Operative repair of a rotator cuff tear requires up to 12 weeks of post-operative (post-op) home-based rehabilitation. Maintaining patients’ compliance in the post-op rehabilitation program is a pivotal component for generating successful outcomes. By developing a post-op rehabilitation-oriented digital healthcare system and applying it in patients who had undergone rotator cuff repair, we aim to increase the efficacy of the rehabilitation program and raise patients’ compliance levels. Here, we present a protocol developed for comparing the efficacy of rehabilitation using a newly developed augmented reality (AR)-based digital healthcare system with that of conventional rehabilitation for post-op rehabilitation of rotator cuff repair.This study will recruit a total of 115 patients who had undergone rotator cuff repair within 3 days after surgery. Patients will be randomly allocated to rehabilitation using an AR-based digital healthcare system  or conventional rehabilitation . Patients in both groups will perform brochure-based exercises from the immediate post-op period to post-op 6 weeks. From post-op 6 weeks to 12 weeks, patients in the digital group will use the AR-based system for post-op exercises, whereas patients in the conventional group will continue brochure-based rehabilitation exercises. The primary outcome will be scores on the Simple Shoulder Test at post-op 12 weeks. Secondary outcomes include numeric rating scale scores for pain, measures of range of motion and muscle strength of the affected shoulder, grip strength of the affected arm, scores on the Disabilities of the Arm, Shoulder and Hand test, the Shoulder Pain and Disability Index, and the EuroQoL-5D-5L quality-of-life measure. Analyses will be conducted using an intention-to-treat approach.This study will examine the effectiveness of an AR-based digital healthcare system for post-op rehabilitation in the patients after rotator cuff repair. The study will add evidence for the application of digital healthcare systems in post-op rehabilitation.ClinicalTrials.gov NCT04511377. Registered on 10 August 2020.The online version contains supplementary material available at 10.1186/s13063-022-06648-4. Rotator cuff tears result in pain and dysfunction of the shoulder and are one of the most common causes of shoulder disability , 2. PrevPost-operative (post-op) rehabilitation is a pivotal component of successful rotator cuff repair. The current consensus on rehabilitation after rotator cuff repair suggests 4–6 weeks of immobilization followed by another 4–6 weeks of rehabilitation directed at recovery of range of motion (ROM) and rotator cuff muscle strengthening , 9. PostRecent developments in information and communication technologies have led to attempts to implement virtual reality (VR)- or augmented reality (AR)-based healthcare systems in musculoskeletal post-op rehabilitation –15. ThesThis protocol was developed for an assessor-blinded superiority randomized controlled trial. The eligible participants are recruited 1–3 days after surgery at the orthopedic ward of Seoul National University Bundang Hospital . The participants are then randomized based on 1:1 allocation to two groups: the digital group will undergo a rehabilitation program using a digital healthcare system, whereas the conventional group will undergo a conventional rehabilitation program. Patients will be discharged home a few days after the surgery with a shoulder brace on the affected shoulder and will immediately begin the rehabilitation program, including early mobilization of the shoulder girdle. Until post-op 6 weeks, when they will remove their braces, both groups will use brochures received at the time of discharge that provide instructions on mobilizing the affected shoulder girdle. From post-op 6 to 12 weeks, participants in the digital group will perform exercises using an AR-based digital healthcare system , whereas participants in the conventional group will perform exercises using only the brochures provided by the hospital. Participants in both groups will be allowed hospital visits for exercise education by physical therapists, up to three sessions (30 min per session) over 12 weeks. The primary and secondary outcomes will be measured at baseline and at post-op 6, 12, and 24 weeks. An overview of the study design and process is given in Fig. In the protocol, the aim is to enroll 115 adult participants over 50 years of age who had undergone rotator cuff repair surgery. Patients who had undergone biceps tenotomy, acromioplasty, or labral repair along with the rotator cuff repair can be included. Patients who had undergone reverse total shoulder arthroplasty or total shoulder arthroplasty will be excluded. Patients who are not discharged home or who cannot understand or read Korean will also be excluded. Other major inclusion and exclusion criteria are described in Table Participants will be randomized after the baseline evaluation and allocated to either the Digital or conventional group at a 1:1 ratio. Randomization sequences will be computer-generated blocks, without stratification, by the institution’s biostatistician, who is independent of the study team. The randomized allocation information was sealed in a numbered opaque envelope. The envelope seals will be checked monthly by the principle investigator to make sure the future participants’ allocation is kept blinded. Participant allocation and follow-up arrangements will be managed by the study coordinator, who will not be blinded to the participants’ group assignments. Assessments will be performed by two research therapists from the study team, who will be blinded to the participants’ intervention groups.Participants in this group will undergo a brochure-based home rehabilitation program, which is the standard protocol for patients who had undergone rotator cuff repair surgery in our hospital. The rehabilitation program can be divided into three phases: on-brace, off-brace, and active mobilization. The on-brace phase (immediate post-op period to post-op 6 weeks) mainly consists of low-intensity whole-body exercises with shoulder girdle, elbow, and hand mobilization exercises on the affected side. Participants in this phase are instructed to perform three sets of exercises with 10 repetitions of each set per day. The off-brace phase (post-op 6–9 weeks) consists of passive shoulder ROM exercises using an exercise stick and an early scapular stabilization exercise. The active mobilization phase (post-op 9–12 weeks) consists of both active and passive shoulder ROM and scapular stabilization exercises. During the off-brace and active mobilization phases, patients are instructed to perform 3–5 sets of exercises with 10 repetitions of each set per day. A detailed exercise protocol is described in Table Participants in the conventional group will be educated by a physical therapist, and a brochure with illustrations of the exercises will be provided before they are discharged home. Additional exercise education sessions will be allowed  at the participants’ request.The rehabilitation program for participants in this group employs a digital healthcare system. During the on-brace phase, participants in this group will use the same brochure as the conventional group participants for home-based rehabilitation. Participants in the digital group will also be educated by a physical therapist before being discharged home. During the off-brace and active mobilization phases, participants will use the digital healthcare system for home-based rehabilitation. The digital healthcare system consists of four components: software for the rehabilitation program, a three-dimensional (3D)-depth camera , a computer, and a display (TV or monitor). The software consists of an AR-based program for post-op rotator cuff tear rehabilitation, and the 3D camera tracks the participant’s motion until it reaches a pre-determined angle or position. The rehabilitation program and prescribed exercises will be matched with those for the conventional group. Participants in the digital group will use this system at home during post-op 6–12 weeks. The daily exercise amount and progression will be logged by the system, and physicians will review the data at the outpatient clinic. Up to three additional exercise education sessions (30 min each) will also be allowed in this group upon participants’ request.The primary outcome will be scores on the Simple Shoulder Test (SST), which range from 0 (worst) to 12 (best). The SST is a self-reported questionnaire consisting of 12 dichotomous (yes/no) questions that measure functional limitations . It is aA number of secondary outcome measures will be employed Table . Pain att-test based on a 2.15-point difference in SST score (50% of the MCID) and an SD of 3.7, while allowing a 5% probability of two-sided type 1 error and applying 80% statistical power. Forty-nine subjects will be required in each group to allow 15% attrition per group; thus, a total of 115 subjects will be required for the study.A minimal clinically important difference (MCID) in scores on the SST in patients with rotator cuff tear was reported to be 4.3 , and theAll participant data will be collected by research team members and will be stored in the secured network of Seoul National University Bundang Hospital. Backup database will be updated regularly and only the research team will have access to the database. The case report forms will be stored in the locked cabinet of the research team. The coordinating investigator will have access to the final study dataset and the anonymized dataset will be available on request to the corresponding author. Final results will be published in peer-reviewed journals and presented at conferences, both nationally and internationally after completion of the study.P < 0.05).The primary hypothesis is that participants in the rehabilitation program using a digital healthcare system will demonstrate better shoulder function compared to those in the conventional rehabilitation group. Analyses will be performed using both intention-to-treat and per-protocol approach. The primary outcome measure for this study will be SST scores at post-op 12 weeks. A two-way repeated-measures ANOVA will be used to explore the effects of intervention, time, and intervention by time interaction on SST scores. The results will be presented with a mean difference with 95% confidence interval at each follow-up time point. Continuous secondary outcomes will be analyzed using repeated-measures ANOVA at each post-op 12 weeks and 24 weeks. Subgroup analysis based on the size of the tear will be performed only if there are sufficient participants in all four subgroups  . StatistThe potential risks for participants in this study are minimal. There is no independent oversight committee and adverse events (AEs) will be monitored by the research team at the scheduled follow-ups. Possible AEs include increased pain due to exercise and re-tear of the repaired rotator cuff tendons. Pain will be managed at the orthopedic outpatient clinic with pain medications or steroid injections, if needed. Surveillance of re-tear of repaired tendon will be routinely performed in post-op 12 weeks; however, if the re-tear is clinically suspected at any time during the follow-up periods, appropriate examinations and treatments will be provided. Participants in both groups can report AEs to the research team via direct telephone contact. Participants in the digital group will also receive a telephone number of the manufacturer for technical support.Participants are allowed to leave the trial at any time. Participants can withdraw from the trial by informing the research team. Participants will be encouraged to visit the pre-scheduled follow-ups even if they withdraw from the study for data collection. Participants in both groups will be regularly reminded with phone calls and text messages to minimize loss of follow-ups and maximize the adherence to the trial.The prevalence of rotator cuff tears is increasing as the general population ages, which will eventually lead to an increased incidence of rotator cuff repair surgery. Because post-op rehabilitation is a crucial element in restoring function and reducing pain after rotator cuff repair , the neeIn this trial, a digital healthcare system will be implemented only during the off-brace (post-op 6–9 weeks) and active mobilization (post-op 9–12 weeks) phases. It will not be applied during the on-brace phase (immediate post-op period to 6 weeks) because exercise programs in this phase are mainly focused on low-intensity whole-body movements under support by a post-operative brace. Also from the previous literatures, patients at this phase have good compliance with seldom having difficulty following the exercise program , 28. TheTM [This trial would have several strengths. First, to our knowledge, this would be the first randomized controlled trial to compare the effectiveness of post-op rehabilitation using a digital healthcare system with that of conventional rehabilitation in patients who had undergone rotator cuff repair. Second, this trial will implement an AR-based digital healthcare system dedicated to post-op rehabilitation. Some previous studies have used commercial fitness programs such as the Nintendo Wii FitTM , 15, whiIn conclusion, this study will examine the effectiveness of an AR-based digital healthcare system for post-op rehabilitation in the patients after rotator cuff repair. The study will add evidence for the application of digital healthcare systems in post-op rehabilitation.Protocol ver 3.0 (approved on 2021-08-03)The study protocol is registered in ClinicalTrials.gov (Identifier: NCT04511377).Participant recruitment started on 2020-07-30 and is anticipated to be completed by 2022-12-31.Additional file 1. Informed Consent Form (Korean).Additional file 2: Supplementary Table 1. Trial registration data.


