Multidisciplinary user experience of a newly implemented electronic patient record in Ireland: An exploratory qualitative study.

BACKGROUND: Implementation of an Electronic Patient Record (EPR) in a key milestone in the digital strategy of modern healthcare organisations. The implementation of EPR systems can be viewed as challenging and complex. OBJECTIVE: The aim of the study was to investigate user perspectives and experiences of the implementation of an Electronic Medical Record in a major academic teaching hospital, with simultaneous 'go-live' across the whole hospital taking place. METHODS: Focus groups and individual in-depth interviews were conducted with stakeholders and users (n = 105), approximately nine months post-EPR implementation. The study explored EPR users' perceptions using an extended theoretical framework of the DeLone and McLean Information Systems Success Model (2003), which measured information systems, system quality, information quality, service quality, use/perceived usefulness & user satisfaction and net benefits. RESULTS: Staff engagement and satisfaction was high and the EPR is accepted as the new standard way of completing care. There was agreement that the EPR affords transparency, and greater accountability. There was some concern expressed regarding impact of the EPR on interprofessional and patient/provider interactions and communication. Physicians reported the inputting of social history through free text as an issue of concern and time consuming. The Big Bang approach with mandatory conversion was key to the successful adoption of EPR. There was consensus across professional and administrative respondents that there was no appetite to return to paper-based records. CONCLUSION: The successful roll out of the EPR reflects the digital readiness of healthcare providers and organisations. The potential for unintended consequences on work process requires continual monitoring. A key future benefit of the EPR will be the capacity to reach a broader understanding and analysis of variation in processes and outcomes within healthcare organisations. It is clear that skills in data analytics will be needed to mine data successfully.

Structural correlates of the audiological and emotional components of chronic tinnitus.

The objective is to investigate white matter tracts, more specifically the arcuate fasciculus and acoustic radiation, in tinnitus and assess their relationship with distress, loudness and hearing loss. DTI images were acquired for 58 tinnitus patients and 65 control subjects. Deterministic tractography was first performed to visualize the arcuate fasciculus and acoustic radiation tracts bilaterally and to calculate tract density, fractional anisotropy, radial diffusivity, and axial diffusivity for tinnitus and control subjects. Tinnitus patients had a significantly reduced tract density compared to controls in both tracts of interest. They also exhibited increased axial diffusivity in the left acoustic radiation, as well as increased radial diffusivity in the left arcuate fasciculus, and both the left and right acoustic radiation. Furthermore, they exhibited decreased fractional anisotropy in the left arcuate fasciculus, as well as the left and right acoustic radiation tracts. Partial correlation analysis showed: (1) a negative correlation between arcuate fasciculus tract density and tinnitus distress, (2) a negative correlation between acoustic radiation tract density and hearing loss, (3) a negative correlation between acoustic radiation tract density and loudness, (4) a positive correlation between left arcuate fasciculus and tinnitus distress for radial diffusivity, (5) a negative correlation between left arcuate fasciculus and tinnitus distress for fractional anisotropy, (6) a positive correlation between left and right acoustic radiation and hearing loss for radial diffusivity, (7) No correlation between any of the white matter characteristics and tinnitus loudness. Structural alterations in the acoustic radiation and arcuate fasciculus correlate with hearing loss and distress in tinnitus but not tinnitus loudness showing that loudness is a more functional correlate of the disorder which does not manifest structurally.

Impaired posterior cingulate cortex-parahippocampus connectivity is associated with episodic memory retrieval problems in amnestic mild cognitive impairment.

Episodic memory retention and retrieval decline are the most common impairments observed in amnestic mild cognitive impairment (aMCI) patients who progress to Alzheimer's disease (AD). Clinical electroencephalography research shows that patients with dementia due to AD exhibit a slowing of neural electrical activity in the parietal cortex. Memory research has further suggested that successful memory performance is associated with changes in a posterior cingulate-parahippocampal cortical network together with increased θ-γ oscillatory coupling, where θ oscillations act as carrier waves for γ oscillations, which contain the actual information. However, the neurophysiological link between the memory research and clinical studies investigating aMCI and AD is lacking. In this study, we look at brain activity in aMCI and how it relates to memory performance. We demonstrate decreased γ power in the posterior cingulate cortex and the left and right parahippocampus in aMCI patients in comparison to control participants. This goes together with reduced θ coherence between the posterior cingulate cortex and parahippocampus associated with altered memory performance aMCI patients in comparison to control participants. In addition, comparing patients with aMCI to control participants reveals an effect for θ-γ coupling for the posterior cingulate cortex, and the left and right parahippocampus. Taken together, our results show that parahippocampus and posterior cingulate cortex interact via θ-γ coupling, which is associated with memory recollection and is altered in aMCI patients, offering a potential candidate mechanism for memory decline in aMCI.

