Icelandic stroke survivors: Functioning and contextual factors and ActivABLES for home-based exercise and physical activity

Aims: The aims of this thesis were: (1) to describe functioning and contextual factors of community-dwelling stroke survivors 1-2 years after their first stroke, based on the International Classification of Functioning, Disability and Health (ICF) with focus on potential differences between age-groups, (2) to describe the process of developing ActivABLES, which aims to increase home-based therapeutic exercise and daily physical activity among stroke survivors, and (3) to investigate the feasibility of ActivABLES in terms of acceptability, demand, implementation and practicality. Methods: A cross-sectional national survey was used to collect data. Potential participants were identified through registries from the two main hospitals in Iceland and included community-dwelling stroke survivors who had been admitted with their first stroke 1-2 years earlier. Exclusion criteria included living in nursing homes, diagnosis of dementia, not having an Icelandic national insurance number and living abroad. Participants were 114 (56.2% response rate), 50% men, 27 to 94 years old (71.6±12.9 years), and categorized into the age-groups: ≥75 years(n=51), 65-74 years (n=34) and <65 years (n=29). They answered questions on health, functioning (body function, activities, participation) and contextual factors (environmental, personal) along with two standardized questionnaires, the Stroke Impact Scale (SIS) and the Behavioural Regulation Exercise Questionnaire-2 (BREQ-2). The process of developing ActivABLES was guided by principles of human-centred design and the Medical Research Council framework for development and evaluation of complex interventions. A mixed methods design was utilized to test the feasibility of ActivABLES among ten stroke survivors (55–79 years) who used six prototypes for four weeks with support from their informal caregivers. Data collection included measures on balance, mobility and hand function before and after the four-week period, along with adherence diaries and motion detectors. Semi-structured interviews were conducted with the stroke survivors and their caregivers after the four-week period. Themes were identified related to four domains of feasibility: acceptability, demand, implementation and practicality. Data was integrated by examining any (dis)congruence in the quantitative and qualitative findings. Results: The results from the cross-sectional survey revealed a complex and informative pattern of functioning and contextual factors in the lives of community-dwelling stroke survivors, where the most common symptom immediately after the stroke was balance impairments. Some differences and similarities in functioning and contextual factors were found between the age- groups. The oldest participants reported more comorbidities, used more walking devices and fewer smart devices than both younger groups. In the SIS, the oldest participants had lower scores than both younger groups in the domains of activities of daily living and mobility. The development of ActivABLES resulted in six prototypes which were tested in the feasibility study: (1) ActivFOAM for balance exercises, (2) WalkingSTARR to facilitate walking, (3) ActivBALL for hand exercises, (4) ActivSTICKS for upper arm exercises, and (5) ActivLAMP and (6) ActivTREE which both give visual feedback on progress of exercise and physical activity. ActivFOAM, ActivBALL and ActivSTICKS were all connected to a tablet which gave exercise instructions. All the exercise prototypes could be connected to ActivLAMP and ActivTREE to give feedback on the magnitude of exercise. Settings could be individualised and recommended in daily time and/or repetition could easily be progressed to match higher activity levels. In the feasibility study, improvements in functional measures were shown after the four-week use and more physical activity was detected with motion detectors. The themes identified from the interviews for each feasibility domain were: (1) acceptability: appreciation, functional improvements, self-initiated activities and expressed potential use for future stroke survivors; (2) demand: reported use, interest in further use and need for follow-up; (3) implementation: importance of feedback, variety of exercises and progression of exercises; and (4) practicality: need for support and technical problems. The quantitative and qualitative findings converged well with each other and supported the feasibility of ActivABLES. Conclusion: This thesis is a good example of how the international language of ICF can be used to holistically describe functioning and contextual factors of a population and how a technical application can be developed and used by stroke survivors to increase exercise and physical activity. Our results show that stroke survivors are highly capable of using ActivABLES in community rehabilitation. Future research should focus on further studies in larger samples to prepare full development and marketing of ActivABLES. Thereby, it is important to focus on heterogeneity among