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Multiple myeloma is the second most common hematological malignancy in the USA and Europe. Despite improvements in the 5-year and overall survival rates over the past decade, older adults (aged ≥65 years) with multiple myeloma continue to experience disproportionately worse outcomes than their younger counterparts. These differences in outcomes arise from the increased prevalence of vulnerabilities such as medical comorbidities and frailty seen with advancing age that can influence treatment-delivery and tolerance and impact survival. In general, geriatric assessments can help identify those patients more likely to benefit from enhanced toxicity risk-prediction and aid treatment decision-making. Despite the observed benefits of geriatric assessments and other screening frailty tools, provider and systems-level barriers continue to influence the overall perception of the feasibility of geriatric assessments in clinical practice settings. Clinical trials are underway evaluating the efficacy and safety of various multiple myeloma therapies in less fit/frail older adults, with a minority examining fitness-based/risk-adapted approaches. Thus, significant gaps exist in knowing which myeloma therapies are most appropriate for older and more vulnerable adults with multiple myeloma. The purpose of this Review is to discuss how geriatric assessments can be used to guide the management of transplant-ineligible patients; and to highlight frontline therapies for standard-risk and high-risk cytogenetic abnormalities [i.e., t(4;14), t(14;16), and del(17p)] associated with multiple myeloma. We also discuss the current shortcomings of the existing clinical approaches to care and highlight ongoing clinical trials evaluating newer fitness-based approaches to managing transplant-ineligible patients.

[Purpose] This study aimed to develop a tablet app that emulates paper questionnaires used in clinical care, and to verify the difference between the utility of tablet survey methods and paper questionnaire methods with elderly people. [Subjects and Methods] A tablet app was developed in the Java language. A questionnaire was provided to 30 community-dwelling elderly people. The subjects were randomly allocated to the group responding on the tablet (tablet group) or that responding to a paper-based questionnaire (questionnaire group). Assessed items included response time to questions, whether or not they had queries regarding the survey, and data input time. For the tablet group, a questionnaire was conducted regarding the operability of the tablet. [Results] There was no difference in response time between the two groups. Significantly more people in the tablet group had queries regarding the survey. Data input time was 426 seconds for the tablet group and 1268 seconds for the questionnaire group. In the survey regarding tablet operability, there were no negative opinions about the visibility of the screen. [Conclusion] Tablets can be used with elderly people to shorten the data input time. The present findings suggested that tablet surveys could be effective for a large-scale investigation.

Paper-based sensors and assays have been highly attractive for numerous biological applications, including rapid diagnostics and assays for disease detection, food safety, and clinical care. In particular, the paper immunoassay has helped drive many applications in global health due to its low cost and simplicity of operation. This review is aimed at examining the fundamentals of the technology, as well as different implementations of paper-based assays and discuss novel strategies for improving their sensitivity, performance, or enabling new capabilities. These innovations can be categorized into using unique nanoparticle materials and structures for detection via different techniques, novel biological species for recognizing biomarkers, or innovative device design and/or architecture.

The Research Paper of the Year award is given annually by the Royal College of General Practitioners (RCGP) to showcase the best research published in the previous year by primary care researchers in the UK. The overall winning study is chosen from the top papers in each of the six research categories used by the National Institute for Health Research. Over 80 entries were received for this year’s award, and the standard was very high. For the first time the award was sponsored by Primary Care People (a medical recruitment consultancy). The five runners up presented summaries of their work in the ‘winners’ enclosure’ at the RCGP Conference in Harrogate, and the winning entry was presented during the closing plenary session of the Conference. The overall winner of the RCGP and Primary Care People Research Paper of …

We enjoyed our colleagues' paper, and see ourselves as pursuing the same goal: the application of NGS technologies to improve clinical care and promote better health outcomes, particularly where alternative approaches are often inadequate. We find we agree on some points, but on others, regrettably, we're still far apart.

Pediatric cardiac anesthesia has developed over the past eight decades into a specialty delivering complex clinical care and contributing remarkable scientific progress. The history of this development can be traced through journal articles that mark the strides of the specialty. This article discusses journal articles, chosen by the author, that he considers had a significant impact on the practice of pediatric cardiac anesthesia or are of historical interest.

Purpose The engagement of patients as key stakeholders in their experience of care processes is a critical component of quality improvement efforts for both clinical care and translational research. Increasingly, health care systems are soliciting input from patients on care processes and experiences through surveys, patient interviews, and patient video narratives. The purpose of this viewpoint article is twofold: (a) to describe the increasing role of patient narratives about their experiences with adverse health conditions to inform patient-centered research and quality improvement efforts and (b) to present three patient narratives that highlight the real-world impacts of hearing loss and tinnitus, the life enhancing impacts of aural rehabilitation, and the importance of prospective ototoxicity monitoring in individuals with complex health conditions. Conclusion Patient narratives provide individual patient perspectives that can be used to build awareness of the range of experiences and impact of hearing disorders, and to explore patient preferences for when and how to implement hearing-related clinical services.

The J Project is a Central-Eastern European collaborative program in the field of physician education and clinical research aimed at improving the clinical care and diagnosis of primary immunodeficiency disorders (PIDs). Ukraine was one of the first to participate in the project, which allowed us to join the whole European PID community. Since 2004, the country has been holding annual J Project meetings with the involvement of new regions. The spread of the J Project impact has contributed to significantly improved early PID diagnosis in Ukraine. Progress has been made not only in identifying patients but also in arranging the treatment. The assistance in genetic diagnosis made it possible to detect PIDs, study their features, and improve approaches to the management. This also gave an impetus to the development of regional PID centers and participation in scientific research. Of utmost importance is the cooperation with colleagues from Poland, Hungary, and Belarus, who are active members of the J Project.

COVID-19 is a public health crisis that has fundamentally altered health care provision. The purpose of this study was to examine the impact of COVID-19 on pre-exposure prophylaxis (PrEP) care. We reviewed all patient records for those who presented for PrEP care at a PrEP program in Providence, Rhode Island from September 1st, 2019 to May 29th, 2020. The number of PrEP encounters decreased but was not significantly different over time (ps .05). Patients were still able to access PrEP clinical services during the COVID-19 pandemic. Implementing flexible and timely PrEP delivery approaches in this setting likely minimized the disruption of PrEP care during COVID-19.COVID-19 es una crisis de salud pública que ha alterado fundamentalmente la prestación de servicios de salud. El propósito de este estudio fue examinar el impacto de COVID-19 en los servicios de la profilaxis preexposición (PrEP). Revisamos todos los registros de pacientes que se presentaron para recibir atención de PrEP en un programa de PrEP en Providence, Rhode Island desde el 1 de septiembre de 2019 hasta el 29 de mayo de 2020. El número de encuentros de PrEP disminuyó pero no fue significativamente diferente con el paso del tiempo (ps .05). Los pacientes aún pudieron acceder a los servicios clínicos de PrEP durante la pandemia de COVID-19. La implementación de enfoques de entrega de PrEP que eran flexibles y oportunos en este entorno probablemente minimizó la interrupción de la atención médica de la PrEP durante COVID-19.

