Data Logger Technologies for Powered Wheelchairs: A Scoping Review.

In recent years, studies increasingly employed data loggers to record the objective behaviors of powered wheelchair users. Of the data logging work reported in the literature, the technologies used offer marked differences in characteristics. In order to identify and describe the extent of published research activity that relies on data logger technologies for powered wheelchairs, we performed a scoping review of the scientific and grey literature. This scoping review, complementary to a previous one related to manual wheelchairs, is part of a process aiming to help further the development and increase the functionality of data loggers with wheelchairs. Five databases were searched: Medline, Compendex, CINAHL, EMBASE, Google Scholar. Sixty papers were retained for analysis. The most frequently used technologies were all installed on the wheelchair: 19.0% were accelerometers, 14.6% were pressure sensors or switches, 13.9% were odometers, 10.9% were global positioning systems, 9.5% were tilt sensors, and 7.3% were force-sensing technologies. The most reported outcomes were pressure-relief activities (17.3%), distance traveled (9.3%), mobility events (8.9%), acceleration (8.5%), and sitting time (6.9%). Future research may be needed to assess the usefulness of different outcomes and to develop methods more appropriate to optimize the practicality of wheelchair data loggers.

Data logger technologies for manual wheelchairs: A scoping review.

In recent years, studies have increasingly employed data logger technologies to record objective driving and physiological characteristics of manual wheelchair users. However, the technologies used offer significant differences in characteristics, such as measured outcomes, ease of use, and level of burden. In order to identify and describe the extent of published research activity that relies on data logger technologies for manual wheelchair users, we performed a scoping review of the scientific and gray literature. Five databases were searched: Medline, Compendex, CINAHL, EMBASE, and Google Scholar. The 119 retained papers document a wide variety of logging devices and sensing technologies measuring a range of outcomes. The most commonly used technologies were accelerometers installed on the user (18.8%), odometers installed on the wheelchair (12.4%), accelerometers installed on the wheelchair (9.7%), and heart monitors (9.7%). Not surprisingly, the most reported outcomes were distance, mobility events, heart rate, speed/velocity, acceleration, and driving time. With decreasing costs and technological improvements, data loggers are likely to have future widespread clinical (and even personal) use. Future research may be needed to assess the usefulness of different outcomes and to develop methods more appropriate to wheelchair users in order to optimize the practicality of wheelchair data loggers.

Clinicians' and Researchers' Perspectives on Manual Wheelchair Data Loggers.

Recent studies have used data loggers to record a wide range of, sometimes differing, objective outcomes associated with the use of manual wheelchairs. To identify which outcomes are broadly perceived to be the most important to measure when objectively documenting manual wheelchair use, a cross-sectional survey was conducted with groups of researchers and clinicians in the field of wheeled mobility. We also surveyed the challenges these groups experienced when using data loggers. The survey was informed by a previous scoping review of the scientific and gray literature. Seventy-four people with various academic and professional backgrounds completed the survey: 57 researchers (77.0%) and 17 clinicians (23.0%). Regarding the importance they attributed to commonly measured outcomes, the most highly rated outcome identified by both groups was "distance traveled." There were significant differences between the groups' perspectives in rating and ranking the importance of "pressure-relief activities," "seat pressure," and "acceleration." In terms of challenges or barriers associated with the use of data loggers for monitoring manual wheelchair use, it appears that researchers and clinicians have relatively similar needs and preferences. However, only clinicians reported that the time they wanted to, or could, allocate to review recorded information was a potential hardship. Our hope is that these results will help further development and increase the functionality and applicability of data loggers for manual wheelchairs in research and clinical contexts.

Rehab on Wheels: A Pilot Study of Tablet-Based Wheelchair Training for Older Adults.

