An Integrated and Distributed Framework for a Malaysian Telemedicine System (MyTel)

The overall aim of the research was to produce a validated framework for a Malaysian integrated and distributed telemedicine system. The framework was constructed so that it was capable of being useful in retrieving and storing a patient's lifetime health record continuously and seamlessly during the downtime of the computer system and the unavailability of a landline telecommunication network. The research methodology suitable for this research was identified including the verification and validation strategies. A case study approach was selected for facilitating the processes and development of this research. The empirical data regarding the Malaysian health system and telemedicine context were gathered through a case study carried out at the Ministry of Health Malaysia (MOHM). The telemedicine approach in other countries was also analysed through a literature review and was compared and contrasted with that in the Malaysian context. A critical appraisal of the collated data resulted in the development of the proposed framework (MyTel) a flexible telemedicine framework for the continuous upkeep o f patients' lifetime health records. Further data were collected through another case study (by way of a structured interview in the outpatient clinics/departments of MOHM) for developing and proposing a lifetime health record (LHR) dataset for supporting the implementation of the MyTel framework. The LHR dataset was developed after having conducted a critical analysis of the findings of the clinical consultation workflow and the usage o f patients' demographic and clinical records in the outpatient clinics. At the end of the analysis, the LHR components, LHR structures and LHR messages were created and proposed. A common LHR dataset may assist in making the proposed framework more flexible and interoperable. The first draft of the framework was validated in the three divisions of MOHM that were involved directly in the development of the National Health JCT project. The division includes the Telehealth Division, Public and Family Health Division and Planning and Development Division. The three divisions are directly involved in managing and developing the telehealth application, the teleprimary care application and the total hospital information system respectively. The feedback and responses from the validation process were analysed. The observations and suggestions made and experiences gained advocated that some modifications were essential for making the MyTel framework more functional, resulting in a revised/ final framework. The proposed framework may assist in achieving continual access to a patient's lifetime health record and for the provision of seamless and continuous care. The lifetime health record, which correlates each episode of care of an individual into a continuous health record, is the central key to delivery of the Malaysian integrated telehealth application. The important consideration, however, is that the lifetime health record should contain not only longitudinal health summary information but also the possibility of on-line retrieval of all of the patient's health history whenever required, even during the computer system's downtime and the unavailability of the landline telecommunication network

Montreal Cognitive Assessment for the diagnosis of Alzheimer's disease and other dementias.

BACKGROUND: Dementia is a progressive syndrome of global cognitive impairment with significant health and social care costs. Global prevalence is projected to increase, particularly in resource-limited settings. Recent policy changes in Western countries to increase detection mandates a careful examination of the diagnostic accuracy of neuropsychological tests for dementia. OBJECTIVES: To determine the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) at various thresholds for dementia and its subtypes. SEARCH METHODS: We searched MEDLINE, EMBASE, BIOSIS Previews, Science Citation Index, PsycINFO and LILACS databases to August 2012. In addition, we searched specialised sources containing diagnostic studies and reviews, including MEDION (Meta-analyses van Diagnostisch Onderzoek), DARE (Database of Abstracts of Reviews of Effects), HTA (Health Technology Assessment Database), ARIF (Aggressive Research Intelligence Facility) and C-EBLM (International Federation of Clinical Chemistry and Laboratory Medicine Committee for Evidence-based Laboratory Medicine) databases. We also searched ALOIS (Cochrane Dementia and Cognitive Improvement Group specialized register of diagnostic and intervention studies). We identified further relevant studies from the PubMed 'related articles' feature and by tracking key studies in Science Citation Index and Scopus. We also searched for relevant grey literature from the Web of Science Core Collection, including Science Citation Index and Conference Proceedings Citation Index (Thomson Reuters Web of Science), PhD theses and contacted researchers with potential relevant data. SELECTION CRITERIA: Cross-sectional designs where all participants were recruited from the same sample were sought; case-control studies were excluded due to high chance of bias. We searched for studies from memory clinics, hospital clinics, primary care and community populations. We excluded studies of early onset dementia, dementia from a secondary cause, or studies where participants were selected on the basis of a specific disease type such as Parkinson's disease or specific settings such as nursing homes. DATA COLLECTION AND ANALYSIS: We extracted dementia study prevalence and dichotomised test positive/test negative results with thresholds used to diagnose dementia. This allowed calculation of sensitivity and specificity if not already reported in the study. Study authors were contacted where there was insufficient information to complete the 2x2 tables. We performed quality assessment according to the QUADAS-2 criteria.Methodological variation in selected studies precluded quantitative meta-analysis, therefore results from individual studies were presented with a narrative synthesis. MAIN RESULTS: Seven studies were selected: three in memory clinics, two in hospital clinics, none in primary care and two in population-derived samples. There were 9422 participants in total, but most of studies recruited only small samples, with only one having more than 350 participants. The prevalence of dementia was 22% to 54% in the clinic-based studies, and 5% to 10% in population samples. In the four studies that used the recommended threshold score of 26 or over indicating normal cognition, the MoCA had high sensitivity of 0.94 or more but low specificity of 0.60 or less. AUTHORS' CONCLUSIONS: The overall quality and quantity of information is insufficient to make recommendations on the clinical utility of MoCA for detecting dementia in different settings. Further studies that do not recruit participants based on diagnoses already present (case-control design) but apply diagnostic tests and reference standards prospectively are required. Methodological clarity could be improved in subsequent DTA studies of MoCA by reporting findings using recommended guidelines (e.g. STARDdem). Thresholds lower than 26 are likely to be more useful for optimal diagnostic accuracy of MoCA in dementia, but this requires confirmation in further studies.This is the final version of the article. It first appeared from Wiley via http://dx.doi.org/10.1002/14651858.CD010775.pub

