Patient and Provider Experiences With a Digital App to Improve Compliance With Enhanced Recovery After Surgery (ERAS) Protocols: Mixed Methods Evaluation of a Canadian Experience.

BACKGROUND: Of all the care provided in health care systems, major surgical interventions are the costliest and can carry significant risks. Enhanced Recovery After Surgery (ERAS) is a bundle of interventions that help improve patient outcomes and experience along their surgical journey. However, given that patients can be overwhelmed by the multiple tasks that they are expected to follow, a digital application, the ERAS app, was developed to help improve the implementation of ERAS. OBJECTIVE: The objective of this work was to conduct a thorough assessment of patient and provider experiences using the ERAS app. METHODS: Patients undergoing colorectal or gynecological oncology surgery at 2 different hospitals in the province of Alberta, Canada, were invited to use the ERAS app and report on their experiences using it. Likewise, care providers were recruited to participate in this study to provide feedback on the performance of this app. Data were collected by an online survey and using qualitative interviews with participants. NVivo was used to analyze qualitative interview data, while quantitative data were analyzed using Excel and SPSS. RESULTS: Overall, patients found the app to be helpful in preparation for and recovery after surgery. Patients reported having access to reliable unbiased information regarding their surgery, and the app provided them with clarity of actions needed along their surgical journey and enhanced the self-management of their care. Clinicians found that the ERAS app was easy to navigate, was simple for older adults, and has the potential to decrease unnecessary visits and phone calls to care providers. Overall, this proof-of-concept study on the use of a digital health app to accompany patients during their health care journey has shown positive results. CONCLUSIONS: This is an important finding considering the massive investment and interest in promoting digital health in health care systems around the world.

Somatosensory stimulation to improve hand and upper limb function after stroke-a systematic review with meta-analyses.

Background Somatosensory stimulation may have a positive impact on recovery of motor function by maintaining cortical representation of the hand and acting to prime the motor system for movement. Objective Determine the efficacy of somatosensory stimulation on upper limb motor function after stroke. Methods Five electronic databases (MEDLINE, CINAHL, Embase, PEDro and OT Seeker) were searched from inception to October 2016. Included studies were English-language randomized controlled trials where a sensory intervention was applied below the elbow to improve upper limb motor control of adults after stroke. One outcome needed to measure arm function at an impairment or activity level. Study selection and quality assessment (using the PEDro scale) were independently conducted by two reviewers. Meta-analysis was completed where there was sufficient homogeneity between trials. Results Fifteen articles were included reporting data from 14 randomized controlled trials (627 participants). There was low-quality evidence from four trials that sensory electrical stimulation did not improve upper limb activity compared to placebo (SMD 0.4, 95%CI -0.07 to 0.87, I2 38%) and moderate-quality evidence from three trials that it did not improve motor impairment (MD 3.45 units, 95%CI -1.47 to 8.36, I2 35%). Low-quality evidence from two trials demonstrated that therapist-delivered sensory stimulation did not improve upper limb activity (SMD 0.25, 95%CI -0.20 to 0.69, I2 0%) compared to usual care. Conclusion Current low- to moderate-quality evidence suggests somatosensory stimulation is not effective in improving upper limb motor impairment or activity after stroke.

'It was like he was in the room with us': patients' and carers' perspectives of telemedicine in acute stroke.

BACKGROUND: Telemedicine can facilitate delivery of thrombolysis in acute stroke. The aim of this qualitative study was to explore patients' and carers' views of their experiences of using a stroke telemedicine system in order to contribute to the development of reliable and acceptable telemedicine systems and training for health-care staff. METHOD: We recruited patients who had, and carers who were present at, recent telemedicine consultations for acute stroke in three hospitals in NW England. Semi-structured interviews were conducted using an interview guide based on normalization process theory (NPT). Thematic analysis was undertaken. RESULTS: We conducted 24 interviews with 29 participants (16 patients; 13 carers). Eleven interviews pertained to 'live' telemedicine assessments (at the time of admission); nine had mock-up telemedicine assessments (within 48 h of admission); four had both assessments. Using the NPT domains as a framework for analysis, factors relating to coherence (sense making) included people's knowledge and understanding of telemedicine. Cognitive participation (relational work) included interaction between staff and with patients and carers. Issues relating to collective action (operational work) included information exchange and support, and technical matters. Findings relating to reflexive monitoring (appraisal) included positive and negative impressions of the telemedicine process, and emotional reactions. CONCLUSION: Although telemedicine was well accepted by many participants, its use added an additional layer of complexity to the acute stroke consultation. The 'remote' nature of the consultation posed challenges for some patients. These issues may be ameliorated by clear information for patients and carers, staff interpersonal skills, and teamworking.

