A Mobile Phone-Based Telemonitoring Program for Heart Failure Patients After an Incidence of Acute Decompensation (Medly-AID): Protocol for a Randomized Controlled Trial.

BACKGROUND: Patients with heart failure (HF) are at the highest risk for hospital readmissions during the first few weeks after discharge when patients are transitioning from hospital to home. Telemonitoring (TM) for HF management has been found to reduce mortality risk and hospital readmissions if implemented appropriately; however, the impact of TM targeted for patients recently discharged from hospital, for whom TM might have the biggest benefit, is still unknown. Medly, a mobile phone-based TM system that is currently being used as a standard of care for HF at a large Canadian hospital, may be an effective tool for the management of HF in patients recently discharged from hospital. OBJECTIVE: The objective of the Medly-After an Incidence of acute Decompensation (Medly-AID) trial is to determine the effect of Medly on the self-care and quality of life of patients with HF who have been recently discharged from hospital after an HF-related decompensation. METHODS: A multisite multimethod randomized controlled trial (RCT) will be conducted at 2 academic hospitals and at least one community hospital to evaluate the impact of Medly-enabled HF management on the outcomes of patients with HF who had been hospitalized for HF-related decompensation and discharged during the 2 weeks before recruitment. The trial will include 144 participants with HF (74 in each control and intervention groups). Control patients will receive standard of care, whereas patients in the intervention group will receive standard of care and Medly. Specifically, patients in the intervention group will record daily weight, blood pressure, and heart rate and answer symptom-related questions via the Medly app. Medly will generate automated patient self-care messages such as to adjust diuretic medications, based on the rules-based algorithm personalized to the individual patient, and send real-time alerts to their health care providers as necessary. All patients will be followed for 3 months. Primary outcome measures are self-care and quality of life as measured through the validated questionnaires Self-Care of Heart Failure Index, EQ-5D-5L, and the Kansas City Cardiomyopathy Questionnaire-12. Secondary outcome measures for this study include cost of health care services used and health outcomes. RESULTS: Patient recruitment began in November 2018 at the Sunnybrook Health Sciences Centre, with a total of 35 participants recruited by July 30, 2019 (17 in the intervention group and 18 in the control group). The final analysis is expected to occur in the fall of 2020. CONCLUSIONS: This RCT will be the first to assess the effectiveness of the Medly TM system for use following discharge from hospital after a HF-related decompensation. TRIAL REGISTRATION: ClinicalTrials.gov NCT03358303; https://clinicaltrials.gov/ct2/show/NCT03358303. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15753.

Neurofeedback as a form of cognitive rehabilitation therapy following stroke: A systematic review.

Neurofeedback therapy (NFT) has been used within a number of populations however it has not been applied or thoroughly examined as a form of cognitive rehabilitation within a stroke population. Objectives for this systematic review included: i) identifying how NFT is utilized to treat cognitive deficits following stroke, ii) examining the strength and quality of evidence to support the use of NFT as a form of cognitive rehabilitation therapy (CRT) and iii) providing recommendations for future investigations. Searches were conducted using OVID (Medline, Health Star, Embase + Embase Classic) and PubMed databases. Additional searches were completed using the Cochrane Reviews library database, Google Scholar, the University of Toronto online library catalogue, ClinicalTrials.gov website and select journals. Searches were completed Feb/March 2015 and updated in June/July/Aug 2015. Eight studies were eligible for inclusion in this review. Studies were eligible for inclusion if they: i) were specific to a stroke population, ii) delivered CRT via a NFT protocol, iii) included participants who were affected by a cognitive deficit(s) following stroke (i.e. memory loss, loss of executive function, speech impairment etc.). NFT protocols were highly specific and varied within each study. The majority of studies identified improvements in participant cognitive deficits following the initiation of therapy. Reviewers assessed study quality using the Downs and Black Checklist for Measuring Study Quality tool; limited study quality and strength of evidence restricted generalizability of conclusions regarding the use of this therapy to the greater stroke population. Progression in this field requires further inquiry to strengthen methodology quality and study design. Future investigations should aim to standardize NFT protocols in an effort to understand the dose-response relationship between NFT and improvements in functional outcome. Future investigations should also place a large emphasis on long-term participant follow-up.

