scholarly journals Efektivitas Alih Baring Tiap 2 Jam Terhadap Pencegahan Ulkus Dekubitus pada Pasien Pasca Stroke dengan Tirah Baring Lama di Bangsal Saraf RSUD Arifin Achmad Pekanbaru

2017 ◽  
Vol 4 (2) ◽  
pp. 133
Author(s):  
Bevi Dewi Citra ◽  
Hermes C. Sitompul ◽  
Tuti Restuastuti
Keyword(s):  
Intervention Study ◽  
Preventive Intervention ◽  
Decubitus Ulcer ◽  
Medical Rehabilitation ◽  
Neurological Deficits ◽  
Stroke Patients ◽  
Cross Sectional ◽  
Post Stroke ◽  
Rehabilitation Programs ◽  
Significant Difference

Neurological deficits on stroke patients can caused immobility. Decubitus ulcer is one of immobilty’s complication.Two hours repositioning is one of medical rehabilitation programs in decubitus prevention. The aim of this study is todescribe effectiveness of two hours repositioning to prevent decubitus ulcer, especially on post-stroke patients. Thisstudy was a preventive intervention study with cross-sectional approach. Sample consists of 32 patients. Group Iconsists of 16 patients with repositioning intervention. On the otherhand, group II consists of 16 patients withoutrepositioning intervention. Then, this two groups were compared and were looked for the effectiveness. from thisstudy, we knew that prevalence of decubitus ulcer on post-stroke patients are 19.4% with the effectiveness of two hoursrepositioning is 87.5%. There was significant difference between these two groups to prevent decubitus. it occurred ongeriatric patients with percentage of 75%. Its Proportion for female: male are 2:1. It is commonly occurred on firstweek hospitalization, especially grade 2 (33.3%). It is mostly located on sacrum (100%).

scholarly journals BEDA LUARAN FUNGSI SENSORIMOTOR PASIEN DENGAN DAN TANPA FATIGUE PASCASTROKE ISKEMIK

2020 ◽  
Vol 36 (2) ◽  
Author(s):  
Maria Putri Utami ◽  
Hexanto Muhartomo ◽  
Maria Immaculata Widisastuti
Keyword(s):  
Ischemic Stroke ◽  
Neurological Deficits ◽  
Sensorimotor Function ◽  
Stroke Patients ◽  
Post Stroke ◽  
Rehabilitation Programs ◽  
Experienced Fatigue ◽  
Outcome Difference ◽  
The Difference