BACKGROUND: Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research. METHODS: A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts. RESULTS: Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%). DISCUSSION: Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes. STUDY REGISTRATION: This scoping review was registered with the Open Science Framework on 18 January 2019 (https://osf.io/bdj2x/). SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06632-9.

Background: Newly approved, drug-modifying therapies are associated with still unknown adverse events, although clinical trials leading to approval have strict inclusion and exclusion criteria and analyse safety and efficacy. Objectives: The aim of this study was to analyse the eligibility of multiple sclerosis (MS) patients treated in routine care into the phase III clinical trial of the respective drug. Methods: In total, 3577 MS patients with 4312 therapies were analysed. Patients with primary-progressive MS were excluded. Inclusion and exclusion criteria of phase III clinical trials in relapsing–remitting MS were adopted and subsequently applied. A comparison in clinical and sociodemographic characteristics was made between patient who met the criteria and those who did not. Results: 83% of registered patients would not have been eligible to the respective phase III clinical trial. Relapse was the single most frequent criterion not fulfilled (74.7%), followed by medication history (21.2%). Conclusion: The majority of MS patients treated in routine care would not have met clinical trials criteria. Thus, the efficacy and safety of therapies in clinical trials can differ from those in the real world. Broader phase III inclusion criteria would increase their eligibility and contribute to a better generalizability of the results in clinical trials.

Hospitalists provide a significant amount of direct clinical care in both academic and community hospitals. Peer feedback is a potentially underutilized and low resource method for improving clinical performance, which lends itself well to the frequent patient care handoffs that occur in the practice of hospital medicine. We review current literature on peer feedback to provide an overview of this performance improvement tool, briefly describe its incorporation into multi-source clinical performance appraisals across disciplines, highlight how peer feedback is currently used in hospital medicine, and present practical steps for hospital medicine programs to implement peer feedback to foster clinical excellence among their clinicians.

Background Data from remote monitoring (RM) of cardiovascular implantable electronic devices (CIEDs) currently are not accessible to patients despite demand. The typical RM report contains multiple pages of data for trained technicians to read and interpret and requires a patient-centered approach to be curated to meet individual user needs. Objective The purpose of this study was to understand which RM data elements are important to patients and to gain design insights for displaying meaningful data in a digital dashboard. Methods Adults with implantable cardioverter–defibrillators (ICDs) and pacemakers (PMs) participated in this 2-phase, user-centered design study. Phase 1 included a card-sorting activity to prioritize device data elements. Phase 2 included one-on-one design sessions to gather insights and feedback about a visual display (labels and icons). Results Twenty-nine adults (mean age 71.8 ± 11.6 years; 51.7% female; 89.7% white) participated. Priority data elements for both ICD and PM groups in phase 1 (n = 19) were related to cardiac episodes, device activity, and impedance values. Recommended replacement time for battery was high priority for the PM group but not the ICD group. Phase 2 (n = 10) revealed that patients would like descriptive, nontechnical terms to depict the data and icons that are intuitive and informative. Conclusion This user-centered design study demonstrated that patients with ICDs and PMs were able to prioritize specific data from a comprehensive list of data elements that they had never seen before. This work contributes to the goal of sharing RM data with patients in a way that optimizes the RM feature of CIEDs for improving patient outcomes and clinical care.

Background High uptake of hepatitis B virus (HBV) tests and antiviral therapy are required to improve the clinical outcomes of patients with chronic hepatitis B (CHB) at the population level. In the current study, we used the Basic Medical Care Insurance for Employees (BMCIE) to investigate the changes of clinical care cascade of CHB in Beijing, China. Methods Records for medical service of CHB patients from January 1, 2010 to December 31, 2018 were retrieved from the BMCIE database. The annual and cumulative rates of CHB patients in care, receiving HBV tests and on antiviral therapy were calculated. The trends of annual percentage changes (APCs) were estimated using Joinpoint regression model. Findings Among estimated HBsAg positive employees, the rate of CHB patients in care increased from 4•77% in 2010 to 18•61% in 2018 (APC=17•3, 95%CI: 14•4-20•4). The rate of HBV tests increased from 4•41% in 2010 to 16•39% in 2018. Among the estimated eligible employees for treatment, the rate of antiviral therapy increased from 3•92% in 2010 to 30•88% in 2018. The proportion of hospital visits for HBV≥4 times per year had increased from 47•07% in 2010 to 65•31% in 2018. By 2018, entecavir (65•07%) and tenofovir (12•98%) had become the predominantly prescribed antiviral agents. Interpretation The rates of CHB patients in care, receiving HBV tests and on antiviral therapy substantially increased in Beijing, China. However, more efforts are still needed to increase the uptake of HBV tests and treatment for achieving the goal of HBV elimination by 2030. Funding Beijing Municipal Science and Technology Commission (No.D161100002716003), National Science and Technology Major Special Project for Infectious Diseases (No.Z191100007619037, No.2018ZX10302204), and Digestive Medical Coordinated Development Center of Beijing Municipal Administration of Hospitals (No. XXX 0104).

