Telerehabilitation Clinical and Vocational Applications for Assistive Technology: Research, Opportunities, and Challenges

Rehabilitation service providers in rural or underserved areas are often challenged in meeting the needs of their complex patients due to limited resources in their geographical area. Recruitment and retention of the rural clinical workforce are beset by the ongoing problems associated with limited continuing education opportunities, professional isolation, and the challenges inherent in coordinating rural community healthcare. People with disabilities who live in rural communities also face challenges accessing healthcare. Traveling long distances to a specialty clinic for necessary expertise may be troublesome due to inadequate or unavailable transportation, disability specific limitations, and financial limitations. Distance and lack of access are just two threats to quality of care that now being addressed by the use of videoconferencing, information exchange, and other telecommunication technologies that facilitate telerehabilitation. This white paper illustrates and summarizes clinical and vocational applications of telerehabilitation. We provide definitions related to the fields of telemedicine, telehealth, and telerehabilitation, and consider the impetus for telerehabilitation. We review the telerehabilitation literature for assistive technology applications; pressure ulcer prevention; virtual reality applications; speech-language pathology applications; seating and wheeled mobility applications; vocational rehabilitation applications; and cost effectiveness. We then discuss external telerehabilitation influencers, such as the positions of professional organizations. Finally, we summarize clinical and policy issues in a limited context appropriate to the scope of this paper. Keywords: Telerehabilitation, Telehealth, Telemedicine, Telepractic

Broad-spectrum Antibiotic Prophylaxis in Tumor and Infected Orthopedic Surgery - the prospective-randomized, microbiologist-blinded, stratified, superiority Trials - BAPTIST trials

Background: The perioperative antibiotic prophylaxis with 1st or 2nd-generation cephalosporins is evidence-based in orthopedic surgery. There are, however, situations with a high risk of prophylaxis-resistant surgical site infections (SSI). Methods: We perform a superiority randomized-controlled trial with a 10% margin and a power of 90% in favor of the broad-spectrum prophylaxis. We will randomize orthopedic interventions with a high risk for SSI (open fractures, surgery under therapeutic antibiotics, tumor surgery, spine surgery with ASA-Score ≥ 3 points) in a prospective-alternating scheme (1:1, standard prophylaxis with mostly cefuroxime versus a broad-spectrum prophylaxis of a combined single-shot of vancomycin 1 g & gentamicin 5 mg/kg parenterally). The primary outcomes are "remission" at 6 weeks; or at 1 year for surgeries with implant. Secondary outcomes are the risk for prophylaxis-resistant SSI pathogens, revision surgery for any reason, change of antibiotic therapy, adverse events and the incidence of non-SSI infections within 6 weeks (e.g. urine infections). With event-free surgeries to 95% in the broad-spectrum versus 85% in the standard arm, we need 2 x 207 orthopedic surgeries among all groups. Discussion: In selected patients with a high risk for prophylaxis-resistant SSI, a broad-spectrum combination might prevent SSIs better than the standard prophylaxis. Trial registration: ClinicalTrial.gov NCT05502380. Registered on 12 August 2022. Protocol version: 2 (3 June 2022

Repair of large segmental bone defects: BMP-2 gene activated muscle grafts vs. autologous bone grafting

Background: Common cell based strategies for the treatment of osseous defects require the isolation and expansion of autologous cells. Since this makes such approaches time-consuming and expensive, we developed a novel expedited technology creating gene activated muscle grafts. We have previously shown that large segmental bone defects in rats can be regenerated by implantation of muscle tissue fragments activated by BMP-2 gene transfer. Results: In the present study, we compared the bone healing capacities of such gene activated muscle grafts with bone isografts, mimicking autologous bone grafting, the clinical gold standard for treatment of bone defects in patients. Two of 14 male, syngeneic Fischer 344 rats used for this experiment served as donors for muscle and bone. Muscle tissue was harvested from both hind limbs and incubated with an adenoviral vector carrying the cDNA encoding BMP-2. Bone was harvested from the iliac crest and long bone epiphyses. Bone defects (5 mm) were created in the right femora of 12 rats and were filled with either BMP-2 activated muscle tissue or bone grafts. After eight weeks, femora were evaluated by radiographs, micro-computed tomography (mu CT), and biomechanical testing. In the group receiving BMP-2 activated muscle grafts as well as in the bone-grafting group, 100\% of the bone defects were healed, as documented by radiographs and mu CT-imaging. Bone volume was similar in both groups and biomechanical stability of the two groups was statistically indistinguishable. Conclusions: This study demonstrates that treatment of large bone defects by implantation of BMP-2 gene activated muscle tissue leads to similar bone volume and stability as bone isografts, mimicking autologous bone grafting

