Emotional adjustment post-stroke: A qualitative study of an online stroke community.

Understanding of emotional adjustment after stroke is limited. Under one-third of stroke survivors reporting emotional problems receive support. The aim of this study was to explore the process of emotional adjustment post-stroke and investigate the role played by participation in an online stroke community. We applied thematic analysis to 124 relevant posts within 114 discussion threads, written by 39 survivors and 29 carers. The contribution of online community engagement to emotional adjustment was explored using the Social Support Behaviour Code. Stroke survivors share common experiences of emotional adjustment and may not necessarily reach complete acceptance. Positive and negative trajectories of emotional adjustment were identified. Survivors progressed along, or moved between, positive and negative pathways not in a time-dependent manner but in response to "trigger events," such as physical setbacks or anti-depressant treatment, which may occur at any chronological time. An adapted version of Suhr's 1990 Social Support Behaviour Code showed that support provided through the online community took many forms, including advice, teaching, empathy and normalization of concerns. Participation in the stroke community was itself deemed to be a positive "trigger event." There is need to improve awareness of emotional adjustment and their "triggers" amongst stroke survivors, carers and clinicians.

Vaccine uptake in the Irish Travelling community: an audit of general practice records.

Background: Compared to the general population, the Traveller community has substantial health inequalities. Vaccination coverage in Traveller children is estimated to be low and Travellers are at higher risk of vaccine-preventable diseases due to their social circumstances. Methods: Audit of vaccination history of Traveller (n = 214) and non-Traveller (n = 776) children registered at a general practice in England. The Green Book childhood immunization schedule was used as a reference standard. Results: There was significantly lower coverage for Traveller children compared to non-Traveller children for all vaccinations in the routine childhood immunization schedule. The percentage of children completing the schedule at all time points was significantly lower in the Traveller community. Conclusions: Traveller communities have significantly lower uptake of vaccinations, and therefore Travellers' children should be targeted by general practitioners for catch-up vaccination to improve outcomes for individuals and local herd immunity.

Promoting dietary diversity to improve child growth in less-resourced rural settings in Uganda.

BACKGROUND: Analyses of global trends indicate that childhood undernutrition is more prevalent in rural areas, and also that maternal education and decision-making power are among the key factors significantly associated with child growth. METHODS: The present study comprised a controlled longitudinal study aiming to assess the effectiveness of nutrition education with respect to improving growth patterns of young children of less-literate, low income caregivers in a rural subsistence farming community. Caregivers in the intervention group (n = 52) attended a structured nutrition education programme, whereas the control group (n = 45) participated in sewing classes. Weights and lengths/heights were measured for children in the intervention and control groups every month for 1 year to assess changes in growth patterns. Repeated measures analysis of covariance was used to access differences between the two groups over time and across age groups. Variability in growth patterns of individual children and clustering of caregiver effects were controlled for during the statistical analysis. RESULTS: After 12 months, children in the intervention group had significant improvements in weight-for-age compared to the controls [mean (SD): 0.61 (0.15) versus -0.99 (0.16), P = 0.038]. Changes in height-for-age, weight-for-height and mid-upper arm circumference-for-age showed a positive trend for children in the intervention group. Changes in weight-for-height were statistically significant across age groups and negatively related to caregiver's age. CONCLUSIONS: Educating caregivers has the potential to improve young children's nutritional status and growth, especially among less literate populations where households subsist on what they produce.

The cost-effectiveness of supervised exercise for the treatment of intermittent claudication.

BACKGROUND: Supervised exercise (SE) is thought to result in improvements in walking distance and quality of life compared with unsupervised exercise (USE) in people with intermittent claudication. However, the cost-effectiveness of SE is unclear. As a result, many patients are currently unable to access supervised programmes. METHODS: We searched MEDLINE, Embase, Cochrane, and Cinahl databases to identify randomised controlled trials comparing USE with SE in adults with intermittent claudication. A Markov model was developed to estimate costs and quality adjusted life years (QALYs) from an NHS and personal social services perspective. Quality of life was obtained from the included clinical trials. Resource use was modelled on current programmes and unit costs were based on published sources. RESULTS: Depending on estimated rates of compliance, SE was cost-effective in over 75% of model simulations, with an incremental cost-effectiveness ratio of £711 to £1,608 per QALY gained. The model was sensitive to long-term effects of exercise on cardiovascular risk and quality of life. CONCLUSIONS: SE is more cost-effective than USE for the treatment of people with intermittent claudication. Supervised programmes should be made widely available and offered as a first line treatment to people with intermittent claudication.

