Speech pathologists’ experience of involving people with stroke-induced aphasia in clinical decision making during rehabilitation

Purpose: Although client participation has been part of legislation and clinical guidelines for several years, the evidence of these recommendations being implemented into clinical practice is scarce, especially for people with communication disorders. The aim of this study was to investigate how speech pathologists experienced client participation during the process of goal-setting and clinical decision making for people with aphasia. Methods: Twenty speech pathologists participated in four focus group interviews. A qualitative analysis using Systematic Text Condensation was undertaken. Results: Analysis revealed three different approaches to client participation: (1) client-oriented, (2) next of kin-oriented and (3) professional-oriented participation. Participants perceived client-oriented participation as the gold standard. The three approaches were described as overlapping, with each having individual characteristics incorporating different facilitators and barriers. Conclusions: There is a need for greater emphasis on how to involve people with severe aphasia in goal setting and treatment planning, and frameworks made to enhance collaboration could preferably be used. Participants reported use of next of kin as proxies in goal-setting and clinical decision making for people with moderate-to-severe aphasia, indicating the need for awareness towards maintaining the clients’ autonomy and addressing the goals of next of kin.

• Implications for Rehabilitation

• Speech pathologists, and most likely other professionals, should place greater emphasis on client participation to ensure active involvement of people with severe aphasia.

• To achieve this, existing tools and techniques made to enhance collaborative goal setting and clinical decision making have to be better incorporated into clinical rehabilitation practice.

• To ensure the autonomy of the person with aphasia, as well as to respect next of kin's own goals, professionals need to make ethical considerations when next of kin are used as proxies in collaborative goal setting and clinical decision making.

     

Speech pathology services for people with aphasia: what is the current practice in Singapore?

Abstract

Purpose: This study reports on current provision of aphasia services by speech pathologists in Singapore. Method: A 44-item web-based survey was conducted looking into areas of service delivery, assessment, cultural and linguistic adaptations, clinical approaches, education of clients, recovery, goal setting and discharge as well as scope and challenges to practice. Results: A total of 36 surveys were completed representing approximately 86% of the potential target population. The intensity of aphasia services provided was well below that recommended by the literature. Participants reported embracing approaches to aphasia rehabilitation that spanned across the ICF domains. Numerous challenges were reported in providing aphasia services. These included the lack of locally relevant resources for aphasia, lack of family support and patient motivation, manpower shortages as well as barriers such as transport and cost restricting access to services. Conclusions: This research reveals several findings with considerable implications for practice planning and future direction in aphasia rehabilitation. There is a need for the development of locally relevant aphasia resources to enable comprehensive provision of aphasia services. In addition, further investigation is required to tackle the resource challenges faced by the profession and improve community support for people with aphasia.

• Implications for Rehabilitation

• Speech pathology services for aphasia in Singapore

• This article has identified the challenges of providing aphasia services in the Singapore context.

• Further investigation is required to address the key issues to improve aphasia services in Singapore.

• This includes developing locally relevant resources, looking at means like telerehabilition to tackle resource challenges, and improving community support for people with aphasia.

     

Registered nurses’ preferences for rural and urban jobs: A discrete choice experiment

BackgroundRecruitment and retention of nurses is an ongoing challenge for employers in rural areas worldwide. There is limited information available regarding influences on nurses’ job choice in the U.S. and little understanding of how nurses make trade-offs between desired and less desirable job characteristics when choosing between jobs.ObjectivesThe purpose of this research was to examine the hospital job preferences of registered nurses in the U.S. The specific objectives of the study were: 1) To identify the relative importance of key job attributes on registered nurse job choice, and 2) To predict the impact of changes in the levels of attributes on the probability of registered nurses choosing one job over another.Design and SettingA discrete choice experiment was developed and applied in the U.S. using California as a study site.Participants190 registered nurses currently working in nursing or intending to return to work in nursing from urban, large-, small- and isolated-rural communities.MethodsThe survey instrument was developed through a literature review and semi-structured interviews with nurse experts, utilizing a hypothetical job in a hospital medical / surgical unit. Experimental design principles were applied to create a discrete choice experiment which was pilot tested with urban and rural nurses. The survey was mailed to a random sample of 1000 licensed registered nurses in California. A mixed logit model was used to estimate nurses’ preferences for different levels of the job attributes. Willingness to pay estimates and simulations of job uptake rates were calculated.ResultsEight factors were identified as important to job choice: earnings, nursing voice in management, tuition reimbursement, scheduling, patient care team, leadership, location and nursing sensitive patient care outcomes. Respondents valued a cohesive patient care team (coefficient 1.95, [SE 0.23]) and a strong nursing voice in management (coefficient 1.56, [SE 0.22]) highest. A job in a large urban inland location was negatively valued (coefficient -0.69, [SE 0.25]). Around 72% of respondents chose to stay in their current job when this choice was offered. While earnings were important, nurses were willing to sacrifice earnings to secure other valued job characteristics when choosing between jobs.ConclusionsStudy findings provide information on how job characteristics are valued by nurses in California. Findings suggest job seekers may be 65–75 percent more likely to choose a job when valued job characteristics are present. Our findings are particularly relevant to rural hospitals with limited financial resources.     

