Changed sleep according to weighted blanket adherence in a 16-week sleep intervention among children with attention-deficit/hyperactivity disorder

STUDY OBJECTIVES

To examine differences in sample characteristics and longitudinal sleep outcomes according to weighted blanket adherence.

METHODS

Children with attention-deficit/hyperactivity disorder (ADHD) (n =94), mean age 9.0 (sd 2.2, range 6-14) participated in a 16-week sleep intervention with weighted blankets (WB). Children were classified as WB adherent (use of WB ≥ 4 nights/week) or non-adherent (use of WB ≤ 3 nights/week). Changes in objectively measured sleep by actigraphy, parent-reported sleep problems (Children's Sleep Habits Questionnaire (CSHQ)) and child-reported Insomnia Severity Index (ISI) were evaluated according to adherence with mixed effect models. Gender, age, and ADHD subtype were examined as potential moderators.

RESULTS

Children adherent to WBs (48/94) showed an early response in sleep outcomes and an acceptance of the WB after four weeks of use as well as a decrease in parent- (CSHQ) (-5.73, P = .000) and child-reported sleep problems (ISI) (-4.29, P = .005) after 16 weeks. The improvement in sleep was larger among WB adherent vs. non-adherent (between-group difference: CSHQ: -2.09, P = .038; ISI: -2.58, P =.007). Total sleep time was stable for children adherent to WB but decreased for non-adherent (between-group difference: +16.90, P = .019).

CONCLUSIONS

An early response in sleep and acceptance of the WB predicted later adherence to WBs. Improvements in sleep were more likely among WB adherents vs. non-adherents. Children with ADHD may thus benefit from using WBs to handle their sleep problems.

The efficacy of weighted blankets for sleep in children with attention-deficit/hyperactivity disorder-A randomized controlled crossover trial

Weighted blankets are a non-pharmacological intervention for treating sleep and anxiety problems in children with attention-deficit/hyperactivity disorder. However, research on the efficacy of weighted blankets is sparse. The aim of this randomized controlled trial with a crossover design (4 + 4 weeks) was to evaluate the efficacy of weighted blankets on sleep among children with attention-deficit/hyperactivity disorder and sleeping problems. Children diagnosed with uncomplicated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition attention-deficit/hyperactivity disorder with verified sleep problems were randomized to start with either a weighted blanket or a lighter control blanket. Data collection was performed at weeks 0, 4 and 8 using actigraphy, questionnaires and a daily sleep diary. T-tests were used to evaluate efficacy. The study included 94 children with attention-deficit/hyperactivity disorder (mean age 9.0 [sd 2.2] years; 54 [57.4%] boys). Weighted blankets had a significant effect on total sleep time (mean diff. 7.72 min, p = 0.027, Cohen's d = 0.24), sleep efficiency (mean diff. 0.82%, p = 0.038, Cohen's d = 0.23) and wake after sleep onset (mean diff. -2.79 min, p = 0.015, Cohen's d = -0.27), but not on sleep-onset latency (p = 0.432). According to our exploratory subgroup analyses, weighted blankets may be especially beneficial for improving total sleep time in children aged 11-14 years (Cohen's d = 0.53, p = 0.009) and in children with the inattentive attention-deficit/hyperactivity disorder subtype (Cohen's d = 0.58, p = 0.016). Our results suggest that weighted blankets may improve children's sleep and could be used as an alternative to pharmacological sleep interventions.

Machine Learning Model for Readmission Prediction of Patients With Heart Failure Based on Electronic Health Records: Protocol for a Quasi-Experimental Study for Impact Assessment

BACKGROUND

Care for patients with heart failure (HF) causes a substantial load on health care systems where a prominent challenge is the elevated rate of readmissions within 30 days following initial discharge. Clinical professionals face high levels of uncertainty and subjectivity in the decision-making process on the optimal timing of discharge. Unwanted hospital stays generate costs and cause stress to patients and potentially have an impact on care outcomes. Recent studies have aimed to mitigate the uncertainty by developing and testing risk assessment tools and predictive models to identify patients at risk of readmission, often using novel methods such as machine learning (ML).

OBJECTIVE

This study aims to investigate how a developed clinical decision support (CDS) tool alters the decision-making processes of health care professionals in the specific context of discharging patients with HF, and if so, in which ways. Additionally, the aim is to capture the experiences of health care practitioners as they engage with the system's outputs to analyze usability aspects and obtain insights related to future implementation.

METHODS

A quasi-experimental design with randomized crossover assessment will be conducted with health care professionals on HF patients' scenarios in a region located in the South of Sweden. In total, 12 physicians and nurses will be randomized into control and test groups. The groups shall be provided with 20 scenarios of purposefully sampled patients. The clinicians will be asked to take decisions on the next action regarding a patient. The test group will be provided with the 10 scenarios containing patient data from electronic health records and an outcome from an ML-based CDS model on the risk level for readmission of the same patients. The control group will have 10 other scenarios without the CDS model output and containing only the patients' data from electronic medical records. The groups will switch roles for the next 10 scenarios. This study will collect data through interviews and observations. The key outcome measures are decision consistency, decision quality, work efficiency, perceived benefits of using the CDS model, reliability, validity, and confidence in the CDS model outcome, integrability in the routine workflow, ease of use, and intention to use. This study will be carried out in collaboration with Cambio Healthcare Systems.

RESULTS

The project is part of the Center for Applied Intelligent Systems Research Health research profile, funded by the Knowledge Foundation (2021-2028). Ethical approval for this study was granted by the Swedish ethical review authority (2022-07287-02). The recruitment process of the clinicians and the patient scenario selection will start in September 2023 and last till March 2024.

CONCLUSIONS

This study protocol will contribute to the development of future formative evaluation studies to test ML models with clinical professionals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52744.