A cross-modal feedback scheme for control of prosthetic grasp strength.

INTRODUCTION: Given the lack of haptic feedback inherent in prosthetic devices, a natural and adaptable feedback scheme must be implemented. While multimodal feedback has proven successful in aiding dexterous performance, it can be mentally tasking on the individual. Conversely, cross-modal schemes relying on sensory substitution have proven to be equally effective in aiding task performance without cognitively burdening the user to the same degree. OBJECTIVES: This experiment investigated the effectiveness of the cross-modal feedback scheme through using audio feedback to represent prosthetic grasping strength during dynamic control of a prosthetic hand. METHODS: A total of five individuals participated in two sets of experiments (four subjects in the first, one subject in the second). Participants were asked to control the grasping strength exerted by a prosthetic hand while using real-time audio feedback in order to reach up to three different levels of force within a trial set. RESULTS: The cross-modal feedback scheme successfully provided users with the robust ability to modulate grasping strength in real-time using only audio feedback. CONCLUSION: Audio feedback effectively conveys haptic information to the user of a prosthetic hand. Retention of the training knowledge is evident and can be generalized to perform new (i.e. untrained) tasks.

Effects of Aquatic Therapy and Land-Based Therapy versus Land-Based Therapy Alone on Range of Motion, Edema, and Function after Hip or Knee Replacement: A Systematic Review and Meta-analysis.

PURPOSE: To determine whether aquatic therapy in combination with land-based therapy improves patient outcomes after hip or knee arthroplasty compared with land-based therapy alone. METHODS: For this systematic review, six online databases (MEDLINE, CINAHL, AMED, EMBASE, Cochrane, and PEDro) were searched from the earliest date available until September 2013. Controlled trials published in English in a peer-reviewed journal that compared aquatic therapy in combination with land-based therapy with land-based therapy alone were included; trial quality was assessed using the PEDro scale. Data were presented as standardized mean differences (SMDs), their associated 95% CIs, and meta-analyses. RESULTS: Three small trials of moderate quality were included in the qualitative analysis. Meta-analysis of two of these studies found moderate-quality evidence that aquatic therapy in combination with land-based therapy improves functional outcomes (SMD=0.53; 95% CI, 0.03-1.03), knee range of motion (measured in knee or hip arthroplasty; SMD=0.78; 95% CI, 0.27-1.29), and edema (SMD=-0.66; 95% CI, -1.16 to -0.15) compared with land-based therapy alone. The results for improved functional outcomes were not considered clinically significant. CONCLUSIONS: It is not possible to draw confident conclusions from this review because of the small number of studies of limited quality and the modest differences found. Further studies of sound methodological quality are required to confirm the results. Economic analysis alongside randomized controlled trials is needed to examine the cost-effectiveness of these clinical outcomes.

