60, 95% CI -1.84 to 5.03, P=.37), cynicism (individualized: -1.26, 95% CI -4.46 to 1.94, P=.44; nonindividualized: 1.00, 95% CI -2.45 to 4.46, P=.57), and academic efficacy (individualized: 0.94, 95% CI -0.90 to 2.79, P=.32; nonindividualized: 2.02, 95% CI 0.02-4.03, P=.05). Following the intervention, the individualized group demonstrated improved psychological flexibility (0.50, 95% CI 0.12-0.89; P=.01), reduced inflexibility (0.48, 95% CI -0.92 to -0.04; P=.04), and reduced stress (-6.89, 95% CI -12.01 to 5.99; P=.01), and the nonindividualized group demonstrated improved well-being (6.46, 95% CI 0.49-12.42; P=.04) and stress (-6.36, 95% CI -11.90 to -0.83; P=.03) compared with waitlist participants. Between-group differences for the individualized and nonindividualized arms were not statistically significant. High attrition (75/143, 52.4%) was observed. CONCLUSIONS: This trial provides early support for the potential benefits of Acceptance and Commitment Training for medical student well-being and psychological outcomes and demonstrates that psychological flexibility and inflexibility can be trained using a smartphone app. Although postintervention burnout outcomes were not statistically significant, improvements in secondary outcomes could indicate early risk mitigation. Replication studies with larger samples and longer-term follow-up are required, and future research should focus on improving implementation frameworks to increase engagement and optimize individualization methods. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry 12621000911897; https://tinyurl.com/2p92cwrw. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/32992.

Using Presurgical Biopsychosocial Features to Develop an Advanced Clinical Decision-Making Support Tool for Predicting Recovery Trajectories in Patients Undergoing Total Knee Arthroplasty: Protocol for a Prospective Observational Study.

BACKGROUND: Following total knee arthroplasty (TKA), 10% to 20% of patients report dissatisfaction with procedural outcomes. There is growing recognition that postsurgical satisfaction is shaped not only by the quality of surgery but also by psychological and social factors. Surprisingly, information on the psychological and social determinants of surgical outcomes is rarely collected before surgery. A comprehensive collection of biopsychosocial information could assist clinicians in making recommendations in relation to rehabilitation, particularly if there is robust evidence to support the ability of presurgical constructs to predict postsurgical outcomes. Clinical decision support tools can help identify factors influencing patient outcomes and support the provision of interventions or services that can be tailored to meet individuals' needs. However, despite their potential clinical benefit, the application of such tools remains limited. OBJECTIVE: This study aims to develop a clinical decision tool that will assist with patient stratification and more precisely targeted clinical decision-making regarding prehabilitation and rehabilitation for TKA, based on the identified individual biopsychosocial needs. METHODS: In this prospective observational study, all participants provided written or electronic consent before study commencement. Patient-completed questionnaires captured information related to a broad range of biopsychosocial parameters during the month preceding TKA. These included demographic factors (sex, age, and rurality), psychological factors (mood status, pain catastrophizing, resilience, and committed action), quality of life, social support, lifestyle factors, and knee symptoms. Physical measures assessing mobility, balance, and functional lower body strength were performed via video calls with patients in their home. Information related to preexisting health issues and concomitant medications was derived from hospital medical records. Patient recovery outcomes were assessed 3 months after the surgical procedure and included quality of life, patient-reported knee symptoms, satisfaction with the surgical procedure, and mood status. Machine learning data analysis techniques will be applied to determine which presurgery parameters have the strongest power for predicting patient recovery following total knee replacement. On the basis of these analyses, a predictive model will be developed. Predictive models will undergo internal validation, and Bayesian analysis will be applied to provide additional metrics regarding prediction accuracy. RESULTS: Patient recruitment and data collection commenced in November 2019 and was completed in June 2022. A total of 1050 patients who underwent TKA were enrolled in this study. CONCLUSIONS: Our findings will facilitate the development of the first comprehensive biopsychosocial prediction tool, which has the potential to objectively predict a patient's individual recovery outcomes following TKA once selected by an orthopedic surgeon to undergo TKA. If successful, the tool could also inform the evolution rehabilitation services, such that factors in addition to physical performance can be addressed and have the potential to further enhance patient recovery and satisfaction. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48801.

TACTICS VR Stroke Telehealth Virtual Reality Training for Health Care Professionals Involved in Stroke Management at Telestroke Spoke Hospitals: Module Design and Implementation Study.