The feasibility of a self-management programme (My Life After Stroke; MLAS) for stroke survivors.

PURPOSE: An evidence-based, theory-driven self-management programme "My Life After Stroke" (MLAS) was developed to address the longer-term unmet needs of stroke survivors.This study's aim was to test the acceptability and feasibility of MLAS as well as exploring what outcomes measures to include as part of further testing. METHODS: Stroke registers in four GP practices across Leicester and Cambridge were screened, invite letters sent to eligible stroke survivors and written, informed consent gained. Questionnaires including Southampton Stroke Self-Management Questionnaire (SSSMQ) were completed before and after MLAS.Participants (and carers) attended MLAS (consisting of two individual appointments and four group sessions) over nine weeks, delivered by two trained facilitators. Feedback was gained from participants (after the final group session and final individual appointment) and facilitators. RESULTS: Seventeen of 36 interested stroke survivors participated alongside seven associated carers. 15/17 completed the programme and attendance ranged from 13-17 per session. A positive change of 3.5 of the SSSMQ was observed. Positive feedback was gained from facilitators and 14/15 participants recommended MLAS (one did not respond). CONCLUSIONS: MLAS was a feasible self-management programme for stroke survivors and warrants further testing as part of the Improving Primary Care After Stroke (IPCAS) cluster randomised controlled trial.IMPLICATIONS FOR REHABILITATIONMy Life After Stroke is a self-management programme developed for stroke survivors living in the community.MLAS is feasible and acceptable to stroke survivors.MLAS could be considered to help address the unmet educational and psychological needs of stroke survivors.

Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice.

BACKGROUND: Recommendations for the management of low back pain in primary care emphasise the importance of recognising and addressing psychosocial factors at an early stage. We compared the effectiveness of a brief pain-management programme with physiotherapy incorporating manual therapy for the reduction of disability at 12 months in patients consulting primary care with subacute low back pain. METHODS: For this pragmatic, multicentre, randomised clinical trial, eligible participants consulted primary care with non-specific low back pain of less than 12 weeks' duration. They were randomly assigned either a programme of pain management (n=201) or manual therapy (n=201). The primary outcome was change in the score on the Roland and Morris disability questionnaire at 12 months. Analysis was by intention to treat. FINDINGS: Of 544 patients assessed for eligibility, 402 were recruited (mean age 40.6 years) and 329 (82%) reached 12-month follow-up. Mean disability scores were 13.8 (SD 4.8) for the pain-management group and 13.3 (4.9) for the manual-therapy group. The mean decreases in disability scores were 8.8 (6.4) and 8.8 (6.1) at 12 months (difference 0 [95% CI -1.3 to 1.4], p=0.99), and median numbers of physiotherapy visits per patient were three (IQR one to five) and four (two to five), respectively (p=0.001). One adverse reaction (an exacerbation of pain after the initial assessment) was recorded. INTERPRETATION: Brief pain management techniques delivered by appropriately trained clinicians offer an alternative to physiotherapy incorporating manual therapy and could provide a more efficient first-line approach for management of non-specific subacute low back pain in primary care.

Understanding stroke survivors' and informal carers' experiences of and need for primary care and community health services--a systematic review of the qualitative literature: protocol.

INTRODUCTION: Despite the rising prevalence of stroke, no comprehensive model of postacute stroke care exists. Research on stroke has focused on acute care and early supported discharge, with less attention dedicated to longer term support in the community. Likewise, relatively little research has focused on long-term support for informal carers. This review aims to synthesise and appraise extant qualitative evidence on: (1) long-term healthcare needs of stroke survivors and informal carers, and (2) their experiences of primary care and community health services. The review will inform the development of a primary care model for stroke survivors and informal carers. METHODS AND ANALYSIS: We will systematically search 4 databases: MEDLINE, EMBASE, PsycINFO and CINAHL for published qualitative evidence on the needs and experiences of stroke survivors and informal carers of postacute care delivered by primary care and community health services. Additional searches of reference lists and citation indices will be conducted. The quality of articles will be assessed by 2 independent reviewers using a Critical Appraisal Skills Programme (CASP) checklist. Disagreements will be resolved through discussion or third party adjudication. Meta-ethnography will be used to synthesise the literature based on first-order, second-order and third-order constructs. We will construct a theoretical model of stroke survivors' and informal carers' experiences of primary care and community health services. ETHICS AND DISSEMINATION: The results of the systematic review will be disseminated via publication in a peer-reviewed journal and presented at a relevant conference. The study does not require ethical approval as no patient identifiable data will be used.