The BDNF Val66Met polymorphism regulates vulnerability to chronic stress and phantom perception.

Auditory phantom percepts, such as tinnitus, are a heterogeneous condition with great interindividual variations regarding both the percept itself and its concomitants. Tinnitus causes a considerable amount of distress, with as many as 25% of affected people reporting that it interferes with their daily lives. Although previous research gives an idea about the neural correlates of tinnitus-related distress, it cannot explain why some tinnitus patients develop distress and while others are not bothered by their tinnitus. BDNF Val66Met polymorphism (rs6265) is a known risk factor for affective disorders due to its common frequency and established functionality. To elucidate, we explore the neural activation pattern of tinnitus associated with the BDNF Val66Met polymorphism using electrophysiological data to assess activity and connectivity changes. A total of 110 participants (55 tinnitus and 55 matched control subjects) were included. In this study, we validate that the BDNF Val66Met polymorphism plays an important role in the susceptibility to the clinical manifestation of tinnitus-related distress. We demonstrate that Val/Met carriers have increased alpha power in the subgenual anterior cingulate cortex that correlates with distress levels. Furthermore, distress mediates the relationship between BDNF Val66Met polymorphism and tinnitus loudness. In other words, for Val/Met carriers, the subgenual anterior cingulate cortex sends distress-related information to the parahippocampus, which likely integrates the loudness and distress of the tinnitus percept.

The peripheral effect of direct current stimulation on brain circuits involving memory.

An ongoing debate surrounding transcranial direct current stimulation (tDCS) of the scalp is whether it modulates brain activity both directly and in a regionally constrained manner enough to positively affect symptoms in patients with neurological disorders. One alternative explanation is that direct current stimulation affects neural circuits mainly indirectly, i.e., via peripheral nerves. Here, we report that noninvasive direct current stimulation indirectly affects neural circuits via peripheral nerves. In a series of studies, we show that direct current stimulation can cause activation of the greater occipital nerve (ON-tDCS) and augments memory via the ascending fibers of the occipital nerve to the locus coeruleus, promoting noradrenaline release. This noradrenergic pathway plays a key role in driving hippocampal activity by modifying functional connectivity supporting the consolidation of a memory event.

Greater Occipital Nerve Stimulation Boosts Associative Memory in Older Individuals: A Randomized Trial.

Transcutaneous electrical stimulation (tES) is a new approach that aims to stimulate the brain. Recently, we have developed tES approaches to enhance plasticity that modulate cortical activity via the greater occipital nerve (ON) in a "bottom-up" way. Thirty subjects between the ages of 55 and 70 years were enrolled and tested using a double-blind, sham-controlled, and randomized design. Half of the participants received active stimulation, while the other half received sham stimulation. Our results demonstrate that ON-tES can enhance memory in older individuals after one session, with effects persisting up to 28 days after stimulation. The hypothesized mechanism by which ON-tES enhances memory is activation of the locus coeruleus-noradrenaline (LC-NA) pathway. It is likely that this pathway was activated after ON-tES, as supported by observed changes in α-amylase concentrations, a biomarker for noradrenaline. There were no significant or long-lasting side effects observed during stimulation. Clinicaltrial.gov (NCT03467698).

The potential interruptive effect of tinnitus-related distress on attention.

