Self-efficacy of older people using technology to self-manage COPD, hypertension, heart failure or dementia at home:An overview of systematic reviews

Background and Objectives Although telehealth research among the general population is voluminous, study quality is low and results are mixed. Little is known specifically concerning older people and their self-efficacy to engage with and benefit from such technologies. This paper reviews the evidence for which self-care telehealth technology supports the self-efficacy of older people with long-term conditions (LTCs) living at home. Research Design and Methods Following PRISMA guidelines, this overview of systematic reviews focused on four LTCs and the concept of ‘self-efficacy’. Quality was appraised using R-AMSTAR and study evaluation was guided by the PRISMS taxonomy for reporting of self-management support. Heterogeneous data evidencing technology-enhanced self-efficacy were narratively synthesised. Results Five included papers contained 74 primary studies involving 9,004 participants with chronic obstructive pulmonary disease (COPD), hypertension, heart failure or dementia. Evidence for self-care telehealth technology supporting self-efficacy of older people with LTCs living at home was limited. Self-efficacy was rarely an outcome, also attrition and drop-out rates and mediators of support or education. The pathway from telehealth to self-efficacy depended on telehealth modes and techniques promoting healthy lifestyles. Increased self-care and self-monitoring empowered self-efficacy, patient-activation or mastery. Discussion and Implications Future research needs to focus on the process by which the intervention works and the effects of mediating variables and mechanisms through which self-management is achieved. Self-efficacy, patient-activation, and motivation are critical components to telehealth’s adoption by the patient, and hence to the success of self-care in self-management of LTCs. Their invisibility as outcomes is a limitation

Regulation of CD4+NKG2D+ Th1 cells in patients with metastatic melanoma treated with sorafenib : role of IL-15Rα and NKG2D triggering

Beyond cancer-cell intrinsic factors, the immune status of the host has a prognostic impact on patients with cancer and influences the effects of conventional chemotherapies. Metastatic melanoma is intrinsically immunogenic, thereby facilitating the search for immune biomarkers of clinical responses to cytotoxic agents. Here, we show that a multi-tyrosine kinase inhibitor, sorafenib, upregulates interleukin (IL)-15Rα in vitro and in vivo in patients with melanoma, and in conjunction with natural killer (NK) group 2D (NKG2D) ligands, contributes to the Th1 polarization and accumulation of peripheral CD4+NKG2D+ T cells. Hence, the increase of blood CD4+NKG2D+ T cells after two cycles of sorafenib (combined with temozolomide) was associated with prolonged survival in a prospective phase I/II trial enrolling 63 patients with metastatic melanoma who did not receive vemurafenib nor immune checkpoint-blocking antibodies. In contrast, in metastatic melanoma patients treated with classical treatment modalities, this CD4+NKG2D+ subset failed to correlate with prognosis. These findings indicate that sorafenib may be used as an "adjuvant" molecule capable of inducing or restoring IL-15Rα/IL-15 in tumors expressing MHCclass I-related chain A/B (MICA/B) and on circulating monocytes of responding patients, hereby contributing to the bioactivity of NKG2D+ Th1 cells.peer-reviewe

The role of combinatorial health technologies in supporting older people with long-term conditions:Responsibilisation or co-management of healthcare?

Neoliberalism, austerity and health responsibilisation are increasingly informing policies and practices designed to encourage older patients to take responsibility for the management of their own healthcare. Combined with an ageing population, novel ways to address the increasing healthcare needs of older people have become a priority, with the emergence in recent years of new models of integrated care enhanced by combinatorial health technologies (CHTs). This paper presents qualitative findings from the evaluation of one programme, the Lancashire and Cumbria Innovation Alliance (LCIA) Test Bed, a programme funded by NHS England and conducted in England between 2016 and 2018. Drawing on data from patients, family carers, and staff members involved in the programme, this paper explores the extent to which CHTs, as part of the LCIA Test Bed programme, contributed to health responsibilisation amongst older people with complex health conditions. Through this programme, we find that relationships between patients, family carers and healthcare professionals combined to create a sense of reassurance and shared responsibility for all parties. Our findings suggest the need for a more nuanced approach to responsibilisation and self-management for older people living with complex health conditions. By focusing on co-management – and recognising the potential of CHTs to facilitate this approach – there is potential to increase patient confidence in managing their health condition, reduce carer burden, and enhance clinician satisfaction in their work roles. While neoliberal agendas are focused on self-management and self-responsibility of one’s own health care, with technology as a facilitator of this, our findings suggest that the successful use of CHTs for older people with complex health conditions may instead be rooted in co-management. This paper argues that co-management may be a more successful model of care for patients, carers and clinicians

