Exploring experiences of people with stroke and health professionals on post-stroke fatigue guidance: getting the right people to the right care at the right time

PURPOSE

This focus group study aimed to explore experiences and perceptions on post-stroke fatigue guidance in Dutch rehabilitation and follow-up care among people/patients with stroke and health professionals.

METHODS

Ten persons with stroke and twelve health professionals with different professions within stroke rehabilitation or follow-up care in the Netherlands were purposively sampled and included. Eight online focus group interviews were conducted. We analysed the data using reflexive thematic analysis.

RESULTS

Three themes were identified. Guidance in fatigue management did not always match the needs of people/patients with stroke. Professionals were positive about the provided fatigue guidance (e.g. advice on activity pacing), but found it could be better tailored to the situation of people/patients with stroke. Professionals believe the right time for post-stroke fatigue guidance is when people/patients with stroke are motivated to change physical activity behaviour to manage fatigue - mostly several months after stroke - while people/patients with stroke preferred information on post-stroke fatigue well before discharge. Follow-up care and suggestions for improvement described that follow-up support after rehabilitation by a stroke coach is not implemented nationwide, while people/patients with stroke and professionals expressed a need for it.

CONCLUSIONS

The study findings will help guide improvement of fatigue guidance in stroke rehabilitation programmes and stroke follow-up care aiming to improve physical activity, functioning, participation, and health.

Maternal blood pressure associates with placental DNA methylation both directly and through alterations in cell-type composition

BACKGROUND

Maternal blood pressure levels reflect cardiovascular adaptation to pregnancy and proper maternal-fetal exchanges through the placenta and are very sensitive to numerous environmental stressors. Maternal hypertension during pregnancy has been associated with impaired placental functions and with an increased risk for children to suffer from cardiovascular and respiratory diseases later on. Investigating changes in placental DNA methylation levels and cell-type composition in association with maternal blood pressure could help elucidate its relationships with placental and fetal development.

METHODS

Taking advantage of a large cohort of 666 participants, we investigated the association between epigenome-wide DNA methylation patterns in the placenta, measured using the Infinium HumanMethylation450 BeadChip, placental cell-type composition, estimated in silico, and repeated measurements of maternal steady and pulsatile blood pressure indicators during pregnancy.

RESULTS

At the site-specific level, no significant association was found between maternal blood pressure and DNA methylation levels after correction for multiple testing (false discovery rate < 0.05), but 5 out of 24 previously found CpG associations were replicated (p-value < 0.05). At the regional level, our analyses highlighted 64 differentially methylated regions significantly associated with at least one blood pressure component, including 35 regions associated with mean arterial pressure levels during late pregnancy. These regions were found enriched for genes implicated in lung development and diseases. Further mediation analyses show that a significant part of the association between steady blood pressure-but not pulsatile pressure-and placental methylation can be explained by alterations in placental cell-type composition. In particular, elevated blood pressure levels are associated with a decrease in the ratio between mesenchymal stromal cells and syncytiotrophoblasts, even in the absence of preeclampsia.

CONCLUSIONS

This study provides the first evidence that the association between maternal steady blood pressure during pregnancy and placental DNA methylation is both direct and partly explained by changes in cell-type composition. These results could hint at molecular mechanisms linking maternal hypertension to lung development and early origins of childhood respiratory problems and at the importance of controlling maternal blood pressure during pregnancy.

A systematic review on ethical challenges of 'field' research in low-income and middle-income countries: respect, justice and beneficence for research staff?

Introduction

Primary data collection in low-income and middle-income countries (LMICs) is associated with a range of ethical complexities. Considerations on how to adequately ensure the well-being of research staff are largely neglected in contemporary ethics discourse. This systematic review aims to identify the ethical challenges that research staff across different hierarchical levels and scientific disciplines face when conducting research in LMICs.

Methods

We searched 13 electronic databases and handsearched publications in six selected journals as well as the reference lists of all included studies. No restrictions were applied with respect to the publication date, research design, and target population.

