Heart Rate Variability as a Reliable Biomarker Following Concussion: A Critically Appraised Topic.

CLINICAL SCENARIO: Recent systematic reviews show conflicting information regarding the effect of concussion on cardiac autonomic function. Controlled aerobic exercise is the most popular intervention for those recovering from a concussion. There is a gap in the literature supporting the utility of objective metrics during exertional return to play protocols and rehabilitation. CLINICAL QUESTION: Can heart rate variability (HRV) during physical exertion be a reliable biomarker over time for those who suffered a sport-related concussion? SUMMARY OF KEY FINDINGS: A literature search produced 3 studies relevant to the clinical question. One, a prospective-matched control group cohort study, reported disturbances in HRV during physical exertion in those with a history of concussion, and identified persistent HRV dysfunction after resolution of subjective complaints, return to play, and with multiple concussive events. Second, a cross-sectional cohort study found an HRV difference in those with and without a history of concussion and in HRV related to age and sex. Finally, the prospective longitudinal case-control cohort study did not find sex or age differences in HRV and concluded that, although postconcussion HRV improved as time passed, resting HRV was not as clinically meaningful as HRV during exertional activities. CLINICAL BOTTOM LINE: There is emerging evidence to support the use of HRV as an observable biomarker, over time, of autonomic function during physical exertion following a sport-related concussion. However, the meaningfulness of HRV data is not fully understood and the utility seems individualized to the level of athlete, age, and sex and, therefore, cannot be generalizable. In order to be more clinically meaningful and to assist with current clinical decision making regarding RTP, a preinjury baseline assessment would be beneficial as an individualized reference for baseline comparison. STRENGTH OF RECOMMENDATION: Although HRV is not fully understood, currently, there is grade B evidence to support the use of individualized baseline exertional HRV data as comparative objective metric to assess the autonomic nervous system function, over time, following a concussive event.

Correction: Association Between Improvement in Baseline Mood and Long-Term Use of a Mindfulness and Meditation App: Observational Study.

[This corrects the article DOI: 10.2196/12617.].

Characterizing Emotional State Transitions During Prolonged Use of a Mindfulness and Meditation App: Observational Study.

BACKGROUND: The increasing demand for mental health care, a lack of mental health care providers, and unequal access to mental health care services have created a need for innovative approaches to mental health care. Digital device apps, including digital therapeutics, that provide recommendations and feedback for dealing with stress, depression, and other mental health issues can be used to adjust mood and ultimately show promise to help meet this demand. In addition, the recommendations delivered through such apps can also be tailored to an individual's needs (ie, personalized) and thereby potentially provide greater benefits than traditional "one-size-fits-all" recommendations. OBJECTIVE: This study aims to characterize individual transitions from one emotional state to another during the prolonged use of a digital app designed to provide a user with guided meditations based on their initial, potentially negative, emotional state. Understanding the factors that mediate such transitions can lead to improved recommendations for specific mindfulness and meditation interventions or activities (MMAs) provided in mental health apps. METHODS: We analyzed data collected during the use of the Stop, Breathe & Think (SBT) mindfulness app. The SBT app prompts users to input their emotional state before and immediately after engaging with MMAs recommended by the app. Data were collected from more than 650,000 SBT users engaging in nearly 5 million MMAs. We limited the scope of our analysis to users with 10 or more MMA sessions that included at least 6 basal emotional state evaluations. Using clustering techniques, we grouped emotions recorded by individual users and then applied longitudinal mixed effect models to assess the associations between individual recommended MMAs and transitions from one group of emotions to another. RESULTS: We found that basal emotional states have a strong influence on transitions from one emotional state to another after MMA engagement. We also found that different MMAs impact these transitions, and many were effective in eliciting a healthy transition but only under certain conditions. In addition, we observed gender and age effects on these transitions. CONCLUSIONS: We found that the initial emotional state of an SBT app user determines the type of SBT MMAs that will have a favorable effect on their transition from one emotional state to another. Our results have implications for the design and use of guided mental health recommendations for digital device apps.

Association Between Improvement in Baseline Mood and Long-Term Use of a Mindfulness and Meditation App: Observational Study.

