The increase in newly diagnosed patients with cancer in South Africa and globally, may contribute to the increase in patients living with chemotherapy-induced peripheral neuropathy (CIPN). Chemotherapy-induced peripheral neuropathy negatively impacts on quality of life (QoL) during and post chemotherapy treatment. Physiotherapy management of CIPN helps patients to manage symptoms and improves function in activity- and participation-levels to ultimately improve QoL. However, little evidence exists regarding the type or combination of physiotherapy management strategies in South Africa.The purpose of our study was to determine how the symptoms of CIPN were managed by physiotherapists in Pretoria, South Africa.A quantitative, descriptive study design was used. Electronic questionnaires were distributed to physiotherapists who worked with cancer patients and who treated patients with CIPN.Physiotherapists used massage, proprioceptive neuromuscular facilitation, sensory integration, activities of daily living training, postural drainage, lifestyle modifications; Bobath-, breathing-, stability-, stretching-, strengthening- and endurance-exercises; electrical stimulation, thermal modalities, transcutaneous electrical nerve stimulation, soft tissue mobilisation; muscle energy-, positional- and Mulligan-techniques in the management of CIPN.Cardiopulmonary therapy, therapeutic exercises, manual therapy and neuro-developmental techniques were used by physiotherapists in the management of CIPN. Almost half of the participants did not use electrotherapy techniques. Physiotherapy management strategies that are used in Pretoria are similar to published research.Physiotherapists in Pretoria are managing CIPN according to international practices. However, studies to determine the effectiveness of the management strategies in a South African context should be conducted. Alternative management strategies, based on the pathophysiology of CIPN, should be explored.physiotherapy; chemotherapy-induced peripheral neuropathy; intervention; management; cancer. Worldwide it is projected that the incidence of cancer diagnoses will increase by 50% in the next 10 years  of cancer survivors for up to 6 months after chemotherapy has been terminated  in symptom severity, compared with the control group .A quantitative, descriptive study utlised electronic questionnaires (PTPQ tool) uploaded onto Survey Monkey (an electronic questionnaire distribution website). The questionnaires were sent to physiotherapists in Pretoria who were known to work in oncology settings. The physiotherapists were recruited by identifying the different oncology treatment centres in Pretoria and then identifying the physiotherapy practices receiving referrals from those oncology centres. Physiotherapists were also recruited by word of mouth from physiotherapists working in the clinical field in Pretoria.After identifying potential participants, an electronic information leaflet and link were sent to them via email and short message services. Participants who were willing to participate in the study provided consent (clicked the consent button) before online access to the questionnaire was granted. Follow-up reminders to complete the questionnaire were sent on a weekly basis. Access to the electronic link was granted to the physiotherapists for 4 months. After completion and submission of the questionnaire, the physiotherapists could not access the link.The PTPQ is a survey tool that was developed to comprehensively describe the practice of physiotherapy in various clinical settings. The questionnaire consists of five different components, namely: general information and demographics; practice profile; treatment preferences; bases for clinical work; and bases for education or research work. For our study, physiotherapists were asked to complete the ‘treatment preferences’ component of the PTPQ for CIPN management specifically. The content validity of the PTPQ was established based on input from an expert panel  were female. Ten (37%) indicated that they have been in practice between two and five years. Eighty two percent (n = 22) had either a Bachelor of Science in Physiotherapy or a Bachelor in Physiotherapy degree (n = 14) worked in a general physiotherapy practice. Three (11.11%) of the 27 participants worked exclusively with oncology patients, the rest  treated oncology patients on an irregular basis.Twenty-seven (27) physiotherapists participated and their ages ranged from 23 to 71 . The majority of the participants  stretching and endurance exercises, breathing exercises and activities of daily living training.These results are similar to the management of CIPN in breast cancer patients reported by Ceprnja and Maka (2017). They found that the majority of physiotherapists prescribed different types of exercise as the first-line treatment for CIPN. They also indicated that 60% of physiotherapists use soft tissue techniques for the management of CIPN and only 5% of their participants  used electrotherapy modalities in the management of CIPN.The neuro-developmental modalities that were mostly implemented by physiotherapists were: proprioceptive neuromuscular facilitation and sensory integration. Streckmann et al.  reportedCardiopulmonary therapy in the management of CIPN was also used with the most frequently used techniques being: breathing exercises, activities of daily living training and lifestyle modifications. Galantino et al.  report tLocally and internationally, exercise prescription for the management of CIPN symptoms and improvement of QoL is the most frequently and effectively implemented physiotherapy modality. However, exercises should not be prescribed in isolation. The inclusion of different forms of therapeutic exercises in an exercise programme has been found to be more effective than the performance of a single type of exercise (Brayall et al. It is noticeable from our study and the literature that physiotherapists use a vast variety of treatment techniques when it comes to the management of CIPN. The development of CIPN is intricate and multifactorial (Zajczkowska et al. Physiotherapy management strategies that are used in Pretoria, South Africa are similar to those in other studies. Because of the geographical restrictions of our study and the fact that the majority of participants did not exclusively treat oncology patients, our results may not be a true reflection of the physiotherapy management strategies of CIPN in South Africa. Future studies should be conducted to determine whether the physiotherapy management strategies that are used in Pretoria, South Africa, improve the QoL of patients living with CIPN and also to explore alternative management strategies.