BACKGROUND: Alternative and innovative strategies such as mHealth and eLearning are becoming a necessity for delivery of rehabilitation services. For example, older adults who require a wheelchair receive little, if any, training for proficiency with mobility skills. This substantive service gap is due in part to restricted availability of clinicians and challenges for consumers to attend appointments. A research team of occupational therapists and computer scientists engaged clinicians, consumers, and care providers using a participatory action design approach. A tablet-based application, Enhancing Participation In the Community by improving Wheelchair Skills (EPIC Wheels), was developed to enable in-chair home training, online expert trainer monitoring, and trainee-trainer communication via secure voice messaging. OBJECTIVE: Prior to undertaking a randomized controlled trial (RCT), a pilot study was conducted to determine the acceptability and feasibility of administering an mHealth wheelchair skills training program safely and effectively with two participants of different skill levels. The findings were used to determine whether further enhancements to the program were indicated. METHODS: The program included two in-person sessions with an expert trainer and four weeks of independent home training. The EPIC Wheels application included video instruction and demonstration, self-paced training activities, and interactive training games. Participants were provided with a 10-inch Android tablet, mounting apparatus, and mobile Wi-Fi device. Frequency and duration of tablet interactions were monitored and uploaded daily to an online trainer interface. Participants completed a structured evaluation survey and provided feedback post-study. The trainer provided feedback on the training protocol and trainer interface. RESULTS: Both participants perceived the program to be comprehensive, useful, and easily navigated. The trainer indicated usage data was comprehensive and informative for monitoring participant progress and adherence. The application performed equally well with multiple devices. Some initial issues with log-in requests were resolved via tablet-specific settings. Inconsistent Internet connectivity, resulting in delayed data upload and voice messaging, was specific to individual Wi-Fi devices and resolved by standardizing configuration. Based on the pilot results, the software was updated to make content download more robust. Additional features were also incorporated such as check marks for completed content, a more consumer-friendly aesthetic, and achievement awards. The trainer web interface was updated to improve usability and provides both a numerical and visual summary of participant data. CONCLUSIONS: The EPIC Wheels pilot study provided useful feedback on the feasibility of a tablet-based home program for wheelchair skills training among older adults, justifying advancement to evaluation in an RCT. The program may be expanded for use with other rehabilitation interventions and populations, particularly for those living in rural or remote locations. Future development will consider integration of built-in tablet sensors to provide performance feedback and enable interactive training activities. TRIAL REGISTRATION: ClinicalTrials.gov NCT01644292; https://clinicaltrials.gov/ct2/show/NCT01644292 (Archived by WebCite at http://www.webcitation.org/6XyvYyTUf).

A Telehealth Intervention Using Nintendo Wii Fit Balance Boards and iPads to Improve Walking in Older Adults With Lower Limb Amputation (Wii.n.Walk): Study Protocol for a Randomized Controlled Trial.

BACKGROUND: The number of older adults living with lower limb amputation (LLA) who require rehabilitation for improving their walking capacity and mobility is growing. Existing rehabilitation practices frequently fail to meet this demand. Nintendo Wii Fit may be a valuable tool to enable rehabilitation interventions. Based on pilot studies, we have developed "Wii.n.Walk", an in-home telehealth Wii Fit intervention targeted to improve walking capacity in older adults with LLA. OBJECTIVE: The objective of this study is to determine whether the Wii.n.Walk intervention enhances walking capacity compared to an attention control group. METHODS: This project is a multi-site (Vancouver BC, London ON), parallel, evaluator-blind randomized controlled trial. Participants include community-dwelling older adults over the age of 50 years with unilateral transtibial or transfemoral amputation. Participants will be stratified by site and block randomized in triplets to either the Wii.n.Walk intervention or an attention control group employing the Wii Big Brain cognitive software. This trial will include both supervised and unsupervised phases. During the supervised phase, both groups will receive 40-minute sessions of supervised group training three times per week for a duration of 4 weeks. Participants will complete the first week of the intervention in groups of three at their local rehabilitation center with a trainer. The remaining 3 weeks will take place at participants' homes using remote supervision by the trainer using Apple iPad technology. At the end of 4 weeks, the supervised period will end and the unsupervised period will begin. Participants will retain the Wii console and be encouraged to continue using the program for an additional 4 weeks' duration. The primary outcome measure will be the "Two-Minute Walk Test" to measure walking capacity. Outcome measures will be evaluated for all participants at baseline, after the end of both the supervised and unsupervised phases, and after 1-year follow up. RESULTS: Study staff have been hired and trained at both sites and recruitment is currently underway. No participants have been enrolled yet. CONCLUSIONS: Wii.n.Walk is a promising in-home telehealth intervention that may have useful applications for older adults with LLA who are discharged from rehabilitation or live in remote areas having limited or no access to existing rehabilitation programs. TRIAL REGISTRATION: Clinicaltrial.gov NCT01942798; http://clinicaltrials.gov/ct2/show/NCT01942798 (Archived by WebCite at http://www.webcitation.org/6V0w8baKP).

