Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study

BACKGROUND

Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.

METHODS

A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.

RESULTS

Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions.

CONCLUSIONS

The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

Teachers' psychological stress and wellbeing during a pandemic: Exploring latent profiles

Teacher stress is at an all-time high. The COVID-19 pandemic created unprecedented challenges for teachers, which resulted in a record number of teachers intending to leave the classroom citing stress as a contributing factor. Understanding teachers' positive and negative psychological experiences, or well-being, during the height of the COVID-19 pandemic will inform teacher wellness interventions intended to keep teachers in the classroom. Two hundred forty-six teachers from a suburban school district participated in a survey of well-being indicators, including affect, perceived stress, teaching self-efficacy, and preventive coping. A latent profile analysis identified four patterns of well-being: strained, resilient, lower teaching self-efficacy, and lower emotional well-being. While many teachers were resilient during the crisis, approximately two-thirds experienced global or isolated areas of strain. Additionally, the Classroom Appraisal of Resources and Demands-Revised, a theory-driven assessment of teachers' workplace appraisal of demands and resources, was associated with teachers' strained and resilient well-being profiles, making it a suitable screening tool for these groups. Layered screening and tailored intervention, based on teachers' well-being patterns, may help minimize teacher attrition during and postcrises. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Barriers to and Facilitators for Teachers' Wellbeing

Teaching is widely recognized as a stressful profession, which has been connected to burnout and high turnover of qualified teachers. Despite increasing attention on teacher wellbeing, stress management interventions are often underutilized and demonstrate small effect sizes, and research on teachers’ informal stress management practices and desired resources is limited. It is likely that formal and informal intervention effectiveness is limited by teachers’ ability to access existing resources and navigate the complex educational systems they inhabit. The study explored the barriers to and facilitators for teachers’ engagement in formal and informal stress management interventions and desired resources across socioecological levels. Thirty-two teachers participated across four focus groups. Inductive thematic analysis was used to identify relevant themes. Personal barriers (e.g., guilt about self-prioritization), environmental barriers (e.g., mixed messages about self-care), and improved campus resources (e.g., scheduled opportunities to destress) were common themes. Recommendations for supporting teachers’ wellbeing include self-care affirming messages from peers and administrators, campus- and district-level changes to remove logistical barriers to stress management, and increased connectedness among campus community members.

Toxicological Response of Chironomus dilutus in Single-Chemical and Binary Mixture Exposure Experiments with 6 Perfluoralkyl Substances

Few studies have determined the toxicity of perfluoralkyl substances (PFAS) to aquatic invertebrates. We exposed Chironomus dilutus to 6 different PFAS to assess single-chemical toxicity and relative or proportional toxicity among substances. A 10-d range-finding test was conducted to inform 20-d assays for the following PFAS: perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluorobutanesulfonic acid (PFBS), perfluorohexanesulfonic acid (PFHxS), and perfluoroheptanoic acid (PFHpA). A 20-d binary mixture study of PFOS+PFHxS followed the single-chemical tests. Measurement endpoints for 20-d tests included larval survival and biomass. Log-logistic concentration response models were used to estimate 10, 20, and 50% effect concentrations (EC20, EC50) for PFOS, PFHxS, and PFOA. Survival EC50s for PFOS, PFHxS, and PFOA were 2.49, 3860, and 192 000 µg/L, respectively, whereas survival EC20s were 1.70, 913, and 119 000 µg/L for PFOS, PFHxS, and PFOA, respectively. Biomass as a combined survival and growth endpoint resulted in EC20s of 1.89, 896, and 137 000 µg/L for PFOS, PFHxS, and PFOA, respectively. Maximum concentrations tested (no-observed-effect concentrations) for PFNA, PFBS, and PFHpA were 2 to 3 orders of magnitude greater than the PFOS EC50s and showed no toxicity to C. dilutus, even at exposure concentrations well above what would be considered environmentally relevant. The binary mixture of 2.5 µg/L PFOS+1000 µg/L PFHxS showed reduced survival compared to controls and some indication of potential additive or synergistic interaction between PFOS and PFHxS. Overall, the present study supports previous studies showing PFOS to be the most toxic PFAS to aquatic life and suggests that PFOS could be more toxic to the freshwater midge than previously reported. Environ Toxicol Chem 2021;40:2319-2333. © 2021 SETAC.

