Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis.

BACKGROUND: There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development. OBJECTIVE: This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom. METHODS: Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls. RESULTS: A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found. CONCLUSIONS: Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184.

Usability, Acceptability, and Effectiveness of Web-Based Conversational Agents to Facilitate Problem Solving in Older Adults: Controlled Study.

BACKGROUND: The usability and effectiveness of conversational agents (chatbots) that deliver psychological therapies is under-researched. OBJECTIVE: This study aimed to compare the system usability, acceptability, and effectiveness in older adults of 2 Web-based conversational agents that differ in theoretical orientation and approach. METHODS: In a randomized study, 112 older adults were allocated to 1 of the following 2 fully automated interventions: Manage Your Life Online (MYLO; ie, a chatbot that mimics a therapist using a method of levels approach) and ELIZA (a chatbot that mimics a therapist using a humanistic counseling approach). The primary outcome was problem distress and resolution, with secondary outcome measures of system usability and clinical outcome. RESULTS: MYLO participants spent significantly longer interacting with the conversational agent. Posthoc tests indicated that MYLO participants had significantly lower problem distress at follow-up. There were no differences between MYLO and ELIZA in terms of problem resolution. MYLO was rated as significantly more helpful and likely to be used again. System usability of both the conversational agents was associated with helpfulness of the agents and the willingness of the participants to reuse. Adherence was high. A total of 12% (7/59) of the MYLO group did not carry out their conversation with the chatbot. CONCLUSIONS: Controlled studies of chatbots need to be conducted in clinical populations across different age groups. The potential integration of chatbots into psychological care in routine services is discussed.

Restoring speech following total removal of the larynx by a learned transformation from sensor data to acoustics.

Total removal of the larynx may be required to treat laryngeal cancer: speech is lost. This article shows that it may be possible to restore speech by sensing movement of the remaining speech articulators and use machine learning algorithms to derive a transformation to convert this sensor data into an acoustic signal. The resulting "silent speech," which may be delivered in real time, is intelligible and sounds natural. The identity of the speaker is recognisable. The sensing technique involves attaching small, unobtrusive magnets to the lips and tongue and monitoring changes in the magnetic field induced by their movement.

Freedom comes at a cost?: An exploratory study on affordances' impact on users' perception of a social robot.

Along with the development of speech and language technologies, the market for speech-enabled human-robot interactions (HRI) has grown in recent years. However, it is found that people feel their conversational interactions with such robots are far from satisfactory. One of the reasons is the habitability gap, where the usability of a speech-enabled agent drops when its flexibility increases. For social robots, such flexibility is reflected in the diverse choice of robots' appearances, sounds and behaviours, which shape a robot's 'affordance'. Whilst designers or users have enjoyed the freedom of constructing a social robot by integrating off-the-shelf technologies, such freedom comes at a potential cost: the users' perceptions and satisfaction. Designing appropriate affordances is essential for the quality of HRI. It is hypothesised that a social robot with aligned affordances could create an appropriate perception of the robot and increase users' satisfaction when speaking with it. Given that previous studies of affordance alignment mainly focus on one interface's characteristics and face-voice match, we aim to deepen our understanding of affordance alignment with a robot's behaviours and use cases. In particular, we investigate how a robot's affordances affect users' perceptions in different types of use cases. For this purpose, we conducted an exploratory experiment that included three different affordance settings (adult-like, child-like, and robot-like) and three use cases (informative, emotional, and hybrid). Participants were invited to talk to social robots in person. A mixed-methods approach was employed for quantitative and qualitative analysis of 156 interaction samples. The results show that static affordance (face and voice) has a statistically significant effect on the perceived warmth of the first impression; use cases affect people's perceptions more on perceived competence and warmth before and after interactions. In addition, it shows the importance of aligning static affordance with behavioural affordance. General design principles of behavioural affordances are proposed. We anticipate that our empirical evidence will provide a clearer guideline for speech-enabled social robots' affordance design. It will be a starting point for more sophisticated design guidelines. For example, personalised affordance design for individual or group users in different contexts.

Using social robots for language learning: are we there yet?