Obesidade versus Ocupações: papeis ocupacionais de adultos com obesidade/Obesety versus occupations: Occupational roles of obese adults

Introdução: Atualmente, a obesidade é considerada um grave problema de saúde pública, pois além de ser uma doença, é um fator de risco para progressão e desenvolvimento de outras doenças crônicas não transmissíveis. Objetivo: Compreender a percepção de indivíduos com obesidade quanto à participação em papeis ocupacionais, grau de importância atribuído a cada papel e padrão de desempenho de papeis ocupacionais ao longo da vida. Método: Configura-se como um estudo transversal do tipo exploratório de caráter descritivo, com análise quantitativa dos dados. Como instrumento, utilizou-se a Lista de Identificação de Papéis Ocupacionais. Resultados: A amostra foi composta por 65 indivíduos com obesidade, 87,7% (n=57) era do sexo feminino e 12,3% (n=8) do sexo masculino, tendo como média de idade 42 anos e 9 meses. Constatou-se que o papel mais comum no passado foi o de estudante e com relação ao presente e futuro, os papeis mais citados foram os de serviço doméstico e membro da família. Quanto ao grau de importância, identificou-se que os indivíduos valorizam os papeis ocupacionais, atribuindo maior valorização aos papeis de membro da família e trabalho, e menor proporção de valor ao papel de participação em organizações. Conclusão: A condição de obesidade pode interferir no modo como o indivíduo se envolve e desempenha suas ocupações, evidenciando a terapia ocupacional como uma estratégia importante no enfrentamento da obesidade. AbstractIntroduction: Currently, obesity is considered a serious public health problem, since it is also a disease, it is a risk factor for progression and development of other chronic non-communicable diseases. Objective: To understand the perception of individuals with obesity regarding the participation in occupational roles throughout life, about the degree of importance attributed to each role, and in a complementary way to identify the performance pattern of occupational roles in Long life. Method: It is configured as a cross-sectional exploratory study of descriptive character, with quantitative analysis of the data, as an instrument used the identification list of occupational roles. Results: The sample consisted of 65 obese individuals. Of these, 87.7% (n = 57) were females and 12.3% (n = 8) were males, with a mean age of 42 years 9 months. It was found that the most common role in the past was that of student and in relation to the present and future the most cited roles were those of domestic service and family member. As to the degree of importance, it was identified that the individuals value the occupational roles, attributing greater value to the roles of family members and work, and less appreciation of the role of participation in organizations. Conclusion: The condition of obesity can interfere in the way the individual engages and performs his occupations, thus placing the occupational therapy professional as an important member in coping with obesity.Key words: Obesity, Activities of Daily Living, Occupations, Occupational Therapy.ResumenIntroducción: Actualmente, la obesidad se considera un grave problema de salud pública, ya que es también una enfermedad, es un factor de riesgo para la progresión y el desarrollo de otras enfermedades crónicas no transmisibles. Objetivo: comprender la percepción de los individuos con obesidad con respecto a la participación en los roles ocupacionales a lo largo de la vida, sobre el grado de importancia atribuido a cada función, y de manera complementaria para identificar el patrón de desempeño de los roles ocupacionales en Larga vida. Método: se configura como un estudio exploratorio transversal de carácter descriptivo, con análisis cuantitativo de los datos, como instrumento utilizó la lista de identificación de roles ocupacionales. Resultados: la muestra consistió en 65 individuos obesos. De ellos, 87,7% (n = 57) fueron hembras y 12,3% (n = 8) fueron varones, con una edad media de 42 años 9 meses. Se descubrió que el papel más común en el pasado era el de los estudiantes y en relación con el presente y el futuro, los papeles más citados eran los del servicio doméstico y el miembro de la familia. En cuanto al grado de importancia se identificó que los individuos valoran los papeles ocupacionales, atribuyendo mayor valoración a los papeles de miembro de la familia y trabajo, y menor valorización al papel de participación en organizaciones. Conclusión: la condición de la obesidad puede interferir en la forma en que el individuo se involucra y realiza sus ocupaciones, colocando así al profesional de la terapia ocupacional como un miembro importante para hacer frente a la obesidad.Palabras clave: Obesidad, Actividades Cotidianas, Ocupaciones, Terapia Ocupacional. 