At the group level, community-based neuropsychological rehabilitation interventions with a vocational focus are generally effective among individuals with brain injuries. However, individual participants vary significantly in the extent of their improvement, prompting attempts to elucidate individual, injury-related, and environmental factors affecting prognosis. In this study, we examined the relationships between one such factor – “time from injury” (the time between injury and intervention) – and two outcome measures: employment status and perceived quality of life (PQoL), in 157 brain injury survivors, before and after a holistic neuropsychological vocational rehabilitation program. We also examined whether relationships between the variables were moderated by age at onset of treatment and injury severity. In the entire sample, both the proportion of employed participants and average PQoL increased following program participation. Neither, time from injury, severity, nor age at onset of treatment predicted the increase in employment proportion, and severity was not a significant predictor of PQoL. However, an interactive effect indicated that when treatment was started at a younger age, longer time from injury predicted higher levels of PQoL, but when treatment was started at older ages, longer time from injury predicted lower levels of PQoL. When interpreted alongside existing literature, these results suggest that delaying vocational components of rehabilitation can be beneficial for younger participants, while the effectiveness of vocational rehabilitation can be maximized by starting as early as possible among older participants. Most importantly, regardless of age, it appears that vocational rehabilitation can be effective even when initiated many years after injury. These iAlthough some degree of neural damage caused by ABI has generally been considered irreversible , there iMany community-based holistic neuropsychological rehabilitation programs focus, among other things, on vocational rehabilitation for individuals who have experienced brain injuries . In accoSeveral studies have addressed the efficacy of community-based neuropsychological rehabilitation interventions with a vocational focus . OverallWhile studies generally show that vocational rehabilitation program outcomes are effective at the group level, individual participants vary significantly in the extent of their improvement . To asseOther factors potentially affecting rehabilitation outcomes relate to the individual and the injury. Some studies have shown that age affects prognosis following rehabilitation . Other wAnother key factor considered in assessing prognosis for community-based vocational rehabilitation is “time from injury,” or the amount of time that has passed between the brain injury and the onset of intervention . Like thAs noted above, vocational rehabilitation generally becomes an option when the more physically-focused acute rehabilitation process has been deemed sufficient. Reaching a level of physical healing that makes it possible to perform the tasks required by vocational rehabilitation designates the earliest possible start point.Beyond this, however, research attempting to determine whether there is a “window of opportunity,” during which vocational rehabilitation is more likely to succeed, has produced varied results. This body of work has addressed two primary questions: (1) when is the optimal time to start rehabilitation, and (2) can rehabilitation be valuable regardless of time from injury, or is there a point when it becomes “too late” to start.Some studies have shown that functional outcomes including return to work are better when multi-disciplinary rehabilitation is started earlier following moderate to severe brain injury . Other wIn the current study, we examined the relationship between time from injury and two outcome measures: employment status and perceived quality of life (PQoL), following a holistic neuropsychological vocational rehabilitation program. We also examined whether these relationships were moderated by age at onset of treatment and severity of injury as measured by length of coma (LOC). Both of these variables are presumably related to clinical and behavioral determinants of rehabilitation outcome, such as self-awareness, adherence, and maturity in the case of age, and cognitive abilities in the case of severity. Essentially, we aimed to determine if starting rehabilitation earlier or later would be associated with better outcomes, and whether the pattern displayed would be consistent throughout the group or vary based on age and severity of injury. Given the clear role of employment status in improving post-ABI outcomes at the individual, familial, and societal levels , we cond2.2.1.M = 34.90, SD = 10.65). As all participants were first assessed at Time 1, upon beginning treatment, their age corresponds with the age of onset of treatment measure. Education ranged from 7 to 21 years . Length of coma (LOC) served as a measure of severity. Of the entire sample, 82 participants (52.2%) experienced comas while 75 (47.8%) did not. All participants were considered “working age” . About 13% were employed at T1 but they, like all program participants, were actively attempting to find or change jobs; vocational reintegration is a specialization of the rehabilitation center and a primary goal in all the programs it offers. Current employment status and details of employment history were assessed and validated by program staff.Participants were 157  individuals who had experienced ABI , the time passed between the date of the injury and date the participant began rehabilitation at the center, and the results of the two outcome measures at two time points: before (T1) and immediately after (T2) the rehabilitation program.All participants had taken part in one of two programs aimed at improving their functional outcome: comprehensive–holistic neuropsychological rehabilitation (CNR) and vocation-focused neuropsychological rehabilitation (VNR). Both programs contained at least three components: neuropsychological psychotherapy, cognitive rehabilitation, and occupational counseling and placement, but varied in scope and intensity in accordance with the needs and abilities of participants, as indicated by a broad neuropsychological assessment and the recommendations of the clinical staff. Brief descriptions of the programs are provided below. They have been described in detail in a previous publication , p. 134.As an integral part of the pretreatment intake process, patients were asked if, in addition to participating in the treatment program to which they were allocated, they would be willing to participate in an ongoing, long-term follow-up study. They were informed that the primary aim was assessment of the rehabilitation institute’s treatment programs, as a basis for continual improvement of care. They were also informed that they would need to complete study measures at multiple time-points, including after program completion. All participants agreed to these conditions and gave informed consent. The study was approved by the institutional ethics committee.2.4.Senior staff members, all certified rehabilitation psychologists and clinical neuropsychologists, determined which patients were admitted to each program based on clinical considerations, to maximize fit between program characteristics and patient capabilities, disabilities, challenges, needs, goals, and prognosis. All interventions in both programs were supervised by certified rehabilitation psychologists and clinical neuropsychologists. Some were administered by psychology residents.Comprehensive–holistic neuropsychological rehabilitation entailed 10 months of intensive treatments, 5 to 7 hours daily, 4 days a week. Groups of 5–10 participants attended a structured, obligatory curriculum of group (about 20 weekly hours) and individual therapy (about 4 weekly hours) sessions. Cognitive interventions addressed attention, memory, communication, executive functioning, and psycho-education about the brain and brain injury. Additional tailored interventions addressed functional skills, such as arithmetic, reading comprehension, and basic computer use. Psychological interventions included individual psychotherapy, group therapy, and vocational counseling.Vocation-focused neuropsychological rehabilitation was also an intensive group-based day program. Patients spent two-thirds of their time in prevocational workshops resembling work environments and a third of their time in individual and group treatments. Groups were ongoing, with individual participants joining and leaving in accordance with their specific needs. Program length ranged from 4 to 18 months, with intensity increasing gradually from 2 to 5 days a week. Workshops included technical assembly, clerical and office tasks, carpentry, or gardening. Individual treatments included psychotherapy, cognitive rehabilitation, vocational counseling, and case management. Group therapy sessions included vocational, cognitive, psycho-education, and support groups.2.5.t-test (for PQoL) and a McNemar test (for proportion of employed participants). Pearson correlations between the study variables were calculated  at onset of rehabilitation, severity of injury (LOC), and time (in years) between the injury and onset of rehabilitation. The dependent variables were PQoL and employment status before and after participation in a rehabilitation program. We examined gender/sex-based differences in the dependent variables and in the change in dependent variables from T1 to T2. As none were significant, we did not include gender/sex in further analyses. Change in outcomes following participation in the program were examined using a 3.3.1.Descriptive statistics for the experimental variables  are presented in 3.2.p < 0.001). Likewise, a paired-samples t-test revealed a significant increase in PQoL, t(156) = 2.32, p = 0.011, d = 0.19, between Time 1 and Time 2.As seen in 3.3.3.4.The results of the Johnson-Neyman analysis used to examine the interaction effect on PQoL indicated a significant positive effect for younger participants (under 27.37 years) and a significant negative effect for older participants (over 47.67 years). 