A computer-human interaction model to improve the diagnostic accuracy and clinical decision-making during 12-lead electrocardiogram interpretation

IntroductionThe 12-lead Electrocardiogram (ECG) presents a plethora of information and demands extensive knowledge and a high cognitive workload to interpret. Whilst the ECG is an important clinical tool, it is frequently incorrectly interpreted. Even expert clinicians are known to impulsively provide a diagnosis based on their first impression and often miss co-abnormalities. Given it is widely reported that there is a lack of competency in ECG interpretation, it is imperative to optimise the interpretation process. Predominantly the ECG interpretation process remains a paper based approach and whilst computer algorithms are used to assist interpreters by providing printed computerised diagnoses, there are a lack of interactive human-computer interfaces to guide and assist the interpreter.MethodsAn interactive computing system was developed to guide the decision making process of a clinician when interpreting the ECG. The system decomposes the interpretation process into a series of interactive sub-tasks and encourages the clinician to systematically interpret the ECG. We have named this model ‘Interactive Progressive based Interpretation’ (IPI) as the user cannot ‘progress’ unless they complete each sub-task. Using this model, the ECG is segmented into five parts and presented over five user interfaces (1: Rhythm interpretation, 2: Interpretation of the P-wave morphology, 3: Limb lead interpretation, 4: QRS morphology interpretation with chest lead and rhythm strip presentation and 5: Final review of 12-lead ECG). The IPI model was implemented using emerging web technologies (i.e. HTML5, CSS3, AJAX, PHP and MySQL). It was hypothesised that this system would reduce the number of interpretation errors and increase diagnostic accuracy in ECG interpreters. To test this, we compared the diagnostic accuracy of clinicians when they used the standard approach (control cohort) with clinicians who interpreted the same ECGs using the IPI approach (IPI cohort).ResultsFor the control cohort, the (mean; standard deviation; confidence interval) of the ECG interpretation accuracy was (45.45%; SD = 18.1%; CI = 42.07, 48.83). The mean ECG interpretation accuracy rate for the IPI cohort was 58.85% (SD = 42.4%; CI = 49.12, 68.58), which indicates a positive mean difference of 13.4%. (CI = 4.45, 22.35) An N − 1 Chi-square test of independence indicated a 92% chance that the IPI cohort will have a higher accuracy rate. Interpreter self-rated confidence also increased between cohorts from a mean of 4.9/10 in the control cohort to 6.8/10 in the IPI cohort (p = 0.06). Whilst the IPI cohort had greater diagnostic accuracy, the duration of ECG interpretation was six times longer when compared to the control cohort.ConclusionsWe have developed a system that segments and presents the ECG across five graphical user interfaces. Results indicate that this approach improves diagnostic accuracy but with the expense of time, which is a valuable resource in medical practice.     

Teaching clinicians practical genomic medicine: 7 years’ experience in a tertiary care center

PurposeIncreased implementation of complex genetic technologies in clinical practice emphasizes the urgency of genomic literacy and proficiency for medical professionals. We evaluated our genomic education model.MethodsWe assessed the 5-day, extended format program, encompassing lectures, videos, interactive tests, practice cases, and clinical exercises. Pre- and post questionnaires assessed knowledge change, using t-tests to compare groups. Satisfaction on program completion and after 3 years were evaluated. Implementation in other centers determined acceptability.ResultsDuring 2012–2018, 774 clinicians from multiple disciplines and career stages attended 35 programs; 334 (43%) attended the 5-day extended format. Evaluations showed significant improvement of genomic literacy (mean 15.05/100 points, p < 0.001). Residents initially had higher scores than specialists (pre: 66.3 ± 17.3 vs. 58.7 ± 16.6, respectively, p = 0.002); both significantly improved, with specialists “catching up” (post: 79.1 ± 17.2 vs. 75.7 ± 15.9, nonsignificant (NS)); there was a similar trend between fellows and subspecialists (pre: 70 ± 18 vs. 59.4 ± 16.4, respectively, p = 0.007; post: 78.6 ± 16.4 vs. 73.2 ± 17.7, respectively, NS). Younger specialists (≤10 years residency) had significantly higher pre- and post scores. Absolute improvement in scores did not depend on medical specialties.ConclusionOur program is effective in improving genomics literacy for clinicians, irrespective of career length or expertise, and could be a model for improving skills in practical genomics for all medical professionals.     

