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Introduction: Utilization of telemedicine for health care delivery increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic. However, physical examination during telehealth visits remains limited. A novel telerehabilitation system-The Augmented Reality-based Telerehabilitation System with Haptics (ARTESH)-shows promise for performing synchronous, remote musculoskeletal examination., Objective: To assess the potential of ARTESH in remotely examining upper extremity passive range of motion (PROM) and maximum isometric strength (MIS)., Design: In this cross-sectional pilot study, we compared the in-person (reference standard) and remote evaluations (ARTESH) of participants' upper extremity PROM and MIS in 10 shoulder and arm movements. The evaluators were blinded to each other's results., Setting: Participants underwent in-person evaluations at a Veterans Affairs hospital's outpatient Physical Medicine and Rehabilitation (PM&R) clinic, and underwent remote examination using ARTESH with the evaluator located at a research lab 30 miles away, connected via a high-speed network., Patients: Fifteen participants with upper extremity pain and/or weakness., Interventions: Not applicable., Main Outcome Measures: Inter-rater agreement between in-person and remote evaluations on 10 PROM and MIS movements and presence/absence of pain with movement was calculated., Results: The highest inter-rater agreements were noted in shoulder abduction and protraction PROM (kappa (κ) = 0.44, confidence interval (CI): -0.1 to 1.0), and in elbow flexion, shoulder abduction, and shoulder protraction MIS (κ = 0.63, CI: 0 to 1.0)., Conclusions: This pilot study suggests that synchronous tele-physical examination using the ARTESH system with augmented reality and haptics has the potential to provide enhanced value to existing telemedicine platforms. With the additional technological and procedural improvements and with an adequately powered study, the accuracy of ARTESH-enabled remote tele-physical examinations can be better evaluated., (© 2022 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Within the context of the evolving SARS-CoV-2 pandemic, we sought to design a project to increase social connectivity among emergency medicine physicians with ties to Vanderbilt University Medical Center. Our project aimed to promote physician wellness through fostering and maintaining community at one large academic institution., (© 2021 by the Society for Academic Emergency Medicine.)

Background: UK Hospital Trusts are charged with increasing patients' research awareness and willingness to take part in research. This includes implementing strategies to encourage patient-initiated enquiries about participation., Objectives: To evaluate the impact of a research statement inserted in outpatient letters in one clinical service, and to derive suggestions on potential steps towards increasing patient-initiated recruitment., Setting: A medical outpatient clinic of a research-active hospital trust, serving an inner-city multi-ethnic population across two boroughs., Methods: Pre-intervention and post-intervention questionnaires were administered face-to-face to new patients. Questionnaires included closed questions and one open comments section. Data were analysed for frequencies, with thematic coding of open-ended responses., Results: The response rates were 87% for the pre-intervention survey and 92% for the post-intervention survey. In the post-intervention survey, 85% of patients did not notice the research statement in the letter. More than half found the statement "a little unclear," whilst one-third considered it "clear." Three-quarters of respondents perceived the statement to be "a little helpful." Only one person enquired about participating in clinical research having read the statement in the outpatient letter., Conclusion: The analysis suggests that simple, single-solution approaches such as including research statements in outpatient letters are unlikely to be sufficient to significantly facilitate patient-initiated recruitment. Recruitment efforts need to take into consideration the diversity of patient constituencies including the reasons they seek health care, and how patients can meaningfully access information (research literacy)., (© 2017 The Authors Health Expectations published by John Wiley & Sons Ltd.)

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Background: Randomized trials and meta-analyses indicate positive effects of stroke unit (SU) care on survival and dependency of patients with stroke. However, data on the advantages of SU in 'real-world' settings are limited. We prospectively assessed, in a large University Hospital, the effect of SU versus other conventional wards (OCW) care on all-cause mortality, death or dependency, death or institutionalization., Methods: In a prospective observational study in the European Registers of Stroke Project, patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, 3-month and 1-year survival, and functional outcome., Results: Overall, 355 patients (54.1% men, mean age 73.4 ± 14.5 years) were registered, 140 (39.4%) admitted to the SU, and 215 (60.6%) to OCW. OCW patients were older, whilst SU patients had more severe strokes according to NIHSS (P for trend = 0.025). SU patients were significantly more often treated by specialists in stroke medicine, stroke nurses, physiotherapists and speech therapists (all P < 0.001), psychologists (P = 0.025), dietitians (P < 0.001), and social workers (P = 0.003). MRI, carotid, and transcranial Doppler were significantly more often performed in SU patients (all P < 0.001). Intravenous fluids (P = 0.003) and intravenous anticoagulation (P < 0.001) were more often prescribed in SU. Controlling for case-mix, SU significantly reduced 1-year mortality (P = 0.020), death or dependency at 3 months (P = 0.006) and 1 year (P = 0.043), and death or institutionalization at 3 months (P = 0.001) and 1 year (P = 0.009)., Conclusions: We confirmed the benefits of SU care in a clinical setting. Further analyses should define the contribution of individual components of care to stroke outcome., (© 2010 The Author(s). European Journal of Neurology © 2010 EFNS.)