4.The current results indicate that both the proportion of employed participants and PQoL increased following participation in the programs. Neither time from injury, severity, or age at onset of treatment predicted the increase in employment proportion. With respect to PQoL, however, while severity was not a significant predictor, there was an interactive effect of time from injury and age. Specifically, when treatment was started at a younger age, longer time from injury predicted higher levels of PQoL. Conversely, when treatment was started at older ages, longer time from injury predicted lower levels of PQoL.Before discussing the effects related to time from injury, we note that the current results are in line with previous work indicating the general efficacy of holistic, community-based neuropsychological rehabilitation programs focused on return to work and improved well-being e.g., . The curWe can therefore say that employment status, which represents the key aim of vocational rehabilitation, improved regardless of time from injury or age at onset of intervention. The significance of this finding is that vocational rehabilitation programs can help participants of different ages return to the workforce even after many years outside it, refuting the idea that there is a “deadline” for beginning intervention. This viewpoint might seem to be supported by studies indicating that employment rates among brain injury survivors tend to stay stable over time or even to decrease . HoweverAnother key aim of neuropsychological rehabilitation, both vocational and otherwise, is improving perceived quality of life . In the Unexpectedly, severity of injury did not affect the relationships between time from injury and either of the outcome variables, employment status and PQoL. Several studies have reported associations between injury severity and reintegration into employment . This, a4.1.The current study had a number of methodological limitations. The retrospective nature of data collection limited us to correlation-based analyses and precluded examination of causal relationships among the variables. As noted above, the study did not include a non-intervention control group, limiting our ability to attribute post-intervention improvements to the rehabilitation interventions. Another limitation, also related to the retrospective nature of the study, involves the lack of information on neurophysiological and neurocognitive measures, particularly at Time 2, which could potentially be associated with the outcome variables. Though the unique data, the large size of the sample, and information on the vocational status of participants in the years prior to beginning intervention do allow us to draw initial conclusions, the relationships between time-since-injury, age at injury onset, and vocational rehabilitation outcomes should be addressed in future prospective, controlled research. To extend and elaborate on the current findings, such research should address specific processes and mechanisms that might explain age-related differences in the relationship between time-since-injury and perceived quality of life following vocational rehabilitation. For example, future studies might address whether employment-related emotional processes experienced by younger survivors, who have often spent less time in the workforce, differ from those of older, more experienced survivors. Additional age-related factors, such as marriage and family status, or social priorities, might also have significant effects on an individual’s capacity and motivation for vocational rehabilitation and on the self-awareness and maturity required to succeed.4.2.Returning to work following brain injury contributes enormously to mental health and perceived life satisfaction . QualityThe data analyzed in this study is subject to the following licenses/restrictions: The dataset is part of a broader dataset recording the clinical outcomes of clients at a neuropsychological rehabilitation center. Requests to access these datasets should be directed to corresponding author.The studies involving human participants were reviewed and approved by National Institute of Neuropsychological Rehabilitation Ethics and Research Committee. The patients/participants provided their written informed consent to participate in this study.AB, TS-U, LS, NB-L, SM, and DH contributed to the conception and design of the study. AB and SM wrote the manuscript. TS-S organized the database. ED performed the statistical analysis. All authors contributed to revision and approved the manuscript.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We report two similar cases of patients diagnosed with hemiballismus–hemichorea syndrome secondary to uncontrolled hyperglycemia. Both patients were treated at an inpatient rehabilitation center and made a significant recovery in both function and activities of daily living. Although hemiballismus–hemichorea syndrome has known pharmacological treatments, little has been reported on the effectiveness of acute rehabilitation on managing and treating this syndrome.The first case involves a 44-year-old Hispanic male with past medical history of type 2 diabetes mellitus, hypertension, anxiety, and depression who presented with continuous, uncontrollable, unilateral movements 1 month following a hospital admission for hyperglycemia. Magnetic resonance imaging findings showed lesions in the basal ganglia, confirming the diagnosis of hemiballismus–hemichorea syndrome. The patient was started on antipsychotic medications and antihyperglycemic medications controlling glucose levels, but continued to have hemiballismus symptoms. The second case involves a 78-year-old Haitian female with past medical history of type 2 diabetes mellitus and hypertension who presented with weakness and continuous, involuntary movements in her upper and lower extremities 1 month following a hospital admission for hyperglycemia and encephalopathy. Magnetic resonance imaging findings were positive for bilateral lesions in the basal ganglia, establishing a diagnosis of hemiballismus–hemichorea syndrome. After a 2-week stay at an acute rehabilitation center, both patients made a significant recovery in function and activities of daily living.The aim in presenting these cases is to elucidate the etiology and progression of a rare disease process known as hemiballismus–hemichorea syndrome and to provide evidence for the potential positive impact of acute rehabilitation on patients with unresolved hemiballismus–hemichorea following an episode of hyperglycemia. Hemiballismus–hemichorea (HBHC) syndrome can be defined as a hyperkinetic movement disorder characterized by involuntary, irregular, continuous, unilateral movements of the body resulting from a contralateral basal ganglia lesion. The most common etiologies include ischemic stroke, hemorrhagic stroke, and autoimmune conditions . AlthougDiagnosis is typically based on the presence of the triad of chorea, hyperglycemia, and striatal abnormalities on neuroimaging. Radiographic findings include contralateral striatal hyperintensity on T1-weighted images and/or hyperdensity on noncontrast computed tomography (CT) scans . For manThis study reports two similar cases of patients diagnosed with HBHC syndrome secondary to uncontrolled hyperglycemia. Both patients were treated at an inpatient rehabilitation center and were able to make significant recovery of function and activities of daily living (ADLs). Though HBHC syndrome has known pharmacological treatments, little has been reported on the effectiveness of acute rehabilitation on managing and treating HBHC syndrome. These cases aim to elucidate the progression of HBHC syndrome in an acute rehabilitation setting. Written patient consent was obtained from both patients for the publication of this case report.A 44-year-old Hispanic male with past medical history of