Predictive Factors for Successful Decannulation in Patients with Tracheostomies and Brain Injuries: A Systematic Review.

Neurological patients frequently have disorders of consciousness, swallowing disorders, or neurological states that are incompatible with extubation. Therefore, they frequently require tracheostomies during their stay in an intensive care unit. After the acute phase, tracheostomy weaning and decannulation are generally expected to promote rehabilitation. However, few reliable predictive factors (PFs) for decannulation have been identified in this patient population. We sought to identify PFs that may be used during tracheostomy weaning and decannulation in patients with brain injuries. We conducted a systematic review of the literature regarding potential PFs for decannulation; searches were performed on 16 March 2021 and 1 June 2022. The following databases were searched: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, PEDro, OPENGREY, OPENSIGLE, Science Direct, CLINICAL TRIALS and CENTRAL. We searched for all article types, except systematic reviews, meta-analyses, abstracts, and position articles. Retrieved articles were published in English or French, with no date restriction. In total, 1433 articles were identified; 26 of these were eligible for inclusion in the review. PFs for successful decannulation in patients with acquired brain injuries (ABIs) included high neurological status, traumatic brain injuries rather than stroke or anoxic brain lesions, younger age, effective swallowing, an effective cough, and the absence of pulmonary infections. Secondary PFs included early tracheostomy, supratentorial lesions, the absence of critical illness polyneuropathy/myopathy, and the absence of tracheal lesions. To our knowledge, this is the first systematic review to identify PFs for decannulation in patients with ABIs. These PFs may be used by clinicians during tracheostomy weaning.

A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study.

Concurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient's characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.

Early multidisciplinary prevention program of post-stroke shoulder pain: A randomized clinical trial.

OBJECTIVE: To evaluate if positioning the upper-limb promoting abduction, external rotation and flexion of the shoulder reduces the intensity of post-stroke shoulder pain at day-7 compared to usual clinical practice. DESIGN & SETTING: Prospective single-center randomized clinical trial using a superiority design comparing two preventive strategies of post-stroke shoulder pain in a stroke unit. SUBJECTS: Patients were included within 2 days from a first symptomatic ischemic stroke affecting shoulder motor function. INTERVENTIONS: Intervention group included specific positioning of the shoulder in abduction, external rotation and flexion in bed, chair and during mobilization. Control group referred to usual practice i.e. positioning using a standard support scarf. MAIN MEASURES: Primary outcome was the intensity of shoulder pain assessed by the visual analog scale (VAS) (0-100) at day-7 post-stroke. Other outcomes measured at day-7 and 2 months post-stroke were the VAS, motor function, spasticity, depression, functional independence and rates of complex regional Pain syndrome (CRPS). RESULTS: 76 patients (49 males; mean age = 68.3) were randomized. The shoulder pain at day-7 was not different between the control group (16.1, SD = 27.4) and the intervention group (10.3, SD = 21.5, p = 0.18) as well as at 2 months (p = 0.12). A lower rate of depression was observed in the intervention group at 2 months 36.7% (CI95% 19.9;56.1) vs 52.9% (CI95% 35.1;70.2). No between-group difference in other outcomes was observed at 2 months. CONCLUSIONS: This study failed to demonstrate the benefit of a specific positioning tool in reducing the intensity of post-stroke shoulder pain which was lower than previously reported in the literature.

TractLearn: A geodesic learning framework for quantitative analysis of brain bundles.