BACKGROUND: The use of smartphone apps to monitor and deliver health care guidance and interventions has received considerable attention recently, particularly with regard to behavioral disorders, stress relief, negative emotional state, and poor mood in general. Unfortunately, there is little research investigating the long-term and repeated effects of apps meant to impact mood and emotional state. OBJECTIVE: We aimed to investigate the effects of both immediate point-of-intervention and long-term use (ie, at least 10 engagements) of a guided meditation and mindfulness smartphone app on users' emotional states. Data were collected from users of a mobile phone app developed by the company Stop, Breathe & Think (SBT) for achieving emotional wellness. To explore the long-term effects, we assessed changes in the users' basal emotional state before they completed an activity (eg, a guided meditation). We also assessed the immediate effects of the app on users' emotional states from preactivity to postactivity. METHODS: The SBT app collects information on the emotional state of the user before and after engagement in one or several mediation and mindfulness activities. These activities are recommended and provided by the app based on user input. We considered data on over 120,000 users of the app who collectively engaged in over 5.5 million sessions with the app during an approximate 2-year period. We focused our analysis on users who had at least 10 engagements with the app over an average of 6 months. We explored the changes in the emotional well-being of individuals with different emotional states at the time of their initial engagement with the app using mixed-effects models. In the process, we compared 2 different methods of classifying emotional states: (1) an expert-defined a priori mood classification and (2) an empirically driven cluster-based classification. RESULTS: We found that among long-term users of the app, there was an association between the length of use and a positive change in basal emotional state (4% positive mood increase on a 2-point scale every 10 sessions). We also found that individuals who were anxious or depressed tended to have a favorable long-term emotional transition (eg, from a sad emotional state to a happier emotional state) after using the app for an extended period (the odds ratio for achieving a positive emotional state was 3.2 and 6.2 for anxious and depressed individuals, respectively, compared with users with fewer sessions). CONCLUSIONS: Our analyses provide evidence for an association between both immediate and long-term use of an app providing guided meditations and improvements in the emotional state.

Immune tolerance induction using a factor VIII/von Willebrand factor concentrate (BIOSTATE), with or without immunosuppression, in Australian paediatric severe haemophilia A patients with high titre inhibitors: a multicentre, retrospective study.

INTRODUCTION: It has been postulated that factor VIII (FVIII) products containing von Willebrand factor (VWF) may improve immune tolerance induction (ITI) success rate in patients with haemophilia A and poor prognostic factors. MATERIALS AND METHODS: We conducted a retrospective cohort analysis of a FVIII/VWF concentrate (BIOSTATE) for ITI in paediatric patients with severe haemophilia A (SHA) and inhibitors, from January 2003 to December 2011 at 3 paediatric-only Haemophilia Treatment Centres in Australia. Response to ITI was assessed at or before 33 months and at completion of ITI. Fifteen male patients with SHA were included in the analysis. RESULTS: BIOSTATE was used for primary ITI in 8 patients (2 years, range 1.1-11.5 years) and for salvage ITI in 7 patients (9.9 years, range 1.1-15.4). At the end of the observation period there were 11 patients who achieved a complete response with BIOSTATE after a median duration of 21 months (range 5-85 months); a partial response was achieved in 2 patients in whom ITI is ongoing. Therefore, the overall response rate was 86.6%. Two patients were deemed treatment failures: one due to non-compliance after 18 months of ITI and another in whom a partial response had not been achieved after 22 months of ITI. CONCLUSION: BIOSTATE was well-tolerated and effective when used for primary or salvage ITI in this cohort of paediatric patients with SHA and a high-level inhibitor.

Barriers to Independent Living for Individuals with Disabilities and Seniors.

Individuals with disabilities and seniors often lack the freedom to choose with whom they live and where they reside. Service options may involve moving consumers to large nursing facilities or other less-preferred settings rather than optimizing environmental supports in their own home or in less restrictive settings. Not only do adults usually enjoy greater choice when they live in their own homes relative to individuals living in congregate care or group home settings but independent and semi-independent settings are also associated with better outcomes and lower costs. Identifying variables that serve as barriers to independent living is especially important given estimates predicting that the numbers of seniors and individuals with disabilities will double in the next 20 years. This doubling will tax an already burdened and costly system of care. The present study queried consumers and other key stakeholders about potential barriers to independent living and their importance. Findings not only revealed a high degree of overlap between identified barriers and their importance ratings within groups but also showed clear differences in potential barriers across the groups assessed (individuals with disabilities and senior citizens).

Allogeneic bone marrow transplantation in juvenile myelomonocytic leukemia without total body irradiation.

Allogeneic bone marrow transplantation (BMT) without a total body irradiation (TBI) conditioning regimen was investigated in children with juvenile myelomonocytic leukemia (JMML). Eight consecutive patients with JMML (n = 6) or monosomy 7 (n = 2) underwent BMT at a median age of 20 months. Donor source included fully matched related (n = 3), mismatched related (n = 2), or fully matched unrelated (n = 3). The conditioning regimen included busulfan, cyclophosphamide, and etoposide (VP16) (melphalan was substituted for VP16 in one patient). The first patient in the series underwent TBI. Graft-versus-host disease prophylaxis was with cyclosporin and methotrexate and in vivo T-cell depletion (Campath 1 g) for mismatched and unrelated transplants. Seven and two patients, respectively, received chemotherapy and splenectomy before BMT. At a median follow-up of 48 months after BMT, five patients remained in remission. The overall survival rate was 63% at 5 years. All deaths occurred in patients with refractory disease at the time of BMT. Allogeneic BMT without TBI appears to be effective therapy for JMML and avoids some of the potential late sequelae of TBI in preschool children.