type 2 diabetes mellitus, hypertension, anxiety, and depression and new diagnosis of HBHC syndrome based on correlating clinical and magnetic resonance imaging (MRI) findings was admitted to an acute rehabilitation hospital for management of symptoms. On admission, initial examination revealed continuous, uncontrolled spasms of the right arm and leg. The patient relied on maximum assistance or was dependent on 2+ helpers for all aspects of self-care. For functional mobility, he required a supervisor/touch assistance for bed mobility, and partial to maximum assistance for transfers.The patient initially presented to the hospital 6 weeks prior for elevated blood glucose levels in the range of 400–500. The patient did not require intubation and did not have any altered mental status during the hospital course. At the time of discharge, his blood glucose was controlled but his wife stated that, upon returning home, they remained elevated in the 400–500 range. Notably, with the patient’s history of anxiety and depression, he had been started on quetiapine 50 mg nightly earlier in the year, which was subsequently changed to olanzapine 7.5 mg prior to this admission.The patient had another hospital admission 2 weeks prior with 2-day history of involuntary movements in his right upper and lower extremities. He was evaluated with brain CT, MRI, and EEG and was discharged on haloperidol 5 mg twice daily for his hemiballismus symptoms. EEG was negative for epileptic waveforms, while CT and MRI findings were consistent with changes of nonketotic hyperglycemia and clinical correlation for HBHC syndrome. During this admission, laboratory values were positive for mild leukocytosis, blood glucose level of 125 mmol/L, and an A1C of 14.6%. Blood workup for secondary causes of hemichorea was unremarkable. The patient was admitted under the neurology service and was started on clonazepam 2 mg TID and quetiapine 25 mg TID for his hemiballismus symptoms, though with little improvement. Endocrinology was consulted for control of his blood glucose, and he was started on Lantus and sliding scale insulin therapy before discharge to the acute rehabilitation hospital.During his 2-week-long admission at the rehabilitation hospital, the patient received daily focused therapy while proper blood glucose control was maintained. He was evaluated by a neurologist, who planned to place him on tetrabenazine which would be started 2–3 weeks after insurance approval. At the time of his discharge, significant improvements in all aspects of self-care, bed mobility, and transfers were appreciated. The patient received a follow-up MRI scan with and without contrast 3 weeks after discharge, which showed continued signal abnormality in the left lentiform nucleus with development of signal in the left caudate nucleus Fig. A. PalliaA 78-year-old Haitian female with type 2 diabetes mellitus and hypertension was admitted to the inpatient rehabilitation unit for chorea secondary to new bilateral basal ganglia T1 hyperintensities on MRI, particularly in the right caudate nucleus, favored to be hyperglycemia related. She was initially admitted to a level 1 tertiary center with 3-day history of involuntary upper and lower extremity movements that progressively worsened with generalized weakness compromising her ability to grasp utensils and ambulate. There were no associated symptoms of headache, fever, weight or appetite change, loss of consciousness, blurred or double vision, dysphagia, or numbness. Furthermore, there were no recent medication changes. One month prior, she had been admitted for encephalopathy, with hyperglycemia greater than 700 and MRI imaging with diffuse low T2 signal in bilateral basal ganglia secondary to hyperglycemia ; cognitive distraction, prolonged exhalation, meditation; ambulation and weight bearing; balance in parallel bars; visual feedback using mirrors; gait training with and without an assistive device. Occupational therapy techniques for chorea and dystonia included energy conservation techniques using figure-4 technique; endurance exercises including ergometer; deep vibration with noted reduction in chorea movements; mass practice task consisting of grasping and transferring rings from right to left with hand over hand; functional grasp tasks; visual feedback to increase standing unsupported tolerance in preparation for ADLs participation; Sander box with 3-pound dumbbell using mirror as visual feedback; Nu Step reciprocal stepper for gross motor coordination and activity endurance. Speech therapy techniques for cognitive deficits included targeted cognition and dysarthria as well as compensatory techniques.Nine months after discharge from acute inpatient rehabilitation, she indicated that she continues to improve, not only in function but with her tremor as well. In addition to the therapies that she received to help her return home and increase independence, she stated that inpatient rehabilitation had helped formulate a home exercise program that she continues to do on a regular basis. She also reported that she is no longer using a walker and is ambulating independently. She stated that all aspects of her therapy, including gait training, were equally beneficial for her recovery. She was pleased with her rehabilitation course and ecstatic about her outcome.HBHC syndrome is a hyperkinetic disorder caused by damage to basal ganglia structures, which can be a result of uncontrolled hyperglycemia. HBHC symptoms typically resolve over the course of weeks to months after proper glycemic control is obtained but can be prolonged or even permanent in some cases . While mThese cases demonstrate the effectiveness of acute rehabilitation as it is uniquely equipped to address many of the initial safety and functional concerns that HBHC syndrome creates. Through patient/family education and directed therapy, concerns such as self-harm from uncontrolled choreiform movements, safety with ambulation, practicalities of performing ADLs, and establishing a safe, patient-friendly living environment can all be adequately assessed and evaluated. Furthermore, a comparison of the admission and discharge assessments for both patients illustrates significant improvements in function and ADLs after inpatient rehabilitation Table . One limThe significant improvements made by both patients in self-care and functionality provide evidence for the positive potential impact that acute rehabilitation can have in patients with continued unresolved HBHC syndrome after an acute uncompensated hyperglycemic episode. Though HBHC is a rare disease process, it is important to be aware of its presentation and to emphasize glucose control, management of chorea symptoms, patient education, and directed therapy for optimal treatment.


Moreover, we revealed the regulatory mechanism between Lnc-ZFAS1 and miR-520b/miR-520e-mediated RHOC and provided a novel clue for ameliorating osteosarcoma.We examined the expression of Lnc-ZFAS1 in osteosarcoma and comprehensively evaluated its effects on osteosarcoma The expression of Long non-coding RNA Zinc Finger Antisense 1 (LncRNA ZFAS1) osteosarcoma tissues and normal tissues in the TCGA database was analyzed. Then, LncRNA ZFAS1 expression was further verified in clinical samples and osteosarcoma cell lines (U2OS and KHOS), as well as the human osteoblast cell line hFOB1.19 by qRT-PCR. Thereafter, LncRNA ZFAS1 was overexpressed or silenced to explore its effects on cell proliferation, apoptosis, migration, invasion, and Epithelial-Mesenchymal Transition (EMT). The fundamental mechanism through which Lnc-ZFAS1 affects osteosarcoma progression was further investigated and verified.in vitro.We found that LncRNA ZFAS1 was upregulated in osteosarcoma, and Lnc-ZFAS1 overexpression facilitated osteosarcoma cells proliferation, migration, invasion and EMT, while Lnc-ZFAS1 silence exerted reverse influence. Mechanistically, Lnc-ZFAS1 functionally acted as a sponger of microRNA-520b (miR-520b) and microRNA-520e (miR-520e) to up-regulate Ras Homologue C (RHOC). In addition, depleted Lnc-ZFAS1 restrained osteosarcoma cells proliferation, migration, and invasion, which could be rescued by RHOC overexpression. Lnc-ZFAS1 was upregulated in osteosarcoma and Lnc-ZFAS1 could exert promoted impact upon osteosarcoma cells proliferation, migration, invasion, and EMT Lnc-ZFAS1 acted sponger of miR-520b and miR-520e to promote RHOC, indicating that Lnc-ZFAS1/miR-520b/RHOC and Lnc-ZFAS1/miR-520e/RHOC axes might serve as potential therapeutic strategies against osteosarcoma. Moreover, we revealed the regulatory mechanism between Lnc-ZFAS1 and miR-520b/miR-520e-mediated RHOC and provided a novel clue for ameliorating osteosarcoma.Thus, in this work, we examined the expression of Lnc-ZFAS1 in osteosarcoma and comprehensively evaluated its effects on osteosarcoma Osteosarcoma and corresponding normal tissues (n = 8) were respectively collected from the First Affiliated Hospital of Dalian Medical University, and the research strategy was formulated in accordance with the Declaration of Helsinki and was