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BMC Musculoskeletal Disorders launched a Collection on digital health to get a sense of where the wind is blowing, and what impact these technologies are and will have on musculoskeletal medicine. This editorial summarizes findings and focuses on some key topics, which are valuable as digital health establishes itself in patient care. Elements discussed are digital tools for the diagnosis, prognosis and evaluation of rheumatic and musculoskeletal diseases, coupled together with advances in methodologies to analyse health records and imaging. Moreover, the acceptability and validity of these digital advances is discussed. In sum, this editorial and the papers presented in this article collection on Digital health in musculoskeletal care will give the interested reader both a glance towards which future we are heading, and which new challenges these advances bring.

Evidence on the cost-effectiveness of eHealth in palliative care is scarce. Oncokompas, a fully automated behavioral intervention technology, aims to support self-management in cancer patients. This study aimed to assess the cost-utility of the eHealth application Oncokompas among incurably ill cancer patients, compared to care as usual. In this randomized controlled trial, patients were randomized into the intervention group (access to Oncokompas) or the waiting-list control group (access after three months). Healthcare costs, productivity losses, and health status were measured at baseline and three months. Intervention costs were also taken into account. Non-parametric bootstrapping with 5000 replications was used to obtain 95% confidence intervals around the incremental costs and quality-adjusted life years (QALYs). A probabilistic approach was used because of the skewness of cost data. Altogether, 138 patients completed the baseline questionnaire and were randomly assigned to the intervention group (69) or the control group (69). In the base case analysis, mean total costs and mean total effects were non-significantly lower in the intervention group (−€806 and −0.01 QALYs). The probability that the intervention was more effective and less costly was 4%, whereas the probability of being less effective and less costly was 74%. Among patients with incurable cancer, Oncokompas does not impact incremental costs and seems slightly less effective in terms of QALYs, compared to care as usual. Future research on the costs of eHealth in palliative cancer care is warranted to assess the generalizability of the findings of this study.

Coronavirus disease 2019 (COVID-19) has emerged as a pandemic with serious clinical manifestations including death. A pandemic at the large-scale like COVID-19 places extraordinary demands on the world's health systems, dramatically devastates vulnerable populations, and critically threatens the global communities in an unprecedented way. While tremendous efforts at the frontline are placed on detecting the virus, providing treatments and developing vaccines, it is also critically important to examine the technologies and systems for tackling disease emergence, arresting its spread and especially the strategy for diseases prevention. The objective of this article is to review enabling technologies and systems with various application scenarios for handling the COVID-19 crisis. The article will focus specifically on 1) wearable devices suitable for monitoring the populations at risk and those in quarantine, both for evaluating the health status of caregivers and management personnel, and for facilitating triage processes for admission to hospitals; 2) unobtrusive sensing systems for detecting the disease and for monitoring patients with relatively mild symptoms whose clinical situation could suddenly worsen in improvised hospitals; and 3) telehealth technologies for the remote monitoring and diagnosis of COVID-19 and related diseases. Finally, further challenges and opportunities for future directions of development are highlighted.

In April 2020, the European Society for Child and Adolescent Psychiatry (ESCAP) Research Academy and the ESCAP Board launched the first of three scheduled surveys to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on child and adolescent psychiatry (CAP) services in Europe and to assess the abilities of CAP centers to meet the new challenges brought on by the crisis. The survey was a self-report questionnaire, using a multistage process, which was sent to 168 heads of academic CAP services in 24 European countries. Eighty-two responses (56 complete) from 20 countries, representing the subjective judgement of heads of CAP centers, were received between mid-April and mid-May 2020. Most respondents judged the impact of the crisis on the mental health of their patients as medium (52%) or strong (33%). A large majority of CAP services reported no COVID-19 positive cases among their inpatients and most respondents declared no or limited sick leaves in their team due to COVID-19. Outpatient, daycare, and inpatient units experienced closures or reductions in the number of treated patients throughout Europe. In addition, a lower referral rate was observed in most countries. Respondents considered that they were well equipped to handle COVID-19 patients despite a lack of protective equipment. Telemedicine was adopted by almost every team despite its sparse use prior to the crisis. Overall, these first results were surprisingly homogeneous, showing a substantially reduced patient load and a moderate effect of the COVID-19 crisis on psychopathology. The effect on the organization of CAP services appears profound. COVID-19 crisis has accelerated the adoption of new technologies, including telepsychiatry. Supplementary Information The online version contains supplementary material available at 10.1007/s00787-020-01699-x.

Background Acute exacerbations have a significant impact on patients with COPD by accelerating the decline in lung function leading to decreased health-related quality of life and survival time. In telehealth, health care professionals exercise clinical judgment over a physical distance. Telehealth has been implemented as a way to monitor patients more closely in daily life with an intention to intervene earlier when physical measurements indicate that health deteriorates. Several studies call for research investigating the ability of telehealth to automatically flag risk of exacerbations by applying the physical measurements that are collected as part of the monitoring routines to support health care professionals. However, more research is needed to further develop, test, and validate prediction algorithms to ensure that these algorithms improve outcomes before they are widely implemented in practice. Method This trial tests a COPD prediction algorithm that is integrated into an existing telehealth system, which has been developed from the previous Danish large-scale trial, TeleCare North (NCT: 01984840). The COPD prediction algorithm aims to support clinical decisions by predicting the risk of exacerbations for patients with COPD based on selected physiological parameters. A prospective, parallel two-armed randomized controlled trial with approximately 200 participants with COPD will be conducted. The participants live in Aalborg municipality, which is located in the North Denmark Region. All participants are familiar with the telehealth system in advance. In addition to the participants’ usual weekly monitored measurements, they are asked to measure their oxygen saturation two more times a week during the trial period. The primary outcome is the number of exacerbations defined as an acute hospitalization from baseline to follow-up. Secondary outcomes include changes in health-related quality of life measured by both the 12-Item Short Form Survey version 2 and EuroQol-5 Dimension Questionnaire as well as the incremental cost-effectiveness ratio. Discussion This trial seeks to explore whether the COPD prediction algorithm has the potential to support early detection of exacerbations in a telehealth setting. The COPD prediction algorithm may initiate timely treatment, which may decrease the number of hospitalizations. Trial registration NCT05218525 (pending at clinicaltrials.gov) (date, month, year)

Background Although the health benefits of physical activity are well established, it remains challenging for people to adopt a more active lifestyle. Mobile health (mHealth) interventions can be effective tools to promote physical activity and reduce sedentary behavior. Promising results have been obtained by using gamification techniques as behavior change strategies, especially when they were tailored toward an individual’s preferences and goals; yet, it remains unclear how goals could be personalized to effectively promote health behaviors. Objective In this study, we aim to evaluate the impact of personalized goal setting in the context of gamified mHealth interventions. We hypothesize that interventions suggesting health goals that are tailored based on end users’ (self-reported) current and desired capabilities will be more engaging than interventions with generic goals. Methods The study was designed as a 2-arm randomized intervention trial. Participants were recruited among staff members of 7 governmental organizations. They participated in an 8-week digital health promotion campaign that was especially designed to promote walks, bike rides, and sports sessions. Using an mHealth app, participants could track their performance on two social leaderboards: a leaderboard displaying the individual scores of participants and a leaderboard displaying the average scores per organizational department. The mHealth app also provided a news feed that showed when other participants had scored points. Points could be collected by performing any of the 6 assigned tasks (eg, walk for at least 2000 m). The level of complexity of 3 of these 6 tasks was updated every 2 weeks by changing either the suggested task intensity or the suggested frequency of the task. The 2 intervention arms—with participants randomly assigned—consisted of a personalized treatment that tailored the complexity parameters based on participants’ self-reported capabilities and goals and a control treatment where the complexity parameters were set generically based on national guidelines. Measures were collected from the mHealth app as well as from intake and posttest surveys and analyzed using hierarchical linear models. Results The results indicated that engagement with the program inevitably dropped over time. However, engagement was higher for participants who had set themselves a goal in the intake survey. The impact of personalization was especially observed for frequency parameters because the personalization of sports session frequency did foster higher engagement levels, especially when participants set a goal to improve their capabilities. In addition, the personalization of suggested ride duration had a positive effect on self-perceived biking performance. Conclusions Personalization seems particularly promising for promoting the frequency of physical activity (eg, promoting the number of suggested sports sessions per week), as opposed to the intensity of the physical activity (eg, distance or duration). Replications and variations of our study setup are critical for consolidating and explaining (or refuting) these effects. Trial Registration ClinicalTrials.gov NCT05264155; https://clinicaltrials.gov/ct2/show/NCT05264155

The 2019 coronavirus pandemic (COVID-19) has resulted in tremendous growth in telehealth services in Australia and around the world. The rapid uptake of telehealth has mainly been due to necessity – following social distancing requirements and the need to reduce the risk of transmission. Although telehealth has been available for many decades, the COVID-19 experience has resulted in heightened awareness of telehealth amongst health service providers, patients and society overall. With increased telehealth uptake in many jurisdictions during the pandemic, it is timely and important to consider what role telehealth will have post-pandemic. In this article, we highlight five key requirements for the long-term sustainability of telehealth. These include: (a) developing a skilled workforce; (b) empowering consumers; (c) reforming funding; (d) improving the digital ecosystems; and (e) integrating telehealth into routine care.