Background Internet-based cognitive behavior therapy (I-CBT) for adolescents with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) has been shown to be effective in a randomized controlled trial (RCT; Fatigue in Teenagers on the Internet [FITNET]). FITNET can cause a significant reduction in fatigue and disability. Objective We aimed to investigate whether FITNET treatment implemented in routine clinical care (IMP-FITNET) was as effective, using the outcomes of the FITNET RCT as the benchmark. Methods Outcomes of CFS/ME adolescents who started IMP-FITNET between October 2012 and March 2018 as part of routine clinical care were compared to the outcomes in the FITNET RCT. The primary outcome was fatigue severity assessed posttreatment. The secondary outcomes were self-reported physical functioning, school attendance, and recovery rates. Clinically relevant deterioration was assessed posttreatment, and for this outcome, a face-to-face CBT trial was used as the benchmark. The attitude of therapists toward the usability of IMP-FITNET was assessed through semistructured interviews. The number of face-to-face consultations during IMP-FITNET was registered. Results Of the 384 referred adolescents with CFS/ME, 244 (63.5%) started IMP-FITNET, 84 (21.9%) started face-to-face CBT, and 56 (14.6%) were not eligible for CBT. Posttreatment scores for fatigue severity (mean 26.0, SD 13.8), physical functioning (mean 88.2, SD 15.0), and full school attendance (mean 84.3, SD 26.5) fell within the 95% CIs of the FITNET RCT. Deterioration of fatigue and physical functioning after IMP-FITNET was observed at rates of 1.2% (n=3) and 4.1% (n=10), respectively, which is comparable to a waiting list condition (fatigue: 1.2% vs 5.7%, χ21=3.5, P=.06; physical functioning: 4.1% vs 11.4%, χ21=3.3, P=.07). Moreover, 41 (16.8%) IMP-FITNET patients made use of face-to-face consultations. Conclusions IMP-FITNET is an effective and safe treatment for adolescents with CFS/ME in routine clinical care.

Contains fulltext : 221007.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To investigate the association between patients' preferred treatment and eventual treatment. Second, to compare patients with surgical treatment to watchful waiting in order to identify predictive factors for surgery. METHODS: A single-centre retrospective study was performed between December 2015 and August 2018. Patients (≥18 years) who used a patient decision aid (PDA) for gallstones or inguinal hernia were included. After their first surgical consultation, patients received access to an online PDA. The patients' preferred treatment after the PDA was compared with their choice of eventual treatment. Multivariable regression analyses were performed for predictive factors for surgery. RESULTS: In total, 567 patients with gallstones and 585 patients with an inguinal hernia were included. Of the patients with gallstones, 121 (21%) preferred watchful waiting, 367 (65%) preferred surgery, and 79 (14%) were not sure. The patients' preferred treatment was performed in 85.9%. Frequent pain attacks (OR 2.1, 95% CI 1.1-3.9, P = .020) and preference for surgery (OR 4.4, 95% CI 1.9-10.1, P = .001) independently predicted surgery. Of the patients with an inguinal hernia, 77 (13.2%) preferred watchful waiting, 452 (78.8%) preferred surgery, and 56 (9.6%) were not sure. The patients' preferred treatment was performed in 86.0%. The preference for surgery (OR 5.2, 95% CI 2.5-10.6, P

Purpose: Comprehensive genomic profiling (CGP) is increasingly used to guide cancer therapy. This study aimed to characterise oncologists’ experiences and needs when utilising genomic results. Materials and Methods: An electronic survey distributed nation-wide to practising medical oncologists in Australia explored oncologists’ experiences with consenting, interpreting and communicating CGP results to patients. Results: The survey was completed by 108 of 333 oncologists (32%) and most respondents (n = 97, 90%) had referred patients for CGP. Using a 100-point visual analogue scale score [VAS], where higher values indicate greater confidence, most oncologists were confident consenting patients for referral [median 75 (Interquartile range, IQR: 53–85), discussing CGP results (median VAS: 70, IQR: 51–80), but significantly less confident discussing secondary germline findings (median VAS: 56, IQR 30–70, p < 0.001). Confidence with pursuing therapies based on CGP results increased with clinical experience (mean VAS increases by 4.8 per 5 years of experience, p < 0.001). Most oncologists (N = 68, 63%) reported wanting assistance with interpretation of CGP and patient-centric resources to aid communication with patients. Conclusions: Oncologists are integrating genomics into clinical care, but only display moderate confidence in communication and changing management accordingly. The development of patient- and clinician- targeted resources may assist with routine utilisation of CGP results in cancer care.

Fanhdi/Alphanate is a plasma derived factor VIII concentrate used for treating hemophilia A, for which there has not been any dedicated model describing its pharmacokinetics (PK). A population PK model was developed using data extracted from the Web-Accessible Population Pharmacokinetic Service-Hemophilia (WAPPS-Hemo) project. WAPPS-Hemo provided individual PK profiles for hemophilia patients using sparse observations as provided in routine clinical care by hemophilia centers. Plasma factor activity measurements and covariate data from hemophilia A patients on Fanhdi/Alphanate were extracted from the WAPPS-Hemo database. A population PK model was developed using NONMEM and evaluated for suitability for Bayesian forecasting using prediction-corrected visual predictive check (pcVPC), cross validation, limited sampling analysis and external evaluation against a population PK model developed on rich sampling data. Plasma factor activity measurements from 92 patients from 12 centers were used to derive the model. The PK was best described by a 2-compartment model including between subject variability on clearance and central volume, fat free mass as a covariate on clearance, central and peripheral volumes, and age as covariate on clearance. Evaluations showed that the developed population PK model could predict the PK parameters of new individuals based on limited sampling analysis and cross and external evaluations with acceptable precision and bias. This study shows the feasibility of using real-world data for the development of a population PK model. Evaluation and comparison of the model for Bayesian forecasting resulted in similar results as a model developed using rich sampling data. Electronic supplementary material The online version of this article (10.1007/s10928-019-09637-4) contains supplementary material, which is available to authorized users.

Adult-onset non-cirrhotic hyperammonemia (NCH) is a rare, but often fatal condition that can result in both reversible and irreversible neurological defects. Here we present five cases of adult-onset non-cirrhotic hyperammonemia wherein brain magnetic resonance spectroscopy (MRS) scans for cerebral glutamine (Gln) and myo-inositol (mI) levels helped guide clinical management. Specifically, we demonstrate that when combined with traditional brain magnetic resonance imaging (MRI) scans, cerebral Gln and mI MRS can help disentangle the reversible from irreversible neurological defects associated with hyperammonemic crisis. Specifically, we demonstrate that whereas an elevated brain MRS Gln level is associated with reversible neurological defects, markedly low mI levels are associated with a risk for irreversible neurological defects such as central pontine myelinolysis. Overall, our findings indicate the utility of brain MRS in guiding clinical care and prognosis in patients with adult-onset non-cirrhotic hyperammonemia.