How 5G wireless (and concomitant technologies) will revolutionize healthcare?

The need to have equitable access to quality healthcare is enshrined in the United Nations (UN) Sustainable Development Goals (SDGs), which defines the developmental agenda of the UN for the next 15 years. In particular, the third SDG focuses on the need to “ensure healthy lives and promote well-being for all at all ages”. In this paper, we build the case that 5G wireless technology, along with concomitant emerging technologies (such as IoT, big data, artificial intelligence and machine learning), will transform global healthcare systems in the near future. Our optimism around 5G-enabled healthcare stems from a confluence of significant technical pushes that are already at play: apart from the availability of high-throughput low-latency wireless connectivity, other significant factors include the democratization of computing through cloud computing; the democratization of Artificial Intelligence (AI) and cognitive computing (e.g., IBM Watson); and the commoditization of data through crowdsourcing and digital exhaust. These technologies together can finally crack a dysfunctional healthcare system that has largely been impervious to technological innovations. We highlight the persistent deficiencies of the current healthcare system and then demonstrate how the 5G-enabled healthcare revolution can fix these deficiencies. We also highlight open technical research challenges, and potential pitfalls, that may hinder the development of such a 5G-enabled health revolution

Improving the accuracy of brief cognitive assessments when used as part of the process for identifying dementia in general practice.

Identifying dementia in general practice remains a considerable challenge, with mild to moderate stages of dementia potentially underdiagnosed in 30-50% of cases. The primary aim of this PhD thesis was to address the question “how can we improve the accuracy of brief cognitive assessments when used as part of the process for identifying dementia in general practice?”. This was carried out via a combination of secondary research through three evidence syntheses, and primary research via a survey of general practitioners with results triangulated with existing research and thesis findings. Through the conduct of a rapid review of clinical practice guidelines (CPGs),I found a lack of consistent recommendations for general practice regarding selection and application of brief cognitive assessment (BCA) tools There was also a paucity of guidance given within the identified CPGs on tailoring BCA choice and use for specific populations. The rapid review indicates that greater clarity and consistency is needed from CPGs relating specifically to the use of BCAs as part of the process for identifying dementia in general practice. The systematic review and overview identified an absence of existing evidence. Where evidence exists, BCAs performed inconsistently and were broadly inadequate as a tool for use in general practice dementia care. Other factors beyond diagnostic accuracy render established tests ill-suited for general practice such as administration time, cost and acceptability for clinicians and patients. A number of areas are identified both in cognitive testing and research methods where progress can be made relatively simply. This thesis demonstrates that many assumptions underlying current practice are without robust foundations, with severe implications for general practice and patient care at a time of scarce resource and growing demand. These assumptions need revising as a priority. What is needed is clear, specific, well-designed primary research to begin to unpick these complexities and realistically address the challenges presented by the identification of dementia within general practice and primary care. I provide explicit recommendations for the design and conduct of a primary comparative accuracy study alongside a trial of effectiveness and cost-effectiveness of using brief cognitive assessments as part of the process of identifying dementia in general practice in order to objectively and systematically assess the suitability of brief cognitive assessments as a tool for use in this population and setting