Development of a wheelchair skills home program for older adults using a participatory action design approach.

Restricted mobility is the most common impairment among older adults and a manual wheelchair is often prescribed to address these limitations. However, limited access to rehabilitation services results in older adults typically receiving little or no mobility training when they receive a wheelchair. As an alternative and novel approach, we developed a therapist-monitored wheelchair skills home training program delivered via a computer tablet. To optimize efficacy and adherence, principles of self-efficacy and adult learning theory were foundational in the program design. A participatory action design approach was used to engage older adult wheelchair users, care providers, and prescribing clinicians in an iterative design and development process. A series of prototypes were fabricated and revised, based on feedback from eight stakeholder focus groups, until a final version was ready for evaluation in a clinical trial. Stakeholder contributions affirmed and enhanced the foundational theoretical principles and provided validation of the final product for the target population.

Feasibility of the Enhancing Participation In the Community by improving Wheelchair Skills (EPIC Wheels) program: study protocol for a randomized controlled trial.

BACKGROUND: Many older adults rely on a manual wheelchair for mobility but typically receive little, if any, training on how to use their wheelchair effectively and independently. Standardized skill training is an effective intervention, but limited access to clinician trainers is a substantive barrier. Enhancing Participation in the Community by Improving Wheelchair Skills (EPIC Wheels) is a 1-month monitored home training program for improving mobility skills in older novice manual wheelchair users, integrating principles from andragogy and social cognitive theory. The purpose of this study is to determine whether feasibility indicators and primary clinical outcome measures of the EPIC Wheels program are sufficiently robust to justify conducting a subsequent multi-site randomized controlled trial. METHODS: A 2 × 2 factorial randomized controlled trial at two sites will compare improvement in wheelchair mobility skills between an EPIC Wheels treatment group and a computer-game control group, with additional wheelchair use introduced as a second factor. A total of 40 community-dwelling manual wheelchair users at least 55 years old and living in two Canadian metropolitan cities (n = 20 × 2) will be recruited. Feasibility indicators related to study process, resources, management, and treatment issues will be collected during data collection and at the end of the study period, and evaluated against proposed criteria. Clinical outcome measures will be collected at baseline (pre-randomization) and post-intervention. The primary clinical outcome measure is wheelchair skill capacity, as determined by the Wheelchair Skills Test, version 4.1. Secondary clinical outcome measures include wheelchair skill safety, satisfaction with performance, wheelchair confidence, life-space mobility, divided-attention, and health-related quality of life. DISCUSSION: The EPIC Wheels training program offers several innovative features. The convenient, portable, economical, and adaptable tablet-based, home program model for wheelchair skills training has great potential for clinical uptake and opportunity for future enhancements. Theory-driven design can foster learning and adherence for older adults. Establishing the feasibility of the study protocol and estimating effect size for the primary clinical outcome measure will be used to develop a multi-site randomized controlled trial to test the guiding hypotheses. TRIAL REGISTRATION: Clinical Trials NCT01740635.

The hidden risks of advancing age and concomitant ischemic heart disease after aortic valve replacement.