Trunk and head muscles originate from distinct embryonic regions: while the trunk muscles derive from the paraxial mesoderm that becomes segmented into somites, the majority of head muscles develops from the unsegmented cranial paraxial mesoderm. Differences in the molecular control of trunk versus head and neck muscles have been discovered about 25 years ago; interestingly, differences in satellite cell subpopulations were also described more recently. Specifically, the satellite cells of the facial expression muscles share properties with heart muscle. In adult vertebrates, neck muscles span the transition zone between head and trunk. Mastication and facial expression muscles derive from the mesodermal progenitor cells that are located in the first and second branchial arches, respectively. The cucullaris muscle (non-somitic neck muscle) originates from the posterior-most branchial arches. Like other subclasses within the chemokines and chemokine receptors, CXCR4 and SDF-1 play essential roles in the migration of cells within a number of various tissues during development. CXCR4 as receptor together with its ligand SDF-1 have mainly been described to regulate the migration of the trunk muscle progenitor cells. This review first underlines our recent understanding of the development of the facial expression (second arch-derived) muscles, focusing on new insights into the migration event and how this embryonic process is different from the development of mastication (first arch-derived) muscles. Other muscles associated with the head, such as non-somitic neck muscles derived from muscle progenitor cells located in the posterior branchial arches, are also in the focus of this review. Implications on human muscle dystrophies affecting the muscles of face and neck are also discussed. Remarkably, skeletal muscles in the trunk and head regions differ in a number of important aspects . The priIn this Review, we intend to provide an update of the research data concerning the origin and gene regulatory networks of vertebrate facial and neck muscles, taking into account the evidence for common embryonic origins of these muscles with heart muscle. We also discuss the roles of SDF-1 and its receptor CXCR4 in the development of skeletal muscles. Since search data concerning the role of chemokines in trunk muscles development have been previously reviewed by Trunk and head muscles originate from distinct embryonic regions: trunk muscles from paraxial mesoderm that becomes segmented into somites, but the majority of head muscles are developed from unsegmented cranial mesoderm . Neck muThere are approximately 80 skeletal muscles in the human neck that control the processes of respiration, vocalization, swallowing and head mobility . Neck muIn the body, the central functions of connective tissues are to link up cells and tissues and to support organs. Connective tissue generates a broad range of derivatives, which can be classified into three groups: specialized connective tissue (corresponds to cartilage and bone), loose connective tissue and dense connective tissue, which is subdivided into regular (refers to tendon and ligament) and irregular. Irregular connective tissue includes cartilage perichondrium, muscle epimysium and connective tissue inside the muscle . BAs areMyogenic programmes are distinct not only between head and trunk muscles, but also amongst neck muscles. Likewise, within the head muscles, extraocular muscles differ from branchial muscles, and myogenic programmes that lead to the formation of branchial muscles vary considerably among the different BAs . A compaPax transcription factor family 3 (Pax3) marks trunk skeletal muscle progenitor cells and controls their entry into the muscle differentiation program . In Pax3The pituitary homeobox 2 (Pitx2) is expressed in the head mesoderm and BA1-mesodermal core. In Pitx2 mutants, the EOM and BA1-derived muscles were affected, whereas BA2-derived muscles were merely altered . Thus, P+ lineage). Instead, they are derived from the head mesoderm and continue to express the early head muscle markers , an autosomal dominant disease, affects in its early stage the muscle of the eye (orbicularis oculi muscle) and the mouth (orbicularis oris muscle). Later, the weakness of the muscles progresses to the upper torso, the muscles connecting shoulder girdle to the thorax, in particular the trapezius muscle. Being the third most common muscular dystrophy with an incidence of 12:100.000  after DuIt has been more than 2 decades since the emergence of a new concept of the cardiopharyngeal field, which proposes that the pharyngeal mesoderm gives rise to second heart field (SHF) and branchiomeric muscles. In recent years, a wide range of investigations have been carried out to reveal the relationship between branchiomeric and heart muscles. However, the mechanisms of the migration of SHF progenitor cells has been largely ignored. We have recently revealed the importance of the CXCR4/SDF-1 for the migration of myogenic progenitor cells during development of branchiomeric muscles. It will be of great interest to investigate the role of the CXCR4/SDF-1 axis in migration of the newly discovered SHF progenitor cells. Understanding the mechanisms that control SHF cells migration is certainly crucial if these cells are intended to be used for therapeutic applications.IY prepared the figures. All authors listed have contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In the cell nuclei, various types of nuclear domains assemble as a result of transcriptional activity at specific chromosomal loci. Giant transcriptionally active lampbrush chromosomes, which form in oocyte nuclei of amphibians and birds enable the mapping of genomic sequences with high resolution and the visualization of individual transcription units. This makes avian and amphibian oocyte nuclei an advantageous model for studying locus-specific nuclear domains. We developed two strategies for identification and comprehensive analysis of the genomic loci involved in nuclear domain formation on lampbrush chromosomes. The first approach was based on the sequential FISH-mapping of BAC clones containing genomic DNA fragments with a known chromosomal position close to the locus of a nuclear domain. The second approach involved mechanical microdissection of the chromosomal region adjacent to the nuclear domain followed by the generation of FISH-probes and DNA sequencing. Furthermore, deciphering the DNA sequences from the dissected material by high throughput sequencing technologies and their mapping to the reference genome helps to identify the genomic region responsible for the formation of the nuclear domain. For those nuclear domains structured by nascent transcripts, identification of genomic loci of their formation is a crucial step in the identification of scaffold RNAs. According to modern knowledge on the mechanisms which underlie the formation of nuclear bodies, the assembly of certain nuclear domains is nucleated by RNA at the transcription loci ,2. FurthA nucleolus forming around transcribing clusters of ribosomal RNA genes is a vivid example of a ubiquitous locus-specific nuclear domain. However, recent studies prove that the maintenance of nucleolus integrity requires non-ribosomal RNA polymerase II transcripts . AnotherCoilin-containing nuclear bodies represent another type of nuclear domain with locus-specific localization. Coilin-containing nuclear bodies form in close