Designing interactive visualizations for analyzing chronic lung diseases in a user-centered approach.

OBJECTIVES: Medical practitioners analyze numerous types of data, often using archaic representations that do not meet their needs. Pneumologists who analyze lung function exams must often consult multiple exam records manually, making comparisons cumbersome. Such shortcomings can be addressed with interactive visualizations, but these must be designed carefully with practitioners' needs in mind. MATERIALS AND METHODS: A workshop with experts was conducted to gather user requirements and common tasks. Based on the workshop results, we iteratively designed a web-based prototype, continuously consulting experts along the way. The resulting application was evaluated in a formative study via expert interviews with 3 medical practitioners. RESULTS: Participants in our study were able to solve all tasks in accordance with experts' expectations and generally viewed our system positively, though there were some usability and utility issues in the initial prototype. An improved version of our system solves these issues and includes additional customization functionalities. DISCUSSION: The study results showed that participants were able to use our system effectively to solve domain-relevant tasks, even though some shortcomings could be observed. Using a different framework with more fine-grained control over interactions and visual elements, we implemented design changes in an improved version of our prototype that needs to be evaluated in future work. CONCLUSION: Employing a user-centered design approach, we developed a visual analytics system for lung function data that allows medical practitioners to more easily analyze the progression of several key parameters over time.

Management of impacted fetal head at cesarean birth: A systematic review and meta-analysis.

INTRODUCTION: Despite increasing incidence of impacted fetal head at cesarean birth and associated injury, it is unclear which techniques are most effective for prevention and management. A high quality evidence review in accordance with international reporting standards is currently lacking. To address this gap, we aimed to identify, assess, and synthesize studies comparing techniques to prevent or manage impacted fetal head at cesarean birth prior to or at full cervical dilatation. MATERIAL AND METHODS: We searched MEDLINE, Emcare, Embase and Cochrane databases up to 1 January 2023 (PROSPERO: CRD420212750016). Included were randomized controlled trials (any size) and non-randomized comparative studies (n ≥ 30 in each arm) comparing techniques or adjunctive measures to prevent or manage impacted fetal head at cesarean birth. Following screening and data extraction, we assessed risk of bias for individual studies using RoB2 and ROBINS-I, and certainty of evidence using GRADE. We synthesized data using meta-analysis where appropriate, including sensitivity analyses excluding data published in potential predatory journals or at risk of retraction. RESULTS: We identified 24 eligible studies (11 randomized and 13 non-randomized) including 3558 women, that compared vaginal disimpaction, reverse breech extraction, the Patwardhan method and/or the Fetal Pillow®. GRADE certainty of evidence was low or very low for all 96 outcomes across seven reported comparisons. Pooled analysis mostly showed no or equivocal differences in outcomes across comparisons of techniques. Although some maternal outcomes suggested differences between techniques (e.g., risk ratio of 3.41 [95% CI: 2.50-4.66] for uterine incision extension with vaginal disimpaction vs. reverse breech extraction), these were based on unreliable pooled estimates given very low GRADE certainty and, in some cases, additional risk of bias introduced by data published in potential predatory journals or at risk of retraction. CONCLUSIONS: The current weaknesses in the evidence base mean that no firm recommendations can be made about the superiority of any one impacted fetal head technique over another, indicating that high quality training is needed across the range of techniques. Future studies to improve the evidence base are urgently required, using a standard definition of impacted fetal head, agreed maternal and neonatal outcome sets for impacted fetal head, and internationally recommended reporting standards.

How to co-design a prototype of a clinical practice tool: a framework with practical guidance and a case study.

Clinical tools for use in practice-such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts-are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co-design of a prototype track-and-trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed-one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think-aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large-scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co-design a prototype track-and-trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied.

Definition, management, and training in impacted fetal head at cesarean birth: a national survey of maternity professionals.