older stroke survivors and the fact that they need person-centred rehabilitation but not “one fit for all”.Markmið: Markmið doktorsverkefnisins voru að: (1) lýsa færni og aðstæðum einstaklinga sem búa í heimahúsum 1-2 árum eftir að hafa fengið fyrsta heilaslag, á grundvelli alþjóða flokkunarkerfisins ICF um færni, fötlun og heilsu og með áherslu á mögulegan mun á milli einstaklinga í þremur aldurshópum, (2) lýsa þróun á tæknibúnaðinum ActivABLES sem miðar að því að auka þátttöku einstaklinga sem hafa fengið heilaslag í markvissum heimaæfingum og daglegri hreyfingu og (3) meta fýsileika ActivABLES með því að rýna í ásættanleika, eftirspurn, útbúnað og hentugleika tæknibúnaðarins. Aðferðir: Þversniðskönnun á landsvísu þar sem upplýsingar um mögulega þátttakendur komu úr sjúkraskrám um þá sem höfðu verið lagðir inn með sjúkdómsgreininguna heilaslag í fyrsta sinn á tímabilinu 1.apríl 2016 – 31.mars 2017. Útilokunarskilyrði voru búseta á hjúkrunarheimili, vitræn skerðing samkvæmt sjúkdómsgreiningu, íslenska kennitölu vantar og búseta erlendis. Þátttakendur voru 114 (56,2% þátttökuhlutfall), 50% karlar, á aldrinum 27-94 ára (71,6±12,9 ára) og úr þremur aldurshópum: 75 ára og eldri (n=51), 65-74 ára (n=34) og yngri en 65 ára (n=29). Könnunin samanstóð af spurningum um heilsufar, færni (líkamsstarfsemi, athafnir og þátttöku) og aðstæður (persónubundnar og umhverfistengdar) ásamt tveimur stöðluðum spurningalistum; Mælistiku um áhrif heilaslags (SIS) og Spurningalista um viðhorf til æfinga (BREQ-2). Þróun ActivABLES var byggð á persónumiðaðri nálgun og líkani um þróun og mat á margþátta íhlutunum frá Medical Research Council í Bretlandi. Blandað snið var notað til að rannsaka fýsileika ActivABLES með tíu einstaklingum (55-79 ára) sem höfðu fengið heilaslag og notuðu sex frumgerðir af tæknibúnaðinum til æfinga og hreyfingar yfir fjögurra vikna tímabil með aðstoð aðstandenda. Jafnvægi, hreyfifærni og færni handa var metin með stöðluðum mælitækjum fyrir og eftir tímabilið, dagleg hreyfing var metin með hreyfimælum og þátttakendur skráðu notkun og athugasemdir í dagbók. Í lokin voru tekin hálf-stöðluð viðtöl við þátttakendur og aðstandendur. Við þemagreiningu viðtalsgagna var tekið tillit til fjögurra þátta fýsileika; ásættanleika, krafna, útbúnaðar og hentugleika. Megindleg og eigindleg gögn voru síðan sameinuð og greint hvort niðurstöður voru samhljóma. Niðurstöður: Niðurstöður könnunarinnar sýndu margbreytilegt og flókið samspil færni og aðstæðna hjá þátttakendum. Algengasta einkennið strax í kjölfar heilaslags var skerðing á jafnvægi. Við samanburð á færni og aðstæðum milli aldurshópa kom fram munur en einnig líkindi á milli hópa. Elsti hópurinn hafði meiri fjölkvilla, notaði frekar gönguhjálpartæki og síður snjalltæki en yngri hóparnir. Jafnframt fékk elsti hópurinn færri stig en yngri hóparnir í þáttum í SIS-spurningalistanum sem lúta að athöfnum dagslegs lífs og hreyfanleika. Þróunarferli ActivABLES skilaði sex frumgerðum sem voru prófaðar í fýsileikarannsókninni: (1) ActivFOAM fyrir jafnvægisæfingar, (2) WalkingSTARR til að ýta undir göngu, (3) ActivBALL til að æfa færni handa og efri útlima, (4) ActivSTICKS til að æfa færni efri útlima, og (5) ActivLAMP og (6) ActivTREE sem veittu endurgjöf í formi ljóss eftir því sem þátttakandanum miðaði áfram í heimaæfingum og hreyfingu. ActivFOAM, ActivBALL og ActivSTICKS voru öll tengd við spjaldtölvu sem sýndi æfingarnar. Þær fjórar frumgerðir sem voru til æfinga og þjálfunar voru tengdar við ActivLAMP eða ActivTREE sem veittu sjónræna endurgjöf um magn æfinga og hreyfingar. Stillingar voru einstaklingsmiðaðar og einfalt var að breyta ráðleggingum um tímalengd og/eða fjölda endurtekninga fyrir viðeigandi stignun. Í fýsileikarannsókninni komu fram bætingar í stöðluðum mælingum að lokinni fjögurra vikna notkun og hreyfimælar sýndu meiri líkamlega virkni. Greining á niðurstöðum fyrir hvern þátt fýsileika leiddi í ljós eftirfarandi þemu: (1) ásættanleiki: þakklæti, meiri færni, frumkvæði í virkni og möguleg notkun fyrir einstaklinga sem munu fá heilaslag í framtíðinni; (2) eftirspurn: raunveruleg notkun, áhugi á frekari notkun og þörf fyrir eftirfylgd; (3) útbúnaður: mikilvægi endurgjafar, fjölbreytni í æfingu og framgangur í æfingum; og (4) hentugleiki: þörf á aðstoð og tæknileg vandkvæði. Megindlegar og eigindlegar niðurstöður voru mjög samhljóma og studdu vel við fýsileika ActivABLES. Ályktun: Þetta verkefni er gott dæmi um hvernig nýta má alþjóðlega flokkunarkerfi ICF fyrir heildræna lýsingu á færni og aðstæðum ákveðins hóps af einstaklingum og hvernig þróa má tæknibúnað tengdan snjalltækjum fyrir einstaklinga sem hafa fengið heilaslag fyrir markvissar heimaæfingar og daglegra hreyfingu. Fýsileiki ActivABLES fyrir einstaklinga sem hafa fengið heilaslag rennir stoðum undir mikilvægi tæknibúnaðar í endurhæfingu þessa hóps og kallar á frekari rannsóknir í stærri hópum til að fullvinna tæknibúnaðinn og koma honum á markað. Frekari rannsóknir á færni og aðstæðum eldri einstaklinga eru einnig nauðsynlegar til að sýna fram á þá staðreynd að endurhæfing einstaklinga eftir heilaslag þarf að vera fjölbreytt og einstaklingsmiðuð.NordForsk, Ranní

