Sensory feedback prosthesis reduces phantom limb pain: proof of a principle

Background

Constrained functionality and phantom limb pain (PLP) are major concerns for forearm amputees. Neuroscientific investigations of PLP suggest that behaviorally relevant stimulation of the stump can decrease PLP. Furthermore the prosthesis user could use feedback information of the prosthesis hand for optimizing prosthesis motor control when handling soft and fragile objects. Somatosensory feedback information from a prosthetic hand may therefore help to improve prosthesis functionality and reduce phantom limb pain.

Objectives

We wanted to find out whether a two weeks training on a hand prosthesis that provides somatosensory feedback may help to improve prosthesis functionality and reduce phantom limb pain.

Methods

Eight forearm amputees with phantom limb pain were trained for two weeks to use a hand prosthesis with somatosensory feedback on grip strength.

Results

The current study demonstrates a significant increase of functionality of the prosthesis in everyday tasks. Furthermore, the study shows that usage of a prosthesis that provides somatosensory feedback on the grip strength is effective to reduce phantom limb pain.

Conclusions

A prosthesis with a feedback function appears to be a promising therapeutic tool to reduce phantom limb pain and to increase functionality in everyday tasks. Future studies should further investigate the scope of application of that principle.     

Studying physician-patient communication in the acute care setting: The hospitalist rapport study

Objective

To assess the feasibility of studying physician-patient communication in the acute care setting.

Methods

We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked.

Results

Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians’ primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: (1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities and (2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges.

Conclusion

Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection.

Practice implications

These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment.     

A randomized controlled trial of communication training with primary care providers to improve patient-centeredness and health risk communication

Objective

To determine the efficacy and effectiveness of training to improve primary care providers’ patient-centered communication skills and proficiency in discussing their patients’ health risks.

Methods

Twenty-eight primary care providers participated in a baseline simulated patient interaction and were subsequently randomized into intervention and control groups. Intervention providers participated in training focused on patient-centered communication about behavioral risk factors. Immediate efficacy of training was evaluated by comparing the two groups. Over the next 3 years, all providers participated in two more sets of interactions with patients. Longer term effectiveness was assessed using the interaction data collected at 6 and 18 months post-training.

Results

The intervention providers significantly improved in patient-centered communication and communication proficiencies immediately post-training and at both follow-up time points.

Conclusions

This study suggests that the brief training produced significant and large differences in the intervention group providers which persisted 2 years after the training.

Practice implications

The results of this study suggest that primary care providers can be trained to achieve and maintain gains in patient-centered communication, communication skills and discussion of adverse childhood events as root causes of chronic disease.     

Annual cost of managing bipolar disorder to the UK healthcare system

Introduction:

Bipolar disorder is a common illness characterized by recurrent episodes of pathological disturbances of mood. The aim of this study was to estimate the annual cost associated with bipolar disorder to the UK healthcare system (National Health Service).

Methods:

A retrospective observational study was conducted. Primary care resource use was estimated using the IMS Disease Analyzer, a nationally representative sample of general practitioner (GP) practices. Two sources of data from the NHS Information Centre were used to assess resource use in secondary care and in outpatient and community mental health. The number of bed days and day attendances for patients hospitalized was obtained from the Hospital Episode Statistics (HES). This was supplemented with Mental Health Minimum Dataset (MHMDS) to quantify outpatient and community mental health face-to-face contacts. Resource use was examined between 01 April 2007 and 31 March 2008.

Results:

The annual NHS cost of bipolar disorder was estimated to be £342 million at 2009/2010 prices. Hospitalizations accounted for 60%, outpatient and community mental health 26.7%, and medication in primary care 7.4% of the overall direct costs of care.

Limitations:

This study may be confounded by the absence of a control group. This study was limited to an assessment of direct healthcare costs only, not the wider societal cost of bipolar disorder.

Conclusions:

The direct medical cost of managing bipolar disorder in the UK healthcare system is considerable. Therapeutic strategies that optimize community-based management, prevention of recurrence and hospitalization could reduce the economic burden of this illness.     

Development and validation of a patient measure of doctor-patient caring

Objective

Conceptualising the doctor-patient relationship as a ‘window mirror’ exposes care delivery from doctor to self, doctor to patient, patient to self, and patient to doctor. These directions have not been measured concurrently. We aimed to develop and validate a patient questionnaire informed by this model.

Methods

A modified-Delphi exercise was conducted to develop, and face and content validate, the questionnaire. Stage 2 surveyed 495 patients in general practice to assess the internal consistency and construct validity of the questionnaire.