The use of stained cytologic direct smears for ALK gene rearrangement analysis of lung adenocarcinoma

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/100150/1/cncy21286.pd

Associations of Statin Use with Deep Surgical Site Infections and Late Non-Infectious Revision Surgeries in Patients Undergoing Orthopedic Surgery: A Clinical Cohort Study

Statins have multiple preventive properties. We investigate if a chronic perioperative statin medication for cardiovascular indications reduces deep orthopedic surgical site infections (SSI), and other late non-infectious complications, in adult patients. We performed a single-center cohort of primary orthopedic interventions 2014-2019; with the exclusion of infection surgery and diabetic foot surgery. Group comparisons with Cox regression analyses; with and without propensity-score matching (nearest neighbor approach). We included 20,088 interventions in 20,088 different patients (median age 53 years, 49% females, 5% diabetes mellitus). Among them, 2,486 episodes (12%) revealed a pre-operative statin therapy (222 different brands and doses). After a median follow-up of 11 months, 1,414 episodes needed a surgical revision: 158 (0.8%) due to deep SSI and 1256 (6.3%) for non-infectious reasons. In multivariate Cox regression analyses, statin use was unrelated to both SSI (hazard ratio (HR) 0.9; 95% confidence interval (CI) 0.6-1.4) and non-infectious complications (HR 1.1, 95%CI 0.9-1.3). We equally lacked associations when we associated deep SSIS with statin use for the subgroups of implant-related surgery (HR 0.8, 95%CI 0.4-1.6) or orthroplasties (HR 0.8, 95%CI 0.3-2.6), separately. Likewise, propensity-score matched analyses on the variable “statin” equally failed to alter these outcomes. In our large cohort study with 20,088 orthopedic interventions, we found no protective association of a statin medication on deep SSI risks; or on other late non-infectious complications requiring revision surgery. Keywords statin medication, orthopedic surgery, surgical site infection, revision surgery, epidemiolog

Role of the 2 zebrafish survivin genes in vasculo-angiogenesis, neurogenesis, cardiogenesis and hematopoiesis

<p>Abstract</p> <p>Background</p> <p>Normal growth and development of organisms requires maintenance of a dynamic balance between systems that promote cell survival and those that induce apoptosis. The molecular mechanisms that regulate these processes remain poorly understood, and thus further <it>in vivo </it>study is required. Survivin is a member of the inhibitor of apoptosis protein (IAP) family, that uniquely also promotes mitosis and cell proliferation. Postnatally, survivin is hardly detected in most tissues, but is upregulated in all cancers, and as such, is a potential therapeutic target. Prenatally, survivin is also highly expressed in several tissues. Fully delineating the properties of survivin <it>in vivo </it>in mice has been confounded by early lethal phenotypes following <it>survivin </it>gene inactivation.</p> <p>Results</p> <p>To gain further insights into the properties of survivin, we used the zebrafish model. There are 2 zebrafish <it>survivin </it>genes (<it>Birc5a </it>and <it>Birc5b</it>) with overlapping expression patterns during early development, prominently in neural and vascular structures. Morpholino-induced depletion of <it>Birc5a </it>causes profound neuro-developmental, hematopoietic, cardiogenic, vasculogenic and angiogenic defects. Similar abnormalities, all less severe except for hematopoiesis, were evident with suppression of <it>Birc5b</it>. The phenotypes induced by morpholino knockdown of one <it>survivin </it>gene, were rescued by overexpression of the other, indicating that the <it>Birc5 </it>paralogs may compensate for each. The potent vascular endothelial growth factor (VEGF) also entirely rescues the phenotypes induced by depletion of either <it>Birc5a </it>and <it>Birc5b</it>, highlighting its multi-functional properties, as well as the power of the model in characterizing the activities of growth factors.</p> <p>Conclusion</p> <p>Overall, with the zebrafish model, we identify survivin as a key regulator of neurogenesis, vasculo-angiogenesis, hematopoiesis and cardiogenesis. These properties of survivin, which are consistent with those identified in mice, indicate that its functions are highly conserved across species, and point to the value of the zebrafish model in understanding the role of this IAP in the pathogenesis of human disease, and for exploring its potential as a therapeutic target.</p