Design and usability evaluation of user-centered and visual-based aids for dietary food measurement on mobile devices in a randomized controlled trial

ObjectiveWe designed and developed two interactive apps interfaces for dietary food measurements on mobile devices. The user-centered designs of both the IPI (interactive photo interface) and the SBI (sketching-based interface) were evaluated. Four types of outcomes were assessed to evaluate the usability of mobile devices for dietary measurements, including accuracy, absolute weight differences, and the response time to determine the efficacy of food measurements.MethodsThe IPI presented users with images of pre-determined portion sizes of a specific food and allowed users to scan and then select the most representative image matching the food that they were measuring. The SBI required users to relate the food shape to a readily available comparator (e.g., credit card) and scribble to shade in the appropriate area. A randomized controlled trial was conducted to evaluate their usability.ResultsA total of 108 participants were randomly assigned into the following three groups: the IPI (n = 36) and SBI (n = 38) experimental groups and the traditional life-size photo (TLP) group as the control. A total of 18 types of food items with 3–4 different weights were randomly selected for assessment by each type. The independent Chi-square test and t-test were performed for the dichotomous and continuous variable analyses, respectively. The total accuracy rates were 66.98%, 44.15%, and 72.06% for the IPI, SBI, and TLP, respectively. No significant difference was observed between the IPI and TLP, regardless of the accuracy proportion or weight differences. The SBI accuracy rates were significantly lower than the IPI and TLP accuracy rates, especially for several spooned, square cube, and sliced pie food items. The time needed to complete the operation assessment by the user was significantly lower for the IPI than for the SBI.ConclusionOur study corroborates that the user-centered visual-based design of the IPI on a mobile device is comparable the TLP in terms of the usability for dietary food measurements. However, improvements are needed because both the IPI and TLP accuracies associated with some food shapes were lower than 60%. The SBI is not yet a viable aid. This innovative alternative required further improvements to the user interface.     

Effectiveness of a standardized back school program for patients with chronic low back pain after implementation in routine rehabilitation care

ObjectiveTo evaluate the effectiveness of a standardized, patient-oriented, biopsychosocial back school after implementation in inpatient orthopedic rehabilitation.MethodsA multi-center, quasi-experimental controlled study of patients with low back pain (n = 535) was conducted. Patients in the control group received the traditional back school before implementation of the new program (usual care); patients in the intervention group received the new standardized back school after implementation into routine care. Patients’ illness knowledge and conduct of back exercises (primary outcomes) and secondary self-management outcomes and treatment satisfaction were obtained at admission, discharge, and 6 and 12 months after rehabilitation.ResultsWe found a significant small between-group intervention effect on patients‘ illness knowledge in medium- to long term (6 months: η² = 0.015; 12 months: η² = 0.013). There were trends for effects on conduct of back exercises among men (6 and 12 months: η² = 0.008 both). Furthermore, significant small effects were observed for treatment satisfaction at discharge and physical activity after 6 months.ConclusionsThe standardized back school seems to be more effective in certain outcomes than a usual care program despite heterogeneous program implementation.Practice implicationsFurther dissemination within orthopedic rehabilitation may be encouraged to foster self-management outcomes.     

Pain evaluation after all-inside anterior cruciate ligament reconstruction and short term functional results of a prospective randomized study

PurposeTo assess post-operative pain in patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction by the all-inside technique.MethodsA prospective randomized comparative parallel trial was performed in 2010–2011 including all patients who underwent an ACL reconstruction in an orthopaedic department in accordance with the CONSORT statement 2010. Patients were randomized to the surgical procedure, all-inside or classical, and were blinded to the surgical technique. Primary evaluation criterion was pain assessed on the Visual Analogical Scale 1 month after surgery. Secondary parameters were analgesic consumption, tunnel positioning on X-ray according to Aglietti's criteria and functional evaluation at six months with IKDC score. None of the patients was lost to follow-up.Results46 consecutive patients were included, 23 in each group, mean age 29.3 ± 9 years. Two patients were excluded due to postoperative complications that required early revision surgery. Forty-four patients were analyzed, 22 in each group. At one month, the pain level was 3.2 ± 5.5 for the all-inside group and 8.6 ± 10 for the classical group, p = 0.057 (95%CI 0.5–10.4). Postoperative analgesic consumption was similar. The position of the tibial tunnels was better with the all-inside method, p = 0.002 (95%CI 1.9–6.6%). There was no significant difference in the mean IKDC subjective score at six months, p = 0.92 (95%CI–9.7 to 9.2).ConclusionAt one month, the pain level seemed lower in the all-inside group than in the classical group, at the limit of statistical significance because the study was underpowered. The all-inside technique is a reliable procedure with very good results for pain, stability and knee function.Level of evidenceI; Therapeutic study     