Considerations for toxicity experiments and risk assessments with PFAS mixtures

Per- and polyfluoroalkyl substances (PFAS) have been around for decades and have been the subject of laboratory and field research studies for nearly as long. Although attention to PFAS has grown in recent years, many unanswered questions remain. Accordingly, the number of research projects designed to improve our understanding of PFAS toxicity, bioaccumulation, and biomagnification, and to improve our ability to predict the interactions of PFAS mixtures, is also increasing. The growing number of ongoing and future research projects focusing on these chemicals will benefit from lessons learned in previous studies. This perspectives article discusses available approaches to mixture risk assessment with specific focus on application to PFAS mixtures. We discuss ongoing research as well as lessons learned from approaches to handling mixtures of other groups of chemicals. Many of these approaches require some detailed understanding of a manageable number of representative chemicals, yet only limited toxicological data are available for most PFAS. With the limited amount of published data currently available, the need for single-chemical and binary-mixture studies persists. Based on our previous work with single-chemical exposures for understudied PFAS, we explored some of the challenges of trying to design and interpret an aquatic concentration-response experiment for a binary mixture of two commonly detected PFAS: perfluorooctane sulfonate (PFOS) and perfluorohexane sulfonic acid (PFHxS). Based on our findings, we propose that addressing risk from PFAS mixtures will likely require combinations of approaches incorporating findings from traditional whole-organism toxicity studies and novel methods relying on in vitro assays, read-across, or quantitative structure activity relationships. Complicating a limited understanding of PFAS mixture toxicity is that relative concentrations of PFAS mixtures vary across sites and time, even at one site. Thus, reliance on empirical data, such as site-specific toxicity sampling or community structure studies, may be needed to fully understand potential impacts of mixtures. Integr Environ Assess Manag 2021;17:697-704. © 2021 SETAC.

Comparing targeted thrust manipulation with general thrust manipulation in patients with low back pain. A general approach is as effective as a specific one. A randomised controlled trial

Background

Spinal manipulation is commonly used to treat back pain. The application of spinal manipulation has traditionally involved an element of targeting the technique to a level of the spine where the proposed movement dysfunction is sited. We evaluated the effects of a targeted manipulative thrust versus a thrust applied generally to the lumbar region.

Methods

A randomised controlled clinical trial in patients with low back pain following CONSORT (Consolidated Standards of Reporting Trials) guidelines. Sixty subjects were randomly allocated to two groups: one group received a targeted manipulative thrust (n=29) and the other a general manipulation thrust (GT) (n=31) to the lumbar spine. Thrust was either localised to a clinician-defined symptomatic spinal level or an equal force was applied through the whole lumbosacral region. We measured pressure-pain thresholds (PPTs) using algometry and muscle activity (magnitude of stretch reflex) via surface electromyography. Numerical ratings of pain and Oswestry Disability Index scores were collected.

Results

Repeated measures of analysis of covariance revealed no between-group differences in self-reported pain or PPT for any of the muscles studied.

Summary

A GT procedure-applied without any specific targeting-was as effective in reducing participants' pain scores as targeted approaches.

Trial registration number

ISRCTN11994230.

Accuracy of 64-section MDCT in the diagnosis of cruciate ligament tears

AIM

To evaluate the accuracy of non-arthrographic 64-section multidetector computed tomography (CT) in the assessment of cruciate ligament tears. A secondary goal was to determine its accuracy in the diagnosis of additional soft-tissue injuries around the knee.

MATERIALS AND METHODS

Forty consecutive outpatients underwent same-day magnetic resonance imaging (MRI) and 64-slice multidetector CT (MDCT) of the knee in this prospective study. MDCT images were independently evaluated for integrity of the anterior (ACL) and posterior cruciate ligaments (PCL), medial and lateral menisci, and medial and lateral collateral ligaments. Recognised secondary signs of ACL tears were also documented. MRI images were subsequently assessed by two radiologists and a consensus reached.

RESULTS

The sensitivity of MDCT for ACL tears was 87.5-100%, with a specificity of 100%. The presence of one or more secondary signs of ACL tears on MDCT had a sensitivity of 50-87.5% with a specificity of 100%. The sensitivity of MDCT for PCL tears was 0-25% with a specificity of 100%. The sensitivity for meniscal tears was 9.1-23.1% with a specificity of 96.3-100%.

CONCLUSION

64-section MDCT has very high sensitivity and specificity for ACL tears and, as on MRI, secondary signs, such as buckling of the PCL, are also useful in their diagnosis. MDCT has a low sensitivity for other soft-tissue injuries at the knee; however, its high specificity indicates that apparent PCL, meniscal, and collateral ligament tears can reliably be treated as true-positive findings.

Attitudes and diagnostic practice in low back pain: A qualitative study amongst Greek and British physiotherapists

AIM

To explore current diagnostic practice and attitudes of Greek and United Kingdom physiotherapists (PTs) on assessing low back pain (LBP) patients.

METHODS

Three focus groups were undertaken, followed by a structured questionnaire-type survey comprising 23 health professionals and a random stratified sample of 150 PTs, respectively. Twenty-nine themes relating to LBP diagnostic practice emerged. These were then given to 30 British PTs assessing their level of agreement with their Greek counterparts. Analysis was performed by percentage agreements and χ² tests.

RESULTS

The survey was divided into three subsections; PTs’ attitudes on LBP assessment, patients’ attitudes and diagnostic/healthcare issues, each constituting 14, 7 and 8 statements, respectively. Over half of the statements fell within the 30%-80% agreement between Greece and United Kingdom whereas, 5 statements reported low (< 10%) and 8 statements demonstrated high (> 90%) PT percentage agreement. Similarities across British and Greek PTs were detected in history taking methods and in the way PTs feel patients perceive physiotherapy practice whereas, re-assessment was undertaken less frequently in Greece. Diagnosis according to 91% of the Greek PTs is considered a “privilege” which is exclusive for doctors in Greece (only 17% British PTs agreed) and is accompanied with a great overuse of medical investigations. Forty percent of Greek PTs (compared to 0% of British) consider themselves as “executers”, being unable to interfere with treatment plan, possibly implying lack of autonomy.

