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Plummer K, Adina J, Mitchell AE, Lee-Archer P, Clark J, Keyser J, Kotzur C, Qayum A, Griffin B. Digital health interventions for postoperative recovery in children: a systematic review. Br J Anaesth 2024; 132:886-898. [PMID: 38336513 DOI: 10.1016/j.bja.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/15/2023] [Accepted: 01/05/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Digital health interventions offer a promising approach for monitoring during postoperative recovery. However, the effectiveness of these interventions remains poorly understood, particularly in children. The objective of this study was to assess the efficacy of digital health interventions for postoperative recovery in children. METHODS A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with the use of automation tools for searching and screening. We searched five electronic databases for randomised controlled trials or non-randomised studies of interventions that utilised digital health interventions to monitor postoperative recovery in children. The study quality was assessed using Cochrane Collaboration's Risk of Bias tools. The systematic review protocol was prospectively registered with PROSPERO (CRD42022351492). RESULTS The review included 16 studies involving 2728 participants from six countries. Tonsillectomy was the most common surgery and smartphone apps (WeChat) were the most commonly used digital health interventions. Digital health interventions resulted in significant improvements in parental knowledge about the child's condition and satisfaction regarding perioperative instructions (standard mean difference=2.16, 95% confidence interval 1.45-2.87; z=5.98, P<0.001; I2=88%). However, there was no significant effect on children's pain intensity (standard mean difference=0.09, 95% confidence interval -0.95 to 1.12; z=0.16, P=0.87; I2=98%). CONCLUSIONS Digital health interventions hold promise for improving parental postoperative knowledge and satisfaction. However, more research is needed for child-centric interventions with validated outcome measures. Future work should focus development and testing of user-friendly digital apps and wearables to ease the healthcare burden and improve outcomes for children. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022351492).
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Affiliation(s)
- Karin Plummer
- School of Nursing and Midwifery, Menzies Health Institute, Griffith University, Gold Coast, QLD, Australia; Department of Anaesthesia and Pain, Queensland Children's Hospital, South Brisbane, QLD, Australia.
| | - Japheth Adina
- Parenting and Family Support Centre, School of Psychology, Brisbane, QLD, Australia
| | - Amy E Mitchell
- Parenting and Family Support Centre, School of Psychology, Brisbane, QLD, Australia; Griffith Centre for Mental Health, Griffith University, Brisbane, QLD, Australia; Midwifery and Social Work, School of Nursing, The University of Queensland, Brisbane, QLD, Australia
| | - Paul Lee-Archer
- Department of Anaesthesia and Pain, Queensland Children's Hospital, South Brisbane, QLD, Australia; Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD, Australia
| | - Janelle Keyser
- Department of Anaesthesia and Pain, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Catherine Kotzur
- Department of Anaesthesia and Pain, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Abdul Qayum
- Department of Critical Care, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Bronwyn Griffin
- School of Nursing and Midwifery, Menzies Health Institute, Griffith University, Gold Coast, QLD, Australia; Pegg Leditschke Children's Burns Centre, Queensland Children's Hospital, South Brisbane, QLD, Australia
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Palermo TM, Lalloo C, Zhou C, Dampier C, Zempsky W, Badawy SM, Bakshi N, Ko YJ, Nishat F, Stinson JN. A cognitive-behavioral digital health intervention for sickle cell disease pain in adolescents: a randomized, controlled, multicenter trial. Pain 2024; 165:164-176. [PMID: 37733479 PMCID: PMC10723646 DOI: 10.1097/j.pain.0000000000003009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 09/23/2023]
Abstract
ABSTRACT Severe acute and chronic pain are the most common complications of sickle cell disease (SCD). Pain results in disability, psychosocial distress, repeated clinic visits/hospitalizations, and significant healthcare costs. Psychosocial pain interventions that teach cognitive and behavioral strategies for managing pain have been effective in other adolescent populations when delivered in person or through digital technologies. Our aim was to conduct a multisite, randomized, controlled trial to improve pain and coping in youth aged 12 to 18 years with SCD using a digital cognitive-behavioral therapy program (iCanCope with Sickle Cell Disease; iCC-SCD) vs Education control. We enrolled 137 participants (ages 12-18 years, 59% female) and analyzed 111 adolescents (107 caregivers), 54 randomized to Education control and 57 randomized to iCC-SCD. Ninety-two percent of youth completed posttreatment assessments and 88% completed 6-month follow-up. There was a significant effect of treatment group (iCC-SCD vs Education) on reduction in average pain intensity from baseline to 6-month follow-up (b = -1.32, P = 0.009, 95% CI [-2.29, -0.34], d = 0.50), and for the number of days with pain, adolescents in the iCC-SCD group demonstrated fewer pain days compared with the Education group at 6-month follow-up (incident rate ratio = 0.63, P = 0.006, 95% CI [0.30, 0.95], d = 0.53). Treatment effects were also found for coping attempts, momentary mood, and fatigue. Several secondary outcomes did not change with intervention, including anxiety, depression, pain interference, and global impression of change. Future studies are needed to identify effective implementation strategies to bring evidence-based cognitive-behavioral therapy for sickle cell pain to SCD clinics and communities.
