Evaluating the Intervention Fidelity of Self-managed Computer Therapy for Aphasia Post-stroke

Introduction: Intervention fidelity refers to whether an intervention is delivered as intended by the designer, which can affect intervention success. This study aimed to evaluate fidelity to the StepByStep approach to aphasia computer therapy delivered in the Big CACTUS trial. Methods: A mixed methods approach was adopted comprising five interrelated studies. Firstly, a narrative literature review explored the methods used in fidelity evaluation in stroke rehabilitation research. Secondly, a qualitative interview study with StepByStep approach experts identified the key components of the intervention delivered in the Big CACTUS trial. Both of these studies informed the data to be collected in the third study, a process evaluation of intervention fidelity in the Big CACTUS trial. The fourth study explored the factors associated with adherence to computer therapy practice through secondary analysis of trial data and qualitative interviews with people with aphasia (PWA) and their carers who had used the computer therapy in the trial. The final study identified ‘essential’ components of the intervention associated with improved word-finding in the Big CACTUS trial. Results: Key informants identified four key components of the StepByStep approach: the StepByStep software, therapy set-up (tailoring and personalising), regular independent practice, and supporting and monitoring use. All components of the intervention were delivered with moderate to high fidelity in the Big CACTUS trial. Factors associated with increased adherence to independent practice included: the PWA having had their stroke longer ago; the PWA’s perceived and actual capability to engage with computer therapy; having the opportunity to carry out practice, which was aided by having the computer therapy for longer; having more input from a speech and language therapist; and a number of motivational factors. Exploratory data analysis indicated that the components of the intervention associated with change in word-finding ability were: rigorous tailoring of the computer therapy exercises and spending more time on naming words in functional sentences exercises. Conclusion: The StepByStep approach was delivered with moderate to high fidelity. This study has informed the interpretation of trial results, recommendations for clinicians delivering the intervention in clinical practice and will inform further intervention refinement

Sun-Protective Clothing Worn Regularly during Early Childhood Reduces the Number of New Melanocytic Nevi: The North Queensland Sun-Safe Clothing Cluster Randomized Controlled Trial

Numerous pigmented moles are associated with sun exposure and melanoma risk. This cluster randomized controlled trial aimed to determine if sun-protective clothing could prevent a significant proportion of the moles developing in young children (ACTRN12617000621314; Australian New Zealand Clinical Trials Registry). Twenty-five childcare centers in Townsville (19.25◦S), Australia, were matched on shade provision and socioeconomic status. One center from each pair was randomized to the intervention arm and the other to the control arm. Children at 13 intervention centers wore study garments and legionnaire hats at childcare and received sun-protective swimwear and hats for home use, while children at the 12 control centers did not. The 1–35-month-old children (334 intervention; 210 control) were examined for moles at baseline (1999–2002) and were re-examined annually for up to 4 years. Both groups were similar at baseline. Children at intervention centers acquired fewer new moles overall (median 12.5 versus 16, p = 0.02; 0.46 versus 0.68 moles/month, p = 0.001) and fewer new moles on clothing-protected skin (6 vs. 8; p = 0.021 adjusted for confounding and cluster sampling) than controls. Intervention children had 24.3% fewer new moles overall (26.5 versus 35) and 31.6% (13 versus 19) fewer moles on clothing-protected skin than controls after 3.5 years. Sunlight’s influence on nevogenesis is mitigated when children regularly wear UPF 30-50+ clothing covering half their body, implying that increased clothing cover reduces melanoma risk. Sun-protective clothing standards should mandate reporting of the percentage of garment coverage for childrenswear

The Effect of Acute Exercise on State Anxiety: A Systematic Review

Acute exercise has been shown to induce a small reduction in state anxiety, yet the most beneficial exercise stimulus is not clear. This review provides an update on the papers published since the last comprehensive review in 2015, with specific emphasis on whether study quality has improved. Randomised control trials, conducted in samples of healthy adults with non-clinical anxiety, were sourced from PubMed, PsycInfo, and Scopus. Study characteristics and study quality were assessed in nine studies comprising thirteen exercise conditions. Acute exercise significantly reduced anxiety in 53% (N = 7/13) of the exercise conditions. In comparison to a control condition, four showed exercising to be more effective, and one was as effective as the control. Two of the effective studies did not contain a control group. Six conditions were ineffective in reducing anxiety. There was no clear pattern of what combination of exercise mode, duration, and intensity was most effective, suggesting a variety may be effective in reducing anxiety. Methodological limitations still exist within the research, e.g., participant recruitment not considering baseline anxiety; variations in the control condition content. Future research should include participant samples exhibiting moderate-to-high levels of anxiety and examine self-selected exercise intensities

Effectiveness of Lifestyle Measures in the Treatment of Gastroesophageal Reflux Disease — A Case Series