Patient knowledge and information-seeking about personalized cancer therapy

BackgroundUnderstanding patients’ knowledge and prior information-seeking regarding personalized cancer therapy (PCT) may inform future patient information systems, consent for molecular testing and PCT protocols. We evaluated breast cancer patients’ knowledge and information-seeking behaviors regarding PCT.MethodsNewly registered female breast cancer patients (n = 100) at a comprehensive cancer center completed a self-administered questionnaire prior to their first clinic visit.ResultsKnowledge regarding cancer genetics and PCT was moderate (mean 8.7 ± 3.8 questions correct out of 16). A minority of patients (27%) indicated that they had sought information regarding PCT. Higher education (p = 0.009) and income levels (p = 0.04) were associated with higher knowledge scores and with seeking PCT information (p = 0.04). Knowledge was not associated with willingness to participate in PCT research.ConclusionEducational background and financial status impact patient knowledge as well as information-seeking behavior. For most patients, clinicians are likely to be patients’ initial source of information about PCT. Understanding patients’ knowledge deficits at presentation may help inform patient education efforts.     

Clinical trainees’ responses to parents who question evidence-based recommendations

ObjectiveWe examined clinicians’ attitudes, beliefs, and behavioral intentions about discussing evidence and eliciting values when patients question recommendations.MethodsWe randomized trainees to read one of three scenarios about a parent of a one-year-old: 1) overuse (parent requests antibiotics for presumed viral infection); 2) equipoise (tubes for recurrent ear infections); 3) underuse (parent hesitates about vaccination). Participants then answered survey questions. Outcomes included time spent clarifying values (primary), attitudes and beliefs about the parent (secondary).Results132 medical students and pediatric residents enrolled; 119 (90%) completed the study. There were no differences in time participants would spend clarifying values (antibiotics 26 ± 12%; equipoise 28 ± 11%; vaccine-hesitancy 22 ± 11%; p = 0.058). Participants in the vaccine-hesitancy group (vs. other groups) would spend less time answering questions (p = 0.006). Participants in the antibiotics (vs. equipoise) group perceived the parent as difficult (p = 0.0002). Those in the vaccine-hesitancy group (vs. other groups) perceived the parent as difficult, saw less value in the conversation, and had lower respect for the parent’s views (all ps < 0.0001). Most (76%) wanted additional training navigating these discussions.ConclusionClinicians’ attitudes may impact conversations when patients question evidence-based recommendations.Practice implicationsClinicians should consider ways to discuss evidence and clarify patients’ values to optimize health without damaging patient-clinician relationships.     

Evaluation of an interactive web-based nursing course with streaming videos for medication administration skills

PurposeNursing students should exhibit competence in nursing skills in order to provide safe and quality patient care. This study describes the design and students’ response to an interactive web-based course using streaming video technology tailored to students’ needs and the course objectives of the fundamentals of nursing skills clinical course.MethodA mixed-methodology design was used to describe the experience of 102 first-year undergraduate nursing students at a school of nursing in Jordan who were enrolled in the course. A virtual course with streaming videos was designed to demonstrate medication administration fundamental skills. The videos recorded the ideal lab demonstration of the skills, and real-world practice performed by registered nurses for patients in a hospital setting. After course completion, students completed a 30-item satisfaction questionnaire, 8 self-efficacy scales, and a 4-item scale solicited their preferences of using the virtual course as a substitute or a replacement of the lab demonstration. Students’ grades in the skill examination of the procedures were measured. Relationships between the main variables and predictors of satisfaction and self-efficacy were examined.ResultsStudents were satisfied with the virtual course (3.9 ± 0.56, out of a 5-point scale) with a high-perceived overall self-efficacy (4.38 ± 0.42, out of a 5-point scale). Data showed a significant correlation between student satisfaction, self-efficacy and achievement in the virtual course (r = 0.45–0.49, p < 0.01). The majority of students accessed the course from home and some faced technical difficulties. Significant predictors of satisfaction were ease of access the course and gender (B = 0.35, 0.25, CI = 0.12–0.57, 0.02–0.48 respectively). The mean achievement score of students in the virtual class (7.5 ± 0.34) was significantly higher than that of a previous comparable cohort who was taught in the traditional method (6.0 ± 0.23) (p < 0.05). Nearly 40% of the students believed that the virtual course is a sufficient replacement of the lab demonstration.ConclusionsThe use of multimedia within an interactive online learning environment is a valuable teaching strategy that yields a high level of nursing student satisfaction, self-efficacy, and achievement. The creation and delivery of a virtual learning environment with streaming videos for clinical courses is a complex process that should be carefully designed to positively influence the learning experience. However, the learning benefits gained from such pedagogical approach are worth faculty, institution and students’ efforts.     