Results

23 151 studies were retrieved, 183 of which met our inclusion criteria. We identified nine different types of ethical challenges that research staff may be exposed to during field research, including (1) role conflicts that can emerge from participants’ help requests and the high level of deprivation found in certain study settings, (2) feelings of guilt and (3) detrimental mental health impacts. Further challenges were (4) sexual harassment (5) safety risks and (6) political repression, particularly in postconflict, disaster-ridden or autocratic study contexts. Additionally, studies reported (7) inadequate working conditions and (8) power imbalances within research teams, while (9) ethics boards were found to be ill equipped to anticipate and address emerging risks, thus increasing the ethical liability of researchers.

Conclusion

This review revealed several complex ethical challenges that research staff may face during data collection. In order to achieve the Sustainable Development Goal 8.8 on ‘safe and secure working environments’ and to protect research staff from harm, amendments must urgently be made to current ethical standards.

PROSPERO registration number

CRD42019131013

Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: a preliminary report

We investigated the role of a functional brace worn for four months in the treatment of patients with an acute isolated tear of the posterior cruciate ligament to determine whether reduction of the posterior tibial translation during the healing period would give an improved final position of the tibia. The initial and follow-up stability was tested by Rolimeter arthrometry and radiography. The clinical outcome was evaluated using the Lysholm score, the Tegner score and the International Knee Documentation Committee scoring system at follow-up at one and two years. In all, 21 patients were studied, 21 of whom had completed one-year and 17 a two-year follow-up. The initial mean posterior sag (Rolimeter measurement) of 7.1 mm (5 to 10) was significantly reduced after 12 months to a mean of 2.3 mm (0 to 6, p < 0.001) and to a mean of 3.2 mm (2 to 7, p = 0.001) after 24 months. Radiological measurement gave similar results. The mean pre-injury Lysholm score was normal at 98 (95 to 100). At follow-up, a slight decrease in the mean values was observed to 94.0 (79 to 100, p = 0.001) at one year and 94.0 (88 to 100, p = 0.027, at two years). We concluded that the posterior cruciate ligament has an intrinsic healing capacity and, if the posteriorly translated tibia is reduced to a physiological position, it can heal with less attentuation. The applied treatment produces a good to excellent functional result.

[Closing wedge osteotomy of the tibial head in treatment of single compartment arthrosis]

Closing wedge high tibial osteotomy is an efficient method for the treatment of medial osteoarthritis of the knee. Prerequisites of successful surgery are proper indication and planning as well as the understanding of biomechanics and pathophysiology. The technique of osteotomy to choose (opening or closing wedge) depends on the type of malalignment and on additional pathologies. The surgical technique demands high precision to realize the planned correction and to avoid complications. Implants with angular stability provide advantages compared to traditional implants. Correct indication and surgical technique results in a desirable follow-up, which often lasts for at least 10 years. The effect on the prognosis of the young patient with cartilage damage is still unclear.

Retrospective evaluation of cardiopulmonary and acid-base variables during long-term balanced anesthesia for experimental surgery in dogs

