c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 1 9 ( 2 0 1 5 ) 101–109
journal homepage: www.intl.elsevierhealth.com/journals/cmpb
Tablet PC-enabled application intervention for patients with gastric cancer undergoing gastrectomy Jin-Ming Wu a,d , Hwan-Jeu Yu b , Te-Wei Ho a , Xing-Yu Su a , Ming-Tsan Lin d,e,∗ , Feipei Lai a,b,c,∗ a
Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taiwan Department of Computer Science and Information Engineering, National Taiwan University, Taiwan c Department of Electrical Engineering, National Taiwan University, Taiwan d Department of Surgery, National Taiwan University Hospital, Taiwan e Department of Medical Education & Bioethics, Graduate Institute of Medical Education & Bioethics, College of Medicine, National Taiwan University, Taiwan b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Background: Gastric cancer is among the most common gastrointestinal cancers worldwide.
Received 22 November 2014
Patients who have undergone surgery for gastric cancer may suffer from malnutrition and
Received in revised form
potential consequences such as gastrointestinal complications, surgical stress, and cancer
8 March 2015
cachexia. A tablet PC-based intervention via a mobile application might enhance the early
Accepted 10 March 2015
recovery of postgastrectomy patients.
Keywords:
assisted intervention to hasten the recovery of postgastrectomy cancer patients with respect
Smartphone
to nutritional status.
Objective: The aim of this study was to develop and test a tablet personal computer (PC)-
Application
Methods: This single-arm pilot study investigated a tablet PC application developed to serve
Gastric cancer
the functions of nutritional monitoring, medical information management, drainage follow-
Surgery
up, and wound care. All services were delivered by medical professionals. Results: Twenty consecutive gastrectomy patients at the National Taiwan University Hospital received perioperative care via this application (App group). During the study period, we retrospectively collected an additional 20 demographically matched gastrectomy cases as a control group. The App group had a lower body weight loss percentage relative to the control group during a 6-month follow-up period (4.8 ± 1.2% vs. 8.7 ± 2.4%; p < 0.01). However, the patients in the App group had more outpatient clinic (OPC) visits than did those in the control group (9.8 ± 0.9 vs. 5.6 ± 0.8; p < 0.01). Conclusions: This study supported the feasibility of a tablet PC-based application for the perioperative care of gastric cancer subjects to promote a lower body weight loss and the collection of comprehensive surgical records. © 2015 Elsevier Ireland Ltd. All rights reserved.
∗
Corresponding authors at: #1 Roosevelt Rd., Sec. 4, Taipei 106, Taiwan. Tel.: +886 972 652 080; fax: +886 2 23123456. E-mail addresses: [email protected] (M.-T. Lin), [email protected] (F. Lai). http://dx.doi.org/10.1016/j.cmpb.2015.03.004 0169-2607/© 2015 Elsevier Ireland Ltd. All rights reserved.
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c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 1 9 ( 2 0 1 5 ) 101–109
Introduction
Gastric cancer is the fourth-most common cancer [1] and the second leading cause of cancer deaths worldwide [2]. In most patients, gastric cancer is discovered at an advanced stage because of the occult early clinical presentation of this type of cancer. Moreover, patients who are diagnosed with advanced gastric cancer more frequently exhibit gastric outlet obstruction and cancer bleeding, which result in a poor general condition and malnutrition (60–85 percent of cases) [3]. Surgery is considered the only potentially curative treatment [4]. However, pre-operatively malnourished patients who undergo curative surgery (another physical stress and insult) may continue to experience body weight loss because of wound pain, surgical complications, and gastrointestinal digestion disorders, which are associated with both reduced food intake and the malabsorption of vitamins, fats, and proteins [5,6]. Patients in whom this malnourished status is not recognized will have inferior clinical outcomes and a decreased quality of life relative to those with good nutritional statuses [7,8]. Moreover, postoperative body weight loss is the most important risk factor associated with oral adjuvant chemotherapy compliance in gastric cancer patients undergoing curative gastrectomy, thus emphasizing the requirement for adequate perioperative nutritional intervention [9]. A poor discharge transition from the medical center to the home represents an important gap between evidence-based clinical practices and current health care delivery. For gastrectomy patients with gastrointestinal complications, some retained intra-abdominal drainage tubes are kept to monitor the leakage fluid with turbid contaminated characteristics. These drainage tubes caused patients or their families to hesitate with regard to returning home where they would be required to care for these tubes by themselves. If the intraabdominal condition were to deteriorate, the drainage fluid may become turbid (new gastrointestinal leakage) or bloody (internal bleeding), which