Deep learning-based convolutional neural networks have recently proved their efficiency in providing fast segmentation of major brain fascicles structures, based on diffusion-weighted imaging. The quantitative analysis of brain fascicles then relies on metrics either coming from the tractography process itself or from each voxel along the bundle. Statistical detection of abnormal voxels in the context of disease usually relies on univariate and multivariate statistics models, such as the General Linear Model (GLM). Yet in the case of high-dimensional low sample size data, the GLM often implies high standard deviation range in controls due to anatomical variability, despite the commonly used smoothing process. This can lead to difficulties to detect subtle quantitative alterations from a brain bundle at the voxel scale. Here we introduce TractLearn, a unified framework for brain fascicles quantitative analyses by using geodesic learning as a data-driven learning task. TractLearn allows a mapping between the image high-dimensional domain and the reduced latent space of brain fascicles using a Riemannian approach. We illustrate the robustness of this method on a healthy population with test-retest acquisition of multi-shell diffusion MRI data, demonstrating that it is possible to separately study the global effect due to different MRI sessions from the effect of local bundle alterations. We have then tested the efficiency of our algorithm on a sample of 5 age-matched subjects referred with mild traumatic brain injury. Our contributions are to propose: 1/ A manifold approach to capture controls variability as standard reference instead of an atlas approach based on a Euclidean mean. 2/ A tool to detect global variation of voxels' quantitative values, which accounts for voxels' interactions in a structure rather than analyzing voxels independently. 3/ A ready-to-plug algorithm to highlight nonlinear variation of diffusion MRI metrics. With this regard, TractLearn is a ready-to-use algorithm for precision medicine.

Changes in resting-state functional brain connectivity associated with head impacts over one men's semi-professional soccer season.

Soccer, as a contact sport, exposes players to repetitive head impacts, especially through heading the ball. The question of a long-term brain cumulative effect remains. Our objective was to determine whether exposure to head impacts over one soccer season was associated with changes in functional brain connectivity at rest, using magnetic resonance imaging (MRI). In this prospective cohort study, 10 semi-professional men soccer players, aged 18-25 years, and 20 age-matched men athletes without a concussion history and who do not practice any contact sport were recruited in Bordeaux (France). Exposure to head impacts per soccer player during competitive games over one season was measured using video analysis. Resting-state functional magnetic resonance imaging data were acquired for both groups at two times, before and after the season. With a seed-based analysis, resting-state networks that have been intimately associated with aspects of cognitive functioning were investigated. The results showed a mean head impacts of 42 (±33) per soccer player over the season, mainly intentional head-to-ball impacts and no concussion. No head impact was found among the other athletes. The number of head impacts between the two MRI acquisitions before and after the season was associated with increased connectivity within the default mode network and the cortico-cerebellar network. In conclusion, our findings suggest that the brain functioning changes over one soccer season in association with exposure to repetitive head impacts.

Video analysis of concussion mechanisms and immediate management in French men's professional football (soccer) from 2015 to 2019.

In this study, the concussion mechanisms were analyzed in male professional competition football, with the main objective to specify the frequency of head-to-head impact, and immediate management of the concussed players was described in order to check its compliance with the recommendations of football's governing bodies. Based on continuously recorded data from the French Football Federation (FFF), a retrospective database of all reported concussions during matches in the 1st and 2nd French Male leagues was generated comprising seasons 2015/16-2018/19. Injury mechanisms, playing action, immediate medical assessment and management of concussed players, and foul play-referee's decision, were analyzed from video recordings. In total, 41 concussions were reported (incidence rate of 0.44/1000 hours of match exposure [95% CI: 0.40 to 0.49]) of which 36 were identified and analyzed on video sequences. The commonest playing action leading to concussion was aerial challenge (61%), and the main mechanism was head-to-head impact (47%). Following the head impact, 28% of concussed players were not medically assessed on pitch and 53% returned to play the same match. Head-to-head impact was not associated with systematic medical assessment, nor with foul play. In conclusion, the main cause of concussions involved head-to-head impact occurring when two players challenge for heading the ball in the air. The detection of potential concussive head impacts and the immediate management of players possibly concussed during matches remain insufficient according to the international recommendations. Some rules changes, with particular vigilance in case of head-to-head impact, should be discussed.

Role of cognitive resources on everyday functioning among oldest-old physically frail.