authorized by the First Affiliated Hospital of Dalian Medical University ethics committee. Signed informed consent was obtained from the patients.Osteosarcoma cell lines U2OS and KHOS, and human osteoblast cell line hFOB1.19 were obtained from ATCC . Based on ATCC's instructions, these cell lines were incubated for further investigation.The pcDNA-ZFAS1, si-ZFAS1-1, si-ZFAS1-2, miR-520b mimics, miR-520e mimics and pcDNA-RHOC were provided by Gene Chem . U2OS and KHOS cells were conducted transfection according to lipofectamine's  protocols.To evaluate the colony formation ability, a 6-well plate was utilized for the incubation of U2OS and KHOS cells. After 10 days of culture, the transfected cells were respectively conducted fixation and stained by paraformaldehyde and crystal violet. The colonies were counted using a microscope.For the EdU assay, U2OS and KHOS cells were mixed with EdU reagent in accordance with instructions of An Edu assay kit , followed by counterstaining using Hoechst 33342. A light microscope was utilized for the visualization and measurement.For the migration and invasion estimation, the upper chamber was employed for a culture of U2OS and KHOS cells, while the lower chamber was replenished with 10% FBS. After incubation, cells were removed from the upper chamber and the migratory or invasive cells were counted.To establish scratched cells, U2OS and KHOS cells were maintained in 6-well plates for 24h, followed by forming the wound using pipette tips, and then these cells were incubated for 24h. The width of the scratch was detected. The images were photographed using a microscope.To verify the interaction between miR-520b and miR-520e with Lnc-ZFAS1 and RHOC, a luciferase reporter assay was performed in KHOS cells. In brief, the Wild-Type (WT) and Mutant (Mut) binding sites of the 3′-untranslated regions of Lnc-ZFAS1 and RHOC for miR-520b and miR-520e were amplified using PCR. The WT and Mut 3′-UTRs were introduced into the pmirGLO luciferase expression vector (Promega Corporation) to construct the following plasmids, Lnc-ZFAS1-WT, Lnc-ZFAS1-MUT, RHOC-WT and RHOC-MUT. KHOS cells were co-transfected with 2.5 µg pmirGLO-Lnc-ZFAS1-WT, pmirGLO-Lnc-ZFAS1-MUT, pmirGLO-RHOC-WT or RHOC-MUT and 50 nM miR-520b mimics, miR-520e mimics, or NC-mimics using Lipofectamine 3000 at 37°C. At 48h post-transfection, luciferase activities were measured using the dual-luciferase reporter assay system (Promega Corporation) according to the manufacturer's protocol. Firefly luciferase activities were normalized to Renilla luciferase activities.Sense or antisense Lnc-ZFAS1 sequences were marked with biotin and then were cultured with protein lysis extracted from KHOS cells lysate, followed by incubating with agarose beads (Invitrogen) coupled with streptavidin. The q-PCR was employed to detect the amounts of Lnc-ZFAS1, miR-520b, miR-520e, and miR-934.For the detection of F-actin, transfected KHOS cells were incubated in the coverslips of six-well plates overnight, followed by mixing with 100 µg/mL PCFE and 1000 µg/mL dacarbazine for 24h. After fixing with methanol, cells were cultured with primary anti-F-actin antibody  for 1h, and then incubated with secondary antibodies. A fluorescence microscope  was utilized for the visualization.To verify the location of Lnc-ZFAS1, KHOS cells were performed the isolation of cytoplasmic and nuclear RNA in accordance with the protocol of PARIS Kit . qRT-PCR was employed to examine the total RNA extracted from the cytoplasm and nucleus.fluorescein amidite-labeled Lnc-ZFAS1 probes were designed and synthesized by RiboBio. A FISH Kit (RiboBio) was used to detect probe signals according to the manufacturer's instructions. Nuclei were stained with DAPI. All images were acquired on a confocal microscope system.By using a Magna RNA-binding protein immunoprecipitation kit , RIP was performed to evaluate the correlation between Lnc-ZFAS1 and miR-520e/miR-520b. KHOS cells were centrifuged and washed prior to mixing with RIP lysis buffer. The lysates were harvested to incubated with RNAs magnetic beads that conjugated Anti-AGO2 antibody  or anti-IgG . After treating samples with Proteinase K for 30 min with gentle agitation, immunoprecipitated RNA was isolated using TRIzol. Finally, co-precipitated RNAs were identified and analyzed via qRT-PCR.Protein samples extracted by RIPA buffer were isolated using SDS-PAGE, and were transferred into PVDF membranes, followed by incubating with primary antibodies. Anti-rabbit antibody coupled with peroxidase was determined as the secondary antibody. ECL reagent (Millipore) was utilized for the visualization of antigen-antibody reaction. The primary antibodies caspase-3 , cleaved caspase-3 , caspase-9 , cleaved caspase-9 , bax , Bcl-2 , Cyclin D1 , E-cadherin , N-cadherin , Vimentin , MMP-9  were purchased from Abcam (UK). GAPDH  was considered as the normalization.Total RNA samples extracted by TRIzol reagent were transcribed to cDNA following the protocols of PrimeScript RT Reagent Kit . Then SYBR Premix Ex Taq (Takara) system was employed for the analysis of real-time PCR. The relative expression was performed normalization with GAPDH and U6. The corresponding primer sequences are listed in Supplementary Table 1.t-test and ANOVA; p < 0.05 indicates statistical significance.In this research, SPSS 20.0  and GraphPad Prism 7  were utilized for all data-related collation. The data were represented as the mean ± SD. The differences between internal groups were analyzed by Student's To explore the role of Lnc-ZFAS1 in osteosarcoma, we first analyzed the expression level of Lnc-ZFAS1 in osteosarcoma tissues and normal tissues in TCGA database. Lnc-ZFAS1 was upregulated in osteosarcoma tissues A, which To uncover the functional influence of Lnc-ZFAS1 upon osteosarcoma progression, we established Lnc-ZFAS1-upregulated U2OS cells and Lnc-ZFAS1-downregulated KHOS cells A. Lnc-ZFWe further investigated the effects of Lnc-ZFAS1 on osteosarcoma cell migration and invasion. Wound healing A and traTo expose the fundamental mechanism through which Lnc-ZFAS1 affects osteosarcoma progression, we first examined the subcellular location of Lnc-ZFAS1 in KHOS cells and found Lnc-ZFAS1 was evenly enriched in the and nucleus A. NotablRNA pull-down results showed that biotin-labeled Lnc-ZFAS1 efficiently enriched miR-520b and miR-520e from KHOS cells lysate D. AdditiWe aimed to reveal the specific mechanism of miR-520b and miR-520e in osteosarcoma progression. Bioinformatics databases including PITA, miRmap, microT, miRanda, PicTar and TargetScan were performed to predict the target genes of miR-520b and miR-520e A. The prTo investigate the correlation between RHOC and two miRNAs, we first analyzed the expression of RHOC in osteosarcoma, based on the Target database, we observed RHOC was upregulated in osteosarcoma tissues C. Next, To verify whether Lnc-ZFAS1 acts oncogenic driver in osteosarcoma progression in an RHOC-dependent manner, we co-transfected Lnc-ZFAS1 siRNA and RHOC overexpression plasmids into KHOS cells A. EdU asIn this study, our findings suggested Lnc-ZFAS1 as an oncogenic driver in osteosarcoma progression. Moreover, we identified Lnc-ZFAS1 functionally acted as a sponger of miR-520b and miR-520e to upregulate RHOC in osteosarcoma. We demonstrated the Lnc-ZFAS1/miR-520b/miR-520e/RHOC axis involved in the development of osteosarcoma.in vitro. In principle, EMT was identified as the transformation of epithelial to mesenchymal cells, imparting the capacities of migration and invasion of cells.As an emerging member of Long non-coding RNAs, Lnc-ZFAS1 has been proven strongly correlated with enormous diseases, like myocardial infarction,in vitro and in vivo, Lnc-ZFAS1 has been proved to act as a sponger of microRNA-135a,It has been believed that LncRNAs interferences the expression of miRNAs by acting as a ceRNA,As referred to above, RHOC belongs to one of the subfamilies of RHO family, and is closely associated with diverse cancers, like breast cancer,in vitro experiments, and further in vivo studies are required to perform in the future study. Besides, only eight patients,  were included in this study. Hence, our study should be viewed as hypothesis-generating, to be followed by larger prospective studies to confirm our findings.Nevertheless, there are several limitations to this study. One limitation is that our results only demonstrated the roles of Lnc-ZFAS1 based on in vitro. Moreover, Lnc-ZFAS1 acted sponger of miR-520b and miR-520e to promote RHOC. Our findings provided Lnc-ZFAS1/miR-520b/RHOC and Lnc-ZFAS1/miR-520e/RHOC axes as potential therapeutic strategies against osteosarcoma.To summarize, our paper concluded that Lnc-ZFAS1 was upregulated in osteosarcoma and Lnc-ZFAS1 could exert promoted impact upon osteosarcoma cells proliferation, migration, invasion and EMT Xiaofeng Liu and Lei Huang designed the research plan. Xiaofeng Liu, Mingyang Wang, Liwen Zhang and Lei Huang performed the experiments. Lei Huang wrote the manuscript.No funding was received.The authors declare no conflicts of interest.