Treatment of Disseminated Aspergillosis with Posaconazole in 10 Dogs.

BACKGROUND: Few effective treatments for disseminated Aspergillus infections in dogs are available. Posaconazole has potent and broad-spectrum activity against Aspergillus spp., but its use has not yet been sufficiently evaluated in dogs. HYPOTHESIS/OBJECTIVES: The aim of this study was to determine the safety and efficacy of posaconazole for the treatment of naturally occurring disseminated Aspergillus infections in dogs. ANIMALS: Ten client-owned dogs with disseminated aspergillosis. METHODS: Prospective, nonrandomized, noncontrolled study with posaconazole administered to dogs at dosage of 5 mg/kg p.o. q12h. The primary veterinarian or the veterinary specialist caring for the dogs provided patient data. RESULTS: The treatment response for dogs with disseminated disease while receiving posaconazole was defined as clinical remission (n = 4) and clinical improvement (n = 6). There was a high rate of relapse during treatment or after cessation of treatment in both groups, and most dogs died or were euthanized due to progressive disease. Excluding 1 dog concurrently treated with terbinafine that remains alive 5 years after diagnosis, the mean survival time for dogs was 241 days (range 44-516 days). Three other dogs lived >1 year after starting treatment. No clinically relevant adverse events or increases in serum liver enzyme activity occurred during treatment with posaconazole. CONCLUSIONS AND CLINICAL IMPORTANCE: Posaconazole appears to be safe and well-tolerated for treatment of disseminated Aspergillus infections in dogs. Long-term survival >1 year is possible with prolonged treatment, but relapse is common.

Patient reactions to nutrition education for cholesterol reduction.

The purpose of this study was to assess the perceptions of patients with elevated cholesterol who participated in a physicians' office-based cholesterol management program and to compare patient reports with clinic counseling records. We conducted telephone interviews with 94 patients from five family practice clinics participating in the Physician-Based Nutrition Program (PBNP) between January and March 1988. Within two weeks after a cholesterol counseling visit, interviewers asked patients what happened during the cholesterol management process, queried their understanding of their health risk and recommended dietary changes, and assessed their attitudes toward the educational process and recommended nutrition behavior changes. Results indicate that a large majority of patients understood the problem of high cholesterol and the needed behavior changes and were highly satisfied with the cholesterol management process. However, patients' memory of specific facts, such as their cholesterol levels and behavioral goals, was often incorrect. We discuss the implications of these findings for developing and providing patient cholesterol education.

Hypertension prevention through nutrition education in youth: a school-based program involving parents.

One approach to the prevention of high blood pressure may be the reduction of sodium intake early in life. To test the effect of nutrition education for salt use in third-grade students (ages 7 to 9), three teaching programs involving a classroom curriculum, a home-based curriculum, or the combination were compared to a control group. Thirty-one schools with 1,839 students were included. Measurements were made at the beginning and end of the school year. Participation rates exceeded 90% for school-based programs and 80% for those at home. Knowledge about salt increased significantly, with the classroom program showing the largest gains. However, reported salting behavior and sodium measured by 24-hr recall and overnight urines failed to show consistent and significant differences between treatments. Further analysis suggested that most ingested salt was hidden in processed foods with only a small fraction added in cooking or at meals (less than 7%). If sodium intake is to be reduced significantly in healthy children, more attention must be paid to hidden sources, particularly processed foods.

The role of depression in pain, psychophysiological syndromes and medically unexplained symptoms associated with chronic fatigue syndrome.

BACKGROUND: The association between depression and pain, function, medically unexplained symptoms and psychophysiological syndromes such as irritable bowel syndrome has not been explored before in chronic fatigue syndrome. METHODS: Cross-sectional controlled study of the current prevalence of psychophysiological syndromes, pain, function and lifetime prevalence of medically unexplained symptoms in 77 out-patients with chronic fatigue syndrome (CFS) without DSM-III-R depression, 42 CFS out-patients with DSM-III-R depression and 26 out-patient with primary DSM-III-R depression. RESULTS: Both CFS groups differed significantly from the primary depression group but not each other in the prevalence of tension headaches (P < 0.001), reporting of widespread bodily pain (P < 0.001) and the number of lifetime medically unexplained symptoms (P < 0.001). The three groups did not significantly differ in the prevalence of irritable bowel syndrome or fibromyalgia. CFS patients with depression were more impaired in social function than other CFS patients. CONCLUSION: Depression is not associated with the reporting of pain, psychophysiological syndromes and medically unexplained symptoms in CFS patients. Depression is associated with decreased social function in CFS patients. LIMITATIONS: Study depended on recall of symptoms, not confirmed by medical records and current investigations. Patients with depression were taking antidepressants. CLINICAL RELEVANCE: Treating depression in chronic fatigue syndrome is unlikely to diminish reporting of pain and medically unexplained symptoms but may improve social function.