The mechanism through which tinnitus affects attention is unclear. This study examines whether distress mediates the relationship(s) between tinnitus and sustained, selective and executive attentions as well as response inhibition. Eighteen participants with tinnitus and fifteen controls completed the Counting Stroop, Vigilance and Stop Signal tasks. Tinnitus distress was assessed using the Tinnitus Questionnaire (TQ), severity of depressive mood states examined using the Beck Depression Inventory-II, and general distress assessed using the Hospital Anxiety and Depression Scale. Tinnitus participants had significantly slower reactions during the Vigilance task (F = 4.86, p = .035), and incongruent trials of the Cognitive Counting task (F = 3.45, p = .045) compared to controls. Tinnitus-related distress significantly mediated the effect of tinnitus in incongruent trials (TQ: Sobel test t = 1.73, p = .042) of the Cognitive Counting Task. Complaints of distress and concentration difficulties are common amongst tinnitus patients in clinical settings and these afflictions have been shown to negatively impact an individual's quality of life. If confirmed in future studies, results suggest that distress may be an important factor in the causal mechanism between tinnitus and attention.

High-Throughput Mass Spectrometric Analysis of the Whole Proteome and Secretome From Sinorhizobium fredii Strains CCBAU25509 and CCBAU45436.

Sinorhizobium fredii is a dominant rhizobium on alkaline-saline land that can induce nitrogen-fixing symbiotic root nodules in soybean. Two S. fredii strains, CCBAU25509 and CCBAU45436, were used in this study to facilitate in-depth analyses of this species and its interactions with soybean. We have previously completed the full assembly of the genomes and detailed transcriptomic analyses for these two S. fredii strains, CCBAU25509 and CCBAU45436, that exhibit differential compatibility toward some soybean hosts. In this work, we performed high-throughput Orbitrap analyses of the whole proteomes and secretomes of CCBAU25509 and CCBAU45436 at different growth stages. Our proteomic data cover coding sequences in the chromosome, chromid, symbiotic plasmid, and other accessory plasmids. In general, we found higher levels of protein expression by genes in the chromosomal genome, whereas proteins encoded by the symbiotic plasmid were differentially accumulated in bacteroids. We identified secreted proteins from the extracellular medium, including seven and eight Nodulation Outer Proteins (Nops) encoded by the symbiotic plasmid of CCBAU25509 and CCBAU45436, respectively. Differential host restriction of CCBAU25509 and CCBAU45436 is regulated by the allelic type of the soybean Rj2(Rfg1) protein. Using sequencing data from this work and available in public databases, our analysis confirmed that the soybean Rj2(Rfg1) protein has three major allelic types (Rj2/rfg1, rj2/Rfg1, rj2/rfg1) that determine the host restriction of some Bradyrhizobium diazoefficiens and S. fredii strains. A mutant defective in the type 3 protein secretion system (T3SS) in CCBAU25509 allowed this strain to nodulate otherwise-incompatible soybeans carrying the rj2/Rfg1 allelic type, probably by disrupting Nops secretion. The allelic forms of NopP and NopI in S. fredii might be associated with the restriction imposed by Rfg1. By swapping the NopP between CCBAU25509 and CCBAU45436, we found that only the strains carrying NopP from CCBAU45436 could nodulate soybeans carrying the rj2/Rfg1 allelic type. However, no direct interaction between either forms of NopP and Rfg1 could be observed.

Tinnitus and neuropathic pain share a common neural substrate in the form of specific brain connectivity and microstate profiles.

Tinnitus and neuropathic pain share similar pathophysiological, clinical, and treatment characteristics. In this EEG study, a group of tinnitus (n = 100) and neuropathic pain (n = 100) patients are compared to each other and to a healthy control group (n = 100). Spectral analysis demonstrates gamma band activity within the primary auditory and somatosensory cortices in patients with tinnitus and neuropathic pain, respectively. A conjunction analysis further demonstrates an overlap of tinnitus and pain related activity in the anterior and posterior cingulate cortex as well as in the dorsolateral prefrontal cortex in comparison to healthy controls. Further analysis reveals that similar states characterize tinnitus and neuropathic pain patients, two of which differ from the healthy group and two of which are shared. Both pain and tinnitus patients spend half of the time in one specific microstate. Seed-based functional connectivity with the source within the predominant microstate shows delta, alpha1, and gamma lagged phase synchronization overlap with multiple brain areas between pain and tinnitus. These data suggest that auditory and somatosensory phantom perceptions share an overlapping brain network with common activation and connectivity patterns and are differentiated by specific sensory cortex gamma activation.

