A smartphone-based health care chatbot to promote self-management of chronic pain (SELMA) : pilot randomized controlled trial

Background: Ongoing pain is one of the most common diseases and has major physical, psychological, social, and economic impacts. A mobile health intervention utilizing a fully automated text-based health care chatbot (TBHC) may offer an innovative way not only to deliver coping strategies and psychoeducation for pain management but also to build a working alliance between a participant and the TBHC. Objective: The objectives of this study are twofold: (1) to describe the design and implementation to promote the chatbot painSELfMAnagement (SELMA), a 2-month smartphone-based cognitive behavior therapy (CBT) TBHC intervention for pain self-management in patients with ongoing or cyclic pain, and (2) to present findings from a pilot randomized controlled trial, in which effectiveness, influence of intention to change behavior, pain duration, working alliance, acceptance, and adherence were evaluated. Methods: Participants were recruited online and in collaboration with pain experts, and were randomized to interact with SELMA for 8 weeks either every day or every other day concerning CBT-based pain management (n=59), or weekly concerning content not related to pain management (n=43). Pain-related impairment (primary outcome), general well-being, pain intensity, and the bond scale of working alliance were measured at baseline and postintervention. Intention to change behavior and pain duration were measured at baseline only, and acceptance postintervention was assessed via self-reporting instruments. Adherence was assessed via usage data. Results: From May 2018 to August 2018, 311 adults downloaded the SELMA app, 102 of whom consented to participate and met the inclusion criteria. The average age of the women (88/102, 86.4%) and men (14/102, 13.6%) participating was 43.7 (SD 12.7) years. Baseline group comparison did not differ with respect to any demographic or clinical variable. The intervention group reported no significant change in pain-related impairment (P=.68) compared to the control group postintervention. The intention to change behavior was positively related to pain-related impairment (P=.01) and pain intensity (P=.01). Working alliance with the TBHC SELMA was comparable to that obtained in guided internet therapies with human coaches. Participants enjoyed using the app, perceiving it as useful and easy to use. Participants of the intervention group replied with an average answer ratio of 0.71 (SD 0.20) to 200 (SD 58.45) conversations initiated by SELMA. Participants’ comments revealed an appreciation of the empathic and responsible interaction with the TBHC SELMA. A main criticism was that there was no option to enter free text for the patients’ own comments. Conclusions: SELMA is feasible, as revealed mainly by positive feedback and valuable suggestions for future revisions. For example, the participants’ intention to change behavior or a more homogenous sample (eg, with a specific type of chronic pain) should be considered in further tailoring of SELMA

Acute kidney injury: an acceptable risk of treatment with renin-angiotensin system blockade in primary care?

Background: Use of renin-angiotensin system (RAS) blockade has become increasingly widespread driven by evidence-based guidance. There is concern about the role of these agents in the genesis of avoidable acute kidney injury (AKI). Objectives: To investigate the association between AKI and use of RAS blockade. Design: Multilevel hierarchical analysis of a large cohort of patients registered with UK general practitioners. Setting: Primary care practices in East and West Kent, United Kingdom. Patients: 244,715 patients from 27 practices. Measurements: Demographic, clinical, biochemical and prescription data. Methods: Analyses of data acquired between 02/3/2004 and 17/04/2012 using multilevel logistic regression to determine the relationship between AKI and use of RAS blockade; further analysed by indication for treatment with RAS blockade. Results: Sufficient serum creatinine data were available to define AKI in 63,735 patients with 208,275 blood test instances. In 95,569 instances the patient was prescribed a RAS antagonist of which 5.4% fulfilled criteria for AKI. The unadjusted odds ratio (OR) for AKI in those prescribed RAS blockade was 1.93 (1.81-2.06, 95%CI) falling to 1.11 (1.02-1.20, 95%CI) when adjusted for age, gender, co-morbidity, GFR category, proteinuria, systolic blood pressure and diuretic therapy. In patients with an evidence-based indication there was no difference in absolute risk of AKI. However, prescription of RAS blockade in the absence of indication appeared to be associated with greater risk of AKI. When analysis was repeated with AKIN2/AKIN3 as the outcome, although risk of AKI remained significant when unadjusted (OR 1.73, 95%CI 1.42-2.11, p<0.001), after full adjustment there was no increased risk (OR 0.83, 95%CI 0.63-1.09) in those taking RAS antagonists. However, when analysed by indication AKIN2/AKIN3 was significantly more likely in those prescribed RAS antagonists without indication (OR 2.04, 95%CI 1.41-2.94, p<0.001). Limitations: Observational database study. No information concerning hospitalisation. Prescribing assumptions and potential inaccurate coding. Potential survival bias; patients surviving longer will contribute more data. Conclusions: Use of RAS antagonists increased the risk of AKI, independent of common confounding variables. After correction for confounders the risk fell away and became non-significant for moderate and severe AKI. However, where there was no evidence-based indication for RAS antagonists the risk of AKI, whether mild, moderate or severe, remained greater