Mental health services are encouraged to use language consistent with principles of recovery-oriented practice. This study presents a novel approach for identifying whether clinical documentation contains recovery-oriented rehabilitation language, and evaluates an intervention to improve the language used within a community-based rehabilitation team.This is a pilot study of training to enhance recovery-oriented rehabilitation language written in care review summaries, as measured through a text-based analysis of language used in mental health clinical documentation.Eleven case managers participated in a programme that included instruction in recovery-oriented rehabilitation principles. Outcomes were measured with automated textual analysis of clinical documentation, using a custom-built dictionary of rehabilitation-consistent, person-centred and pejorative terms. Automated analyses were run on Konstanz Information Miner (KNIME), an open-source data analytics platform. Differences in the frequency of term categories in 50 pre-training and 77 post-training documents were analysed with inferential statistics.P < 0.001). There was no significant change in use of person-centred or pejorative terms, possibly because of a relatively high frequency of person-centred language (22% of sentences) and low use of pejorative language (2.3% of sentences) at baseline.The average percentage of sentences with recovery-oriented rehabilitation terms increased from 37% before the intervention to 48% afterward, a relative increase of 28% (This computer-driven textual analysis method identified improvements in recovery-oriented rehabilitation language following training. Our study suggests that brief interventions can affect the language of clinical documentation, and that automated text-analysis may represent a promising approach for rapidly assessing recovery-oriented rehabilitation language in mental health services. Furthermore, the type of language adopted by mental health services, including that recorded in clinical documentation, has been found to be a mediator in the behaviours and attitudes of mental health clinicians.3 Despite this, the documentation produced by mental health clinicians, and the degree to which it is recovery-oriented, has received little attention in the literature.Person-centred and recovery-oriented practices are now a central tenet of mental health service delivery, both within Australia and internationally.4 Therefore, the current study implemented and evaluated an intervention to increase the amount of recovery-oriented rehabilitation and person-centred language, and decrease the amount of pejorative language, written down in care review summaries in a public mental health intensive rehabilitation service. The setting was the Metropolitan region of Queensland, Australia. To evaluate the hypothesised changes in language from pre- to post-intervention, an automated, computational content analysis approach was developed based on the generation of a custom-built dictionary of recovery-oriented rehabilitation-consistent, person-centred and pejorative terms. As clinical information is now increasingly available via electronic health records, the use of automated approaches to audit clinical information has also increased because of the savings in time and resources compared with traditional qualitative analysis.8 This data resource is relatively underutilised and provides an opportunity for mental health research.8In a preliminary exploration of the relationship between language and recovery-oriented practice, Kemp and Howard concluded that language was a ‘gap in the research of the recovery approach’, and that more systematic research in specific mental health settings was needed.Care review summaries after the intervention will show increased rates of recovery-oriented rehabilitation words, phrases and themes.The rate of person-centred words, phrases and themes that are not also recovery-oriented rehabilitation words, phrases or themes will increase following the intervention.There will be a decrease in words, phrases or themes that directly contravene person-centred principles, or are derogatory in nature, termed pejorative language.We hypothesised that following the delivery of an intervention to promote increased recording of rehabilitation-focused language in documentation, care review summary documents would include more recovery-oriented rehabilitation and person-centred language. Several specific primary hypotheses were tested in this study.Ethics approval was obtained before study commencement, from the Metro South Human Research Ethics Committee (reference number: HREC/18/QPAH/24), and all participation in this study was based on voluntary informed consent.The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving participants were approved by Metro South Human Research Ethics Committee. All participants provided written informed consent to participate in this study.11The pilot intervention was trialled in a community-based public mental health service model that provides intensive care for people with severe mental illnesses (predominantly schizophrenia) to work on their recovery goals . It follows an assertive community treatment model, but with an enhanced emphasis on psychosocial rehabilitation. Beyond intensive case management and medication support, a range of evidence-based psychosocial interventions are available . Previous evaluation has found engagement with the service is associated with functional improvement for consumers.A critical component of the service model is the availability of intensive case management, with case management roles being filled by a range of clinical disciplines . It is an expectation that case managers will complete care review summaries every 3 months. These summaries provide an overview of a person's progress over the previous 3 months, and outlines their goals and plan for moving forward. These summaries are generally produced as a record for the service and, at the time of this study, were not commonly shared with patients. However, there were concerns that the language used by case managers in these care review summaries was not recovery-oriented rehabilitation language and did not reflect actual collaboration between the case manager and the consumer. This was the reason for the present study.A training programme was developed to improve the use of recovery-oriented rehabilitation language in care review summaries. The intervention provided case managers with the opportunity to reflect on the use of the language documented in their care reviews. The group intervention involved two in-service presentations by the team neuropsychologist that were delivered 1 week apart to the rehabilitation team leader, consultant psychiatrist, psychiatric registrar and case managers. All clinicians were then mentored in a one-on-one session by the neuropsychologist, which included feedback on their care reviews. The data for the evaluation were de-identified care review summaries completed by the clinicians. All 11 case managers in the team consented to participate. To evaluate the effectiveness of the intervention, we conducted an uncontrolled pre–post textual analysis of the care review summaries. For this, care review summaries completed by consenting clinicians before delivery of the pilot intervention were the ‘pre-sample’ data-set. This was then compared with care review summaries completed after the delivery of the intervention (the ‘post-sample’ data-set). The time frame between completion of the pre-sample data-set and the completion of the post-sample data-set was approximately 5 months.10 Rehabilitation ‘refers to the development of skills and supports needed to achieve one's goals … focuses on increasing ability and builds on a person's strengths to facilitate success in meeting the person's own goals … Rehabilitation promotes a partnership (between person and clinician)’.10 In other words, recovery refers to the person's individual experience and journey through mental health difficulties to develop and pursue their goals, whereas rehabilitation is a vehicle for recovery that can involve both the person and clinician. Given this distinction, and that the aim of this study was for care review summaries to better reflect the work undertaken by clinicians in collaboration with patients, we chose to use the term ‘recovery-oriented rehabilitation language’ instead of simply ‘recovery-focused’ or ‘recovery-oriented’.The Psychiatric Rehabilitation Association defines recovery as a process through which a person with mental health difficulties gains ‘a sense of meaning, a positive identity, fulfilling relationships, the role of citizen and community member, the capacity to cope with adversity and recognition of the gifts and lessons learned through the recovery struggle’.10 In this study, we conceptualised person-centred language as being a broader term that denotes respect for the person, first and foremost, and is non-judgemental, clear and understandable, and carries a sense of commitment, hope and opportunity.10Recovery-oriented rehabilitation language also encompasses person-centred language as it places the individual at the centre of the service and reflects unconditional positive regard for the person being spoken with or written about.9Given these principles, particularly that of conveying hope, commitment and opportunity, recovery-oriented rehabilitation language is necessarily person-centred by nature. However person-centred language is not necessarily rehabilitation-focused. For example, the use of the person's name instead of the label patient/client/consumer is considered to be highly person-centred, but does not necessarily convey a rehabilitation focus. Similarly, shifting language from declarative and impersonal medicalised statements, such as the statement ‘the patient is delusional’, to person-centred language that understands these experiences from the individual's perspective and the distress it causes (e.g. in terms of ‘the person is worried that … ’), is an important part of a person-centred approach but does not convey information about how recovery may be facilitated through rehabilitation.To evaluate changes in language from pre- to post-intervention, we compiled a dictionary of terms pertaining to each language category . Traditionally, the coding of text in this way is performed manually by multiple readers, with reference to established words or phrases that indicate the language being analysed. Manual coding of text allows for nuanced and contextually informed judgements about the presence or absence of textual features. Although this approach is labour-intensive and established content analysis dictionaries can allow for more automated coding, such dictionaries are often not applicable outside of the contexts or domains in which they are developed. As far as we are aware, no dictionary has been published that categorises recovery-oriented rehabilitation language. Therefore, it was decided that straightforward statistical techniques in combination with selective manual coding would be used, and dictionary terms would be defined as indicators of a given language type, rather than complete instances or partial components. It was also decided that the presence of language types would be measured at the level of whole sentences rather than by individual terms, to allow individual sentences to be coded with multiple categories, define language type by multiple words in combination or sequence, and reduce the risk of double counting a language instance that contains two or more dictionary terms. To allow the dictionary to encode grammatically or semantically distinct occurrences of a given word, sequences of up to three words long  were included in addition to single words; for example, the dictionary terms ‘CNAME will’ and ‘CNAME was’, where CNAME denotes the consumer's name.9 The study team identified terms from this document that were deemed to be rehabilitation-oriented, person-centred or non-person-centred. To supplement this, we analysed 728 short segments of manually classified text sampled from all care review summaries in the data-set. This coding, in which a language category was assigned to each text segment, was performed by a member of the research team, and reviewed by a second member. Where the second member disagreed with the original member's coding, the segment was discussed with the wider research team. Agreement on coding was reached 100% of the time by using this method. We searched for sequences of one, two or three words whose occurrence showed a strong relationship with any of the language categories. These terms were then manually inspected to confirm that they were reliable indicators of the associated categories.An initial set of dictionary terms was identified with the New South Wales Mental Health Coordinating Council guidelines for use of person-centred language.https://doi.org/10.1192/bjo.2023.14).Having compiled a first draft of the dictionary from these two sources, we expanded and refined the listed terms by examining their sentence-level co-occurrences with the dictionary categories and with unclassified words in the data-set. To do this, we used a measure called normalised pointwise mutual information, which essentially compares the observed co-occurrence of two features with their expected co-occurrence, given how often they each occur independently. The result is a number from –1 to 1, which can be interpreted in much the same way as a correlation coefficient. If, by this measure, a dictionary term had a weak association with its own category, or