Objet: Déterminer si l'aquathérapie combinée à un traitement hors de l'eau améliore les résultats pour le patient après une arthroplastie de la hanche ou du genou par opposition à un traitement sans aquathérapie. Méthodes: Pour cet examen systématique, la recherche a été effectuée dans six bases de données en ligne (MEDLINE, CINAHL, AMED, EMBASE, Cochrane, et PEDro) à partir de la date accessible la plus éloignée jusqu'à septembre 2013. Des essais contrôlés publiés en anglais dans une revue à comité de lecture et comparant l'aquathérapie combinée à un traitement hors de l'eau au traitement sans aquathérapie ont été inclus dans l'examen; la qualité des essais a été évaluée au moyen de l'échelle PEDro. Les données ont été présentées sous forme de différences moyennes normalisées (DMN), d'intervalles de confiance (IC) connexes de 95% et de méta-analyses. Résultats: Trois petits essais de qualité modérée faisaient partie de l'analyse qualitative. La méta-analyse de deux de ces études a permis de trouver des preuves de qualité modérée que l'aquathérapie combinée à un traitement hors de l'eau améliore les résultats fonctionnels (DMN=0,53; selon un IC de 95%, 0,03­1,03), l'amplitude des mouvements du genou (mesurée dans l'arthroplastie du genou ou de la hanche) (DMN=0,78; selon un IC de 95%, 0,27­1,29), et l'œdème (DMN =−0,66; selon un IC de 95%, −1,16­−0,15) comparativement au traitement sans aquathérapie. Les données des résultats fonctionnels améliorés n'ont pas été considérées comme cliniquement significatives. Conclusions: Il n'est pas possible de tirer des conclusions fiables de cet examen en raison du petit nombre d'études de qualité limitée et des modestes différences constatées. Il faudra effectuer d'autres études de bonne qualité méthodologique pour confirmer les résultats. Parallèlement aux essais contrôlés randomisés, il faut effectuer une analyse économique pour examiner la rentabilité de ces résultats cliniques.

Object discrimination using optimized multi-frequency auditory cross-modal haptic feedback.

As the field of brain-machine interfaces and neuro-prosthetics continues to grow, there is a high need for sensor and actuation mechanisms that can provide haptic feedback to the user. Current technologies employ expensive, invasive and often inefficient force feedback methods, resulting in an unrealistic solution for individuals who rely on these devices. This paper responds through the development, integration and analysis of a novel feedback architecture where haptic information during the neural control of a prosthetic hand is perceived through multi-frequency auditory signals. Through representing force magnitude with volume and force location with frequency, the feedback architecture can translate the haptic experiences of a robotic end effector into the alternative sensory modality of sound. Previous research with the proposed cross-modal feedback method confirmed its learnability, so the current work aimed to investigate which frequency map (i.e. frequency-specific locations on the hand) is optimal in helping users distinguish between hand-held objects and tasks associated with them. After short use with the cross-modal feedback during the electromyographic (EMG) control of a prosthetic hand, testing results show that users are able to use audial feedback alone to discriminate between everyday objects. While users showed adaptation to three different frequency maps, the simplest map containing only two frequencies was found to be the most useful in discriminating between objects. This outcome provides support for the feasibility and practicality of the cross-modal feedback method during the neural control of prosthetics.

Sensory motor mechanisms unify psychology: the embodiment of culture.

Sensorimotor mechanisms can unify explanations at cognitive, social, and cultural levels. As an example, we review how anticipated motor effort is used by individuals and groups to judge distance: the greater the anticipated effort the greater the perceived distance. Anticipated motor effort can also be used to understand cultural differences. People with interdependent self- construals interact almost exclusively with in-group members, and hence there is little opportunity to tune their sensorimotor systems for interaction with out-group members. The result is that interactions with out-group members are expected to be difficult and out-group members are perceived as literally more distant. In two experiments we show (a) interdependent Americans, compared to independent Americans, see American confederates (in-group) as closer; (b) interdependent Arabs, compared to independent Arabs, perceive Arab confederates (in- group) as closer, whereas interdependent Americans perceive Arab confederates (out-group) as farther. These results demonstrate how the same embodied mechanism can seamlessly contribute to explanations at the cognitive, social, and cultural levels.

Using telemedicine for acute stroke assessment.

In acute stroke care, urgent specialist assessment and treatment are essential to reduce the risk of death and disability. However, many patients do not receive them due to a lack of specialist services. One solution is to use telemedicine. This can give all patients with acute stroke symptoms access to immediate expert assessment and advice, regardless of when and where they present to hospital. This article describes a telemedicine system developed and implemented in Lancashire and Cumbria. In its first year of operation, 319 patients received a telestroke video assessment with a consultant stroke physician; 131 of these patients were given thrombolysis. We discuss how the service was designed, staff training and development, and the implications for nursing practice. The development of a standardised telemedicine toolkit that may facilitate future telemedicine projects is also discussed.