The effects of interpersonal development programmes with sport coaches and parents on youth athlete outcomes: A systematic review and meta-analysis

Interpersonal coach-and parent development programmes (CDP and PDP, respectively), have the goal to foster positive youth sport experiences through high-quality relations between coaches, parents, and youth athletes. In this paper we systematically reviewed the extant literature and estimate the overall magnitude of such programmes and how they can inform future interventions. Specifically, we aimed to: (a) conduct a systematic review on the literature of interpersonal CDPs and PDPs within the youth sport context; (b) examine the effects of such interventions on youth athlete outcomes via a meta-analysis. English written peer-reviewed publications and grey literature was identified through electronic search in databases and manual searches of reference lists. By utilising a priori criteria for inclusion and exclusion, 33 studies describing interpersonal CDPs, and PDPs were identified in the systematic review. Studies that presented required data for estimation of Hedge's g effect sizes were included in the meta-analysis (k = 27). By and large, the included studies used a quasi-experimental design (58%), sampled from team sports (79%), and reported several delivery methods (e.g., workshops, audio feedback, observations, peer group discussions) and outcome measures (e.g., anxiety, autonomous motivation, self-confidence). Some interventions were based on the same delivery protocols (e.g., Coach Effectiveness Training, Mastery Approach to Coaching) or theoretical frameworks (e.g., Achievement Goal Theory, Self-Determination Theory). The meta-analysis showed statistically significant small, and medium, effect sizes on a subsample of youth athlete outcomes (e.g., task-related climate, fun and enjoyment, anxiety), indicating that coach interpersonal skills can contribute to positive youth sport experiences. Theory-based interpersonal CDPs and PDPs are recommended to expand the knowledge in this field of research.

A Framework to Guide Implementation of AI in Health Care: Protocol for a Cocreation Research Project

BACKGROUND

Artificial intelligence (AI) has the potential in health care to transform patient care and administrative processes, yet health care has been slow to adopt AI due to many types of barriers. Implementation science has shown the importance of structured implementation processes to overcome implementation barriers. However, there is a lack of knowledge and tools to guide such processes when implementing AI-based applications in health care.

OBJECTIVE

The aim of this protocol is to describe the development, testing, and evaluation of a framework, "Artificial Intelligence-Quality Implementation Framework" (AI-QIF), intended to guide decisions and activities related to the implementation of various AI-based applications in health care.

METHODS

The paper outlines the development of an AI implementation framework for broad use in health care based on the Quality Implementation Framework (QIF). QIF is a process model developed in implementation science. The model guides the user to consider implementation-related issues in a step-by-step design and plan and perform activities that support implementation. This framework was chosen for its adaptability, usability, broad scope, and detailed guidance concerning important activities and considerations for successful implementation. The development will proceed in 5 phases with primarily qualitative methods being used. The process starts with phase I, in which an AI-adapted version of QIF is created (AI-QIF). Phase II will produce a digital mockup of the AI-QIF. Phase III will involve the development of a prototype of the AI-QIF with an intuitive user interface. Phase IV is dedicated to usability testing of the prototype in health care environments. Phase V will focus on evaluating the usability and effectiveness of the AI-QIF. Cocreation is a guiding principle for the project and is an important aspect in 4 of the 5 development phases. The cocreation process will enable the use of both on research-based and practice-based knowledge.

RESULTS

The project is being conducted within the frame of a larger research program, with the overall objective of developing theoretically and empirically informed frameworks to support AI implementation in routine health care. The program was launched in 2021 and has carried out numerous research activities. The development of AI-QIF as a tool to guide the implementation of AI-based applications in health care will draw on knowledge and experience acquired from these activities. The framework is being developed over 2 years, from January 2023 to December 2024. It is under continuous development and refinement.

CONCLUSIONS

The development of the AI implementation framework, AI-QIF, described in this study protocol aims to facilitate the implementation of AI-based applications in health care based on the premise that implementation processes benefit from being well-prepared and structured. The framework will be coproduced to enhance its relevance, validity, usefulness, and potential value for application in practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50216.

A Pragmatic Mapping of Perceptions and Use of Digital Information Systems in Primary Care in Sweden: Survey Study

BACKGROUND

Electronic health records and IT infrastructure in primary care allow for digital documentation and access to information, which can be used to guide evidence-based care and monitor patient safety and quality of care. Quality indicators specified by regulatory authorities can be automatically computed and presented to primary care staff. However, the implementation of digital information systems (DIS) in health care can be challenging, and understanding factors such as relative advantage, compatibility, complexity, trialability, and observability is needed to improve the success and rate of adoption and diffusion.

OBJECTIVE

This study aims to explore how DIS are used and perceived by health care professionals in primary care.

METHODS

This study used quantitative assessment to gather survey data on the use and potential of DIS in health care in Sweden from the perspectives of primary care personnel in various roles. The digital questionnaire was designed to be short and contained 3 sections covering respondent characteristics, current use of platforms, and perceptions of decision support tools. Data were analyzed using descriptive statistics, nonparametric hypothesis testing, ordinal coefficient α, and confirmatory factor analysis.

RESULTS

The study collected responses from participants across 10 regions of Sweden, comprising 31.9% (n=22) from private clinics and 68.1% (n=47) from public clinics. Participants included administrators (18/69, 26.1%), a medical strategist (1/69, 1.4%), and physicians (50/69, 72.5%). Usage frequency varied as follows: 11.6% (n=8) used DIS weekly, 24.6% (n=17) monthly, 27.5% (n=19) a few times a year, 26.1% (n=18) very rarely, and 10.1% (n=7) lacked access. Administrators used DIS more frequently than physicians (P=.005). DIS use centered on quality improvement and identifying high-risk patients, with differences by role. Physicians were more inclined to use DIS out of curiosity (P=.01). Participants desired DIS for patient follow-up, lifestyle guidance, treatment suggestions, reminders, and shared decision-making. Administrators favored predictive analysis (P<.001), while physicians resisted immediate patient identification (P=.03). The 5 innovation attributes showed high internal consistency (α>.7). These factors explained 78.5% of questionnaire variance, relating to complexity, competitive advantage, compatibility, trialability, and observability. Factors 2, 3, and 4 predicted intention to use DIS, with factor 2 alone achieving the best accuracy (root-mean-square=0.513).

