Chatbots to Support Mental Wellbeing of People Living in Rural Areas: Can User Groups Contribute to Co-design?

Digital technologies such as chatbots can be used in the field of mental health. In particular, chatbots can be used to support citizens living in sparsely populated areas who face problems such as poor access to mental health services, lack of 24/7 support, barriers to engagement, lack of age appropriate support and reductions in health budgets. The aim of this study was to establish if user groups can design content for a chatbot to support the mental wellbeing of individuals in rural areas. University students and staff, mental health professionals and mental health service users (N = 78 total) were recruited to workshops across Northern Ireland, Ireland, Scotland, Finland and Sweden. The findings revealed that participants wanted a positive chatbot that was able to listen, support, inform and build a rapport with users. Gamification could be used within the chatbot to increase user engagement and retention. Content within the chatbot could include validated mental health scales and appropriate response triggers, such as signposting to external resources should the user disclose potentially harmful information or suicidal intent. Overall, the workshop participants identified user needs which can be transformed into chatbot requirements. Responsible design of mental healthcare chatbots should consider what users want or need, but also what chatbot features artificial intelligence can competently facilitate and which features mental health professionals would endorse.

Tick (Acari: Ixodidae) infestation at two rural, seasonal camps in Maine and Vermont.

In July 2008, owners of seasonal camps in Vermont and Maine were exposed to large numbers of questing ticks after opening their camps for the season. Examination of collected specimens revealed that the camp in Vermont was infested with Ixodes cookei Packard, and the camp in Maine was infested with Ixodes marxi Banks. In both instances, numerous tick bites were reported by residents. Both camps were also occupied by wildlife during the off-season, primarily squirrels (Maine) and skunks (Vermont). Subsequent samples from the Vermont site were tested for the presence of Powassan encephalitis virus, though no viral activity was detected.

Partnering with clinical providers to enhance the efficiency of an EMR.

Implementing an electronic medical record to replace paper records and associated processes does not guarantee the benefits of an EMR will be achieved. Specifically, it can introduce steps into a provider's work flow that adversely affect the projected benefits of efficiency, and, ultimately, quality and safety. At Mayo Clinic in Rochester, Minnesota, implementation of the Mayo Integrated Clinical Systems, or MICS, the organization's EMR, is nearly complete. However providers perceive inefficiencies in their work flow using MICS. In response, a study was undertaken to enhance MICS and associated processes to improve provider efficiency. Through direct observation and feedback from 101 providers, this study identified seven major themes for enhancements: training; work flow and processes; dual environments; navigation-viewing integration;patient-reported information; clinical problems management; and consolidated medication documentation. This paper reviews the methods used to collect and analyze the data and discusses how improvement opportunities can positively enhance efficiency in using an EMR.

Functional strength training in cerebral palsy: a pilot study of a group circuit training class for children aged 4-8 years.

OBJECTIVE: To determine the effects of intensive task-specific strength training on lower limb strength and functional performance in children with cerebral palsy. DESIGN: A nonrandomized ABA trial. SETTING: Sydney school. SUBJECTS: Eight children with cerebral palsy, aged 4-8 years, seven with diagnosis of spastic diplegia, one of spastic/ataxic quadriplegia. INTERVENTION: Four weeks of after-school exercise class, conducted for one hour twice weekly as group circuit training. Each work station was set up for intensive repetitive practice of an exercise. Children moved between stations, practising functionally based exercises including treadmill walking, step-ups, sit-to-stands and leg presses. MAIN OUTCOME MEASURES: Baseline test obtained two weeks before training, a pre-test immediately before and a post-test following training, with follow-up eight weeks later. Lower limb muscle strength was tested by dynamometry and Lateral Step-up Test; functional performance by Motor Assessment Scale (Sit-to-Stand), minimum chair height test, timed 10-m test, and 2-minute walk test. RESULTS: Isometric strength improved pre- to post-training by a mean of 47% (SD 16) and functional strength, on Lateral Step-up Test, by 150% (SD 15). Children walked faster over 10 m, with longer strides, improvements of 22% and 38% respectively. Sit-to-stand performance had improved, with a reduction of seat height from 27 (SD 15) to 17 (SD 11) cm. Eight weeks following cessation of training all improvements had been maintained. CONCLUSIONS: A short programme of task-specific strengthening exercise and training for children with cerebral palsy, run as a group circuit class, resulted in improved strength and functional performance that was maintained over time.