Results

The questionnaire is face and content valid. Its internal reliability and construct validity appear good. Patients who care more about their doctor also care more about themselves. A patient or doctor who cares about the other person is associated with increased self-care by that person.

Conclusions

Further development and testing of the patient questionnaire is warranted to validate measurement of how patients perceive the caring they and their doctor give, and receive from, each other.

Practice implications

From the patient perspective the questionnaire may increase awareness of the importance of family doctors and patients caring about each other and themselves. It may inform and evaluate medical students, educational programmes and caring in doctor-patient relationships.     

Patient preference to use a questionnaire varies according to attributes

Objective

Health care professionals may assume questionnaires are burdensome to patients, and this limits their use in clinical settings and promotes simplification. However, patient adherence may improve by optimizing questionnaire attributes and contexts.

Methods

This cross-sectional survey used Contingent Valuation methods to directly elicit patient preference for conventional monitoring of symptoms, versus adding a tool to monitoring. Under explicit consideration was the 10-question Edmonton Symptom Assessment System (ESAS). In the questionnaire, attributes of ESAS were sequentially altered to try and force preference reversal. A separate group of participants completed both questionnaire and interviews to explore questionnaire reliability, and extend validity.

Results

Overall, 24 of 43 participants preferred using ESAS. Most important attributes to preference were frequency, specificity, and complexity. Where preference is initially against ESAS, it may reverse by simplifying the tool and its administrative processes. Interviews in 10 additional participants supported reproducibility and validity of the questionnaire method.

Conclusions

Preference for using tools increases when tools are made relevant and used more appropriately.

Practice implications

Questionnaires completed by patients as screening tools or aids to communication may be under-utilized. Optimization of ESAS and similar tools may be guided by empirical findings, including those obtained from Contingent Valuation methodologies.     

Epidemiological and genetic analyses of a diffuse outbreak of hepatitis A in Japan, 2010

Background

Hepatitis A virus (HAV) is still one of the most common causative agents of acute hepatitis in Japan. Although a relatively small number of annual acute hepatitis A cases (approximately 100-150, 0.78-1.17 per million) were recently reported, a larger number of cases (346, 2.71 per million) were reported in 2010.

Objectives

To investigate the causes of the 2010 HAV resurgence in Japan by using molecular epidemiological and genetic analyses.

Study design

HAV specimens were obtained from 61 cases from 22 different prefectures. These viral specimens were genotyped by PCR amplification and sequencing of the VP1/2A region of HAV genome.

Results

Phylogenetic analysis revealed that 61 HAV strains could be divided into three genotypes: IA (44 cases), IB (1 case) and IIIA (16 cases). The IA genotype consisted of two genomic sub-lineages. The sequences of one of the two IA sub-lineages (corresponding to 31 cases) were very similar, 26 of these 31 isolates had 100% identity. The other IA sub-lineage corresponded to strains endemic to Japan. The sequences of Japanese IIIA strains were similar to those of strains that caused a large epidemic in the Republic of Korea from 2007 to 2009.

Conclusions

The resurgence of HAV in 2010 can be attributed to importation of two newly emerged HAV genotypes.     

Survey of family physicians' perspectives on management of immigrant patients: attitudes, barriers, strategies, and training needs

Objective

Immigrants in Canada form a significant portion of the population and have unique and complex health needs. This study was undertaken to evaluate family physicians’ perspectives on the care of this population.

Methods

Questionnaires were distributed to family physicians in Montreal (n = 598). The main outcomes of interest were attitudes of family physicians to care of immigrants including barriers perceived, resources and strategies used to accommodate immigrant patients, as well as physicians’ training in immigrant care.

Results

Family physicians find communication difficulties to be the key barrier and would like to see the access to interpreters improved. Very few physicians make use of professional interpreters. Only a minority of physicians have received specific cross-cultural competence training but those who have seem to provide better quality of care.

Conclusions

Knowledge of physician perspectives is an essential element on which to base interventions to improve the quality of care to this population.

Practice implications

Physicians should be reminded of the importance of using professional interpretation services in multi-lingual encounters. Cross-cultural training should be further advanced in Canadian medical curricula.     

The role of numeracy on client knowledge in BRCA genetic counseling

Objective

To assess the impact of numeracy and health literacy on client's ability to learn information orally communicated during a BRCA 1/2 genetic counseling session.

Methods

Fifty-nine videotaped simulated genetic counseling sessions were shown to 246 analogue clients (AC) recruited to imagine themselves as the client in the genetic counseling session. AC numeracy, genetic literacy, state and trait anxiety, and decisional conflict were assessed. The primary outcome was AC learning about BRCA 1/2.