CONCLUSIONS

Administrators and physicians exhibited role-based DIS use patterns highlighting the need for tailored approaches to promote DIS adoption. The study reveals a link between positive perceptions and intention to use DIS, emphasizing the significance of considering all factors for successful health care integration. The results suggest various directions for future studies. These include refining the trialability and observability questions for increased reliability and validity, investigating a larger sample with more specific target groups to improve generalization, and exploring the relevance of different groups' perspectives and needs in relation to decisions about and use of DIS.

Implementing AI in healthcare-the relevance of trust: a scoping review

Background

The process of translation of AI and its potential benefits into practice in healthcare services has been slow in spite of its rapid development. Trust in AI in relation to implementation processes is an important aspect. Without a clear understanding, the development of effective implementation strategies will not be possible, nor will AI advance despite the significant investments and possibilities.

Objective

This study aimed to explore the scientific literature regarding how trust in AI in relation to implementation in healthcare is conceptualized and what influences trust in AI in relation to implementation in healthcare.

Methods

This scoping review included five scientific databases. These were searched to identify publications related to the study aims. Articles were included if they were published in English, after 2012, and peer-reviewed. Two independent reviewers conducted an abstract and full-text review, as well as carrying out a thematic analysis with an inductive approach to address the study aims. The review was reported in accordance with the PRISMA-ScR guidelines.

Results

A total of eight studies were included in the final review. We found that trust was conceptualized in different ways. Most empirical studies had an individual perspective where trust was directed toward the technology's capability. Two studies focused on trust as relational between people in the context of the AI application rather than as having trust in the technology itself. Trust was also understood by its determinants and as having a mediating role, positioned between characteristics and AI use. The thematic analysis yielded three themes: individual characteristics, AI characteristics and contextual characteristics, which influence trust in AI in relation to implementation in healthcare.

Conclusions

Findings showed that the conceptualization of trust in AI differed between the studies, as well as which determinants they accounted for as influencing trust. Few studies looked beyond individual characteristics and AI characteristics. Future empirical research addressing trust in AI in relation to implementation in healthcare should have a more holistic view of the concept to be able to manage the many challenges, uncertainties, and perceived risks.

What Are We Talking About When We Talk About Information-Driven Care? A Delphi-Study on a Definition

In Sweden, the term information-driven care has recently been put forward by healthcare organizations and researchers as a means for taking a comprehensive approach to the introduction of Artificial Intelligence (AI) in healthcare. The aim of this study is to systematically generate a consensus definition of the term information-driven care. To this end, we are conducting a Delphi study utilizing literature and experts' opinions. The definition is needed to enable knowledge exchange on information-driven care and operationalize its introduction into healthcare practice.

Interdisciplinary Human-Centered AI for Hospital Readmission Prediction of Heart Failure Patients

The evolution of clinical decision support (CDS) tools has been improved by usage of new technologies, yet there is an increased need to develop user-friendly, evidence-based, and expert-curated CDS solutions. In this paper, we show with a use-case how interdisciplinary expertise can be combined to develop CDS tool for hospital readmission prediction of heart failure patients. We also discuss how to make the tool integrated in clinical workflow by understanding end-user needs and have clinicians-in-the-loop during the different development stages.

Patients' Health Experiences of Post COVID-19 Condition-A Qualitative Study

Patients who suffer from long-term symptoms of COVID-19, described as post COVID-19 condition, are a new and large group of patients. There is a lack of knowledge concerning health experiences in this patient group. The aim of this study was to explore patients' health experiences of post COVID-19 condition. Data collection was performed through 14 semi-structured interviews. The qualitative content analysis resulted in six sub-categories, three categories, and an overall theme. Patients experienced symptoms of varying duration-ranging from 5-21 months. The results showed that patients' health experiences of post COVID-19 condition moved between uncertainty and new insights. This was shown by patients experiencing: (1) loss of abilities, including losing smell and taste and lacking energy, (2) loss of control, including being foreign to oneself and seeking answers, and (3) revaluation of life, including accepting the transformed body and prioritizing health. This study illustrates that patients living with post COVID-19 condition need to be treated with flexibility, based on each individual's unique challenges and experiences of the symptoms and the consequences for their health.

Realizing the potential of artificial intelligence in healthcare: Learning from intervention, innovation, implementation and improvement sciences

Introduction

Artificial intelligence (AI) is widely seen as critical for tackling fundamental challenges faced by health systems. However, research is scant on the factors that influence the implementation and routine use of AI in healthcare, how AI may interact with the context in which it is implemented, and how it can contribute to wider health system goals. We propose that AI development can benefit from knowledge generated in four scientific fields: intervention, innovation, implementation and improvement sciences.

Aim

The aim of this paper is to briefly describe the four fields and to identify potentially relevant knowledge from these fields that can be utilized for understanding and/or facilitating the use of AI in healthcare. The paper is based on the authors' experience and expertise in intervention, innovation, implementation, and improvement sciences, and a selective literature review.

Utilizing knowledge from the four fields

The four fields have generated a wealth of often-overlapping knowledge, some of which we propose has considerable relevance for understanding and/or facilitating the use of AI in healthcare.

Conclusion

Knowledge derived from intervention, innovation, implementation, and improvement sciences provides a head start for research on the use of AI in healthcare, yet the extent to which this knowledge can be repurposed in AI studies cannot be taken for granted. Thus, when taking advantage of insights in the four fields, it is important to also be explorative and use inductive research approaches to generate knowledge that can contribute toward realizing the potential of AI in healthcare.

Implementation Frameworks for Artificial Intelligence Translation Into Health Care Practice: Scoping Review

Background

Significant efforts have been made to develop artificial intelligence (AI) solutions for health care improvement. Despite the enthusiasm, health care professionals still struggle to implement AI in their daily practice.

Objective

This paper aims to identify the implementation frameworks used to understand the application of AI in health care practice.