Testing the role of the posterior cingulate cortex in processing salient stimuli in cannabis users: an rTMS study.

The posterior cingulate cortex (PCC) and precuneus are hubs in the default mode network and play a role in processing external salient stimuli. Accordingly, activation in these regions has been associated with response to salient stimuli using drug cue-reactivity paradigms in substance using populations. These studies suggest that the PCC and precuneus may underlie deficits in processing salient stimuli that contribute toward the development of substance use disorders. The goal of this study was to directly test this hypothesis using repetitive transcranial magnetic stimulation (rTMS). Using a double-blind, placebo-controlled design, we used rTMS to target the PCC and precuneus with a double-cone coil at 10 Hz (high frequency) and 1 Hz (low frequency) in 10 adult cannabis users and 10 age- and sex-matched non-using controls. Electroencephalography data were collected before and after rTMS during a modified oddball paradigm with neutral, oddball, self-relevant, and cannabis-related stimuli. Cannabis users exhibited increased amplitude in P3 and faster latencies in the P3, N2, and P2 components in response to self-relevant stimuli compared to controls during baseline that normalized after rTMS. These results suggest that cannabis users exhibited heightened salience to external self-relevant stimuli that were modulated after rTMS. PCC dysfunction in cannabis users may be related to abnormalities in processing salient stimuli, such those during cue-reactivity, and provides a potential target for cannabis use disorder intervention.

Changing Brain Networks Through Non-invasive Neuromodulation.

Background/Objective: Non-invasive neuromodulation techniques, such as repetitive Transcranial Magnetic Stimulation (rTMS) and transcranial Direct Current Stimulation (tDCS), have increasingly been investigated for their potential as treatments for neurological and psychiatric disorders. Despite widespread dissemination of these techniques, the underlying therapeutic mechanisms and the ideal stimulation site for a given disorder remain unknown. Increasing evidence support the possibility of non-invasive neuromodulation affecting a brain network rather than just the local stimulation target. In this article, we present evidence in a clinical setting to support the idea that non-invasive neuromodulation changes brain networks. Method: This article addresses the idea that non-invasive neuromodulation modulates brain networks, rather than just the local stimulation target, using neuromodulation studies in tinnitus and major depression as examples. We present studies that support this hypothesis from different perspectives. Main Results/Conclusion: Studies stimulating the same brain region, such as the dorsolateral prefrontal cortex (DLPFC), have shown to be effective for several disorders and studies using different stimulation sites for the same disorder have shown similar results. These findings, as well as results from studies investigating brain network connectivity on both macro and micro levels, suggest that non-invasive neuromodulation affects a brain network rather than just the local stimulation site targeted. We propose that non-invasive neuromodulation should be approached from a network perspective and emphasize the therapeutic potential of this approach through the modulation of targeted brain networks.

Exploring the effects of anodal and cathodal high definition transcranial direct current stimulation targeting the dorsal anterior cingulate cortex.

The dorsal anterior cingulate cortex (dACC) has been identified as a core region affected by many disorders, representing a promising target for neuromodulation. High Definition-transcranial Direct Current Stimulation (HD-tDCS) is a non-invasive neuromodulation technique that has already shown promising outcomes and has been tested to engage deeper structures. This study investigates whether it is possible to modulate dACC activity using anodal and cathodal HD-tDCS. Furthermore, it examines what effects anodal and cathodal HD-tDCS targeting dACC have on cognitive and emotional processing. Forty-five healthy subjects were randomly assigned to 1 of 3 groups: anodal, cathodal, and sham. Resting-state electroencephalography (rsEEG) and a cognitive and emotional Counting Stroop task were administered before and after HD-tDCS. RsEEG showed changes: anodal HD-tDCS showed significant increase in beta frequency band activity in dACC, while cathodal HD-tDCS led to significant increase in activity at dorsal and rostral ACC in the theta frequency band. Behavioral changes were also found after anodal HD-tDCS in the cognitive Counting Stroop for incongruent trials and after cathodal HD-tDCS in the emotional Counting Stroop for emotional trials. This study demonstrated that HD-tDCS is able to modulate dACC activity, suggesting that it has the potential to be used as a treatment tool.