IntroductionRecent years have witnessed an upsurge of demand in eye care services in the UK. With a large proportion of patients referred to Hospital Eye Services (HES) for diagnostics and disease management, the referral process results in unnecessary referrals from erroneous diagnoses and delays in access to appropriate treatment. A potential solution is a teleophthalmology digital referral pathway linking community optometry and HES.Methods and analysisThe HERMES study (Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease: a cluster randomised superiority trial with a linked diagnostic accuracy study) is a cluster randomised clinical trial for evaluating the effectiveness of a teleophthalmology referral pathway between community optometry and HES for retinal diseases. Nested within HERMES is a diagnostic accuracy study, which assesses the accuracy of an artificial intelligence (AI) decision support system (DSS) for automated diagnosis and referral recommendation. A postimplementation, observational substudy, a within-trial economic evaluation and discrete choice experiment will assess the feasibility of implementation of both digital technologies within a real-life setting. Patients with a suspicion of retinal disease, undergoing eye examination and optical coherence tomography (OCT) scans, will be recruited across 24 optometry practices in the UK. Optometry practices will be randomised to standard care or teleophthalmology. The primary outcome is the proportion of false-positive referrals (unnecessary HES visits) in the current referral pathway compared with the teleophthalmology referral pathway. OCT scans will be interpreted by the AI DSS, which provides a diagnosis and referral decision and the primary outcome for the AI diagnostic study is diagnostic accuracy of the referral decision made by the Moorfields-DeepMind AI system. Secondary outcomes relate to inappropriate referral rate, cost-effectiveness analyses and human–computer interaction (HCI) analyses.Ethics and disseminationEthical approval was obtained from the London—Bromley Research Ethics Committee (REC 20/LO/1299). Findings will be reported through academic journals in ophthalmology, health services research and HCI.Trial registration numberISRCTN18106677 (protocol V.1.1).

Background and purpose: Several studies have compared fast-track with conventional pathways for total hip arthroplasty (THA) patients, but none have compared different fast-track pathways. Due to COVID-19 restrictions, our department had to minimize patient–staff contact in the THA pathway. First, telephone consultations were implemented instead of an outpatient clinic visit and subsequently preoperative patient education was discontinued. This enabled us to compare patient-reported outcomes and satisfaction among 3 fast-track pathways. Patients and methods: We collected data from patients treated for hip osteoarthritis with THA at Gødstrup Hospital between 2018 and 2021. The patients had experienced 1 of 3 pathways and were interviewed via telephone between 2 and 6 months after discharge. We analyzed the influence of patient pathway on patient-reported pain and mobility level, self-perceived complications, and compliance using logistic regression. We then compared the pathway’s effect on patient satisfaction both for the total sample and for the patients who experienced complications. Results: The amount of patient–staff contact in the patient pathway did not have any influence on patientreported outcomes or the probability of self-perceived complications. For the full sample, patient–staff contact had no statistically significant influence on patient satisfaction either, but for the subgroup of patients experiencing complications, the pathways with less patient–staff contact reducedsatisfaction. Patient satisfaction was primarily related to pain and mobility outcomes. Interpretation: Our results indicate that reducing patient–staff contact in fast-track THA can be done without influencing mobility and pain outcomes, but the overall satisfaction among patients with self-perceived complications will be negatively affected.

Use of digital patient-reported outcomes is being introduced in care of chronic conditions, including Inflammatory Bowel Disease. The aim is to supplement face-to-face follow-up sessions through symptom screening, and to inform follow-up through questions about mental health and quality of life. However, little is known about who is using this as intended. This study aimed to map differences between users and non-users among people with IBD and explore the mechanisms behind. We administered a questionnaire including the Readiness and Enablement Index for Health Technology (ReadHy) and the Service User Technology Acceptability Questionnaire (SUTAQ) to all people with IBD registered at Silkeborg Regional Hospital. Comparison between users and non-users and cluster analysis was conducted. Effect size (Cohen’s d) was used to estimate magnitude of difference between groups. The user and non-user groups differed most strongly by level of emotional distress ( d = 0.45). Cluster analysis of the ReadHy scales showed profiles have different sets of difficulties and reservations towards digital solutions. These difficulties correlated moderately with SUTAQ dissatisfaction and low acceptability. The dimensions of ReadHy may help to better understand particular needs of people with IBD when accessing digital PROs, which may lead to higher acceptability and improved quality of care.

Purpose: Diabetes mellitus is a leading cause of impaired vision. The objective of this study was to evaluate the feasibility of use of portable retinograph and remote analysis of images along with a virtual questionnaire for screening for diabetic retinopathy in basic health units in the city of Ribeirão Preto/SP during the Covid-19 pandemic. Methods: Standard Covid-19 protocol was followed during the screening. Blood pressure and capillary blood glucose were measured. Demographic and social data were collected through a standardized online questionnaire via smartphone. After pupillary dilation, fundal images were obtained with portable retinographs by trained ophthalmology residents. Two standardized 45° images were acquired: one posterior segment and another nasal to the optic nerve. Diabetic retinopathy was classified according to the Early Treatment Diabetic Retinopathy Study. Results: A total of 350 patients (64% female; 45% aged 55-70 years; 55% Caucasian) were evaluated. For 40.5% of patients, the campaign was the first opportunity for retinal evaluation; 47.56% had diabetes mellitus for >10 years. On repeat analysis of images stored in a cloud-based repository by retinal specialist, a 7.8% difference was observed in the Early Treatment Diabetic Retinopathy Study diabetic retinopathy classification, compared to the screening findings. Mild diabetic retinopathy was observed in 12.23%, moderate diabetic retinopathy in 6.31%, and proliferative diabetic retinopathy in 2.58% patients. Macular edema was present in 4.58% patients. Diabetic retinopathy was not detected in 72.78% patients. Conclusion: Use of portable retinographs together with telemedicine can provide efficient alternative to traditional methods for screening and diagnosis of diabetic retinopathy.

Background: The implementation of Telecardiology in primary care in the city of Porto Alegre, Brazil, is a viable and promising strategy. It would decrease the distance between patient and specialized professional services by reducing unnecessary referrals and improving the quality of primary care and satisfaction of patients and health professionals. Objective: To implement a Telecardiology service and assess user satisfaction using the CARDIOSATIS scale. Methods: This was a pilot study developed by a partnership between the Institute of Cardiology and the Telehealth Center of Rio Grande do Sul. The study was carried out at Eri Flores-Vila Vargas health center in the city of Porto Alegre, from May to October 2019, and included 21 patients attending the health center. The descriptive analysis of data was performed using the SPSS program (Statistical Package for the Sciences) version 23. Data normality was checked using the Kolmogorov-Smirnov test. Statistical significance was set at 10%. Results: Mean age of participants was 43.8 ± 16.1 years. The most common risk factors in the sample were physical inactivity (81%) and smoking (43%). Most patients had normal electrocardiogram (ECG) readings. The time elapsed from the performance of the ECG test, transmission of the ECG traces to Telehealth, and return of the final ECG report to the health center was 0-7 days. The CARDIOSATIS scale revealed a high prevalence of “very satisfied” users for the general satisfaction domain, and only 14.3% of patients were dissatisfied with their health. Conclusions: Telecardiology reduced the distance between patient and the specialized professional, with a high level of patient and health professional satisfaction. Our study can serve as a basis for the implementation of a telecardiology network in the city of Porto Alegre in the future.