BACKGROUND: Everyday functioning becomes a challenge with aging, particularly among frail oldest-old adults. Several factors have been identified as influencing everyday activities realization, including physical and cognitive functioning. However, the influence of cognitive resources as a compensatory factor in the context of physical frailty deserves further consideration. AIMS: This study aims to investigate in older adults physically frail the possible compensatory role of cognitive resources to perform everyday tasks. METHODS: Two groups of community-dwelling old participants (n = 26 per group) matched for their age and cognitive resources, have been drawn according to their level of physical functioning. Two measures of everyday functioning have been assessed: one self-reported by the participant (the IADL scale) and one performance-based measure (the TIADL tasks). RESULTS: Participants performed equally the TIADL tasks irrespective of their physical condition. Contrariwise, participants with low physical functioning reported more everyday difficulties than their counterparts with a high level of physical functioning. Additionally, regressions analyses revealed differential influence of cognitive resources on performance and reported measures of everyday functioning. DISCUSSION: Our data suggests that cognitive resources are more strongly involved in the performance-based IADL measure in situation of physical frailty. Additionally, for participants with low physical functioning, lower cognitive resources are associated with more perceived difficulties in everyday life. CONCLUSION: These results highlight the compensatory role of cognitive resources in physically frail older adults, and suggest that an overestimation of everyday difficulties compared to performance on IADL tasks is an early indicator of physical decline and cognitive compensation.

Head impacts in semiprofessional male Soccer players: a prospective video analysis over one season of competitive games.

Soccer exposes players to head injuries and involves repeated intentional head impacts through heading the ball. Our objective was to investigate the rate of both intentional headers and involuntary head impacts in semiprofessional male soccer players during one season. In this prospective cohort study, we followed 54 men (16-35 years) playing in two soccer clubs participating in the same regional French championship throughout the 2017-2018 season. All head impacts that occurred in competitive games were analyzed using video recordings. Player position, game exposure, referee's decision were also reported. Head impact incidence rate (IR) per 1000 player-hours, with the 95% confidence intervals (CIs) were calculated. Results: Headers IR was 3584.7 per 1000 player-hours (95% CI = 3431.9, 3737.5). Forwards and center-backs performed a higher number of headers. Involuntary head impacts IR was 44.1/1000 player-hours (95% CI = 27.1, 60.9). Just under half led the referee to stop playing time for a caregiver examination. Three concussions with a loss of consciousness after a head-to-head impact in a heading duel were recorded. Conclusions: Intentional headers were relatively common, contrary to involuntary head impacts that were however mainly due to heading duels. Head-to-head impact should lead to a systematic exit from the game for suspicion of concussion.

Post-stroke follow-up: Time to organize.

BACKGROUND/OBJECTIVE: General practitioners (GPs) are pivotal in the organization of the entire post-stroke management system. This study aimed to examine the sequelae of chronic post-stroke patients and to assess whether the medical follow-up organized by GPs is truly in accordance with current recommendations and patients' clinical needs. METHODS: This was an observational study including chronic post-stroke patients after a first stroke. Their post-stroke follow-ups (visits to GPs and specialist doctors) were compared with guidelines and with clinical needs as evaluated through a number of questionnaires. RESULTS: Overall, 53.2% of patients visited a neurologist as recommended and, although 49.4% had neuropsychiatric consequences, only 6.3% visited a psychiatrist. Similarly, while 34.2% had significant post-stroke disability, only 6.3% saw a rehabilitation physician. CONCLUSION: Taking into account not only cardiovascular prevention, but all post-stroke consequences, medical follow-ups as organized by GPs were not in accordance with recommendations and failed to take advantage of the currently available multidisciplinary resources required to improve patients' needs.

Construction and pilot assessment of the Upper Limb Assessment in Daily Living Scale.