Aim: To assess the effectiveness of lifestyle measures in the treatment of gastroesophageal reflux disease (GERD) among adults attending a dietetic practice.\ud \ud Methods: A retrospective case series of adult patients presenting with GERD to a dietetic practice over a three year period. The routine lifestyle counselling for treatment of symptoms of GERD included: not reclining within two to three hours of eating; a diet low in fat; small frequent meals; avoiding dietary components considered to relax the lower esophageal sphincter; and avoiding local irritants.\ud \ud Results: Twenty three cases were included (12 male). Eighteen, (9 female) were referred by their doctor, 7 (6 female) presented for GERD alone, 7 (4 female) presented for GERD together with comorbidities, and 9 (1 female) incidentally mentioned GERD during a dietary consultation for another disorder. Thirteen participants (9 female) had previously undergone endoscopies, 18 (11 female) were taking medication for GERD, and 19 (7 female) had comorbidities. Twenty two (10 female) reported an improvement in symptoms with 11/18 taking GERD medication at presentation reducing their medication following treatment.\ud \ud Conclusions: These results suggest that a more thorough investigation of lifestyle modification in the treatment of GERD is warranted

Negotiating excess treatment costs in a clinical research trial: the good, the bad and the innovative

Barriers to recovering the excess treatment costs associated with health research from local organisations in the United Kingdom can increase research costs, delay completion of high- quality studies and risk disenfranchising health trusts and patients from participation. The authors demonstrate how the process for recovering excess treatment costs at a local National Health Service (NHS) trust level in a multicentre study was inconsistent and resulted in excess effort and cost to the research budget. An innovative example of how an organisation acting as a broker between commissioners and researchers facilitated a more timely excess treatment cost agreement is highlighted

Developing, monitoring, and reporting of fidelity in aphasia trials: Core recommendations from the collaboration of aphasia trialists (CATs) trials for aphasia panel

Background: Developing, monitoring, and reporting of fidelity are essential and integral components to the design of randomised controlled trials (RCTs) in stroke and aphasia. Treatment fidelity refers to the degree to which an intervention is delivered as intended and is directly related to the quality of the evidence generated by RCTs. Clear documentation of treatment fidelity in trials assists in the evaluation of the clinical implications of potential benefits attributed to the intervention. Consideration of the implementation requirements of a research-based intervention as intended in a clinical context is necessary to achieve similar outcomes for a clinical population. Despite this, treatment fidelity is rarely reported in RCTs of aphasia intervention. Aim: To describe fidelity strategies and develop core recommendations for developing, monitoring, and reporting of fidelity in aphasia intervention RCTs. Scope: Relevant conceptual frameworks were considered. The Behaviour Change Consortium comprehensive framework of fidelity was adopted. It includes five areas: study design, training providers, delivery of treatment, treatment receipt, and treatment enactment. We explored fidelity in RCTs with a range of complex aphasia interventions (e.g., ASK, Big CACTUS, COMPARE, FCET2EC, POLAR, SUPERB, and VERSE) and described how different trial design factors (e.g., phase of trial, explanatory vs. pragmatic, number and location of sites, and number and type of treatment providers) influenced the fidelity strategies chosen. Strategies were mapped onto the five areas of the fidelity framework with a detailed exploration of how fidelity criteria were developed, measured, and monitored throughout each trial. This information was synthesised into a set of core recommendations to guide aphasia researchers towards the adequate measurement, capture, and reporting of fidelity within future aphasia intervention studies. Conclusions/Recommendations: Treatment fidelity should be a core consideration in planning an intervention trial, a concept that goes beyond treatment adherence alone. A range of strategies should be selected depending on the phase and design of the trial being undertaken and appropriate investment of time and costs should be considered

Localized precipitation and runoff on Mars

We use the Mars Regional Atmospheric Modeling System (MRAMS) to simulate lake storms on Mars, finding that intense localized precipitation will occur for lake size >=10^3 km^2. Mars has a low-density atmosphere, so deep convection can be triggered by small amounts of latent heat release. In our reference simulation, the buoyant plume lifts vapor above condensation level, forming a 20km-high optically-thick cloud. Ice grains grow to 200 microns radius and fall near (or in) the lake at mean rates up to 1.5 mm/hr water equivalent (maximum rates up to 6 mm/hr water equivalent). Because atmospheric temperatures outside the surface layer are always well below 273K, supersaturation and condensation begin at low altitudes above lakes on Mars. In contrast to Earth lake-effect storms, lake storms on Mars involve continuous precipitation, and their vertical velocities and plume heights exceed those of tropical thunderstorms on Earth. Convection does not reach above the planetary boundary layer for lakes O(10^2) mbar. Instead, vapor is advected downwind with little cloud formation. Precipitation occurs as snow, and the daytime radiative forcing at the land surface due to plume vapor and storm clouds is too small to melt snow directly (<+10 W/m^2). However, if orbital conditions are favorable, then the snow may be seasonally unstable to melting and produce runoff to form channels. We calculate the probability of melting by running thermal models over all possible orbital conditions and weighting their outcomes by probabilities given by Laskar et al., 2004. We determine that for an equatorial vapor source, sunlight 15% fainter than at present, and snowpack with albedo 0.28 (0.35), melting may occur with 4%(0.1%) probability. This rises to 56%(12%) if the ancient greenhouse effect was modestly (6K) greater than today.Comment: Submitted to JGR Planet