Survival effect of lung transplantation among patients with cystic fibrosis.

CONTEXT: Patients with cystic fibrosis (CF) are the second largest group of lung transplant recipients in the United States. The survival effect of transplantation on a general CF population has not previously been measured. OBJECTIVE: To determine the impact of bilateral lung transplantation on survival in patients with CF. DESIGN, SETTING, AND PATIENTS: Retrospective observational cohort study of 11 630 CF patients who did not undergo lung transplantation (controls) and 468 transplant recipients with CF from 115 CF centers in the United States, 1992-1998. Patients were stratified into 5 groups based on a 5-year survival prediction model (survival group 1: <30%; survival group 2: 30 to <50%; survival groups 3-5: 50 to <100%.) MAIN OUTCOME MEASURE: Five-year survival from date of transplantation in 1992-1997 in the transplant group and from January 1, 1993, in the control group. RESULTS: Lung transplantation increased 5-year survival of CF patients in survival group 1. Survival group 2 had equivocal survival effects, and groups 3-5 had negative survival effects from transplantation. From 1994-1997, there was a mean annual prevalence of 238 patients in survival group 1 and mean annual incidence of 154 patients entering the group, approximately 1.5 times the number of lung transplantations performed each year in CF patients (mean, 104). Use of the criterion of forced expiratory volume in 1 second of less than 30% resulted in an equivocal survival benefit and identified 1458 potential candidates for transplantation in 1993. CONCLUSIONS: Cystic fibrosis patients in group 1 have improved 5-year survival after lung transplantation. The majority of patients with CF have equivocal or negative survival effects from the procedure. Selection of patients with CF for transplantation based on group 1 survival predictions maximizes survival benefits to individuals and may reduce the demand for scarce donor organs.

Prevention of bone loss and fracture after lung transplantation: a pilot study.

BACKGROUND: Osteoporotic fracture is a significant source of morbidity after lung transplantation. Therapies to prevent posttransplant fracture are largely untested among lung transplant recipients. METHODS: In this prospective uncontrolled study, lung transplant referrals were assessed for bone health with metabolic, radiographic, and bone mineral density measurements. Transplant recipients were treated with an antiresorptive regimen that included a bisphosphonate starting before or after transplantation. One year after transplantation, the fracture rate and bone density of patients in each group were reassessed and compared to historical controls. Between January 1996 and August 1999, 45/50 (90%) lung transplant referrals underwent bone health assessment. Transplant candidates received calcium, vitamin D, and hormone replacement therapy as indicated for hypogonadism. After July 1998, bisphosphonate therapy was added for candidates with osteopenia or osteoporosis (T score <1). After transplantation, all patients received 90 mg of pamidronate i.v. every 12 weeks, regardless of pretransplant bone density. Radiologic evaluation was performed for clinical suspicion of fracture. Bone density was remeasured 1 year after transplantation. RESULTS: Most transplant referrals suffered from osteopenia or osteoporosis, and 29% of transplant referrals had prevalent vertebral compression fractures. Hypogonadism was untreated in 50% of men and 20% of women, and 15% of patients had hypovitaminosis D. Of the 21 patients assessed 1 year after transplantation, new fractures occurred in 4% of these patients. Lateral lumbar spine and hip bone density remained stable or improved in 65% and 86% of patients, respectively. Most of those who lost bone density had started bisphosphonate therapy after transplantation. CONCLUSIONS: Antiresorptive therapy with a bisphosphonate decreases the fracture rate and preserves bone mass 1 year after lung transplantation. In end-stage lung disease patients with osteopenia or osteoporosis, bisphosphonate therapy should be initiated before transplant surgery is contemplated.

The three critical components in the conservative treatment of juvenile osteochondritis dissecans (JOCD). Physician, parent, and child.

There has been explosive growth of intensive, year-round sports for children of both sexes, with a resulting high degree of family involvement and commitment. Consequently, a diagnosis of juvenile osteochondritis dissecans (JOCD) impacts parent and child on many different levels. Compliance is the key element when a conservative treatment plan for JOCD is appropriate. An informed physician understands the dynamics between the "compliance triad" of physician, parent, and child, and recognizes that compliance is a process with foreseeable stages and characteristic behaviors.