Background With populations aging, digital health tools and mobile health applications (mHealth) are becoming more common to assist older people in independent living and self-management of (chronic) illnesses. These mHealth services can be beneficial to older patients, provided that they are adjusted to their needs and characteristics, as the current mHealth landscape lacks user-friendly services for this target group. Understanding of intrinsic aging barriers, which cause and impact usability problems older patients encounter, is needed to achieve this. Objectives This study set out to assess usability problems older patients encounter in two mHealth apps and aims to show the value of MOLD-US, a recent aging barriers framework, as a classification tool to identify the intrinsic cause of these problems. Method A case-study design, with in-depth analysis of usability issues older adult patients’ experience. Data on usability issues were collected using the Think Aloud Protocol for two mHealth apps. The MOLD-US framework and Nielsen’s severity rating were used to classify identified issues and their potential impact. Results In total 28 high severe usability issues of the mHealth apps were identified. Core natures of most issues were related to motivational and cognitive barriers of older adults. Participants had difficulties in understanding the navigation structure of the apps. Important text, buttons and icon elements were overseen. Conclusion Current knowledge on creating interfaces for older target groups is not well applied within the assessed mHealth designs. Specifically, design guidelines should address older adults’ diminishing cognition skills, physical ability and motivational barriers. By classifying usability problems with MOLD-US, insights on these barriers can be enhanced to adequately address these issues in new designs. In addition, we propose that future research focuses on investigating suitable usability evaluation methods adapted to older patients’ characteristics to ultimately be able to gain unbiased sight on usability issues older patients may experience while interacting with technology.

Background Online misinformation proliferation during the COVID-19 pandemic has become a major public health concern. Objective We aimed to assess the prevalence of COVID-19 misinformation exposure and beliefs, associated factors including psychological distress with misinformation exposure, and the associations between COVID-19 knowledge and number of preventive behaviors. Methods A cross-sectional online survey was conducted with 1049 South Korean adults in April 2020. Respondents were asked about receiving COVID-19 misinformation using 12 items identified by the World Health Organization. Logistic regression was used to compute adjusted odds ratios (aORs) for the association of receiving misinformation with sociodemographic characteristics, source of information, COVID-19 misinformation belief, and psychological distress, as well as the associations of COVID-19 misinformation belief with COVID-19 knowledge and the number of COVID-19 preventive behaviors among those who received the misinformation. All data were weighted according to the Korea census data in 2018. Results Overall, 67.78% (n=711) of respondents reported exposure to at least one COVID-19 misinformation item. Misinformation exposure was associated with younger age, higher education levels, and lower income. Sources of information associated with misinformation exposure were social networking services (aOR 1.67, 95% CI 1.20-2.32) and instant messaging (aOR 1.79, 1.27-2.51). Misinformation exposure was also associated with psychological distress including anxiety (aOR 1.80, 1.24-2.61), depressive (aOR 1.47, 1.09-2.00), and posttraumatic stress disorder symptoms (aOR 1.97, 1.42-2.73), as well as misinformation belief (aOR 7.33, 5.17-10.38). Misinformation belief was associated with poorer COVID-19 knowledge (high: aOR 0.62, 0.45-0.84) and fewer preventive behaviors (≥7 behaviors: aOR 0.54, 0.39-0.74). Conclusions COVID-19 misinformation exposure was associated with misinformation belief, while misinformation belief was associated with fewer preventive behaviors. Given the potential of misinformation to undermine global efforts in COVID-19 disease control, up-to-date public health strategies are required to counter the proliferation of misinformation.

We established an international consortium to review and discuss relevant clinical evidence in order to develop expert consensus statements related to cancer management during the severe acute respiratory syndrome coronavirus 2-related disease (COVID-19) pandemic. The steering committee prepared 10 working packages addressing significant clinical questions from diagnosis to surgery. During a virtual consensus meeting of 62 global experts and one patient advocate, led by the European Society for Medical Oncology, statements were discussed, amended and voted upon. When consensus could not be reached, the panel revised statements until a consensus was reached. Overall, the expert panel agreed on 28 consensus statements that can be used to overcome many of the clinical and technical areas of uncertainty ranging from diagnosis to therapeutic planning and treatment during the COVID-19 pandemic.

Background\ud People with cancer experience a variety of symptoms as a result of their disease and the therapies involved in its management. Inadequate symptom management has implications for patient outcomes including functioning, psychological well‐being, and quality of life (QoL). Attempts to reduce the incidence and severity of cancer symptoms have involved the development and testing of psycho‐educational interventions to enhance patients' symptom self‐management. With the trend for care to be provided nearer patients' homes, telephone‐delivered psycho‐educational interventions have evolved to provide support for the management of a range of cancer symptoms. Early indications suggest that these can reduce symptom severity and distress through enhanced symptom self‐management.\ud \ud Objectives\ud To assess the effectiveness of telephone‐delivered interventions for reducing symptoms associated with cancer and its treatment. To determine which symptoms are most responsive to telephone interventions. To determine whether certain configurations (e.g. with/without additional support such as face‐to‐face, printed or electronic resources) and duration/frequency of intervention calls mediate observed cancer symptom outcome effects.\ud \ud Search methods\ud We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1); MEDLINE via OVID (1946 to January 2019); Embase via OVID (1980 to January 2019); (CINAHL) via Athens (1982 to January 2019); British Nursing Index (1984 to January 2019); and PsycINFO (1989 to January 2019). We searched conference proceedings to identify published abstracts, as well as SIGLE and trial registers for unpublished studies. We searched the reference lists of all included articles for additional relevant studies. Finally, we handsearched the following journals: Cancer, Journal of Clinical Oncology, Psycho‐oncology, Cancer Practice, Cancer Nursing, Oncology Nursing Forum, Journal of Pain and Symptom Management, and Palliative Medicine. We restricted our search to publications published in English.\ud \ud Selection criteria\ud We included randomised controlled trials (RCTs) and quasi‐RCTs that compared one or more telephone interventions with one other, or with other types of interventions (e.g. a face‐to‐face intervention) and/or usual care, with the stated aim of addressing any physical or psychological symptoms of cancer and its treatment, which recruited adults (over 18 years) with a clinical diagnosis of cancer, regardless of tumour type, stage of cancer, type of treatment, and time of recruitment (e.g. before, during, or after treatment).\ud \ud Data collection and analysis\ud We used Cochrane methods for trial selection, data extraction and analysis. When possible, anxiety, depressive symptoms, fatigue, emotional distress, pain, uncertainty, sexually‐related and lung cancer symptoms as well as secondary outcomes are reported as standardised mean differences (SMDs) with 95% confidence intervals (CIs), and we presented a descriptive synthesis of study findings. We reported on findings according to symptoms addressed and intervention types (e.g. telephone only, telephone combined with other elements). As many studies included small samples, and because baseline scores for study outcomes often varied for intervention and control groups, we used change scores and associated standard deviations. The certainty of the evidence for each outcome was interpreted using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.\ud \ud Main results\ud Thirty‐two studies were eligible for inclusion; most had moderate risk of bias,often related to blinding. Collectively, researchers recruited 6250 people and studied interventions in people with a variety of cancer types and across the disease trajectory, although many participants had breast cancer or early‐stage cancer and/or were starting treatment. Studies measured symptoms of anxiety, depression, emotional distress, uncertainty, fatigue, and pain, as well as sexually‐related symptoms and general symptom intensity and/or distress.\ud \ud Interventions were primarily delivered by nurses (n = 24), most of whom (n = 16) had a background in oncology, research, or psychiatry. Ten interventions were delivered solely by telephone; the rest combined telephone with additional elements (i.e. face‐to‐face consultations and digital/online/printed resources). The number of calls delivered ranged from 1 to 18; most interventions provided three or four calls.\ud \ud Twenty‐one studies provided evidence on effectiveness of telephone‐delivered interventions and the majority appeared to reduce symptoms of depression compared to control. Nine studies contributed quantitative change scores (CSs) and associated standard deviation results (or these could be calculated). Likewise, many telephone interventions appeared effective when compared to control in reducing anxiety (16 studies; 5 contributed quantitative CS results); fatigue (9 studies; 6 contributed to quantitative CS results); and emotional distress (7 studies; 5 contributed quantitative CS results). Due to significant clinical heterogeneity with regards to interventions introduced, study participants recruited, and outcomes measured, meta‐analysis was not conducted.\ud \ud For other symptoms (uncertainty, pain, sexually‐related symptoms, dyspnoea, and general symptom experience), evidence was limited; similarly meta‐analysis was not possible, and results from individual studies were largely conflicting, making conclusions about their management through telephone‐delivered interventions difficult to draw. Heterogeneity was considerable across all trials for all outcomes.\ud \ud Overall, the certainty of evidence was very low for all outcomes in the review. Outcomes were all downgraded due to concerns about overall risk of bias profiles being frequently unclear, uncertainty in effect estimates and due to some inconsistencies in results and general heterogeneity.\ud \ud Unsubstantiated evidence suggests that telephone interventions in some capacity may have a place in symptom management for adults with cancer. However, in the absence of reliable and homogeneous evidence, caution is needed in interpreting the narrative synthesis. Further, there were no clear patterns across studies regarding which forms of interventions (telephone alone versus augmented with other elements) are most effective. It is impossible to conclude with any certainty which forms of telephone intervention are most effective in managing the range of cancer‐related symptoms that people with cancer experience.\ud \ud Authors' conclusions\ud Telephone interventions provide a convenient way of supporting self‐management of cancer‐related symptoms for adults with cancer. These interventions are becoming more important with the shift of care closer to patients' homes, the need for resource/cost containment, and the potential for voluntary sector providers to deliver healthcare interventions. Some evidence supports the use of telephone‐delivered interventions for symptom management for adults with cancer; most evidence relates to four commonly experienced symptoms ‐ depression, anxiety, emotional distress, and fatigue. Some telephone‐delivered interventions were augmented by combining them with face‐to‐face meetings and provision of printed or digital materials. Review authors were unable to determine whether telephone alone or in combination with other elements provides optimal reduction in symptoms; it appears most likely that this will vary by symptom. It is noteworthy that, despite the potential for telephone interventions to deliver cost savings, none of the studies reviewed included any form of health economic evaluation.\ud \ud Further robust and adequately reported trials are needed across all cancer‐related symptoms, as the certainty of evidence generated in studies within this review was very low, and reporting was of variable quality. Researchers must strive to reduce variability between studies in the future. Studies in this review are characterised by clinical and methodological diversity; the level of this diversity hindered comparison across studies. At the very least, efforts should be made to standardise outcome measures. Finally, studies were compromised by inclusion of small samples, inadequate concealment of group allocation, lack of observer blinding, and short length of follow‐up. Consequently, conclusions related to symptoms most amenable to management by telephone‐delivered interventions are tentative.