Along with the development of speech and language technologies and growing market interest, social robots have attracted more academic and commercial attention in recent decades. Their multimodal embodiment offers a broad range of possibilities, which have gained importance in the education sector. It has also led to a new technology-based field of language education: robot-assisted language learning (RALL). RALL has developed rapidly in second language learning, especially driven by the need to compensate for the shortage of first-language tutors. There are many implementation cases and studies of social robots, from early government-led attempts in Japan and South Korea to increasing research interests in Europe and worldwide. Compared with RALL used for English as a foreign language (EFL), however, there are fewer studies on applying RALL for teaching Chinese as a foreign language (CFL). One potential reason is that RALL is not well-known in the CFL field. This scope review paper attempts to fill this gap by addressing the balance between classroom implementation and research frontiers of social robots. The review first introduces the technical tool used in RALL, namely the social robot, at a high level. It then presents a historical overview of the real-life implementation of social robots in language classrooms in East Asia and Europe. It then provides a summary of the evaluation of RALL from the perspectives of L2 learners, teachers and technology developers. The overall goal of this paper is to gain insights into RALL's potential and challenges and identify a rich set of open research questions for applying RALL to CFL. It is hoped that the review may inform interdisciplinary analysis and practice for scientific research and front-line teaching in future.

Cross-species parallels in babbling: animals and algorithms.

A key feature of vocal ontogeny in a variety of taxa with extensive vocal repertoires is a developmental pattern in which vocal exploration is followed by a period of category formation that results in a mature species-specific repertoire. Vocal development preceding the adult repertoire is often called 'babbling', a term used to describe aspects of vocal development in species of vocal-learning birds, some marine mammals, some New World monkeys, some bats and humans. The paper summarizes the results of research on babbling in examples from five taxa and proposes a unifying definition facilitating their comparison. There are notable similarities across these species in the developmental pattern of vocalizations, suggesting that vocal production learning might require babbling. However, the current state of the literature is insufficient to confirm this suggestion. We suggest directions for future research to elucidate this issue, emphasizing the importance of (i) expanding the descriptive data and seeking species with complex mature repertoires where babbling may not occur or may occur only to a minimal extent; (ii) (quasi-)experimental research to tease apart possible mechanisms of acquisition and/or self-organizing development; and (iii) computational modelling as a methodology to test hypotheses about the origins and functions of babbling. This article is part of the theme issue 'Vocal learning in animals and humans'.

e-Therapies in England for stress, anxiety or depression: how are apps developed? A survey of NHS e-therapy developers.

OBJECTIVE: To document the quality of web and smartphone apps used and recommended for stress, anxiety or depression by examining the manner in which they were developed. DESIGN: The study was conducted using a survey sent to developers of National Health Service (NHS) e-therapies. DATA SOURCES: Data were collected via a survey sent out to NHS e-therapy developers during October 2015 and review of development company websites during October 2015. DATA COLLECTION/EXTRACTION METHODS: Data were compiled from responses to the survey and development company websites of the NHS e-therapies developers. RESULTS: A total of 36 (76.6%) out of the 48 app developers responded. One app was excluded due to its contact details and developer website being unidentifiable. Data from the missing 10 was determined from the app developer's website. The results were that 12 out of 13 web apps and 20 out of 34 smartphone apps had clinical involvement in their development. Nine out of 13 web apps and nine out of 34 smartphone apps indicated academic involvement in their development. Twelve out of 13 web apps and nine out of 34 smartphone apps indicated published research evidence relating to their app. Ten out of 13 web apps and 10 out of 34 smartphone apps indicated having other evidence relating to their app. Nine out of 13 web apps and 19 out of 34 smartphone apps indicated having a psychological approach or theory behind their app. CONCLUSIONS: As an increasing number of developers are looking to produce e-therapies for the NHS it is essential they apply clinical and academic best practices to ensure the creation of safe and effective apps.

Clinical implications of QRS duration and QT peak prolongation in patients with suspected coronary disease referred for elective cardiac catheterization.