Cardiopulmonary and acid-base variables recorded during long-term balanced anesthesia lasting between 12.5 and 16.9 h were evaluated retrospectively in 15 healthy foxhounds that underwent experimental bulla osteotomy with implantation of hearing aids. After premedication with propionylpromazine (0.11 +/- 0.02 mg/kg of body weight) and L-methadone (0.71 +/- 0.06 mg/kg) intravenously (i.v.) and induction with pentobarbital sodium (6.02 +/- 0.83 mg/kg i.v.), anesthesia was maintained with halothane (end-tidal concentration; ETHAL: 0.4 to 1.5%) in nitrous oxide (2 L/min) and oxygen (1 L/min). Because of positional changes from sternal to right lateral recumbency after presurgical brain stem electric response audiometry and differences in duration of surgery, data obtained between 4 (baseline) and 14 h after induction of anesthesia were analyzed. Arterial (PaO2) and alveolar (PAO2) O2 tensions, arterial-to-alveolar O2 tension ratio (PaO2/PAO2), and arterial O2 content (CaO2) remained relatively stable throughout anesthesia. Arterial carbon dioxide tension (PaCO2) was significantly increased above baseline (39, 33 to 46 mm Hg [median, range]) between 7 (39.8, 36.5 to 48.9 mm Hg) and 9 (42, 37.5 to 49.5 mm Hg) h after induction. Because changes in PaCO2 were accompanied by significant increases in body temperature from baseline (36.3, 34.6 to 37.4 degrees C) between 8 (37.1, 35 to 38 degrees C) and 11 (37.6, 35.3 to 38.1 degrees C) h after anesthesia induction as well as by slight increases in arterial blood pressure, the PaCO2 increase may have been caused by increase in metabolic CO2 production and enhanced drainage of CO2 from the tissues into systemic circulation. Furthermore, mild metabolic acidosis (pHa: 7.31, 7.26 to 7.38; HCO3-: 18.9, 16.7 to 21.8 mEq/L; base deficit [BD]: -6.3, -8.5 to -3.4 mEq/L) already existed at 4 h after induction and was related in part to tissue hypoperfusion. Small increases in pHa during the course of anesthesia were accompanied by significant increases in HCO3- concentration and significant decreases in BD between 5 and 10 h after induction. Minor circumscribed swelling of the dependent triceps or masseter muscle was noticed on the first postoperative day in two dogs, and marked tissue swelling with hematoma formation at the medial side of one hind limb was noticed in a third dog. All dogs recovered completely and were submitted to follow-up studies. The anesthetic protocol and extent of monitoring used were adequate to provide safe long-term anesthesia for an experimental surgical procedure with a 100% survival rate and uneventful recovery in most of the dogs.

Acute plasmapheresis during cardiac surgery: volume replacement by crystalloids versus colloids

Acute plasmapheresis (APP) is an additional tool for blood conservation during cardiac surgery. In a randomized study of 60 aortocoronary bypass patients undergoing APP, the influence of replacement of the withdrawn autologous plasma (10 mL/kg) by either colloids (low molecular weight hydroxyethyl starch solution [6% HES 200/0.5]) or crystalloids (Ringer's solution) was investigated. APP was performed by means of a centrifugation technique producing platelet-poor plasma. During and after cardiopulmonary bypass (CPB), either a cell saver (CS) or a hemofiltration (HF) device was also used for blood concentration. Almost three times as much crystalloid as HES solution was necessary for replacement of autologous plasma. Fluid balance during CPB was significantly more positive in the crystalloid patients, particularly when a CS was used. Blood loss was highest in the crystalloid patients in whom a CS was used in addition to APP, and these were the only patients who needed packed red cells. The platelet count, AT-III and fibrinogen plasma concentrations, colloid osmotic pressure, albumin, and total protein were significantly less compromised in the patients with colloid volume replacement. These parameters were closest to control values in patients receiving colloid replacement and HF. It is concluded that colloid is preferred for replacement of autologous plasma withdrawn by APP, and HF is superior to the CS when the combined technique for blood conservation is used.

RETRACTED: Acute preoperative plasmapheresis and established blood conservation techniques

Plasmapheresis performed weeks before an operation producing autologous plasma has proved to be of benefit in elective operations. First experiences in acute plasmapheresis, which is performed immediately before the operation, have been reported recently. When acute plasmapheresis is used in cardiac operations, however, it must be viewed in connection with other techniques for reducing blood consumption such as the Cell Saver (CS) and ultrafiltration devices. In 60 patients undergoing elective aortocoronary bypass grafting, acute plasmapheresis was performed, producing either platelet-poor plasma or platelet-rich plasma, in combination with either the Cell Saver or hemofiltration. Fluid balance during cardiopulmonary bypass was significantly lower in the hemofiltration patients. Postoperatively, none of these patients received donor blood, whereas 4 patients of the Cell-Saver groups needed packed red blood cells. AT-III, fibrinogen, the number of platelets, albumin, total protein, and colloid osmotic pressure were less compromised when hemofiltration was used in combination with acute plasmapheresis in contrast to combination with the Cell-Saver technique. Plasma hemoglobin was without differences during the investigation period, and polymorphonuclear elastase was less increased when platelet-rich plasma was produced preoperatively. On the first postoperative day, most of the differences between the groups had already disappeared. We conclude that when acute plasmapheresis is used in cardiac operations, discarding of plasma by the Cell Saver should be avoided and ultrafiltration devices should replace centrifugation techniques for blood conservation.