association with the transcription units of RNA species requiring specific processing machinery , although they are not structured by the nascent transcripts themselves .The giant lampbrush chromosomes represent transcriptionally active meiotic half-bivalents forming at the diplotene stage of meiosis in oocytes of non-mammalian species; lampbrush chromosomes are the most well-studied in amphibians and birds ,19. SimiThe centromere protein bodies represent spherical bodies attached to the centromere regions of lampbrush chromosomes and evidently belong to meiosis-specific nuclear domains. Centromere protein bodies lack components of the RNA-processing machinery and accumulate chromosome architectural proteins: DNA topoisomerase II  and coheAnother group of locus-specific domains on lampbrush chromosomes combines RNP-rich non-spherical structures forming in association with specific transcription units. Immunofluorescence and 3D RNA FISH on isolated oocyte nuclei revealed that certain lampbrush lateral loops or loci-specific RNP aggregates manifest as nuclear domains since they accumulate specific RNA-binding proteins and RNA species as opposed to the nucleoplasm . For exaSeveral genome-wide approaches for identification of genomic loci proximal to nuclear domains were recently developed for interphase nuclei. These approaches were used to study the 3D genomic environment of nuclear speckles ,43,44, nRecently, we developed two strategies for analyzing the loci of nuclear domain formation on giant lampbrush chromosomes. The first approach was based on sequential FISH mapping of BAC clones containing genomic DNA fragments with a known position in the genome and located close to the site of the formation of a nuclear domain or marker structure in order to narrow the area of subsequent bioinformatics search and analysis of genomic loci a. This aThe second suggested approach was based on mechanical microdissection of chromosome regions adjacent to a particular nuclear structure, followed by in vitro amplification of DNA from the dissected material, FISH-mapping and high throughput sequencing of the obtained DNA samples b. We demSubsequently, deciphering the DNA sequence from the dissected material using the next generation sequencing technologies and mapping of sequenced DNA fragments to the reference genome allows for the identification of genomic loci occupying 1.5–5 Mb ,50. One It is important to emphasize that the use of such an integrated approach will accurately determine the genomic position of the nuclear domain formation, and then analyze its genomic and epigenetic characteristics. Moreover, great efforts should be given to the subsequent bioinformatics and functional analysis of the established genomic loci followed by identification of the transcripts involved in nuclear domain formation. At the moment, application of the aforementioned approaches is restricted to species with a lampbrush stage during oogenesis. However, in prospect, these approaches can be extended to mammalian species with artificial induction of lampbrush chromosomes formation using sperm head injection into the amphibian oocyte nucleus .


Despite widely appreciated barriers to successful clinical implementation, the literature regarding how to operationalize electronic health record-integrated patient-reported outcomes (PROs) remains sparse. We offer a detailed summary of the implementation of PROs into the standard of care at a major tertiary academic medical center.Collection of four Patient-Reported Outcomes Measurement Information System computer adaptive tests was piloted in a large academic orthopaedic surgery ambulatory clinic starting in October 2016. The Patient-Reported Outcomes Measurement Information System computer adaptive tests  were initially implemented as manual order sets to be administered before surgery through 2 years after surgery. Completion rate over time, mean time to completion for all PRO domains, and the overall distribution of symptom severity were used to evaluate the success of the pilot. A subsequent optimization and redesign of the pilot was conducted using tablets, automation of questionnaire deployment, and improved results review to address obstacles encountered during the pilot phase.Two thousand nine distinct joint arthroplasty patients (mean age = 65) completed at least one set of PRO assessments, with overall completion rates reaching 68% and mean completion time of 3 minutes. Focal points during the implementation process included engagement and training of staff, selection of an appropriate patient population and outcome measures, and user friendly data displays for patients and providers.Our pilot program successfully demonstrated that PROs can be administered, scored, and made immediately available within the electronic health record to patients and their providers with minimal disruption of clinical workflows. Although considerable operational and technological challenges remain, we found that the implementation of PROs in clinical care within an ambulatory practice at an academic medical center can be achieved through a constellation of several key factors. Although traditional clinician-mediated measures of patient symptoms and outcomes such as clinical examination and radiographic results provide valuable information, they do not directly measure a patient's concerns and symptom burden. Patient-reported outcomes (PROs) are “any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else.”2 Broadly defined, they quantify health-related quality of life such as health perceptions, well-being, symptoms, and function. PRO measures can assess universal  or disease-specific  symptoms or function. A wide array of PROs have been validated for use in clinical research after surgical interventions and in many chronic and acute conditions such as depression, cancer, chronic obstructive pulmonary disease, and heart failure.345678910 PROs can capture patients' perspectives on the severity and impact of symptoms on physical health and mental well-being. Routine inclusion of PROs in care has the potential to improve treatment decision-making, focus patient-provider discussions on the most burdensome symptoms, and increase patients' engagement in their care.111213141516 PROs may also be better measures of the targets of care and therefore useful in evaluating the healthcare quality rather than relying solely on provider-centric metrics.17Health care in the United States is continuing to evolve toward a value-based system in which compensation is increasingly driven by patient-centered clinical outcomes.18192021 few teams have described the development of a PRO program implemented in a high-volume setting that can be potentially applicable across multiple clinics and conditions.22-24Determining how to collect and efficiently use PRO data to improve the health of patients continues to present a challenge for health systems. Although multiple studies have offered guidance on methodological and practical decisions to implement PROs in practice,The Northwestern Medicine Patient-Reported Outcomes (NMPROs) platform was developed as an integrated tool within the electronic health record (EHR) system Epic  used at our institution to administer, score, and display Patient-Reported Outcomes Measurement Information System computer adaptive tests through the patient communication portal in Epic MyChart at home or in a clinic at the point of care. This study outlines the pilot implementation