Methods

A scoping review was conducted using the Cochrane, Evidence Based Medicine Reviews, Embase, MEDLINE, and PsycINFO databases to identify publications that reported frameworks, models, and theories concerning AI implementation in health care. This review focused on studies published in English and investigating AI implementation in health care since 2000. A total of 2541 unique publications were retrieved from the databases and screened on titles and abstracts by 2 independent reviewers. Selected articles were thematically analyzed against the Nilsen taxonomy of implementation frameworks, and the Greenhalgh framework for the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) of health care technologies.

Results

In total, 7 articles met all eligibility criteria for inclusion in the review, and 2 articles included formal frameworks that directly addressed AI implementation, whereas the other articles provided limited descriptions of elements influencing implementation. Collectively, the 7 articles identified elements that aligned with all the NASSS domains, but no single article comprehensively considered the factors known to influence technology implementation. New domains were identified, including dependency on data input and existing processes, shared decision-making, the role of human oversight, and ethics of population impact and inequality, suggesting that existing frameworks do not fully consider the unique needs of AI implementation.

Conclusions

This literature review demonstrates that understanding how to implement AI in health care practice is still in its early stages of development. Our findings suggest that further research is needed to provide the knowledge necessary to develop implementation frameworks to guide the future implementation of AI in clinical practice and highlight the opportunity to draw on existing knowledge from the field of implementation science.

Health-related quality of life in adults treated for paediatric acute lymphoblastic leukaemia: a cross-sectional and longitudinal cohort study

INTRODUCTION

Acute lymphoblastic leukaemia (ALL) is the most common form of cancer in children. Although treatment methods have improved and resulted in significant improvement of survival and reduction in late effects and late mortality risk, the health-related quality of life (HRQOL) of survivors might be affected. To introduce new interventions in clinical practice with the potential to support positive HRQOL outcomes, more knowledge is needed on how HRQOL in this group is constructed and stimulated. The purpose of this study is to investigate how HRQOL is affected in adults treated for paediatric ALL, in a long-term perspective and possible factors influencing this relationship.

METHODS AND ANALYSIS

This cohort of young adult ALL survivors allows for investigations of factors influencing HRQOL outcomes on a national level. Eligible participants are obtained from the Swedish Childhood Cancer quality registry. Data collection includes both a follow-up of data collected in 2012 (n=224) and recruitment of new eligible participants to the cohort (n=601). The cohort will cover survivors of paediatric ALL, diagnosed between 1985 and 2007, at an age between 0 and 15 years. Data will be collected using validated, multidimensional, self-administered instruments, designed to measure HRQOL (SF-36), social support, sense of coherence and resilience.

ETHICS AND DISSEMINATION

The study will be carried out in accordance with the ethics permit obtained from the Swedish ethics review authority (Dnr 2019-05181). Dissemination of study results will take place through research articles and reports to the national patient organisation and the national network for consultancy nurses for this target group and to the working group for the Swedish national long-term care programme for childhood cancer. Results will also reach practical application within the follow-up clinic for adult childhood cancer survivors at Sahlgrenska Hospital in Gothenburg.

Accelerating the impact of artificial intelligence in mental healthcare through implementation science

Background

The implementation of artificial intelligence (AI) in mental healthcare offers a potential solution to some of the problems associated with the availability, attractiveness, and accessibility of mental healthcare services. However, there are many knowledge gaps regarding how to implement and best use AI to add value to mental healthcare services, providers, and consumers. The aim of this paper is to identify challenges and opportunities for AI use in mental healthcare and to describe key insights from implementation science of potential relevance to understand and facilitate AI implementation in mental healthcare.

Methods

The paper is based on a selective review of articles concerning AI in mental healthcare and implementation science.

Results

Research in implementation science has established the importance of considering and planning for implementation from the start, the progression of implementation through different stages, and the appreciation of determinants at multiple levels. Determinant frameworks and implementation theories have been developed to understand and explain how different determinants impact on implementation. AI research should explore the relevance of these determinants for AI implementation. Implementation strategies to support AI implementation must address determinants specific to AI implementation in mental health. There might also be a need to develop new theoretical approaches or augment and recontextualize existing ones. Implementation outcomes may have to be adapted to be relevant in an AI implementation context.

Conclusion

Knowledge derived from implementation science could provide an important starting point for research on implementation of AI in mental healthcare. This field has generated many insights and provides a broad range of theories, frameworks, and concepts that are likely relevant for this research. However, when taking advantage of the existing knowledge basis, it is important to also be explorative and study AI implementation in health and mental healthcare as a new phenomenon in its own right since implementing AI may differ in various ways from implementing evidence-based practices in terms of what implementation determinants, strategies, and outcomes are most relevant. Plain Language Summary: The implementation of artificial intelligence (AI) in mental healthcare offers a potential solution to some of the problems associated with the availability, attractiveness, and accessibility of mental healthcare services. However, there are many knowledge gaps concerning how to implement and best use AI to add value to mental healthcare services, providers, and consumers. This paper is based on a selective review of articles concerning AI in mental healthcare and implementation science, with the aim to identify challenges and opportunities for the use of AI in mental healthcare and describe key insights from implementation science of potential relevance to understand and facilitate AI implementation in mental healthcare. AI offers opportunities for identifying the patients most in need of care or the interventions that might be most appropriate for a given population or individual. AI also offers opportunities for supporting a more reliable diagnosis of psychiatric disorders and ongoing monitoring and tailoring during the course of treatment. However, AI implementation challenges exist at organizational/policy, individual, and technical levels, making it relevant to draw on implementation science knowledge for understanding and facilitating implementation of AI in mental healthcare. Knowledge derived from implementation science could provide an important starting point for research on AI implementation in mental healthcare. This field has generated many insights and provides a broad range of theories, frameworks, and concepts that are likely relevant for this research.