Needs analysis and development of a tailored mobile message program linked with electronic health records for weight reduction

ObjectiveWe developed and pilot-tested a personalized text messaging service program based on data from electronic health records (EHRs) and lifestyle questionnaires for weight control.MethodsIn the health promotion center of a hospital, 340 participants with a body mass index (BMI) greater than 25 were recruited and surveyed for the development of a text messaging program. After developing the interface linking the EHRs with personalized text messages for weight loss, we pilot-tested this program in 102 participants for its feasibility, acceptability and satisfaction.ResultsAccording to the needs analysis, the participants desired additional information about personalized nutrition and exercise. We selected many variables from the EHRs and questionnaires to create text messages with a more personalized program. After a 1-month trial of the text messaging program, the participants’ satisfaction score was 7.9 ± 1.5 and recommendation score was 7.5 ± 1.8.ConclusionsA personalized short message service (SMS) linked with EHRs was feasible, and the pilot test showed high satisfaction and recommendation scores. Further evaluation using a well-designed trial will be needed.     

One-year outcome of an interactive internet-based physical activity intervention among university students

ObjectiveThe purpose of the present study was to evaluate whether improvement in physical activity of students following a 4-month intervention of a university course was maintained 8 months later.MethodsData on 77 students who responded to our scheduled inquiries completely through 1 year were analyzed. Participants of the intervention group (n = 49) using the internet-based physical activity program exhibited significant increases in energy expenditures measured by IPAQ compared with the no-treatment control group (n = 28) through 1 year.ResultsParticipants who did not engage in regular university sports activities (baseline: 450 ± 351 kcal day⁻¹; post: 587 ± 320 kcal day⁻¹; 8-month follow-up: 580 ± 394 kcal day⁻¹) only exhibited significant increases in energy expenditures compared with those of the control group (baseline: 498 ± 341 kcal day⁻¹; post: 414 ± 242 kcal day⁻¹; 8-month follow-up: 347 ± 275 kcal day⁻¹).ConclusionThese results suggested that an internet-based interactive intervention could become a helpful tool in promoting and maintaining physical activity in the long term.     

The accuracy of component alignment in custom cutting blocks compared with conventional total knee arthroplasty instrumentation: Prospective control trial

BackgroundThe purpose of this study was to assess whether custom cutting blocks improve accuracy of component alignment compared to conventional TKA instrumentation.MethodsEighty primary TKA patients were enrolled in an open-label randomized prospective clinical trial and were divided into two groups, 40 custom cutting blocks and 40 conventional TKA instrumentations. The primary outcome was prosthetic alignment with respect to mechanical axis and epicondylar axis. Secondary outcomes included operative time, 24-hour postoperative blood loss and hemoglobin at discharged.ResultsThere were no statistical significant differences in the postoperative mechanical axis between the custom cutting blocks group and conventional TKA group, (95% vs. 87.5% within 3° of neutral mechanical alignment, p = 0.192). The average rotational alignment was statistically significantly different in the custom cutting blocks group (1.0° ± 0.6° vs. 1.6° ± 1.8° external rotation from epicondylar axis, p < 0.001). There were statistical significant differences in operation time between custom cutting blocks group and conventional group, skin to skin [57.5 ± 2.3 min vs. 62.1 ± 1.5,p < 0.001]. We found an improvement in group 1 compared with group 2 regarding the proportion of patients with postoperative blood loss within 24 h.ConclusionsCustom cutting blocks technique was a surgical procedure which provided better accuracy in rotational alignment but no statistical differences in mechanical axis, less operative time and reduced blood loss than the conventional TKA instrumentation in the majority of patients.     

