Spatial Neglect Therapy With the Augmented Reality App "Negami" for Active Exploration Training: A Randomized Controlled Trial on 20 Stroke Patients With Spatial Neglect

OBJECTIVE

To investigate the efficacy of the augmented reality (AR) app "Negami" as an active exploration training for the treatment of spatial neglect. Improvements of the ipsilesional attention and orientation bias (and resulting contralesional neglect) will be examined in stroke patients with spatial neglect and compared with a control group.

DESIGN

Randomized controlled trial with an experimental Negami group, consisting of patients with spatial neglect, and a group of neglect patients receiving standard neglect therapy.

SETTING

Three rehabilitation hospitals.

PARTICIPANTS

Twenty right hemispheric stroke patients with spatial neglect (N=20).

INTERVENTION

Over a period of 2 weeks, both groups received 5 training sessions per week (à 25 minutes). Neglect behavior was assessed weekly over a 5-week period, with the Negami therapy group receiving a second follow-up assessment at 1-to-2-month intervals after completion of training.

MAIN OUTCOME MEASURES

Letter Cancellation, Bells Test, Copying Task, Line Bisection Task, and a self-developed "Exploration Test".

RESULTS

Both groups improved significantly. While the Negami therapy group improved in 4 of 5 neglect tests used, the standard therapy group improved in only 1 of these tests. We observed significantly better improvement in the Negami group already after the first week of training. This difference was also significant after the end of the training as well as 1 week after the end of training and remained stable 1-2 months after the end of treatment.

CONCLUSION

Negami can be used as an effective alternative or addition to current standard neglect therapy, and may even be superior to it.

Negami: An Augmented Reality App for the Treatment of Spatial Neglect After Stroke

BACKGROUND

A widely applied and effective rehabilitation method for patients experiencing spatial neglect after a stroke is "visual exploration training." Patients improve their ipsilesional bias of attention and orientation by training exploration movements and search strategies toward the contralesional side of space. In this context, gamification can have a positive influence on motivation for treatment and thus on the success of treatment. In contrast to virtual reality applications, treatment enhancements through augmented reality (AR) have not yet been investigated, although they offer some advantages over virtual reality.

OBJECTIVE

This study aimed to develop an AR-based app (Negami) for the treatment of spatial neglect that combines visual exploration training with active, contralesionally oriented rotation of the eyes, head, and trunk.

METHODS

The app inserts a virtual element (origami bird) into the real space surrounding the patient, which the patient explores with the camera of a tablet. Subjective reports from healthy elderly participants (n=10) and patients with spatial neglect after stroke (n=10) who trained with the new Negami app were analyzed. Usability, side effects, and game experience were assessed by various questionnaires.

RESULTS

Training at the highest defined difficulty level was perceived as differently challenging but not as frustrating by the group of healthy elderly participants. The app was rated with high usability, hardly any side effects, high motivation, and entertainment. The group of patients with spatial neglect after stroke consistently evaluated the app positively on the dimensions of motivation, satisfaction, and fun.

CONCLUSIONS

The Negami app represents a promising extension by adding AR to traditional exploration training for spatial neglect. Through participants' natural interaction with the physical surrounding environment during playful tasks, side effects as symptoms of cybersickness are minimized and patients' motivation appeared to markedly increase. The use of AR in cognitive rehabilitation programs and the treatment of spatial neglect seems promising and should receive further investigation.

Capnographic monitoring of anesthetized African grey parrots receiving intermittent positive pressure ventilation

OBJECTIVE

To determine whether end-tidal partial pressure of carbon dioxide (PETCO2) correlated with PaCO2 in isoflurane-anesthetized African grey parrots receiving intermittent positive pressure ventilation (IPPV).

DESIGN

Prospective study.

ANIMALS

14 healthy mature African grey parrots (Psittacus erithacus timnus).