of PROs in the Total Joint Replacement Program in the Department of Orthopaedic Surgery as a model for other large and complex high-volume academic healthcare systems.The most critical decision made in the development of NMPRO was to fully integrate it within the EHR. This integration was chosen primarily because it enables clinician access to PRO scores in the same location as all other health information, thereby facilitating the use of the data clinically in care in addition to making the data available through the enterprise data warehouse for future retrospective research activities. The Northwestern Medicine Enterprise Data Warehouse is a single, comprehensive and integrated repository of all clinical and research data sources to facilitate research, clinical quality, healthcare operations, and medical education at our institution. The NMPRO design also includes the ability to select clinically relevant PROs for each population of interest. Administration is flexible and can be triggered by condition-specific, time-based triggers or through an on-demand feature at the clinician's discretion with the ability for patients to complete the assessments at home or in clinic. Finally, NMPRO provides the clinical staff with immediate access to the results within the EHR.A steering committee consisting of a multidisciplinary group of stakeholders was established to provide guidance and oversight for coordination of PRO implementation. They serve as a governing body and prioritize expansion efforts across the healthcare system.25 Finally, the program had a high level of readiness and high levels of engagement from key operational partners.The Total Joint Replacement Program in the Department of Orthopaedic Surgery was chosen as a pilot for three primary reasons. First, there was considerable interest from the surgical team to monitor changes in symptom severity over time, support shared clinical decision-making, assess treatment effectiveness, and use the data generated for future research endeavors. Second, the Centers for Medicare and Medicaid Services expressed interest in using PROs in the future performance measures for value-based purchasing and satisfying meaningful use requirements.(1) Preimplementation phase—identification of key operational and clinical partners, assessment of readiness and scope of change needed to current-state workflow, and selection of appropriate PRO measures per clinical requirements.(2) Technical build phase—technical Epic build programming, functionality testing, and technical build revisions.(3) Implementation phase—education/training of clinical staff, live demonstrations, and at-the-elbow support.(4) Postimplementation phase—formal postimplementation review, analysis of postimplementation data, and development of optimization plan.A four-step approach of prioritization and resource planning was applied to implement PROs in Orthopaedic Surgery:The orthopaedic surgery pilot included all English-speaking patients undergoing primary and revision total hip and knee arthroplasties. Non-English speakers were excluded from the pilot to remove possible confounding effects such as language barriers and health literacy issues. PROs were collected using three manual order sets  built to assess the following validated Patient-Reported Outcomes Measurement Information System computer adaptive test domains relevant to orthopaedic surgery patient populations: Physical Function, Pain Interference, Pain Intensity, and Ability to Participate in Social Roles and Activities. Each domain poses questions to patients regarding their level of physical difficulty or severity of pain in completing a variety of daily activities, such as household chores or socialization with friends and family. The assessment duration was kept to a maximum of 8 minutes to reduce thev risk of fatigue and potential abandonment.Customized workflows were developed for each surgical team to place the presurgical and postsurgical orders at appropriate points in care. The presurgical PRO assessments were completed during the presurgical visit in the clinic using the examination room workstations. The postsurgery order set was placed in Epic the week before surgery “P1”) by a member of the surgeon's clinical team to trigger an automatic cascade of five time windows chosen by the surgeons based on meaningful clinical benchmarks for recovery over time: 3 weeks , 5 weeks , 10 weeks , 23 weeks , 1 year , and 2 years . These PRO assessments could be completed outside of the clinic through the patient portal or in the clinic during routine visits using the examination room workstations. The designated staff member in each surgeon's clinic reviewed the clinic schedule ahead of time to identify patients who had failed to complete the PRO assessments in advance using the MyChart portal and therefore needed to complete these assessments in the clinic. Once the PRO assessments were launched by the designated staff member in the clinic through a hyperlink window, the EHR was securely locked in the background. The designated staff member also remained available to answer any questions or clarify responses for the patient. The on-demand order set supplemented the presurgery and postsurgery order sets by initiating an additional PRO assessment during the course of care if required by the clinical team. Once completed, all PRO results were available in table and graphed formats for immediate review in the EHR  had PRO assessment orders placed using manual order sets. Of these, 1,151 (57%)  completed at least one set of PRO assessments. Presurgical and postsurgical PRO assessment completion peaked at 77% between October 2016 and December 2018 and demonstrated notable variation within this period  integrating the collection of PROs seamlessly into the patient encounter through integration into workflows, (2) getting the correct PRO triggered to the correct patient at the correct time, and 3) engaging and educating the patient to promote PRO completion. Consequently, after the pilot phase, the NMPRO implementation team initiated an optimization phase, defined as the period between December 2018 and September 2019 in which the team deployed strategies aimed at addressing the obstacles affecting evaluation metrics as discussed in detail below. During this period, the four orthopaedic surgeons performed a total joint arthroplasty on 997 distinct patients. Of the patients who underwent a total joint arthroplasty, 858 distinct patients (86%)  had PRO assessment generated and 229 (26%) completed at least one set of PRO assessments. The discrepancy between surgical case volume and PRO assessments generated was attributable to patients who underwent bilateral surgeries and were not prompted to begin a new assessment series. The rationale for this decision was that patients would not be able to accurately distinguish symptoms and physical limitations after one procedure versus the other. Finally, presurgical and postsurgical PRO assessment completion reached 68% between December 2018 and September 2019 and demonstrated notable variation over time . Although the use of tablets increased the number of staff who could initiate an assessment, no notable change was observed in the overall completion rate after their introduction Figure . The lacThe initial implementation required manual order placement for the pre-op and post-op PRO assessment series for each patient. Consequently, the completion rates were dependent on