INTRODUCTION: This study assessed views, understanding and current practices of maternity professionals in relation to impacted fetal head at cesarean birth, with the aim of informing a standardized definition, clinical management approaches and training. MATERIAL AND METHODS: We conducted a survey consultation including the range of maternity professionals who attend emergency cesarean births in the UK. Thiscovery, an online research and development platform, was used to ask closed-ended and free-text questions. Simple descriptive analysis was undertaken for closed-ended responses, and content analysis for categorization and counting of free-text responses. Main outcome measures included the count and percentage of participants selecting predefined options on clinical definition, multi-professional team approach, communication, clinical management and training. RESULTS: In total, 419 professionals took part, including 144 midwives, 216 obstetricians and 59 other clinicians (eg anesthetists). We found high levels of agreement on the components of an impacted fetal head definition (79% of obstetricians) and the need for use of a multi-professional approach to management (95% of all participants). Over 70% of obstetricians deemed nine techniques acceptable for management of impacted fetal head, but some obstetricians also considered potentially unsafe practices appropriate. Access to professional training in management of impacted fetal head was highly variable, with over 80% of midwives reporting no training in vaginal disimpaction. CONCLUSIONS: These findings demonstrate agreement on the components of a standardized definition for impacted fetal head, and a need and appetite for multi-professional training. These findings can inform a program of work to improve care, including use of structured management algorithms and simulation-based multi-professional training.

Training for managing impacted fetal head at caesarean birth: multimethod evaluation of a pilot.

BACKGROUND: Implementation of national multiprofessional training for managing the obstetric emergency of impacted fetal head (IFH) at caesarean birth has potential to improve quality and safety in maternity care, but is currently lacking in the UK. OBJECTIVES: To evaluate a training package for managing IFH at caesarean birth with multiprofessional maternity teams. METHODS: The training included an evidence-based lecture supported by an animated video showing management of IFH, followed by hands-on workshops and real-time simulations with use of a birth simulation trainer, augmented reality and management algorithms. Guided by the Kirkpatrick framework, we conducted a multimethod evaluation of the training with multiprofessional maternity teams. Participants rated post-training statements about relevance and helpfulness of the training and pre-training and post-training confidence in their knowledge and skills relating to IFH (7-point Likert scales, strongly disagree to strongly agree). An ethnographer recorded sociotechnical observations during the training. Participants provided feedback in post-training focus groups. RESULTS: Participants (N=57) included 21 midwives, 25 obstetricians, 7 anaesthetists and 4 other professionals from five maternity units. Over 95% of participants agreed that the training was relevant and helpful for their clinical practice and improving outcomes following IFH. Confidence in technical and non-technical skills relating to managing IFH was variable before the training (5%-92% agreement with the pre-training statements), but improved in nearly all participants after the training (71%-100% agreement with the post-training statements). Participants and ethnographers reported that the training helped to: (i) better understand the complexity of IFH, (ii) recognise the need for multiprofessional training and management and (iii) optimise communication with those in labour and their birth partners. CONCLUSIONS: The evaluated training package can improve self-reported knowledge, skills and confidence of multiprofessional teams involved in management of IFH at caesarean birth. A larger-scale evaluation is required to validate these findings and establish how best to scale and implement the training.

Handrim Wheelchair Propulsion Technique in Individuals With Spinal Cord Injury With and Without Shoulder Pain: A Cross-sectional Comparison.

OBJECTIVE: The aim of this study was to compare handrim wheelchair propulsion technique between individuals with spinal cord injury with and without shoulder pain. DESIGN: A cross-sectional study including 38 experienced handrim wheelchair users with spinal cord injury was conducted. Participants were divided into the "shoulder pain" ( n = 15) and "no-shoulder pain" ( n = 23) groups using the Local Musculoskeletal Discomfort scale. Kinetic and spatiotemporal aspects of handrim wheelchair propulsion during submaximal exercise on a motor-driven treadmill were analyzed. Data were collected using a measurement wheel instrumented with three-dimensional force sensors. RESULTS: After correction for confounders (time since injury and body height), linear regression analyses showed that the pain group had a 0.30-sec (95% confidence interval, -0.5 to -0.1) shorter cycle time, 0.22-sec (95% confidence interval, -0.4 to -0.1) shorter recovery time, 15.6 degrees (95% confidence interval, -27.4 to -3.8) smaller contact angle, and 8% (95% confidence interval, -15 to 0) lower variability in work per push compared with the no-pain group. Other parameters did not differ between groups. CONCLUSIONS: This study indicates that individuals with spinal cord injury who experience shoulder pain propel their handrim wheelchair kinematically differently from individuals with spinal cord injury without shoulder pain. This difference in propulsion technique might be a pain-avoiding mechanism aimed at decreasing shoulder range of motion.

Acute submaximal exercise does not impact aspects of cognition and BDNF in people with spinal cord injury: A pilot study.