PROCEDURE

Each bird was anesthetized via mask with isoflurane, intubated, and connected to a pressure-limited intermittent-flow ventilator. Respiratory rate was altered while holding peak inspiratory pressure constant (5 cm H2O) to achieve a PETCO2 in 1 of 3 ranges: < 30 mm Hg, 30 to 40 mm Hg, and > 40 mm Hg. Blood was collected from the superficial ulnar artery of each bird at least once during each of the 3 ranges. Arterial blood samples were collected for blood gas analysis while PETCO2 was recorded simultaneously.

RESULTS

A strong correlation between PETCO2 and PaCO2 was detected over a wide range of partial pressures, although PETCO2 consistently overestimated PaCO2 by approximately 5 mm Hg. End-tidal partial pressure of CO2 and PaCO2 also correlated well with arterial blood pH, and the acute response of the bicarbonate buffer system to changes in ventilation was similar to that of mammals.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that PETCO2 reliably estimates PaCO2 in isoflurane-anesthetized African grey parrots receiving IPPV and suggest that IPPV combined with capnography is a viable option for anesthetic maintenance in avian anesthesia.

Pharmacokinetics of enrofloxacin in the red pacu (Colossoma brachypomum) after intramuscular, oral and bath administration

The intramuscular (i.m.), oral (p.o.), and bath immersion disposition of enrofloxacin were evaluated following administration to a cultured population of red pacu. The half-life for enrofloxacin following i.m. administration was 28.9 h, considerably longer than values calculated for other animals such as dogs, birds, rabbits, and tortoises. The 4 h maximum concentration (Cmax) of 1.64 micrograms/ml, following a single 5.0 mg/kg dosing easily exceeds the in vitro minimum inhibitory concentration (MIC) for 20 bacterial organisms known to infect fish. At 48 h post i.m. administration, the mean plasma enrofloxacin concentration was well above the MIC for most gram-negative fish pathogens. The gavage method of oral enrofloxacin administration produced a Cmax of 0.94 microgram/mL at 6-8 h. This Cmax was well above the reported in vitro MIC. A bath immersion concentration of 2.5 mg/L for 5 h was used in this study. The Cmax of 0.17 microgram/mL was noted on the 2 hour post-treatment plasma sample. Plasma concentrations of enrofloxacin exceeded published in vitro MIC's for most fish bacterial pathogens 72 h after treatment was concluded. Ciprofloxacin, an active metabolite of enrofloxacin, was detected and measured after all methods of drug administration. It is possible and practical to obtain therapeutic blood concentrations of enrofloxacin in the red pacu using p.o., i.m., and bath immersion administration. The i.m. route is the most predictable and results in the highest plasma concentrations of the drug.

Administration of total parenteral nutrition in pigeons

Venous access devices connected to jugular vein catheters were implanted SC in 2 groups of 6 White Carneau pigeons (Columba livia). Total parenteral nutrition (TPN), or a control solution (lactated Ringer's solution) was infused as a bolus 4 times daily. Physiologic, hematologic, and biochemical variables were monitored over 5 days. Complications in the TPN-treated pigeons included 8.7% weight loss during the 5-day trial, hyperglycemia for up to 90 minutes after infusion, and glucosuria after infusion. Control pigeons lost 1.3% of their body weight and did not become hyperglycemic or glucosuric after infusion. Hematocrit in both groups of pigeons decreased to a value slightly below published reference values for pigeons. Five pigeons developed venous thrombosis in the proximal part of the cranial vena cava. Results indicated that intermittent administration of TPN is possible in birds; however, further research is required to develop better techniques for administration of TPN solutions. Additionally, it is important to determine, more specifically, the caloric and nutrient requirements of pigeons under stress and receiving TPN.

Doxycycline plasma concentrations in macaws fed a medicate corn diet

A trial was conducted to determine the doxycycline plasma concentrations attained by feeding a medicated corn diet to large psittacine birds. Doxycycline is the preferred drug for the treatment of chlamydiosis in psittacine birds. Healthy macaws were fed a 0.1% doxycycline-medicated corn diet for 45 days, and plasma doxycycline concentrations were determined by microbiological assay on treatment days 3, 15, 30, and 45. Plasma doxycycline concentrations exceeded 1 microgram/ml in 87% of the samples assayed. As blood concentrations of 1 microgram/ml are considered therapeutic, a doxycycline-medicated corn diet may be efficacious in the treatment of chlamydiosis in large psittacine birds.