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Affiliation(s)
- Tonya M. Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Chitra Lalloo
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Chuan Zhou
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Carlton Dampier
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - William Zempsky
- Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, Department of Pediatrics, University of Connecticut School of Medicine, Hartford, CT, United States
| | - Sherif M. Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Division of Hematology, Oncology, and Stem Cell Transplant, Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Nitya Bakshi
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Yeon Joo Ko
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Fareha Nishat
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jennifer N. Stinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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Clairman H, Dover S, Tomlinson G, Beebe D, Cameron B, Laxer RM, Levy D, Narang I, Paetkau S, Schneider R, Spiegel L, Stephens S, Stinson J, Tse S, Weiss S, Whitney K, Feldman BM. Lengthening sleep reduces pain in childhood arthritis: a crossover randomised controlled trial. RMD Open 2023; 9:e003352. [PMID: 37914178 PMCID: PMC10619109 DOI: 10.1136/rmdopen-2023-003352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVES Juvenile idiopathic arthritis (JIA) is a common chronic childhood disease and chronic pain is a debilitating feature. A strong link has been shown between poor sleep and pain in JIA. However, the causal direction is unknown. This study's aim was to determine if, in adolescents with JIA, a recommended healthful sleep duration leads to reductions in pain when compared with the restricted sleep (RS) duration that is commonly seen. METHODS Patients with JIA (12-18 years old; pain score of ≥1 on a visual analogue scale) participated in a randomised, crossover sleep manipulation protocol. The 3-week protocol comprised a baseline week (BL), a week with healthy sleep duration (HSD; 9.5 hours in bed/night) and a RS week (RS; 6.5 hours in bed/night). After BL, participants were randomly assigned to either HSD or RS, and then crossed over to the other condition. Pain was self-assessed using the iCanCope with Pain app. We used Bayesian hierarchical models to estimate the effect of sleep duration on pain. RESULTS Participants (n=31; mean age=15.0±1.8 years) averaged 1.4 (95% credible interval (CrI) 1.2-1.6) more hours of sleep per night during HSD relative to RS. Compared with RS, HSD resulted in a favourable effect on pain scores (OR 0.61, 95% CrI 0.39-0.95). CONCLUSION It is possible to have adolescents with childhood arthritis get a healthier sleep duration, and this longer sleep results in reduced pain. These findings complement prior correlational studies and confirm a causal relationship between reduced sleep duration and increased pain. TRIAL REGISTRATION NUMBER NCT04133662.