Postoperative diarrhea in Crohn’s disease: Pathogenesis,diagnosis, and therapy

Diarrhea is a frequent symptom in postoperative patients with Crohn’s diseases (CD), and several different mechanisms likely account for postoperative diarrhea in CD. A targeted strategy based on a comprehensive understanding of postoperative diarrhea is helpful for better postoperative recovery.     

Subarachnoid techniques for cancer pain therapy: When, why, and how?

For cancer patients who obtain inadequate pain relief with conservative treatment, there is a growing list of effective options for subarachnoid therapy. Morphine and bupivacaine have been the most frequently used drugs for intrathecal infusion, and their use has consistently yielded good results. Despite their effectiveness, however, a therapeutic deficit remains, primarily in the treatment of neuropathic cancer pain. Because of this limitation, more recent research has focused on novel compounds for intrathecal therapy such as clonidine, midazolam, ketamine, and SNX-111. In addition to new drug options, there are various catheter delivery systems from which to choose. In reviewing the literature and experience to date with these various medications and delivery systems, we hope to better aid the clinician in tailoring the best treatment for each patient.     

Resounding attachment: cancer inpatients’ song lyrics for their children in music therapy

Goals of work  Scant attention focuses on supporting parent–child communication during the parents’ cancer hospitalizations. Parents may struggle to remain emotionally available. Caregiver absences may threaten secure attachment relationships with infants and elicit problems amongst older children. Music therapists help many parents with cancer to compose songs for their children. Their lyric analysis may provide insight into song writing’s communicative and therapeutic potential. Materials and methods  Two song lyric groups were comparatively analyzed (based on grounded theory). One group included 19 songs written by 12 patients with the first author. Another included 16 songs written by 15 patients with three music therapists (including two authors), which were previously published or recorded for the public. Songs were composed by 20 mothers and seven fathers for at least 46 offspring. All parents had hematological or metastatic diseases. Qualitative inter-rater reliability was integrated. Main results  Comparable lyrical ideas in the two parent song groups included: love; memories; yearning for children; metaphysical presence (now and afterlife); loss and grief; the meaning and helpfulness of the children in their lives; hopes for and compliments about their children; encouragement; requests; personal reflections; existential beliefs; and suggestions about to whom the children can turn. Conclusions  Parents’ song lyric messages may support their children during the parents’ illnesses and through the children’s developmental transitions and possible bereavement. Some parents use song writing for catharsis and to encourage their children’s continuing attachment with them after death. Through promoting parent–child connectedness and emotional expression, therapeutic song writing can be a valuable oncologic supportive care modality.

“In the physio we trust”: A qualitative study on patients’ preferences for physiotherapy

Background: Patients’ preferences should be integrated in evidence-based practice. This study aimed to explore patients’ preferences for physiotherapy treatment and participation in decision making. Methods: A qualitative study set in an urban physiotherapy clinic in Gothenburg, Sweden. Individual, semi-structured interviews were conducted with 20 individuals who sought physiotherapy for musculoskeletal disorders. The interviews were recorded, transcribed, and analyzed with qualitative content analysis. Results: An overarching theme, embracing six categories, was conceptualized: Trust in the physiotherapist fosters active engagement in therapy. The participants preferred active treatment strategies such as exercise and advice for self-management, allowing them to actively engage in their therapy. Some preferred passive treatments. Key influencers on treatment preferences were previous experiences and media. All participants wanted to be involved in the clinical decision making, but to varying extents. Some expressed a preference for an active role and wanting to share decisions while others were content with a passive role. Expectations for a professional management were reflected in trust and confidence in physiotherapists’ skills and competence, expectations for good outcomes, and believing that treatment methods should be evidence-based. Conclusion: Trust in the physiotherapist’s competence, as well as a desire to participate in clinical decision making, fosters active engagement in physiotherapy.     

Long-term plasma exchange as maintenance therapy for cerebellar-type Hashimoto’s encephalopathy,a case report

Hashimoto’s encephalopathy (HE) is a presumed autoimmune disorder associated with anti-thyroid autoantibodies and signs and symptoms of encephalopathy. A sub-type of HE is associated with cerebellar dysfunction and ataxia. Immunosuppressive therapy, particularly corticosteroid treatment, is utilized in the majority of cases. Short-term apheresis has been reported with variable patient responses. Here we report the case of a 72?year-old female with an ～15?year history of cerebellar type HE that had profound improvement in symptoms after long-term apheresis treatment over an ～2?year period. Following an induction phase, twice-weekly maintenance apheresis of 1 plasma volume reversed long-standing severe gait ataxia that had required a walker, as well as mild cognitive symptoms. This paralleled reductions in anti-thyroid antibody levels. Holidays from apheresis lasting several weeks and/or reductions in maintenance apheresis frequency to once per-week resulted in re-expression of ataxia and cognitive impairments along with a rise in anti-thyroid antibody levels. An apheresis dose-effect was observed whereby parallel rise and fall in both symptomatology and antibody levels would mirror duration between apheresis intervals. To our knowledge, this is the first report of profound therapeutic benefit and a dose-response relationship to long-term apheresis in cerebellar-type HE. This case suggests that maintenance apheresis be considered in responsive patients, particularly in those with contraindications to medical immunosuppression.     