Linking e-health records, patient-reported symptoms and environmental exposure data to characterise and model COPD exacerbations: protocol for the COPE study.

INTRODUCTION: Relationships between exacerbations of chronic obstructive pulmonary disease (COPD) and environmental factors such as temperature, humidity and air pollution are not well characterised, due in part to oversimplification in the assignment of exposure estimates to individuals and populations. New developments in miniature environmental sensors mean that patients can now carry a personal air quality monitor for long periods of time as they go about their daily lives. This creates the potential for capturing a direct link between individual activities, environmental exposures and the health of patients with COPD. Direct associations then have the potential to be scaled up to population levels and tested using advanced human exposure models linked to electronic health records. METHODS AND ANALYSIS: This study has 5 stages: (1) development and deployment of personal air monitors; (2) recruitment and monitoring of a cohort of 160 patients with COPD for up to 6 months with recruitment of participants through the Clinical Practice Research Datalink (CPRD); (3) statistical associations between personal exposure with COPD-related health outcomes; (4) validation of a time-activity exposure model and (5) development of a COPD prediction model for London. ETHICS AND DISSEMINATION: The Research Ethics Committee for Camden and Islington has provided ethical approval for the conduct of the study. Approval has also been granted by National Health Service (NHS) Research and Development and the Independent Scientific Advisory Committee. The results of the study will be disseminated through appropriate conference presentations and peer-reviewed journals.This work is funded by the Medical Research Council (MR/L019744/1). MRC-PHE funding has been obtained for a pilot study to collect blood and sputum samples on a subset of 20 participants. Enrolment will take place at The Royal Brompton and Harefield (RBH) and Guy's and St Thomas' (GSTT) NHS Foundation Trusts. Support will be provided by the Respiratory Clinical Research Facility at RBH and the Lane Fox Unit at GSTT. The project is a portfolio adopted by the National Institute for Health Research (NIHR) UK Clinical Research Network (CRN). Additional support was provided by the NIHR Biomedical Research Centre based at GSTT and King's College London.This is the final version of the article. It first appeared from the BMJ Publishing Group via http://dx.doi.org/10.1136/bmjopen-2016-01133

Applying the Minimal Detectable Change of a Static and Dynamic Balance Test Using a Portable Stabilometric Platform to Individually Assess Patients with Balance Disorders

Balance disorders have a high prevalence among elderly people in developed countries, and falls resulting from balance disorders involve high healthcare costs. Therefore, tools and indicators are necessary to assess the response to treatments. Therefore, the aim of this study is to detect relevant changes through minimal detectable change (MDC) values in patients with balance disorders, specifically with vertigo. A test-retest of a static and dynamic balance test was conducted on 34 healthy young volunteer subjects using a portable stabilometric platform. Afterwards, in order to show the MDC applicability, eight patients diagnosed with balance disorders characterized by vertigo of vestibular origin performed the balance test before and after a treatment, contrasting the results with the assessment by a specialist physician. The balance test consisted of four tasks from the Romberg test for static balance control, assessing dynamic postural balance through the limits of stability (LOS). The results obtained in the test-retest show the reproducibility of the system as being similar to or better than those found in the literature. Regarding the static balance variables with the lowest MDC value, we highlight the average velocity of the center of pressure (COP) in all tasks and the root mean square (RMS), the area, and the mediolateral displacement in soft surface, with eyes closed. In LOS, all COP limits and the average speed of the COP and RMS were highlighted. Of the eight patients assessed, an agreement between the specialist physician and the balance test results exists in six of them, and for two of the patients, the specialist physician reported no progression, whereas the balance test showed worsening. Patients showed changes that exceeded the MDC values, and these changes were correlated with the results reported by the specialist physician. We conclude that (at least for these eight patients) certain variables were sufficiently sensitive to detect changes linked to balance progression. This is intended to improve decision making and individualized patient monitoring

Cognitive Assessment Tools Recommended in Geriatric Oncology Guidelines: A Rapid Review.

