Development and Evaluation of a New Tablet Computer Application for the Therapy of Brain-Injured Patients with Aphasia

Introduction Language is the most important mean of communication and plays a central role in our everyday life. Brain damage (e.g. stroke) can lead to acquired disorders of lan- guage affecting the four linguistic modalities (i.e. reading, writing, speech production and comprehension) in different combinations and levels of severity. Every year, more than 5000 people (Aphasie Suisse) are affected by aphasia in Switzerland alone. Since aphasia is highly individual, the level of difficulty and the content of tasks have to be adapted continuously by the speech therapists. Computer-based assignments allow patients to train independently at home and thus increasing the frequency of ther- apy. Recent developments in tablet computers have opened new opportunities to use these devices for rehabilitation purposes. Especially older people, who have no prior experience with computers, can benefit from the new technologies. Methods The aim of this project was to develop an application that enables patients to train language related tasks autonomously and, on the other hand, allows speech therapists to assign exercises to the patients and to track their results online. Seven categories with various types of assignments were implemented. The application has two parts which are separated by a user management system into a patient interface and a therapist interface. Both interfaces were evaluated using the SUS (Subject Usability Scale). The patient interface was tested by 15 healthy controls and 5 patients. For the patients, we also collected tracking data for further analysis. The therapist interface was evaluated by 5 speech therapists. Results The SUS score are xpatients = 98 and xhealthy = 92.7 (median = 95, SD = 7, 95% CI [88.8, 96.6]) in case of the patient interface and xtherapists = 68 in case of the therapist interface. Conclusion Both, the patients and the healthy subjects, attested high SUS scores to the patient interface. These scores are considered as "best imaginable". The therapist interface got a lower SUS score compared to the patient interface, but is still considered as "good" and "usable". The user tracking system and the interviews revealed that there is room for improvements and inspired new ideas for future versions.

Nonverbale Synchronisation in Dyaden: ein Vergleich von kooperativen und kompetitiven Interaktionen

Nonverbales Verhalten spielt in zwischenmenschlichen Interaktionen eine bedeutende Rolle. Es beeinflusst mutmaßlich den Verlauf eines Gesprächs, die Beziehung zwischen den Interaktionspartnern und die reziproke Sympathie. Trotz dieser immensen Bedeutung wird nonverbales Verhalten von den Beteiligten meist nicht bewusst wahrgenommen. Die vorliegende Arbeit widmet sich diesem wirkungsvollen Phänomen und vergleicht nonverbales Verhalten in kooperativen und kompetitiven Interaktionsbedingungen. Im Fokus der Experimentalstudie steht die nonverbale Synchronisation. Diese bezieht sich auf den dynamischen, quantitativen Aspekt der Koordination nonverbalen Verhaltens zwischen den Interaktionspartnern, konkret auf die Angleichung der Bewegungsenergie. Primäres Ziel ist es zu evaluieren, ob und inwiefern das nonverbale Verhalten, insbesondere das Ausmaß an Synchronisation, zwischen kooperativen und kompetitiven Bedingungen variiert. Hierzu wurden in einer Stichprobe von N = 168 gesunden Teilnehmern fünf standardisierte Interaktionen à fünf Minuten mit gleichgeschlechtlichen Dyaden realisiert. Die Probanden kannten sich vorher nicht. Die Interaktanten sahen sich aufgefordert, sowohl aktive Kooperationen zu etablieren, als auch in bestimmten Aufgaben zu konkurrieren. Kompromiss, Konsens, Konflikt, ungleicher Konflikt und Spiel waren die verschiedenen Bedingungen. Die resultierenden Synchronisationswerte basieren auf digitalen Videoaufnahmen von dyadischen Interaktionen, die durch das automatisierte, objektive Verfahren der Motion Energy Analysis (MEA) quantifiziert wurden. Neben den Synchronisationsprozessen wurden auch globale Bewegungscharakteristika wie Geschwindigkeit oder Maxima durch MEA erfasst. Des Weiteren wurden mittels Fragebögen individuelle Charakteristika (u.a. Empathie, Stimmung) sowie Einschätzungen (z.B. Sympathie) der Probanden erhoben und mit Synchronie in Zusammenhang gesetzt. Die Ergebnisse zeigen, dass sich nonverbale Synchronisation auf signifikant höherem Level manifestiert, als dies per Zufall erwartet werden könnte. Dabei war die Synchronisation in der spielerischen Kooperation am höchsten ausgeprägt - gefolgt von kompetitiven und (seriös-)kooperativen Interaktionen. Außerdem korrespondierten höhere Synchronisationswerte mit verstärkt positiven Affekten und verringerten negativen Emotionen. Darüber hinaus waren globale Bewegungsparameter wie Dauer und Komplexität oder der Prozentsatz von Bewegungen über dem Schwellenwert positiv mit Synchronisationsprozessen assoziiert. Das MEA-Verfahren sowie ein erstmals erprobtes Interaktionsparadigma konnten validiert werden.