In vivo evaluation of femoral and tibial graft tunnel placement following all-inside arthroscopic tibial inlay reconstruction of the posterior cruciate ligament

BackgroundThe arthroscopic all-inside tibial inlay technique represents a novel procedure for posterior cruciate ligament (PCL) reconstruction. However, in vivo investigations that evaluate the accuracy of this technique regarding anatomic graft tunnel placement are few. The objective of this study was to analyse the femoral and tibial tunnel apertures using computed tomography (CT) and compare these findings to recommendations in the literature.MethodsCT scans were obtained in 45 patients following single-bundle PCL reconstruction. The centres of the tibial and femoral tunnel apertures were correlated to measurement grid systems used as a radiographic reference.ResultsThe centre of the femoral tunnel aperture was located at 42.9% ± 9.4% of the total intercondylar depth and at 12.9% ± 7.2% of the total intercondylar height. The angle α for the femoral tunnel position was measured at 64.2° ± 10.0°. The centre of the tibial tunnel aperture was found at 51.8% ± 4.1% of the total mediolateral diameter of the tibial plateau. The superoinferior distance of the tibial tunnel aperture to the joint line was 9.6 mm ± 4.4 mm on frontal and 9.3 mm ± 3.4 mm on sagittal 3D-CT scans. The distance of the tibial tunnel aperture to the former physis line averaged to 0.8 mm ± 3.4 mm. Comparison to the corresponding reference values revealed no statistically significant difference.ConclusionArthroscopic tibial inlay reconstruction is an efficient procedure for precise replication of the anatomical footprint of the PCL.Level of evidenceIV, prospective case series     

The role of virtual interactive simulators in medical education: Exploring their integration as an assessment methodology in clinical years

IntroductionAssessment takes a fundamental role in medical education. In Portugal, the main assessment method used is multiple-choice questions (MCQ). The virtual interactive patients (VIP) as an assessment method can be indicated for the development of clinical reasoning for medical students of the clinical years. This study compared the use of MCQ and VIP as assessment methodologies in medical students.MethodsA randomized crossover study carried out, which 35 Portuguese medical students from clinical years evaluated by MCQ and VIP in four medical specialties. In each specialty, students randomized into two groups. One group started being evaluated by MCQ and finished with VIP, the other vice-versa. After the evaluation, students asked to complete a satisfaction questionnaire.ResultsThe final score was higher with the VIP than MCQ method (MCQ: 67.40 ± 8.96 vs. VIP: 73.34 ± 10.8; p < 0.01) with significant differences higher in Clinical History and Physical Examination. The satisfaction quiz showed although both methodologies are adequate and satisfactory, but VIP method allows to improve knowledge.ConclusionVIP is more accurate for clinical reasoning, accepted by medical students and should be integrated into the pre-graduate medical curriculum with other methodologies already used. The COVID-19 pandemic allowed a digital transformation of medical education and VIP will have a crucial role as a knowledge and evaluation method.     

Circuit resistance training is an effective means to enhance muscle strength in older and middle aged adults: A systematic review and meta-analysis

BackgroundPhysical exercise, particularly resistance training (RT), is proven treatment to reduce the accelerated decline in muscle strength exhibited by older adults, but its effect is hindered by low adherence rate, even under well-structured programs.Objective and data sourcesWe investigated the efficacy of circuit resistance training (CRT) on muscle strength, lean mass and aerobic capacity in older adults based on report in MEDLINE, EMBASE, ClinicalTrials.gov and Cochrane electronic (through 8/2016). Study eligibility criteria: middle and older aged men and/or women who followed a structured program, assigned to CRT. Study appraisal and synthesis methods: Out of 237 originally identified articles, 10 articles were included with a total of 362 patients with mean: age −64.5 ± 7.4 years; 3 ± 1.15 sessions/week; session duration 41.8 ± 15.9 min.ResultsUpper body strength modestly increased, by 1.14 kg (95% CI; 0.28–2.00), whereas larger increment was seen in lower body strength (11.99; 2.92–21.06). Higher program volume (>24 sessions) positively influenced upper body strength and aerobic capacity.Limitations(1) variability in the studies’ validity; (2) relatively low number of studies.ConclusionCRT is a valid alternative to conventional RT. Its shorter duration and lower intensity relative to traditional RT, may increase adherence to training in older adults.     