Maternal diet in early and late pregnancy in relation to weight gain

To access Publisher full text version of this article. Please click on the hyperlink in Additional Links fieldOBJECTIVE: To identify dietary factors related to the risk of gaining weight outside recommendations for pregnancy weight gain and birth outcome.Design:An observational study with free-living conditions.Subjects:Four hundred and ninety five healthy pregnant Icelandic women. METHODS: The dietary intake of the women was estimated with a semiquantitative food frequency questionnaire covering food intake together with lifestyle factors for the previous 3 months. Questionnaires were filled out at between 11 and 15 weeks and between 34 and 37 weeks gestation. Comparison of birth outcome between the three weight gain groups was made with ANOVA and Bonferroni post hoc tests. Dietary factors related to at least optimal and excessive weight gain during pregnancy were represented with logistic regression controlling for potential confounding. RESULTS: Of the women, 26% gained suboptimal and 34% excessive weight during pregnancy. Women in late pregnancy with at least optimal, compared with women with suboptimal, weight gain were eating more (OR = 3.32, confidence interval (CI)=1.81-6.09, P < 0.001) and drinking more milk (OR = 3.10, CI = 1.57-6.13, P = 0.001). The same dietary factors were related to excessive, compared with optimal, weight gain. Furthermore, eating more sweets early in pregnancy increased the risk of gaining excessive weight (OR=2.52, CI=1.10-5.77, P=0.029). Women with a body mass index of 25.0-29.9 kg/m(2) before pregnancy were most likely to gain excessive weight (OR = 7.37, CI 4.13-13.14, P < 0.001). Women gaining suboptimal weight gave birth to lighter children (P < 0.001) and had shorter gestation (P = 0.008) than women gaining optimal or excessive weight. CONCLUSION: Women who are overweight before pregnancy should get special attention regarding lifestyle modifications affecting consequent weight gain during pregnancy. They are most likely to gain excessive weight and therefore most likely to suffer pregnancy and delivery complications and struggle with increasing overweight and obesity after giving birth