clinic staff to place the correct order at the correct time. Some patients were therefore missed, enrolled late, or enrolled early. Automated questionnaire deployment using the current procedural terminology procedural codes to trigger both the presurgery and postsurgery PRO assessments was implemented in December 2018. Although more assessments were triggered and made available for completion, no actual change was observed in the completion rates between the pilot and optimization phase Figure .26 The surgeons attempted to review the results of the PROs with each patient during their clinic visit as an additional data point to patient's progress, describing the routine nature of PROs as similar to the ubiquity of radiographs in orthopaedic care. Patients cited multiple reasons as to why PROs had not been completed, with most citing a lack of understanding regarding their purpose. Additional training to providers and operational staff was therefore provided in May 2019. Scripts for staff explaining PRO collection were also revised to emphasize rationale. Although the short time frame of available data limits the strength of our interpretation, an increase in overall completion rates (46% to 68%) was observed between May 2019 and September 2019 and may be attributed to revisions in the training and scripts provided to the providers and operational staff.Providing information on the purpose of PROs including their role in identifying care needs has been identified as critical for patient engagement.Across both phases, the completion rates demonstrated attrition because time since surgery increased Figure . The aveOverall, the integration of PRO measures into this busy ambulatory practice within an academic medical center was successful in many respects. Patients were observed to routinely complete the four PRO measures for physical function, pain, and social well-being in approximately 3 minutes on average. The scores demonstrated an expected range of severity, and the postsurgical improvement in these domains was well aligned with the surgeon's clinical expectations.Despite the many successes of the NMPRO program, the implementation in Orthopaedic Surgery encountered multiple hurdles in the form of technological barriers, operational barriers, and overall challenges in quantifying the success of the implementation that are discussed in detail below.26-28 Like others, we encountered similar hurdles that required notable resources, programming time, and management to address. The implementation required a designated information services analyst team member and software programmer who constructed the technical build of the PRO assessments and automated triggers within the EHR. The difficulty of integrating the assessment into the EHR was considerably more arduous than anticipated and will conceivably remain a potential area of difficulty for other systems. The information service team members therefore continued to be retained to perform functionality testing and troubleshoot a multitude of issues that materialized during the build. In addition, the implementation required oversight and management from a project manager to comprehensively support the rollout. Finally, the implementation required identifying specific operational leaders and clinical staff to install as dedicated team members tasked with operationalizing and managing the rollout within the practice.Multiple publications have documented the notable effort required to program customizable PROs into the EHR.Second, only approximately 66% of our patients currently use the patient communication portal MyChart to track their care and communicate with the care team. In NMPRO, MyChart is the primary mode for completing PRO assessments remotely. As a result, the completion rates declined because time since surgery increased. This decline in completion rates may be attributable to patients no longer returning for in-person follow-up, decreased symptom severity, or a variety of other reasons. Finally, the introduction of tablets to expedite the clinic workflow and improve PRO completion rates had no impact on the completion rates. Furthermore, the completed PRO results were not accessible to patients in an easily interpretable format to facilitate self-monitoring. Having the results accessible to the patients via MyChart could potentially have an effect on completion rates.29 Physician champions are vital in emphasizing the value of PROs and their utility in clinical care to their peers, role-modeling the use of PROs in the clinical encounter.31 However, despite concerted efforts, our department faced notable challenges in being able to effectively integrate the PROs into their workflow and convey their importance to patients.32 Lack of time and competing clinician priorities regularly interfered with review and discussion of PROs with patients. Additional training for patients and staff on the rationale for PRO collection did not alter the completion rates, suggesting that other interventions were needed. Although the automation of the PRO increased the number of assigned assessments, it proved insufficient in improving the completion rates. Embedding PROs as another “vital sign” similar to radiographs in a comprehensive view of patient heath status as previously mentioned will therefore require a cultural shift to view PRO data having the same foundational value as other clinical data.Maintaining consistent engagement with process owners at key decision-making stages is fundamental to sustaining change in workflow and overall culture.Evaluation metrics are vital to advancing quality improvement, and research endeavors and insufficient PRO data volume greatly hampers clinicians' ability to use these data in a meaningful manner. Our primary evaluation metric, completion rate, varied over time. Furthermore, limited data prevent the construction of representative data sets that can be used to establish the norms for PRO scores over time. Consequently, a concerted effort to increase patient participation is vital. Evaluation of the frequency and efficacy of clinicians' use of PROs as a tool for patient education and engagement is needed.The next phase of improvement in NMPRO will implement and assess modifications to increase PRO completion. These include the use of an electronic dashboard to track completion rates and encouraging point-of-care use. In addition, we are developing a patient friendly data visualization system accessible via the patient portal that could aid patients in tracking their outcomes over time. Engagement with clinician and patient stakeholders remains extremely important to achieve these goals.The pilot program successfully demonstrated that PROs can be administered, scored, and made immediately available within the EHR, with minimal disruption in the efficiency of clinical workflows. However, considerable operational and technological challenges remain. The NMPRO initiative offers a scalable model for process implementation and highlights key barriers to be considered during implementation. We assert that the NMPRO initiative can help guide PRO implementations in a variety of clinical populations and similarly structured hospitals and medical groups. The development of new strategies for more effective engagement and retention of patients to improve the response rates and accumulate a more complete longitudinal data set will continue to be vital in maximizing the utility and value of initiatives like ours.