Improved understanding of the current burden of hypertension, including awareness, treatment, and control, is needed to guide relevant preventative measures in Nigeria. A systematic search of studies on the epidemiology of hypertension in Nigeria, published on or after January 1990, was conducted. The authors employed random‐effects meta‐analysis on extracted crude hypertension prevalence, and awareness, treatment, and control rates. Using a meta‐regression model, overall hypertension cases in Nigeria in 1995 and 2020 were estimated. Fifty‐three studies (n = 78 949) met our selection criteria. Estimated crude prevalence of pre‐hypertension (120‐139/80‐89 mmHg) in Nigeria was 30.9% (95% confidence interval [CI]: 22.0%‐39.7%), and the crude prevalence of hypertension (≥140/90 mmHg) was 30.6% (95% CI: 27.3%‐34.0%). When adjusted for age, study period, and sample, absolute cases of hypertension increased by 540% among individuals aged ≥20 years from approximately 4.3 million individuals in 1995 (age‐adjusted prevalence 8.6%, 95% CI: 6.5‐10.7) to 27.5 million individuals with hypertension in 2020 (age‐adjusted prevalence 32.5%, 95% CI: 29.8‐35.3). The age‐adjusted prevalence was only significantly higher among men in 1995, with the gap between both sexes considerably narrowed in 2020. Only 29.0% of cases (95% CI: 19.7‐38.3) were aware of their hypertension, 12.0% (95% CI: 2.7‐21.2) were on treatment, and 2.8% (95% CI: 0.1‐5.7) had at‐goal blood pressure in 2020. Our study suggests that hypertension prevalence has substantially increased in Nigeria over the last two decades. Although more persons are aware of their hypertension status, clinical treatment and control rates, however, remain low. These estimates are relevant for clinical care, population, and policy response in Nigeria and across Africa., From 53 studies covering a population of 78 949 Nigerians, we estimated an age‐adjusted prevalence of hypertension of 8.6% in 1995 representing 4.3 million persons aged ≥20 years. Age‐adjusted prevalence increased to 32.5% (27.5 million individuals) in 2020. Of these, 29.0% of (95% CI: 19.7‐38.3) were aware of their hypertension, 12.0% (95% CI: 2.7‐21.2) were on treatment, and 2.8% (95% CI: 0.1‐5.7) had at‐goal blood pressure. Being the most populous country in Africa, our findings offer insights on the current status of hypertension in Africa, and are highly relevant for international comparisons. Improving hypertension awareness and clinical management is a public health priority.

Telemedicine and eHealth refer to the use of information and communication technology (ICT) embedded in software programs with highspeed telecommunications systems for delivery, management, and monitoring of healthcare services. Application of telemedicine have become timely while providing great potentials to protect both medical practitioners and patients, as well as limit social mobility of patients contributing to reduce the spread of the virus. This study employs data from the existing literature to describe the application of telemedicine and eHealth as a proactive measure to improve clinical care. Findings from this study present the significance of telemedicine and current applications adopted during the pandemic. More importantly, the findings present practical application of telemedicine and eHealth for clinical services. Also, polices initiated across the world to promote management of COVID-19 are discussed. Respectively, this study suggests that telemedicine and eHealth can be adopted in times of health emergency, as a convenient, safe, scalable, effective, and green method of providing clinical care. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

The aim of this empirically grounded philosophical paper is to explore the notion of holistic care with the intention to expand it into a notion of ecological care and in such a way revisit the original ideas of caring science. The philosophical analysis, driven by lifeworld theory and especially Merleau-Ponty’s philosophy, is firmly rooted in contemporary clinical care. We used interview data from patients in a study at an anthroposophic clinic in Sweden, which forms part of an ecological community with, for example, ecological agriculture. The empirical study is analysed according to reflective lifeworld research. Starting from the fact that illness can be defined as a loss of homelikeness in the body and in the familiar world, our findings illustrate how ecological care helps the patient to once again find one’s place in a world that is characterized by interconnectedness. The task of ecological care is thus not only to see the patient within a world of relationships but to help the patient find his/her place again, to understand himself/herself and the world anew. Ecological care is not only about fighting an illness, but also recognizes a patient from inside a world that s/he is affected by and affects, that s/he is understood and understands from. Such care tries to restore this connection by making possible the rhythmical movement as well as the space in-between activity and rest, between being cared for and actively involving oneself in one’s recovery and between closing oneself off from the world and once again going out into it.Key words: Ecological care, ecology and health care, phenomenology, Merleau-Ponty, lifeworld-led care(Published: 30 November 2016)Citation: Int J Qualitative Stud Health Well-being 2016, 11: 33344 - http://dx.doi.org/10.3402/qhw.v11.33344

Novel viral load monitoring strategies are needed to help individuals maintain an undetectable viral load (UVL). In 2018, U.S. MSM living with HIV with a past detectable VL received a dried blood spot (DBS) kit at baseline and 3-month follow-up and returned specimens to a research laboratory. Of 56 consenting participants, 91% returned specimens at baseline and 77% at 3-month follow-up; 74% who returned two specimens had UVL at both time points. At-home DBS collection and longitudinal VL monitoring is feasible among U.S. MSM with fluctuating viral load. This complementary approach to clinical care could improve viral suppression maintenance.Se necesitan nuevas estrategias para evaluar los niveles de la carga viral para ayudar a las personas viviendo con VIH a mantener una carga viral indetectable (CVI). En 2018, hombres viviendo con VIH, que reportaron sexo con hombres y una carga viral detectable, recibieron dos paquetes de materiales para colectar muestras de sangre seca después de completar una evaluación basal y después de tres meses de seguimiento. Participantes devolvieron las muestras de sangre seca a un laboratorio. De 56 participantes que dieron su consentimiento a participar en el estudio, el 91% devolvió una muestra de sangre seca al inicio del estudio y el 77% a los 3 meses de seguimiento. Además, el 74% que devolvió dos muestras de sangre seca tenían CVI en ambos puntos de tiempo. La colección de sangre seca en el hogar y el monitoreo longitudinal de la carga viral de VIH es factible entre los hombres viviendo con el VIH y que tienen sexo con hombres. Los resultados de este estudio pueden proporcionar un enfoque complementario a la atención clínica para mejorar la supresión viral del VIH.

Background Questions have been raised regarding differences in the standards of care that patients receive when they are admitted to or discharged from in-patient units at weekends. Aims To compare the quality of care received by patients with anxiety and depressive disorders who were admitted to or discharged from psychiatric hospital at weekends with those admitted or discharged during the ‘working week’. Method Retrospective case-note review of 3795 admissions to in-patient psychiatric wards in England. Quality of care received by people with depressive or anxiety disorders was compared using multivariable regression analyses. Results In total, 795 (20.9%) patients were admitted at weekends and 157 (4.8%) were discharged at weekends. There were minimal differences in quality of care between those admitted at weekends and those admitted during the week. Patients discharged at weekends were less likely to be given sufficient notification (48 h) in advance of being discharged (OR = 0.55, 95% CI 0.39–0.78), to have a crisis plan in place (OR = 0.65, 95% CI 0.46–0.92) or to be given medication to take home (OR = 0.45, 95% CI 0.30–0.66). They were also less likely to have been assessed using a validated outcome measure (OR = 0.70, 95% CI 0.50–0.97). Conclusions There is no evidence of a ‘weekend effect’ for patients admitted to psychiatric hospital at weekends, but the quality of care offered to those who were discharged at weekends was relatively poor, highlighting the need for improvement in this area.