Objective: To investigate the effect of acute submaximal exercise, based on the spinal cord injury (SCI) Exercise Guidelines, on cognition and brain-derived neurotrophic factor (BDNF) in people with SCI. Design: Eight adults (7 males) with traumatic SCI volunteered in this pre-registered pilot study. In randomized order, participants completed submaximal intensity arm cycling (60% of measured peak-power output at 55-60 rpm) for 30 min or time-matched quiet rest (control condition) on separate days. Blood-borne BDNF was measured in serum and plasma at pre-intervention, 0 min and 90 min post-intervention. Cognition was assessed using the Stroop Test and Task-Switching Test on an electronic tablet pre- and 10 min post-intervention. Results: Submaximal exercise had no effect on plasma [F(2,12) = 1.09; P = 0.365; η² = 0.069] or serum BDNF [F(2,12) = 0.507; P = 0.614; η² = 0.024] at either 0 min or 90 min post-intervention. Similarly, there was no impact of exercise on either Stroop [F(1,7) = 2.05; P = 0.195; η² = 0.065] or Task-Switching performance [F(1,7) = 0.016; P = 0.903; η² < 0.001] compared to the control condition. Interestingly, there was a positive correlation between years since injury and resting levels of both plasma (r = 0.831; P = 0.011) and serum BDNF (r = 0.799; P = 0.023). However, there was not relationship between years since injury and the BDNF response to exercise. Conclusions: Acute guideline-based exercise did not increase BDNF or improve aspects of cognition in persons with SCI. This work establishes a foundation for continued investigations of exercise as a therapeutic approach to promoting brain health among persons with SCI.

Visualization Techniques of Time-Oriented Data for the Comparison of Single Patients With Multiple Patients or Cohorts: Scoping Review.

BACKGROUND: Visual analysis and data delivery in the form of visualizations are of great importance in health care, as such forms of presentation can reduce errors and improve care and can also help provide new insights into long-term disease progression. Information visualization and visual analytics also address the complexity of long-term, time-oriented patient data by reducing inherent complexity and facilitating a focus on underlying and hidden patterns. OBJECTIVE: This review aims to provide an overview of visualization techniques for time-oriented data in health care, supporting the comparison of patients. We systematically collected literature and report on the visualization techniques supporting the comparison of time-based data sets of single patients with those of multiple patients or their cohorts and summarized the use of these techniques. METHODS: This scoping review used the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. After all collected articles were screened by 16 reviewers according to the criteria, 6 reviewers extracted the set of variables under investigation. The characteristics of these variables were based on existing taxonomies or identified through open coding. RESULTS: Of the 249 screened articles, we identified 22 (8.8%) that fit all criteria and reviewed them in depth. We collected and synthesized findings from these articles for medical aspects such as medical context, medical objective, and medical data type, as well as for the core investigated aspects of visualization techniques, interaction techniques, and supported tasks. The extracted articles were published between 2003 and 2019 and were mostly situated in clinical research. These systems used a wide range of visualization techniques, most frequently showing changes over time. Timelines and temporal line charts occurred 8 times each, followed by histograms with 7 occurrences and scatterplots with 5 occurrences. We report on the findings quantitatively through visual summarization, as well as qualitatively. CONCLUSIONS: The articles under review in general mitigated complexity through visualization and supported diverse medical objectives. We identified 3 distinct patient entities: single patients, multiple patients, and cohorts. Cohorts were typically visualized in condensed form, either through prior data aggregation or through visual summarization, whereas visualization of individual patients often contained finer details. All the systems provided mechanisms for viewing and comparing patient data. However, explicitly comparing a single patient with multiple patients or a cohort was supported only by a few systems. These systems mainly use basic visualization techniques, with some using novel visualizations tailored to a specific task. Overall, we found the visual comparison of measurements between single and multiple patients or cohorts to be underdeveloped, and we argue for further research in a systematic review, as well as the usefulness of a design space.

Guiding organisational decision-making about COVID-19 asymptomatic testing in workplaces: mixed-method study to inform an ethical framework.