Most people infected with SARS-CoV-2 have mild disease with non-specific symptoms, although a few becoming critically ill with septic shock and multiple organ failure. There is an unknown proportion of infected individuals who remain asymptomatic and infectious. Universal screening for COVID-19 infections to detect individuals who are infected before they present clinically could therefore be an important measure to contain the spread of the disease. We highlight a Cochrane rapid review which assessed the effectiveness and accuracy of universal screening for COVID-19 infection.the authors of the Cochrane review searched multiple electronic databases to identify studies reporting on the effectiveness of universal screening and reporting on screening test accuracy. Eligible participants for the review included people who had not sought care for potential COVID-19 symptoms.the authors included 22 publications, with none of them conducted in Africa. Two modelling studies reported on the beneficial and negative effects of screening; and 20 studies (cohort and modelling) reported data on the accuracy of screening tests. The included studies had wide variability in the baseline prevalence of COVID-19 infection as well as study settings and methods. All cohort studies compared screening strategies to reverse transcriptase-polymerase chain reaction (RT-PCR) as the gold standard. The rapid review suggests that there is low certainty of evidence that screening at travel hubs may slow the importation of infected cases. Furthermore, the review highlights the uncertainty and variation in the accuracy of screening.given the low accuracy of the tests included in this review, a high proportion of COVID-19 infected individuals may be missed and go on to infect others. In addition, some healthy individuals may be falsely identified as positive, requiring confirmatory testing and potentially leading to the unnecessary isolation of these individuals. Coronavirus disease 2019 (COVID-19), caused by a novel coronavirus (SARS-CoV-2), is responsible for an ongoing global pandemic. COVID-19 protocols such as universal screening have included strategies to minimise the spread of the virus to identify any of the symptoms suggestive of having been infected . The scrThe review assessed the effectiveness of universal screening for SARS-CoV-2 infection compared with no screening, and the accuracy of universal screening in people who have not presented to clinical care for symptoms of COVID-19 . SpecifiSearches were conducted in various databases between 04 April 2020 - 26 May 2020 to identifies trials, observational studies and modelling studies assessing the effectiveness and accuracy of screening in the general population. The databases searched were Ovid MEDLINE and the Centers for Disease Control (CDC) COVID-19 Research Articles Downloadable Database, Embase.com, the Central, and the Cochrane COVID-19 Study Register, LitCOVID, and three model repositories . The review authors included randomized and nonrandomized studies and modelling studies to answer the question of screening effectiveness. For accuracy, the review authors included study designs on patients that provided information on test accuracy which also included modelling studies. The languages considered were English and Chinese. Screening of articles was conducted followed by data extraction and the assessment of the quality of the included studies conducted in duplicate. The results were synthesized narratively and in a tabular form. Paired forest plot for sensitivity and specificity with 95% confidence interval reported. Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used for assessment of certainty of the evidence the synthesized studies.The review included 22 publications with 17 cohort studies reporting on diagnostic accuracy and 5 modelling studies reporting on the effectiveness of screening and screening test accuracy. The studies were conducted in the United States of America, Europe, and Asia. The modelling studies that evaluated the effectiveness of screening strategies which included symptoms screening of air travellers and symptomatic laboratory testing of asymptomatic healthcare workers in emergency departments. To assess the effectiveness of screening, one study suggested that symptom screening at travel hubs, such as airports, may slightly slow but not stop the importation of infected cases. The authors assessed risk of bias as minor or with no concerns, and low certainty of evidence, but further downgraded for very serious indirectness. The second modelling study indicated that screening of healthcare workers in emergency departments using laboratory tests may reduce transmission to patients and other healthcare workers. The certainty of evidence was downgraded for high risk of bias (major concerns) and indirectness. No modelling studies reported on harms of screening.To assess the accuracy of screening, all 17 cohort studies compared an index screening strategy to a reference RT-PCR test. Only one study reported on the accuracy of single point-in-time screening and varied widely in the prevalence of COVID-19, settings, and method of measurement. The overall risk of bias was unclear in 16 out of 17 studies, mainly due to limited information on the index test and reference standard. One study was rated at high risk of bias due to the inclusion of two separate populations with likely different prevalence. For several screening strategies, the estimates of sensitivity came from small samples. All screening strategies in 17 studies with 17,574 people incorrectly identified infected people as healthy; healthy people as infected. Thirteen studies which included 16,762 people incorrectly identified infected people as healthy and healthy people as infected. A similar trend observed in 6 studies with 14,741 people where temperature measurements were taken and asking about international travel, exposure to known infected people and exposure to known or suspected infected people. Also asking about symptoms plus temperature measurement observed in 2 studies with 779 people incorrectly identified infected people as healthy and healthy people as infected. Three studies modelling entry and exit screening in airports indicated 70% of infected travellers being missed while another detected 90% of infections but used an unrealistic scenario. The third study used very unreliable methods which the review authors could not use evidence from this study. The review authors highlight that there are limitations in the confidence of these findings because most studies did not describe their screening methods clearly, some found very few cases of infections and the types of participants and settings varied greatly, making it difficult to judge whether the results apply broadly.The ability to perform effective screening for COVID-19 infection at the earliest presentation is a critically important first step to curbing the spread of the virus in any setting . COVID-1African countries have challenges with implementing many of the recommended strategies because of weak public health infrastructures while having the greatest infectious disease burdens beside COVID-19 . It is tThe findings from this review suggest that screening at travel hubs may slightly slow the importation of infected cases. However, the uncertainty and variation in the accuracy of screening strategies suggest that a high proportion of infected individuals may be missed and go on to infect others, and some healthy individuals may be falsely identified as positive, requiring confirmatory testing and potentially leading to the unnecessary isolation of these individuals. This becomes critical as many African countries open their borders to resuming economic activity. While the African continent had a relatively low number of cases compared to high-income countries, screening at borders remains the only tool available to ensure that there is no importation of new cases to Africa. As thus, studies are needed to evaluate the utility of rapid laboratory tests, combined screening, and repeated screening. The accuracy of RT-PCR is needed for further research to be used as a reference standard. Given the poor sensitivity of existing approaches, the findings of this review point to the greater emphasis on other ways that may prevent transmissions such as face coverings, physical distancing, quarantine, and adequate personal protective equipment for frontline workers.Universal screening for COVID-19 is used as a strategy to assess potential individuals who may need to be isolated and seek medical care;The screening method uses a questionnaire accompanied by a temperature check to assess if a person may have been infected with COVID-19;Asymptomatic individuals do not present with symptoms which make the screening likely to miss infected individuals.The current screening approach is likely to miss the asymptomatic individual infected with COVID-19;As many countries open their borders, this study emphases the need to incorporate multiple screening approaches which incorporate point of care tests for everyone in their screening protocols to ensure that there is a rapid response in the management of cases.