BACKGROUND: Despite an increasing patient risk profile, in-hospital mortality after aortic valve replacement (AVR) has declined. HYPOTHESIS: Advanced age, concomitant coronary artery bypass grafting (CABG), and increasing comorbidity negatively affect outcomes after AVR and do so particularly in the early months after hospital discharge, where results compare much less favorably with mortality during the first 30 days. METHODS: The study population consisted of all patients undergoing elective AVR by a single surgeon, with and without CABG, in the decade of 2000-2009. Age, logistic EuroSCORE, diabetes, type of operation, and 30-day and 1-year mortality were recorded. RESULTS: One hundred ninety-one patients underwent isolated AVR; 133 underwent AVR + CABG. The average age increased by 5.7 years, octogenarians by 50%, logistic EuroSCORE by 18%, and the proportion of diabetics from 4% to 25.5%. Concomitant CABG surgery increased from 36% to 49%. Overall mortality for isolated AVR was zero in the first 30 days and 1.6% in the next 11 months. For AVR and CABG, mortality was 3.75% and 9%, respectively. For octogenarians, mortality was zero and 5.9% for AVR and 4.76% and 14.29% for AVR and CABG at 30 days and in the next 11 months, respectively. CONCLUSIONS: Thirty-day mortality in all age groups remained low but was much higher in the short term after discharge from hospital, particularly in octogenarians and those with concomitant ischemic heart disease. This should inform the consent process (which traditionally concentrates on in-hospital mortality) and there should be greater awareness of the frailty and particular requirements of the elderly after discharge.

A 15-year study of the changing demographics and infection risk in a new UK cardiac surgery unit.

OBJECTIVES: National trends in cardiac surgery show a shift towards a higher preoperative risk profile and factors that might also be expected to increase the risk of postoperative infective complications. We document the changing patient demographics in the first 15 years of a new cardiac surgery unit and examine the impact of these and other changes in estate, staffing and clinical protocols, on the risks of common postoperative infections. METHODS: Data recorded included patient age, sex and body mass index, type and number of operations, logistic EuroSCORE, mortality rate, urgency of operation, reoperation rate, requirement for intra-aortic balloon pump, incidence of diabetes and the incidence of common postoperative infections. RESULTS: A total of 8449 cardiac operations were undertaken. The mean patient age increased from 62.71 to 65.82 years; procedural complexity increased with the proportion of isolated coronary artery bypass procedures falling from 72.8 to 54%; there were increases in the urgency of operation (11.3-26.9%), average patient body mass index (27.01-28.67), the incidence of diabetes (12.3-21.2%), logistic EuroSCORE (5.36-7.74) and intra-aortic balloon pump usage (6.4-15.6%). The incidence of superficial sternal infection reduced (3.9-1.4%); other wound infection rates were low and showed no overall trend with time. Urinary tract infection varied between 0 and 1.7%, but did show a significant increase over the last 3 years (P < 0.01). CONCLUSIONS: This study demonstrates a change in the patient profile, yet despite an increase in infection risk factors, no increase in actual infection rates. The importance of non-patient factors in influencing the outcomes after cardiac surgery is discussed.

Reverse elephant trunk technique: a novel approach to pseudoaneurysm repair.

Traditional surgical access to the upper descending aorta is via a left thoracotomy. For postcoarctation pseudoaneurysm repair, this approach is difficult because of the risk of rupture while dissecting the aorta for proximal and distal control. Access from a median sternotomy may be safer, but is difficult because of the depth of the wound and because of the angle of approach to the distal aspect of the repair site. We describe a novel approach via a median sternotomy incision, using circulatory arrest and "elephant trunk" principles to achieve tube graft replacement of the aneurysmal section of aorta.

Inversion of the left atrial appendage: a complication of cardiac surgery.

An inverted left atrial appendage which fails to revert spontaneously is a rare complication of cardiac surgery. We present a case of an inverted left atrial appendage discovered intraoperatively on transoesophageal echocardiography. This was readily identified and was easily corrected with digital manipulation. Intraoperative transoesophageal echocardiography plus an awareness of the possibility that a newly presenting left atrial mass post-bypass might be an inverted left atrial appendage, facilitates immediate correction. So doing removes any need for further investigation or further cardiac surgery and reduces the risk of a subsequent thromboembolic event if the diagnosis is not made until later.

The Alfieri stitch: the advantages for mitral valve repair in difficult circumstances.

In certain complex cases, where there is severe calcification of the mitral annulus but significant mitral regurgitation or systolic anterior motion (SAM), or in high-risk cases where prolonged bypass is to be avoided, the Alfieri-stitch repair of the mitral valve may be the most appropriate option available, particularly as it can be performed quickly through the aortic valve. We describe three cases undergoing aortic valve replacement, in which this technique was successfully applied in patients in whom more conventional repair techniques or valve replacement would have been hazardous, due to annular calcification and patient frailty.