Health care commissioning: the UK health policy reforms

editoria

Adolescent Sexual and Reproductive Health:Report on an Assessment and Review of Training Materials

Young people in Tanzania face a range of serious reproductive health risks – from early unwanted pregnancy and unsafe abortion to sexually transmitted infections, including HIV/AIDS. These reproductive health problems do not only have an immediate impact on the lives and well being of young people, but also contribute to long-term pattern of high fertility, poverty, dependency and poor socio-economic development. In recognition of the extent of adolescent health problems, the Government of Tanzania has initiated an effort to address young people’s needs for reproductive health information, counseling and services. To guide improved adolescent sexual and reproductive health programming, the Reproductive and Child Health Section (RCHS) of the Ministry of Health, with technical assistance from Family Care International (FCI) and financial assistance from the United Nations Population Fund (UNFPA), launched an effort to assess and review training curricula and related resource materials that are available in Ta nzania and internationally. Specific objectives of the Assessment were: To provide an overview of adolescent sexual and reproductive health (ASRH) training curricula that is available in Tanzania and at the international level. To identify priorities for curriculum development in Tanzania. To recommend training materials that could be used as models for developing national training curricula for various target audiences. Through interviews with key ASRH stakeholders in Tanzania and literature reviews, a \ud range of training materials were identified and reviewed. Materials were analyzed by target user and audience as well as by content and depth of coverage. The Assessment and Review served to illuminate critical ASRH issues that need to be addressed through training programmes for those working with youth. In addition, the Assessment highlighted key gaps in available curricula. Based on the Assessment findings, priorities for curriculum development include. An in-service training curriculum for orienting health service providers. The Assessment revealed that there are few materials for orienting service providers to youth friendly service delivery. Therefore, a standardized curriculum is needed to guide in-service training of facility-based health staff, as well as school-based health workers, outreach workers, lay counselors and other community-based providers in adolescent sexual and reproductive health counseling and service delivery. A comprehensive peer education training manual. Many organizations working with peer educators have developed training curricula, and there is considerable variety in the content and quality of these resources. To ensure the content and quality of peer education programmes for youth, it is recommended that a comprehensive peer education manual be developed, which could be used for training various types of peer educators and youth counselors (i.e. those working with in-school adolescents, those working with out-of-school adolescents, etc). Curricula and teaching aids for primary and secondary schools. Although the Ministry of Education and Culture has begun developing syllabi to guide implementation of the Family Life Education Programme in primary and secondary schools, teachers need more detailed curricula, reference materials and teaching aids to successfully carry out this important education programme. In developing the above curricula, it is recommended that special emphasis be placed on designing training resources comprised of separate training modules – modules that can be used either separately or together, depending on the specific training needs of various audiences. For example, the curriculum for service providers should include separate modules on adolescent sexual and reproductive health, information and counseling, and service provision to young people. While all tree modules would be used in training service providers, select modules could be used to train lay counselors and outreach workers. Similarly, the comprehensive training manual for peer educators should include separate modules on topics, such as adolescent sexual and reproductive health, facilitation and peer education skills, and working with different target audiences – in school adolescents, out-of-school youth, and parents and other adults – to ensure that peer education programmes could use the specific modules that are appropriate to their outreach efforts.The Assessment revealed that a large number of training curricula and related materials exist to support adolescent sexual and reproductive health initiatives in Tanzania. Although none of these resources is precisely suited to meet the above-mentioned gaps,many of the existing materials contain excellent content, which should be used as the basis for developing standardized national curricula

Preparing young people with complex needs and their families for transition to adult services

© RCN Publishing Company Limited 2018Improving survival rates for children and young people with complex health needs requires a robust system for transition to adult services. Effective planning is essential to ensure a smooth transition process that is in the best interests of the young person and their family. This article discusses the needs and requirements for planned and purposeful transition processes to support young people with complex healthcare needs and their families. It considers the preparation of adult services, the team, the young person and their parents in line with an integrated approach and the nurse’s role. Recommendations for practice include the necessity for an integrated approach to ensure optimum outcomes and ascertaining the potential value of a nurse-led service in delivering the transition process. A carefully tailored planning strategy should be developed to prepare and support young people with complex health needs through transition

Do psychological treatments reduce symptoms of post-traumatic stress disorder? Evidence update - Summary of a Cochrane Review

Trauma focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management, and group TFCBT reduce traumatic symptoms in post-traumatic stress disorder