SciKit-SurgeryGlenoid, an Open Source Toolkit for Glenoid Version Measurement

Correct understanding of the geometry of the glenoid (the socket of the shoulder joint) is key to successful planning of shoulder replacement surgery. This surgery typically involves placing an implant in the shoulder joint to restore joint function. The most relevant geometry is the glenoid version, which is the angular orientation of the glenoid surface relative to the long axis of the scapula in the axial plane. However, measuring the glenoid version is not straightforward and there are multiple measurement methods in the literature and used in commercial planning software. In this paper we introduce SciKit-SurgeryGlenoid, an open source toolkit for the measurement of glenoid version. SciKit-SurgeryGlenoid contains implementations of the 4 most frequently used glenoid version measurement algorithms enabling easy and unbiased comparison of the different techniques. We present the results of using the software on 10 sets of pre-operative CT scans taken from patients who have subsequently undergone shoulder replacement surgery. We further compare these results with those obtained from a commercial implant planning software. SciKit-SurgeryGlenoid currently requires manual segmentation of the relevant anatomical features for each method. Future work will look at automating the segmentation process to build an automatic and repeatable pipeline from CT or radiograph to quantitative glenoid version measurement

Individual risk assessment and information technology to optimise screening frequency for diabetic retinopathy.

To access publisher full text version of this article. Please click on the hyperlink in Additional Links field.AIMS/HYPOTHESIS: The aim of this study was to reduce the frequency of diabetic eye-screening visits, while maintaining safety, by using information technology and individualised risk assessment to determine screening intervals. METHODS: A mathematical algorithm was created based on epidemiological data on risk factors for diabetic retinopathy. Through a website, www.risk.is , the algorithm receives clinical data, including type and duration of diabetes, HbA(1c) or mean blood glucose, blood pressure and the presence and grade of retinopathy. These data are used to calculate risk for sight-threatening retinopathy for each individual's worse eye over time. A risk margin is defined and the algorithm recommends the screening interval for each patient with standardised risk of developing sight-threatening retinopathy (STR) within the screening interval. We set the risk margin so that the same number of patients develop STR within the screening interval with either fixed annual screening or our individualised screening system. The database for diabetic retinopathy at the Department of Ophthalmology, Aarhus University Hospital, Denmark, was used to empirically test the efficacy of the algorithm. Clinical data exist for 5,199 patients for 20 years and this allows testing of the algorithm in a prospective manner. RESULTS: In the Danish diabetes database, the algorithm recommends screening intervals ranging from 6 to 60 months with a mean of 29 months. This is 59% fewer visits than with fixed annual screening. This amounts to 41 annual visits per 100 patients. CONCLUSION: Information technology based on epidemiological data may facilitate individualised determination of screening intervals for diabetic eye disease. Empirical testing suggests that this approach may be less expensive than conventional annual screening, while not compromising safety. The algorithm determines individual risk and the screening interval is individually determined based on each person's risk profile. The algorithm has potential to save on healthcare resources and patients' working hours by reducing the number of screening visits for an ever increasing number of diabetic patients in the world

DMEK Surgery at a Tertiary Hospital in Sweden. Results and Complication Risks

Kinga Dabrowska-Kloda,1 Eydis Olafsdottir,1 Anastasia Stefanou,1 Sven Crafoord1,2 1Department of Ophthalmology, Örebro University Hospital, Örebro, Sweden; 2Department of Ophthalmology, Faculty of Medicine and Health, Örebro University, Örebro, SwedenCorrespondence: Kinga Dabrowska-Kloda, Department of Ophthalmology, Örebro University Hospital, PO Box 1613, Örebro, SE 70116, Sweden, Tel +46 19 6021000, Fax +46 19 6021052, Email [email protected]: This study reports clinical outcomes up to 6 years after Descemet’s membrane endothelial keratoplasty (DMEK) performed at the Department of Ophthalmology, Örebro University Hospital, Örebro, Sweden.Methods: The study has a cross-sectional and case series design. Inclusion criteria were all DMEK-operated eyes during 2013– 2018 until repeat keratoplasty.Results: Altogether 162 eyes from 120 patients were enrolled. Among eyes without preoperative comorbidities, examined 1– 6 years after DMEK, 85.8% achieved visual acuity of 0.1 logMAR or better. The median endothelial cell density (ECD) loss was 27% in a cohort of eyes examined 1– 2 years post-DMEK, 31% at 2– 3 years, 42% at 3– 4 years, and > 60% at 4– 6 years post–DMEK. ECD at the examination timepoint was correlated with donor ECD (as expected) and time since surgery.Conclusion: The results from DMEK surgeries in Örebro, Sweden, are promising. Further studies with even longer follow–up are needed to evaluate graft sustainability.Keywords: DMEK, Descemet’s membrane endothelial keratoplasty, endothelial cell density, endothelial cell loss, corneal surgery in Sweden, corneal surgery in Scandinavi