Coronavirus disease 2019 (COVID‐19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), started in the city of Wuhan late in 2019. Within a few months, the disease spread toward all parts of the world and was declared a pandemic on March 11, 2020. The current health care dilemma worldwide is how to sustain the capacity for quality services not only for those suffering from COVID‐19 but also for non‐COVID‐19 patients, all while protecting physicians, nurses, and other allied health care workers.

Background There is a need for shorter-length assessments that capture patient questionnaire data while attaining high data quality without an undue response burden on patients. Computerized adaptive testing (CAT) and classification and regression tree (CART) methods have the potential to meet these needs and can offer attractive options to shorten questionnaire lengths. Objective The objective of this study was to test whether CAT or CART was best suited to reduce the number of questionnaire items in multiple domains (eg, anxiety, depression, quality of life, and social support) used for a needs assessment procedure (NAP) within the field of cardiac rehabilitation (CR) without the loss of data quality. Methods NAP data of 2837 CR patients from a multicenter Cardiac Rehabilitation Decision Support System (CARDSS) Web-based program was used. Patients used a Web-based portal, MyCARDSS, to provide their data. CAT and CART were assessed based on their performances in shortening the NAP procedure and in terms of sensitivity and specificity. Results With CAT and CART, an overall reduction of 36% and 72% of NAP questionnaire length, respectively, was achieved, with a mean sensitivity and specificity of 0.765 and 0.817 for CAT, 0.777 and 0.877 for classification trees, and 0.743 and 0.40 for regression trees, respectively. Conclusions Both CAT and CART can be used to shorten the questionnaires of the NAP used within the field of CR. CART, however, showed the best performance, with a twice as large overall decrease in the number of questionnaire items of the NAP compared to CAT and the highest sensitivity and specificity. To our knowledge, our study is the first to assess the differences in performance between CAT and CART for shortening questionnaire lengths. Future research should consider administering varied assessments of patients over time to monitor their progress in multiple domains. For CR professionals, CART integrated with MyCARDSS would provide a feedback loop that informs the rehabilitation progress of their patients by providing real-time patient measurements.

Not required.

BackgroundAn online weight management intervention (POWeR+) combined with a small amount of primary care healthcare practitioner support is effective in helping patients to lose weight, but little is known about how practitioners interact with the POWeR+ intervention or their experiences of providing support for patients using POWeR+. The aim of this study was to explore practitioners’ usage of POWeR+ and their experiences of providing support to patients using POWeR+. MethodsSet within a randomised controlled trial of POWeR+, practitioners’ usage of POWeR+ was automatically captured and a qualitative process analysis was conducted employing semi-structured telephone interviews with practitioners who provided support to patients using POWeR+. The usage analysis captured how 54 practitioners used the POWeR+ intervention. Thirteen telephone interviews explored practitioners’ experiences of using POWeR+ and providing patients with face-to-face or remote (email and telephone) support. Interview data were analysed using inductive thematic analysis. ResultsUsage analysis indicated that almost all practitioners engaged with POWeR+. Pages which displayed patients’ progress and allowed practitioners to email patients were used the most. Practitioners found POWeR+ straightforward and easy to use. Some practitioners preferred providing support face-to-face, which they enjoyed more than remote support. A small number of nurses found providing non-directive support using the CARe approach (Congratulate, Ask, Remind) challenging, feeling it was the opposite of their normal approach. POWeR+ enabled practitioners to raise the topic of weight loss with patients, and POWeR+ was viewed as a superior alternative to existing weight management support which was limited in most practices. Still some practitioners found it difficult to fit providing support into their busy schedules. ConclusionsOverall, practitioners engaged well with POWeR+ and perceived providing patients with support whilst using POWeR+ as acceptable and feasible. CARe provides a potentially useful model for how practitioners can combine human and digital support in a cost-effective way, which could be useful for the management of other conditions. Some potential barriers to implementation were identified, which allowed modification of POWeR+. The findings suggest that implementing this cost-effective online weight management intervention in Primary Care would be feasible and acceptable to practitioners.

Purpose: Compare accuracy and precision in XYZ of stationary and dynamic tasks performed by surgeons with and without the use of a tele-operated robotic micromanipulator in a simulated vitreoretinal environment. The tasks were performed using a surgical microscope or while observing a video monitor. Method: Two experienced and two novice surgeons performed tracking and static tasks at a fixed depth with hand-held instruments on a Preceyes Surgical System R0.4. Visualization was through a standard microscope or a video display. The distances between the instrument tip and the targets (in μm) determined tracking errors in accuracy and precision. Results: Using a microscope, dynamic or static accuracy and precision in XY (planar) movements were similar among test subjects. In Z (depth) movements, experience lead to more precision in both dynamic and static tasks (dynamic 35 ± 14 versus 60 ± 37 μm; static 27 ± 8 versus 36 ± 10 μm), and more accuracy in dynamic tasks (58 ± 35 versus 109 ± 79 μm). Robotic assistance improved both precision and accuracy in Z (1–3 ± 1 μm) in both groups. Using a video screen in combination with robotic assistance improved all performance measurements and reduced any differences due to experience. Conclusions: Robotics increases precision and accuracy, with greater benefit observed in less experienced surgeons. However, human control was a limiting factor in the achieved improvement. A major limitation was visualization of the target surface, in particular in depth. To maximize the benefit of robotic assistance, visualization must be optimized.

Introducao O Conselho Federal de Medicina (CFM) publicou recentemente uma nova resolucao sobre o uso da telemedicina no Brasil. A resolucao numero 2227 de 2018, que estabelece os criterios para o uso da telemedicina, foi publicado no Diario Oficial da Uniao (DOU) em 6 de fevereiro de 2019. Essa nova resolucao, que definiu a telemedicina como uma maneira de oferecer servicos medicos por meio da tecnologia, e bem mais agressiva que a anterior publicada em 2002. Essa limitava o uso [...]