Measurement of intraperitoneal metabolites during hypothermic cardiopulmonary bypass using microdialysis.

OBJECTIVE: Splanchnic hypoxia, with resultant mucosal acidosis during cardiopulmonary bypass (CPB) has been demonstrated using tonometry. Microdialysis is a minimally-invasive method of obtaining peritoneal fluid samples. We measured the intraperitoneal metabolites during peri-operative period following hypothermic CPB and studied the safety of intraperitoneal microdialysis. DESIGN: Eleven consecutive patients undergoing coronary artery bypass grafting (CABG) were included after obtaining ethics committee approval and informed consent. Microdialysis catheters were placed intraperitoneally after sternotomy. Intraperitoneal samples and arterial blood samples were obtained peri-operatively for first 24 hours. The samples were analysed for levels of glucose, lactate, pyruvate and glycerol. Repeated measures ANOVA test was used to compare timed serum and intraperitoneal samples. RESULTS: The study population included nine males and two females with a mean age of 63.7 ± 11 years. The mean CPB and X clamp times were 50.9 ± 7.3 minutes and 27.3 ± 4.9 minutes, respectively. There were no complications related to microdialysis. The intraperitoneal lactate (L), pyruvate (P) and glycerol increased during CPB and four to six hours postoperatively. The L:P ratio was >10:1 during CPB, but in the postoperative period showed evidence of impaired oxygen utilisation. CONCLUSIONS: This prospective study confirms incidence of intraperitoneal anaerobic metabolism of glucose during CPB and impaired utilisation of glucose in the postoperative period. Microdialysis provides a novel and minimally-invasive method to measure real time intraperitoneal events.

The effect of fenoldopam and dopexamine on cytokine and endotoxin release following on-pump coronary artery bypass grafting: a prospective randomized double-blind trial.

BACKGROUND: Surgical trauma, exposure to an external circuit, and reduced organ perfusion contribute to the systemic inflammatory response following cardiopulmonary bypass (CPB). Reduced splanchnic perfusion causes disruption of the gastrointestinal mucosal barrier and the release of endotoxins. Fenoldopam (a new dopamine 1 receptor agonist) has been shown to be a specific renosplanchnic vasodilator in animal and human studies. We studied the effects of fenoldopam on the systemic inflammatory response and the release of endotoxins after CPB and compared the results with those for dopexamine. METHODS: Our prospective randomized study included 42 consecutive patients with good to moderate left ventricular function who were to undergo elective or inpatient coronary artery bypass grafting. We used closed envelope method to randomize patients to receive 0.2 µg/kg per minute of fenoldopam (n = 14), 2 µg/kg per minute of dopexamine (n = 14), or normal saline (n = 14). Patients received their respective treatments continuously from anesthesia induction until the end of the first 24 postoperative hours. Interleukin 1ß (IL-1ß), IL-6, IL-8, IL-10, IL-12, tumor necrosis factor α, complement 3a (C3a), C4a, C5a, and endotoxins were measured during the perioperative period. Repeated-measures analysis of variance was used to evaluate the results for the timed samples. RESULTS: There were no statistical differences between the groups with respect to pre- and intraoperative variables. Release of C3a was attenuated in the fenoldopam group (P = .002), and release of IL-6 and IL-8 was attenuated in the postoperative period in the fenoldopam group (P = .012 and .015, respectively). The other interleukins showed no uniform release in any of the 3 groups. There were no statistically significant differences in serum endotoxin elevation between the 3 groups. CONCLUSION: A partial attenuation in the inflammatory response is possible with fenoldopam infusion. The elevation in serum endotoxin levels was not affected by dopexamine or fenoldopam infusion.

Effect of increased pump flow on hepatic blood flow and systemic inflammatory response following on-pump coronary artery bypass grafting.