Predictive 5-year survivorship model of cystic fibrosis.

The objective of this study was to create a 5-year survivorship model to identify key clinical features of cystic fibrosis. Such a model could help researchers and clinicians to evaluate therapies, improve the design of prospective studies, monitor practice patterns, counsel individual patients, and determine the best candidates for lung transplantation. The authors used information from the Cystic Fibrosis Foundation Patient Registry (CFFPR), which has collected longitudinal data on approximately 90% of cystic fibrosis patients diagnosed in the United States since 1986. They developed multivariate logistic regression models by using data on 5,820 patients randomly selected from 11,630 in the CFFPR in 1993. Models were tested for goodness of fit and were validated for the remaining 5,810 patients for 1993. The validated 5-year survivorship model included age, forced expiratory volume in 1 second as a percentage of predicted normal, gender, weight-for-age z score, pancreatic sufficiency, diabetes mellitus, Staphylococcus aureus infection, Burkerholderia cepacia infection, and annual number of acute pulmonary exacerbations. The model provides insights into the complex nature of cystic fibrosis and supplies a rigorous tool for clinical practice and research.

Tracheobronchial metal stents: effects of covering a bronchial ostium in pigs.

RATIONALE AND OBJECTIVES: The purpose of this study was to examine the effects of placing a metal stent across a bronchial orifice. MATERIALS AND METHODS: Nine pigs were used as test subjects, because the right upper lobe bronchus comes directly off the trachea in these animals. One of three types of metal stents was placed into the trachea of each pig and covered the orifice of the right upper lobe bronchus. Follow-up studies were performed at 1 and 3 months to evaluate the right upper lobe for signs of bronchial obstruction, infection, and atelectasis. The animals were sacrificed at 3 months to study the histopathologic changes of the trachea and lungs. RESULTS: Two upper lobe bronchi remained patent; seven were obstructed by granulation tissue or plugs of mucus and inflammatory cells. Right upper lobe infiltration and atelectasis were seen in eight animals. Interestingly, radiographic opacities were also common in other lung segments. There was a tendency toward fewer and less extensive lung opacities at 3 months compared with that at 1 month. At histopathologic examination, areas of both acute and chronic pneumonia were found in the right upper lobe of all animals. The segment of trachea covered by the stent was lined with a thin layer of granulation tissue containing neutrophils, monocytes, and lymphocytes. The stent luminal surface was covered with columnar, cuboidal, and stratified squamous epithelium. Tracheal stenosis was seen in three animals because of excessive granulation tissue in two and a collapsed stent in one. CONCLUSION: Placement of metal stents in pig trachea covering the orifice of the right upper lobe bronchus resulted in retention of secretions and secondary infection in the right upper lobe and other distant lung segments.

Inter-segmental co-ordination in sit-to-stand: an age cross-sectional study.

BACKGROUND AND PURPOSE: Being able to sit-to-stand (STS) effectively is an important functional skill, but there is little information available on the changes that occur with growth and maturity. This study aimed to investigate the inter-segmental co-ordination of STS in three different age groups (12-18 months, 4-5 years and 9-10 years). METHOD: The children studied wore reflective markers and were videotaped as they stood up from a height-adjustable seat that straddled a forceplate. Segmental kinematics and vertical ground reaction force were determined from the co-ordinate and forceplate data. RESULTS: Even at the earliest developmental stage the children had mastered the basic inter-segmental pattern observed in adults. The youngest children, however, were not able to end the movement in quiet standing; rather they raised up on their toes or took a step forward. Performance varied both within and between subjects. Although there was a similarity in the motor pattern used by the younger subjects to that of the older subjects, developmental trends were evident on the videotapes and on examination of the kinematic and kinetic variables. Movement time, amplitude and peak angular velocity of trunk flexion increased with age. Whereas the children in the older age groups displayed a pattern of vertical ground reaction force similar to that reported for adults, the youngest children tended to reach peak force gradually, often with fluctuations. Although there were characteristic trajectories in the phase-plane plots for each group, the overall trend was for the percentage of smooth plots representing a co-ordinated movement, to increase with age. CONCLUSIONS: Differences in inter-segmental co-ordination between the ages studied may relate to the child's ability to control horizontal momentum and to balance.

