Medical Rehabilitation: Guidelines to Advance the Field With High-Impact Clinical Trials

The purpose of this Special Communication is to summarize guidelines and recommendations stemming from an expert panel convened by the National Institutes of Health, National Center for Medical Rehabilitation Research (NCMRR) for a workshop entitled The Future of Medical Rehabilitation Clinical Trials, held September 29-30, 2016, at the NCMRR offices in Bethesda, Maryland. The ultimate goal of both the workshop and this summary is to offer guidance on clinical trials design and operations to the medical rehabilitation research community, with the intent of maximizing the effect of future trials.     

Sex Differences in Prevalence of Emergency Department Patient Substance Use

Purpose

Substance use and misuse is prevalent in emergency department (ED) populations. While the prevalence of substance use and misuse is reported, sex-specific trends in ED populations have not been documented. We set out to determine the sex-specific prevalence of ED patient substance use during this current epidemic.

Racial and Ethnic Differences in Mental Health among Asian Americans and Non-Hispanic Whites: Based on California Health Interview Survey

While Asians are becoming the largest ethnic group in the United States, studies have focused on Asians as a single population. The purpose of this study was to explore the racial and ethnic mental health differences between non-Hispanic Whites and Asians, with an emphasis on understudied subgroups, from the California Health Interview Survey 2011/2012. In this dataset Asians had significantly lower adjusted odds ratios for both mental distress and serious mental illness. However, when Asians were divided into subgroups and compared to Whites, Vietnamese and Japanese subgroups were significantly lower than Whites for mental distress while Koreans were significantly higher. Vietnamese and Chinese were found to have significantly less serious mental illness than Whites in the subgroup analyses. Our results underscore the importance of recognizing that Asian subgroups should not be overlooked, and all Asians should not automatically be treated as a homogenous group.     

Early PREdiction of sepsis using leukocyte surface biomarkers: the ExPRES-sepsis cohort study

Purpose

Reliable biomarkers for predicting subsequent sepsis among patients with suspected acute infection are lacking. In patients presenting to emergency departments (EDs) with suspected acute infection, we aimed to evaluate the reliability and discriminant ability of 47 leukocyte biomarkers as predictors of sepsis (Sequential Organ Failure Assessment score?≥?2 at 24 h and/or 72 h following ED presentation).

Methods

In a multi-centre cohort study in four EDs and intensive care units (ICUs), we standardised flow-cytometric leukocyte biomarker measurement and compared patients with suspected acute infection (cohort-1) with two comparator cohorts: ICU patients with established sepsis (cohort-2), and ED patients without infection or systemic inflammation but requiring hospitalization (cohort-3).

Results

Between January 2014 and February 2016, we recruited 272, 59 and 75 patients to cohorts 1, 2, and 3, respectively. Of 47 leukocyte biomarkers, 14 were non-reliable, and 17 did not discriminate between the three cohorts. Discriminant analyses for predicting sepsis within cohort-1 were undertaken for eight neutrophil (cluster of differentiation antigens (CD) CD15; CD24; CD35; CD64; CD312; CD11b; CD274; CD279), seven monocyte (CD35; CD64; CD312; CD11b; HLA-DR; CD274; CD279) and a CD8 T-lymphocyte biomarker (CD279). Individually, only higher neutrophil CD279 [OR 1.78 (95% CI 1.23–2.57); P?=?0.002], higher monocyte CD279 [1.32 (1.03–1.70); P?=?0.03], and lower monocyte HLA-DR [0.73 (0.55–0.97); P?=?0.03] expression were associated with subsequent sepsis. With logistic regression the optimum biomarker combination was increased neutrophil CD24 and neutrophil CD279, and reduced monocyte HLA-DR expression, but no combination had clinically relevant predictive validity.

Conclusions

From a large panel of leukocyte biomarkers, immunosuppression biomarkers were associated with subsequent sepsis in ED patients with suspected acute infection.

Clinical trial registration

NCT02188992.

     

“I had no idea what a complicated business eating is…”: a qualitative study of the impact of dysphagia during stroke recovery

Aim: Persons with dysphagia following stroke may experience uncomfortable symptoms such as persistent coughing, choking and poor salivary management. They may also spend long periods of time unable to eat or drink or with restrictions on oral intake. Experiences of dysphagia post-stroke are richly described in unsolicited narratives such as autobiographies on the stroke event, which often include details of the author’s journey through their stroke recovery. The aim of this study is to use autobiographical accounts to explore the experiences of those living with dysphagia following stroke.

Method: Published autobiographies narrating the author’s experiences of living with dysphagia following stroke were sourced. Ten autobiographies were retrieved and the texts were manually inspected. All references to eating, drinking and swallowing were extracted and pooled to form the data set. A qualitative approach using a six-step interpretive phenomenological analysis process was taken to analyze this data set.

Results: A wide range of interconnected themes emerged from the data, allowing further synthesis into six overarching super-ordinate themes. These six super-ordinate themes were: “physical consequences of dysphagia”; “process of recovery”; “coping and adjusting”; “changed relationships”; “society” and “control”.

Conclusions: This study highlights the unique contribution of autobiographical accounts in developing our understanding of living with dysphagia following stroke. The findings emphasize the significant emotional and social impact of dysphagia during the stroke recovery process and add further depth to our understanding of the experience of this clinical group.

• Implications for Rehabilitation

• Autobiographical accounts often hold valuable first-hand information on patient perspectives and journeys, which when viewed through the eyes of a qualitative researcher, can add depth to our understanding of particular healthcare experiences.

• Persons who experience dysphagia as a result of stroke travel a complex rehabilitation journey, involving the interaction of many physical, emotional and social considerations.

• Healthcare professionals should be aware of not only the physical, but also the significant psychosocial consequences of living with dysphagia following stroke.

• Further research is required in this field, so that the experiences of these persons can be better understood and findings can be used to contribute to high-quality and evidence-based service delivery.