The price of tumor control

Ipilimumab, a cytotoxic T-lymphocyte antigen-4 (CTLA-4) blocking antibody, has been approved for the treatment of metastatic melanoma and induces adverse events (AE) in up to 64% of patients. Treatment algorithms for the management of common ipilimumab-induced AEs have lead to a reduction of morbidity, e.g. due to bowel perforations. However, the spectrum of less common AEs is expanding as ipilimumab is increasingly applied. Stringent recognition and management of AEs will reduce drug-induced morbidity and costs, and thus, positively impact the cost-benefit ratio of the drug. To facilitate timely identification and adequate management data on rare AEs were analyzed at 19 skin cancer centers. Patient files (n = 752) were screened for rare ipilimumab-associated AEs. A total of 120 AEs, some of which were life-threatening or even fatal, were reported and summarized by organ system describing the most instructive cases in detail. Previously unreported AEs like drug rash with eosinophilia and systemic symptoms (DRESS), granulomatous inflammation of the central nervous system, and aseptic meningitis, were documented. Obstacles included patientś delay in reporting symptoms and the differentiation of steroid-induced from ipilimumab-induced AEs under steroid treatment. Importantly, response rate was high in this patient population with tumor regression in 30.9% and a tumor control rate of 61.8% in stage IV melanoma patients despite the fact that some patients received only two of four recommended ipilimumab infusions. This suggests that ipilimumab-induced antitumor responses can have an early onset and that severe autoimmune reactions may reflect overtreatment. The wide spectrum of ipilimumab-induced AEs demands doctor and patient awareness to reduce morbidity and treatment costs and true ipilimumab success is dictated by both objective tumor responses and controlling severe side effects

Experiences of stigma and discrimination among people living with dementia and family carers in Brazil: qualitative study

This study aimed to understand stigma in relation to people living with dementia in São Paulo, Brazil. A critical narrative inquiry methodology was used. Home-based semi-structured interviews were conducted between January and March 2020 with six people living with dementia and 15 family carers. Data analysis was conducted using inductive and deductive techniques. The latter was informed by Link and Phelan's sociological theory of stigma. We found that dementia was commonly viewed by people living with dementia as part of ageing and carers reported low levels of knowledge and awareness about the condition. To avoid negative reactions from people, people living with dementia managed the negative views of dementia by minimising and normalising the condition, by expressing their ability to live an active life, and by emphasising the positive impacts of dementia in their lives. Fear of negative reactions appeared to lead to a selective disclosure of their diagnosis. Among carers, stigmatising attitudes coincided with a strong willingness to provide good care, to protect the person cared for, as well as to understand and validate their own caring experiences, rather than to cause any harm. In doing so, however, carers ended up depersonalising and infantilising people living with dementia, underestimating their capacities, demanding ‘obedience’ and restricting the person's freedom. There is a need to increase awareness about dementia and to provide support and training on person-centred and ethical care for carers in Brazil

As fases de adaptação no cuidar: intervenções com cuidadores familiares no domicílio

A partir do Projeto de Extensão “Um olhar sobre o cuidador familiar: quem cuida merece ser cuidado”, realizado com 52 cuidadores de pacientes crônicos dos Serviços de Atenção Domiciliar no sul do Rio Grande do Sul, objetivou-se relatar a experiência da identificação das fases de adaptação do processo de cuidar e intervenções realizadas aos cuidadores no contexto domiciliar. Por meio de quatro visitas domiciliares por acadêmicos de Enfermagem e da Terapia Ocupacional, no período de junho de 2015 a dezembro de 2016, produziu-se registros, nos quais a fase de resolução foi a mais frequente e a escuta terapêutica foi a intervenção mais realizada. Assim, a identificação das fases de adaptação de Ferré-Grau et al. (2011) possibilitou conhecer as necessidades do cuidador e o planejamento de ações de promoção de saúde e prevenção de agravos

The price of tumor control: an analysis of rare side effects of anti-CTLA-4 therapy in metastatic melanoma from the ipilimumab network