Towards successful implementation of artificial intelligence in healthcare practice: A research program (Preprint)

Background

Objective

Methods

Results

Conclusions

International Registered Report Identifier (IRRID)

Advancing knowledge on social capital for young people's mental health

Inequalities in young people's mental health have been documented according to social class but less is known about determinants that can buffer or mediate the relationship. Social capital has the potential to contribute to alleviating observed health inequalities. However, clarity about how it can be understood and measured in relation to mental health among younger populations remains inconsistent. This scoping review examined published literature to investigate how social capital has been researched for young people's mental health. An established framework was used to guide the methodology. Studies were included: on age (10-19 years); publication year (since 2000); language (English). Only studies using social capital as a central theme were included. No restriction was placed on mental health outcomes. Nine bibliographic databases were interrogated. Articles (1541) were screened, 793 retained for analysis and 73 articles were included. Most studies were conducted in North America and Europe. Twenty per cent provided insights into how social capital should be described in relation to young people. A majority of the studies provided links between varying social capital indicators and a range of mental health outcomes (70%), however such evidence was associational. Only few studies inferred the causal direction between social capital and health (10%) and there were no dedicated studies on measurement. Findings suggest that literature on social capital and young people's mental health has grown but continues to be variously described and measured. It requires better utilization of existing knowledge and new research to improve its application in practice.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Cyberbullying and traditional bullying among Nordic adolescents and their impact on life satisfaction

Aims: The aim of this study was to investigate the prevalence of cybervictimization in the six Nordic countries and to assess its overlap with traditional bullying. A further aim was to examine potential associations between life satisfaction, on the one hand, and traditional bullying and cyberbullying on the other. Methods: Analyses were based on data from the 2013⁄2014 Health Behaviour in School-aged Children study. It included 32,210 boys and girls, aged 11, 13, and 15, living in the six Nordic countries. Results: The prevalence of cyberbullying by both pictures and by messages was around 2% in all the Nordic countries except Greenland. There it was considerably higher. The prevalence of being bullied in a traditional manner varied widely by country. For boys, this type of bullying was most frequent in the youngest age group and then decreased steadily in the older age groups. Girls were on average more likely to be cyberbullied. Cyberbullying was more common among 13- and 15-year-olds than 11-year-olds. Higher family affluence was unrelated to the risk of cyberbullying. However, it was related to traditional bullying and combined forms of bullying. Compared with intact families, cybervictimization was commoner among single-parent families and stepfamilies. Adjusting for age, gender, family affluence, and family structure, those subjected to cyberbullying had lower life satisfaction than those who were not bullied. Conclusions: We found relatively little overlap between cyberbullying and traditional bullying, indicating that the two may be separate phenomena stemming from different mechanisms, at least in the Nordic context.

Sustainability of the relationship between preoperative symptoms and postoperative improvement in quality of life after inguinal hernia repair

PURPOSE

Chronic pain and discomfort are common before and after inguinal hernia repair (IHR) and pain is clearly linked to reduced quality of life (QoL). The long-term effect of IHR on QoL in relation to preoperative symptoms is incompletely described.

METHODS

309 men (18-75 years) undergoing IHR under local anesthesia and day care surgery were included. Pre- and postoperative symptoms, pain and QoL (SF-36) were measured before and up to 3 years after surgery.

RESULTS

Before surgery, 197 patients (64%) reported pain (VAS 0.9-5.4) from their inguinal hernia. 102 patients (33%) had other inguinal symptoms, and 26% were asymptomatic. Patients with preoperative groin pain (P) scored their physical QoL (PCS) lower compared with controls (C) (median (IQR) 43.5 (34.7-50.3) vs. 53.9 (47.8-56.9, p < 0.001)), whereas patients with no pain (N) did not (53.0 (47.9-55.9), p = 0.57). Mental QoL was not affected before or after surgery. At 1, 2 and 3 years after surgery, 14, 12 and 7% of patients, respectively, reported groin pain. In P, PCS increased from 43.5 before surgery to 55.3 (p < 0.001) at 36 months, but was unchanged in N (53.0 vs 55.9, p = ns).

CONCLUSIONS

The incidence of inguinal pain decreases over time after inguinal hernia repair. Both preoperative reduction and long-term improvement in physical QoL are strongly associated with the presence of preoperative groin pain. This supports, from a QoL perspective, that patients with preoperative pain are those who benefit the most from IHR, also from a long-term perspective.

User Participation in Coproduction of Health Innovation: Proposal for a Synergy Project

Background

This project concerns advancing knowledge, methods, and logic for user participation in coproduction of health innovations. Such advancement is vital for several reasons. From a user perspective, participation in coproduction provides an opportunity to gain real influence over goal definition, design, and implementation of health innovations, ensuring that the solution developed solves real problems in right ways. From a societal perspective, it’s a mean to improve the efficiency of health care and the implementation of the Patient Act. As for industry, frameworks and knowledge of coproduction offer tools to operate in a complex sector, with great potential for innovation of services and products.

Objective

The fundamental objective of this project is to advance knowledge and methods of how user participation in the coproduction of health innovations can be applied in order to benefit users, industry, and public sector.

Methods

This project is a synergy project, which means that the objective will be accomplished through collaboration and meta-analysis between three subprojects that address different user groups, apply different strategies to promote human health, and relate to different parts of the health sector. Furthermore, subprojects focus on distinctive stages in the spectrum of innovation, with the objective to generate knowledge of the innovation process as a whole. The project is organized around three work packages related to three challenges—coproduction, positioning, and realization. Each subproject is designed such that it has its own field of study with clearly identified objectives but also targets work packages to contribute to the project as a whole. The work on the work packages will use case methodology for data collection and analysis based on the subprojects as data sources. More concretely, logic of multiple case studies will be applied with each subproject representing a separate case which is similar to each other in its attention to user participation in coproduction, but different regarding, for example, context and target groups. At the synergy level, the framework methodology will be used to handle and analyze the vast amount of information generated within the subprojects.

Results

The project period is from July 1, 2018 to June 30, 2022.