Acid-base status is an important factor for inflammation,but don’t forget CO2!

Zampieri and colleagues used sophisticated statistical methods to create a picture of acid-base pattern and inflammation relationship in a clinical context. The observed independent relationship between acidosis and albumin concentration and inflammatory pattern opens up a new area for research. It has become clear that, in addition to the characterization of mediators, receptors, and cellular phenotypes, the inflammatory response has to be interpreted in light of acid-base status, albumin concentration, and probably also carbon dioxide level.Until now, the interplay between acid-base status and inflammation has received little attention, especially in a clinical context. The article by Zampieri and colleagues [1] in a previous issue of Critical Care is a pioneering study analyzing the relationship between acidosis variables, inflammatory mediators, and end-organ failures (acute kidney injury and shock). Since the metabolic and inflammatory reactions are simultaneous, the demonstration of interplay that is more than a simultaneous modification remains a difficult challenge. Because of this, the authors used three different statistical methods to separate the confounding factors. First, they developed a generalized linear model using the measured mediator as a dependent variable and components of acid-base status as variables. Second, they performed a multivariate adaptive regression with splines in order to evaluate the association of selected cytokines and acid-base components. Third, they performed a principal component analysis using Simplified Acute Physiology Score 3 as a way of quantifying illness severity in order to assess the independent association of acid-base variables and cytokine levels. The authors found that, in 87 prospective unselected patients, the level of strong anion gap (SIG) was positively associated with TNFα and IL-6, IL-8, and IL-10. A negative association was found between albumin level and TNFα and IL-6, IL-7, IL-8, and IL-10 and IFNγ. The conclusion drawn from these results opens up a new route for research to understand the mechanisms that link acid-base variables, albumin level, and immunological activation.Such a topic is important and clinically relevant since plasma and interstitial fluid constitute the microenvironment for immune and tissue cells. Acid-base and albumin characteristics may then interfere with the cell response to different signals such as endotoxin. In addition, both fluid resuscitation and capillary leak may largely influence the composition of the cell microenvironment, especially when a crystalloid such as saline or a balanced crystalloid such as Ringer’s lactate is used. The role of surrounding cell pH could be seen as a result of metabolic acidosis and carbon dioxide (CO₂) level, an aspect that was not investigated in the study [2,3]. Given the picture presented in this article, some approaches might be tested to clarify the mechanisms involved in immune modifications induced by acid-base changes. First, immune cells should be drawn from septic patients that have been incubated in the septic plasma or drawn after replacement of septic plasma by healthy plasma; both acid-base conditions or albumin concentration can then be modified to test their impact on immune cells phenotype. This might help to clarify how the pH, the SIG, and albumin concentration change the immune cell phenotypes. Second, similar experiments with healthy cells incubated in plasma from acutely injured patients could be performed to demonstrate the role of physicochemical plasma patterns. Mediators and cell functions then could be evaluated in different acid-base conditions. Until now, few data on alkalosis have been reported in terms of immunity, and the essential information comes from acidosis situations. One author of the study was part of a group [4] that showed that metabolic acidosis induced by hydrochloric acid and lactic acidosis added to culture media of RAW 264.7 cells have opposite effects: hydrochloric acid at a pH of 7 seems essentially pro-inflammatory (nitric oxide level, IL-6/IL-10 ratio, NF-κB DNA binding), whereas lactic acidosis is essentially anti-inflammatory. A group with the same author, using a rat model, confirmed these results in terms of systemic cytokines [5]. In that study, the authors found a positive relationship between SIG and IL-6, IL-8, and IL-10 and TNFα, which was independent of illness severity. Even though albumin was not administered in the presented cohort, it can be discussed in light of immune effects. The authors observed a negative correlation between albumin level and IL-6, IL-8, IL-10, monocyte chemoattractant protein-1 and IFNγ. In addition to its complex effects, albumin was shown to be immunosuppressive for peripheral blood monocytes (IFNγ and TNFα) and also for T lymphocyte clone [6], which confirmed the presented results. Except for specific indications, albumin is not recommended for use in fluid resuscitation, especially after the recent negative results of a randomized clinical trial [7]. Third, the role of hypo- or hypercarbia has to be investigated since elevated CO₂ was shown to modulate mammalian inflammatory and innate immune responses in vitro and in vivo [3], independently of extra- and intra-cellular pH. During a sterile insult of inflammation stimulation, hypercapnia may be of benefit but would be deleterious in the setting of infection due to host immunosuppression. The underlying mechanism implicates the NF-κB signaling pathway as an important hub of CO₂ sensitivity [3,8]. This, in combination with the ability of elevated CO₂ to enhance bacterial and fungal virulence and survival, suggests that hypercapnia may predispose humans to infections or worsen outcomes [3]. Understanding the involved molecular signaling pathways will be of great importance in the identification of new approaches to control infection and inflammation in the clinical setting.