BACKGROUND: The electrocardiogram (ECG) remains a simple, universally available, and prognostically powerful investigation in heart failure, and acute coronary syndromes. We sought to assess the prognostic utility of clinical, angiographic, and simple ECG parameters in a large cohort of patients undergoing elective cardiac catheterization (CC) for known or suspected coronary artery disease. METHODS: Consecutive consenting patients undergoing CC for coronary disease were enrolled at a single tertiary center. Patient data, drug therapy, catheter reports, and ECG recordings were prospectively recorded in a validated electronic archive. The primary outcome measure was death or nonfatal myocardial infarction (MI) over 1 year or until percutaneous or cardiac surgical intervention. Independent prognostic markers were identified using the Cox proportional hazard model. RESULTS: A total of 682 individuals were recruited of whom 17(2.5%) died or suffered a nonfatal MI in 1 year. In multivariate analysis QRS duration (ms) (HR 1.03 95% CI 1.01-1.05, P = 0.003), extent of coronary disease (HR 2.01 95% CI 1.24-3.58, P = 0.006), and prolonged corrected QT peak interval in lead I (HR 1.02 95% CI 1.00-1.03, P = 0.044) were independently associated with death or nonfatal MI. Receiver-operator characteristic (ROC) analysis for the multivariate model against the primary end point yielded an area under the curve of 0.759 (95% CI 0.660-0.858), P < 0.001. CONCLUSIONS: QRS duration and QT peak are independently associated with increased risk of death or nonfatal MI in stable patients attending for coronary angiography.

A brief cognitive-behavioral intervention reduces hospital admissions in refractory angina patients.

Chronic refractory angina is an increasingly prevalent, complex chronic pain condition, which results in frequent hospitalization for chest pain. We have previously shown that a novel outpatient cognitive-behavioral chronic disease management program (CB-CDMP) improves angina status and quality of life in such patients. In the present study of 271 chronic refractory angina patients enrolled in our CB-CDMP, total hospital admissions were reduced from 2.40 admissions per patient per year to 1.78 admissions per patient per year (P<0.001). The rising trend of total hospital bed day occupancy prior to enrollment fell from 15.48 days per patient per year to a stable 10.34 days per patient per year (P<0.001). There were 32 recorded myocardial infarctions prior to enrollment compared to eight in the year following enrollment (14% vs. 2.3%, P<0.001) and overall mortality was lower that comparable groups treated with surgery. This study shows that educating patients and demystifying angina using a brief outpatient CB-CDMP produces an immediate and sustained reduction in hospital admission costs that represents a major potential health care saving. This benefit accrues in addition to the known effects of CB-CDMP on symptoms and quality of life. These data suggest that a CB-CDMP approach to symptom palliation represents a low cost alternative to palliative revascularization.

Restoring Speech Following Total Removal of the Larynx.

By speech articulator movement and training a transformation to audio we can restore the power of speech to someone who has lost their larynx. We sense changes in magnetic field caused by movements of small magnets attached to the lips and tongue. The sensor transformation uses recurrent neural networks.

Heart rate turbulence and death due to cardiac decompensation in patients with chronic heart failure.

BACKGROUND: As treatment strategies for patients with chronic heart failure (HF) become more sophisticated, identifying patients at high risk of death and predicting mode of death is important. The aim of this study was to explore the potential utility of heart rate turbulence (HRT) to identify patients with HF at high risk of death. METHODS AND RESULTS: In a prospective study, 553 ambulant outpatients age 63+/-10 with symptoms of HF and evidence of cardiac dysfunction were recruited. All patients underwent 24-h Holter ECG recordings, which were analysed for arrhythmias, heart rate variability and HRT a measurement that is thought to quantify cardiac autonomic regulatory mechanisms. Baseline chest radiograph, biochemistry and 12-lead electrocardiograms were also obtained. In patients with HRT measurements at 5 years follow up, 146 patients had died, 59 due to decompensated HF. Independent predictors of death from decompensated HF at 5-year follow up (Cox proportional hazard model) were HRT slope (HR for 10% increment 0.84, 95% CI 0.77-0.91), serum sodium (HR for 10% increment 0.75, 95% CI 0.62-0.91) and serum creatinine (for 10% increment HR 1.14, 95% CI 1.08-1.19) all P<0.01. These 3 variables combined had excellent discrimination between patients dying of decompensated HF and other patients, C-statistic=0.82. CONCLUSIONS: In patients with mild-to-moderate HF, HRT slope is an independent predictor of death due to decompensated HF. HRT may have the potential to help tailor therapy in this patient group.

