The Feasibility of a Telehealth Exercise Program Aimed at Increasing Cardiorespiratory Fitness for People After Stroke

Background: Accessing suitable fitness programs post-stroke is difficult for many. The feasibility of telehealth delivery has not been previously reported.Objectives: To assess the feasibility of, and level of satisfaction with home-based telehealth-supervised aerobic exercise training post-stroke.Methods: Twenty-one ambulant participants (?3 months post-stroke) participated in a home-based telehealth-supervised aerobic exercise program (3 d/week, moderate-vigorous intensity, 8-weeks) and provided feedback via questionnaire postintervention. Session details, technical issues, and adverse events were also recorded.Results: Feasibility was high (83% of volunteers met telehealth eligibility criteria, 85% of sessions were conducted by telehealth, and 95% of participants rated usability favourably). Ninety-five percent enjoyed telehealth exercise sessions and would recommend them to others. The preferred telehealth exercise program parameters were: frequency 3 d/week, duration 20-30 min/session, program length 6-12 weeks.Conclusion: The telehealth delivery of exercise sessions to people after stroke appear

Development of strategies to support home-based exercise adherence after stroke: a Delphi consensus

Objective To develop a set of strategies to enhance adherence to home-based exercises after stroke, and an overarching framework to classify these strategies. Method We conducted a four-round Delphi consensus (two online surveys, followed by a focus group then a consensus round). The Delphi panel consisted of 13 experts from physiotherapy, occupational therapy, clinical psychology, behaviour science and community medicine. The experts were from India, Australia and UK. Results In round 1, a 10-item survey using open-ended questions was emailed to panel members and 75 strategies were generated. Of these, 25 strategies were included in round 2 for further consideration. A total of 64 strategies were finally included in the subsequent rounds. In round 3, the strategies were categorised into nine domains - (1) patient education on stroke and recovery, (2) method of exercise prescription, (3) feedback and supervision, (4) cognitive remediation, (5) involvement of family members, (6) involvement of society, (7) promoting self-efficacy, (8) motivational strategies and (9) reminder strategies. The consensus from 12 experts (93%) led to the development of the framework in round 4. Conclusion We developed a framework of comprehensive strategies to assist clinicians in supporting exercise adherence among stroke survivors. It provides practical methods that can be deployed in both research and clinical practices. Future studies should explore stakeholders' experiences and the cost-effectiveness of implementing these strategies

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Retrospective evaluation of whole exome and genome mutation calls in 746 cancer samples

Funder: NCI U24CA211006Abstract: The Cancer Genome Atlas (TCGA) and International Cancer Genome Consortium (ICGC) curated consensus somatic mutation calls using whole exome sequencing (WES) and whole genome sequencing (WGS), respectively. Here, as part of the ICGC/TCGA Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium, which aggregated whole genome sequencing data from 2,658 cancers across 38 tumour types, we compare WES and WGS side-by-side from 746 TCGA samples, finding that ~80% of mutations overlap in covered exonic regions. We estimate that low variant allele fraction (VAF < 15%) and clonal heterogeneity contribute up to 68% of private WGS mutations and 71% of private WES mutations. We observe that ~30% of private WGS mutations trace to mutations identified by a single variant caller in WES consensus efforts. WGS captures both ~50% more variation in exonic regions and un-observed mutations in loci with variable GC-content. Together, our analysis highlights technological divergences between two reproducible somatic variant detection efforts

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Assessing and training cardiorepiratory fitness after stroke

