Toward the Value Sensitive Design of eHealth Technologies to Support Self-management of Cardiovascular Diseases: Content Analysis.

BACKGROUND: eHealth can revolutionize the way self-management support is offered to chronically ill individuals such as those with a cardiovascular disease (CVD). However, patients' fluctuating motivation to actually perform self-management is an important factor for which to account. Tailoring and personalizing eHealth to fit with the values of individuals promises to be an effective motivational strategy. Nevertheless, how specific eHealth technologies and design features could potentially contribute to values of individuals with a CVD has not been explicitly studied before. OBJECTIVE: This study sought to connect a set of empirically validated, health-related values of individuals with a CVD with existing eHealth technologies and their design features. The study searched for potential connections between design features and values with the goal to advance knowledge about how eHealth technologies can actually be more meaningful and motivating for end users. METHODS: Undertaking a technical investigation that fits with the value sensitive design framework, a content analysis of existing eHealth technologies was conducted. We matched 11 empirically validated values of CVD patients with 70 design features from 10 eHealth technologies that were previously identified in a systematic review. The analysis consisted mainly of a deductive coding stage performed independently by 3 members of the study team. In addition, researchers and developers of 6 of the 10 reviewed technologies provided input about potential feature-value connections. RESULTS: In total, 98 connections were made between eHealth design features and patient values. This meant that some design features could contribute to multiple values. Importantly, some values were more often addressed than others. CVD patients' values most often addressed were related to (1) having or maintaining a healthy lifestyle, (2) having an overview of personal health data, (3) having reliable information and advice, (4) having extrinsic motivators to accomplish goals or health-related activities, and (5) receiving personalized care. In contrast, values less often addressed concerned (6) perceiving low thresholds to access health care, (7) receiving social support, (8) preserving a sense of autonomy over life, and (9) not feeling fear, anxiety, or insecurity about health. Last, 2 largely unaddressed values were related to (10) having confidence and self-efficacy in the treatment or ability to achieve goals and (11) desiring to be seen as a person rather than a patient. CONCLUSIONS: Positively, existing eHealth technologies could be connected with CVD patients' values, largely through design features that relate to educational support, self-monitoring support, behavior change support, feedback, and motivational incentives. Other design features such as reminders, prompts or cues, peer-based or expert-based human support, and general system personalization were also connected with values but in narrower ways. In future studies, the inferred feature-value connections must be validated with empirical data from individuals with a CVD or similar chronic conditions.

The Dutch COVID-19 Contact Tracing App (the CoronaMelder): Usability Study.

BACKGROUND: Adoption and evaluation of contact tracing tools based on information and communications technology may expand the reach and efficacy of traditional contact tracing methods in fighting COVID-19. The Dutch Ministry of Health, Welfare and Sports initiated and developed CoronaMelder, a COVID-19 contact tracing app. This app is based on a Google/Apple Exposure Notification approach and aims to combat the spread of the coronavirus among individuals by notifying those who are at increased risk of infection due to proximity to someone who later tests positive for COVID-19. The app should support traditional contact tracing by faster tracing and greater reach compared to regular contact tracing procedures. OBJECTIVE: The main goal of this study is to investigate whether the CoronaMelder is able to support traditional contact tracing employed by public health authorities. To achieve this, usability tests were conducted to answer the following question: is the CoronaMelder user-friendly, understandable, reliable and credible, and inclusive? METHODS: Participants (N=44) of different backgrounds were recruited: youth with varying educational levels, youth with an intellectual disability, migrants, adults (aged 40-64 years), and older adults (aged >65 years) via convenience sampling in the region of Twente in the Netherlands. The app was evaluated with scenario-based, think-aloud usability tests and additional interviews. Findings were recorded via voice recordings, observation notes, and the Dutch User Experience Questionnaire, and some participants wore eye trackers to measure gaze behavior. RESULTS: Our results showed that the app is easy to use, although problems occurred with understandability and accessibility. Older adults and youth with a lower education level did not understand why or under what circumstances they would receive notifications, why they must share their key (ie, their assigned identifier), and what happens after sharing. In particular, youth in the lower-education category did not trust or understand Bluetooth signals, or comprehend timing and follow-up activities after a risk exposure notification. Older adults had difficulties multitasking (speaking with a public health worker and simultaneously sharing the key in the app). Public health authorities appeared to be unprepared to receive support from the app during traditional contact tracing because their telephone conversation protocol lacks guidance, explanation, and empathy. CONCLUSIONS: The study indicated that the CoronaMelder app is easy to use, but participants experienced misunderstandings about its functioning. The perceived lack of clarity led to misconceptions about the app, mostly regarding its usefulness and privacy-preserving mechanisms. Tailored and targeted communication through, for example, public campaigns or social media, is necessary to provide correct information about the app to residents in the Netherlands. Additionally, the app should be presented as part of the national coronavirus measures instead of as a stand-alone app offered to the public. Public health workers should be trained to effectively and empathetically instruct users on how to use the CoronaMelder app.