A Bayesian explanation of the 'Uncanny Valley' effect and related psychological phenomena.

There are a number of psychological phenomena in which dramatic emotional responses are evoked by seemingly innocuous perceptual stimuli. A well known example is the 'uncanny valley' effect whereby a near human-looking artifact can trigger feelings of eeriness and repulsion. Although such phenomena are reasonably well documented, there is no quantitative explanation for the findings and no mathematical model that is capable of predicting such behavior. Here I show (using a Bayesian model of categorical perception) that differential perceptual distortion arising from stimuli containing conflicting cues can give rise to a perceptual tension at category boundaries that could account for these phenomena. The model is not only the first quantitative explanation of the uncanny valley effect, but it may also provide a mathematical explanation for a range of social situations in which conflicting cues give rise to negative, fearful or even violent reactions.

Reduction in mortality and target-lesion revascularisation at 2 years: a comparison between drug-eluting stents and conventional bare-metal stents in the "real world".

BACKGROUND: Long-term safety of drug-eluting stent (DES) is still a concern. We aimed to assess the impact of DES use on all-cause mortality and target-lesion revascularisation (TLR) in routine clinical practice. METHODS: Retrospective analysis of all patients undergoing percutaneous coronary intervention with stent implantation at our institution between January 2003 and December 2004. To account for differences in patient characteristics, logistic regression was used to produce a propensity score for DES group membership. Patients receiving DES were then matched to patients receiving bare metal stents (BMS) with identical propensity scores. These two groups were then compared with respect to the incidence of TLR and all-cause mortality. RESULTS: During the study period 995 patients received DES. Of these, 82 patients had combined DES and BMS use and were therefore excluded; leaving 913 DES patients compared to 2105 BMS patients. Patients who received DES were more likely to be diabetic, hypertensive, had more lesions treated, restenotic lesions treated, left anterior descending and left main stem interventions, long lesions treated, small diameter lesions treated, and American Heart Association C-type lesions treated. After performing propensity-matching, to account for differences in patient characteristics, we were able to successfully match 777 DES patients to 777 BMS patients. The TLR rates at 24 months were significantly lower for DES patients (DES-4.2% vs BMS-9.2%, p<0.001). All-cause mortality was also significantly lower for DES patients (DES-1.8% vs BMS-4.0%, p=0.01). CONCLUSIONS: In routine clinical practice DES implantation continued to demonstrate a significant reduction in the need for repeat intervention at 24 months. All-cause and cardiac mortality was also significantly lower for DES patients compared to BMS patients.

Twin circumflex arteries: a rare coronary artery anomaly.

Dual origin of the circumflex artery is an extremely rare anomaly. We report a rare case of a left circumflex artery arising from the left mainstem and an anomalous circumflex artery from a separate ostium in the right coronary sinus. Both these arteries supplied the circumflex territory. The potential pathological significance of the anomaly and pitfalls of the misdiagnosis are also discussed.

Left atrial myxoma presenting with ventricular fibrillation.

Coronary artery embolism with myocardial infarction is a very rare and potentially life-threatening complication of left atrial myxoma. We report the case of a 51-year-old male who presented with chest pain. Whilst awaiting medical review in the emergency department, he collapsed and a cardiac monitor revealed ventricular fibrillation. Following successful resuscitation, a 12-lead electrocardiogram demonstrated anterior myocardial infarction that was initially presumed to be secondary to atheromatous coronary disease. An echocardiogram performed before discharge, however, revealed a mass in the left atrium, which was highly suggestive of a myxoma. His subsequent coronary angiogram demonstrated coronary disease limited to a single lesion within a small first obtuse marginal branch of his circumflex coronary artery. He underwent curative surgery, and histology confirmed the diagnosis of myxoma. We have discussed embolic complications of myxoma and the possible reasons for rarity of coronary embolisation. Emphasis is given to the importance of considering other causes of myocardial infarction in relatively young patients and the important role of early echocardiography following myocardial infarction.