Results

Health literacy and numeracy were moderately correlated, and each independently predicted learning. Higher numeracy was associated with higher knowledge scores only among ACs with adequate literacy. Decisional conflict was not related to literacy, numeracy, or knowledge acquisition. It was, however, inversely related to state anxiety so that the higher post-session state anxiety, the lower the AC's decisional conflict.

Conclusion

Numeracy and health literacy are associated with learning of orally communicated information during genetic counseling. It appears that numeracy can facilitate learning for literate subjects; it does not, however, make any difference in learning ability of clients with significant literacy deficits.

Practice implications

Numeracy plays an important role in client's ability to learn information communicated during medical sessions, especially among clients who are otherwise regarded as literate.     

Solid organ transplantation: technical progress meets human dignity: a review of the literature considering elderly patients' health related quality of life following transplantation

Introduction

Many transplant studies in elderly patients focus on survival and mortality rates. It was the aim of this review to evaluate publications dealing with individual patient performance and independence.

Methods

The literature search included all articles retrievable for the hit “transplantation in elderly recipients” between 1960 and 2010. For quality search the inclusion criteria were as follows: older than 60 years and transplanted kidney, liver, heart, lung or pancreas from a deceased or living donor. We focussed on parameters concerning quality of life, frailty, nutritional status/weight loss, drugs/interactions/polypharmacy, gait/osteoporosis/fracture, delirium/dementia and geriatric assessment to address physical and psychosocial functionality of elderly recipients.

Results

The initial hit list contained 1427 citations from electronic databases. 249 abstracts thereof were selected for full review. A total of 60 articles met final inclusion criteria. Finally, only five studies met the qualitative inclusion criteria as listed above.

Conclusion

The number of elderly patients placed on waiting lists has increased dramatically and will further grow. Interdisciplinary collaboration and distinct patient selection is recommended in most of the studies. However, data concerning quality of life and related parameters in elderly transplant recipients are rare.     

Identifying patient information needs about cancer clinical trials using a Question Prompt List

Objective

Question Prompt Lists (QPLs) have demonstrated significant promise in facilitating communication in general, surgical and palliative oncology settings yet have not been tested in the oncology clinical trial setting. We aimed to develop a targeted QPL for Clinical Trials (QPL-CT).

Methods

Breast, lung, and genitourinary cancer patients who either had (trial experienced) or had not (trial naive) participated in a clinical trial joined focus groups to help develop and explore the acceptability of a QPL-CT. Clinicians also participated in separated focus groups. Focus groups were audio-recorded and transcribed. We explored patients’ trial information needs and views about the utility of the QPL-CT.

Results

Patients focused on four trial information needs: understanding foundational information, conflict of interest issues and financial implications of trial participation. Of note, experienced patients need to personalize foundational information.

Conclusion

Patient information needs varied considerably and were influenced by trial experience. Patients valued the QPL-CT as an aid to gathering new trial information and ensuring that their information needs were met.

Practice implications

Physicians need to carefully elicit patient information needs and tailor trial information to meet these needs. The QPL-CT, may be of great benefit during clinical trial discussions.     

Variation in question asking during cancer clinical interactions: A potential source of disparities in access to information

Objective

To investigate whether patient demographic characteristics and patients’ companions influence variation in patient question asking during cancer clinical interactions, thus representing a potential disparity in access to information.

Methods

Data included 109 oncologist-patient-companion interactions video recorded at a comprehensive cancer center. Interactions were observed and analyzed using the Karmanos Information Seeking Analysis System (K-ISAS).

Results

Significant relationships were found between patient race/ethnicity and question asking. Black patients asked fewer questions and a smaller proportion of direct questions (relative to the total frequency of questions) than White patients. Black patients were also less likely to have companions present during the interaction, which resulted in fewer questions asked on Black patients’ behalf.

Conclusion

Differences in question asking by Black and White patients suggest that Black patients may receive less information from their oncologists than White patients.

Practice/research implications

Patients should be encouraged to ask more questions and more direct questions and to bring a companion to the interaction to assist them in gaining information from their physician. Future research is needed to investigate ways to eliminate this potential source of disparities in access to information.     

Expectations and experiences of eHealth in primary care: A qualitative practice-based investigation

Objectives

(1) To assess expectations and experiences of a new eHealth service by patients and staff in three primary care settings; (2) to ascertain attitudes to a range of future, primary care-oriented eHealth services.