ObjectiveTo investigate the clinical effectiveness and safety of stand alone and blended internet based vestibular rehabilitation (VR) in the management of chronic vestibular syndromes in general practice.DesignPragmatic, three armed, parallel group, individually randomised controlled trial.Setting59 general practices in the Netherlands.Participants322 adults aged 50 and older with a chronic vestibular syndrome.InterventionsStand alone VR comprising a six week, internet based intervention with weekly online sessions and daily exercises (10-20 minutes a day). In the blended VR group, the same internet based intervention was supplemented by face-to-face physiotherapy support (home visits in weeks 1 and 3). Participants in the usual care group received standard care from a general practitioner, without any restrictions.Main outcome measuresThe primary outcome was vestibular symptoms after six months as measured by the vertigo symptom scale-short form (VSS-SF range 0-60, clinically relevant difference ≥3 points). Secondary outcomes were dizziness related impairment, anxiety, depressive symptoms, subjective improvement of vestibular symptoms after three and six months, and adverse events.ResultsIn the intention-to-treat analysis, participants in the stand alone and blended VR groups had lower VSS-SF scores at six months than participants in the usual care group (adjusted mean difference −4.1 points, 95% confidence interval −5.8 to −2.5; and −3.5 points, −5.1 to −1.9, respectively). Similar differences in VSS-SF scores were seen at three months follow-up. Participants in the stand alone and blended VR groups also experienced less dizziness related impairment, less anxiety, and more subjective improvement of vestibular symptoms at three and six months. No serious adverse events related to online VR occurred during the trial.ConclusionStand alone and blended internet based VR are clinically effective and safe interventions to treat adults aged 50 and older with a chronic vestibular syndrome. Online VR is an easily accessible form of treatment, with the potential to improve care for an undertreated group of patients in general practice.Trial registrationNetherlands Trial Register NTR5712.

Background: Efficient incorporation of e-health in patients with heart failure (HF) may enhance health care efficiency and patient empowerment. We aimed to assess the effect on self-care of (i) the European Society of Cardiology/Heart Failure Association website ‘heartfailurematters.org’ on top of usual care, and (ii) an e-health adjusted care pathway leaving out ‘in person’ routine HF nurse consultations in stable HF patients. Methods and results: In a three-group parallel-randomized trial in stable HF patients from nine Dutch outpatient clinics, we compared two interventions (heartfailurematters.org website and an e-health adjusted care pathway) to usual care. The primary outcome was self-care measured with the European Heart Failure Self-care Behaviour Scale. Secondary outcomes were health status, mortality, and hospitalizations. In total, 450 patients were included. The mean age was 66.8 ± 11.0 years, 74.2% were male, and 78.8% classified themselves as New York Heart Association I or II at baseline. After 3 months of follow-up, the mean score on the self-care scale was significantly higher in the groups using the website and the adjusted care pathway compared to usual care (73.5 vs. 70.8, 95% confidence interval 0.6–6.2; and 78.2 vs. 70.8, 95% confidence interval 3.8– 9.4, respectively). The effect attenuated, until no differences after 1 year between the groups. Quality of life showed a similar pattern. Other secondary outcomes did not clearly differ between the groups. Conclusions: Both the heartfailurematters.org website and an e-health adjusted care pathway improved self-care in HF patients on the short term, but not on the long term. Continuous updating of e-health facilities could be helpful to sustain effects. Clinical Trial registration: ClinicalTrials.gov ID NCT01755988.

Background: Electronic health (e-Health) interventions are emerging as an effective alternative model for improving secondary prevention of coronary artery disease (CAD). The aim of this study was to describe the effectiveness of different modes of delivery and components in e-Health secondary prevention programmes on adherence to treatment, modifiable CAD risk factors and psychosocial outcomes for patients with CAD. Method: A systematic review was carried out based on articles found in MEDLINE, CINAHL, and Embase. Studies evaluating secondary prevention e-Health programmes provided through mobile-Health (m-Health), web-based technology or a combination of m-Health and web-based technology were eligible. The main outcomes measured were adherence to treatment, modifiable CAD risk factors and psychosocial outcomes. The quality appraisal of the studies included was conducted using the Joanna Briggs Institute critical appraisal tool for RCT. The results were synthesised narratively. Result: A total of 4834 titles were identified and 1350 were screened for eligibility. After reviewing 123 articles in full, 24 RCTs including 3654 participants with CAD were included. Eight studies delivered secondary prevention programmes through m-Health, nine through web-based technology, and seven studies used a combination of m-Health and web-based technology. The majority of studies employed two or three secondary prevention components, of which health education was employed in 21 studies. The m-Health programmes reported positive effects on adherence to medication. Most studies evaluating web-based technology programmes alone or in combination with m-Health also utilised traditional CR, and reported improved modifiable CAD risk factors. The quality appraisal showed a moderate methodological quality of the studies. Conclusion: Evidence exists that supports the use of e-Health interventions for improving secondary prevention of CAD. However, a comparison across studies highlighted a wide variability of components and outcomes within the different modes of delivery. High quality trials are needed to define the most efficient mode of delivery and components capable of addressing a favourable outcome for patients. © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Introduction: Implantable cardioverter-defibrillator (ICD) monitoring zones (MZ) provide passive features that do not interfere with the functioning of active treatment zones. However, it is not known for certain whether programming an MZ affects arrhythmia detection by the ICD. The aim of the present study is to assess the clinical relevance of MZ in a population of patients with ICDs. Methods: In this retrospective analysis of patients with ICDs, with or without cardiac resynchronization therapy, for primary prevention under remote monitoring, the MZ was analyzed and recorded arrhythmias were assessed in detail. Results: A total of 221 patients were studied (77% men; age 64±12 years). Mean ejection fraction was 30±12%. The mean follow-up was 63±35 months. One hundred and seventy-four MZ events were documented in 139 patients (62.9%): 74 of non-sustained ventricular tachycardia (NSVT), 42 of supraventricular tachycardia, 44 of atrial fibrillation/atrial flutter, and five cases of noise. Among the 137 patients who presented with arrhythmias in the MZ (excluding two cases with noise detection only), 22 (16.1%) received appropriate shocks and/or antitachycardia pacing (ATP), while of the other 84 patients, 15.5% received appropriate ICD treatment (p=NS). In patients who presented with NSVT in the MZ, 15 (20.5%) received appropriate shocks and/or ATP. In accordance with the MZ findings, physicians decided to change outpatient medication in 41.7% of all patients in whom arrhythmic events were reported. Conclusion: Ventricular and supraventricular arrhythmias are common findings in the MZ of ICD patients. Programming an MZ is valuable in the diagnosis of arrhythmias and may be a useful tool in clinical practice. Resumo: Introdução: A zona de monitorização (ZM) de cardioversor desfibrilhador implantável (CDI) permite uma funcionalidade passiva que não interfere com o funcionamento das zonas de tratamento ativo. Contudo, não é perfeitamente conhecido se a programação de ZM afeta a deteção de arritmias pelo CDI. O objetivo do presente estudo é avaliar a relevância clínica de ZM numa população submetida a implantação de CDI. Métodos: Análise retrospetiva de doentes submetidos a implantação de CDI, com ou sem terapia de ressincronização cardíaca, em prevenção primária, sob monitorização remota. ZM foi analisada e as arritmias documentadas avaliadas em detalhe. Resultados: Foram estudados 221 doentes (77% homens; 64±12 anos). Fração de ejeção média foi 30±12%. O período de seguimento médio foi 63±35 meses. Foram documentados 174 eventos na ZM, em 139 doentes (62.9%): taquicardia ventricular não sustentada (TVNS) – 74, taquicardia supraventricular – 42, fibrilhação/flutter auricular – 44, ruído – 5. Dos 137 doentes que apresentaram arritmia na ZM (excluindo dois casos de deteção de ruído), 22 (16,1%) receberam choques apropriados ou pacing antitaquicardia (PAT), enquanto que dos restantes 84 doentes, 15,5% receberam terapias apropriadas do CDI (p=NS). Dos doentes que apresentaram TVNS na ZM, 15 (20,5%) receberam choques apropriados e/ou pacing anti-taquicardia (PAT). De acordo com os achados em ZM, o médico decidiu alterar a terapia oral de ambulatório em 41,7% de todos os doentes com eventos arrítmicos reportados. Conclusão: Arritmas ventriculares e supraventriculares são achados comuns na ZM de CDI. A programação de ZM é importante no diagnóstico de arritmias e poderá ser um elemento útil na prática clínica. Keywords: Implantable cardioverter-defibrillator, Monitoring zone, Supraventricular arrhythmias, Ventricular arrhythmias, Clinical practice, Palavras-chave: Cardioversor desfibrilhador implantável, Zona de monitorização, Arritmias supraventriculares, Arritmias ventriculares, Prática clínica