Lean meats make the grade--a collaborative nutrition intervention program.

Lean Meats Make the Grade is a collaborative nutrition intervention program involving the Minnesota Heart Health Program (MHHP), the Minnesota Beef Council, and the Pork Producers Council. The purposes of this program were to educate consumers about identification of leaner cuts of meat, low-fat preparation methods, and selection of appropriate meat portion size. Program components included training for meat managers, taste testing for consumers, recipes and customer information brochures, and labels on individual meat packages to assist in the identification of leaner cuts of meat. The program was implemented through grocery stores in two of the towns selected for MHHP intervention. Population-based telephone surveys indicated that respondents in the intervention towns were more aware of the lean meats program than those in the comparison communities. Knowledge of lean cuts of meat and low-fat preparation methods also increased as a result of the program. Independently collected sales data from five participating and two control stores provided some indications of a greater interest in lean cuts and 80% lean ground beef as a result of the intervention program. Programs such as this have potential for community-wide nutrition education.

Model utilization in evaluation of a Dial-A-Dietitian system.

The purpose of this study was to determine the effectiveness of selected factors of performance of a telephone delivery system, Dial-A-Dietitian, which was established to provide nutrition information to the public. A model, developed for this use, entailed a systems approach with five phases, which included enabling factors (inputs), the interaction process, effort factors (outputs), performance (outcome), and feedback (reporting). The data analysis indicated that the Dial-A-Dietitian program was effective as measured by this model.

Process guides for nutrition care in community health.

The process of nutrition care is central to the clinical management of the public health client. However, this care is not often provided by the public health nurse. Thus, process guides that describe the techniques and strategies for providing nutrition care are important components of continuing education for those health professionals. This article presents one format for the development and presentation of such guides. Procedures for implementing the guides in public health practice are also described.

Developing nutrient criteria for food-specific dietary guidelines for the general public.

Consumers are asking for specific information about which foods and, in particular, which brands of packaged foods to choose when they eat or purchase food. Point-of-purchase nutrition intervention programs that identify specific foods in restaurants and grocery stores are particularly promising community-based strategies for providing that type of information. However, such strategies demand consistent criteria for determining which foods and/or products should be labeled. This article describes the process of developing and validating criteria and the subsequent uses of the criteria in community nutrition intervention programs. Steps in the process include (a) identifying the scientific basis for the criteria, (b) developing food-group-specific nutrient criteria based on a referent meal pattern, (c) developing the eligibility of single servings of specific foods for labeling based on the nutrient criteria of the food group to which the specific food belongs, and (d) validating the criteria by reviewing actual food products in the grocery stores and restaurants. We conclude that the use of criteria provides a consistent standard for evaluating specific foods and food items in nutrition evaluation programs.

The National Cholesterol Education Program: implications for dietetic practitioners from the Adult Treatment Panel recommendations.

The National Cholesterol Education Program (NCEP) was initiated to contribute to the prevention of illness and death from coronary heart disease by reducing the prevalence of high blood cholesterol. The report of an expert panel of this program provides guidelines for the treatment of high blood cholesterol in adults 20 years of age and over. Dietary therapy is the primary treatment. The goal of the recommended dietary therapy is to lower the LDL-cholesterol concentration, although measurement of total blood cholesterol can be used to monitor the response to diet. Dietary modification involves a progressive decrease in intake of saturated fatty acids and cholesterol. The Step-One Diet calls for an intake of total fat less than 30% of calories, saturated fatty acids less than 10% of calories, and cholesterol less than 300 mg/day. If the desired decrease in LDL-cholesterol is not achieved with that dietary change, then the Step-Two Diet is begun. It requires a reduction in saturated fatty acids to less than 7% of calories and cholesterol to less than 200 mg/day. This article provides background information on the organization and objectives of the NCEP and focuses on the recommendations of the Adult Treatment Panel (ATP), e.g., classification of risk for developing coronary heart disease based on total and low-density-lipoprotein cholesterol levels and recommendations for treatment of patients with high blood cholesterol. The emphasis of the discussion is on dietary treatment. The implications of the recommendations for the dietetic practitioner are discussed. These include an expanded leadership role to meet the education needs of health professionals and patients.