Cognitive assessment is a cornerstone of geriatric care. Cognitive impairment has the potential to significantly impact multiple phases of a person's cancer care experience. Accurately identifying this vulnerability is a challenge for many cancer care clinicians, thus the use of validated cognitive assessment tools are recommended. As international cancer guidelines for older adults recommend Geriatric Assessment (GA) which includes an evaluation of cognition, clinicians need to be familiar with the overall interpretation of the commonly used cognitive assessment tools. This rapid review investigated the cognitive assessment tools that were most frequently recommended by Geriatric Oncology guidelines: Blessed Orientation-Memory-Concentration test (BOMC), Clock Drawing Test (CDT), Mini-Cog, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Short Portable Mental Status Questionnaire (SPMSQ). A detailed appraisal of the strengths and limitations of each tool was conducted, with a focus on practical aspects of implementing cognitive assessment tools into real-world clinical settings. Finally, recommendations on choosing an assessment tool and the additional considerations beyond screening are discussed

Validity of temporo-spatial characteristics of gait as an index for fall risk screening in community-dwelling older people（地域在住高齢者の転倒リスク・スクリーニングの指標としての歩行における時間的・空間的パラメータの妥当性）

信州大学(Shinshu university)博士（保健学）次の雑誌に発表。 /Journal of Pyisical Therapy Science 35(3) :265-269(2023); doi:10.1589/jpts.35.265 2023©by the Society of Physical Therapy Science. Published by IPEC Inc.Thesis馬場　孝浩. Validity of temporo-spatial characteristics of gait as an index for fall risk screening in community-dwelling older people（地域在住高齢者の転倒リスク・スクリーニングの指標としての歩行における時間的・空間的パラメータの妥当性）. 信州大学, 2023, 博士論文. 博士（保健学）, 甲第47号, 令和05年03月31日授与.doctoral thesi

Challenges and opportunities in the co-management of older inpatients undergoing high-performance medicine: Internal Medicine and Geriatrics in the Cologne model "Universitäre Altersmedizin"