Objective: We conducted a randomized controlled trial to compare the effects of three types of Internet-delivered Inhibitory Control Training (ICT) with each other and with an active control intervention on alcohol consumption in a community sample of problem drinkers. Method: Two hundred and 46 heavy drinkers, who were motivated to reduce their alcohol consumption (mean age 41.32, 130 female) self-monitored their alcohol consumption for 1 week before being randomized to receive 1 of 3 variants of ICT (Associative No-Go, Associative Stop Signal, General Inhibition) or an active control. Participants then completed up to 14 ICT/control sessions on the Internet over a 4-week period, while regularly recording their alcohol consumption. Results: There were significant reductions in alcohol consumption across all groups over the 4-week training period (main effect of time, F(2, 402) = 77.12, p < .01, ηp2 = .28, BF10 > 99), however there were no differences between ICT groups, or between ICT groups and the active control group (Group × Time interaction, F(6, 402) = 1.10, p = .36, ηp2 = .02, BF10 = 0.03). Contrary to hypotheses, there were no changes in general inhibitory control, the disinhibiting effects of alcohol cues, or alcohol affective associations after ICT. Conclusions: In this study, which attempted to translate findings from proof-of-concept laboratory studies into a viable behavior change intervention, we found that multiple sessions of ICT delivered over the Internet did not help heavy drinkers to reduce their alcohol consumption beyond nonspecific effects associated with taking part in a trial., What is the public health significance of this article? Findings from this randomized controlled trial demonstrated that Inhibitory Control Training (ICT), a novel Internet-delivered behavioral intervention that is intended to improve inhibitory control, did not help problem drinkers to reduce their alcohol consumption beyond the nonspecific effects associated with taking part in a trial and regular self-monitoring of alcohol consumption. These findings suggest that interventions developed in laboratory settings may require substantial modification if they are to be translated info effective behavior change interventions suited for remote delivery.

Background: The Dutch Ministry of Health has formulated ambitious goals concerning the use of telehealth, leading to subsequent changes compared with the current health care situation, in which 93% of care is delivered face-to-face. Since most care is delivered to older people, the prospect of telehealth raises the question of whether this population is ready for this new way of receiving care. To study this, we created a theoretical framework consisting of 6 factors associated with older people’s intention to use technology. Objective: The objective of this study was to understand community-dwelling older people’s readiness for receiving telehealth by studying their intention to use videoconferencing and capacities for using digital technology in daily life as indicators. Methods: A mixed-method triangulation design was used. First, a cross-sectional survey study was performed to investigate older people’s intention to use videoconferencing, by testing our theoretical framework with a multilevel path analysis (phase 1). Second, for deeper understanding of older people’s actual use of digital technology, qualitative observations of older people executing technological tasks (eg, on a computer, cell phone) were conducted at their homes (phase 2). Results: In phase 1, a total of 256 people aged 65 years or older participated in the survey study (50.0% male; median age, 70 years; Q1-Q3: 67-76). Using a significance level of .05, we found seven significant associations regarding older people’s perception of videoconferencing. Older people’s (1) intention to use videoconferencing was predicted by their performance expectancy (odds ratio [OR] 1.26, 95% CI 1.13-1.39), effort expectancy (OR 1.23, 95% CI 1.07-1.39), and perceived privacy and security (OR 1.30, 95% CI 1.17-1.43); (2) their performance expectancy was predicted by their effort expectancy (OR 1.38, 95% CI 1.24-1.52); and (3) their effort expectancy was predicted by their self-efficacy (OR 1.55, 95% CI 1.42-1.68). In phase 2, a total of 6 men and 9 women aged between 65 and 87 years participated in the qualitative observation study. Of the primary themes, 5 themes were identified that could provide greater understanding of older people’s capacities and incapacities in using digital technology: (1) “self-efficacy and digital literacy,” (2) “obstacles to using technology,” (3) “prior experience and frequency of use,” (4) “sources of support and facilitating conditions,” and (5) “performance expectancy.” These 5 themes recurred in all 15 observations. Conclusions: Performance expectancy, effort expectancy, and perceived privacy and security are direct predictors of older people’s intention to use videoconferencing. Self-efficacy appeared to play a role in both older people’s intention to use, as well as their actual use of technology. The path analysis revealed that self-efficacy was significantly associated with older people’s effort expectancy. Furthermore, self-efficacy and digital literacy appeared to play a major role in older people’s capacities to make use of digital technology. [J Med Internet Res 2018;20(4):e123]

Background Antenatal care (ANC) has the potential to identify and manage obstetric complications, educate women about risks during pregnancy and promote skilled birth attendance during childbirth. The aim of this study was to assess women’s knowledge of obstetric danger signs and factors associated with this knowledge in Ambanja, Madagascar. It also sought to evaluate whether the participation in a mobile health (mHealth) project that aimed to provide comprehensive ANC to pregnant women in remote areas influenced women’s knowledge of obstetric danger signs. Methods From April to October 2015, a non-random, convenience sample of 372 women in their first year postpartum were recruited, including 161 who had participated in the mHealth project. Data were analyzed using bivariate and multivariate logistic regression. Results Knowledge of at least one danger sign varied from 80.9% of women knowing danger sign(s) in pregnancy, to 51.9%, 50.8% and 53.2% at delivery, postpartum and in the newborn, respectively. Participation in the mHealth intervention, higher household income, and receipt of information about danger signs during pregnancy were associated with knowledge of danger signs during delivery, in bivariate analysis; only higher household income and mHealth project participation were independently associated. Higher educational attainment and receipt of information about danger signs in antenatal care were associated with significantly higher odds of knowing danger sign(s) for the newborn in both bivariate and multivariate analysis. Conclusions Knowledge of obstetric danger signs is low. Information provision during pregnancy and with mHealth is promising. Trial registration This trial was retrospectively registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN15798183; August 22, 2015). Electronic supplementary material The online version of this article (10.1186/s12884-018-1664-x) contains supplementary material, which is available to authorized users.

Background:The internet offers major opportunities in supporting mental health care, and a variety of technology-mediated mental and behavioral health services have been developed. Yet, despite growing evidence for the effectiveness of these services, their acceptance and use in clinical practice remains low. So far, the current literature still lacks a structured insight into the experienced drivers and barriers to the adoption of electronic mental health (eMental health) from the perspective of clinical psychologists.Objective:The aim of this study was to gain an in-depth and comprehensive understanding of the drivers and barriers for psychologists in adopting eMental health tools, adding to previous work by also assessing drivers and analyzing relationships among these factors, and subsequently by developing a structured representation of the obtained findings.Methods:The study adopted a qualitative descriptive approach consisting of in-depth semistructured interviews with clinical psychologists working in the Netherlands (N=12). On the basis of the findings, a model was constructed that was then examined through a communicative validation.Results:In general, a key driver for psychologists to adopt eMental health is the belief and experience that it can be beneficial to them or their clients. Perceived advantages that are novel to literature include the acceleration of the treatment process, increased intimacy of the therapeutic relationship, and new treatment possibilities due to eMental health. More importantly, a relation was found between the extent to which psychologists have adopted eMental health and the particular drivers and barriers they experience. This differentiation is incorporated in the Levels of Adoption of eMental Health (LAMH) model that was developed during this study to provide a structured representation of the factors that influence the adoption of eMental health.Conclusions:The study identified both barriers and drivers, several of which are new to the literature and found a relationship between the nature and importance of the various drivers and barriers perceived by psychologists and the extent to which they have adopted eMental health. These findings were structured in a conceptual model to further enhance the current understanding. The LAMH model facilitates further research on the process of adopting eMental health, which will subsequently enable targeted recommendations with respect to technology, training, and clinical practice to ensure that mental health care professionals as well as their clients will benefit optimally from the current (and future) range of available eMental health options.