Background: Health researchers are encouraged to involve service users as partners in their research. There is a need to increase the evidence base of involvement, including an accumulation of empirical accounts of involvement practices, demonstrating how involvement influences research and refinement of the concept itself., Aims: To report the development of a pilot study by academic researchers and stroke service users belonging to a user research group to investigate costs of stroke to individuals and families; to reflect on what this example of user involvement achieved and implications for what involvement means., Methods: We conducted a 2-year ethnographic study that included participant observation, formal and informal interviews with professionals and user group members and documentary analysis. Data were systematically recorded to permit description of processes and reflexive analysis., Results and Conclusions: We report on five stages of the research process from service user identification of a research question to interpretation of pilot study findings. Professional researchers led the research process and developed a novel method to involve stroke service users in the development of a questionnaire. Some academic colleagues questioned the value of the proposed investigation as it did not appear to conform to implicit criteria of quality research. We argue that the moral status that user involvement has acquired means that academics' concerns about quality did not prevent the pilot study from being conducted. We suggest that much of what was undertaken might be considered standard good practice in developing new research studies but also identify additional benefits of user involvement. Implications for conceptual development and evaluation are discussed.

Background and Purpose: Data on patient-specific recovery after stroke are lacking and the effects of complex healthcare interventions on the course of recovery were not reported. To quantify the recovery pattern up to 1 year post-stroke and assess effects of evidence-based treatments on the patient-specific course of recovery allowing its prediction., Methods: A total of 355 patients after first-ever stroke from the population-based South London Stroke Register (source population >270,000) participated in a substudy between August 2002 and October 2004. At 1, 2, 3, 4, 6, 8, 12, 26, and 52 weeks post-stroke, Barthel Index (BI; ranging from 0 to 20) was documented. Multilevel growth models allowing predictions for patients with specific characteristics were calculated., Results: Mean age was 70 years, 48% were male and 23% died within the first year. The age-, gender- and stroke subtype-adjusted BI curve sharply increased until week 8 to 24 depending on patient characteristics and subsequently plateaued. Multivariable analysis identified stroke unit care, appropriate secondary prevention and physiotherapy for those with disabilities as independent predictors of improved functional ability over time (P < 0.05). Patients receiving stroke unit care additionally gained 4 BI points within 6 months compared with their counterparts (P = 0.004)., Conclusions: Functional outcome in the general population showed an increase followed by a plateau. Care parameters reflecting guideline treatment independently improved recovery illustrating the beneficial effects of evidence-based interventions on recovery in an unbiased population.

Valid classification of stroke is essential to initiate effective acute management and early secondary prevention strategies. To accurately evaluate stroke subtype a number of diagnostic procedures have to be performed. This study sought to investigate variations in use of diagnostic procedures across selected European hospitals. First-ever stroke patients were sampled over a 1-year period through 11 hospital-based registers across 10 European countries. We defined a diagnostic standard for valid aetiological classification of ischemic stroke including brain imaging, vascular imaging and echocardiography. The impact of socio-demographic, clinical and structural characteristics on performance of the diagnostic standard was assessed using multivariate logistic regression analyses. A total of 1721 patients were included in the study. 83.1% received brain imaging, ranging from 32.8% to 100%. The diagnostic standard was performed in 40.4% of stroke patients, ranging from 0% to 77.2%. Patients with increasing age (P < 0.001) and with more severe strokes (P = 0.001) were less probably to receive the diagnostic standard. Patients treated in stroke units and neurological departments were more frequently investigated with the diagnostic standard (P < 0.001). Less than half of hospitalized stroke patients across Europe underwent diagnostic procedures to allow for aetiological classification of stroke, which may hamper the initiation of effective early management and secondary prevention.