BACKGROUND: Stroke management in rural areas is more variable and there is less access to reperfusion therapies, when compared with metropolitan areas. Delays in treatment contribute to worse patient outcomes. To improve stroke management in rural areas, health districts are implementing telestroke networks. The New South Wales Telestroke Service provides neurologist-led telehealth to 23 rural spoke hospitals aiming to improve treatment delivery and patient outcomes. The training of clinical staff was identified as a critical aspect for the successful implementation of this service. Virtual reality (VR) training has not previously been used in this context. OBJECTIVE: We sought to develop an evidence-based VR training module specifically tailored for stroke telehealth. During implementation, we aimed to assess the feasibility of workplace deployment and collected feedback from spoke hospital staff involved in stroke management on training acceptability and usability as well as perceived training impact. METHODS: The TACTICS VR Stroke Telehealth application was developed with subject matter experts. During implementation, both quantitative and qualitative data were documented, including VR use and survey feedback. VR hardware was deployed to 23 rural hospitals, and use data were captured via automated Wi-Fi transfer. At 7 hospitals in a single local health district, staff using TACTICS VR were invited to complete surveys before and after training. RESULTS: TACTICS VR Stroke Telehealth was deployed to rural New South Wales hospitals starting on April 14, 2021. Through August 20, 2023, a total of 177 VR sessions were completed. Survey respondents (n=20) indicated a high level of acceptability, usability, and perceived training impact (eg, accuracy and knowledge transfer; mean scores 3.8-4.4; 5=strongly agree). Furthermore, respondents agreed that TACTICS VR increased confidence (13/18, 72%), improved understanding (16/18, 89%), and improved awareness (17/18, 94%) regarding stroke telehealth. A comparison of matched pre- and posttraining responses revealed that training improved the understanding of telehealth workflow practices (after training: mean 4.2, SD 0.6; before training: mean 3.2, SD 0.9; P<.001), knowledge on accessing stroke telehealth (mean 4.1, SD 0.6 vs mean 3.1, SD 1.0; P=.001), the awareness of stroke telehealth (mean 4.1, SD 0.6 vs mean 3.4, SD 0.9; P=.03), ability to optimally communicate with colleagues (mean 4.2, SD 0.6 vs mean 3.7, SD 0.9; P=.02), and ability to make improvements (mean 4.0, SD 0.6 vs mean 3.5, SD 0.9; P=.03). Remote training and deployment were feasible, and limited issues were identified, although uptake varied widely (0-66 sessions/site). CONCLUSIONS: TACTICS VR Stroke Telehealth is a new VR application specifically tailored for stroke telehealth workflow training at spoke hospitals. Training was considered acceptable, usable, and useful and had positive perceived training impacts in a real-world clinical implementation context. Additional work is required to optimize training uptake and integrate training into existing education pathways.

Fluoxetine prevents development of an early stress-related molecular signature in the rat infralimbic medial prefrontal cortex. Implications for depression?

BACKGROUND: Psychological stress, particularly in chronic form, can lead to mood and cognitive dysfunction and is a major risk factor in the development of depressive states. How stress affects the brain to cause psychopathologies is incompletely understood. We sought to characterise potential depression related mechanisms by analysing gene expression and molecular pathways in the infralimbic medial prefrontal cortex (ILmPFC), following a repeated psychological stress paradigm. The ILmPFC is thought to be involved in the processing of emotionally contextual information and in orchestrating the related autonomic responses, and it is one of the brain regions implicated in both stress responses and depression. RESULTS: Genome-wide microarray analysis of gene expression showed sub-chronic restraint stress resulted predominantly in a reduction in transcripts 24 hours after the last stress episode, with 239 genes significantly decreased, while just 24 genes had increased transcript abundance. Molecular pathway analysis using DAVID identified 8 pathways that were significantly enriched in the differentially expressed gene list, with genes belonging to the brain-derived neurotrophic factor - neurotrophin receptor tyrosine kinase 2 (BDNF-Ntrk2) pathway most enriched. Of the three intracellular signalling pathways that are downstream of Ntrk2, real-time quantitative PCR confirmed that only the PI3K-AKT-GSK3B and MAPK/ERK pathways were affected by sub-chronic stress, with the PLCγ pathway unaffected. Interestingly, chronic antidepressant treatment with the selective serotonin reuptake inhibitor, fluoxetine, prevented the stress-induced Ntrk2 and PI3K pathway changes, but it had no effect on the MAPK/ERK pathway. CONCLUSIONS: These findings indicate that abnormal BDNF-Ntrk2 signalling may manifest at a relatively early time point, and is consistent with a molecular signature of depression developing well before depression-like behaviours occur. Targeting this pathway prophylactically, particularly in depression-susceptible individuals, may be of therapeutic benefit.