BACKGROUND Socioeconomically disadvantaged newborns receive care from primary care providers (PCPs) and Women, Infants, and Children (WIC) nutritionists. However, care is not coordinated between these settings, which can result in conflicting messages. Stakeholders support an integrated approach that coordinates services between settings with care tailored to patient-centered needs. OBJECTIVE This analysis describes the usability of advanced health information technologies aiming to engage parents in self-reporting parenting practices, integrate data into electronic health records to inform and facilitate documentation of provided responsive parenting (RP) care, and share data between settings to create opportunities to coordinate care between PCPs and WIC nutritionists. METHODS Parents and newborns (dyads) who were eligible for WIC care and received pediatric care in a single health system were recruited and randomized to a RP intervention or control group. For the 6-month intervention, electronic systems were created to facilitate documentation, data sharing, and coordination of provided RP care. Prior to PCP visits, parents were prompted to respond to the Early Healthy Lifestyles (EHL) self-assessment tool to capture current RP practices. Responses were integrated into the electronic health record and shared with WIC. Documentation of RP care and an 80-character, free-text comment were shared between WIC and PCPs. A care coordination opportunity existed when the dyad attended a WIC visit and these data were available from the PCP, and vice versa. Care coordination was demonstrated when WIC or PCPs interacted with data and documented RP care provided at the visit. RESULTS Dyads (N=131) attended 459 PCP (3.5, SD 1.0 per dyad) and 296 WIC (2.3, SD 1.0 per dyad) visits. Parents completed the EHL tool prior to 53.2% (244/459) of PCP visits (1.9, SD 1.2 per dyad), PCPs documented provided RP care at 35.3% (162/459) of visits, and data were shared with WIC following 100% (459/459) of PCP visits. A WIC visit followed a PCP visit 50.3% (231/459) of the time; thus, there were 1.8 (SD 0.8 per dyad) PCP to WIC care coordination opportunities. WIC coordinated care by documenting RP care at 66.7% (154/231) of opportunities (1.2, SD 0.9 per dyad). WIC visits were followed by a PCP visit 58.9% (116/197) of the time; thus, there were 0.9 (SD 0.8 per dyad) WIC to PCP care coordination opportunities. PCPs coordinated care by documenting RP care at 44.0% (51/116) of opportunities (0.4, SD 0.6 per dyad). CONCLUSIONS Results support the usability of advanced health information technology strategies to collect patient-reported data and share these data between multiple providers. Although PCPs and WIC shared data, WIC nutritionists were more likely to use data and document RP care to coordinate care than PCPs. Variability in timing, sequence, and frequency of visits underscores the need for flexibility in pragmatic studies. CLINICALTRIAL ClinicalTrials.gov NCT03482908; https://clinicaltrials.gov/ct2/show/NCT03482908 INTERNATIONAL REGISTERED REPORT RR2-10.1186/s12887-018-1263-z

Background Successful integrations of machine learning into routine clinical care are exceedingly rare, and barriers to its adoption are poorly characterized in the literature. Objective This study aims to report a quality improvement effort to integrate a deep learning sepsis detection and management platform, Sepsis Watch, into routine clinical care. Methods In 2016, a multidisciplinary team consisting of statisticians, data scientists, data engineers, and clinicians was assembled by the leadership of an academic health system to radically improve the detection and treatment of sepsis. This report of the quality improvement effort follows the learning health system framework to describe the problem assessment, design, development, implementation, and evaluation plan of Sepsis Watch. Results Sepsis Watch was successfully integrated into routine clinical care and reshaped how local machine learning projects are executed. Frontline clinical staff were highly engaged in the design and development of the workflow, machine learning model, and application. Novel machine learning methods were developed to detect sepsis early, and implementation of the model required robust infrastructure. Significant investment was required to align stakeholders, develop trusting relationships, define roles and responsibilities, and to train frontline staff, leading to the establishment of 3 partnerships with internal and external research groups to evaluate Sepsis Watch. Conclusions Machine learning models are commonly developed to enhance clinical decision making, but successful integrations of machine learning into routine clinical care are rare. Although there is no playbook for integrating deep learning into clinical care, learnings from the Sepsis Watch integration can inform efforts to develop machine learning technologies at other health care delivery systems.

The COVID-19 pandemic has posed significant challenges to health care globally, and individuals with bipolar disorder are likely disproportionally affected. Based on review of literature and collective clinical experience, we discuss that without special intervention, individuals with bipolar disorder will experience poorer physical and mental health outcomes due to interplay of patient, provider and societal factors. Some risk factors associated with bipolar disorder, including irregular social rhythms, risk-taking behaviours, substantial medical comorbidities, and prevalent substance use, may be compounded by lockdowns, social isolation and decrease in preventive and maintenance care. We further discuss implications for clinical research of bipolar disorders during the pandemic. Finally, we propose mitigation strategies on working with individuals with bipolar disorder in a clinical and research context, focusing on digital medicine strategies to improve quality of and accessibility to service.

Background Although guidelines for the management of HIV infection include recommendations for aging people living with HIV (PLWH), clinical practice of European HIV care providers may vary. Method We performed a study using a 3-phase Delphi methodology by involving a panel of clinicians with expertise in HIV infection clinical management. The main aim of the study was to assess the care provider prospective on how HIV clinical care should be delivered to ageing PLWH. The first phase involved ten clinicians to identify HIV comorbidities of interest. The second and third phases recruited clinicians virtually via a web-based questionnaire that included 137 questions focussed on 11 comorbidities (e.g. cardiovascular disease, pulmonary disease, etc.). Results Results were analysed thematically and consensus (or not) among European physicians reported. Ninety-seven and 85 responses were collected in phase 2 and 3, respectively. High levels of agreement were found among clinical care providers across Europe and with the European AIDS Conference Society guidelines regarding key items of clinical management of comorbidities in ageing PLWH. Conclusion However, we identified some important gaps, such as the lack of standardisation or implementation of the assessment of frailty or menopause, which are emerging as important factors to optimise ageing PLWH clinical care. Further studies are warranted to confirm whether intensified screening translates into HIV morbidity advances.