Altern ist ein Prozess, der die Menschheit und die Wissenschaft seit Anbeginn fasziniert. Warum und wie wir gesund altern, ist bis heute nicht gänzlich verstanden. Aber es ist Fakt, dass in Industrienationen die Lebenserwartung stetig ansteigt und der Anteil der 80-jährigen in diesen Gesellschaften stetig zunimmt. Einige dieser alten Menschen schaffen es, durch eine Kombination aus genetischen und lebensstil-bedingten Faktoren, bis ins hohe Alter gesund und selbstständig zu bleiben. Der größere Anteil dieser Altersgruppe leidet aber an einer oder mehreren chronischen Erkrankungen und benötigt Unterstützung in den Aktivitäten des täglichen Lebens. Diese Menschen sind gebrechlich (frail) oder drohen es zu werden (pre-frail). Chronische Erkrankungen in Kombination mit Gebrechlichkeit führen zu häufigen Krankenhausaufenthalten. Die enormen Kosten, die das Gesundheitssystem durch die meist lange Verweildauer dieser Patienten trägt, ist nur ein Grund, die Prävention und Behandlung von Erkrankungen des höheren Lebensalters zu optimieren. Ziel der modernen Altersmedizin ist es, die Gebrechlichkeit (frailty) der Patienten multidimensional und interdisziplinär zu beurteilen. Den Goldstandard hierfür stellt das Comprehensive Geriatric Assessment (CGA) dar, welches in der vorliegenden Arbeit um den Multidimensionalen Prognostischen Index (MPI) ergänzt wird. Der MPI beleuchtet die physischen, psychischen, funktionellen und sozialen Aspekte älterer Patienten mittels insgesamt acht verschiedener Fragebögen und Scores und ist ein Risikoindex, der Mortalität, Rehospitalisierungen und Institutionalisierungen für einen Monat und ein Jahr nach Erhebung prognostiziert. Hierfür werden die Patienten drei Risikogruppen (MPI-1, niedriges, MPI-2, mittleres und MPI-3, hohes Risiko) zugeordnet. In der vorliegenden Arbeit wurde einerseits durch die Rekrutierung von insgesamt 200 multimorbiden (>2 chronische Erkrankungen) und älteren (>65 Jahre) Patienten in der Klinik II für Innere Medizin der Uniklinik Köln, die Durchführbarkeit und Validität des MPI in einer hochspezialisierten internistischen Klinik bestätigt und es konnte andererseits gezeigt werden, dass der MPI zur Verlaufsbeobachtung von Patienten während des stationären Aufenthaltes herangezogen werden kann und nicht nur Momentaufnahmen abbildet. Durch das dreimalige Erheben des MPIs (bei Aufnahme ins Krankenhaus, nach 7-10 Tagen und bei Entlassung) konnten dynamische Verläufe sichtbar gemacht werden. Interessant war hier, dass besonders Patienten der niedrigsten Risikogruppe (MPI-1) während des Aufenthalts von einer Verschlechterung ihrer Prognose betroffen waren, während Patienten der höchsten Risikogruppe (MPI-3) von einem längeren Aufenthalt eher profitierten. Beide Trends waren bereits nach einer Woche durch den MPI darstellbar und bestätigen das „geriatrische Paradoxon“. Dieses Wissen kann den behandelnden Ärzten und Therapeuten die Möglichkeit geben, Behandlungen maßgeschneidert auf den Patienten anzupassen. Perspektivisch soll der MPI auch in Kombination mit klinischen Aspekten interpretiert werden (wie z.B. Laborparametern), um das Co- Management der Inneren Medizin und Geriatrie zu optimieren. Die Kombination aus internistischer Hochleistungsmedizin und multidimensionaler Altersmedizin wird aktuell in der neu eröffneten Kölner „Universitären Altersmedizin“ auf der Station 17.1 der Uniklinik Köln medizinisch und wissenschaftlich erprobt. Eine derartige Kombination ist die Erste dieser Form in Deutschland und könnte maßgeblich dazu beitragen, den „silbernen Tsunami“, der in den nächsten Jahrzehnten auf die Gesundheitssysteme der Industrienationen zurollt, optimal zu versorgen. Dieses Pilotprojekt wird wissenschaftlich begleitet und die ersten Fallberichte, die im Rahmen des Co-Managements zwischen Innerer Medizin und Altersmedizin veröffentlich wurden, zeigen den positiven Einfluss dieser Zusammenarbeit auf die Prognose älterer gebrechlicher Patienten. Weitere Forschung ist notwendig, um individuelle Behandlungskonzepte für ältere Patienten zu ermöglichen und um ein besseres Verständnis der Einflussfaktoren auf den physiologischen und pathologischen Alterungsprozess zu erlangen. So könnte jedem Menschen die Chance gegeben werden, im hohen Lebensalter selbstbestimmt und individuell zu leben und behandelt zu werden

Body composition and functional assessment of nutritional status in adults: a narrative review of imaging, impedance, strength and functional techniques

This is the peer reviewed version of the following article: S, Smith & A. M. Madden (2016) ‘Body Composition and functional assessment of nutritional status in adults: a narrative review of imaging, impedance, strength and functional techniques’, Journal of Human Nutrition and Dietetics, 29 (6): 714-732, which has been published in final form at https://dx.doi.org/10.1111/jhn.12372. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving.The accurate and valid assessment of body composition is essential for the diagnostic evaluation of nutritional status, identifying relevant outcome measures, and determining the effectiveness of current and future nutritional interventions. Developments in technology and our understanding of the influences of body composition on risk and outcome will provide practitioners with new opportunities to enhance current practice and to lead future improvements in practice. This is the second of a two-part narrative review that aims to critically evaluate body composition methodology in diverse adult populations, with a primary focus on its use in the assessment and monitoring of under-nutrition. Part one focused on anthropometric variables [Madden and Smith (2016) J Hum Nutr Diet 29: 7–25] and part two focuses on the use of imaging techniques, bioelectrical impedance analysis, markers of muscle strength and functional status, with particular reference to developments relevant to practice.Peer reviewe