  THE DIFFERENCE OF SENSORIMOTOR FUNCTION OUTCOME IN PATIENTS WITH AND WITHOUT POST ISCHEMIC STROKE FATIGUEABSTRACTIntroduction: Post-stroke fatigue is a burden in improving neurological deficits, rehabilitation, quality of life and capacity at work. Thus, the consequences of post-stroke fatigue should be dealt seriously, considering this is a problem for the patients and difficult to deal with.Aims: To obtain the difference between sensorimotor outcome after ischemic stroke in patients with and without fatigue.Methods: Cohort prospective study of first ischemic stroke patients, conducted at Dr. Kariadi Hospital and Dr. Adhyatma Tugurejo Hospital, Semarang in May-July 2018. Fatigue was determined two weeks post stroke using FACIT-F questionnaire. Sensorimotor outcome was evaluated with Fugl-Meyer Assessment (FMA) two weeks post-stroke and two weeks after the first examination.Results: Among 44 patients with first ischemic stroke, 31.8% patients experienced fatigue and 68.2% patients did not experience it. There was significant sensorimotor outcome difference between patients with fatigue and without fatigue, and also significant variance of sensorimotor outcome difference between those groups.Discussions: Sensorimotor outcome was different between patients with and without post-stroke fatigue. Patients who experienced fatigue had poorer sensorimotor outcome (lower FMA score). They tended to be pessimistic about exercise function and avoided physical activity. Post-stroke fatigue inhibited patient participation in rehabilitation programs and was associated with poor improvement in neurological function.Keywords: FACIT-F, fatigue, Fugl-Meyer Assessment, ischemic stroke, sensorimotor outcomeABSTRAKPendahuluan: Keadaan lelah atau fatigue pascastroke akan menghambat perbaikan defisit neurologis, rehabilitasi, kualitas hidup, dan kapasitas dalam bekerja. Oleh karena itu, konsekuensi fatigue pascastroke harus ditangani secara serius, mengingat hal ini menjadi masalah bagi pasien dan sulit untuk ditangani.Tujuan: Didapatkan perbedaan luaran fungsi sensorimotor pascastroke iskemik pada pasien dengan fatigue dan tanpa fatigue.Metode: Studi kohort prospektif pada pasien stroke iskemik pertama yang dirawat di RSUP Dr. Kariadi dan RSUD Dr. Adhyatma Tugurejo, Semarang pada bulan Mei-Juli 2018. Status fatigue ditentukan 2 minggu pascastroke dengan kuesioner FACIT-F. Luaran fungsi sensorimotor dievaluasi dengan Fugl-Meyer Assessment (FMA) 2 minggu pascastroke dan 2 minggu setelah pemeriksaan pertama.Hasil: Diantara 44 pasien stroke iskemik pertama kali, 31,8% pasien mengalami fatigue dan 68,2% tidak mengalaminya. Adanya perbedaan bermakna luaran fungsi sensorimotor antara pasien dengan fatigue dan tanpa fatigue, juga didapatkan perbedaan bermakna perubahan luaran fungsi sensorimotor antara kedua kelompok tersebut.Diskusi: Luaran fungsi sensorimotor berbeda antara pasien dengan dan tanpa fatigue pascastroke iskemik. Pasien yang mengalami fatigue memiliki luaran fungsi sensorimotor lebih buruk (skor FMA lebih rendah). Pasien dengan fatigue cenderung pesimis akan fungsi olahraga dan menghindari aktivitas fisik. Fatigue pascastroke menghambat partisipasi pasien dalam program rehabilitasi serta berkaitan dengan buruknya perbaikan fungsi neurologis.Kata kunci: FACIT-F, fatigue, Fugl-Meyer Assessment, luaran fungsi sensorimotor, stroke iskemik  

scholarly journals Analysis of Factors Affecting Post-Stroke Fatigue: An Observational, Cross-Sectional, Retrospective Chart Review Study

Healthcare ◽  
2021 ◽  
Vol 9 (11) ◽  
pp. 1586
Author(s):  
Seungwon Kwon ◽  
Chul Jin ◽  
Seung-Yeon Cho ◽  
Seong-Uk Park ◽  
Woo-Sang Jung ◽  
...  
Keyword(s):  
Linear Regression ◽  
Multiple Linear Regression ◽  
Hemorrhagic Stroke ◽  
Neurological Deficits ◽  
Control Group ◽  
Regression Analyses ◽  
Stroke Patients ◽  
Cross Sectional ◽  
Factors Affecting ◽  
Post Stroke

Post-stroke fatigue (PSF) is one of the most common emotional and mood disorders in stroke survivors. Several studies have suggested associations between PSF and various factors. However, they describe conflicting results. Therefore, this study aimed to evaluate the factors affecting PSF. We retrospectively reviewed the medical records of 178 hospitalized stroke patients. The collected data were compared between the PSF and control groups. To evaluate the association between factors and PSF, regression analysis was conducted. A total of 96 patients (53.9%) were assigned to the PSF group, and 82 patients were assigned to the control group. Age, neurological deficits, cognitive dysfunction, degree of depression, hs-CRP, and ESR differed significantly between the two groups. For both types of stroke, multiple linear regression analyses showed that degree of depression and degree of inflammation were significantly associated with PSF. Through subgroup analysis, multiple linear regression analyses showed that the degree of depression in ischemic and hemorrhagic stroke and the platelet-to-lymphocyte ratio in hemorrhagic stroke had a significant association with PSF. In conclusion, post-stroke depression and degree of inflammation could be clinically significant predictors of PSF in all types of stroke patients. However, larger, prospective studies are required to obtain more concrete results.

scholarly journals Post-Stroke Quality of Life Perceived by Patients and Caregivers

2021 ◽  
Vol 24 (3) ◽  
pp. 165-172
Author(s):  
Gitalia Putri Medea ◽  
Elly Nurachmah ◽  
Muhamad Adam
Keyword(s):  
Quality Of Life ◽  
Social Relationship ◽  
Structured Interview ◽  
Cognitive Effects ◽  
Stroke Patients ◽  
Cross Sectional ◽  
Post Stroke ◽  
Significant Difference ◽  
Cross Sectional Design