CONCLUSION

Although similarities on history taking methods and on patients’ attitudes were detected across both groups, gross differences were found in re-assessment procedures and diagnostic issues between Greek and British physiotherapists, highlighting differences in service delivery and professional autonomy.

Sub-grouping patients with non-specific low back pain based on cluster analysis of discriminatory clinical items

OBJECTIVE

To identify potential subgroups amongst patients with non-specific low back pain based on a consensus list of potentially discriminatory examination items.

DESIGN

Exploratory study.

PARTICIPANTS

A convenience sample of 106 patients with non-specific low back pain (43 males, 63 females, mean age 36 years, standard deviation 15.9 years) and 7 physiotherapists.

METHODS

Based on 3 focus groups and a two-round Delphi involving 23 health professionals and a random stratified sample of 150 physiotherapists, respectively, a comprehensive examination list comprising the most "discriminatory" items was compiled. Following reliability analysis, the most reliable clinical items were assessed with a sample of patients with non-specific low back pain. K-means cluster analysis was conducted for 2-, 3- and 4-cluster options to explore for meaningful homogenous subgroups.

RESULTS

The most clinically meaningful cluster was a two-subgroup option, comprising a small group (n = 24) with more severe clinical presentation (i.e. more widespread pain, functional and sleeping problems, other symptoms, increased investigations undertaken, more severe clinical signs, etc.) and a larger less dysfunctional group (n = 80).

CONCLUSION

A number of potentially discriminatory clinical items were identified by health professionals and sub-classified, based on a sample of patients with non-specific low back pain, into two subgroups. However, further work is needed to validate this classification process.

Inter-tester reliability of discriminatory examination items for sub-classifying non-specific low back pain

OBJECTIVE

To investigate the inter-tester reliability of a non-specific low back pain examination procedure, for sub-classifying non-specific low back pain.

DESIGN

Reliability study.

PARTICIPANTS

Thirty patients with non-specific low back pain (12 males, 18 females, mean age: 27.7 years (standard deviation 10.3) and 7 physiotherapists (raters).

METHODS

Based on a health professionals' consensus via focus groups and a Delphi servey, an examination procedure was developed comprising 206 items discriminatory for non-specific low back pain, 108 of which were from the History (clinical questions) and 98 from the Physical Examination (clinical tests) section. Utilizing this procedure, each patient was examined by a blinded pair of raters.

RESULTS

Moderate to excellent agreement was obtained in 125 (61%) items (77 History and 48 Physical Examination items), 47 of which obtained substantial or excellent agreement (kappa >0.61), 37 moderate agreement (kappa between 0.41 and 0.6), and 41 excellent percentage agreements. Poor reliability (kappa < 0.41) was yielded in the remaining 81 items (31 History and 50 Physical Examination items).

CONCLUSION

Satisfactory reliability was obtained in nearly two-thirds of History and half of the Physical Examination items on a non-specific low back pain assessment list generated through consensus agreement. These findings provide clinicians and researchers with valuable information regarding which items are considered reliable and can be utilized in non-specific low back pain patient evaluation/assessment procedures, classification attempts and clinical trials.

Dorsal root ganglion neurons innervating pelvic organs in the mouse express tyrosine hydroxylase

Previous studies in rat and mouse documented that a subpopulation of dorsal root ganglion (DRG) neurons innervating non-visceral tissues express tyrosine hydroxylase (TH). Here we studied whether or not mouse DRG neurons retrogradely traced with Fast Blue (FB) from colorectum or urinary bladder also express immunohistochemically detectable TH. The lumbar sympathetic chain (LSC) and major pelvic ganglion (MPG) were included in the analysis. Previously characterized antibodies against TH, norepinephrine transporter type 1 (NET-1) and calcitonin gene-related peptide (CGRP) were used. On average, ∼14% of colorectal and ∼17% of urinary bladder DRG neurons expressed TH and spanned virtually all neuronal sizes, although more often in the medium-sized to small ranges. Also, they were more abundant in lumbosacral than thoracolumbar DRGs, and often coexpressed CGRP. We also detected several TH-immunoreactive (IR) colorectal and urinary bladder neurons in the LSC and the MPG, more frequently in the former. No NET-1-IR neurons were detected in DRGs, whereas the majority of FB-labeled, TH-IR neurons in the LSC and MPG coexpressed this marker (as did most other TH-IR neurons not labeled from the target organs). TH-IR nerve fibers were detected in all layers of the colorectum and the urinary bladder, with some also reaching the basal mucosal cells. Most TH-IR fibers in these organs lacked CGRP. Taken together, we show: (1) that a previously undescribed population of colorectal and urinary bladder DRG neurons expresses TH, often CGRP but not NET-1, suggesting the absence of a noradrenergic phenotype; and (2) that TH-IR axons/terminals in the colon or urinary bladder, naturally expected to derive from autonomic sources, could also originate from sensory neurons.