would imply a new medical emergency. Traditionally, medical professionals have not been able to immediately access the above-described information, thus potentially delaying a diagnosis or medical help. A major challenge to medical providers is the continued provision of postoperative care at home for patients with complications. Telecare is becoming a feasible and helpful tool for perioperative patient care [10,11]. With the popularity of smartphones or tablet personal computers (tablet PCs), the methods used to accessing information have changed, which has revolutionized the original telecare concept. There is an increased interest in smartphone applications (apps) as tools with which medical professionals and patients can deliver medical information and provide care [12–15]. It has been reported that the market for mobile health apps for smartphones and tablets will reach US $26 billion by 2017 [16]. As of 2013, there are an estimated 40,000 medical apps available on the market. Previous studies have addressed the feasibility of smartphone apps for patient self-monitoring [17,18] or surgical cases [19]. However, app-facilitated perioperative care for gastrectomy patients is lacking. We hypothesized that tablet PC application for gastrectomy patients compared with traditional care would be associated
with less percentage of body weight loss, with that being associated with close follow-up and clinical rule support. To test our hypothesis, we designed one experimental pre/post single-arm study to investigate whether a 6-month intervention involving this application would contribute to a more rapid recovery after gastrectomy in gastric cancer patients (App group). The primary study outcome was the change in the percentage of body weight loss. Body weight is a reliable predictor of the general nutritional statuses of cancer subjects. Additionally, we prospectively collected age, sex, body mass index (BMI), operation method, and cancer staging-matched gastrectomy subjects during the same period to compare with the App group (Control group).
2.
Methods
2.1.
Recruitment
The participants were recruited at the National Taiwan University Hospital (NTUH) in Taipei, Taiwan. The recruitment occurred through the health care provider. The inclusion criteria were an age >20 years, gastric cancer diagnosis, and treatment via curative gastrectomy. Participants were excluded if they or their caregivers experienced difficulties with accessing the app. The study was approved by the review board at NTUH, and all participants provided signed informed consent.
2.2.
App function and development
This app was developed using the objective-C language and iOS (previously iPhone OS) 6.1 SDK (Software Development Kit; Apple, Inc., Cupertino, CA, USA), which provides compatibility for iOS 5.1 and later platforms. We designed a client/server architecture to integrate the app service. The client side is the app itself for uploading images, inputting data and viewing personal history data. The app calls mobile web services provided by a web server to upload and store the image or data on the server side for medical professionals to evaluate personal query. Additionally, the application can store data on the client side temporarily and automatically synchronize with the server-side database by calling web services implemented in the C# language in a .NET framework. A Microsoft SQL server was utilized for server data storage. In order to improve security, the target system was designed to transmit data via the https protocol and the patient’s name or personal ID was omitted. Instead, a temporary ID (the subject number) was provided by the physician to represent the patient. After keying in secret keys, only the physician is allowed access to the data transmitted by the patients on the website. Fig. 1 shows the architecture of the overall system. To provide real-time remote care, we designed and developed a platform for the patients and medical staff to permit reviews of the entire historical upload record, including weight, drainage, symptoms, and patients’ wound images. In addition, the web service would automatically send a cell phone message to medical staff when a patient uploaded a wound image. Via this service, medical professionals could immediately determine the wound condition and notify the
c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 1 9 ( 2 0 1 5 ) 101–109
103
Fig. 1 – The application system: we developed a client/server architecture to integrate the app service, including database, web, and message servers. The client side is the app itself for uploading image, inputting data and viewing the personal history data.
patient if the wound infection should be investigated. This feedback interaction led to significant improvements in the software developed for a previous trial and for our study in terms of reducing the gap between the medical staff members and patients [20]. We divided the major functions of this application into 6 interfaces: the home page, my weight, my drains, wound pictures, surgery, and symptoms. Screenshots of the tablet PC application are shown in Figs. 2–7 along with the descriptions of each major function.
2.3.