The role of the dorsal Anterior Cingulate Cortex (dACC) in a cognitive and emotional counting Stroop task: Two cases.

BACKGROUND: The anterior cingulate cortex (ACC) has been implicated in both cognitive and emotional processing, with cognitive information proposed to be processed through the dorsal/caudal ACC and emotional information through the rostral/ventral ACC. OBJECTIVE: The objective of this study is to investigate the role of the dorsal anterior cingulate cortex (dACC) in cognitive and emotional processing using a cognitive and emotional counting Stroop task in two patients in whom abnormalities in the dACC were identified and treated. METHODS: Two patients performed the cognitive and emotional counting Stroop task before and after treatment to examine whether the dACC has a specific or more general processing function. RESULTS: We observed an overall improvement in the emotional, cognitive, and neutral trials of the counting Stroop task after the intervention, indicating that the dACC is not a subregion of the ACC that only contributes to a specific domain. CONCLUSION: This study reveals that the dACC is not just a subregion of the ACC that contributes to a specific cognitive function, but is rather part of a salience network that influences general brain functioning, influencing cognitive as well as emotional processing.

Differential effects of bifrontal and occipital nerve stimulation on pain and fatigue using transcranial direct current stimulation in fibromyalgia patients.

Fibromyalgia is a disorder characterized by widespread musculoskeletal pain frequently accompanied by other symptoms such as fatigue. Moderate improvement from pharmacological and non-pharmacological treatments have proposed non-invasive brain stimulation techniques such as transcranial direct current stimulation (tDCS) to the occipital nerve (more specifically the C2 area) or to the dorsolateral prefrontal cortex (DLPFC) as potential treatments. We aimed to explore the effectiveness of repeated sessions of tDCS (eight sessions) targeting the C2 area and DLPFC in reducing fibromyalgia symptoms, more specifically pain and fatigue. Forty-two fibromyalgia patients received either C2 tDCS, DLPFC tDCS or sham procedure (15 C2 tDCS-11 DLPFC tDCS-16 sham). All groups were treated with eight sessions (two times a week for 4 weeks). Our results show that repeated sessions of C2 tDCS significantly improved pain, but not fatigue, in fibromyalgia patients, whereas repeated sessions of DLPFC tDCS significantly improved pain as well as fatigue. This study shows that eight sessions of tDCS targeting the DLPFC have a more general relief in fibromyalgia patients than when targeting the C2 area, suggesting that stimulating different targets with eight sessions of tDCS can lead to benefits on different symptom dimensions of fibromyalgia.

The added value of auditory cortex transcranial random noise stimulation (tRNS) after bifrontal transcranial direct current stimulation (tDCS) for tinnitus.

Tinnitus is the perception of a sound in the absence of a corresponding external sound source. Research has suggested that functional abnormalities in tinnitus patients involve auditory as well as non-auditory brain areas. Transcranial electrical stimulation (tES), such as transcranial direct current stimulation (tDCS) to the dorsolateral prefrontal cortex and transcranial random noise stimulation (tRNS) to the auditory cortex, has demonstrated modulation of brain activity to transiently suppress tinnitus symptoms. Targeting two core regions of the tinnitus network by tES might establish a promising strategy to enhance treatment effects. This proof-of-concept study aims to investigate the effect of a multisite tES treatment protocol on tinnitus intensity and distress. A total of 40 tinnitus patients were enrolled in this study and received either bifrontal tDCS or the multisite treatment of bifrontal tDCS before bilateral auditory cortex tRNS. Both groups were treated on eight sessions (two times a week for 4 weeks). Our results show that a multisite treatment protocol resulted in more pronounced effects when compared with the bifrontal tDCS protocol or the waiting list group, suggesting an added value of auditory cortex tRNS to the bifrontal tDCS protocol for tinnitus patients. These findings support the involvement of the auditory as well as non-auditory brain areas in the pathophysiology of tinnitus and demonstrate the idea of the efficacy of network stimulation in the treatment of neurological disorders. This multisite tES treatment protocol proved to be save and feasible for clinical routine in tinnitus patients.