OBJECTIVE: The upper limb function of hemiplegic patients is currently evaluated using scales that assess physical capacity or daily activities under test conditions. The present scale, the Upper Limb Assessment in Daily Living (ULADL) Scale, was developed to explore the subjective and objective functional capacities of such patients in a proximal to distal sequence. METHODS: A group of experts constructed a scale addressing 17 upper limb functions (five active passive and 12 active) which could be explored by a questionnaire (Q) and a test (T). Reproducibility, internal consistency, concurrent validity (Rivermead Motor Assessment (RMA)) and learning effect were estimated in a multicentre study. RESULTS: 49 stroke patients were each rated three times within 7 days by a total of 21 physicians, yielding a total of 142 ratings. The ULADL took 16±8 min to complete compared with 9±5 min for the RMA. Cronbach's alpha coefficient was 0.95 for Q and 0.97 for the practical tests (T). The global Q and T scores, and in particular the global Q score, were slightly higher at the second rating. The intra-rater intraclass correlation coefficient (ICC) was 0.65 (95% CI (0.44 to 0.79)) for Q and 0.97 (0.95 to 0.98) for T, and the inter-rater ICC was 0.95 for both Q and T. The Bland and Altman method showed good intra- and inter-rater reliability with no systematic trend. Correlation coefficients for ULADL versus RMA were >0.80 for both Q and T. CONCLUSIONS: The ULADL Scale has good psychometric properties and can explore patients with different degrees of upper limb impairment.

Safety and self-reported efficacy of botulinum toxin for adult spasticity in current clinical practice: a prospective observational study.

OBJECTIVE: To determine the safety and the self-reported efficacy of botulinum toxin injections for adult spasticity in current clinical practice. DESIGN: A prospective observational study. SUBJECTS: A total of 406 adult patients with focal spasticity received of 1136 series botulinum toxin injections at Bordeaux University Hospital from January 2007 to December 2009. METHODS: Adverse events following botulinum toxin injections were reported. Their severity and the therapeutic efficacy of botulinum toxin injections were estimated with a four-point self-reporting scale (0 to 3). Latency and duration of adverse events and subjective improvement were also noted. RESULTS: The data of 640 series of injections were analyzed. Forty-six (7.2%) adverse events were reported, of which 36 (78%) were local. There were 18 (39%) cases of local muscular weakness with an average duration of 30.0 (SD 38.2) days, and an average severity score of 1.0 (SD 0.97). Among systemic adverse events, there were 8 (17%) cases of excessive fatigue without global muscular weakness and 2 (4%) cases of transitory generalized muscular weakness. The average subjective improvement score was 1.89 (SD 0.97) and was higher for upper, than for lower, limbs (P=0.007). CONCLUSION: Self-reported adverse events following botulinum toxin injections in spasticity are rare, often benign and of short duration in current clinical practice. Botulinum toxin is considered effective by patients in treating spasticity of the upper and lower limbs.

A 10-year follow-up study of patients with severe traumatic brain injury and dysautonomia treated with intrathecal baclofen therapy.

PRIMARY OBJECTIVE: To describe the long-term disorders of consciousness in patients with dysautonomia and hypertonia treated with intrathecal baclofen therapy (IBT). METHODS AND PROCEDURES: Forty-three patients with severe traumatic brain injuries who were previously implanted with an intrathecal baclofen pump were included to be evaluated in the long-term with the Coma Recovery Scale-Revised. The Barthel Index, the Glasgow Outcome Scale, the Ashworth scale, the scores of hypertonic attacks, of sweating episodes and of voluntary motor responses were used to describe functional abilities and residual impairments. A retrospective analysis highlighted patients' characteristics at admission, before surgery and their complications. MAIN OUTCOMES AND RESULTS: After a mean follow-up of 10 years, nine of 43 (20.9%) patients had died, 13/43 (30.2%) patients were severely disabled or in an unresponsive wakefulness syndrome and 21/43 (48.8%) patients had good recovery of consciousness. The latter patients tended to receive IBT later, suggesting a later development of uncontrolled symptoms of dysautonomia and hypertonia. They needed lower doses of baclofen, suggesting that they had less severe symptoms. Their dysautonomia, limb hypertonia and voluntary motor responses improved significantly compared to patients with poor outcome. CONCLUSIONS: Recovery of good long-term consciousness is possible. A low level of consciousness recovery and the early development of severe and persistent symptoms of dysautonomia associated with hypertonia could be linked to poor long-term outcome.