Robot-assisted surgery has numerous patient benefits compared to open surgery including smaller incisions, lower risk of infection, less post-operative pain, shorter hospital stays and a quicker return to the workforce. As such, it has become the first-choice surgical modality for several surgical procedures with the most common being prostatectomy and hysterectomy. However, research has identified that the perceptions of robot-assisted surgery among surgical patients and medical staff often do not accurately reflect the real-world situation. This study aimed to understand male and female perceptions of robot-assisted surgery with the objective of identifying the factors that might inhibit or facilitate the acceptance of robotic surgery. Semi-structured interviews were undertaken with 25 men/women from diverse social/ethnic backgrounds. The interviews were transcribed and analysed using thematic analysis. The majority of female participants expressed concerns in relation to the safety and perception of new technology in surgery, whereas many male participants appeared to be unfazed by the notion of robotic surgery. There were clear differences in how males and females understood and conceptualised the robot-assisted surgical process. Whilst male participants tended to humanise the process, female participants saw it as de-humanising. There is still a discrepancy between the public perceptions of robotic surgery and the clinical reality perceived by healthcare professionals. The findings will educate medical staff and support the development of current informative techniques given to patients prior to surgery. Advances in technology have been increasingly adopted in surgery. The introduction of laparoscopic surgery marked the birth of minimally invasive surgery (MIS) and placed a technology interface between surgeons and their patients . MIS hasRobot-assisted surgery (RS) involves a surgeon at a console operating remote-controlled robotic arms which facilitates the performance of laparoscopic procedures . RS was Currently the most common RS procedures are prostatectomy and hysterectomy. However, research has consistently demonstrated that patient understanding of robotic-assisted surgery is poor. Irani et al.  examinedResearch has also identified that the perceptions of robotic surgery among surgical patients and medical staff often do not accurately reflect the real-world situation  and therShared decision making in healthcare services involves the collaboration of patients and clinicians in selecting tests and treatment options based on the clinician’s expertise and the informed preferences of the patients . This isGiven this fear and the reported widespread misunderstanding about robot-assisted surgery, this study utilised semi-structured interviews to gain insight into male and female perceptions of robot-assisted surgery with the objective of identifying the factors that might inhibit or facilitate the acceptance of robotic surgery among participants.Ethical approval was given for this study by Loughborough University Ethical Advisory Committee. An interview schedule was developed at the beginning of the study, which was informed through engagement with the literature, and was piloted before producing the final version. Open-ended questions were utilised in conjunction with probing questions to elicit deep, meaningful data to encourage further discussion and to clarify participant responses. The interview schedule focused on gynaecological surgery for female participants and prostrate surgery for male participants.Sampling was on a convenience basis and was used to recruit participants from diverse, backgrounds to capture their understandings of the research area. Participant selection was made on the basis that they were over the age of 18 and from a variety of ethnic backgrounds. An online advertisement was posted on social media (Facebook) outlining details of the study. Snow-ball sampling was also utilised as volunteers can sometimes skew data as they share similar characteristics .The interviews were undertaken by two researchers (NC and ML) both of whom had been trained in interview techniques. Prior to the interviews, participants were presented with a participant information sheet and informed consent was obtained from all individual participants. The interviews were audio recorded with the knowledge and consent of the interviewee and lasted between 20 and 30 min.The recorded interviews were transcribed and coded accordingly following the phases of thematic analysis outlined by Braun and Clarke . This apIn total, 25 face-to-face semi-structured interviews were undertaken with 12 males and 13 females  , as the This study is, to the authors’ knowledge, the first to investigate lay perceptions of robot-assisted surgery in relation with UTAUT. The findings suggest an overall fear and lack of trust of new technology in medicine and this was greater among lay women than men. This is an important finding for medicine, as this may prevent patients from accepting robot-assisted surgery over other methods. It is also interesting that these views were expressed given the age of the participants, where the incorporation of technology into everyday life appears to be ubiquitous.Despite the potential limitations, the findings in this study demonstrate support for existing research on patient’s perception towards robotic surgery , 7. MoreThe findings from this study identify that there is still a discrepancy between the public perceptions of robot-assisted surgery and the clinical reality perceived by healthcare professionals. The findings will educate medical staff and support the development of current informative techniques given to patients prior to surgery.