Patient perceptions of implantable cardioverter-defibrillator deactivation discussions: A qualitative study.

BACKGROUND: There is a class I recommendation for implantable cardioverter-defibrillator deactivation discussions to occur between physicians and heart failure patients. Few studies have reported the patient's perspective on the timing of implantable cardioverter-defibrillator deactivation discussions. AIM: To determine patient awareness, preferences and timing of implantable cardioverter-defibrillator deactivation discussions. DESIGN: Grounded theory was used to collect and analyze interview data from 25 heart failure patients with an implantable cardioverter-defibrillator. SETTING AND PARTICIPANTS: Patients with an implantable cardioverter-defibrillator, from the Heart Function Clinic at University Health Network (Toronto, Canada). RESULTS: The sample (n = 25) was predominately male (76%) with an average age of 62 years. Patients identified three stages where they felt implantable cardioverter-defibrillator deactivation should be discussed: (1) prior to implantation, (2) with any significant deterioration but while they were of sound mind to engage in and communicate their preferences and (3) at end of life, where patients wished further review of their previously established preferences and decisions about implantable cardioverter-defibrillator deactivation. Most patients (n = 17, 68%) said they would consider deactivation, six (24%) were undecided and two (8%) were adamant they would never turn it off. CONCLUSION: The patient preferences identified in this study support the need to include information on implantable cardioverter-defibrillator deactivation at implant, with change in clinical status and within broader discussions about end-of-life treatment preferences. Using this process to help patients determine and communicate their implantable cardioverter-defibrillator deactivation preferences may reduce the number of patients experiencing distressing implantable cardioverter-defibrillator shocks at end of life.

A Qualitative Synthesis of Families' and Students' Hospital-to-School Transition Experiences Following Acquired Brain Injury.

Acquired brain injury (ABI) is one of the greatest causes of death and disability among children in Canada. Following ABI, children are required to transition back to school and adapt to the physical, cognitive, behavioral, social, and emotional demands of the school environment. We conducted a qualitative systematic review of students' and parents' experiences of the transition back to school following ABI. We identified 20 articles that met our inclusion criteria. Six themes emerged: (a) lack of ABI-specific education for families and professionals, (b) communication-related factors as a facilitator and/or barrier to transition, (c) emotional focus, (d) peer relationships, (e) supports, and (f) ABI sequelae in the classroom. Students' and families' personal motivations and abilities and the support they receive in their environment affect their experiences of transitioning back to school and the disrupted occupations they face.

Using heart failure instruments to determine when to refer heart failure patients to palliative care.

AIM: The purpose of this study was to determine whether the Edmonton Symptom Assessment Scale (ESAS) or the Palliative Performance Scale (PPS) are associated with traditionally used scores for heart failure patients -- specifically, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), an overall health visual analog scale (VAS), and the Seattle Heart Failure Model (SHFM). Furthermore, we sought to determine whether the PPS or the ESAS provided additional information on quality of life, symptom severity, or prognosis above that provided by the traditional scores for patients with heart failure. METHODS: We administered the ESAS, MLHFQ, VAS, PPS, and SHFM in a shuffled manner to 78 New York Heart Association Functional Classification (NYHA-FC) Ill-IV ambulatory heart failure patients. Pearson's r correlation was used to determine whether the scores from the ESAS and PPS correlated with the scores from the MLHFQ, VAS, and SHFM. RESULTS: The sample was predominately male (62.8 percent), mean age 60.1 +/- 13 years, with a diagnosis of idiopathic cardiomyopathy (45 percent). Moderate correlations were found between the ESAS and MLHFQ (r = 0.483, p < 0.01), the ESAS and VAS (r = -0.345, p < 0.01), the PPS and MLHFQ (r = -0.54, p < 0.01), and the PPS and VAS (r = 0.53, p < 0.01). There was no significant correlation between the PPS and SHFM. CONCLUSION: The results of this study suggest that administration of the ESAS and PPS provides additional information on symptom severity and functional decline for patients with heart failure. Standardized administration of these scales may aid in the assessment and evaluation of heart failure patients.