The Challenges of Treating Female Soccer Players With ACL Injuries: Hamstring Versus Bone-Patellar Tendon-Bone Autograft.

BACKGROUND: Although anterior cruciate ligament (ACL) injuries are common in female soccer players, the optimal graft option for ACL reconstruction is currently unclear. PURPOSE/HYPOTHESIS: To compare the outcomes of female soccer players after ACL reconstruction using either hamstring tendon autograft or bone-patellar tendon-bone (BTB) autograft. We hypothesized that there would be no difference in clinical outcome scores, return to sport, or retear rates between BTB and hamstring grafts in our study cohort. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We performed a retrospective review of all skeletally mature adolescent female soccer players who underwent primary ACL reconstruction using either hamstring tendon or BTB autograft between 2013 and 2016. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation, Tegner activity score, and visual analog scales for pain and for satisfaction, as well as ability to return to sport. RESULTS: Overall, 90 female soccer players met the inclusion criteria, of whom 79% (41 BTB and 30 hamstring) were available for a minimum 2-year follow-up or had a graft failure before the follow-up. The BTB group had a lower body mass index (mean ± SD, 23 ± 3 vs 25 ± 4; P = .02) and shorter postoperative follow-up time in months (mean ± SD, 37.4 vs 46.1; P ≤ .001); otherwise, no differences in demographic, injury, or surgical variables between groups were noted. Regarding outcome measures, the BTB group achieved a higher Tegner score (6.0 vs 4.2; P = .004), and there was no other difference between groups. Of the patients who did not return to soccer, 44.7% reported fear as the reason. Of the patients who did return to soccer, 31.9% sustained another ACL injury (retear or contralateral tear), with no differences in reinjury rates based on graft selection. CONCLUSION: Adolescent female soccer players undergoing ACL reconstruction had relatively high satisfaction and outcome scores independent of autograft choice. Notwithstanding, patients and families need to be counseled that less than half of patients will return to their preinjury level of sport and, if an athlete attempts to return, there is a high risk of further ACL injury.

What Was the Change in Telehealth Usage and Proportion of No-show Visits for an Orthopaedic Trauma Clinic During the COVID-19 Pandemic?

BACKGROUND: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Centers for Medicare and Medicaid Services pledged payment for telehealth visits for the duration of this public health emergency in an effort to decrease COVID-19 transmission and allow for deployment of residents and attending physicians to support critical-care services. Although the COVID-19 pandemic has vastly expanded telehealth use, no studies to our knowledge have analyzed the implementation and success of telehealth for orthopaedic trauma. This population is unique in that patients who have experienced orthopaedic trauma range in age from early childhood to late adulthood, they vary across the socioeconomic spectrum, may need to undergo emergent or urgent surgery, often have impaired mobility, and, historically, do not always follow-up consistently with healthcare providers. QUESTIONS/PURPOSES: (1) To what extent did telehealth usage increase for an outpatient orthopaedic trauma clinic at a Level 1 trauma center from the month before the COVID-19 stay-at-home order compared with the month immediately following the order? (2) What is the proportion of no-show visits before and after the implementation of telehealth? METHODS: After nonurgent clinic visits were postponed, telehealth visits were offered to all patients due to the COVID-19 stay-at-home order. Patients with internet access who had the ability to download the MyChart application on their mobile device and agreed to a telehealth visit were seen virtually between March 16, 2020 and April 10, 2020 (COVID-19) by three attending orthopaedic trauma surgeons at a large, urban, Level 1 trauma center. Clinic schedules and patient charts were reviewed to determine clinical volumes and no-show proportions. The COVID-19 period was compared with the 4 weeks before March 16, 2020 (pre-COVID-19), when all visits were conducted in-person. The overall clinic volume decreased from 340 to 233 (31%) between the two periods. The median (range) age of telehealth patients was 46 years (20 to 89). Eighty-four percent (72 of 86) of telehealth visits were postoperative and established nonoperative patient visits, and 16% (14 of 86) were new-patient visits. To avoid in-person suture or staple removal, patients seen for their 2-week postoperative visit had either absorbable closures, staples, or nonabsorbable sutures removed by a home health registered nurse or skilled nursing facility registered nurse. If radiographs were indicated, they were obtained at outside facilities or our institution before patients returned home for their telehealth visit. RESULTS: There was an increase in the percentage of office visits conducted via telehealth between the pre-COVID-19 and COVID-19 periods (0% [0 of 340] versus 37% [86 of 233]; p < 0.001), and by the third week of implementation, telehealth comprised approximately half of all clinic visits (57%; [30 of 53]). There was no difference in the no-show proportion between the two periods (13% [53 of 393] for the pre-COVID-19 period and 14% [37 of 270] for the COVID-19 period; p = 0.91). CONCLUSIONS: Clinicians should consider implementing telehealth strategies to provide high-quality care for patients and protect the workforce during a pandemic. In a previously telehealth-naïve clinic, we show successful implementation of telehealth for a diverse orthopaedic trauma population that historically has issues with mobility and follow-up. Our strategies include postponing long-term follow-up visits, having sutures or staples removed by a home health or skilled nursing facility registered nurse, having patients obtain pertinent imaging before the visit, and ensuring that patients have access to mobile devices and internet connectivity. Future studies should evaluate the incidence of missed infections or stiffness as a result of telehealth, analyze the subset of patients who may be more vulnerable to no-shows or technological failures, and conduct patient surveys to determine the factors that contribute to patient preferences for or against the use of telehealth. LEVEL OF EVIDENCE: Level III, therapeutic study.