Intramuscular and oral disposition of enrofloxacin in African grey parrots following single and multiple doses

The intramuscular (IM) and oral (PO) disposition of enrofloxacin, a new fluoroquinolone antimicrobial drug, were evaluated in African grey parrots. Peak enrofloxacin concentration, mean (+/- SEM), at 1 h following a 15-mg/kg IM dose was 3.87 (+/- 0.27) micrograms/ml and declined with a mean residence time of 3.05 h. Peak enrofloxacin plasma concentrations at 2 to 4 h following oral doses of 3, 15, and 30 mg/kg were 0.31 (+/- 0.11), 1.12 (+/- 0.11), and 1.69 (+/- 0.23) micrograms/ml, respectively, and declined with a mean residence time of 3.44-5.28 h. The relative bioavailability of the 15-mg/kg oral dose was 48%. An equipotent metabolite, ciprofloxacin, was detected in plasma at concentrations ranging from 3 to 78% of those of enrofloxacin. Enrofloxacin concentrations and area under the curve were significantly lower, the mean residence time significantly shorter and the ciprofloxacin/enrofloxacin ratios higher, following 10 days of oral treatment at 30 mg/kg every 12 h. Following 10 days of treatment, no significant biochemical changes were noted; however, polydipsia and polyuria occurred in treated birds, but resolved quickly upon discontinuation of enrofloxacin administration. These studies indicate that a rational starting dose for enrofloxacin in psittacines (7.5-30 mg/kg BID) should be higher than those in other domestic animals.

Congo red binding of Escherichia coli isolated from the cloacae of psittacine birds

Binding of Congo red dye by Escherichia coli is associated with the pathogenicity of the organism. The purpose of the present study was to determine the incidence of Congo red binding exhibited by E. coli isolated from the cloacae of psittacine birds, to examine the association between the Congo red status of the E. coli isolates and the health status of birds, and to assess the potential value of Congo red binding as a screening test for identifying pathogenic strains of E. coli isolated form the cloacae of psittacine birds. Escherichia coli was isolated from the cloacae of 120/435 (28%) psittacine birds; 17/120 (14%) of the E. coli isolates bound the dye (Congo red-positive) and 103/120 (86%) did not bind the dye (Congo red-negative). All of the Congo red-positive isolates were recovered from subjectively abnormal birds, whereas Congo red-negative isolates were recovered from both subjectively normal (71/120 [59%]) and abnormal (32/120 [27%]) birds.

Plasma concentrations of enrofloxacin in African grey parrots treated with medicated water

Plasma concentrations of enrofloxacin were measured four times during a 7-day treatment period in African grey parrots that were fed with enrofloxacin-medicated drinking water. Water medicated at doubling doses of 0.09, 0.19, 0.38, 0.75, 1.5, and 3.0 mg/ml achieved mean concentrations (+/- SEM) of 0.10 (+/- 0.05), 0.12 (+/- 0.05), 0.12 (+/- 0.03), 0.15 (+/- 0.05), 0.30 (+/- 0.11), and 0.20 (+/- 0.06) micrograms/ml, respectively. A portion of the administered enrofloxacin was metabolized to an equipotent metabolite, ciprofloxacin. Mean ciprofloxacin concentrations paralleled enrofloxacin concentrations but were lower, ranging from 0.04 to 0.27 micrograms/ml. Acceptance of medicated water was adequate at lower doses; however, at doses of 1.5 and 3.0 mg/ml, acceptance was unsatisfactory, and mean weight loss in these groups was significantly higher than the control group. Based on the concentrations achieved in these preliminary trials and the susceptibility patterns of gram-negative bacteria isolated from psittacine birds, drinking water medicated with enrofloxacin at 0.19-0.75 mg/ml might be effective for treating highly susceptible gram-negative bacterial infections in African grey parrots.