Percutaneous coronary intervention in a single coronary artery originating from the right sinus of Valsalva.

The origin of the left coronary artery (LCA) from the right sinus of Valsalva is a rare congenital anomaly that may be associated with myocardial infarction and sudden or exercise-related death. We report a rare case of a single coronary artery originating from the right coronary sinus and bifurcating into LCA and right coronary artery (RCA). The RCA was found to contain a significant flow-limiting lesion that was successfully treated with percutaneous coronary intervention. In this short report, we discuss the variations in anomalous LCA originating from the right coronary sinus and their clinical implications.

A study comparing the incidence and predictors of creatine kinase MB and troponin T release after coronary angioplasty. Does Clopidogrel preloading reduce myocardial necrosis following elective percutaneous coronary intervention?

BACKGROUND: To investigate the incidence and associated factors for enzyme release following percutaneous coronary intervention comparing assessment with creatine kinase MB (CK-MB) and troponin T (TnT). METHOD: TnT and CK-MB were measured post procedure in a consecutive series of 933 patients undergoing elective percutaneous coronary intervention between 1/4/2003 and 1/5/2004 at a single regional cardiac centre. RESULTS: CK-MB level significantly correlated to TnT levels (R=0.747, p<0.001) and a CK-MB level of above 3 times the upper limit of the local reference range (>3 x ULN) was predicted with 95% sensitivity (48% specificity) at a TnT level of 0.11. Multivariate predictors of >3 x ULN CK-MB release for uncomplicated percutaneous coronary intervention (n=898) were multi-vessel angioplasty (OR=2.51, 95% CI=1.57 to 4.01; p<0.001), saphenous venous graft angioplasty (OR=5.5, 95% CI=1.94 to 13.00; p=0.005) and lack of Clopidogrel preloading (OR=2.02, 95% CI=1.30 to 4.38; p=0.027). CONCLUSIONS: TnT was found to be a sensitive although not a highly specific marker of CK-MB release. In this study a TnT level above a threshold of 0.11 would identify 95% of the prognostically important 3-fold CK-MB releases. Replacing the >3 x ULN CK-MB threshold with a TnT level of 0.1 ng/l following percutaneous coronary intervention would increase the apparent rate of myocardial infarction from 11% to 20%. Lack of Clopidogrel preloading was independently associated with a >3 x ULN CK-MB release following uncomplicated elective percutaneous coronary intervention.

Spectral analysis, death and coronary anatomy following cardiac catheterisation.

OBJECTIVE: To establish the associations and prognostic utility of angiographic, clinical and HRV parameters in a large cohort of patients undergoing diagnostic cardiac catheterisation (CC). METHODS: Patients undergoing CC as elective day cases were enrolled at a single tertiary center from September 2001 to January 2003. Patient data, serum biochemistry, current drug therapy, catheter reports and five minute high resolution electrocardiograph (ECG) recordings were prospectively recorded and validated in an electronic archive. ECG recordings were used to generate time domain (SDNN (standard deviation of NN intervals)) and spectral HRV parameters (low frequency (LF) and high frequency (HF) power). Significant associations between dichotomized HRV variables and covariates were investigated using binary logistic regression. The independent prognostic ability of clinical markers was evaluated using the Cox proportional hazard model. RESULTS: 841 consecutive consenting patients of mean age 61+/-10 years were recruited into the study with a mean follow-up period of 690+/-436 days. In multivariate analysis decreasing LF spectral power was independently associated with proximal right coronary stenosis OR (odds ratio)=1.65 (95% CI=1.16-2.36), P=0.006 and to all cause mortality OR=5.01 (95% CI=1.47-17.01), P=0.010. Increasing LF power was also independently associated with normal coronary angiograms in patients investigated suspected coronary disease without a confirmed prior history of a coronary ischaemic event OR=2.16 (95% CI=1.26-3.73), P=0.002. CONCLUSIONS: Reduced LF power independently predicts all cause mortality in a large cohort of patients receiving medical therapy after elective CC. LF power was also independently associated with >75% proximal RCA stenosis.