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Affiliation(s)
- Hayyah Clairman
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Saunya Dover
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - George Tomlinson
- Division of Clinical Decision Making & Health Care, Toronto General Research Institute, Toronto, Ontario, Canada
| | - Dean Beebe
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Bonnie Cameron
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronald M Laxer
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Deborah Levy
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Indra Narang
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susan Paetkau
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rayfel Schneider
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lynn Spiegel
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Samantha Stephens
- Neurosciences & Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
| | - Jennifer Stinson
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Shirley Tse
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shelly Weiss
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kristi Whitney
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian M Feldman
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Nascimento Leite M, Kamper SJ, O'Connell NE, Michaleff ZA, Fisher E, Viana Silva P, Williams CM, Yamato TP. Physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents. Cochrane Database Syst Rev 2023; 7:CD013527. [PMID: 37439598 PMCID: PMC10339856 DOI: 10.1002/14651858.cd013527.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Chronic pain is a major health and socioeconomic burden, which is prevalent in children and adolescents. Among the most widely used interventions in children and adolescents are physical activity (including exercises) and education about physical activity. OBJECTIVES To evaluate the effectiveness of physical activity, education about physical activity, or both, compared with usual care (including waiting-list, and minimal interventions, such as advice, relaxation classes, or social group meetings) or active medical care in children and adolescents with chronic musculoskeletal pain. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PEDro, and LILACS from the date of their inception to October 2022. We also searched the reference lists of eligible papers, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared physical activity or education about physical activity, or both, with usual care (including waiting-list and minimal interventions) or active medical care, in children and adolescents with chronic musculoskeletal pain. DATA COLLECTION AND ANALYSIS Two review authors independently determined the eligibility of the included studies. Our primary outcomes were pain intensity, disability, and adverse events. Our secondary outcomes were depression, anxiety, fear avoidance, quality of life, physical activity level, and caregiver distress. We extracted data at postintervention assessment, and long-term follow-up. Two review authors independently assessed risk of bias for each study, using the RoB 1. We assessed the overall certainty of the evidence using the GRADE approach. We reported continuous outcomes as mean differences, and determined clinically important differences from the literature, or 10% of the scale. MAIN RESULTS We included four studies (243 participants with juvenile idiopathic arthritis). We judged all included studies to be at unclear risk of selection bias, performance bias, and detection bias, and at high risk of attrition bias. We downgraded the certainty of the evidence for each outcome to very low due to serious or very serious study limitations, inconsistency, and imprecision. Physical activity compared with usual care Physical activity may slightly reduce pain intensity (0 to 100 scale; 0 = no pain) compared with usual care at postintervention (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -0.82 to -0.08; 2 studies, 118 participants; recalculated as a mean difference (MD) -12.19, 95% CI -21.99 to -2.38; I² = 0%; very low-certainty evidence). Physical activity may slightly improve disability (0 to 3 scale; 0 = no disability) compared with usual care at postintervention assessment (MD -0.37, 95% CI -0.56 to -0.19; I² = 0%; 3 studies, 170 participants; very low-certainty evidence). We found no clear evidence of a difference in quality of life (QoL; 0 to 100 scale; lower scores = better QoL) between physical activity and usual care at postintervention assessment (SMD -0.46, 95% CI -1.27 to 0.35; 4 studies, 201 participants; very low-certainty evidence; recalculated as MD -6.30, 95% CI -18.23 to 5.64; I² = 91%). None of the included studies measured adverse events, depression, or anxiety for this comparison. Physical activity compared with active medical care We found no studies that could be analysed in this comparison. Education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison. Physical activity and education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison. AUTHORS' CONCLUSIONS We are unable to confidently state whether interventions based on physical activity and education about physical activity are more effective than usual care for children and adolescents with chronic musculoskeletal pain. We found very low-certainty evidence that physical activity may reduce pain intensity and improve disability postintervention compared with usual care, for children and adolescents with juvenile idiopathic arthritis. We did not find any studies reporting educational interventions; it remains unknown how these interventions influence the outcomes in children and adolescents with chronic musculoskeletal pain. Treatment decisions should consider the current best evidence, the professional's experience, and the young person's preferences. Further randomised controlled trials in other common chronic musculoskeletal pain conditions, with high methodological quality, large sample size, and long-term follow-up are urgently needed.