The clinical importance of the anaerobic energy system and its assessment in human performance.

The anaerobic energy system is involved in providing energy for all forms of physical activity. The relevance of this system to human performance and physical fitness throughout the age spectrum is underscored here and contrasted with the aerobic energy system. The anaerobic system responds to high-intensity training with biochemical, neural, and anatomic adaptations. Unlike the aerobic system, this response tends to be primarily a local phenomenon with little systemic adaptation. An important factor distinguishing anaerobic training from aerobic training is the intensity of the exercise dose. For anaerobic training to occur, the dose must be of high intensity and performed to near-exhaustion. The anaerobic system can be indirectly assessed by performance tests, such as a vertical jump or stair climb, or more directly by supramaximal bicycle tests. The impact of recent research regarding the trainability of the anaerobic system, particularly in the elderly population, is encouraging. The elderly respond to anaerobic training and, as a result, their independence, quality of life, and safety from falls can be improved. While little is known about anaerobic rehabilitation after injury, it is known that isokinetic and performance tests may be considered normal after rehabilitation, despite incomplete rehabilitation of the anaerobic system. Thus, appropriate application of the anaerobic system assessments and training principles is an important aspect of sports medicine practice.

Aspergillus airway colonization and invasive disease after lung transplantation.

BACKGROUND: Invasive Aspergillus is an important cause of morbidity and mortality among lung transplant recipients. The diagnosis can be difficult and treatment is often unsuccessful so many centers preemptively treat all Aspergillus airway isolates to prevent invasive disease. This approach is untested as little is known about the relationship between Aspergillus airway colonization and invasive disease. This study was undertaken to evaluate the incidence of Aspergillus airway colonization after lung transplantation and the risk of invasive disease after colonization. DESIGN: All cultures and histologic specimens obtained from a consecutive series of 151 lung transplant cases were reviewed for the presence of Aspergillus and compared with clinical data. RESULTS: Aspergillus was isolated from the airway in 69 (46%) of 151 transplant recipients. Invasive disease occurred in five cases and was uniformly fatal, accounting for 13% of all posttransplant deaths. Results of cytologic examination of BAL fluid were normal in all cases of invasive disease and cultures were positive in only one of five patients prior to invasion. Invasive disease occurred exclusively in patients who died or were colonized with Aspergillus fumigatus within the first 6 months posttransplant. Patients growing A. fumigatus from the airway during the first 6 months were 11 times more likely to develop invasive disease relative to those not colonized. CONCLUSION: Aspergillus airway colonization after lung transplantation is common and in most cases, transient. In contrast, invasive Aspergillus disease is less common, but fatal. Bronchoscopy with cytologic examination and fungal culture are not sensitive or timely predictors of invasive disease. Invasive Aspergillus occurred only in patients initially colonized with A. fumigatus within the first 6 months posttransplant. A trial of empiric anti-Aspergillus therapy limited to the first 6 months posttransplant may be warranted.

Methotrexate for lung transplant recipients with steroid-resistant acute rejection.

BACKGROUND: Steroid-resistant or recurrent acute rejection is a risk factor for the development of chronic graft failure in lung transplant recipients. The best treatment for these patients is not known. Methotrexate has been used successfully in heart transplant recipients with persistent or recurrent acute rejection. This study was performed to evaluate the efficacy of methotrexate in lung transplant recipients with steroid-resistant acute rejection. METHODS: From January 1991 to December 1995, 12 patients with steroid-resistant acute rejection were treated with methotrexate given weekly for 6 weeks and dose-adjusted according to laboratory data and clinical side effects. After completion of therapy, all patients underwent transbronchial biopsy to evaluate the efficacy of methotrexate treatment. RESULTS: Twelve patients underwent treatment with methotrexate for steroid-resistant acute rejection. Acute rejection resolved in all patients completing at least 4 weeks of therapy; 10 of 12 patients (83%) had no further episodes of acute rejection during a mean follow-up period of 12.5 months (range 1 to 42 months). Acute rejection recurred in two patients 6 and 16 months after methotrexate therapy. Both resolved with high-dose corticosteroid therapy. One patient had asymptomatic cytomegalovirus shedding 8 weeks after completion of methotrexate therapy. One patient had aseptic meningitis after her fourth dose of methotrexate. Neither infectious complication was associated with neutropenia. One patient had bone marrow suppression and neutropenic fevers after augmentation of her methotrexate dose. Two patients received shortened methotrexate courses because of gastrointestinal side effects. CONCLUSIONS: Methotrexate is efficacious in the treatment of lung transplant recipients with steroid-resistant acute rejection. Patients must be monitored for side effects during therapy and dosing must be individualized based on laboratory and clinical parameters.