The aim of the present study is to report the outcomes of round window reinforcement surgery performed with the application of a Vibrant Soundbridge middle ear implant  in a patient with superior semicircular canal dehiscence (SSCD) who presented with recurrent vertigo, Tullio phenomenon, Hennebert's sign, bone conduction hypersensitivity, and bilateral moderate to severe mixed hearing loss. Vestibular evoked myogenic potentials (VEMPs) and high-resolution computed tomography (HRCT) confirmed bilateral superior semicircular canal dehiscence while this was not seen in magnetic resonance imaging. The surgical procedure was performed in the right ear as it had worse vestibular and auditory symptoms, a poorer hearing threshold, and greatly altered HRCT and VEMPs findings. With local-assisted anesthesia, round window reinforcement surgery (plugging) with perichondrium was performed with simultaneous positioning of a VSB on the round window niche. At the one and 3 months follow-up after surgery, VSB-aided hearing threshold in the right ear improved to mild, and loud sounds did not elicit either dizziness or pain in the patient. Superior semicircular canal dehiscence (SSCD) was first described by Minor et al. , and is Both high resolution computed tomography (HRCT) with reconstruction on the plane of the superior canal and vestibular evoked myogenic potentials (VEMPs) are mandatory to confirm the diagnosis of SSCD.Surgical approaches are not mandatory in SSCD. The decision to treat the pathological canal side is based on various assessments including severity of symptoms, surgical candidacy of patients, and their desire for an improvement in quality of life. Conventional surgery provides direct treatment of the canal fistula through either a transmastoid or middle cranial fossa approach: the most common and well-described surgical treatments include capping, resurfacing, and plugging of the superior semicircular canal , 4.Despite the demonstrated efficacy, these interventions are invasive and imply a potential risk of persistent hearing deterioration and vestibular loss. Both the middle fossa and transmastoid approaches require general anesthesia which might increase the overall surgical and anesthesiologic risk. Recently, it has been proposed that a two-window inner ear system can be restored by directly plugging the round window (RW). This procedure has been demonstrated to be safe, fast, and effective compared to classical SSCD surgical treatments , 6.The Vibrant Soundbridge middle ear implant  is an implantable hearing aid that transduces sounds into electromechanical vibrations to the ossicular chain or directly to the RW. It is indicated for the treatment of conductive or mixed moderate to severe hearing loss .We describe the first case in literature of RW plugging and VSB positioning performed simultaneously under local anesthesia in a patient with bilateral SSCD and severe mixed hearing loss.Figures 2a–c).A 78-year-old woman was referred to our clinic with bilateral hearing loss with sound distortion, tinnitus and auditory hypersensitivity, recurrent vertigo/dizziness induced by loud noises (Tullio phenomenon), and a diagnosis of bilateral SSCD at the temporal bone HRCT performed in the emergency room  were discussed with the patient. Comorbid cardiopulmonary conditions represented major contraindications for general anesthesia, so the latter procedure was the only possible option to pursue.Since the patient did not show bilaterally any benefit from an air conduction hearing aid but rather had deteriorating auditory and vestibular symptoms on the right, we decided to perform the surgical procedure in the right ear as it had worse vestibular and auditory symptoms, a poorer hearing threshold, and greatly altered HRCT and VEMPs findings.With local-assisted anesthesia, we performed a transcanal approach with elevation of the tympanomeatal flap and preservation of the chorda tympani nerve with a minimally invasive retroauricular incision. Ossicular mobility and continuity were assessed, we excluded the stapedial fixation, and no cerebrospinal fluid (CSF) leak was observed during the surgical procedure. After identification and reshaping of the RW niche, a vibroplasty was performed paying particular attention to correctly plugging the round window and coupling it with the floating mass transducer (FMT) of the VSB . We opteThe plugging of the round window was achieved using cartilage and perichondrium (tragus). This autologous tissue also helped to seal off the FMT in the round window niche. Furthermore, VSB hearing outcomes were monitored with electrocochleography using a cotton-wick recording electrode placed on the hypotympanum  Figure .The wire of the VSB was housed in a canal tunnel drilled up to the tympanic attic. Minimal drilling of the cortical temporal bone posterosuperior to the external auditory meatus was necessary to house the implant receiver and extra wire . The earThis study received an exemption from the ethics committee of the University Hospital of Siena  on 10/21/2019 for publication.Surgery was uncomplicated, the patient did not complain of any post-operative vestibular symptoms. Sutures and external meatus packing were removed on the 10th postoperative day. At the 1-month follow-up, the patient underwent VSB activation and hearing and vestibular examination. She reported a significant improvement in auditory hypersensitivity and reduced sound distortion although tinnitus remained unchanged. No disabling vestibular symptoms were reported. Neither dizziness nor nystagmus could be observed in response to loud sounds or increased external ear pressure on the right side. The postoperative pure tone audiogram revealed a mild increase at 500, 1,000, and 2,000 Hz and a mild decrease at 250 and 4,000 Hz for bone conduction thresholds . An imprTo the best of our knowledge, this is the first report in the literature of local-assisted anesthesia with simultaneous RW reinforcement surgery and VSB positioning in a patient suffering from SSCD. The outcome of this new procedure confirmed the results in terms of safety and improvement in auditory and vestibular symptoms related to SSCD using the minimally invasive procedure for RW plugging reported by Silverstein et al.  and SuccThe major improvements in terms of vestibular symptoms over auditory symptoms have been described in the literature for RW plugging vs. superior canal plugging. Several studies , 6, 9–11The main limitations of the present study are that it is a report on a single case, and there was only a short follow-up period.In conclusion, simultaneous RW plugging and VSB positioning may be an effective, safe, and rapid surgical approach for SSCD associated with severe mixed hearing loss.Immediately after the surgical procedure the patient reported an improvement of vestibular symptoms due to loud sounds. She also reported a significant reduction in auditory hypersensitivity and sound distortion. Although tinnitus remained unchanged, the significant improvement in hearing threshold (VSB-aided) led to a higher quality of life.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written, informed consent, including all data and images, was obtained from the patient for the publication of this case report. Surgical procedure was performed in accordance with the Code of Ethics of the World Medical Association (Helsinki Declaration). This study received approval from the ethics committee of the Universitary Hospital of Siena  for the publication on 10/21/2019.MM performed the surgery. All authors contributed to the preparation and revision of manuscript and analyzed the data.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.