BACKGROUND: Workplace programmes to test staff for asymptomatic COVID-19 infection have become common, but raise a number of ethical challenges. In this article, we report the findings of a consultation that informed the development of an ethical framework for organisational decision-making about such programmes. METHODS: We conducted a mixed-method consultation - a survey and semi-structured interviews during November-December 2020 in a UK case study organisation that had introduced asymptomatic testing for all staff working on-site in its buildings. Analysis of closed-ended survey data was conducted descriptively. An analysis approach based on the Framework Method was used for the open-ended survey responses and interview data. The analyses were then integrated to facilitate systematic analysis across themes. Inferences were based on the integrated findings and combined with other inputs (literature review, ethical analysis, legal and public health guidance, expert discussions) to develop an ethical framework. RESULTS: The consultation involved 61 staff members from the case study organisation (50 survey respondents and 11 interview participants). There was strong support for the asymptomatic testing programme: 90% of the survey respondents viewed it as helpful or very helpful. Open-ended survey responses and interviews gave insight into participants' concerns, including those relating to goal drift, risk of false negatives, and potential negative impacts for household members and people whose roles lacked contractual and financial stability. Integration of the consultation findings and the other inputs identified the importance of a whole-system approach with appropriate support for the key control measure of isolation following positive tests. The need to build trust in the testing programme, for example through effective communication from leaders, was also emphasised. CONCLUSIONS: The consultation, together with other inputs, informed an ethical framework intended to support employers. The framework may support organisational decision-making in areas ranging from design and operation of the programme through to choices about participation. The framework is likely to benefit from further consultation and refinement in new settings.

Impact of an Acute Bout of Submaximal Aerobic Exercise on Circulating Leukocytes in Individuals with Spinal Cord Injury.

Individuals with spinal cord injury (SCI) may experience cardiovascular, musculoskeletal and organ function dysregulation. Sequelae include reduced catecholamine secretion and attenuated immune responses which may impact exercise-induced leukocytosis. The purpose of this study was to characterize major leukocyte subtypes following 30 minutes of acute, submaximal aerobic exercise, in line with updated international SCI exercise guidelines for adults. It was hypothesized that exercise would increase major leukocyte subtypes when compared to fasted baseline. Eight participants with SCI (incomplete n = 6; complete n = 2) completed a 30-minute bout of aerobic exercise on an arm cycle ergometer at 60% of their peak power output followed by 90 minutes of recovery, or a 2-hour seated control condition, in a randomized crossover design, separated by 7-14 days. Blood samples were taken at baseline, post exercise, and 90 minutes after exercise (with time matched control). Leukocyte subtypes were analyzed via flow cytometry and plasma catecholamines by ELISA. Several leukocytes increased from pre- to post-exercise (time X condition interaction; all P < 0.05; mean ± SD), including CD3+ Lymphocytes (19 ± 16%), CD4+ T helper (16 ± 13%), CD8+ T cytotoxic (24 ± 23%), CD3+/CD56+ natural killer T (31 ± 34%), and CD3-/CD56+ natural killer (63 ± 82%). CD16+/CD14dim monocytes decreased by 27 ± 38% following exercise to 90 minutes post-exercise. No changes were observed for catecholamines for either condition. Thirty minutes of acute submaximal aerobic exercise sufficiently increased most lymphocyte subsets with effector functions, while leading to decreased proinflammatory monocytes during the recovery phase. This exercise duration and intensity appear to be an appropriate option for modulating circulating immune cells in individuals with SCI.

Lipid metabolism after mild cold stress in persons with a cervical spinal cord injury.

STUDY DESIGN: Experimental study. OBJECTIVES: To compare lipid metabolism in individuals with a cervical spinal cord injury (SCIC) and able-bodied (AB) persons in response to mild cold stress. SETTINGS: Laboratory of Wakayama Medical University, Japan. METHODS: Nine males with SCIC and 11 AB wore a water-perfusion suit in a supine position. Following 30-min rest thermoneutrality, the whole body was cooled by perfusing 25 °C water through the suit for 15-20 min (CS). Blood samples were collected before, immediately, and 60 (post-CS60) and 120 min after CS (post-CS120). Concentrations of serum free fatty acid ([FFA]s), total ketone bodies ([tKB]s), insulin ([Ins]s) and plasma adrenaline ([Ad]p), noradrenaline ([NA]p) and glucose ([Glc]p) were assessed. RESULTS: [Ad]p in SCIC were lower than AB throughout the study (p = 0.0002) and remained largely unchanged in both groups. [NA]p increased after cold stress in AB only (p < 0.0001; GxT p = 0.006). [FFA]s increased by 62% immediately after cold stress in SCIC (p = 0.0028), without a difference between groups (p = 0.65). [tKB]s increased by 69% at post-CS60 and 132% at post-CS120 from the start in SCIC with no differences between groups (p = 0.54). [Glc]p and [Ins]s were reduced in SCIc only (GxT p = 0.003 and p = 0.001, respectively). CONCLUSION: These data indicate that mild cold stress acutely elevates lipid and ketone body metabolism in persons with SCIc, despite the presence of sympathetic dysfunction.