The interaction of adiposity with the CRP gene affects CRP levels: age, gene/environment susceptibilty-Reykjavik study

To access publisher full text version of this article. Please click on the hyperlink in Additional Links fieldOBJECTIVE: Common diseases often have an inflammatory component reflected by associated markers such as serum C-reactive protein (CRP) levels. Circulating CRP levels have also been associated with adipose tissue as well as with specific CRP genotypes. We examined the interaction between measures of body mass index (BMI), waist circumference and fat percent (total fat measured by bioimpedance) with genotypes of the CRP gene in the determination of CRP levels. METHODS: The first 2296 participants (mean age 76+/-6 years, 42% men) in the Age, Gene/Environment Susceptibility-Reykjavik Study, a multidisciplinary epidemiological study to determine risk factors in aging, were genotyped for 10 single nucleotide polymorphisms (SNPs) in the CRP gene. General linear models with age and terms for interaction of CRP genotypes with BMI, waist circumference and percent fat were used to evaluate the association of genotypes to CRP levels (high-sensitivity method, range 0-10 mg l(-1)) in men and women separately. RESULTS: We focused on the SNP rs1205 that represents the allele that captures the strongest effects of the gene on CRP levels. Carriers of the rs1205 G allele had significantly higher CRP levels than noncarriers in a dose-dependent manner. Compared to the AA genotype, the slope of the increase in CRP with increasing BMI (P=0.045) and waist circumference (P=0.014) was different for the G allele carriers and of similar magnitude in both men and women. The rs1205 interactions were not significant for fat mass percent, suggesting a possible association with fat localization. CONCLUSIONS: This study further illuminates the known association between measures of adiposity and CRP levels and is shown to be dependent on variation in the rs1205 SNP of the CRP gene. The correlated increase in CRP levels with adiposity is accentuated by presence of the G allele

Genomic and phenotypic analysis of BRCA2 mutated breast cancers reveals co-occurring changes linked to progression

To access publisher full text version of this article. Please click on the hyperlink in Additional Links field.Inherited mutations in the BRCA2 gene greatly increase the risk of developing breast cancer. Consistent with an important role for BRCA2 in error-free DNA repair, complex genomic changes are frequently observed in tumors derived from BRCA2 mutation carriers. Here, we explore the impact of DNA copy-number changes in BRCA2 tumors with respect to phenotype and clinical staging of the disease. METHODS: Breast tumors (n = 33) derived from BRCA2 999del5 mutation carriers were examined in terms of copy-number changes with high-resolution aCGH (array comparative genomic hybridization) containing 385 thousand probes (about one for each 7 kbp) and expression of phenotypic markers on TMAs (tissue microarrays). The data were examined with respect to clinical parameters including TNM staging, histologic grade, S phase, and ploidy. RESULTS: Tumors from BRCA2 carriers of luminal and basal/triple-negative phenotypes (TNPs) differ with respect to patterns of DNA copy-number changes. The basal/TNP subtype was characterized by lack of pRb (RB1) coupled with high/intense expression of p16 (CDKN2A) gene products. We found increased proportions of Ki-67-positive cells to be significantly associated with loss of the wild-type (wt) BRCA2 allele in luminal types, whereas BRCA2wt loss was less frequent in BRCA2 tumors displaying basal/TNP phenotypes. Furthermore, we show that deletions at 13q13.1, involving the BRCA2wt allele, represents a part of a larger network of co-occurring genetic changes, including deletions at 6q22.32-q22.33, 11q14.2-q24.1, and gains at 17q24.1. Importantly, copy-number changes at these BRCA2-linked networking regions coincide with those associated with advanced progression, involving the capacity to metastasize to the nodes or more-distant sites at diagnosis. CONCLUSIONS: The results presented here demonstrate divergent paths of tumor evolution in BRCA2 carriers and that deletion of the wild-type BRCA2 allele, together with co-occurring changes at 6 q, 11 q, and 17 q, are important events in progression toward advanced disease.Eimskipafelag University Minningarsjodur Bergthoru Magnusdottur and Jakobs J Bjarnasonar Gongum Saman Icelandic Cancer Research Fund SKI Icelandic Centre for Research RANNIS The University of Icelan