Conclusions

By addressing the objective of this project, we will create new knowledge on how to manage challenges to health innovation associated with the coproduction process, the positioning of solutions, and realization.

Rates of and methods used at reoperation for recurrence after primary inguinal hernia repair with Prolene Hernia System and Lichtenstein

Introduction

Since the introduction of tension-free mesh repair of inguinal hernia ad modum Lichtenstein (L), recurrence rates have been reduced to 1–2%. The bi-layer mesh Prolene Hernia System (PHS) is an alternative mesh with a theoretical potential to further reduce recurrence rates. However, a reoperation due to recurrence after PHS might be technically difficult since both the anterior and posterior space has been utilized.

Methods

Data on all males 18–75 years undergoing primary inguinal hernia repair (IHR) with PHS or L between January 1999 and October 2010 was collected from the Swedish Hernia Register (SHR). Moreover, data was collected for all operations due to recurrence after primary IHR with PHS or L between January 1st 1999 and December 31st 2014.

Results

A total of 1229 primary IHR with PHS and 78,230 with L was identified. Rates of reoperation for recurrence after PHS was significantly lower compared to L (1.5 vs. 2.7 %), [OR 0.38 (0.20–0.74)]. A medial recurrence was most common in both groups. At reoperation, an open anterior mesh repair was used in 74 % after PHS and a posterior mesh repair was performed in 58 % after L. Re-operating time was shorter, although not statistically significant in the PHS group (47 vs. 58 min, p = 0.29). Complication rates after surgery due to recurrence did not differ between groups.

Conclusion

The findings from this dataset suggest that recurrence rates after primary IHR with PHS might be lower and that reoperation due to recurrence after PHS is not more complicated than after L.

Redesign and Validation of Sisom, an Interactive Assessment and Communication Tool for Children With Cancer

Background

Children with cancer undergo intensive and long treatment periods that expose them and their families to a number of difficult physical, mental, and social challenges. Empowering children by actively involving them in their care can help them to cope with these challenges. It can, however, be difficult for children to be involved and talk about their illness experiences in a “traditional” conversation with health care professionals, especially for younger children. Sisom (Norwegian acronym “Si det som det er” or “Tell it how it is”) is an interactive computer-based assessment and communication tool to give children (aged 6-12 years) with cancer a “voice” in their care. Because of technological advances and widespread use of mobile devices Sisom had to be redesigned to better meet the needs of children of today.

Objective

To redesign Sisom for use on mobile devices and to validate and adapt it for use in a Swedish population of children with cancer.

Methods

A user-experience design was used. Content adaptation included forward-backward translation by Swedish and Norwegian translators. Healthy children (n=5), children with experiences of cancer treatment (n=5) and their parents (n=5), and pediatric nurses (n=2) were then involved in culturally adapting Sisom to the Swedish context. The iterative low- and high-fidelity evaluation was supported by a think aloud method, semistructured interviews, and drawings to capture children’s views of Sisom. The redesign and evaluation continued until no further changes or improvements were identified by the participants or the researchers.

Results

Children, parents, and pediatric nurses offered many suggestions for improvements to the original version in terms of content, aesthetics, and usability of Sisom. The most significant change that emerged through user input was a modification that entailed not using problem-focused statements in the assessment items. The parents and pediatric nurses considered the revised assessment items to be general and less diagnosis specific. The evaluation of aesthetics resulted in brighter colors and more positive and exciting details in the animations. The evaluation of usability included improvements of the verbal instructions on how to navigate in Sisom 2, and also that the answers to assessment items in Sisom 2 should be saved to provide the children with the option to pause and to continue answering the remaining assessment items at a later stage.

Conclusions

Overall, this paper describes the process of using user-experience design with children in order to redesign and validate an interactive assessment and communication tool and how the outcomes of this process resulted in a new version, Sisom 2. All participants confirmed the usability and qualities of using the final version. Future research should be directed toward the implementation of Sisom 2 in clinical practice and to evaluate outcomes from individual and organizational levels.

UltraPro Hernia System, Prolene Hernia System and Lichtenstein for primary inguinal hernia repair: 3-year outcomes of a prospective randomized controlled trial

PURPOSE

Chronic pain and discomfort are common after inguinal hernia repair (IHR). In this study, results from a 3-year follow-up from a randomized controlled study comparing three different mesh repairs for postoperative pain, discomfort, Quality of Life (QoL) and patient satisfaction are reported.

METHODS

Between November 1, 2006 and January 31, 2009, 309 men, who underwent day surgery for primary unilateral inguinal hernia under local anesthesia, were randomized to three different mesh repairs; UltraPro Hernia System (U), Prolene Hernia System (P) and Lichtenstein procedure (L).

RESULTS

Preoperatively, there were no differences between groups regarding demographics, symptoms, inguinal pain or QoL (SF-36 and a hernia-specific questionnaire). Operating time, postoperative pain, complications and time to full recovery were similar. At 36 months, 21 patients indicated pain [L, n = 6, P, n = 6 and U, n = 9; VAS (median (IQR)): L 0.4 (0.2-1.7), P 0.2 (0.1-2.3) and U 1.6 (0.7-4.6), p = ns]. Physical QoL was reduced in all groups before surgery and was similarly increased to normal levels after 3 months without further changes throughout the study. Although 92 % of participants were satisfied, sixteen percent reported any discomfort from the groin (ns between groups). Five recurrences were reported (L, n = 2, P, n = 1 and U, n = 2, p = ns).

CONCLUSIONS

After 3 years of follow-up, all three procedures provided equally good results regarding, pain, discomfort and QoL and could therefore be recommended for primary IHR in LA.

The effect of diverting stoma on long-term morbidity and risk for permanent stoma after low anterior resection for rectal cancer

BACKGROUND

Anastomotic leakage (AL) is a severe complication after low anterior resection (LAR) in rectal cancer surgery. A diverting loop ileostomy has been reported to reduce early clinical AL and thereby decrease short-term morbidity. Less is known if long-term morbidity is affected by a loop ileostomy constructed at LAR.

