Conceptualizations of occupation in relation to health: A conversation between theory and experience-near data

Current occupational science theory describes a positive link between occupation and human health. This theory asserts that an essential unit of analysis for understanding health is in every-day human actions (Wilcock, 2006). Indeed, extant literature has identified occupation as a powerful facilitator of health and wellbeing. Consequently, basic theory in occupational science has favored positive implications for health based on engagement in occupations. However, experience-near accounts reveal that engaging in occupation has both positive and negative implications. Recent scholarship in occupational science has recognized this conflict and asserts that further understanding of the occupation-health link is necessary (Durocher, Rappolt, & Gibson, 2014). This panel will advance the discussion between experience-near accounts and basic theory by employing case examples from interdisciplinary research. Presentation #1 will frame the discourse by providing a conceptual map (Feyerabend, 2011) of how occupational science has described the relationship between occupation and health, and identify opportunities for theoretical expansion. We will argue for adopting a dialectic perspective on the occupation-health link. To illustrate the need for expanded theory, a case example will be given employing data from a large mixed-methods ethnographic study (‘Autism in urban context: linking heterogeneity with health and service disparities’, NIMH, R01MH089474, 09/30/2009 - 08/31/2012, Solomon, O., P.I.). These data capture the experiences of a child with ASD and his family related to ways in which his medical and developmental conditions make participation in physical play both transformative and detrimental. Presentation #2 extends this dialogue to the clinical care setting by challenging notions of the health-promoting effects of healthcare providers’ recommendations within chronic disease management. This presenter will provide one exemplar case from a study on diabetes as a lens into the experiences of making agentic choices between maintaining the intensive requirements of diabetes management and engaging in developmentally normative, though potentially risky activities. These choices are further examined using theoretical tools from medical sociology and anthropology combined with concepts introduced within occupational science literature. Presentation #3 will describe the activities of a Latino gang. Drawing from a transactionalism framework and understanding the interrelatedness of contextual conditions to occupation (Dickie, Cutchin & Humphry, 2006). The presenter will discuss the affordances and constraints typical of a gang-inhabited neighborhood, and evaluate both the positive and negative health-related aspects of gangs. Additional excerpts from memoirs and first-hand accounts of former gang members (Rodriguez, 2005) will be analyzed to describe the occupational activities of gangs from a participant perspective. This presentation will critically appraise the limitations of a health-promoting view of occupation by framing culturally grounded information as necessary when describing possible impacts on health. As these presentations will illustrate, occupations lead to flourishing for some aspects of health, but may also lead to some negative impact. The panel will demonstrate the importance of including both the positive and the negative impact into conceptualizations of occupation to better understand how it is linked to human health, wellness and participation. Key Words: Health Promotion, Critical Occupational Science, Experience-Near Research Presenter information Mark E. Hardison, MS, OTR/L¹ Kristine M. Carandang, MS, OTR/L¹ Lucía I. Floríndez, MA¹ Elizabeth A. Pyatak, PhD, OTR/L, CDE² Olga Solomon, PhD² Ruth Zemke, PhD, OTR(Retired), FAOTA³ 1 = Presenter and author, 2 = Author only, 3 = Moderator Affiliation University of Southern California, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy Acknowledgements Autism in Urban Context: Linking Heterogeneity with Health and Service Disparities (NIMH, R01 MH089474, 2009-2012, O. Solomon, P.I.) Objectives for the Discussion Period 1. Participants will ask questions of the panel to clarify or expand the presentation. 2. Participants will share other experiential examples critically appraising the health-promoting view of occupation. 3. Participants and panel members will explore reconciliation of these observations with basic theory of occupation

2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

ObjectiveTo develop updated guidelines for the pharmacologic management of rheumatoid arthritis.MethodsWe developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.ResultsThe guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).ConclusionThis clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities

2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis

Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide general guidance for commonly encountered clinical scenarios. The recommendations do not dictate the care for an individual patient. The ACR considers adherence to the recommendations described in this guideline to be voluntary, with the ultimate determination regarding their application to be made by the clinicians in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed and endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. ACR recommendations are not intended to dictate payment or insurance decisions, or drug formularies or other third-party analyses. Third parties that cite ACR guidelines should state that these recommendations are not meant for this purpose. These recommendations cannot adequately convey all uncertainties and nuances of patient care. The American College of Rheumatology is an independent, professional, medical and scientific society that does not guarantee, warrant, or endorse any commercial product or service. OBJECTIVE. To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS. We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS. The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION. This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients’ values, goals, preferences, and comorbidities

Global Survey of Outcomes of Neurocritical Care Patients: Analysis of the PRINCE Study Part 2

BACKGROUND: Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study. METHODS: We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality. RESULTS: We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47). CONCLUSION: PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.status: publishe