Design

Qualitative case study.

Setting

Three UK general practices introducing an eHealth service for booking patient appointments.

Participants

Ninety patients purposively selected from users and non-users of the new service and 28 staff (clinicians, management and administrative staff).

Results

Actual patient use of the service was lower than stated intention. Patients and staff felt that more active promotion of the service would have resulted in more use. Low usage did not result in a negative assessment of the service by most staff. Different patient groupings were identified with characteristics that may be used as predictors of eHealth service use and indicators of training needs. GPs and patients expressed opposing viewpoints on a range of future eHealth services.

Conclusions

Take-up of eHealth services may be lower than expected. To overcome patient barriers, factors that may narrow the intention-behaviour gap such as level of service promotion, GP endorsement, and usage by different patient groups, should be investigated. For clinician barriers, the eHealth evidence base needs strengthening, while for primary care practices, a learning process including staff training needs to be instituted. The differing views of patients and GPs about components of eHealth means that policymakers need to plan for a lengthy political process to obtain agreement on contentious issues if they are to achieve successful eHealth services.     

Managing uncertainty about treatment decision making in early stage prostate cancer: A randomized clinical trial

Objectives

Several new methods are available, but we know little about successful integration of contraceptive technologies into services. We investigated provider factors associated with the initiation of new hormonal methods among women at high risk of unintended pregnancy.

Methods

This cohort study enrolled 1387 women aged 15-24 starting hormonal contraception (vaginal ring, transdermal patch, oral contraceptive, or injectable) at four family planning clinics in low-income communities. We measured provider factors associated with method choice, using multinomial logistic regression.

Results

Ring and patch initiators were more likely than women starting oral contraceptives to report that they chose their method due to provider counseling (p < 0.001). Contraceptive knowledge in general was low, but initiation of a new method, the ring, was associated with higher knowledge about all methods after seeing the provider (p < 0.001). Method initiated varied with provider site (p < 0.001). These associations remained significant, controlling for demographics and factors describing the provider-patient relationship, including trust in provider and continuity of care.

Conclusion

Women's reports of provider counseling and of their own contraceptive knowledge after the visit was significantly associated with hormonal method initiated.

Practice implications

More extensive counseling and patient education should be expected for successful integration of new hormonal methods into clinical practice.     

Real-Time Patient-Specific Finite Element Analysis of Internal Stresses in the Soft Tissues of a Residual Limb: A New Tool for Prosthetic Fitting

Fitting of a prosthetic socket is a critical stage in the process of rehabilitation of a trans-tibial amputation (TTA) patient, since a misfit may cause pressure ulcers or a deep tissue injury (DTI: necrosis of the muscle flap under intact skin) in the residual limb. To date, prosthetic fitting typically depends on the subjective skills of the prosthetist, and is not supported by biomedical instrumentation that allows evaluation of the quality of fitting. Specifically, no technology is presently available to provide real-time continuous information on the internal distribution of mechanical stresses in the residual limb during fitting of the prosthesis, or while using it and this severely limits patient evaluations. In this study, a simplified yet clinically oriented patient-specific finite element (FE) model of the residual limb was developed for real-time stress analysis. For this purpose we employed a custom-made FE code that continuously calculates internal stresses in the residual limb, based on boundary conditions acquired in real-time from force sensors, located at the limb-prosthesis interface. Validation of the modeling system was accomplished by means of a synthetic phantom of the residual limb, which allowed simultaneous measurements of interface pressures and internal stresses. Human studies were conducted subsequently in five TTA patients. The dimensions of bones and soft tissues were obtained from X-rays of the residual limb of each patient. An indentation test was performed in order to obtain the effective elastic modulus of the soft tissues of the residual limb. Seven force sensors were placed between the residual limb and the prosthetic liner, and subjects walked on a treadmill during analysis. Generally, stresses under the shinbones were ∼threefold higher than stresses at the soft tissues behind the bones. Usage of a thigh corset decreased the stresses in the residual limb during gait by approximately 80%. Also, the stresses calculated during the trial of a subject who complained about pain and discomfort were the highest, confirming that his socket was not adequately fitted. We conclude that real-time patient-specific FE analysis of internal stresses in deep soft tissues of the residual limb in TTA patients is feasible. This method is promising for improving the fitting of prostheses in the clinical setting and for protecting the residual limb from pressure ulcers and DTI.     

The relationship of patient participation and diabetes outcomes for patients with high vs. low health literacy

Objective

To examine whether patient participation in medical consultations have differing effects on self-efficacy and diabetes control by the level of patient communicative health literacy (CHL).