Considering the influence of stimulation parameters on the effect of conventional and high-definition transcranial direct current stimulation.

Recently, techniques to non-invasively modulate specific brain areas gained popularity in the form of transcranial direct current stimulation (tDCS) and high-definition transcranial direct current stimulation. These non-invasive techniques have already shown promising outcomes in various studies with healthy subjects as well as patient populations. Despite widespread dissemination of tDCS, there remain significant unknowns about the influence of a diverse number of tDCS parameters (e.g. polarity, size, position of electrodes & duration of stimulation) in inducing neurophysiological and behavioral effects. This article explores both techniques starting with the history of tDCS, to the differences between conventional tDCS and high-definition transcranial direct current stimulation, the underlying physiological mechanism, the (in)direct effects, the applications of tDCS with varying parameters, the efficacy, the safety issues and the opportunities for future research.

The Treatment Perspectives of Mentally Ill Offenders in Medium- and High-Secure Forensic Settings in Flanders.

There is an increasing interest in mentally ill offenders' (MIOs) treatment experiences in forensic settings. This study focuses on the treatment perspectives of MIOs in treatment as well as in prison settings in Flanders. Seventeen MIOs were interviewed about the treatment they received. Data were analyzed using thematic analysis to derive key themes while acknowledging the individuality of the participants' experiences. Treatment perspectives of MIOs in both settings revolved around similar themes, including "good" staff and privacy. However, their views differed on two themes: MIOs in treatment settings reported on feelings of lacking control and experiencing too much pressure, whereas MIOs in prison settings reported the opposite. The positive experiences in prison settings may complicate the transition from prison to a forensic treatment setting. The study further underscores the major challenge to create more opportunities for MIOs to meet their needs of self-determination in secure forensic treatment settings.

Screening for intellectual disability in persons with a substance abuse problem: Exploring the validity of the Hayes Ability Screening Index in a Dutch-speaking sample.

There is an increasing interest in screening instruments to detect intellectual disability (ID) in a quick and accurate way in mental health services as well as in the criminal justice system in order to provide appropriate support for people with undetected needs caused by ID. An instrument that has been proven to be useful in both settings is the Hayes Ability Screening Index (HASI). This study assessed the validity of the Dutch version of the HASI in persons with a substance abuse problem residing in mental health services, whether or not mandated to treatment by court order. The HASI was conducted along with the Wechsler Adult Intelligence Scale III as the criterion for validity to 90 participants. Additionally, the influence of psychiatric disorder and medication use on the HASI result was examined. A significant positive relationship was found between the two instruments, demonstrating convergent validity. Using a Receiver Operating Characteristic (ROC) curve analysis, the discriminative ability of the HASI with a cut-off score of 85 was found to be adequate, yielding in a good balance between sensitivity and specificity. The HASI was not distorted by the presence of the substance abuse problem or other psychiatric illnesses and medication did not influence the HASI scores in this study. These findings indicate that the HASI provides a time-efficient and resource-conscious way to detect ID in persons with a substance problem, thus addressing a critical need in mental health settings.

Neuronal correlates of maladaptive coping: an EEG-study in tinnitus patients.

Here we aimed to investigate the neuronal correlates of different coping styles in patients suffering from chronic tinnitus. Adaptive and maladaptive coping styles were determined in 85 tinnitus patients. Based on resting state EEG recordings, coping related differences in brain activity and connectivity were found. Maladaptive coping behavior was related to increases in subjective tinnitus loudness and distress, higher tinnitus severity and higher depression scores. EEG recordings demonstrated increased alpha activity over the left dorsolateral prefrontal cortex (DLPFC) and subgenual anterior cingulate cortex (sgACC) as well as increased connectivity in the default (i.e. resting state) network in tinnitus patients with a maladaptive coping style. Correlation analysis revealed that the changes in the DLPFC correlate primarily with maladaptive coping behavior, whereas the changes in the sgACC correlate with tinnitus severity and depression. Our findings are in line with previous research in the field of depression that during resting state a alpha band hyperconnectivity exists within the default network for patients who use a maladaptive coping style, with the sgACC as the dysfunctional node and that the strength of the connectivity is related to focusing on negative mood and catastrophizing about the consequences of tinnitus.