Nutrition education in postmenopausal women: Changes in dietary and cardiovascular indices

ObjectiveThe aim of the current study was to examine whether a diet rich in dairy products followed by a nutrition education program for the prevention of osteoporosis could have any adverse effect on certain cardiovascular disease (CVD) risk factors over a 5-month intervention period.MethodsA total sample of 82 women (55–65 years old) was randomized to a dietary intervention group (IG: n = 42), attending biweekly nutrition education program and provided with low-fat, fortified dairy products and to a control group (CG: n = 40). Changes in dietary, biochemical and clinical indices related to CVD were determined at the end of the 5-month intervention period.ResultsThe IG was found to have a higher decrease in the percentage of energy intake derived from total fat and a higher increase in the intake of calcium, phosphorus, magnesium and potassium compared to the CG (p < 0.05). Furthermore, the IG subjects were found to have a lower increase in BMI (0.7 ± 0.1 versus 1.4 ± 0.2 Kg/m², p = 0.011) and systolic blood pressure (SBP) (2.5 ± 2.9 versus 7.8 ± 2.2 mmHg, p = 0.040) and a higher decrease in serum total cholesterol (−5.2 ± 3.3 versus 6.9 ± 5.1 mg/dl, p = 0.042) and LDL-cholesterol levels (−20.0 ± 2.6 versus −12.4 ± 4.2 mg/dl, p = 0.034) compared to the CG.ConclusionsThe findings of the current study indicate that a dietary intervention aiming to minimize the risk for osteoporosis did not have any adverse effects on CVD risk factors. On the contrary, it has induced favourable changes in BMI, serum lipids and SBP.     

Efficacy of passive extension mobilization in addition to exercise in the osteoarthritic knee: An observational parallel-group study

Study designPretest post-test observational parallel-group design.ObjectivesTo evaluate the efficacy of passive knee extension mobilization in addition to exercise therapy on extension range of motion (ROM) in patients with osteoarthritis (OA) of the knee. Secondary objectives were to determine changes in pain and functional abilities.BackgroundPatients with knee OA complain of pain, limited range of motion, and impaired activities. Efficacy of mobilization as a treatment option next to exercises has not been studied rigorously.Methods and measuresThirty-four participants with persistent knee pain, a positive radiography for knee OA, and a passive extension deficit were included. Seventeen participants (mean age ± SD, 59.8 ± 6.1 years) were treated with an exercise protocol and were additionally given manual mobilizations to improve passive extension ROM. The other group (mean age ± SD, 61.5 ± 7.3 years) with equal characteristics was treated with an identical exercise therapy protocol only. Prior to participation, detailed ROM measurements were recorded next to muscle function tests, pain (VAS), six-minute walking tests (6MWTs), a condition-specific questionnaire, and the patient-specific function scale (PSFS). Participants in both groups completed 16 treatment sessions each.ResultsPassive mobilization significantly improved extension ROM in the intervention group (5.2 versus 8.6°, p = .017). The manually mobilized group also had better physical capacities as assessed by 6MWT, less pain, and a lower PSFS score.ConclusionA combined protocol including exercise therapy and passive mobilization was beneficial for patients with OA of the knee complaining of pain, decreased extension ROM and decreased limited abilities.Level of evidenceTherapy, 2b.     

A physiotherapist-delivered,combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: A pilot study

BackgroundOsteoarthritis (OA) of the knee is associated with a number of physical and psychological impairments. Unfortunately, very few treatment strategies are capable of addressing both types of impairments concurrently. We performed a pilot, randomized controlled, proof of principle trial investigating the feasibility and effects of an intervention combining physical exercise and pain coping skills training (PCST).MethodsTwenty patients with a clinical and radiographical diagnosis of tibiofemoral OA were randomized to receive either 10 weeks of physiotherapist supervised exercises (lower limb strengthening and walking) combined with non-directive counseling (NDC) or the same exercise program delivered concurrently with PCST. Primary outcomes included self-reported pain and pain coping, while secondary outcomes included self efficacy and self-reported physical function.ResultsTen participants were randomized to each group and both groups exhibited significant improvements in isometric knee strength, self-reported knee pain and physical function, self efficacy for control of pain management and other arthritis symptoms. Only those in the exercise + PCST group reported statistically significant improvements in pain control coping and rational thinking. No between-group differences existed in any outcome (0.07 < p < 0.98). Based on our findings, 63 participants per group would be needed for future large-scale studies using similar outcome measures and design.ConclusionsOur study showed that an intervention that combines exercise and PCST within the same treatment session and delivered by specially-trained physiotherapists is feasible and can improve both physical and psychological outcomes in individuals with knee OA.Level of evidenceLevel IIClinical Trials Registry number: ACTRN12609000623291     