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Affiliation(s)
- Mariana Nascimento Leite
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil
| | - Steven J Kamper
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Zoe A Michaleff
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Emma Fisher
- Cochrane Pain, Palliative and Supportive Care Group, Pain Research Unit, Churchill Hospital, Oxford, UK
- Centre for Pain Research, University of Bath, Bath, UK
| | | | | | - Tiê P Yamato
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Buono FD, Larkin K, Pham Q, De Sousa D, Zempsky WT, Lalloo C, Stinson JN. Maintaining Engagement in Adults with Neurofibromatosis Type 1 to Use the iCanCope Mobile Application (iCanCope-NF). Cancers (Basel) 2023; 15:3213. [PMID: 37370823 PMCID: PMC10296339 DOI: 10.3390/cancers15123213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic condition in which chronic pain is a predominant issue. Given the rarity of the disease, there are limited psychosocial treatments for individuals with NF1 suffering with chronic pain. Using mobile applications can facilitate psychosocial treatments; however, there are consistent issues with engagement. Utilizing a mixed methodology, the current study evaluated the customized iCanCope mobile application for NF1 on increasing engagement through the usage of contingency management. METHODS A mixed methods study from a subset of data coming from a randomized clinical trial that occurred from January 2021 to August 2022 was undertaken. Two groups (iCC and iCC + CM) were exposed to the customized iCanCope mobile application in which engagement data were captured in real-time with daily check-ins for interference, sleep, mood, physical activity, energy levels, goal setting, and accessing article content (coping strategies). Additionally, semi-structured interviews were conducted to gain insight into the participants' experience at the end of the trial. RESULTS Adults (N = 72) were recruited via NF patient advocacy groups. Significant differences were noted between the groups in total articles read (p = 0.002), goals achieved (p = 0.017), and goals created (p = 008). Additionally, there were significant differences observed between user-generated goals and those that were app recommended (p < 0.001). Both groups qualitatively reported positive feedback on the customized mobile application, indicating that continued usage and engagement of the mobile application were acceptable. CONCLUSIONS Employing customized mobile applications for adults with NF1 along with contingency management can leverage self-managed pain treatments while providing auxiliary resources to this population.
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Affiliation(s)
- Frank D. Buono
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Kaitlyn Larkin
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Quynh Pham
- Centre for Digital Therapeutics, University Health Network, Toronto, ON M5G 2C4, Canada; (Q.P.); (D.D.S.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada;
| | - Diane De Sousa
- Centre for Digital Therapeutics, University Health Network, Toronto, ON M5G 2C4, Canada; (Q.P.); (D.D.S.)
| | - William T. Zempsky
- Department of Pain and Palliative Medicine, Connecticut Children’s Medical Center, Hartford, CT 06106, USA;
- Department of Pediatrics and Nursing, University of Connecticut School of Medicine, Stores, CT 06032, USA
| | - Chitra Lalloo
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada;
- The Research Institute, The Hospital of Sick Children, Toronto, ON M5G 1X8, Canada;
| | - Jennifer N. Stinson
- The Research Institute, The Hospital of Sick Children, Toronto, ON M5G 1X8, Canada;
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5T 1P8, Canada
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Fujiwara T, Sheppard JP, Hoshide S, Kario K, McManus RJ. Medical Telemonitoring for the Management of Hypertension in Older Patients in Japan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2227. [PMID: 36767594 PMCID: PMC9916269 DOI: 10.3390/ijerph20032227] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/13/2023] [Accepted: 01/24/2023] [Indexed: 06/18/2023]
Abstract
Hypertension is the most frequent modifiable risk factor associated with cardiovascular disease (CVD) morbidity and mortality. Even in older people, strict blood pressure (BP) control has been recommended to reduce CVD event risks. However, caution should be exercised since older hypertensive patients have increased physical vulnerability due to frailty and multimorbidity, and older patients eligible for clinical trials may not represent the general population. Medical telemonitoring systems, which enable us to monitor a patient's medical condition remotely through digital communication, have become much more prevalent since the coronavirus pandemic. Among various physiological parameters, BP monitoring is well-suited to the use of such systems, which enable healthcare providers to deliver accurate and safe BP management, even in the presence of frailty and/or living in geographically remote areas. Furthermore, medical telemonitoring systems could help reduce nonadherence to antihypertensive medications and clinical inertia, and also enable multi-professional team-based management of hypertension. However, the implementation of medical telemonitoring systems in clinical practice is not easy, and substantial barriers, including the development of user-friendly devices, integration with existing clinical systems, data security, and cost of implementation and maintenance, need to be overcome. In this review, we focus on the potential of medical telemonitoring for the management of hypertension in older people in Japan.
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Affiliation(s)
- Takeshi Fujiwara
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
| | - James P. Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
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