The quality of life (QOL) of post-stroke patients can be assessed from the reports of patients themselves obtained through a structured interview or a questionnaire. However, some individuals are unable to comprehensively describe their QOL because of language disorders, cognitive effects caused by stroke, or pre-existing conditions. This study aims to identify differences in post-stroke QOL perception between patients and caregivers. A cross-sectional design involving 115 stroke patients and 115 caregivers was adopted, and Mann–Whitney test was used for statistical analysis. Results showed no significant difference in QOL perception (p = 0.166; α < 0.05), particularly in the physical (p = 0.278; α < 0.05), psychological (p = 0.068; α < 0.05), social relationship (p = 0.976; α < 0.05), and environmental (p = 0.157; α < 0.05) domains between patients and caregivers. Therefore, information from caregivers can be used to assess QOL when patients are incapable of reporting their condition. AbstrakKualitas Hidup Pasca Stroke yang Dipersepsikan oleh Pasien dan Caregiver. Kualitas hidup pasien pasca stroke dapat diketahui berdasarkan laporan dari pasien stroke dengan wawancara terstruktur atau dengan pengisian kuesioner. Namun, beberapa dari pasien stroke tidak dapat menggambarkan kualitas hidup mereka karena adanya gangguan bahasa dan efek kognitif lainnya akibat stroke atau kondisi yang sudah ada sebelumnya. Penelitian ini bertujuan mengidentifikasi perbedaan persepsi kualitas hidup antara perspektif pasien pasca stroke dan  caregiver. Penelitian ini menggunakan desain cross sectional yang melibatkan 115 pasien dan 115 caregiver dengan menggunakan analisis statistik Mann Whitney. Hasil analisis menunjukkan tidak terdapat perbedaan secara signifikan antara persepsi kualitas hidup dari pasien dan caregiver (p = 0,166 ; α < 0,05), khususnya pada domain fisik (p = 0,278; α < 0,05), psikologis (p = 0,068; α < 0,05), hubungan sosial (p = 0,976; α < 0,05), dan lingkungan (p = 0.157; α < 0,05) dari kualitas hidup yang dipersepsikan oleh pasien dan yang dipersepsikan oleh caregiver. Informasi dari caregiver dapat digunakan saat pasien tidak dapat memberikan informasi terkait kualitas hidupnya.Kata Kunci: caregiver, kualitas hidup, persepsi, stroke

scholarly journals Studi Epidemiologi Kualitas Hidup Penderita Paska Stroke di RSUD Propinsi Nusa Tenggara Barat

2019 ◽  
Vol 5 (1) ◽  
pp. 53
Author(s):  
Ilsa Hunaifi ◽  
Pujiarohman Pujiarohman
Keyword(s):  
Quality Of Life ◽  
General Hospital ◽  
Normal Population ◽  
Social Health ◽  
Average Score ◽  
Life Questionnaire ◽  
Stroke Patients ◽  
Cross Sectional ◽  
Post Stroke

troke is a leading cause of mortality and morbidity in Indonesia.  Post stroke patients has a higher disability hence results in poor quality of life compared with normal population. In Indonesia, studies related to the quality of life of post-stroke patients are scarce, so studies are required to explore the quality of life of post-stroke patients, particularly in West Nusa Tenggara. Aim of this study is to determine the epidemiology of quality of life for post-stroke patients in West Nusa Tenggara. Methods of this study is An Observational with cross-sectional design was performed in population of post-stroke patients admitted to West Nusa Tenggara General Hospital. The quality of life of post stroke patient was evaluated with SSQOL (Stroke Specific Quality of Life) questionnaire. The collected data was analyzed by the appropriate test. Result of this study is the average age of subject is 60.33±10.68 years. Hypertension is a major risk factor of stroke. The average SSQOL score is 177.02±45.75. SSQOL assesses 4 dimension are physical, functional, psychological and social health. Based on the physical dimension, the average score is 17.00, the functional dimension, the average score is 14.91, the psychological dimension, the average score is 13.17 and the social health dimension  the average score is 13.44.  The quality of life for post-stroke patients in West Nusa Tenggara General Hospital is good.