Comparison of long-term outcomes of patients with severe traumatic or hypoxic brain injuries treated with intrathecal baclofen therapy for dysautonomia.

PRIMARY OBJECTIVE: To compare the long-term outcome of patients with severe traumatic brain injury and patients with hypoxic brain injury with dysautonomia and hypertonia treated with intrathecal baclofen therapy. METHODS AND PROCEDURES: Fifty-three patients with severe traumatic (n = 43/53) or hypoxic (n = 10/53) brain injuries treated by intrathecal baclofen therapy were included to be evaluated with the Coma Recovery Scale-Revised, the Barthel Index, the Glasgow Outcome Scale, the Ashworth scale, the scores of hypertonic attacks, of sweating episode and of voluntary motor responses. A retrospective analysis highlighted patients' characteristics at admission and before surgery and their complications. MAIN OUTCOMES AND RESULTS: After a mean follow-up time of 9.6 years, 13/53 (24.5%) patients had died. Alive patients with traumatic brain injury had a higher level of consciousness recovery (p < 0.02) and more abilities in activities of daily living (p < 0.008) in the long-term. Their dysautonomia and limb hypertonia also significantly improved, contrary to patients with hypoxic brain injury who needed higher doses of baclofen (p < 0.03). CONCLUSIONS: At long-term follow-up, patients with hypoxic brain injury had a poorer functional outcome than patients with traumatic brain injury with persistent symptoms of dysautonomia associated with uncontrolled hypertonia, despite the use of intrathecal baclofen.

Post-vaccination SARS-cov-2 infection in nursing home residents, Bordeaux, France.

OBJECTIVE: To describe COVID-19 breakthrough infections in two nursing homes (NHs) sites of active COVID-19 clusters despite optimal vaccination coverage. METHODS: A cross-sectional study was conducted in two NHs of south-western France, following the investigation of COVID-19 clusters (February-March 2021). SARS-CoV-2-confirmed infection was defined by positive RT-PCR. Antibodies neutralization capacities were tested in a subgroup of fully-vaccinated and seropositive-residents. RESULTS: Of the 152 residents, 66% were female with median age 87 years (IQR: 80.0-90.2). Overall, 132 (87%) residents received 2 doses of vaccine, 14 (9%) one dose and 6 (4%) were unvaccinated. Forty-seven (31%) residents had confirmed infection (45 (98%) with variant 20I/501Y.V1). All 6 non-vaccinated residents, 4 /14 who had one dose and 37/132 that had two doses, were infected. Of the 39 residents reporting symptoms, 12 and 3 presented severe and critical disease, respectively. One resident with a confirmed infection died. Infected-residents had a median anti-S IgG titre of 19 116.0 (IQR: 3 028.0-39 681.8 AU/mL), 19 times higher than that of non-infected vaccinated persons (1,207.0; IQR: 494.0-2,782.0). In the subgroup of 19 residents tested for neutralizing antibodies, the neutralizing titre (50%) was strongly positively correlated with the anti-S IgG titre (correlation coefficient = 0.83), and 1.5 times higher for the infected than non-infected residents [5.9 (IQR: 5.3-6.9) vs. 3.6 (2.9-3.8)]. CONCLUSION: Institutionalized elderly persons who undergo breakthrough infection develop higher titres of anti-S IgGs, which are strongly correlated with the neutralizing capacity of the antibodies. These results advocate for additional vaccine doses in this population.