Methods

Participants were 143 outpatients with type 2 diabetes at a university-affiliated hospital. Patient CHL was measured using a newly developed self-rated scale of health literacy. Patient perceived participation in medical consultations and self-efficacy of diabetes self-care were assessed using the self-reported questionnaire. Patient clinical characteristics were obtained from electronic medical records.

Results

Both patient CHL and perceived participation were related to greater self-efficacy and decreased HbA1c at the 3-month follow-up. Patient CHL had a moderating effect on the relationship between perceived participation and self-efficacy. Patients with lower CHL reported greater self-efficacy when they actively participated in patient-physician communication, whereas this relationship was less evident among patients with higher CHL.

Conclusions

The examination of patient CHL levels may provide a better understanding of the potential barriers to patients’ self-management of disease.

Practice implications

The benefit of active participation may be greater among patients with lower CHL who are likely to have greater difficulties in communicating with the physician, yet tend to rely on the physician as the sole source of health information.     

Evidence-based treatments for depression and anxiety versus treatment-as-usual: a meta-analysis of direct comparisons

Objective

The aim of this study was to examine the relative efficacy of evidence-based treatments (EBTs) versus treatment-as-usual (TAU) in routine care for anxiety and depression in adults.

Method

A computerized search of studies that directly compared an EBT with a TAU was conducted. Meta-analytic methods were used to estimate effectiveness of EBTs relative to TAU and to model how various confounding variables impacted the results of this comparative research.

Results

A total of 14 studies were included in the final meta-analysis. There was significant heterogeneity in the TAU conditions, which ranged from unknown and/or minimal mental health treatment to psychotherapeutic interventions provided by trained professionals. Although the effect for EBT vs. TAU was significantly greater than zero, the effect for EBT vs. TAUs that were psychotherapeutic interventions was not statistically different from zero.

Conclusions

Heterogeneity of TAU conditions in this meta-analysis highlight the importance of clarifying the research questions being asked when investigating and drawing conclusions from EBT-TAU comparisons. Researchers need to clarify if they are comparing an EBT to psychotherapeutic services in routine care or to minimal mental health services. Extant research on EBT versus TAU reveals that there is insufficient evidence to recommend the transportation of EBTs for anxiety and depression to routine care, particularly when the routine care involves psychotherapeutic services.     

Information about medicines to cardiac in-patients: patient satisfaction alongside the role perceptions and practices of doctors, nurses and pharmacists

Objective

To explore the satisfaction of cardiac in-patients regarding the information they received about their medicines, and the role perceptions and practices of practitioners whose responsibility it was to provide such information.

Method

A questionnaire was constructed by selecting medicine information topics from a validated instrument, the Satisfaction with Information about Medicines Scale. Patients and practitioners were recruited from cardiac wards at a London teaching hospital providing tertiary care.

Results

Questionnaires were returned by 140 patients and 52 doctors, 53 nurses and 4 pharmacists. Patients were satisfied with information about the action and usage of medicines but were significantly less satisfied with information about potential problems with their medicines. In parallel, practitioners provided more information about the action and usage of medicines than its potential problems.

Conclusions

Information gaps existed largely around potential problems with medicines which reflected the general lack of focus on these issues by the healthcare professionals studied. There was no consensus between doctors, nurses and pharmacists on perceptions of role responsibility of information provision.

Practice implications

Patients may become non-adherent to their medicines if insufficient information is provided. Role responsibilities should be co-ordinated when information about medicines is provided by a range of practitioners.     

Road to help-seeking among (dedicated) human service professionals with burnout

Objective

Describe and interpret the process of help-seeking among human service professionals with burnout.

Methods

Semi-structured interviews were conducted with 14 participants. Analysis was conducted using principles of grounded theory.

Results

All participants were dedicated and responsible workers, selflessly giving themselves to their work. Work was demanding, and often included some form of organisational change. After a period of time the problems of ill health appeared, since persons were overstretching their resources. However, the symptoms were denied, since the image of the ideal worker has been internalised and persons expected maximum performance from themselves. They kept on working hard and delayed the help-seeking process. Eventually, help was sought for medical symptoms or by talking to the supervisors. If postponed for too long, persons experienced a breaking point.

Conclusion

Human service professionals with burnout internalise the ideal image of their professional role. They strive to keep this ideal image at the cost of their own needs, taking a long time to seek help for the obstacles they encounter.

Practice implications

More awareness raising is needed in order to recognise early burnout symptoms. Particularly crucial in this process are supervisors and doctors, who have an authority role over employees.