Background: Telecardiology may be a useful support in diagnosis and management of chest pain. Objective: Evaluate the application of telecardiology to support the differential diagnosis of chest pain in patients admitted to Emergency Care Units. Method: Observational, retrospective and documental study of 5,816 patients admitted with supposedly cardiological chest pain in twenty two Emergency Care Units in the state of Rio de Janeiro. Data were tabulated and analyzed by Excel® software, using simple descriptive statistics, from the database of the Cardiology Consultancy Nucleus. Results: Diagnostic disagreement was found in 1,593 (27.39%) cases. Of these, 1,477 (92.72%) were diagnosed locally as non-ST-elevation myocardial infarction (non-STEMI), 74 (4.64%) as acute myocardial infarction with ST-segment elevation (STEMI), 40 (2.52%) as acute pulmonary edema (APE) and 2 (0.12%) as tachyarrhythmia. Intensive care referral was requested to 100% of these patients. After telecardiology, the diagnoses were: 385 (24.17%) unstable angina, 289 (18.14%) congestive heart failure, 212 (13.31%) APE, 174 (10.92%) STEMI, 152 (9.54%) hypertensive emergency, 113 (7.09%) acute chronic renal failure, 89 (5.59%) non-STEMI, 89 (5.59%) pneumonia, 39 (2.45%) sepsis, 26 (1.63 %) myopericarditis, 20 (1.26%) tachyarrhythmia and 5 (0.31%) orovalvar disease. The outcome after telecardiology was 1,178 discharges (73.94%), 338 (21.21%) referrals, 62 (3.90%) deaths and 15 (0.95%) unknown. Conclusion: Telecardiology was effective in chest pain diagnosis and management, optimizing hospital admission in the public health system.

OBJECTIVE The role of telemedical monitoring in diabetic foot ulcer care is still uncertain. Our aim was to compare telemedical and standard outpatient monitoring in the care of patients with diabetic foot ulcers in a randomized controlled trial. RESEARCH DESIGN AND METHODS Of the 736 screened individuals with diabetic foot ulcers, 401 met the eligibility criteria and were randomized between October 2010 and November 2014. The per-protocol telemedical monitoring consisted of two consultations in the patient’s own home and one consultation at the outpatient clinic. Standard practice consisted of three outpatient clinic visits. The three-visit cycle was repeated until study end point. The study end points were defined as complete ulcer healing, amputation, or death. RESULTS One hundred ninety-three individuals were randomized to telemedical monitoring and 181 to standard care. Demographics were similar in both groups. A cause-specific Cox proportional hazards model showed no difference in individuals monitored through telemedicine regarding wound healing (hazard ratio 1.11 [95% CI 0.87, 1.42], P = 0.42) or amputation (0.87 [0.54, 1.42], P = 0.59). We found a higher mortality incidence in the telemedical monitoring group compared with the standard outpatient monitoring group (8.68 [6.93, 10.88], P = 0.0001). CONCLUSIONS The findings of no significant difference regarding amputation and healing between telemedical and standard outpatient monitoring seem promising; however, for telemedical monitoring, a higher mortality throws into question the role of telemedicine in monitoring diabetic foot ulcers. Further studies are needed to investigate effects of telemedicine on mortality and other clinical outcomes and to identify patient subgroups that may have a poorer outcome through telemedical monitoring.

Background For behaviour-change interventions to be successful they must be acceptable to users and overcome barriers to behaviour change. The Person-Based Approach can help to optimise interventions to maximise acceptability and engagement. This article presents a novel, efficient and systematic method that can be used as part of the Person-Based Approach to rapidly analyse data from development studies to inform intervention modifications. We describe how we used this approach to optimise a digital intervention for patients with hypertension (HOME BP), which aims to implement medication and lifestyle changes to optimise blood pressure control. Methods In study 1, hypertensive patients (N=12) each participated in three think-aloud interviews, providing feedback on a prototype of HOME BP. In study 2 patients (N=11) used HOME BP for three weeks and were then interviewed about their experiences. Studies 1 and 2 were used to identify detailed changes to the intervention content and potential barriers to engagement with HOME BP. In study 3 (N=7) we interviewed hypertensive patients who were not interested in using an intervention like HOME BP to identify potential barriers to uptake, which informed modifications to our recruitment materials. Analysis in all three studies involved detailed tabulation of patient data and comparison to our modification criteria. Results Studies 1 and 2 indicated that the HOME BP procedures were generally viewed as acceptable and feasible, but also highlighted concerns about monitoring blood pressure correctly at home and making medication changes remotely. Patients in study 3 had additional concerns about the safety and security of the intervention. Modifications improved the acceptability of the intervention and recruitment materials. Conclusions This paper provides a detailed illustration of how to use the Person-Based Approach to refine a digital intervention for hypertension. The novel, efficient approach to analysis and criteria for deciding when to implement intervention modifications described here may be useful to others developing interventions.

STUDY DESIGN: Narrative review.OBJECTIVES: To find and discuss what has been published about the use of telehealth, on people with spinal cord injury (teleSCI).SETTING: International.METHOD: Cochrane Library, Ovid Medline, EMBASE and CINAHL, from 1996 till June 2017 have been searched. Searches in PsycINFO, from 1996 till September 2017, were included afterwards. Extracted data include studies in English language, containing information about spinal cord injury and disorders, and telehealth. Literature reviews, systematic reviews, and studies containing other types of neurological disorders, were excluded. Studies were grouped based on how and to whom telehealth was offered.RESULTS: Twenty nine studies were included in the review. They were categorized according to the way teleSCI was provided, and to what modality was used. Some studies utilized more than one modality. TeleSCI seems to be favorable concerning treatment and follow-up, as well as favorable socioeconomically and environmentally. The studies spanned across several aims and outcomes. There was also heterogeneity in number of participants, the differences in modalities, and in the level of evidence. Thus it was challenging to compare studies and make future recommendations.CONCLUSIONS: TeleSCI can be used for examination and guiding purposes. Further research is warranted to evaluate optimal utilization, methodology and efficacy.SPONSORSHIP: The first author has received funding from the Norwegian Extra Foundation.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a progressive, chronic respiratory disease with a significant socioeconomic burden. Exacerbations, the sudden and sustained worsening of symptoms, can lead to hospitalization and reduce quality of life. Major limitations of previous telemonitoring interventions for COPD include low compliance, lack of consensus on what constitutes an exacerbation, limited numbers of patients, and short monitoring periods. We developed a telemonitoring system based on a digital health platform that was used to collect data from the 1-year EDGE (Self Management and Support Programme) COPD clinical trial aiming at daily monitoring in a heterogeneous group of patients with moderate to severe COPD.OBJECTIVE: The objectives of the study were as follows: first, to develop a systematic and reproducible approach to exacerbation identification and to track the progression of patient condition during remote monitoring; and second, to develop a robust algorithm able to predict COPD exacerbation, based on vital signs acquired from a pulse oximeter.METHODS: We used data from 110 patients, with a combined monitoring period of more than 35,000 days. We propose a finite-state machine-based approach for modeling COPD exacerbation to gain a deeper insight into COPD patient condition during home monitoring to take account of the time course of symptoms. A robust algorithm based on short-period trend analysis and logistic regression using vital signs derived from a pulse oximeter is also developed to predict exacerbations.RESULTS: On the basis of 27,260 sessions recorded during the clinical trial (average usage of 5.3 times per week for 12 months), there were 361 exacerbation events. There was considerable variation in the length of exacerbation events, with a mean length of 8.8 days. The mean value of oxygen saturation was lower, and both the pulse rate and respiratory rate were higher before an impending exacerbation episode, compared with stable periods. On the basis of the classifier developed in this work, prediction of COPD exacerbation episodes with 60%-80% sensitivity will result in 68%-36% specificity.CONCLUSIONS: All 3 vital signs acquired from a pulse oximeter (pulse rate, oxygen saturation, and respiratory rate) are predictive of COPD exacerbation events, with oxygen saturation being the most predictive, followed by respiratory rate and pulse rate. Combination of these vital signs with a robust algorithm based on machine learning leads to further improvement in positive predictive accuracy.TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 40367841; http://www.isrctn.com/ISRCTN40367841 (Archived by WebCite at http://www.webcitation.org/6olpMWNpc).