Incidence of Revision Surgery After Decompression With vs Without Fusion Among Patients With Degenerative Lumbar Spinal Stenosis.

Importance Only limited data derived from large prospective cohort studies exist on the incidence of revision surgery among patients who undergo operations for degenerative lumbar spinal stenosis (DLSS). Objective To assess the cumulative incidence of revision surgery after 2 types of index operations-decompression alone or decompression with fusion-among patients with DLSS. Design, Setting, and Participants This cohort study analyzed data from a multicenter, prospective cohort study, the Lumbar Stenosis Outcome Study, which included patients aged 50 years or older with DLSS at 8 spine surgery and rheumatology units in Switzerland between December 2010 and December 2015. The follow-up period was 3 years. Data for this study were analyzed between October and November 2021. Exposures All patients underwent either decompression surgery alone or decompression with fusion surgery for DLSS. Main Outcomes and Measures The primary outcome was the cumulative incidence of revision operations. Secondary outcomes included changes in the following patient-reported outcome measures: Spinal Stenosis Measure (SSM) symptom severity (higher scores indicate more pain) and physical function (higher scores indicate more disability) subscale scores and the EuroQol Health-Related Quality of Life 5-Dimension 3-Level questionnaire (EQ-5D-3L) summary index score (lower scores indicate worse quality of life). Results A total of 328 patients (165 [50.3%] men; median age, 73.0 years [IQR, 66.0-78.0 years]) were included in the analysis. Of these, 256 (78.0%) underwent decompression alone and 72 (22.0%) underwent decompression with fusion. The cumulative incidence of revisions after 3 years of follow-up was 11.3% (95% CI, 7.4%-15.1%) for the decompression alone group and 13.9% (95% CI, 5.5%-21.5%) for the fusion group (log-rank P = .60). There was no significant difference in the need for revision between the 2 groups over time (unadjusted absolute risk difference, 2.6% [95% CI, -6.3% to 11.4%]; adjusted absolute risk difference, 3.9% [95% CI, -5.2% to 17.0%]; adjusted hazard ratio, 1.40 [95% CI, 0.63-3.13]). The number of revisions was significantly associated with higher SSM symptom severity scores (β, 0.171; 95% CI, 0.047-0.295; P = .007) and lower EQ-5D-3L summary index scores (β, -0.061; 95% CI, -0.105 to -0.017; P = .007) but not with higher SSM physical function scores (β, 0.068; 95% CI, -0.036 to 0.172; P = .20). The type of index operation was not significantly associated with the corresponding outcomes. Conclusions and Relevance This cohort study showed no significant association between the type of index operation for DLSS-decompression alone or fusion-and the need for revision surgery or the outcomes of pain, disability, and quality of life among patients after 3 years. Number of revision operations was associated with more pain and worse quality of life

Application of immunocytochemistry and BRAF mutational analysis to direct smears of metastatic melanoma