Background: Ipilimumab, a cytotoxic T-lymphocyte antigen-4 (CTLA-4) blocking antibody, has been approved for the treatment of metastatic melanoma and induces adverse events (AE) in up to 64% of patients. Treatment algorithms for the management of common ipilimumab-induced AEs have lead to a reduction of morbidity, e.g. due to bowel perforations. However, the spectrum of less common AEs is expanding as ipilimumab is increasingly applied. Stringent recognition and management of AEs will reduce drug-induced morbidity and costs, and thus, positively impact the cost-benefit ratio of the drug. To facilitate timely identification and adequate management data on rare AEs were analyzed at 19 skin cancer centers. Methods and Findings: Patient files (n = 752) were screened for rare ipilimumab-associated AEs. A total of 120 AEs, some of which were life-threatening or even fatal, were reported and summarized by organ system describing the most instructive cases in detail. Previously unreported AEs like drug rash with eosinophilia and systemic symptoms (DRESS), granulomatous inflammation of the central nervous system, and aseptic meningitis, were documented. Obstacles included patientś delay in reporting symptoms and the differentiation of steroid-induced from ipilimumab-induced AEs under steroid treatment. Importantly, response rate was high in this patient population with tumor regression in 30.9% and a tumor control rate of 61.8% in stage IV melanoma patients despite the fact that some patients received only two of four recommended ipilimumab infusions. This suggests that ipilimumab-induced antitumor responses can have an early onset and that severe autoimmune reactions may reflect overtreatment. Conclusion: The wide spectrum of ipilimumab-induced AEs demands doctor and patient awareness to reduce morbidity and treatment costs and true ipilimumab success is dictated by both objective tumor responses and controlling severe side effects

Systematic voiding programme in adults with urinary incontinence following acute stroke: the ICONS-II RCT

Background: Urinary incontinence affects around half of stroke survivors in the acute phase, and it often presents as a new problem after stroke or, if pre-existing, worsens significantly, adding to the disability and helplessness caused by neurological deficits. New management programmes after stroke are needed to address urinary incontinence early and effectively. Objective: The Identifying Continence OptioNs after Stroke (ICONS)-II trial aimed to evaluate the clinical effectiveness and cost-effectiveness of a systematic voiding programme for urinary incontinence after stroke in hospital. Design: This was a pragmatic, multicentre, individual-patient-randomised (1 : 1), parallel-group trial with an internal pilot. Setting: Eighteen NHS stroke services with stroke units took part. Participants: Participants were adult men and women with acute stroke and urinary incontinence, including those with cognitive impairment. Intervention: Participants were randomised to the intervention, a systematic voiding programme, or to usual care. The systematic voiding programme comprised assessment, behavioural interventions (bladder training or prompted voiding) and review. The assessment included evaluation of the need for and possible removal of an indwelling urinary catheter. The intervention began within 24 hours of recruitment and continued until discharge from the stroke unit. Main outcome measures: The primary outcome measure was severity of urinary incontinence (measured using the International Consultation on Incontinence Questionnaire) at 3 months post randomisation. Secondary outcome measures were taken at 3 and 6 months after randomisation and on discharge from the stroke unit. They included severity of urinary incontinence (at discharge and at 6 months), urinary symptoms, number of urinary tract infections, number of days indwelling urinary catheter was in situ, functional independence, quality of life, falls, mortality rate and costs. The trial statistician remained blinded until clinical effectiveness analysis was complete. Results: The planned sample size was 1024 participants, with 512 allocated to each of the intervention and the usual-care groups. The internal pilot did not meet the target for recruitment and was extended to March 2020, with changes made to address low recruitment. The trial was paused in March 2020 because of COVID-19, and was later stopped, at which point 157 participants had been randomised (intervention, n = 79; usual care, n = 78). There were major issues with attrition, with 45% of the primary outcome data missing: 56% of the intervention group data and 35% of the usual-care group data. In terms of the primary outcome, patients allocated to the intervention group had a lower score for severity of urinary incontinence (higher scores indicate greater severity in urinary incontinence) than those allocated to the usual-care group, with means (standard deviations) of 8.1 (7.4) and 9.1 (7.8), respectively. Limitations: The trial was unable to recruit sufficient participants and had very high attrition, which resulted in seriously underpowered results. Conclusions: The internal pilot did not meet its target for recruitment and, despite recruitment subsequently being more promising, it was concluded that the trial was not feasible owing to the combined problems of poor recruitment, poor retention and COVID-19. The intervention group had a slightly lower score for severity of urinary incontinence at 3 months post randomisation, but this result should be interpreted with caution. Future work: Further studies to assess the effectiveness of an intervention starting in or continuing into the community are required