Ubiquilin 1 polymorphisms are not associated with late-onset Alzheimer's disease.

Several studies have reported evidence for linkage of late-onset Alzheimer's disease (LOAD) to chromosome 9. Recently, an intronic polymorphism affecting alternative splicing of exon 8 of ubiquilin 1 (UBQLN1) was reported to be associated with LOAD. We attempted to replicate this observation by genotyping this polymorphism, rs12344615 (also known as UBQ-8i), in a large sample of 1,544 LOAD cases and 1,642 nondemented controls. We did not find any evidence that this single nucleotide polymorphism, or any of six others tested in UBQLN1, increases risk for LOAD.

Angiotensin converting enzyme insertion/deletion polymorphisms in vasovagal syncope.

UNLABELLED: Recent studies suggest vasovagal syncope (VVS) has a significant heritable component (crude estimate sibling relative risk (lambda(s)): 1080) indicating that at least some forms of VVS may have a genetic cause. Here we present the first study examining a potential genetic abnormality in VVS. METHODS: DNA was collected from consecutive patients attending our unit with head up tilt confirmed VVS (n=165). One hundred and fourteen affected and unaffected first-degree relatives of those with a definitive diagnosis of VVS and positive family history also provided DNA. RESULTS: DNA from 165 VVS index cases was genotyped for the ACE insertion/deletion polymorphism. Mean+/-SD age of cases was 56+/-19 years (103 (62%) females). There was no significant difference in distribution of ACE insertion or deletion gene frequencies in cases compared with a large (>6000 subjects) national control population. No preferential transmission of alleles in families was identified using tests of association (P=0.1789) CONCLUSION: We have shown using both a case control and a small family based association study that polymorphisms of ACE alone are not associated with increased risk of VVS. Further studies are planned to clarify the genotype/phenotype relationship in VVS and examine other candidate genes.

Association studies between risk for late-onset Alzheimer's disease and variants in insulin degrading enzyme.

Linkage studies have suggested there is a susceptibility gene for late onset Alzheimer's disease (LOAD) in a broad region of chromosome 10. A strong positional and biological candidate is the gene encoding the insulin-degrading enzyme (IDE), a protease involved in the catabolism of Abeta. However, previous association studies have produced inconsistent results. To systematically evaluate the role of variation in IDE in the risk for LOAD, we genotyped 18 SNPs spanning a 276 kb region in and around IDE, including three "tagging" SNPs identified in an earlier study. We used four case-control series with a total of 1,217 cases and 1,257 controls. One SNP (IDE_7) showed association in two samples (P-value = 0.0066, and P = 0.026, respectively), but this result was not replicated in the other two series. None of the other SNPs showed association with LOAD in any of the tested samples. Haplotypes, constructed from the three tagging SNPs, showed no globally significant association. In the UK2 series, the CTA haplotype was over-represented in cases (P = 0.046), and in the combined data set, the CCG haplotype was more frequent in controls (P = 0.015). However, these weak associations observed in our series were in the opposite direction to the results in previous studies. Although our results are not universally negative, we were unable to replicate the results of previous studies and conclude that common variants or haplotypes of these variants in IDE are not major risk factors for LOAD.

Polymorphism in the human DJ-1 gene is not associated with sporadic dementia with Lewy bodies or Parkinson's disease.

Genetic analysis of early onset Parkinson's disease (PD) has indicated that the mutation DJ-1 gene is one cause of autosomal recessive PD. Its role in the development of late onset PD and other Lewy body associated disorders such as dementia with Lewy bodies (DLB) is however unknown. We have therefore determined the influence of a common polymorphism in the DJ-1 gene that shows strong linkage disequilibrium with other DJ-1 polymorphisms, in late onset PD and DLB. No alteration in the frequency of the intron 1 deletion allele was seen in PD or DLB, nor were DJ-1 genotypes altered by disease. Stratification of the cases according to the apolipoprotein E epsilon4 allele additionally failed to show any significant association. The DJ-1 gene does not appear to be a significant risk factor for late onset Lewy body disease in this population.