Subacute High-Energy Traumatic Knee Dislocation in an Ambulatory Patient: A Case Report.

CASE: A 62-year-old man presented with a posterolateral knee dislocation sustained in a motorcycle collision initially managed nonsurgically. His treatment was complicated by recurrent dislocation from noncompliance with bracing and weight-bearing restrictions and by comorbidities including peripheral artery disease, type 2 diabetes, and heavy smoking and drinking. He was treated with a multiplanar knee-spanning external fixator and patellar tendon repair without further ligamentous reconstruction. This treatment provided a stable, functional knee with minimal pain. CONCLUSIONS: In this complex, noncompliant patient with a subacute knee dislocation, knee-spanning biplanar external fixation and patellar tendon repair without ligament reconstruction were crucial in achieving a satisfactory outcome.

Acute Pediatric Monteggia Fractures: A Conservative Approach to Stabilization.

BACKGROUND: In 2015, a multicenter study group proposed a treatment algorithm for pediatric Monteggia fractures based upon the ulnar fracture pattern. This strategy recommends surgical stabilization for all complete ulna fractures. The purpose of this study was to evaluate whether an initial nonoperative approach to pediatric Monteggia fractures resulted in poorer outcomes and a higher rate of complications. METHODS: This institutional review board approved retrospective study evaluated all Monteggia fractures presenting to a level 1 pediatric trauma center between 2008 and 2014. Chart and radiographic reviews were performed on 94 patients who met inclusion criteria. The mean age was 5.5 years (range, 1 to 13 y). The mean clinical follow-up was 18 weeks. Major complications were defined as those requiring an unplanned second procedure (other than implant removal) or that may result in long-term disability (residual radial head subluxation/dislocation). Univariate (P<0.05) and Multivariate Classification and Regression Tree (CART) (P<0.05) analyses were used to identify variables associated with the need for surgical stabilization. RESULTS: At final follow-up, there were no cases of residual radiocapitellar joint subluxation or dislocation and all fractures had healed. The majority (83%) of patients were successfully managed with a cast. Univariate analysis found Bado type and maximum ulna angulation as significant predictors (P<0.05), whereas the CART analysis found ulna angulation >36.5 degrees as the only primary predictor of requiring surgical stabilization. Overall, good outcomes were achieved in all patients with few major complications. CONCLUSIONS: Although treatment algorithms are intended to minimize complications and maximize good outcomes, we believe that an unintentional consequence of the recently proposed pediatric Monteggia fracture treatment guideline may be the overtreatment of these injuries. In our cohort, the majority of patients were able to avoid the operating room and surgical implants without compromising outcomes or complications. This more conservative approach, however, requires close monitoring of patients in the first 3 weeks during which most reductions were lost. LEVEL OF EVIDENCE: Level IV-therapeutic studies, case series.