Assessing the Efficacy of an Individualized Psychological Flexibility Skills Training Intervention App for Medical Student Burnout and Well-being: Protocol for a Randomized Controlled Trial.

BACKGROUND: Medical student burnout is a prevalent problem with adverse long-term outcomes. Incorporating psychological resource-building interventions into comprehensive burnout prevention approaches during medical training is an identified priority among educators. These interventions could reduce burnout risk by buffering students against nonmodifiable career stressors. However, there is a need for rigorous investigation into optimal intervention targets and methods. Psychological flexibility (PF) is an adaptive behavioral skill set that has demonstrated relationships with medical student burnout and well-being. More broadly, there is evidence that PF mediates burnout and well-being outcomes and may be a protective factor. Efficacy studies assessing the benefits of interventions targeting PF among medical students are needed. Research also supports the need to establish optimal methods for increasing intervention efficacy in the context of individual differences in burnout and PF by using individualized approaches. OBJECTIVE: This study aims to assess whether an app-delivered PF intervention (Acceptance and Commitment Training) reduces burnout and improves well-being among medical students. We will examine whether changes in burnout and well-being are mediated by changes in PF. The potential benefits of an individualized version of the app versus those of a nonindividualized version will also be evaluated. METHODS: In this 3-arm, parallel, randomized controlled study, a sample of medical students will be randomly allocated to 1 of 3 intervention arms (individualized, nonindividualized, and waiting list) by using a 1:1:1 allocation ratio. Participants in the individualized and nonindividualized intervention arms will have 5 weeks to access the app, which includes a PF concepts training session (stage 1) and access to short PF skill activities on demand (stage 2). Stage 2 will be either individualized to meet participants' identified PF training needs at each log-in or nonindividualized. RESULTS: Burnout, well-being, and PF will be assessed at baseline and after the intervention. Quantitative analyses will include descriptive and inferential statistics. We hypothesize that the Acceptance and Commitment Training intervention app will be effective in improving burnout and well-being and that changes in these outcomes will be mediated by changes in PF. We further hypothesize that participants in the individualized intervention group will demonstrate greater improvements in burnout and well-being outcomes than those in the nonindividualized group. CONCLUSIONS: The findings of this study could guide the development of burnout prevention and well-being initiatives for medical students. Identifying PF as a mediating process would provide support for the delivery of preventive intervention programs that train individuals to strengthen this psychological resource before burnout symptoms emerge. This would be an important step in addressing and potentially offsetting the significant costs of burnout among medical students and physicians. Demonstrating the superiority of an individualized version of the app over a nonindividualized version would have implications for enhancing intervention precision and efficacy by using scalable interventions. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ANZCTR 12621000911897; https://www.anzctr.org.au/ACTRN12621000911897.aspx. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/32992.

Correction: Assessing the Efficacy of an Individualized Psychological Flexibility Skills Training Intervention App for Medical Student Burnout and Well-being: Protocol for a Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/32992.].

Correction: Assessing the Efficacy of an Individualized Psychological Flexibility Skills Training Intervention App for Medical Student Burnout and Well-being: Protocol for a Randomized Controlled Trial.

[This corrects the article DOI: .].

Unraveling the Physiological Correlates of Mental Workload Variations in Tracking and Collision Prediction Tasks.

Modern work environments have extensive interactions with technology and greater cognitive complexity of the tasks, which results in human operators experiencing increased mental workload. Air traffic control operators routinely work in such complex environments, and we designed tracking and collision prediction tasks to emulate their elementary tasks. The physiological response to the workload variations in these tasks was elucidated to untangle the impact of workload variations experienced by operators. Electroencephalogram (EEG), eye activity, and heart rate variability (HRV) data were recorded from 24 participants performing tracking and collision prediction tasks with three levels of difficulty. Our findings indicate that variations in task load in both these tasks are sensitively reflected in EEG, eye activity and HRV data. Multiple regression results also show that operators' performance in both tasks can be predicted using the corresponding EEG, eye activity and HRV data. The results also demonstrate that the brain dynamics during each of these tasks can be estimated from the corresponding eye activity, HRV and performance data. Furthermore, the markedly distinct neurometrics of workload variations in the tracking and collision prediction tasks indicate that neurometrics can provide insights on the type of mental workload. These findings have applicability to the design of future mental workload adaptive systems that integrate neurometrics in deciding not just "when" but also "what" to adapt. Our study provides compelling evidence in the viability of developing intelligent closed-loop mental workload adaptive systems that ensure efficiency and safety in complex work environments.