Objetivo: Determinar a eficácia de um programa de gestão da qualidade para reduzir a incidência e a gravidade de úlceras por pressão em pacientes de terapia intensiva. Métodos: Estudo com metodologia quasi-experimental, antes-e-depois, conduzido em uma unidade de terapia intensiva clínica e cirúrgica. Incluíram-se os pacientes consecutivos que receberam ventilação mecânica por um período igual ou superior a 96 horas. Uma equipe de Melhoria de Processos delineou um processo de intervenção multifacetado, que consistiu de uma sessão educacional, uma lista de verificação de úlcera de pressão, um aplicativo para smartphone para monitoramento de lesões e um conjunto de normas de tomada de decisão, além de prevenção familiar. Resultados: O Grupo Pré-I incluiu 25 pacientes, e o Grupo Pós-I foi constituído por 69 pacientes. A incidência de úlcera de pressão nestes grupos foi de 41 (75%) e 37 (54%), respectivamente. O tempo mediano para o desenvolvimento das úlceras por pressão foi de 4,5 (4-5) dias no Grupo Pré-I e 9 (6-20) dias no Grupo Pós-I após a admissão para cada um dos períodos. A incidência de úlceras por pressão de grau avançado foi de 27 (49%) no Grupo Pré-I e 7 (10%) no Grupo Pós-I. A presença de úlceras por pressão na alta foi de 38 (69%) e 18 (26%), respectivamente, para os Grupos Pré-I e Pós-I (p < 0,05 para todas as comparações). A participação da família totalizou 9% no Grupo Pré-I e aumentou para 57% no Grupo Pós-I (p < 0,05). Utilizou-se um modelo de regressão logística para analisar os preditores de úlcera de pressão com grau avançado. A duração da ventilação mecânica e a presença de falência de órgão associaram-se positivamente com o desenvolvimento de úlceras por pressão, enquanto o programa multifacetado de intervenção atuou como fator de proteção. Conclusão: Um programa de qualidade, com base em um aplicativo para smartphone e na participação da família, pode reduzir a incidência e a gravidade de úlceras por pressão em pacientes com ventilação mecânica aguda prolongada., Objective: To determine the effectiveness of a quality management program in reducing the incidence and severity of pressure ulcers in critical care patients. Methods: This was a quasi-experimental, before-and-after study that was conducted in a medical-surgical intensive care unit. Consecutive patients who had received mechanical ventilation for ≥ 96 hours were included. A "Process Improvement" team designed a multifaceted interventional process that consisted of an educational session, a pressure ulcer checklist, a smartphone application for lesion monitoring and decision-making, and a "family prevention bundle". Results: Fifty-five patients were included in Pre-I group, and 69 were included in the Post-I group, and the incidence of pressure ulcers in these groups was 41 (75%) and 37 (54%), respectively. The median time for pressure ulcers to develop was 4.5 [4 - 5] days in the Pre-I group and 9 [6 - 20] days in the Post-I group after admission for each period. The incidence of advanced-grade pressure ulcers was 27 (49%) in the Pre-I group and 7 (10%) in the Post-I group, and finally, the presence of pressure ulcers at discharge was 38 (69%) and 18 (26%), respectively (p < 0.05 for all comparisons). Family participation totaled 9% in the Pre-I group and increased to 57% in the Post-I group (p < 0.05). A logistic regression model was used to analyze the predictors of advanced-grade pressure ulcers. The duration of mechanical ventilation and the presence of organ failure were positively associated with the development of pressure ulcers, while the multifaceted intervention program acted as a protective factor. Conclusion: A quality program based on both a smartphone application and family participation can reduce the incidence and severity of pressure ulcers in patients on prolonged acute mechanical ventilation., Facultad de Ciencias Médicas

Objective To test the effect of patient-reported outcome (PRO)–based tele-health followup for tight control of disease activity in patients with rheumatoid arthritis (RA), and the differences between tele-health followup performed by rheumatologists or rheumatology nurses. Methods A total of 294 patients were randomized (1:1:1) to either PRO-based tele-health followup carried out by a nurse (PRO-TN) or a rheumatologist (PRO-TR), or conventional outpatient followup by physicians. The primary outcome was a change in the Disease Activity Score in 28 joints (DAS28) after week 52. Secondary outcomes were physical function, quality of life, and self-efficacy. The noninferiority margin was a DAS28 score change of 0.6. Mean differences were estimated following per protocol, intent-to-treat (ITT), and multivariate imputation analysis. Results Overall, patients had low disease activity at baseline and end followup. Demographics and baseline characteristics were similar between groups. Noninferiority was established for the DAS28. In the ITT analysis, mean differences in the DAS28 score between PRO-TR versus control were −0.10 (90% confidence interval [90% CI] −0.30, 0.13) and −0.19 (90% CI −0.41, 0.02) between PRO-TN versus control. When including 1 yearly visit to the outpatient clinic, patients in PRO-TN had mean ± SD 1.72 ± 1.03 visits/year, PRO-TR had 1.75 ± 1.03 visits/year, and controls had 4.15 ± 1.0 visits/year. This included extra visits due to inflammatory flare. Conclusion Among RA patients with low disease activity or remission, a PRO-based tele-health followup for tight control of disease activity in RA can achieve similar disease control as conventional outpatient followup. The degree of disease control did not differ between patients seen by rheumatologists or rheumatology nurses.

Background: Low back pain (LBP) is a common cause of disability and is ranked as the most burdensome health condition globally. Self-management, including components on increased knowledge, monitoring of symptoms, and physical activity, are consistently recommended in clinical guidelines as cost-effective strategies for LBP management and there is increasing interest in the potential role of digital health. Objective: The study aimed to synthesize and critically appraise published evidence concerning the use of interactive digital interventions to support self-management of LBP. The following specific questions were examined: (1) What are the key components of digital self-management interventions for LBP, including theoretical underpinnings? (2) What outcome measures have been used in randomized trials of digital self-management interventions in LBP and what effect, if any, did the intervention have on these? and (3) What specific characteristics or components, if any, of interventions appear to be associated with beneficial outcomes? Methods: Bibliographic databases searched from 2000 to March 2016 included Medline, Embase, CINAHL, PsycINFO, Cochrane Library, DoPHER and TRoPHI, Social Science Citation Index, and Science Citation Index. Reference and citation searching was also undertaken. Search strategy combined the following concepts: (1) back pain, (2) digital intervention, and (3) self-management. Only randomized controlled trial (RCT) protocols or completed RCTs involving adults with LBP published in peer-reviewed journals were included. Two reviewers independently screened titles and abstracts, full-text articles, extracted data, and assessed risk of bias using Cochrane risk of bias tool. An independent third reviewer adjudicated on disagreements. Data were synthesized narratively. Results: Of the total 7014 references identified, 11 were included, describing 9 studies: 6 completed RCTs and 3 protocols for future RCTs. The completed RCTs included a total of 2706 participants (range of 114-1343 participants per study) and varied considerably in the nature and delivery of the interventions, the duration/definition of LBP, the outcomes measured, and the effectiveness of the interventions. Participants were generally white, middle aged, and in 5 of 6 RCT reports, the majority were female and most reported educational level as time at college or higher. Only one study reported between-group differences in favor of the digital intervention. There was considerable variation in the extent of reporting the characteristics, components, and theories underpinning each intervention. None of the studies showed evidence of harm. Conclusions: The literature is extremely heterogeneous, making it difficult to understand what might work best, for whom, and in what circumstances. Participants were predominantly female, white, well educated, and middle aged, and thus the wider applicability of digital self-management interventions remains uncertain. No information on cost-effectiveness was reported. The evidence base for interactive digital interventions to support patient self-management of LBP remains weak. [J Med Internet Res 2017;19(5):e179]

Background: The use of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices is expanding in the treatment of heart failure. Most of the current devices are equipped with remote monitoring functions, including bioimpedance for fluid status monitoring. The question remains whether bioimpedance measurements positively impact clinical outcome. Objective: The aim of this study was to provide a comprehensive overview of the clinical interventions taken based on remote bioimpedance monitoring alerts and their impact on clinical outcome. Methods: This is a single-center observational study of consecutive ICD and CRT patients (n=282) participating in protocol-driven remote follow-up. Bioimpedance alerts were analyzed with subsequently triggered interventions. Results: A total of 55.0% (155/282) of patients had an ICD or CRT device equipped with a remote bioimpedance algorithm. During 34 (SD 12) months of follow-up, 1751 remote monitoring alarm notifications were received (2.2 per patient-year of follow-up), comprising 2096 unique alerts (2.6 per patient-year of follow-up). Since 591 (28.2%) of all incoming alerts were bioimpedance-related, patients with an ICD or CRT including a bioimpedance algorithm had significantly more alerts (3.4 versus 1.8 alerts per patient-year of follow-up, P