A systematic review of repetitive transcranial magnetic stimulation in aphasia rehabilitation: Leads for future studies.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive tool that induces neuromodulation in the brain. Several studies have shown that rTMS improves language recovery in patients with post-stroke aphasia. OBJECTIVE: This systematic review summarizes the role of rTMS in aphasia rehabilitation. METHODS: We searched MEDLINE via PubMed and Scopus on 30October, 2020, for English articles (1996-2020). Eligible studies involved post-stroke aphasia rehabilitation with rTMS. In some of these studies, rTMS was also combined with speech therapy. RESULTS: In total, seven meta-analyses and 59studies (23randomized clinical trials) were included in this systematic review. The methods used in these studies were heterogeneous. Only six studies did not find that rTMS had a significant effect on language performance. CONCLUSIONS: The evidence from the peer-reviewed literature suggests that rTMS is an effective tool in post-stroke aphasia rehabilitation. However, the precise mechanisms that underlie the effects of rTMS and the reorganization of language networks in patients who have had a stroke remain unclear. We discuss these crucial challenges in the context of future studies.

Accuracy of COVID-19 rapid antigenic tests compared to RT-PCR in a student population: The StudyCov study.

OBJECTIVE: There is a lack of data evaluating performance of antigenic test (AT) for SARS-CoV-2 diagnosis (Ag-RDT) in clinical practice, especially in asymptomatic subjects. The main objective of this study was to evaluate the diagnostic performance of AT compared to Reverse Transcription Polymerase Chain Reaction (RT-PCR) for SARS-CoV-2 diagnosis. METHODS: StudyCov is a monocentric cross-sectional study. A SARS-CoV-2 screening facility was set up in the Bordeaux University health campus from October 28th to November 20th 2020. Students willing to have a RT-PCR test (ARGENE SARS-CoV-2 R-GENE, BioMérieux, France) for SARS-CoV-2 diagnosis were also offered the Abbott Panbio™ SARS-CoV-2 antigenic rapid test. All participants attending the screening facility with an AT in addition to RT-PCR and having signed an informed consent were included in the study. The main objective was to assess performance of AT as compared with RT-PCR in the recruited population. Secondary objectives dealt with the analysis of the main objective stratified by current symptoms and risk exposure. A sensitivity analysis with different RT-PCR cycle thresholds was included. RESULTS: RT-PCR and AT results were available for 692 subjects. Overall sensitivity and specificity of AT tests were respectively 63.5% (95% confidence interval (CI): 49.0 - 76.4) and 100% (95% CI: 99.4 - 100). In the asymptomatic sub-group, they were respectively 35.0% (95% CI: 15.4% - 59.2%) and 100% (95% CI: 99.3 - 100). CONCLUSIONS: This study shows the poor sensitivity of AT in asymptomatic subjects, specificity being however excellent. The performance results fall below the World Health Organization recommendation of 80% sensitivity and question using AT in general population, especially when asymptomatic.

Individualized Cognition-Action intervention to prevent behavioral disturbances and functional decline in institutionalized older adults: a randomized pilot trial.

OBJECTIVE: To evaluate the effectiveness of an individualized Cognition-Action (CA) intervention to reduce behavioral disturbances in severely deconditioned institutionalized old adults. DESIGN: 12 weeks randomized pilot trial of either individualized Cognition-Action program (n = 24) or routine medical care as control (C, n = 25). SETTING: Long-term care (LTC) of the Geriatric Department from the University State Hospital in Bordeaux, France. PARTICIPANTS: 49 institutionalized old patients with at least one Neuropsychiatric symptoms > or =4. INTERVENTION: The CA rationale was a non-preconceived ideas approach over the patient's abilities and discourse. Patients received short bouts of 5-15 min and accumulated 50 min of interaction per week. CA intervention used five standardized exercises as tools to enhance communication and social interactions. CA was compared to usual care. MEASUREMENTS: Primary outcomes were the Neuropsychiatric inventory (NPI) total and symptoms scores. Secondary outcomes were the BERG balance scale, the Geriatric Depression Scale (GDS), Quality of life AM-PAC-CAT and Muscle strength. RESULTS: The CA group had a clinically significant NPI total score reduction compared to C, -7, 95%CI [-10.8 to -3], eta2 = 0.24. CA group showed a risk reduction of NPI total score worsening, OR = 0.09, 95%CI [0.02-0.37]. BERG total score was clinically improved in the CA group compared to C, 4.9 95%CI [0.7-9.2], eta2(p)= 0.11. CA patients reduced their GDS score and improved their Quality of life and Strength. CONCLUSIONS: The combination of tailored guidance and simple standardized exercises was an effective behavioral management approach for behavioral disturbances reduction and functional autonomy improvement in institutionalized old adult populations.