BackgroundSexual dysfunctions are associated with multiple medical and psychiatric disorders, as well as pharmacotherapies used to treat these disorders. Although sexual dysfunctions negatively affect both quality of life and treatment adherence, patients infrequently volunteer these symptoms and clinicians do not pose directed questions to determine their presence or severity. This issue is especially important in psychiatric patients, for whom most common psychotropics may cause sexual dysfunctions (antidepressants, antipsychotics, anxiolytics and mood-stabilising agents). There is limited literature addressing benzodiazepines, and alprazolam in particular.AimsTo report dose-dependent alprazolam anorgasmia.MethodCase analysis with PubMed literature review.ResultsA 30-year-old male psychiatric patient presented with new-onset anorgasmia in the context of asymptomatic generalised anxiety disorder, social anxiety, panic disorder with agoraphobia, obsessive–compulsive disorder, major depression in remission, and attention-deficit hyperactivity disorder treated with escitalopram 10 mg q.a.m., gabapentin 1000 mg total daily dose, lisdexamfetamine dimesylate 70 mg q.a.m., nortriptyline 60 mg q.h.s. and alprazolam extended-release 2.5 mg total daily dose. All psychotropic doses had been constant for >6 months excluding alprazolam, which was titrated from 1 mg to 2.5 mg total daily dose. The patient denied any sexual dysfunction with alprazolam at 1 mg q.d. and 1 mg b.i.d. Within 1 week of increasing alprazolam to 2.5 mg total daily dose, the patient reported anorgasmia. Anorgasmia was alprazolam dose-dependent, as anorgasmia resolved with reduced weekend dosing (1 mg b.i.d. Saturday/1.5 mg total daily dose Sunday).ConclusionsSexual dysfunction is an important adverse effect negatively influencing therapeutic outcome. This case reports alprazolam-induced dose-dependent anorgasmia. Clinicians/patients should be aware of this adverse effect. Routine sexual histories are indicated.Declaration of interestNone.

Data-driven tools and techniques, particularly machine learning methods that underpin artificial intelligence, offer promise in improving healthcare systems and services. One of the companies aspiring to pioneer these advances is DeepMind Technologies Limited, a wholly-owned subsidiary of the Google conglomerate, Alphabet Inc. In 2016, DeepMind announced its first major health project: a collaboration with the Royal Free London NHS Foundation Trust, to assist in the management of acute kidney injury. Initially received with great enthusiasm, the collaboration has suffered from a lack of clarity and openness, with issues of privacy and power emerging as potent challenges as the project has unfolded. Taking the DeepMind-Royal Free case study as its pivot, this article draws a number of lessons on the transfer of population-derived datasets to large private prospectors, identifying critical questions for policy-makers, industry and individuals as healthcare moves into an algorithmic age.

Background The range of decisions and considerations that women with advanced breast cancer (ABC) face can be overwhelming and difficult to manage. Research shows that most patients prefer a shared decision-making (SDM) approach as it provides them with the opportunity to be actively involved in their treatment decisions. The current engagement of these patients in their clinical decisions is suboptimal. Moreover, implementing SDM into routine clinical care can be challenging as patients may not always feel adequately prepared or may not expect to be involved in the decision-making process. Objective Avalere Health developed the Preparation for Shared Decision-Making (PFSDM) tool to help patients with ABC feel prepared to communicate with their clinicians and engage in decision making aligned with their preferences. The goal of this study was to validate the tool for its acceptability and usability among this patient population. Methods We interviewed a diverse group of women with ABC (N=30). Interviews were audiorecorded, transcribed, and double coded by using NVivo. We assessed 8 themes to understand the acceptability and usability of the tool. Results Interviewees expressed that the tool was acceptable for preparing patients for decision making and would be useful for helping patients know what to expect in their care journey. Interviewees also provided useful comments to improve the tool. Conclusions This validation study confirms the acceptability and usability of the PFSDM tool for women with ABC. Future research should assess the feasibility of the tool’s implementation in the clinical workflow and its impact on patient outcomes.

More implementation research is needed to further close the gap between research and practice in lifestyle interventions for people with severe mental illness, The scandal of premature mortality in people with serious mental illness is well established. Despite an increase in studies evaluating the efficacy of lifestyle interventions, translating this evidence into routine clinical care and policies is challenging, in part due to limited effectiveness or implementation research. We highlight the challenge of implementation that is increasingly recognized in clinical practice, advocate for adopting implementation science to study the implementation and systematic update of effective interventions in practice and policy, and provide directions for future research.

Background In a clinical trial, internet-based cognitive behavioral therapy (I-CBT) embedded in stepped care was established as noninferior to face-to-face cognitive behavioral therapy (CBT) for chronic fatigue syndrome (CFS). However, treatment effects observed in clinical trials may not necessarily be retained after implementation. Objective This study aimed to investigate whether stepped care for CFS starting with I-CBT, followed by face-to-face CBT, if needed, was also effective in routine clinical care. Another objective was to explore the role of therapists’ attitudes toward electronic health (eHealth) and manualized treatment on treatment outcome. Methods I-CBT was implemented in five mental health care centers (MHCs) with nine treatment sites throughout the Netherlands. All patients with CFS were offered I-CBT, followed by face-to-face CBT if still severely fatigued or disabled after I-CBT. Outcomes were the Checklist Individual Strength, physical and social functioning (Short-Form 36), and limitations in daily functioning according to the Work and Social Adjustment Scale. The change scores (pre to post stepped care) were compared with a benchmark: stepped care from a randomized controlled trial (RCT) testing this treatment format. We calculated correlations of therapists’ attitudes toward manualized treatment and eHealth with reduction of fatigue severity. Results Overall, 100 CFS patients were referred to the centers. Of them, 79 started with I-CBT, 20 commenced directly with face-to-face CBT, and one did not start at all. After I-CBT, 48 patients met step-up criteria; of them, 11 stepped up to face-to-face CBT. Increase in physical functioning (score of 13.4), social functioning (20.4), and reduction of limitations (10.3) after stepped care delivered in routine clinical care fell within the benchmarks of the RCT (95% CIs: 12.8-17.6; 25.2-7.8; and 7.4-9.8, respectively). Reduction of fatigue severity in the MHCs was smaller (12.6) than in the RCT (95% CI 13.2-16.5). After I-CBT only, reduction of fatigue severity (13.2) fell within the benchmark of I-CBT alone (95% CI 11.1-14.2). Twenty therapists treated between one and 18 patients. Therapists were divided into two groups: one with the largest median reduction of fatigue and one with the smallest. Patients treated by the first group had a significantly larger reduction of fatigue severity (15.7 vs 9.0; t=2.42; P=.02). There were no (statistically significant) correlations between therapists’ attitudes and reduction in fatigue. Conclusions This study is one of the first to evaluate stepped care with I-CBT as a first step in routine clinical care. Although fatigue severity and disabilities were reduced, reduction of fatigue severity appeared smaller than in the clinical trial. Further development of the treatment should aim at avoiding dropout and encouraging stepping up after I-CBT with limited results. Median reduction of fatigue severity varied largely between therapists. Further research will help understand the role of therapists’ attitudes in treatment outcome.