scholarly journals COGNITIVE IMPAIRMENT, THEIR DYNAMICS AND STRUCTURE IN THE ACUTE AND RECOVERY PERIODS OF STROKE, DEPENDING ON ARTERIAL HYPERTENSION SEVERITY AND DURATION

2018 ◽  
Vol 13 (3-4) ◽  
pp. 22-27
Author(s):  
T.M. Cherenko ◽  
Yu.L. Heletyuk
Keyword(s):  
Blood Pressure ◽  
Cognitive Impairment ◽  
Arterial Hypertension ◽  
Blood Pressure Monitoring ◽  
Cognitive Status ◽  
Neurological Deficits ◽  
Stroke Patients ◽  
Mean Values ◽  
Post Stroke ◽  
The Mean

Relevance. Cognitive impairment is common in the post-stroke period. Different characteristics of arterial hypertension (AH), namely its severity, duration and variability of blood pressure, can affect the development of cognitive impairment in stroke patients. Objective: to investigate cognitive impairment, their dynamics and structure in acute and recovering stroke periods, depending on the arterial hypertension severity and duration. Materials and methods. 150 patients with a primary ischemic stroke and history of hypertension: 74 (49,3 %) women and 76 (50,7 %) men, the mean age (67,4±0,7) years have been examined. Neurological deficits was evaluated by the NIHSS scale. The cognitive status was evaluated by the MMSE scale at the end of an acute period of 21 days and 1 year. Diagnosis of hypertension was based on the clinical and instrumental examination results and medical documents. Daily blood pressure monitoring was using on admission and every 4 hours during 6 days of acute stroke stage. Mean SBP, mean DBP, maximum SBP and DBP, standard deviation (SD) of SBP and DBP were studied. Results. By the mean score on the MMSE scale, there are differences in patients during acute post-stroke period, depending on the severity of hypertension: 27,2±0,6 points in the case of hypertension stage 1, 24,3±0,6 in the case of hypertension stage 2 and 20,7±0,8 in case of AH stage 3, (p=0.001). By this indicator, patients with different AH duration were different: 26,4±0,9 points; 25,1±0,5 points; 20,5±0,7 points, respectively. The significance of these differences by the mean values of MMSE score was obtained in patients with a duration of AH less than 5 years and more than 10 years, as well as when comparing the group of "6-10 years" and "over 10 years" (p=0,001). Significant differences in the structure of cognitive deficits severity, depending on the hypertension stage and its duration, were observed only in patients with moderate and severe stroke (p=0,006). Cognitive deterioration a year after a stroke was observed in 40 (31,5 %) patients. They have significantly higher mean values SD 1-3, SD 1-6, SBP on the first day after a stroke, and duration of hypertension. Conclusions. The relationship between the degree of intellectual decline and the duration of hypertension (r=0,592, p=0,001), severity of hypertension (r=0,459, p=0,001) was found. The severity of the neurological deficiency affects the structure of cognitive impairment at discharge in patients with different severity and duration of hypertension, and higher mean values of the variability of blood pressure from 1 to 6 days, SBP on the first day after stroke and higher duration of hypertension in the history is associated with a negative dynamics of cognitive impairment in stroke patients in a year after stroke.

scholarly journals Gothenburg Very Early Supported Discharge study (GOTVED): a randomised controlled trial investigating anxiety and overall disability in the first year after stroke

BMC Neurology ◽  
2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Lena Rafsten ◽  
Anna Danielsson ◽  
Asa Nordin ◽  
Ann Björkdahl ◽  
Asa Lundgren-Nilsson ◽  
...  
Keyword(s):  
Multidisciplinary Team ◽  
Controlled Trial ◽  
Stroke Care ◽  
Secondary Outcome ◽  
Outpatient Rehabilitation ◽  
Control Group ◽  
Stroke Patients ◽  
Post Stroke ◽  
Early Supported Discharge ◽  
Significant Difference

