Metronome-Cued Stepping in Place after Hemiparetic Stroke: Comparison of a One- and Two-Tone Beat

Hemiparetic gait is characterised by temporal asymmetry and variability, and these variables are improved by auditory cueing. Stepping in place incorporates aspects of gait and may be a useful tool for locomotor training. The aim of this pilot study was to investigate the use of a single-tone and dual-tone metronome to cue stepping in place after hemiparetic stroke. Eight participants completed an uncued baseline stepping condition and two cued stepping conditions utilising a single-tone and a dualtone metronome. Step times were determined from force plate data, and asymmetry and variability were calculated for the three conditions. Step time asymmetry was significantly reduced in the single-tone condition compared to baseline, and paretic step time variability was significantly reduced in both cued conditions.The single-tone metronome appeared to be preferred to the dual-tone metronome based on participant feedback.The results of this pilot study suggest that metronome cueing produces similar benefits on stepping in place to previously reported findings in walking. Further research on whether stepping in place to a metronome can be used for locomotor training is needed

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)