Influence of child diagnosis on family and parental functioning: Down syndrome versus other disabilities.

Although children with Down syndrome are popularly conceived of as having easy temperaments and agreeable personalities, conflicting reports exist as to whether they are easier to rear than are children with other developmental disabilities. To compensate for possibly biased samples in earlier studies, we employed three methodological strategies, including case-by-case matching of families raising children with Down syndrome and families raising children with other types of developmental disabilities. Results showed no differences between matched groups on various measures of functioning, a finding replicated with multiple regression techniques. However, in unmatched samples families of children with Down syndrome showed better functioning. Thus, previous research demonstrating better adjustment for families rearing children with Down syndrome should be re-examined for sampling biases.

Non-radioisotopic detection of human xenogeneic DNA in a mouse transplantation model.

Xenogeneic mouse models are widely used for the study of human tumor growth and metastasis. To date, few methods have been developed to track and quantitate the colonization of mouse organs with transplanted human cells. In this paper, a family of nonradioisotopic DNA oligonucleotide probes that are complementary to sequences within the human Alu element are characterized. These probes can be used in Southern hybridization reactions to quantitate the colonization of mouse organs with human derived cells. One oligonucleotide probe, the Alu-C probe, was identified as the most sensitive and specific in the family of probes synthesized for the distinction of human genomic DNA in a mouse genomic DNA background. The Alu-C probe can identify 0.05 ng human diploid DNA in a mouse background of 500 ng of genomic DNA. This represents 7.5 human diploid cells admixed with 75,000 mouse diploid cells. The Alu-C probe can therefore be employed to assess human colonization in xenograft models for a variety of human tumors and non-neoplastic tissues.

Glomerular disease and lung transplantation.

Three patients with lung or heart/lung transplants developed nephrotic-range proteinuria 2 to 5 years posttransplantation. Kidney biopsy showed focal segmental glomerulosclerosis in two patients and probable focal sclerosis in the third. A retrospective review of postmortem kidney specimens from 18 lung transplant recipients who died did not indicate additional cases of glomerular disease. The three patients with glomerular disease after lung transplantation had very few clinical similarities other than nephrotic-range proteinuria and lung transplantation. Their underlying lung diseases were different, and their posttransplantation courses were very different in terms of pulmonary function, cyclosporine nephrotoxicity, and other complications. We did not find in the literature previous reports of de novo focal segmental glomerulosclerosis or other glomerular lesions after lung transplantation. We suspect that additional cases will be identified in the future.

Prevalence of anabolic steroid use among illinois high school students.

This study was conducted to quantify anabolic steroid use in Illinois, investigate student knowledge and perception of anabolic steroid use, and identify characteristics of the anabolic steroid user. We surveyed 3047 freshman and senior high school students from 38 high schools, randomly selected from three school enrollment sizes and five geographic locations, using a six-page anonymous questionnaire. Anabolic steroid use was reported by 58 (1.9%) of the participants, 44 of 1477 (3%) males and 14 of 1562 (0.9%) females. Thirty-four of 1679 (2%) freshman and 24 of 1366 (1.8%) seniors reported use. Anabolic steroids were used in all possible school enrollment sizes and geographic locations (matrix cells). Four (7%) of the users reported starting at age 10 or younger. A teacher/coach was reported as a primary source by 8 (14%) of the users, as well as identified by 11 (19%) of the users as the individual they knew using anabolic steroids. It appears that anabolic steroids are being introduced to students in elementary and junior high schools, and that teachers/coaches are actively involved in their use.