Abstract Background and purpose Early supported discharge (ESD) has been shown to be efficient and safe as part of the stroke care pathway. The best results have been seen with a multidisciplinary team and after mild to moderate stroke. However, how very early supported discharge (VESD) works has not been studied. The aim of this study was to investigate whether VESD for stroke patients in need of ongoing individualized rehabilitation affects the level of anxiety and overall disability for the patient compared with ordinary discharge routine. Methods A randomized controlled trial was performed with intention to treat analyses comparing VESD and ordinary discharge from hospital. All patients admitted at the stroke care unit at Sahlgrenska University Hospital of Gothenburg between August 2011 and April 2016 were screened. Inclusion occurred on day 4 using a block randomization of 20 and with a blinded assessor. Assessments were made 5 days post-stroke and 3 and 12 months post-stroke. Patients in the VESD group underwent continued rehabilitation in their homes with a multidisciplinary team from the stroke care unit for a maximum of 1 month. The patients in the control group had support as usual after discharge when needed such as home care service and outpatient rehabilitation. The primary outcome was anxiety as assessed by the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). The secondary outcome was the patients’ degree of overall disability, measured by the modified Rankin Scale (mRS). Results No significant differences were found between the groups regarding anxiety at three or 12 months post-stroke (p = 0.811). The overall disability was significantly lower in the VESD group 3 months post-stroke (p = 0.004), compared to the control group. However, there was no significant difference between the groups 1 year post-stroke. Conclusions The VESD does not affects the level of anxiety compared to ordinary rehabilitation. The VESD leads to a faster improvement of overall disability compared to ordinary rehabilitation. We suggest considering coordinated VESD for patients with mild to moderate stroke in addition to ordinary rehabilitation as part of the service from a stroke unit. Trial registration Clinical Trials.gov: NCT01622205. Registered 19 June 2012 (retrospectively registered).

scholarly journals Depression and functional disability in stroke patients

2020 ◽  
Author(s):  
Puji Astuti ◽  
Kusnanto ◽  
Ferra Dwi Novitasari
Keyword(s):  
Functional Disability ◽  
Recovery Process ◽  
Simple Random Sampling ◽  
Observational Research ◽  
Stroke Patients ◽  
Cross Sectional ◽  
Post Stroke ◽  
Post Stroke Depression ◽  
Design And Methods ◽  
Depressive Episodes

Background: Stroke patients often suffer from depression, a mental disorder that worsens their condition and slows down the recovery process. Depression is the leading cause of functional disability due to inability to cope with daily stressors and to function independently in their activities. The purpose of this study is to analyze the relationship between depression and functional disability levels in post-stroke patients. Design and Methods: This is an analytic observational research with a cross-sectional approach. The population in exam consisted of all 4-12 week post-stroke patient in the hospital (about 139 patients). The study focused on 104 respondents, who were selected using simple random sampling techniques. Results: The results show that 62.5% stroke patients suffered mild depressive episodes after the stroke while 58.7% experienced mild disabilities. Analysis results using the Pearson Product Moment Test obtained P=0,000. This shows there is a relationship between the level of depression and the degree of functional disability in post-stroke patients. Conclusions: It can be concluded that there is a significant relationship between the levels of post-stroke depression and the functional disability. Families are expected to provide a safe, supportive, and comfortable environment to lessen the level of depression.

Electromyography Activation Levels of the 3 Gluteus Medius Subdivisions During Manual Strength Testing

2015 ◽  
Vol 24 (3) ◽  
pp. 244-251
Author(s):  
Roald Otten ◽  
Johannes L. Tol ◽  
Per Holmich ◽  
Rodney Whiteley
Keyword(s):  
Study Design ◽  
Repeated Measures ◽  
Gluteus Medius ◽  
Strength Testing ◽  
Cross Sectional ◽  
Physically Active ◽  
Rehabilitation Programs ◽  
Significant Difference ◽  
The Individual ◽  
Hip Internal Rotation

Study Design:Cross-sectional.Context:Gluteus medius (GM) muscle dysfunction is associated with overuse injury. The GM is functionally composed of 3 separate subdivisions: anterior, middle, and posterior. Clinical assessment of the GM subdivisions is relevant to detect strength and activation deficits and guide specific rehabilitation programs. However, the optimal positions for assessing the strength and activation of these subdivisions are unknown.Objective:The first aim was to establish which strength-testing positions produce the highest surface electromyography (sEMG) activation levels of the individual GM subdivisions. The second aim was to evaluate differences in sEMG activation levels between the tested and contralateral (stabilizing) leg.Method:Twenty healthy physically active male subjects participated in this study. Muscle activity using sEMG was recorded for the GM subdivisions in 8 different strength-testing positions and analyzed using repeated-measures analysis of variance.Results:Significant differences between testing positions for all 3 GM subdivisions were found. There were significant differences between the tested and the contralateral anterior and middle GM subdivisions (P < .01). The posterior GM subdivision showed no significant difference (P = .154).Conclusion:Side-lying in neutral and side-lying with hip internal rotation are the 2 positions recommended to evaluate GM function and guide specific GM rehabilitation.