Circulating anodic antigen (CAA) testing is a powerful, increasingly-used tool for diagnosis of active schistosome infection. We sought to determine the feasibility and reliability of measuring CAA in blood spots collected on Whatman 903 protein saver cards, which are the predominant filter papers used worldwide for dried blood spot (DBS) research and clinical care. CAA was eluted from blood spots collected from 19 individuals onto Whatman 903 cards in Mwanza, Tanzania, and the assay was optimized to achieve CAA ratios comparable to those obtained from the spots' corresponding serum samples. The optimized assay was then used to determine the correlation of serum samples (n=16) with DBS from cards that had been stored for 8 years at ambient temperature. Using a DBS volume equivalent to approximately four times the quantity of serum, CAA testing in DBS had a sensitivity of 76% and a specificity of 79% compared to CAA testing in serum. CAA testing was reliable in samples eluted from Whatman 903 cards that had been stored for 8 years at ambient temperature. The overall kappa coefficient was 0.53 (standard error 0.17, p

Pressure injuries increase morbidity and mortality in geriatric patients by 400%. Residents in long-term care (LTC) are at high risk of developing pressure injuries because of limited mobility, poor nutritional status, impaired cognition, and incontinence. This study aims to determine whether a no-sting barrier film (NSBF) treatment protocol is more effective than current physician practices for treating stage 1 and 2 pressure injuries in LTC. A retrospective cohort study of 129 residents from one LTC facility was performed after a six-month implementation trial of a NSBF treatment protocol. The six-month incidence rate of stage 1 and 2 pressure injuries was 9% and 38% respectively. There was a statistically significant reduction in healing time in those treated with the NSBF protocol. In summary, the NSBF protocol reduces healing time of stage 1 and 2 pressure injuries; this protocol could be easily incorporated into existing pressure injury treatment strategies in LTC.

We summarize the available in vivo validation of cerebral near-infrared spectroscopy (NIRS) oximetry to inform future in vivo validation strategies. In particular, to establish a way forward in the assessment of NIRS instrumentation for future randomized trials, a systematic literature search is performed. The records are screened and abstracts are assessed to select studies fulfilling our inclusion criteria. Twenty-two pediatric and 28 adult studies are analyzed after exclusion of three articles in each group. All studies compare regional cerebral tissue oxygenation measured by cerebral NIRS to invasive measurement of central or jugular venous oxygen saturation. In studies without Bland–Altman plots, we extracted data from scatter plots enabling estimation of mean difference (MD), standard deviation (SD), and limits of agreement (LOA). To assess the agreement between [Formula: see text] (regional cerebral tissue oxygenation) estimated by NIRS and by blood samples, weighted averages of the MDs and SDs from each study are calculated. We found a fair agreement between the overall mean of cerebral tissue oxygenation and the mean of a reference value measured by co-oximetry whatever NIRS instrument or site of blood sampling used. Cerebral oxygenation overestimates the reference at low values, some instruments apparently more than others. Thus, a high degree of scatter and a lack of a good reference method complicate in vivo validation of NIRS. It is difficult to draw any firm conclusions despite the large number of studies, and the result of this review leaves us questioning if more of such validation studies of cerebral NIRS oximetry are really needed. Furthermore, the combination of lack of validation and poor repeatability is an important issue when designing a randomized clinical trial of implementing cerebral NIRS oximetry into clinical care.

Introduction In the Netherlands birth centres have recently become an alternative option as places where women with uncomplicated pregnancies can give birth. This article focusses on the job satisfaction of three groups of maternity care providers (community midwives, clinical care providers and maternity care assistants) working in or with a birth centre compared to those working only in a hospital or at home. Methods In 2015, an existing questionnaire was adapted and distributed to maternity care providers and 4073 responses were received. Using factor analyses, two composite measures were constructed, a Composite Job Satisfaction scale and an Assessment-of-Working-in-or-with-a-Birth-Centre scale. Differences between groups were tested with Student’s t-test and MANOVA with post hoc test and linear regression analyses. Results The overall score on the Composite Job Satisfaction scale did not differ between community midwives or clinical care providers working in or with a birth centre and those working in a different setting. For maternity care assistants there was a small but significantly higher score for those not working in a birth centre. Maternity care assistants’ overall job satisfaction score was higher than that of both other groups. In a linear regression analysis working or not working in or with a birth centre was related to the overall job satisfaction score, but repeated for the three professional groups separately, this relation was only found for maternity care assistants. Conclusions Job satisfaction is generally high, but, except for maternity care assistants, not related to the setting (working or not working in or with a birth centre). (aut. ref.)

Purpose Socioeconomic deprivation is associated with increased rates of self-harm but its association with levels of clinical care has not previously been explored. The aim of the current study was to investigate socioeconomic differences in the clinical management of people who self-harm. Methods Cross-sectional analysis of 3607 people presenting to a large inner-city hospital following self-harm. Results People living in the least deprived quintile were more likely to receive a psychosocial assessment (most vs. least deprived: 63.51 vs. 70.14%). This effect persisted in our fully adjusted model (OR 1.45, CI 1.15–1.82, p = 0.002). Mediation analysis suggested this association was in large part explained by higher rates of self-discharge in people presenting from areas of higher deprivation. Conclusions Compared to those from more deprived areas, people from less deprived areas are more likely to receive a psychosocial assessment when presenting to hospital following self-harm. The occurrence of higher rates of self-discharge from emergency departments among those from more deprived areas may explain the association. Electronic supplementary material The online version of this article (doi:10.1007/s00127-017-1438-1) contains supplementary material, which is available to authorized users.