UNLABELLED: Reduced organ perfusion during cardiopulmonary bypass (CPB) is responsible for morbidity associated with cardiac surgery. Non-pulsatile flow and hypothermia during CPB have been shown to cause reduced perfusion. During CPB, cardiac output is directly proportional to the pump flow rate. Therefore, we hypothesised that increasing pump flow during hypothermic CPB would improve organ perfusion and reduce the inflammatory response in the post-operative period. METHODS: Ethics committee approval was obtained. Twelve consecutive patients with good or moderate left ventricular function undergoing elective or inpatient coronary artery bypass grafting were included in the study after obtaining informed consent. Patients were randomised to receive either normal flow or higher pump flow (20% more than the usual flow during hypothermia). Hepatic blood flow, cytokines such as interleukins 1ß, 6, 8, 10 and 12, tumour necrosis factor-α and complements C3a, C4a and C5a were measured during the peri-operative period. Data were analysed using SPSS (ver.15). Categorical data were compared using the chi-square test and trends in cytokines were compared using a repeated measures ANOVA test. RESULTS: Both the groups were similar in pre- and peri-operative variables. Hepatic blood flow almost doubled in the high-pump-flow group following an increase in the flow rate during hypothermia(p=0.026). The release of serum complement IL-6 and 8 appeared to be reduced in the high-flow group; however, the difference did not reach statistical significance. CONCLUSIONS: Higher pump flows during hypothermic CPB increase hepatic blood flow. There was a trend towards attenuation of post-operative inflammatory response; however, larger studies will be needed to confirm these findings.

Propionibacterium acnes endocarditis of a prosthetic aortic valve.

In the few reported cases of Propionibacterium infective endocarditis involving prosthetic aortic valves, abscess is common and frequently requires surgery. We report a case of P. acnes infective endocarditis identified on prolonged blood cultures with aortic root abscess involving a Starr-Edwards valve. Intravenous antibiotics and valve replacement led to recovery.

Pulmonary thromboembolism with floating thrombus trapped in patent foramen ovale.

A 39-year-old man was hospitalized with symptoms of acute deep vein thrombosis, and computed tomography showed that he had pulmonary thromboembolism. Transthoracic echocardiography showed a large, right atrial thrombus and transesophageal echocardiography showed migrating thrombus trapped in a patent foramen ovale and extending all the way up to the ascending aorta. He underwent surgical embolectomy under cardiopulmonary bypass. At the conclusion of the operation, repeat transesophageal echocardiography examination revealed fresh but small thrombus in the right atrium. This continued entry of thrombi into the heart was further managed with fluoroscopy-guided insertion of a retrievable inferior vena cava filter through the internal jugular vein in the operating room itself.

Can lean body mass be used to reduce the dose of heparin and protamine for obese patients undergoing cardiopulmonary bypass?

Increasing numbers of obese patients are presenting for cardiac surgery. The convention for heparin dose dictates that a bolus of 300 IU heparin per kilogram of total body weight (TBW) is administered before CPB. During CPB, the activated clotting time (ACT) is maintained for longer than 480 seconds. At the end of the procedure, protamine is administered to neutralize heparin and achieve hemostasis. Both of these drugs can have serious side effects: heparin can induce thrombocytopenia, and protamine has been known to cause reactions in patients allergic to fish, vasectomized men, and some patients with insulin-dependent diabetes. The calculation of lean body mass (LBM) may be a more accurate method of determining drug doses as opposed to TBW and may avoid giving obese patients a relative overdose of heparin, which must subsequently be neutralized with protamine. LBM can be determined by different methods. This study used bio-electrical impedance analysis as a simple, quick, and accurate method of calculating LBM. A comparison was made between two groups of patients whose body mass index (BMI) was >27 kg/m2: Group 1, n = 13, mean BMI = 32, mean body fat = 36% received the conventional dose of 300 IU/kg heparin for their TBW. Group 2, n = 14, mean BMI = 31, mean body fat = 35% received a dose of 300 IU/kg heparin for their calculated LBM. ACT was conducted before and after heparin administration. Additional heparin was administered as required to achieve target ACT > 400 s. Mean ACT results and total heparin doses were analyzed using unpaired two tailed t tests. Our results indicate that with care, a reduction of as much as 25% in the doses of heparin (p = 0.0001) and protamine can be achieved for a substantial number of patients classified as overweight or obese.