METHODS

At Ersta Hospital, Sweden, 287 consecutive patients were operated on with LAR, 2002-2011. Follow-up time was 3 years after LAR. Due to a shift in routines, 15% were diverted at LAR, 2002-2006 and 91%, 2007-2011. Data on long-term morbidity and permanent stoma in patients with or without a diversion at primary surgery were compared.

RESULTS

During LAR, 139 patients were diverted (S+), 148 were not (S-). Total rate of AL, both early and late, was 26% in S+ and 30% in S-, p 0.25. Late AL (>30 days after LAR) was found in 6% and 15% were readmitted in the late postoperative period with no difference between the groups. Total length of hospital stay (30 days-3 years after LAR) was longer among S+ compared to S-, mean 7 vs. 4 days (p < 0.001). One out of six ended up with a permanent stoma (17% S+, 14% S-, p 0.47). Clinical AL was an independent risk factor and the most common cause for a permanent stoma in both groups.

CONCLUSION

A diverting loop ileostomy at LAR did not reduce long-term morbidity but was associated with a longer total length of hospital stay during a 3-year follow up.

The effect of diverting stoma on postoperative morbidity after low anterior resection for rectal cancer in patients treated within an ERAS program

BACKGROUND

Anastomotic leakage (AL) is a serious complication after low anterior resection (LAR) with total mesorectal excision (TME) for rectal cancer. Whether the Enhanced Recovery After Surgery (ERAS)-protocol influences the risk of short-term morbidity in relation to the use of a diverting stoma is unclear.

METHODS

Between 2002 and 2011, 287 consecutive patients underwent LAR with TME for rectal cancer at Ersta Hospital, Sweden. All patients were treated according to the ERAS program and thereby included. Between 2002 and 2006 15% had a diverting stoma compared to 91 %, 2007 to 2011.

RESULTS

One hundred and thirty-nine patients were operated with a diverting stoma at primary surgery (S+), 148 patients were not (S-). The groups were comparable regarding pre- and peroperative data and patients' characteristics. Postoperative morbidity within 30 days after surgery (S+ 53% vs. S- 43%) and hospital stay (S+ 11 days vs. S- 9 days) did not differ. AL occurred in 22% of all patients. In a multivariate analysis, no significant difference in AL was found in relation to the use of a diverting stoma (S+ vs. S-, OR 0.64, 95% CI 0.34-1.19). Eleven patients (8%) in the S+ group underwent relaparotomy versus 22 (15%) in the S- group (p = 0.065). Total overall compliance to the ERAS program was 65%. Patients in S- had faster postoperative recovery.

CONCLUSION

A diverting stoma did not affect postoperative morbidity in this large cohort of patients undergoing LAR within an ERAS program. However, the routine use of a diverting stoma could be expected to delay postoperative recovery.

Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol.

METHODS

Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.

RESULTS

For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate).

CONCLUSIONS

Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

Myogenic reprogramming of bone marrow derived cells in a W⁴¹Dmd(mdx) deficient mouse model

Lack of expression of dystrophin leads to degeneration of muscle fibers and infiltration of connective and adipose tissue. Cell transplantation therapy has been proposed as a treatment for intractable muscle degenerative disorders. Several reports have demonstrated the ability of bone-marrow derived cells (BMDC) to contribute to non-haematopoietic tissues including epithelium, heart, liver, skeletal muscle and brain following transplantation by means of fusion and reprogramming. A key issue is the extent to which fusion and reprogramming can occur in vivo, particularly under conditions of myogenic deterioration.To investigate the therapeutic potential of bone marrow transplantation in monogenetic myopathy, green fluorescent protein-positive (GFP+) bone marrow cells were transplanted into non-irradiated c-kit receptor-deficient (W⁴¹) mdx mice. This model allows BMDC reconstitution in the absence of irradiation induced myeloablation. We provide the first report of BMDC fusion in a W⁴¹Dmd(mdx) deficient mouse model.In the absence of irradiation induced injury, few GFP+ cardiomyocytes and muscle fibres were detected 24 weeks post BMT. It was expected that the frequency of fusion in the hearts of W⁴¹Dmd(mdx) mice would be similar to frequencies observed in infarcted mice. Although, it is clear from this study that individual cardiomyocytes with monogenetic deficiencies can be rescued by fusion, it is as clear that in the absence of irradiation, the formation of stable and reprogrammed fusion hybrids occurs, with the current techniques, at very low levels in non-irradiated recipients.

Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery

Background

Hyperglycaemia following major surgery increases morbidity, but may be improved by use of enhanced-recovery protocols. It is not known whether preoperative haemoglobin (Hb) A1c could predict hyperglycaemia and/or adverse outcome after colorectal surgery.

Methods

Some 120 patients without known diabetes underwent major colorectal surgery within an enhanced-recovery protocol. HbA1c was measured at admission and 4 weeks after surgery. All patients received an oral diet beginning 4 h after operation. Plasma glucose was monitored five times daily. Patients were stratified according to preoperative levels of HbA1c (within normal range of 4·5–6·0 per cent, or higher).

Results

Thirty-one patients (25·8 per cent) had a preoperative HbA1c level over 6·0 per cent. These had higher mean(s.d.) postoperative glucose (9·3(1·5) versus 8·0(1·5) mmol/l; P &lt; 0·001) and C-reactive protein (137(65) versus 101(52) mg/l; P = 0·008) levels than patients with a normal HbA1c level. Postoperative complications were more common in patients with a high HbA1c level (odds ratio 2·9 (95 per cent confidence interval 1·1 to 7·9)).

Conclusion

Postoperative hyperglycaemia is common among patients with no history of diabetes, even within an enhanced-recovery protocol. Preoperative measurement of HbA1c may identify patients at higher risk of poor glycaemic control and postoperative complications.

Chromatin‐ and temperature‐dependent modulation of radiation‐induced double‐strand breaks

PURPOSE

To investigate the influence of chromatin organization and scavenging capacity in relation to irradiation temperature on the induction of double-strand breaks (DSB) in structures derived from human diploid fibroblasts.