Mixed-methods exploration of views on choice in a university asymptomatic COVID-19 testing programme.

Asymptomatic COVID-19 testing programmes are being introduced in higher education institutions, but stakeholder views regarding the acceptability of mandating or incentivizing participation remain little understood. A mixed-method study (semi-structured interviews and a survey including open and closed questions) was undertaken in a case study university with a student testing programme. Survey data were analysed descriptively; analysis for interviews was based on the framework method. Two hundred and thirty-nine people participated in the study: 213 in the survey (189 students, 24 staff), and 26 in interviews (19 students, 7 staff). There was majority (62%) but not universal support for voluntary participation, with a range of concerns expressed about the potentially negative effects of mandating testing. Those who supported mandatory testing tended to do so on the grounds that it would protect others. There was also majority (64%) opposition to penalties for refusing to test. Views on restricting access to face-to-face teaching for non-participants were polarized. Three-quarters (75%) supported incentives, though there were some concerns about effectiveness and unintended consequences. Participants emphasized the importance of communication about the potential benefits of testing. Preserving the voluntariness of participation in student asymptomatic testing programmes is likely to be the most ethically sound policy unless circumstances change.

Cultural validation and language translation of the scientific SCI exercise guidelines for use in Indonesia, Japan, Korea, and Thailand.

CONTEXT: Indonesia, Japan, Korea, Thailand. OBJECTIVE: To culturally validate and translate the Scientific Exercise Guidelines for Adults with Spinal Cord Injury (SEG-SCI) for use in four Asian countries. DESIGN: Systematic Review. PARTICIPANTS: N/A. METHODS: A systematic review was conducted to identify all published English- and local-language studies conducted in Indonesia, Japan, Korea, and Thailand, testing the effects of exercise training interventions on fitness and cardiometabolic health in adults with acute or chronic SCI. Protocols and results from high-quality controlled studies were compared with the SEG-SCI. Forward and backward translation processes were used to translate the guidelines into Bahasa Indonesian, Japanese, Korean and Thai languages. RESULTS: Fifteen studies met the review criteria. At least one study from each country implemented exercise prescriptions that met or exceeded the SEG-SCI. Two were controlled studies. In those two studies, relative to control conditions, participants in exercise conditions achieved significant improvements in fitness or cardiometabolic health outcomes only when the exercise intervention protocol met or exceeded the SEG-SCI. During the language translation processes, end-users confirmed that SEG-SCI language and terminology were clear. CONCLUSION: Clinical researchers in Indonesia, Japan, Korea and Thailand have implemented exercise protocols that meet or exceed the SCI-SEG. Results of high-quality studies align with the SEG-SCI recommendations. Based on this evidence, we recommend that the SEG-SCI be adopted in these countries. The cultural validation and translation of the SEG-SCI is an important step towards establishing consistent SCI exercise prescriptions in research, clinical and community settings around the world.

The effects of a high-fat/high-carbohydrate meal on leukocyte populations in adults with chronic spinal cord injury.

STUDY DESIGN: Secondary analysis of aggregated case series data. OBJECTIVES: To examine the effects of a high-fat/high-carbohydrate meal on leukocyte populations in adults with a chronic SCI. SETTING: University-based laboratories in British Columbia, Canada. METHODS: Ten individuals (M = 9) with a traumatic SCI (>1-year post-injury; M = 15.5 years; n = 2 sensory complete, n = 7 motor complete) participated in this study. Participants arrived fasted (≥12 h) prior to both the control (quiet sitting, no food/drink) and experimental meal conditions (high-fat/high-carb meal: 880 kcal, 52 g fat, 73 g carbohydrates, 29 g protein). Blood samples were taken in the fasted state and at 120-min post-meal/baseline in both conditions. Immune cell counts were assessed using multi-color flow cytometry. RESULTS: A significant time × condition interaction effect was seen in CD3+, CD4+, and CD8+ T cells as well as CD56+ and CD3+/CD56+ natural killer (NK) cells (p < 0.05). CD14+/CD16+ monocytes and CD19+ B cells approached a significant time × condition interaction (p < 0.07). A main effect of time was observed in CD19+ B cells (p < 0.05). Cell counts for T-lymphocytes and NK cells followed the general trend of an increase in the control condition from baseline to 120-min with no change observed following the experimental meal condition. CONCLUSIONS: Following the HFHC meal, immune cells did not show the same general increase observed following the control condition. Future research is needed to determine if there are any potential consequences of these immune cell responses in immunosuppressed populations and if other factors (e.g., diurnal variation) might influence immune cell response.