Selecting coral species for reef restoration

1. Humans have long sought to restore species but little attention has been directed at how to best select a subset of foundation species for maintaining rich assemblages that support ecosystems, like coral reefs and rainforests, which are increasingly threatened by environmental change. 2. We propose a two-part hedging approach that selects optimized sets of species for restoration. The first part acknowledges that biodiversity supports ecosystem functions and services, and so it ensures precaution against loss by allocating an even spread of phenotypic traits. The second part maximizes species and ecosystem persistence by weighting species based on characteristics that are known to improve ecological persistence—for example abundance, species range and tolerance to environmental change. 3. Using existing phenotypic-trait and ecological data for reef building corals, we identified sets of ecologically persistent species by examining marginal returns in occupancy of phenotypic trait space. We compared optimal sets of species with those from the world's southern-most coral reef, which naturally harbours low coral diversity, to show these occupy much of the trait space. Comparison with an existing coral restoration program indicated that current corals used for restoration only cover part of the desired trait space and programs may be improved by including species with different traits. 4. Synthesis and applications. While there are many possible criteria for selecting species for restoration, the approach proposed here addresses the need to insure against unpredictable losses of ecosystem services by focusing on a wide range of phenotypic traits and ecological characteristics. Furthermore, the flexibility of the approach enables the functional goals of restoration to vary depending on environmental context, stakeholder values, and the spatial and temporal scales at which meaningful impacts can be achieved

Service change and innovation in community end-of-life care during the COVID-19 pandemic: Qualitative analysis of a nationwide primary care survey.

Funder: yorkshire cancer research; FundRef: https://doi.org/10.13039/100011703Funder: Connects Senior Research FellowshipsBACKGROUND: Primary healthcare teams (general practice and community nursing services) within the United Kingdom provided the majority of community end-of-life care during COVID-19, alongside specialist palliative care services. As international healthcare systems move to a period of restoration following the first phases of the pandemic, the impact of rapidly-implemented service changes and innovations across primary and specialist palliative care services must be understood. AIM: To provide detailed insights and understanding into service changes and innovation that occurred in UK primary care to deliver end-of-life care during the first phase of the COVID-19 pandemic. DESIGN: Cross-sectional online survey. Responses were analysed using descriptive statistics and thematic analysis. SETTING/PARTICIPANTS: United Kingdom survey of general practitioners and community nurses, circulated via regional and national professional networks. RESULTS: A total of 559 valid responses were received from 387 community nurses, 156 general practitioners and 16 'other'. Over a third of respondents (n = 224; 40.8%) experienced changes in the organisation of their team in order to provide end-of-life care in response to the COVID-19 pandemic. Three qualitative themes were identified: COVID-19 as a catalyst for change in primary palliative care; new opportunities for more responsive and technological ways of working; and pandemic factors that improved and strengthened interprofessional collaboration. CONCLUSION: Opportunity has arisen to incorporate cross-boundary service changes and innovations, implemented rapidly at the time of crisis, into future service delivery. Future research should focus on which service changes and innovations provide the most benefits, who for and how, within the context of increased patient need and complexity

Exploring patient and public involvement in stroke research: a qualitative study

PURPOSE: To explore the experiences of patients and carers involved in patient and public involvement (PPI) activities for stroke research. METHODS: Semi-structured interviews conducted with stroke survivors and carers (n = 11) were analysed using thematic analysis. RESULTS: Four key themes emerged: impact of PPI on the individual and the research process, credibility and expertise, level of involvement and barriers and facilitators to PPI for stroke survivors and carers. The perceived benefits to the research process included: asking questions, keeping researchers grounded and directing the research agenda. All participants drew upon their experiential expertise in their PPI role, but some also drew upon their professional expertise to provide additional credibility. Stroke survivors and carers can be involved in PPI at different levels of involvement simultaneously and the majority of participants wanted to be more involved. Barriers to involvement included: location, transport and stroke survivors capacity to concentrate and comprehend complex information. Facilitators included: reimbursement for travel and time and professionals effort to facilitate involvement. CONCLUSIONS: PPI in stroke research benefits stroke survivors and carers and is perceived to benefit the research process. The barriers and facilitators should be considered by professionals intending to engage stroke survivors and carers collaboratively in research. IMPLICATIONS FOR REHABILITATION: This study has implications for PPI in stroke rehabilitation research, which could also be extrapolated to stroke rehabilitation service development and evaluation. Professionals facilitating PPI need to invest in developing supportive relationships in order to maintain ongoing involvement. Professionals need to be aware of how the varied consequences of stroke might impede participation and strategies to facilitate involvement for all who wish to be involved. For each rehabilitation issue being considered professionals need to decide: (1) how representative of the specific rehabilitation population the PPI members need to be, (2) whether experience alone is sufficient or whether additional professional skills are required and (3) whether training is likely to assist involvement or potentially reduce the lay representation