a stronger association with a different category, then its classification was reviewed. If an unclassified term had a strong association with a dictionary category, it was considered for inclusion in the dictionary. A total of 130 dictionary terms were identified (Supplementary Table 1 available at https://www.knime.com/), an open-source, visually oriented data analytics platform that includes specialised text-processing functionality. To achieve a more consistent sentence length, we split sentences longer than 30 words into strings no longer than 20 words, splitting around punctuation marks such as periods and commas wherever possible. In addition, we merged sentences shorter than five words into adjacent sentences. Processed in this manner, the data-set contained 6740 sentences with an average length of 16 words. We measured the presence of a given language category within a document by calculating the percentage of sentences in which the language category appeared. To assess the impact of the intervention, we calculated and compared average document-level percentages before and after the intervention. To assess qualitative changes in language use, we compared the presence of individual dictionary terms before and after the intervention. As with the language categories, the metric we used was percentage of sentences per document in which each term occurred.Care review summaries were de-identified (excluding the pre-populated fields and header), processed and analysed computationally with Konstanz Information Miner .P < 0.001). There was no significant change in person-centred language. Pejorative language appeared in a very small fraction of sentences both before and after the intervention. The prevalence of pejorative language decreased, but not to a degree that was statistically significant. A significant increase in the use of recovery-oriented rehabilitation language was found, with the average percentage of sentences in which recovery-oriented rehabilitation terms occurred increasing from 37% before the intervention to 48% afterward, translating to a relative increase of 28% . Although the use of recovery-oriented rehabilitation language increased overall, some specific terms decreased following the intervention, albeit only modestly.Although the use of person-centred language did not change overall, the use of certain terms in this category did change. The term that increased the most was ‘enduring’, which is typically seen as being more person-centred than a term such as ‘chronic’.The use of some specific terms that are not recovery-oriented rehabilitation language, such as ‘not been able’, ‘is not able’ and ‘CNAME was’ decreased from pre-intervention to post-intervention.This study was an evaluation of a training programme designed to promote the use of recovery-oriented rehabilitation language in clinical documentation in a rehabilitation-oriented community mental health team. We found a significant increase in the recording of recovery-oriented rehabilitation language following the intervention. The largest increase in use of a specific term was a 1.17% relative increase in the term ‘well-being’. The was followed by a 1.18% relative increase in use of the term ‘(consumer's name) will’, with an associated 1.90% relative decrease in the term ‘(consumer's name) was’ and an associated 0.69% relative decrease in the term ‘(consumer name) had’. These are significant outcomes, as ‘(consumer name) will’ is mostly used in the care review summaries to describe actions that the consumer intends to take to work toward recovery goals, whereas ‘(consumer name) was’ and ‘(consumer name) had’ is language that is backward-looking. Together, these results suggest a shift from language focusing on a consumer's past to language that describes actions that the consumer intends to take to work toward recovery goals. By contrast, we did not find significant changes in person-centred, non-recovery-oriented rehabilitation language, nor pejorative language. The lack of significant change in pejorative language can be explained by a floor effect attributable to extremely low rates of pejorative language before the intervention. Similarly, there was a relatively high rate of person-centred language before the intervention, creating a ceiling effect and likely explaining the lack of significant difference.18 A multicentre study of mental health services in Ireland showed that those who received rehabilitation services were eight times more likely to remain in the community or live in less supported accommodation compared with those in receipt of standard care; those who received rehabilitation services were also more likely to show improvement in social functioning.19International studies have shown that recovery-oriented interventions have significant economic advantages. These include decreases to direct costs such as costs related to hospital stays and community treatment, as well as indirect benefits such as increased productivity.4 The type of language adopted by mental health services across verbal and written modalities has been shown to be a significant mediator of the behaviours of people with mental health concerns and those involved in their daily lives, as well as the attitudes and behaviours of mental health clinicians. Use of recovery-oriented language has, in turn, been shown to be associated with more frequent rehabilitation-focused behaviours and interventions by clinicians.3 This study has built upon a growing area of research into recovery and rehabilitation in mental health settings. The current study shows that with a structured intervention, clinicians can be guided to more accurately reflect the rehabilitation work undertaken as part of these interventions in their clinical documentation. In evaluating an intervention that promoted recovery-oriented rehabilitation and person-centred language in documentation, this study appears to be a first in addressing the gap in systematic research exploring the relationship between language and recovery-oriented practice in mental health settings identified by Kemp and Howard.4Language can promote a sense of hope and empowerment in not only the person, but other stakeholders in the person's life, including clinicians, and can contribute positively to improved care for the person as a result.This study also developed a method to objectively identify and evaluate the use of recovery-oriented rehabilitation language in documentation, which can be used by services to evaluate service provision and by clinicians to demonstrate professional knowledge and skills. As far as we are aware, no similar methodology has been used for a similar application, nor have we seen published studies that specifically classify and quantify recovery-oriented rehabilitation language in this way. This study also appears to be the first to develop a method to objectively identify and evaluate the use of recovery-oriented rehabilitation and person-centred language in documentation, and to begin generating a dictionary of such terms. This set of techniques, and the development of a dictionary of recovery-oriented rehabilitation terms, could have broader applications in mental health services evaluations; for example, in providing a means to automate auditing and evaluation of large volumes of clinical documentation that services accumulate. It could also be used by mental health clinicians to demonstrate professional knowledge and skill in the area of recovery-oriented language.3 As such, the training programme used in this study, or one like it, could be offered to mental health clinicians wishing to increase their knowledge of rehabilitation in mental health settings and appropriately document rehabilitation-focused interventions, or to mental health services interested in increasing their overall ability to provide, document and evaluate rehabilitation-focused services. The change in documentation and the hypothesised increase in engagement in recovery-oriented rehabilitation practices could then lead to more positive, recovery-oriented outcomes for consumers, such as decreased hospital admissions, increased productivity and increased social functioning.The implications of this study are that a structured training programme involving both group and individual interventions, and including instruction on formulation and rehabilitation principles, can lead to increased documentation of language that is recovery-oriented and rehabilitation-focused. Increased use of recovery-oriented rehabilitation language in documentation will then more adequately and appropriately reflect any rehabilitation work undertaken. Furthermore, use of recovery-oriented rehabilitation language has been hypothesised to lead to increased rehabilitation-focused practices and interventions by clinicians, and therefore more positive and recovery-focused experiences for consumers of mental health services.In addition to the training programme promoting an increased rehabilitation focus in documentation and outcomes, the second implication of this study was the development of a unique textual analysis methodology. One advantage of this textual analysis methodology is that, when paired with a suitable dictionary of terms, language in electronic medical records can be automatically audited for person-centred and rehabilitation-oriented language, and other types of language at scale.It would be important to replicate the results of this study with a larger, more diverse clinician population. Further research in larger-scale, more diverse mental health services that evaluate the utility of the analysis methods used and add to the dictionary formed in this study would further contribute to developing efficient, automated means of evaluating documentation and services in mental health settings. Furthermore, future research using non-automatic, qualitative content analysis to validate the automated analysis would be beneficial. It would be prudent to check that the findings of the automated analysis align with what would emerge under a more traditional approach. This would more soundly justify the use of the automated process as a quick tool for services to track their rehabilitation language. Also, although the text analysis approach developed in this study could be used by services to evaluate service provision and by clinicians to demonstrate professional knowledge and skills, including recovery-oriented rehabilitation practice, this needs to be tempered by the fact that what clinicians write may be very different from what they do, and might not adequately capture verbal responses and clinical interactions. Although potentially useful, the current approach is limited by the inherent nature of documentation, which may contain formulaic terminology and phraseology resulting from convention and content that is required administratively but is not specifically relevant to rehabilitation, or able to be meaningfully phrased with reference to person-centred care.3The focus of the current study on the documentation of recovery-oriented rehabilitation language has meant that attitudinal components of the clinicians to the recovery approach and how this can manifest in practice are yet to be examined. Therefore, it will be important to evaluate if providing training such as that evaluated in this study and/or increasing recovery-oriented rehabilitation language in documentation leads to a corresponding increase in recovery-oriented rehabilitation attitudes and practice for clinicians. Future research should also include studies of consumer experiences of the language clinicians use both verbally and in documentation before and after clinicians are trained in recovery-oriented rehabilitation language, their perception of the rehabilitation work undertaken with clinicians at these time points and the impact of this on their recovery journey. Following on from this, the involvement of patients and carers in the development of the dictionary and classification of language did not occur in this study, and should be considered in future research. This would complement Davidson's findings that the type of language adopted by mental health services was a mediator in the behaviours of consumers, carers and mental health clinicians.Finally, it is unclear if patient characteristics may have played a role in the language documented by clinicians in this study. Given its size, it was not possible to investigate this in the current study. Future research should investigate the relationship between patient characteristics and the documenting of recovery-oriented rehabilitation language by clinicians.In conclusion, language used in documentation of rehabilitation-oriented services needs to reflect the nature of the interventions provided. We found that the training programme developed for this study promoted increased use of recovery-oriented rehabilitation language in the clinical documentation of a rehabilitation-oriented, assertive community treatment team. The methodology used in this study to automate the evaluation of clinical documentation in electronic medical records has the capacity to identify recovery-oriented rehabilitation terms quickly and objectively, assisting assessment of documentation fidelity.This computer-driven, textual analysis method identified improvements in recovery-oriented rehabilitation language following training. Our study suggests that brief interventions can affect the language of clinical documentation, and that automated text analysis may represent a promising approach for rapidly assessing recovery-oriented rehabilitation language in mental health services.