Functional electrical stimulation cycling exercise after spinal cord injury: a systematic review of health and fitness-related outcomes.

OBJECTIVES: The objective of this review was to summarize and appraise evidence on functional electrical stimulation (FES) cycling exercise after spinal cord injury (SCI), in order to inform the development of evidence-based clinical practice guidelines. METHODS: PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, SPORTDiscus, and CINAHL were searched up to April 2021 to identify FES cycling exercise intervention studies including adults with SCI. In order to capture the widest array of evidence available, any outcome measure employed in such studies was considered eligible. Two independent reviewers conducted study eligibility screening, data extraction, and quality appraisal using Cochranes' Risk of Bias or Downs and Black tools. Each study was designated as a Level 1, 2, 3 or 4 study, dependent on study design and quality appraisal scores. The certainty of the evidence for each outcome was assessed using GRADE ratings ('High', 'Moderate', 'Low', or 'Very low'). RESULTS: Ninety-two studies met the eligibility criteria, comprising 999 adults with SCI representing all age, sex, time since injury, lesion level and lesion completeness strata. For muscle health (e.g., muscle mass, fiber type composition), significant improvements were found in 3 out of 4 Level 1-2 studies, and 27 out of 32 Level 3-4 studies (GRADE rating: 'High'). Although lacking Level 1-2 studies, significant improvements were also found in nearly all of 35 Level 3-4 studies on power output and aerobic fitness (e.g., peak power and oxygen uptake during an FES cycling test) (GRADE ratings: 'Low'). CONCLUSION: Current evidence indicates that FES cycling exercise improves lower-body muscle health of adults with SCI, and may increase power output and aerobic fitness. The evidence summarized and appraised in this review can inform the development of the first international, evidence-based clinical practice guidelines for the use of FES cycling exercise in clinical and community settings of adults with SCI. Registration review protocol: CRD42018108940 (PROSPERO).

Assessment of body composition in spinal cord injury: A scoping review.

The objective of this scoping review was to map the evidence on measurement properties of body composition tools to assess whole-body and regional fat and fat-free mass in adults with SCI, and to identify research gaps in order to set future research priorities. Electronic databases of PubMed, EMBASE and the Cochrane library were searched up to April 2020. Included studies employed assessments related to whole-body or regional fat and/or fat-free mass and provided data to quantify measurement properties that involved adults with SCI. All searches and data extractions were conducted by two independent reviewers. The scoping review was designed and conducted together with an expert panel (n = 8) that represented research, clinical, nutritional and lived SCI experience. The panel collaboratively determined the scope and design of the review and interpreted its findings. Additionally, the expert panel reached out to their professional networks to gain further stakeholder feedback via interactive practitioner surveys and workshops with people with SCI. The research gaps identified by the review, together with discussions among the expert panel including consideration of the survey and workshop feedback, informed the formulation of future research priorities. A total of 42 eligible articles were identified (1,011 males and 143 females). The only tool supported by studies showing both acceptable test-retest reliability and convergent validity was whole-body dual-energy x-ray absorptiometry (DXA). The survey/workshop participants considered the measurement burden of DXA acceptable as long as it was reliable, valid and would do no harm (e.g. radiation, skin damage). Practitioners considered cost and accessibility of DXA major barriers in applied settings. The survey/workshop participants expressed a preference towards simple tools if they could be confident in their reliability and validity. This review suggests that future research should prioritize reliability and validity studies on: (1) DXA as a surrogate 'gold standard' tool to assess whole-body composition, regional fat and fat-free mass; and (2) skinfold thickness and waist circumference as practical low-cost tools to assess regional fat mass in persons with SCI, and (3) females to explore potential sex differences of body composition assessment tools. Registration review protocol: CRD42018090187 (PROSPERO).

How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a framework and a case study of its application.