Background: Obtaining collateral information from a patient is an essential component of providing effective psychiatric and psychotherapeutic care. Research indicates that patients’ social and electronic media contains information relevant to their psychotherapy and clinical care. However, it remains unclear to what degree this content is being actively utilized by clinicians as a part of diagnosis or therapy. Moreover, clinicians’ attitudes around this practice have not been well characterized. Objective: This survey aimed to establish the current attitudes and behaviors of outpatient clinicians regarding the incorporation of patients’ social and electronic media into psychotherapy. Methods: A Web-based survey was sent to outpatient psychotherapists associated with McLean Hospital in Belmont, Massachusetts. The survey asked clinicians to indicate to what extent and with which patients they reviewed patients’ social and electronic media content as part of their clinical practice, as well as their reasons for or against doing so. Results: Of the total 115 respondents, 71 (61.7%) indicated that they had viewed at least one patient’s social or electronic media as part of psychotherapy, and 65 of those 71 (92%) endorsed being able to provide more effective treatment as a result of this information. The use of either short message service text messages or email was significantly greater than the use of other electronic media platforms (χ21=24.1, n=115, P

BackgroundThe landmark US Multimodal Treatment of ADHD (MTA) study established the benefits of individualised medication titration and optimisation strategies to improve short- to medium-term outcomes in attention-deficit hyperactivity disorder (ADHD). This individualised medication management approach was subsequently incorporated into the National Institute for Health and Care Excellence (NICE) ADHD Clinical Guidelines (NICE CG78). However, little is known about clinicians' attitudes towards implementing these medication management strategies for ADHD in routine care.AimsTo examine National Health Service (NHS) healthcare professionals' consensus on ADHD medication management strategies.MethodUsing the Delphi method, we examined perceptions on the importance and feasibility of implementing 103 ADHD treatment statements from sources including the UK NICE ADHD guidelines and US medication management algorithms.ResultsCertain recommendations for ADHD medication management were judged as important and feasible to implement, including a stepwise titration of stimulant medication. Other recommendations were perceived as important but not feasible to implement in routine practice, such as weekly clinic follow-up with the family during titration and collection of follow-up symptom questionnaires.ConclusionsMany of the key guideline recommendations for ADHD medication management are viewed by clinicians as important and feasible to implement. However, some recommendations present significant implementation challenges within the context of routine NHS clinical care in England.

Background: In the absence of reliable predictive equations, indirect calorimetry (IC) remains the gold standard for assessing energy requirements after spinal cord injury (SCI), but it is typically confined to a research setting. The purpose of this study is to assess the feasibility and acceptability of implementing IC into routine clinical care in an Australian SCI rehabilitation facility. Methods: Bedside IC (canopy hood) was performed, and patients completed an IC acceptability questionnaire (open-ended; yes/no; 5-point Likert scale). Fasted resting energy expenditure (REE) steady-state criteria were applied to assess data quality, and adherence to a test ≥20 minutes was recorded. Staff were surveyed to assess impact of IC on usual care. Results: Of 35 eligible patients, 9 declined (7 reported claustrophobia). One patient could not be tested before discharge and 25 underwent IC (84% male, injury level C2-L2, AIS A-D). Anxiety prevented one patient from completing IC, while another failed to fast. The remaining 23 patients achieved a steady-state REE (≥5 consecutive minutes with ≤10% coefficient of variation for VO2 and VCO2). Test-retest (n = 5) showed

Background: Health apps are increasingly being used in clinical care and may hold significant theoretical potential. However, they are often implemented in clinical care before any research has been done to confirm actual benefits for patients, physicians, and researchers. Objective: This study aimed to explore experiences of patients and health care providers with the use of a supportive breast cancer app during the first 6 months following diagnosis, in terms of benefits for clinical practice and research purposes. Methods: Between June 2013 and April 2014, breast cancer patients of all ages were invited shortly after diagnosis to use a supportive breast cancer app, and were followed for 6 months. Patients were asked to use the app at their own convenience. In-depth interviews were conducted regularly with patients and their medical team (ie, physicians and nurses) to evaluate their experiences. Results: A total of 15 patients aged 30-63 years participated. The medical team consisted of 7 physicians and 3 specialized breast cancer nurses. Out of the 15 patients, 12 (80%) used the app to obtain information on breast cancer and treatment. A total of 11 out of 12 patients (92%) evaluated this information as useful. All 15 patients used the app to record consultations with practitioners, and 14 (93%) found this useful. Symptom registration was used by 8 out of 15 patients (53%), and was found useful by 4 out of these 8 patients (50%). Overall, 14 out of 15 patients (93%) would recommend the app to other patients. The app, in particular the recording function, was rated as useful by 9 out of 10 medical professionals (90%), and they reported that it did not increase consultation time. These 9 professionals would recommend the app to their patients. Conclusions: This evaluation of a supportive health app shows positive experiences among patients and their medical teams. Based on experiences in this study, patients may need to be actively encouraged to regularly register symptoms within health apps to generate sufficient patient-reported app data for use in clinical practice and scientific research. [JMIR Cancer 2016;2(1):e8]

In South Asia, general hospital psychiatric units (GHPUs) have developed as an alternative to mental hospitals for the provision of comprehensive mental health services, training and research. GHPUs provide clinical care for all types of patients, including those with severe mental illnesses (SMIs). However, psychosocial rehabilitation is often neglected in GHPUs, partly because of the predominance of the medical model in routine clinical care and a lack of resources. This paper discusses the challenges in the management of SMIs in GHPUs and proposes a model of psychosocial rehabilitation which could be used in such settings.

Objective: To summarize current clinical research practice and develop methodological standards for objective scientific evaluation of knee cartilage repair procedures and products. Design: A comprehensive literature review was performed of high-level original studies providing information relevant for the design of clinical studies on articular cartilage repair in the knee. Analysis of cartilage repair publications and synopses of ongoing trials were used to identify important criteria for the design, reporting, and interpretation of studies in this field. Results: Current literature reflects the methodological limitations of the scientific evidence available for articular cartilage repair. However, clinical trial databases of ongoing trials document a trend suggesting improved study designs and clinical evaluation methodology. Based on the current scientific information and standards of clinical care, detailed methodological recommendations were developed for the statistical study design, patient recruitment, control group considerations, study endpoint definition, documentation of results, use of validated patient-reported outcome instruments, and inclusion and exclusion criteria for the design and conduct of scientifically sound cartilage repair study protocols. A consensus statement among the International Cartilage Repair Society (ICRS) and contributing authors experienced in clinical trial design and implementation was achieved. Conclusions: High-quality clinical research methodology is critical for the optimal evaluation of current and new cartilage repair technologies. In addition to generally applicable principles for orthopedic study design, specific criteria and considerations apply to cartilage repair studies. Systematic application of these criteria and considerations can facilitate study designs that are scientifically rigorous, ethical, practical, and appropriate for the question(s) being addressed in any given cartilage repair research project.