Adverse effects of gentamicin in scarlet macaws and galahs

The adverse effects of administration of gentamicin (5 mg/kg of body weight, IM, q 12 h) for 7 days were studied in healthy scarlet macaws (Ara macao) and galahs (Eolophus roseicapillus; cockatoos). Polydipsia and polyuria developed in each species, but were greater and persisted longer in the cockatoos. Peak water intake in the cockatoos more than quadrupled, and remained increased for 23 days after cessation of gentamicin administration. Plasma aspartate transaminase activity increased significantly (P less than 0.05) after treatment in the macaws, and plasma aspartate transaminase and lactate dehydrogenase activities increased in the cockatoos. Single IM administration of gentamicin (5 mg/kg) resulted in mean (+/- SEM) plasma concentration of 20.6 (+/- 1.85) micrograms/ml at 0.5 hour for either species of birds. There were no significant differences between mean plasma gentamicin concentrations for cockatoos and macaws at any time after drug administration, except at 12 hours, when values for cockatoos were significantly (P less than 0.05) greater than those for macaws. The elimination half-life for gentamicin after IM administration of 5 and 10 mg/kg was 1.17 and 1.07 hours, respectively, for macaws and 1.23 and 1.44 hours, respectively, for cockatoos. Correlation between drug disposition and adverse side effects could not be detected.

Potential use of long-acting injectable oxytetracycline for treatment of chlamydiosis in Goffin's cockatoos

To determine the potential use of parenteral therapy in the treatment of chlamydiosis in psittacine birds, the disposition and toxicity of a long-acting oxytetracycline (OTC) was evaluated in Goffin's cockatoos. Following intramuscular and subcutaneous administration of 50 to 100 mg/kg body weight, plasma OTC concentrations of 7 to 15 micrograms/ml were obtained 3 hr following injection and declined with a terminal half-life between 8.9 to 14.7 hr. Plasma concentrations in excess of 1.0 microgram/ml were maintained for 48 to 68 hr. Multiple-dose treatment of 100 mg/kg subcutaneously every 3 days for 30 days caused focal necrosis and scabs at the injection site but no other clinical or serological evidence of adverse effects. Long-term treatment did not result in accumulation or alteration in the disposition of OTC. Based on this study, a dosage regimen of 50 to 100 mg/kg of OTC subcutaneously every 2-3 days would safely maintain plasma concentrations in excess of 1.0 microgram/ml and could potentially be used as an alternative to medicated feeds or daily oral dosing regimens for the treatment of chlamydiosis in psittacine birds.

Blood concentrations of chlortetracycline in macaws fed medicated pelleted feed

A trial was conducted to determine the suitability of using a pelleted diet containing chlortetracycline (CTC) for treatment of chlamydiosis in macaws. Macaws, normally fed seed and fruit diets in captivity, are notoriously difficult to treat with CTC-medicated mash diets. Healthy macaws fed a pelleted diet containing 1% or 1.5% CTC for 30 or 45 days maintained adequate food intake and mean blood concentrations of 1-2 CTC micrograms/ml blood throughout the treatment period. There were no significant differences between blood concentrations induced by the different dietary CTC concentrations. Blood concentrations of 1 microgram/ml are considered therapeutic, so it is likely that 1% CTC-medicated pellets will be adequate for treating chlamydiosis in these species.

Species-related differences in the incidence of gram-negative bacteria isolated from the cloaca of clinically normal psittacine birds

Cloacal swabs from 506 clinically normal psittacine birds of 22 species were aerobically cultured for bacteria and yeasts. In 45 (9%) samples, no microbial organisms were recovered. Gram-positive bacteria were recovered from 474 (91%) samples. The incidences of gram-negative bacteria and yeasts were: Escherichia coli 157 (31%), Enterobacter sp. 21 (4%), Klebsiella sp. 3 (0.6%), Pseudomonas sp. 4 (0.8%), and yeasts 26 (5%). Differences were noted in the recovery rate of E. coli among the various species of birds cultured. Escherichia coli was recovered from 101 of 168 cockatoos (60%) of the genus Cacatua but from only 18% of 338 non-Cacatua species. As all birds were housed in the same facility under similar conditions, this difference in the incidence rate of E. coli cannot be explained on the basis of differences in husbandry or diet alone.