Cardiovascular disease in Switzerland - health care, mortality and geographical pattern

SUMMARY Switzerland is facing an aging population and a growing amount of patients with chronic diseases. It is crucial to display health care processes and pathways, to identify inequalities and obstacles, and to point out possibilities for improvements of the Swiss health care system (e.g. increase efficiency). The introductory part of the thesis presents a brief description of the Swiss health care system, health services research and regional variation as well as an introduction of CVD and its epidemiological key figures, aetiology and treatments. This is followed by the description of the utilized methods and data, and the objectives of this thesis. The subsequent sections present the four articles included in this thesis. The first article focuses on a small area analysis on regional variation of avoidable hospitalisations in Switzerland including density of primary care physicians and specialists, rurality and hospital supply factors as explanatory variables in the analysis. Lower rates of avoidable hospitalisations were found in areas with very high supply of primary care physicians, increased avoidable hospitalisation rates in areas with more specialists and in areas with higher proportion of rural residents. The second article aims to examine whether emergency patients with acute ST-segment elevation myocardial infarction were adequately treated, i.e. according to the treatment guidelines, in Switzerland. Results show that older and female patients were less likely to receive revascularization which suggests that the treatment guidelines may not be uniformly applied in Switzerland. Similar to the first article, also in the third article a small area analysis was performed but this time investigating regional variation in costs at the end of life. Strongest associations of cost was found with cause of death, age and language region of the decedents. The strong spatial variation of costs could only partly be explained by the included covariates. Article four aims to examine the relationship of distance to different hospital types and mortality from AMI or stroke. We found that AMI mortality in the Swiss population 30 and older and stroke mortality in those 65 and above increased with distance to central and university hospitals, while adjusting for sociodemographic and economic characteristics of the population. The presentation of the four articles is followed by a discussion, which summarizes the main findings and the strengths and limitations of the presented articles. The thesis concludes with a discussion about the challenges for policy, practice and future research.

Analysis of Phenotypic Variation in Childhood Wheezing Disorders

Recurrent wheezing or asthma is a common problem in children that has increased considerably in prevalence in the past few decades. The causes and underlying mechanisms are poorly understood and it is thought that a numb er of distinct diseases causing similar symptoms are involved. Due to the lack of a biologically founded classification system, children are classified according to their observed disease related features (symptoms, signs, measurements) into phenotypes. The objectives of this PhD project were a) to develop tools for analysing phenotypic variation of a disease, and b) to examine phenotypic variability of wheezing among children by applying these tools to existing epidemiological data. A combination of graphical methods (multivariate co rrespondence analysis) and statistical models (latent variables models) was used. In a first phase, a model for discrete variability (latent class model) was applied to data on symptoms and measurements from an epidemiological study to identify distinct phenotypes of wheezing. In a second phase, the modelling framework was expanded to include continuous variability (e.g. along a severity gradient) and combinations of discrete and continuo us variability (factor models and factor mixture models). The third phase focused on validating the methods using simulation studies. The main body of this thesis consists of 5 articles (3 published, 1 submitted and 1 to be submitted) including applications, methodological contributions and a review. The main findings and contributions were: 1) The application of a latent class model to epidemiological data (symptoms and physiological measurements) yielded plausible pheno types of wheezing with distinguishing characteristics that have previously been used as phenotype defining characteristics. 2) A method was proposed for including responses to conditional questions (e.g. questions on severity or triggers of wheezing are asked only to children with wheeze) in multivariate modelling.ii 3) A panel of clinicians was set up to agree on a plausible model for wheezing diseases. The model can be used to generate datasets for testing the modelling approach. 4) A critical review of methods for defining and validating phenotypes of wheeze in children was conducted. 5) The simulation studies showed that a parsimonious parameterisation of the models is required to identify the true underlying structure of the data. The developed approach can deal with some challenges of real-life cohort data such as variables of mixed mode (continuous and categorical), missing data and conditional questions. If carefully applied, the approach can be used to identify whether the underlying phenotypic variation is discrete (classes), continuous (factors) or a combination of these. These methods could help improve precision of research into causes and mechanisms and contribute to the development of a new classification of wheezing disorders in children and other diseases which are difficult to classify.