Research Doctorate - Doctor of Philosophy (PhD)Introduction: Cardiorespiratory fitness levels of people after stroke are low compared to non-stroke people of the same age and sex. Improving cardiorespiratory fitness has many potential health benefits for stroke survivors. Despite this, cardiorespiratory fitness is often overlooked in post-stroke management. Access to metropolitan-based services can be difficult for residents of regional and rural communities. Aims: The aims of the project were to: 1. Identify the characteristics and to determine the effectiveness of interventions to improve cardiorespiratory fitness after stroke. ; 2. Compare cardiorespiratory responses and performance measures during three clinically-applicable exercise tests. ; 3. Examine the exercise intensity parameters achieved by stroke survivors during task-specific and ergometer workstation activities. ; 4. Explore the feasibility and efficacy of an individually-tailored home- and community-based exercise program to improve cardiorespiratory fitness in stroke survivors. Methods: Characteristics of exercise interventions were investigated by systematic review. Change in cardiorespiratory fitness, measured by peak oxygen consumption (VO_2peak), was examined by meta-analysis. Community-dwelling stroke survivors were recruited. The primary outcome, oxygen consumption (VO₂) was assessed using a portable metabolic measurement system. Cardiorespiratory responses and performance measures were assessed on three exercise tests [Six-Minute Walk Test (6MWT), distance; Shuttle Walk Test (SWT), number of shuttles; cycle progressive exercise test (cPXT), final workload]. VO₂ was recorded during an individualised circuit exercise session incorporating an interval training approach on 5-minute workstations (task-specific and ergometer activities). A pilot controlled trial of an individually-tailored exercise program was undertaken. Feasibility was measured by retention, participation and adverse events. Control and intervention groups both received usual care, and the intervention group undertook the 12-week program, including once-weekly telephone/email support. Cardiorespiratory fitness was assessed at baseline and 12 weeks. Results: Aim 1: Twenty eight studies were included in the systematic review with 12 randomised controlled trials able to be included in the meta-analysis. Baseline fitness was low (8-23mL/kg/min). Interventions were typically centre-based, included an aerobic component and used three 30 to 60 minutes sessions per week at a prescribed intensity. Despite the modest dose of interventions, cardiorespiratory fitness improvement favoured intervention [increase in VO_2peak of 2.27 mL/kg/min (95% CI: 1.58 to 2.95)]. Aim 2: There was no difference in VO_2peak among the three exercise tests (range: 17.1- 18.1 mL/kg/min). Correlations between VO_2peak and performance measures were high (r=0.78, 0.73, 0.77). Aim 3: Nine task-specific (eg walking, stairs, balance) and three ergometer (upright cycle, rower, treadmill) workstations were used. Participants exercised for at least 11 minutes on the circuit. Moderate or higher intensity was achieved for 78% of task-specific and 83% of ergometer workstations. Aim 4: All intervention participants reported undertaking their prescribed program. No adverse events occurred. VO_2peak improved by 16% more in the intervention group (1.17 ± 0.29 to 1.35 ± 0.33 L/min) than the control group (1.24 ± 0.23 to 1.24 ± 0.27 L/min) (p=0.044). Conclusions: I have shown it is feasible to assess and train cardiorespiratory fitness using strategies applicable to most clinical settings. The 16% improvement in cardiorespiratory fitness observed in the home- and community-based program was similar to centre-based, resource-intensive programs. Performance measures of the 6MWT, SWT and cPXT may be clinically useful as proxies for cardiorespiratory fitness. An interval training approach using task-specific and ergometer activities appears a promising way to incorporate both cardiorespiratory fitness and functional training into post-stroke management. The studies provide preliminary data to inform the design of a future large, multicentre randomised controlled trial. This trial would the test effectiveness of the home- and community-based exercise intervention in improving cardiorespiratory fitness and functional recovery of stroke survivors living in metropolitan, regional and rural areas

Urine testing for diabetic analysis

Urine testing is relatively cheap and easy to do. Urine testing can be used to check for blood in the urine, to check for infection (by detecting the presence of white blood cells or protein) and can show up other systemic problems such as liver problems (by showing abnormal bilirubin levels). Urine testing can also detect ketones in the urine

How to measure blood glucose

The level of glucose in the blood can be measured by applying a drop of blood to a chemically treated, disposable ‘test-strip’, which is then inserted into an electronic blood glucose meter. The reaction between the test strip and the blood is detected by the meter and displayed in units of mg/dL or mmol/L. There are a number of different types of meters available, and all are slightly different. Take care when applying the general principles described in this article to the specific glucose meter you are using

Barriers and enablers to providing evidence-based in-hospital urinary continence care: A cross-sectional survey informed by the Theoretical Domains Framework

Aims: To identify the barriers and enablers perceived by hospital-based clinicians to providing evidence-based continence care to inpatients. Design: This was a cross-sectional study of inpatient clinicians using a questionnaire. Methods: Acute care and rehabilitation clinicians from 15 wards that admit patients after stroke at 12 hospitals (NSW = 11, Queensland =1, metropolitan = 4, regional = 8) were invited to complete an online questionnaire. The 58 questions (answered on a 5-point Likert scale) were aligned to 13 of the 14 domains of the Theoretical Domains Framework. Results were dichotomized into ‘strongly agree/agree’ and ‘unsure/disagree/strongly disagree’ and proportions were calculated. Data collection occurred between January 2019 and March 2019. Results: The questionnaire was completed by 291 participants with 88% being nurses. Barriers were found in nine domains including knowledge; skills; memory attention and decision making; emotion; environmental context and resources; behavioural regulation; social professional role; intensions, social influences; and beliefs about capabilities. Enablers were found in seven domains including goals; social influences; knowledge; skills; social, professional role and identity; reinforcement and beliefs about consequences. Conclusion: This multi-site, multi-professional study that included predominantly nurses highlights the barriers and enablers to inpatient continence care. Future implementation studies in inpatient continence management should address these identified barriers and enablers to improve effectiveness of implementation of evidence-based care. Implications for the profession: This study highlights that although there are many barriers to ward nurses providing evidence-based continence care, there are also several enablers. Both should be addressed to improve practice. Reporting method: We adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) (Supplementary File 1). Relevance to clinical practice: Establishing barriers to practice gives a broader understanding of why practice does not occur and establishes areas where researchers and clinicians need to address in order to change behaviour.</p