MATERIALS AND METHODS

Agarose plugs with different chromatin structures (intact cells+/-wortmannin, permeabilized cells with condensed chromatin, nucleoids and DNA) were prepared and irradiated with X-rays at 2 or 37 degrees C and lysed using two different lysis protocols (new ice-cold lysis or standard lysis at 37 degrees C). Induction of DSB was determined by constant-field gel electrophoresis.

RESULTS

The dose-modifying factor (DMF(temp)) for irradiation at 37 compared with 2 degrees C was 0.92 in intact cells (i.e. more DSB induced at 2 degrees C), but gradually increased to 1.5 in permeabilized cells, 2.2 in nucleoids and 2.6 in naked DNA, suggesting a role of chromatin organization for temperature modulation of DNA damage. In addition, DMF(temp) was influenced by the presence of 0.1 M DMSO or 30 mM glutathione, but not by post-irradiation temperature.

CONCLUSION

The protective effect of low temperature was correlated to the indirect effects of ionizing radiation and was not dependent on post-irradiation temperature. Reasons for a dose modifying factor <1 in intact cells are discussed.

The Filter Does Not Act as a DNA Size Discriminator in the Neutral Filter Elution Technique

Various types of filters were used with the neutral filter elution technique. No significant differences in elution rate or curve shapes were found. Therefore we assume that the release of DNA fragments from the DNA gel formed by lysis of cells is the rate-determining event in elution and not the rate of migration through the filter. We suggest that the filter only serves as a support for the DNA gel.

Determinants of outcome after colorectal resection within an enhanced recovery programme

BACKGROUND

Postoperative outcomes were studied in relation to adverse nutritional risk (body mass index (BMI) below 20 kg/m(2)), advanced age (80 years or more) and co-morbidity (American Society of Anesthesiologists (ASA) grade III-IV) in patients undergoing colorectal resection within an enhanced recovery after surgery programme.

METHODS

Outcomes were audited prospectively in 1035 patients. Morbidity and mortality were compared with those predicted using the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, and a multivariable model was used to determine independent predictors of outcome.

RESULTS

Postoperative morbidity was lower than predicted (observed to expected 0.68; P < 0.001). Independent predictors of delayed mobilization were ASA III-IV (P < 0.001) and advanced age (P = 0.025). Prolonged hospital stay was related to advanced age (P = 0.002), ASA III-IV (P < 0.001), male sex (P = 0.037) and rectal surgery (P < 0.001). Morbidity was related to ASA III-IV (P = 0.004), male sex (P = 0.023) and rectal surgery (P = 0.002). None of the factors predicted 30-day mortality.

CONCLUSION

Age and nutritional status were not independent determinants of morbidity or mortality. Pre-existing co-morbidity was an independent predictor of several outcomes.

Pre-operative carbohydrate loading may be used in type 2 diabetes patients

BACKGROUND

Post-operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery. Pre-operative oral carbohydrate loading (CHO) reduces post-operative insulin resistance with a reduced risk of hyperglycaemia during post-operative nutrition. Insulin-resistant diabetic patients have not been given CHO because the effects on pre-operative glycaemia and gastric emptying are unknown.

METHODS

Twenty-five patients (45-73 years) with type 2 diabetes [glycated haemoglobin (HbA1c) 6.2 +/- 0.2%, mean +/- SEM] and 10 healthy control subjects (45-72 years) were studied. A carbohydrate-rich drink (400 ml, 12.5%) was given with paracetamol 1.5 g for determination of gastric emptying.

RESULTS

Peak glucose was higher in diabetic patients than in healthy subjects (13.4 +/- 0.5 vs. 7.6 +/- 0.5 mM; P<0.01) and occurred later after intake (60 vs. 30 min; P<0.01). Glucose concentrations were back to baseline at 180 vs. 120 min in diabetic patients and healthy subjects, respectively (P<0.01). At 120 min, 10.9 +/- 0.7% and 13.3 +/- 1.2% of paracetamol remained in the stomach in diabetic patients and healthy, subjects respectively. Gastric half-emptying time (T50) occurred at 49.8 +/- 2.2 min in diabetics and at 58.6 +/- 3.7 min in healthy subjects (P<0.05). Neither peak glucose, glucose at 180 min, gastric T50, nor retention at 120 min differed between insulin (HbA1c 6.8 +/- 0.7%)- and non-insulin-treated (HbA1c 5.6 +/- 0.4%) patients.

CONCLUSIONS

Type 2 diabetic patients showed no signs of delayed gastric emptying, suggesting that a carbohydrate-rich drink may be safely administrated 180 min before anaesthesia without risk of hyperglycaemia or aspiration pre-operatively.

Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics

Background

Preoperative oral carbohydrate (CHO) reduces postoperative insulin resistance. In this randomized trial, the effect of CHO on postoperative whole-body protein turnover was studied.

Methods

Glucose and protein kinetics ([6,62H2]D-glucose, [2H5]phenylalanine, [2H2]tyrosine and [2H4]tyrosine) and substrate oxidation (indirect calorimetry) were studied at baseline and during hyperinsulinaemic normoglycaemic clamping before and on the first day after colorectal resection. Fifteen patients were randomized to receive a preoperative beverage with high (125 mg/ml) or low (25 mg/ml) CHO content.

Results

Three patients were excluded after the intervention, leaving six patients in each group. After surgery whole-body protein balance did not change in the high oral CHO group, whereas it was more negative in the low oral CHO group after surgery at baseline (P = 0·003) and during insulin stimulation (P = 0·005). Insulin-stimulated endogenous glucose release was similar before and after surgery in the high oral CHO group, but was higher after surgery in the low oral CHO group (P = 0·013) and compared with the high oral CHO group (P = 0·044).

Conclusion

Whole-body protein balance and the suppressive effect of insulin on endogenous glucose release are better maintained when patients receive a CHO-rich beverage before surgery.