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In the present review, we describe the interaction between AV and LVAD placement, in terms of patient management and prognosis. Also it is provided a comprehensive echocardiographic strategy for the precise assessment of AV regurgitation severity.Patients suffering from end-stage heart failure tend to have high mortality rates. With growing numbers of patients progressing into severe heart failure, the shortage of available donors is a growing concern, with less than 10% of patients undergoing cardiac transplantation (CTx). Fortunately, the use of left ventricular assist devices (LVADs), a variant of mechanical circulatory support has been on the rise in recent years. The expansion of LVADs has led them to be incorporated into a variety of clinical settings, based on the goals of therapy for patients ailing from heart failure. However, with an increase in the use of LVADs, there are a host of complications that arise with it. One such complication is the development and progression of aortic regurgitation (AR) which is noted to adversely influence patient outcomes and compromise pump benefits leading to increased morbidity and mortality. The underlying mechanisms are likely multifactorial and involve the aortic root-aortic valve (AV) complex, as well as the LVAD device, patient, and other factors, all of them alter the physiological mechanics of the heart resulting in AV dysfunction. Thus, it is imperative to screen patients before LVAD implantation for AR, as moderate or greater AR requires a concurrent intervention at the time of LVADs implantation. No current strict guidelines were identified in the literature search on how to actively manage and limit the development and/or progression of AR, due to the limited information. However, some recommendations include medical management by targeting fluid overload and arterial blood pressure, along with adjusting the settings of the LVADs device itself. Surgical interventions are to be considered depending on patient factors, goals of care, and the underlying pathology. These interventions include the closure of the AV, replacement of the valve, and percutaneous approach  Aortic valve pathophysiology and the associated risk factors predisposing to AR development in patients with left ventricular assist device (LVAD) should be taken into account considering the increasing number of patients with end-stage heart failure (HF) that temporarily or permanently are implanted, despite being on optimal medical management  while waIn the present review, we describe the interaction between AV and LVAD placement, in terms of patient management and prognosis. We also provide a comprehensive echocardiographic strategy for the precise assessment of AV regurgitation.via a LV apical cannula to the aorta, to maintain systemic perfusion (The function of the LVAD is to reduce the workload of the LV by pumping blood erfusion .Left ventricular assist devices can be divided into pulsatile or continuous flow. Pulsatile flow LVADs (PF-LVAD), mimic the heart’s natural rhythmic motion , whereas continuous flow LVADs (CFL-VAD) use a motor operating at a fixed speed, resulting in continuous ejection of blood into the aorta. This causes a decreased pulse pressure and a non-palpable peripheral pulse. CF-LVAD can be further subdivided into axial flow  and centrifugal flow . Axial flow employs a turbine rotation, pushing blood into the outflow cannula, whereas centrifugal flow draws blood along the rotor’s axis and propels it tangentially into the systemic circulation. Continuous flow LVAD has substantially prolonged the longevity of the pump .Between 2011 and 2022, there has been a progressive increase in LVAD implantation , with a drop in 2020, because of the COVID-19 pandemic effect on cardiac surgical volumes in the United States . At presLeft ventricular assist device is employed in a variety of clinical settings, based on the goals of therapy:a)Short term: Bridge to recovery. These are patients awaiting cardiac surgery, or who suffer from ventricular arrhythmias, cardiogenic shock, or heart failure that are refractory to medical management.b)Medium term: Bridge to Transplantation (BTT) and Bridge To candidacy (BTC). These patients require additional support while awaiting CTx or are currently unfit for CTx, but not have absolute contraindications , 25–27. c)Long-term: Destination Therapy (DT). Patients who are ineligible for CTx due to age, comorbidities, or psychosocial factors can have prolonged survival with LVAD implantation. Due to the new heart allocation, heart strategy by the United Network for Organ Sharing (UNOS) in 2018, DT has increased from 42.7% (2011–2015) to 50.4% (2015–2020) . ReporteLeft ventricular assist device implantation is associated with several complications . Despitede novo AR over the first 6 months post-implantation  after adjustment for confounders. Moreover, patients with severe AR had at least moderate mitral regurgitation (MR), leading to lower systolic blood pressures and cardiac output, and higher rehospitalization rates for HF. Auvil et al.  .The altered physiological mechanics of the heart, resulting from LVAD-host integration might cause the development of AV dysfunction .Under normal conditions, the aortic root-aortic valve complex guarantees unidirectional, intermittent blood flow under optimal conditions, with laminar flow, minimal shear stress and resistance, and complete diastolic coaptation of the AV leaflets . MoreoveThe high shear stress produced by CF-LVADs is found throughout the whole cardiac cycle, exposing the aortic valve leaflets and aortic wall to continuous turbulent flow and higher arterial pressures. Normally, the valve leaflets relax in the open position when stretch and stress are low, allowing nutrient flow to the tissue. With CF-LVADs, the leaflets are usually persistently closed, so that the valve leaflets are under maximum stretch with a continuously high transvalvular gradient. This provides a stimulus for collagen production and increased inflammation, causing adverse remodeling of the valve leaflets, with retraction, degenerative involvement, and focal nodular calcification , 35, 63.Shear stress can also affect the aortic wall, as the outflow graft can be smaller than the native aorta, with higher velocity and flow. The consequence of this process is aortic dilatation, with progressive thinning of the aorta media layer, decrease in smooth muscle cells and elastic fibers of the media layer –71. Finade novo AR and worsening of pre-existing AR. This pathophysiology is seen in animal models, leading to aortic atrophy and worsening AR /American Society of Echocardiography (ASE) guidelines , it is cStratification of AR severity pre-LVAD implantation is fundamental for patient management and should be done according to guidelines for accurate long-term prognosis since some of the parameters are predictors of future development of AR –80. TablTraditional TTE tends to underestimate the severity of AR as it occurs throughout the cardiac cycle due to insufficient residual LV contractile forces to oppose the backflow in systole, thus even a relatively small AV orifice can account for severe AR. Aortic flow, as a result, becomes highly dependent on global hemodynamics such as LV pre-load, residual contractility, and heart rate . FurtherAs previously mentioned, the duration of AR should be considered when the AR is quantified (measure of flow over time). For this reason, the calculation of regurgitant volume (RVol) can be estimated by measuring PISA by M-mode, AR by CW, and the duration of AR (ms) adjusted by heart rate  Table 5Table 5.Importantly, the degree of AV opening can be significantly reduced or intermittent, depending on the LVAD speed. Ideally, LVAD support aims to open the aortic valve every two or three beats. M-Mode of the AV long-axis can help to quantify the degree of AV opening  and if color is added also the AR characteristics  It is suggested to acquire at low speed (25 mm/s) and at least 3–5 cardiac cycles.Following LVAD implantation, it is recommended to perform routine TTE according to the algorithm shown in the flow chart .Standard comprehensive echocardiography will be performed, with a particular emphasis on LV and RV dimensions, systolic function, inflow and outflow cannula interrogation, valvular apparatus included AV function  . It is rThe consequence of AR determines backward flow through the AV during diastole that contribute to energy loss and reducing systemic flow and worsening HF. The re-entering of blood in the LVAD causes a vicious regurgitant flow loop with the consequence that the pump needs to run at a higher speed to maintain the cardiac output and extend the time of shear stress to the blood increasing hemolysis and thrombogenicity . Aortic If the AR is mild, the patient is treated medically. When AR is more than mild, AV needs to be tackled before or at the time of device implantation to prevent its progression. The intervention of choice is AV replacement with a bio-prosthesis as described below. If the patient already has an AV replaced with a mechanical valve at the time of device implantation, it is recommended to replace it with a bioprosthetic valve, or bypass the valve from the circulation to avoid thromboembolic complications , 85. To Patients with moderate to severe AR after device implantation should be promptly treated since it affects the patient either clinically or prognostically as previously explained  12–15, , 15, 60.de novo AR or AR progression  .Prohibitive surgical risk patients can be candidates for percutaneous techniques including percutaneous occluding devices (PODs) or transcatheter aortic valve implantation (TAVI) –99. AlthThe most common complications associated with TAVI procedures are embolization of the device into the aorta or migration of the prosthesis in the left ventricle , as well as the intra-and paravalvular leaks that either occurs after the valve is released or develop during the follow-up period and call for additional intervention . Prior tde novo AR, which is estimated to have a prevalence of 10–55% in the first 6 months, and the worsening of pre-existing AR. The AV is considerably impacted by the LVAD; hence, this factor should be carefully considered along with the aortic dimension. The specific hemodynamics of AR make it difficult for TTE/TEE to accurately identify this condition, which is crucial because AR affects mortality and morbidity. It is advised that AR be addressed at the time of LVAD implantation if it is moderate or worse before the implantation. Intervention must be taken into consideration if moderate or worse AR occurs after implantation. Non-invasive, medical, and/or LVAD pump modification settings, or invasive management options are available. Since patients frequently have advanced HF with severely compromised end organ damage and high-risk surgery, TAVI is regarded as a possible alternative to invasive therapies, even though it is currently off-label.The ability of LVAD support to function as a BTT, BTC, and DT has greatly increased its appeal in recent years. A major concern with LVAD implantation is the development of OV, AM, AS, and AE-S equally contributed in writing the manuscript and editing. KF, AE, HA, NK, MA, DA-B, ARS, and FT assisted in visualization and editing. All authors contributed to the article and approved the submitted version.