Statistical analysis
All values were expressed as means with associated standard deviations or as frequencies. The Mann–Whitney test was used to assess continuous variables, and Fisher’s exact test was used for categorical variables. Differences in body weight changes (from the baseline to 6 months) were analyzed using a paired Student’s t-test. Data analyses were performed
using SPSS software (version 22.0, 2012; SPSS Inc., Chicago, IL, USA). A 2-sided p-value of
journal homepage: www.intl.elsevierhealth.com/journals/cmpb
Tablet PC-enabled application intervention for patients with gastric cancer undergoing gastrectomy Jin-Ming Wu a,d , Hwan-Jeu Yu b , Te-Wei Ho a , Xing-Yu Su a , Ming-Tsan Lin d,e,∗ , Feipei Lai a,b,c,∗ a
Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taiwan Department of Computer Science and Information Engineering, National Taiwan University, Taiwan c Department of Electrical Engineering, National Taiwan University, Taiwan d Department of Surgery, National Taiwan University Hospital, Taiwan e Department of Medical Education & Bioethics, Graduate Institute of Medical Education & Bioethics, College of Medicine, National Taiwan University, Taiwan b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Background: Gastric cancer is among the most common gastrointestinal cancers worldwide.
Received 22 November 2014
Patients who have undergone surgery for gastric cancer may suffer from malnutrition and
Received in revised form
potential consequences such as gastrointestinal complications, surgical stress, and cancer
8 March 2015
cachexia. A tablet PC-based intervention via a mobile application might enhance the early
Accepted 10 March 2015
recovery of postgastrectomy patients.
Keywords:
assisted intervention to hasten the recovery of postgastrectomy cancer patients with respect
Smartphone
to nutritional status.
Objective: The aim of this study was to develop and test a tablet personal computer (PC)-
Application
Methods: This single-arm pilot study investigated a tablet PC application developed to serve
Gastric cancer
the functions of nutritional monitoring, medical information management, drainage follow-
Surgery
up, and wound care. All services were delivered by medical professionals. Results: Twenty consecutive gastrectomy patients at the National Taiwan University Hospital received perioperative care via this application (App group). During the study period, we retrospectively collected an additional 20 demographically matched gastrectomy cases as a control group. The App group had a lower body weight loss percentage relative to the control group during a 6-month follow-up period (4.8 ± 1.2% vs. 8.7 ± 2.4%; p < 0.01). However, the patients in the App group had more outpatient clinic (OPC) visits than did those in the control group (9.8 ± 0.9 vs. 5.6 ± 0.8; p < 0.01). Conclusions: This study supported the feasibility of a tablet PC-based application for the perioperative care of gastric cancer subjects to promote a lower body weight loss and the collection of comprehensive surgical records. © 2015 Elsevier Ireland Ltd. All rights reserved.
∗
Corresponding authors at: #1 Roosevelt Rd., Sec. 4, Taipei 106, Taiwan. Tel.: +886 972 652 080; fax: +886 2 23123456. E-mail addresses: [email protected] (M.-T. Lin), [email protected] (F. Lai). http://dx.doi.org/10.1016/j.cmpb.2015.03.004 0169-2607/© 2015 Elsevier Ireland Ltd. All rights reserved.
102
1.
c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 1 9 ( 2 0 1 5 ) 101–109
Introduction
Gastric cancer is the fourth-most common cancer [1] and the second leading cause of cancer deaths worldwide [2]. In most patients, gastric cancer is discovered at an advanced stage because of the occult early clinical presentation of this type of cancer. Moreover, patients who are diagnosed with advanced gastric cancer more frequently exhibit gastric outlet obstruction and cancer bleeding, which result in a poor general condition and malnutrition (60–85 percent of cases) [3]. Surgery is considered the only potentially curative treatment [4]. However, pre-operatively malnourished patients who undergo curative surgery (another physical stress and insult) may continue to experience body weight loss because of wound pain, surgical complications, and gastrointestinal digestion disorders, which are associated with both reduced food intake and the malabsorption of vitamins, fats, and proteins [5,6]. Patients in whom this malnourished status is not recognized will have inferior clinical outcomes and a decreased quality of life relative to those with good nutritional statuses [7,8]. Moreover, postoperative body weight loss is the most important risk factor associated with oral adjuvant chemotherapy compliance in gastric cancer patients undergoing curative gastrectomy, thus emphasizing the requirement for adequate perioperative nutritional intervention [9]. A poor discharge transition from the medical center to the home represents an important gap between evidence-based clinical practices and current health care delivery. For gastrectomy patients with gastrointestinal complications, some retained intra-abdominal drainage tubes are kept to monitor the leakage fluid with turbid contaminated characteristics. These drainage tubes caused patients or their families to hesitate with regard to returning home where they would be required to care for these tubes by themselves. If the intraabdominal condition were to deteriorate, the drainage fluid may become turbid (new gastrointestinal leakage) or bloody (internal bleeding), which would imply a new medical emergency. Traditionally, medical