Effects of robotic gait training after stroke: A meta-analysis.

BACKGROUND: Robotic devices are often used in rehabilitation and might be efficient to improve walking capacity after stroke. OBJECTIVE: First to investigate the effects of robot-assisted gait training after stroke and second to explain the observed heterogeneity of results in previous meta-analyses. METHODS: All randomized controlled trials investigating exoskeletons or end-effector devices in adult patients with stroke were searched in databases (MEDLINE, EMBASE, CENTRAL, CINAHL, OPENGREY, OPENSIGLE, PEDRO, WEB OF SCIENCE, CLINICAL TRIALS, conference proceedings) from inception to November 2019, as were bibliographies of previous meta-analyses, independently by 2 reviewers. The following variables collected before and after the rehabilitation program were gait speed, gait endurance, Berg Balance Scale (BBS), Functional Ambulation Classification (FAC) and Timed Up and Go scores. We also extracted data on randomization method, blinding of outcome assessors, drop-outs, intention (or not) to treat, country, number of participants, disease duration, mean age, features of interventions, and date of outcomes assessment. RESULTS: We included 33 studies involving 1466 participants. On analysis by subgroups of intervention, as compared with physiotherapy alone, physiotherapy combined with body-weight support training and robot-assisted gait training conferred greater improvement in gait speed (+0.09m/s, 95% confidence interval [CI] 0.03 to 0.15; p=0.002), FAC scores (+0.51, 95% CI 0.07 to 0.95; p=0.022) and BBS scores (+4.16, 95% CI 2.60 to 5.71; p=0.000). A meta-regression analysis suggested that these results were underestimated by the attrition bias of studies. CONCLUSIONS: Robot-assisted gait training combined with physiotherapy and body-weight support training seems an efficient intervention for gait recovery after stroke.

Evaluation of a virtual agent to train medical students conducting psychiatric interviews for diagnosing major depressive disorders.

BACKGROUND: A psychiatric diagnosis involves the physician's ability to create an empathic interaction with the patient in order to accurately extract semiology (i.e., clinical manifestations). Virtual patients (VPs) can be used to train these skills but need to be evaluated in terms of accuracy, and to be perceived positively by users. METHODS: We recruited 35 medical students who interacted in a 35-min psychiatric interview with a VP simulating major depressive disorders. Semiology extraction, verbal and non-verbal empathy were measured objectively during the interaction. The students were then debriefed to collect their experience with the VP. RESULTS: The VP was able to simulate the conduction of a psychiatric interview realistically, and was effective to discriminate students depending on their psychiatric knowledge. Results suggest that students managed to keep an emotional distance during the interview and show the added value of emotion recognition software to measure empathy in psychiatry training. Students provided positive feedback regarding pedagogic usefulness, realism and enjoyment in the interaction. LIMITATIONS: Our sample was relatively small. As a first prototype, the measures taken by the VP would need improvement (subtler empathic questions, levels of difficulty). The face-tracking technique might induce errors in detecting non-verbal empathy. CONCLUSION: This study is the first to simulate a realistic psychiatric interview and to measure both skills needed by future psychiatrists: semiology extraction and empathic communication. Results provide evidence that VPs are acceptable by medical students, and highlight their relevance to complement existing training and evaluation tools in the field of affective disorders.