We show that overexpression of Sub2p, a multifunctional Saccharomyces cerevisiae helicase family member that is involved in mRNA elongation and transport, also suppresses heterochromatic silencing at telomeres. Genetic assays show cells that overexpress SUB2 from a high copy plasmid exhibit increased survival rates when selecting for a telomere-silenced URA3 reporter. Two temperature-sensitive sub2 mutations that affect different helicase domains were also examined at the permissive temperature; these mutants also overcome silencing of the URA3 reporter. The degree to which silencing is suppressed correlates with SUB2 RNA and protein levels. Additionally, we find that Sub2p localizes to the telomeres, as determined by chromatin immunoprecipitation assays, suggesting that Sub2p has a direct effect at telomeres. Genome-wide analysis of transcripts was used to assess whether Sub2p overproduction affects only the silenced URA3 reporter gene, or whether other subtelomeric genes are also affected. Of the 70 RNA transcripts elevated in the Sub2p overexpressing cells, 28% are encoded by subtelomeric genes that are located within 5 Kbp of a core X or Y' repeat. The remainder of the transcripts clustered into several functional groups, including the iron homeostasis pathway, purine nucleotide metabolism, and miscellaneous transport genes, among others. These results suggest a targeted effect of Sub2p on transcription. Our results also confirm that Sub2p affects heterochromatic gene expression, similar to that observed with the Drosophila Hel25E homologue. The above observations imply that Sub2p affects chromatin structure in addition to, or in parallel with, its functions in transcription elongation, splicing and mRNA transport.

The 2-week wait rule for cancer referrals became effective in December 2000 for all cancers treated by the National Health Service in the UK. Attainment of this target depends initially on appropriate and timely referral by general practitioners (GPs). General practitioners' views and referral practices under the 2-week wait rule were examined based on a postal survey of 508 GPs in an inner London area (65% response). Data on mode of referral indicated that 90% of GPs used the urgent suspected cancer form, although 38% also sent a letter with further information. General practitioners generally regarded the 2-week wait rule as working well in terms of improving patients' initial access, and 50% thought communication with the hospital had improved. However, 46% expressed some concerns, including problems arising from the different sets of forms required by local cancer networks, the lack of a dedicated referral form for breast cancer, and feelings of a loss of autonomy. General practitioners also acknowledged an element of over-referral under this rule due to the effects of clinical uncertainty and patient pressure and their concerns about increased waiting times for non-target referrals. The survey therefore indicates that GPs are generally positive about the 2-week wait rule but identified some problems of implementation including a need for standardized national cancer referral forms.

In measuring the progression of, or recovery from, a disease an individual's outcome may be assessed on a number of occasions. A model of the relationship between outcome and time since disease occurred which accounts for patient characteristics could be used to describe patterns of recovery, to predict outcome for a patient, or to evaluate health interventions. We use multilevel models to analyse such data, focusing on the choice of powers of time both for mean outcome and covariate effects. We give equations for predicted outcome and corresponding standard errors (i) based only on baseline characteristics, and (ii) by conditioning on previous outcomes for an individual. In a study of 331 stroke patients, outcome was measured approximately 0, 2,4,6 and 12 months after stroke. Patient characteristics included age, sex, and pre-stroke handicap, together with stroke-severity indicators (presence of limb deficit, dysphasia, dysarthria or incontinence). Of these, only the effects of age, dysphasia and presence of deficit varied with time. Conditioning on previous observations improved the accuracy of predictions. The outcome variable clearly had a skewed distribution, and the model residuals showed evidence of non-Normality. We discuss alternative models for non-Normal data, and show that, here, the standard (Normal errors) multilevel model gives equivalent parameter estimates and predictions to those obtained from alternative models., (Copyright 2001 John Wiley & Sons, Ltd.)

Background: Stroke patients are usually admitted to hospital for their acute care and rehabilitation. Services to help acute stroke patients avoid admission to hospital ("hospital-at-home") have now been developed., Objectives: The objective of this review was to establish the costs and effects of such services compared with conventional services., Search Strategy: The Stroke Group Specialist Register of Controlled Trials was searched and supplemented by discussion with colleagues and trialists. This was last updated in March 1999., Selection Criteria: Controlled clinical trials recruiting stroke patients who have not been admitted to hospital and compare; a) services which provided support with an aim of helping prevent admission to hospital with b) conventional services (which could include hospital admission)., Data Collection and Analysis: Two independent reviewers determined the eligibility and methodological quality of trials. Trialists were then contacted to obtain standardised descriptive and outcome data., Main Results: Four trials are included in the review of which three currently have outcome data available (921 patients; 857 from one controlled trial, 64 from two randomised trials). There were no statistically significant differences between the patient and carer outcomes of the intervention and control groups either within individual trials or in pooled analyses. There was a trend toward greater hospital bed use and increased costs in the intervention groups., Reviewer's Conclusions: There is currently no evidence from clinical trials to support a radical shift in the care of acute stroke patients from hospital-based care.