The Eating Pattern Assessment Tool: a simple instrument for assessing dietary fat and cholesterol intake.

OBJECTIVE: This study describes the development of the self-administered Eating Pattern Assessment Tool (EPAT), which is designed to assess dietary fat and cholesterol intake and aid patients and health professionals in achieving control of blood cholesterol levels. DESIGN: Test-retest reliability of the instrument over five visits and concurrent validity testing compared with 4-day food records. SETTING AND SAMPLE: The instrument was tested at multiple sites of a large manufacturing corporation using 436 adult volunteers with approximately equal proportions of men and women from three socioeconomic levels. MAIN OUTCOME MEASURE: Development of the EPAT centered on creating an instrument that was simple and easy to use in a primary-care setting, that would provide a reliable assessment of intake of dietary fat and cholesterol among adults, and that would measure frequency of consumption of foods from high-fat and low-fat categories. ANALYSES: Test-retest reliability for repeated use was estimated by between-visit Pearson product-moment correlations of EPAT section scores. Concurrent validity was assessed by using product-moment correlation between EPAT section scores and mean daily B-scores obtained from 4-day food records. RESULTS: Test-retest reliability estimates were 0.91 between all adjacent pairs of visits and 0.83 between visits 1 and 5 (4 months). Validity was 0.56. APPLICATIONS/CONCLUSIONS: The EPAT is a simple, quick, self-administered tool using an easy scoring method for accurately assessing fat and cholesterol intake. It is a reliable and valid substitute for more time-consuming food records. EPAT also provides an efficient way to monitor eating patterns of patients over time and is arranged to provide an educational message that reinforces the consumption of recommended types and numbers of servings of low-fat foods.

Exploring the validity of the Chalder Fatigue scale in chronic fatigue syndrome.

The Chalder fatigue scale is widely used to measure physical and mental fatigue in chronic fatigue syndrome patients, but the constructs of the scale have not been examined in this patient sample. We examined the constructs of the 14-item fatigue scale in a sample of 136 chronic fatigue syndrome patients through principal components analysis, followed by correlations with measures of subjective and objective cognitive performance, physiological measures of strength and functional work capacity, depression, anxiety, and subjective sleep difficulties. There were four factors of fatigue explaining 67% of the total variance. Factor 1 was correlated with subjective everyday cognitive difficulties, concentration difficulties, and a deficit in paired associate learning. Factor 2 was correlated with difficulties in maintaining sleep. Factor 3 was inversely correlated with grip strength, peak VO2, peak heart rate, and peak functional work capacity. Factor 4 was correlated with interview and self-rated measures of depression. The results support the validity of mental and physical fatigue subscales and the dropping of the "loss of interest" item in the 11-item version of the fatigue scale.

The effect of ablation of the preoptic anterior hypothalamus on energy metabolism and plasma catecholamines after burn injury in the rat.

Rats with burn injuries demonstrate changes in thermoregulation including an upward shift of the set-point and reference temperatures with no change in sensitivity of the response in heat production to displacement of the temperature of the preoptic anterior hypothalamus. In the present studies, the response in plasma and urinary catecholamines to burn injury after destruction of the preoptic anterior hypothalamus was examined in the rat. Preoptic anterior hypothalamic lesioning impaired the hypermetabolic response to burn injury, and at 22 degrees C, burned lesioned rats were hypothermic. Furthermore, plasma levels and urinary excretion rates for catecholamines were not decreased in burned lesioned rats, but rather showed an inverse relationship with heat production. Burned lesioned rats were capable of maintaining body temperature at an ambient temperature of 28 degrees C. This suggests that a less precise thermoregulation is present in lesioned animals. Rats in which the preoptic anterior hypothalamus has been destroyed have reduced tolerance to burn injury.

Parent nutrition education: a conceptual model.

Getting nutrition information to parents is beneficial for several reasons. Children need support from their parents to implement behavior changes learned in primary prevention interventions. In addition, positive eating behavior changes last longer if interventions are aimed at family attitudes and habits rather than individuals. Finally, parents also can benefit from the information. This article summarizes selected research about the impact of youth-directed nutrition education interventions on parents. A conceptual model is proposed to guide development and evaluation of future interventions with a parent component.