BACKGROUND: The cytodiagnosis of melanoma in fine‐needle aspiration (FNA) specimens can be challenging, often requiring the use of immunocytochemistry. As constitutively activating mutations in the BRAF oncogene are present in at least 40% of melanomas, the use of FNA material to interrogate the BRAF mutational status is likely to increase. Because cell blocks, traditionally used for these studies, can occasionally exhibit insufficient tumor cellularity, the authors investigated the utility of direct smears for immunocytochemistry and BRAF mutational analysis. METHODS: Immunocytochemistry for S‐100, HMB‐45, and Mart‐1 was prospectively performed on direct smears in 17 FNAs of metastatic melanoma. Next, BRAF sequencing was performed using DNA isolated from archived Diff‐Quik–stained direct smears for 15 cases. In parallel, sequencing was performed using DNA obtained from corresponding cell blocks. RESULTS: S‐100 positivity in the tumor cells was observed in all 17 cases. HMB‐45 and Mart‐1 positivity was noted in 81% and 88% of cases, respectively. All 3 markers were positive in 76% of cases. Next, of the 15 archived melanoma FNAs tested, BRAF mutations were observed in 8 (53%); 5 and 3 melanomas harbored the V600E and V600K mutation, respectively. Corresponding cell blocks were also tested for all 15 cases, yielding concordant BRAF results in 14 (93%); 1 cell block yielded a false‐negative result. CONCLUSIONS: Cytologic direct smears represent a robust and valuable source of cellular material for immunocytochemistry and molecular studies, especially in instances in which inadequate cell block cellularity is anticipated or encountered. Cancer (Cancer Cytopathol) 2012. © 2011 American Cancer Society. This study demonstrates that direct smears represent a robust and valuable source of cellular material for ancillary studies used in the cytologic diagnosis of melanoma. Direct smears can be effectively used for confirmatory immunocytochemical studies and molecular assays designed to interrogate the BRAF mutational status of melanoma, especially in scenarios in which inadequate cell block cellularity is anticipated or encountered.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90193/1/20180_ftp.pd

Increased cranio-caudal spinal cord oscillations are the cardinal pathophysiological change in degenerative cervical myelopathy.

INTRODUCTION Degenerative cervical myelopathy (DCM) is the most common cause of non-traumatic incomplete spinal cord injury, but its pathophysiology is poorly understood. As spinal cord compression observed in standard MRI often fails to explain a patient's status, new diagnostic techniques to assess DCM are one of the research priorities. Minor cardiac-related cranio-caudal oscillations of the cervical spinal cord are observed by phase-contrast MRI (PC-MRI) in healthy controls (HCs), while they become pathologically increased in patients suffering from degenerative cervical myelopathy. Whether transversal oscillations (i.e., anterior-posterior and right-left) also change in DCM patients is not known. METHODS We assessed spinal cord motion simultaneously in all three spatial directions (i.e., cranio-caudal, anterior-posterior, and right-left) using sagittal PC-MRI and compared physiological oscillations in 18 HCs to pathological changes in 72 DCM patients with spinal canal stenosis. The parameter of interest was the amplitude of the velocity signal (i.e., maximum positive to maximum negative peak) during the cardiac cycle. RESULTS Most patients suffered from mild DCM (mJOA score 16 (14-18) points), and the majority (68.1%) presented with multisegmental stenosis. The spinal canal was considerably constricted in DCM patients in all segments compared to HCs. Under physiological conditions in HCs, the cervical spinal cord oscillates in the cranio-caudal and anterior-posterior directions, while right-left motion was marginal [e.g., segment C5 amplitudes: cranio-caudal: 0.40 (0.27-0.48) cm/s; anterior-posterior: 0.18 (0.16-0.29) cm/s; right-left: 0.10 (0.08-0.13) cm/s]. Compared to HCs, DCM patients presented with considerably increased cranio-caudal oscillations due to the cardinal pathophysiologic change in non-stenotic [e.g., segment C5 amplitudes: 0.79 (0.49-1.32) cm/s] and stenotic segments [.g., segment C5 amplitudes: 0.99 (0.69-1.42) cm/s]). In contrast, right-left [e.g., segment C5 amplitudes: non-stenotic segment: 0.20 (0.13-0.32) cm/s; stenotic segment: 0.11 (0.09-0.18) cm/s] and anterior-posterior oscillations [e.g., segment C5 amplitudes: non-stenotic segment: 0.26 (0.15-0.45) cm/s; stenotic segment: 0.11 (0.09-0.18) cm/s] remained on low magnitudes comparable to HCs. CONCLUSION Increased cranio-caudal oscillations of the cervical cord are the cardinal pathophysiologic change and can be quantified using PC-MRI in DCM patients. This study addresses spinal cord oscillations as a relevant biomarker reflecting dynamic mechanical cord stress in DCM patients, potentially contributing to a loss of function