professionals have not been able to immediately access the above-described information, thus potentially delaying a diagnosis or medical help. A major challenge to medical providers is the continued provision of postoperative care at home for patients with complications. Telecare is becoming a feasible and helpful tool for perioperative patient care [10,11]. With the popularity of smartphones or tablet personal computers (tablet PCs), the methods used to accessing information have changed, which has revolutionized the original telecare concept. There is an increased interest in smartphone applications (apps) as tools with which medical professionals and patients can deliver medical information and provide care [12–15]. It has been reported that the market for mobile health apps for smartphones and tablets will reach US $26 billion by 2017 [16]. As of 2013, there are an estimated 40,000 medical apps available on the market. Previous studies have addressed the feasibility of smartphone apps for patient self-monitoring [17,18] or surgical cases [19]. However, app-facilitated perioperative care for gastrectomy patients is lacking. We hypothesized that tablet PC application for gastrectomy patients compared with traditional care would be associated
with less percentage of body weight loss, with that being associated with close follow-up and clinical rule support. To test our hypothesis, we designed one experimental pre/post single-arm study to investigate whether a 6-month intervention involving this application would contribute to a more rapid recovery after gastrectomy in gastric cancer patients (App group). The primary study outcome was the change in the percentage of body weight loss. Body weight is a reliable predictor of the general nutritional statuses of cancer subjects. Additionally, we prospectively collected age, sex, body mass index (BMI), operation method, and cancer staging-matched gastrectomy subjects during the same period to compare with the App group (Control group).
2.
Methods
2.1.
Recruitment
The participants were recruited at the National Taiwan University Hospital (NTUH) in Taipei, Taiwan. The recruitment occurred through the health care provider. The inclusion criteria were an age >20 years, gastric cancer diagnosis, and treatment via curative gastrectomy. Participants were excluded if they or their caregivers experienced difficulties with accessing the app. The study was approved by the review board at NTUH, and all participants provided signed informed consent.
2.2.
App function and development
This app was developed using the objective-C language and iOS (previously iPhone OS) 6.1 SDK (Software Development Kit; Apple, Inc., Cupertino, CA, USA), which provides compatibility for iOS 5.1 and later platforms. We designed a client/server architecture to integrate the app service. The client side is the app itself for uploading images, inputting data and viewing personal history data. The app calls mobile web services provided by a web server to upload and store the image or data on the server side for medical professionals to evaluate personal query. Additionally, the application can store data on the client side temporarily and automatically synchronize with the server-side database by calling web services implemented in the C# language in a .NET framework. A Microsoft SQL server was utilized for server data storage. In order to improve security, the target system was designed to transmit data via the https protocol and the patient’s name or personal ID was omitted. Instead, a temporary ID (the subject number) was provided by the physician to represent the patient. After keying in secret keys, only the physician is allowed access to the data transmitted by the patients on the website. Fig. 1 shows the architecture of the overall system. To provide real-time remote care, we designed and developed a platform for the patients and medical staff to permit reviews of the entire historical upload record, including weight, drainage, symptoms, and patients’ wound images. In addition, the web service would automatically send a cell phone message to medical staff when a patient uploaded a wound image. Via this service, medical professionals could immediately determine the wound condition and notify the
c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 1 9 ( 2 0 1 5 ) 101–109
103
Fig. 1 – The application system: we developed a client/server architecture to integrate the app service, including database, web, and message servers. The client side is the app itself for uploading image, inputting data and viewing the personal history data.
patient if the wound infection should be investigated. This feedback interaction led to significant improvements in the software developed for a previous trial and for our study in terms of reducing the gap between the medical staff members and patients [20]. We divided the major functions of this application into 6 interfaces: the home page, my weight, my drains, wound pictures, surgery, and symptoms. Screenshots of the tablet PC application are shown in Figs. 2–7 along with the descriptions of each major function.
2.3.
Statistical analysis
All values were expressed as means with associated standard deviations or as frequencies. The Mann–Whitney test was used to assess continuous variables, and Fisher’s exact test was used for categorical variables. Differences in body weight changes (from the baseline to 6 months) were analyzed using a paired Student’s t-test. Data analyses were performed
using SPSS software (version 22.0, 2012; SPSS Inc., Chicago, IL, USA). A 2-sided p-value of