BACKGROUND: Practical methods for facilitating process improvement are needed to support high quality, safe care. How best to specify (identify and define) process improvements - the changes that need to be made in a healthcare process - remains a key question. Methods for doing so collaboratively, rapidly and remotely offer much potential, but are under-developed. We propose an approach for engaging diverse stakeholders remotely in a consensus-building exercise to help specify improvements in a healthcare process, and we illustrate the approach in a case study. METHODS: Organised in a five-step framework, our proposed approach is informed by a participatory ethos, crowdsourcing and consensus-building methods: (1) define scope and objective of the process improvement; (2) produce a draft or prototype of the proposed process improvement specification; (3) identify participant recruitment strategy; (4) design and conduct a remote consensus-building exercise; (5) produce a final specification of the process improvement in light of learning from the exercise. We tested the approach in a case study that sought to specify process improvements for the management of obstetric emergencies during the COVID-19 pandemic. We used a brief video showing a process for managing a post-partum haemorrhage in women with COVID-19 to elicit recommendations on how the process could be improved. Two Delphi rounds were then conducted to reach consensus. RESULTS: We gathered views from 105 participants, with a background in maternity care (n = 36), infection prevention and control (n = 17), or human factors (n = 52). The participants initially generated 818 recommendations for how to improve the process illustrated in the video, which we synthesised into a set of 22 recommendations. The consensus-building exercise yielded a final set of 16 recommendations. These were used to inform the specification of process improvements for managing the obstetric emergency and develop supporting resources, including an updated video. CONCLUSIONS: The proposed methodological approach enabled the expertise and ingenuity of diverse stakeholders to be captured and mobilised to specify process improvements in an area of pressing service need. This approach has the potential to address current challenges in process improvement, but will require further evaluation.

Specialty COPD care during COVID-19: patient and clinician perspectives on remote delivery.

INTRODUCTION: The COVID-19 pandemic has impacted specialty chronic obstructive pulmonary disease (COPD) care. We examined the degree to which care has moved to remote approaches, eliciting clinician and patient perspectives on what is appropriate for ongoing remote delivery. METHODS: Using an online research platform, we conducted a survey and consensus-building process involving clinicians and patients with COPD. RESULTS: Fifty-five clinicians and 19 patients responded. The majority of clinicians felt able to assess symptom severity (n=52, 95%), reinforce smoking cessation (n=46, 84%) and signpost to other healthcare resources (n=44, 80%). Patients reported that assessing COPD severity and starting new medications were being addressed through remote care. Forty-three and 31 respondents participated in the first and second consensus-building rounds, respectively. When asked to rate the appropriateness of using remote delivery for specific care activities, respondents reached consensus on 5 of 14 items: collecting information about COPD and overall health status (77%), providing COPD education and developing a self-management plan (74%), reinforcing smoking cessation (81%), deciding whether patients should seek in-person care (72%) and initiating a rescue pack (76%). CONCLUSION: Adoption of remote care delivery appears high, with many care activities partially or completely delivered remotely. Our work identifies strengths and limitations of remote care delivery.

The Impact of Sub-maximal Exercise on Neuropathic Pain, Inflammation, and Affect Among Adults With Spinal Cord Injury: A Pilot Study.

Introduction: Persons with spinal cord injury (SCI) often report high levels of neuropathic pain (NP) and poor well-being, which may result from increased inflammation. This study examined the impact of sub-maximal aerobic exercise on NP, inflammation and psychological affect among adults with SCI. Methods: Eight active adults with tetraplegia (n-4, AIS A-C) and paraplegia (n = 4, AIS A-C) performed 30-min of arm-crank aerobic exercise and reported their ratings of perceived exertion (RPE) each minute. Measures of NP, affect, and inflammatory cytokines (IL-6, IL-10, IL-1ra, TNF-α) were taken pre-(T0), immediately post-(T1), and 90-min post-exercise (T2). Results: NP decreased between T0 and T1 for tetraplegics (-60%, d = 0.47; CI = -0.32, 2.02) and paraplegics (-16%, d = 0.15; CI = -0.30, 0.90). Correlations between change in cytokines and change in NP were medium-to large for tetraplegics (rs ranged from -0.820 to 0.965) and paraplegics (rs ranged from -0.598 to 0.833). However, the pattern of correlations between change in cytokines and affect was inconsistent between groups. Lower baseline levels of IL-1ra predicted greater decreases in NP immediately post-exercise (r = 0.83, p = 0.01). Conclusion: Sub-maximal exercise can positively impact NP for some persons with SCI. Further experimental research should identify the optimal exercise intensity to reduce NP for persons with SCI, in addition to understanding biomarkers which may predict changes in NP. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03955523.