scholarly journals HUBUNGAN ANTARA DUKUNGAN KELUARGA DENGAN KEMAMPUAN PERAWATAN DIRI (SELF CARE) PADA PASIEN PASCA STROKE DI RSUD PIRNGADI KOTA MEDAN

2019 ◽  
Vol 2 (2) ◽  
pp. 70
Author(s):  
Patimah Sari Siregar ◽  
Elis Anggeria
Keyword(s):  
Family Support ◽  
Self Care ◽  
Rank Correlation ◽  
Sampling Technique ◽  
Stroke Patients ◽  
Cross Sectional ◽  
Post Stroke ◽  
Need Support ◽  
The Family ◽  
The Relationship

Stroke is a condition of brain experiencing neurodegenerative disorders such as local or global, occuring in sudden emergence, progressive, and fast. Impaired nerve function in stroke caused by circulatory disorders of the brain non-traumatic. Post-stroke patients need support and help the family in the treatment himself. This study aims to determine the relationship between family support with self-care skills  in patients with post-stroke. The study design is analytic survey with cross sectional approach. The study populations were 40 people and samples of this study were all post-stroke patients who were undergoing rehabilitation of physiotherapy with drawn by saturated sampling technique. The results showed that 47.5% of respondents got enough family support, and 55% of respondents have the ability of self-care with some aid. Based on the test results from Spearman Rank correlation, family support with self-care skills  has a correlation coefficient of 0.38 and Sig. (2-tailed) 0.01, meaning there is a relationship between family support and self-care skills on post-stroke patients in the Royal Prima Hospital Medan. In conclusion, this study shows that family support and self-care skills strongly influence at the level of the patient's recovery. It is hoped that families to be more attentive to the needs and provide optimal support either support of awards/emotional, facilities and support information.

scholarly journals REHABILITATION NURSING: DIFFERENTIATION IN PROMOTING THE AUTONOMY OF THE ELDERLY

2021 ◽  
Vol 4 (1) ◽  
pp. 15-22
Author(s):  
Andreia Maria Lima ◽  
Maria Manuela Ferreira da Silva Martins ◽  
Maria Salomé Martins Ferreira ◽  
Francisco Sampaio ◽  
Soraia Dornelles Schoeller ◽  
...  
Keyword(s):  
Activities Of Daily Living ◽  
Daily Living ◽  
The Elderly ◽  
Nurse Specialist ◽  
Snowball Sampling ◽  
Cross Sectional ◽  
Rehabilitation Programs ◽  
Instrumental Activities ◽  
Significant Difference ◽  
Specialist Nurses

Introduction: The promotion of autonomy, through the use of nursing interventions that promote physical, cognitive and social integration skills, are added competencies of nurses specialized in rehabilitation nursing, so it is important to realize whether these professionals invest in this area in their practices. Objectives: To identify and compare the perception of nurses who are specialists in rehabilitation nursing and nurses who are specialists in other specialty areas. Methodology: A descriptive, correlational, cross-sectional, quantitative study with non-probabilistic snowball sampling. For data collection, the Self-Assessment Scale of Elderly Autonomy was used between September and October 2020. Results: The sample consists of 151 specialist nurses, 72 specialists in rehabilitation nursing, and 79 specialists in other specialty areas. All specialist nurses promote the autonomy of the elderly with less visibility in the development of interventions for instrumental activities of daily living. It is perceived that the nurse specialist in rehabilitation nursing promotes more autonomy of the elderly on a broader scale (p <0.05), with a more significant difference concerning the development of physical and cognitive interventions (<0.001). Conclusion: All specialist nurses perceive that they promote the elderly's autonomy but have weaknesses in interventions that promote instrumental activities of daily living. The specialist nurses in rehabilitation nursing realize that they promote more autonomy for the elderly, probably due to the implementation of rehabilitation programs aimed at this promotion.

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