The effect of vertical whole-body vibration on lower limb muscle activation in elderly adults: Influence of vibration frequency,amplitude and exercise

ObjectiveThis study aimed to investigate how whole-body vibration (WBV) and exercise and their interactions influenced leg muscle activity in elderly adults.Study designAn experimental study with repeated measures design that involved a group of ambulatory, community-dwelling elderly adults (n = 30; 23 women; mean age = 61.4 ± 5.3 years).Main outcome measuresMuscle activity of the vastus lateralis (VL), biceps femoris (BF), tibialis anterior (TA), and gastrocnemius (GS) was measured by surface electromyography (EMG), while participants were performing seven different exercises during 4 WBV conditions (condition 1: frequency = 30 Hz, amplitude = 0.6 mm, intensity = 2.25 units of Earth’s gravity (g); condition 2: 30 Hz, 0.9 mm, 3.40 g; condition 3: 40 Hz, 0.6 mm, 3.65 g; condition 4: 40 Hz, 0.9 mm, 5.50 g) and a no-WBV condition in a single experimental session.ResultsSignificantly greater muscle activity was recorded in VL (3%–148%), BF (16%–202%), and GS (19% –164%) when WBV was added to the exercises, compared with the same exercises without WBV (p ≤ 0.015). The effect of vibration intensity on EMG amplitude was exercise-dependent in VL (p = 0.002), and this effect was marginally significant in GS (p = 0.052). The EMG activity induced by the four WBV intensities was largely similar, and was the most pronounced during static erect standing and static single-leg standing.ConclusionsThe EMG amplitude of majority of leg muscles tested was significantly greater during WBV exposure compared with the no-WBV condition. Low-intensity WBV can induce muscle activity as effectively as higher-intensity protocols, and may be the preferred choice for frail elderly adults.     

Zastosowanie koncentratu czynników zespołu protrombiny w leczeniu zaburzeń hemostazy osoczowej po operacji transplantacji serca

Hemostasis involves complex processes meaning blood not to extravasate. It's temporary cessation is necessary to perform cardiac surgery procedure with cardiopulmonary bypass. In heart transplantation, standard procedures of heparine neutralization are insufficient. We present results obtained from the group of 10 patients (8 men and 2 women) in mean age of 41 ± 15 years, who underwent heart transplantation procedure with Lower-Shumway technique in moderate hypothermia (28°C). Mean cardiopulmonary bypass time was 218 ± 20 min, cross clampling aortic time was 114 ± 18 min and organ cold ischemia time was 221 ± 16 min. Postoperative human prothrombin complex was given after INR result (2.2 ± 0.3) was obtained followed by normalized activated clotting time (ACT) 124 ± 17 seconds. In high risk patients undergoing cardiac surgery procedure, standard international normalized ration (INR) measurements following ACT results are required to obtain more detailed information concerning plasma hemostasis disturbances. Prothromplex Total NF (Baxter International Inc, USA) is a safe option to correct the problem without risk of overloading the patients circulatory system.     

Disclosing genetic risk of Alzheimer’s disease to cognitively impaired patients and visit companions: Findings from the REVEAL Study

ObjectiveTo describe the impact of genetic information on Alzheimer’s disease (AD) risk communication to patients with mild cognitive impairment (MCI) and their visit companions.MethodsParticipants of the fourth REVEAL Study trial were randomized to receive AD risk assessments with or without genotype results. We coded 79 audio recorded risk disclosure sessions with the Roter Interaction Analysis System. Multilevel analyses explored differences in communication when disclosed risks were based on age and MCI diagnosis alone or in addition to APOE genotype status.ResultsThe addition of genotype results diminished the patient-centered nature of the sessions (p < 0.001). When ε4 positive relative to ε4 negative results were disclosed, visit companions were more verbally active (p < 0.05), disclosed more medical information (p < 0.05), were more positive verbally and non-verbally (p < 0.05) and were more proactive in setting the visit agenda (p < 0.05).ConclusionsDelivery of complex genetic risk information reduces the patient-centeredness of disclosure sessions. Visit companions are more actively engaged in session communication when patients are at increased genetic risk for AD.Practice implicationsAD risk discussions can be improved by supporting the positive role of visit companions and addressing the challenges inherent in the delivery of complex genetic information in a patient-centered manner.