Shame as a social phenomenon: A critical analysis of the concept of dispositional shame

An increased clinical interest in shame has been reflected in the growing number of research studies in this area. However, clinically-orientated empirical investigation has mostly been restricted to the investigation of individual differences in dispositional shame. This paper reviews recent work on dispositional shame but then argues that the primacy of this construct has been problematic in a number of ways. Most importantly, the notion of shame as a context-free intrapsychic variable has distracted clinical researchers from investigating the management and repair of experiences of shame and shameful identities, and has made the social constitution of shame less visible. Several suggestions are made for alternative ways in which susceptibility to shame could be conceptualised, which consider how shame might arise in certain contexts and as a product of particular social encounters. For example, persistent difficulties with shame may relate to the salience of stigmatising discourses within a particular social context, the roles or subject positions available to an individual, the establishment of a repertoire of context-relevant shame avoidance strategies and the personal meaning of shamefulness

Shame as a social phenomenon

Purpose: This paper argues for a theoretical approach to chronic shame which emphasises social factors in the development of psychological problems. Some of the implications of this for research and clinical practice are considered. Context: Clinical psychologists are increasingly drawing on the concept of shame to inform therapeutic work. However, a comprehensive review of clinically-orientated research on shame over a four-year period revealed that this has mostly been restricted to the investigation of individual differences, conceptualising shame as an attribute of the individual. Key Points: It is argued that the notion of shame as a context-free intrapsychic variable has distracted clinical researchers from investigating shame as a lived emotional experience and has made the social constitution of shame less visible. As such, there is very little data available on the avoidance, management and repair of experiences of shame and little exploration of how shameful identities might emerge in particular social contexts. Several suggestions are made for alternative ways in which susceptibility to shame could be conceptualised, which consider the individual’s social world and the importance of the roles or subject positions available. Conclusions: To better inform clinical practice, research needs to focus more explicitly on the social and interpersonal processes which either enable or inhibit the avoidance, management and repair of shame. The implications of a more contextualised understanding of shame for practitioners include a willingness to (a) work with clients at achieving real changes in their social worlds and (b) to develop services which offer positive identities for user

Promotors and barriers to the implementation and adoption of assistive technology and telecare for people with dementia and their caregivers: a systematic review of the literature

Background One of the most pressing issues in our society is the provision of proper care and treatment for the growing global health challenge of ageing. Assistive Technology and Telecare (ATT) is a key component in facilitation of safer, longer, and independent living for persons with Dementia (PwD) and has the potential to extend valuable care and support for caregivers (formal and informal) globally. Results of this systematic review are of key importance because well-executed ATT implementation, leading to habitual usage and adoption, can assist and strengthen current healthcare services, improve access to healthcare and decrease societal and caregiver burden. Objective The objective of this study is to identify promotors and barriers to implementation and adoption of ATT for PwD and their informal (family and friends) and formal (healthcare professionals) caregivers. In addition, we aim to provide valuable insight for municipalities and healthcare organizations for improved implementation strategies. Methods The study was registered in PROSPERO 25th of February, 2021: CRD42021239448. NVivo was utilized for synthesis and analysis of article content. As the results were from diverse disciplines using varied methods of analysis, a semi-systematic approach with narrative synthesis was used for the review. PICO criteria and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines have been used to guide all processes and results. Rayyan and NVivo were utilized for selection of articles and analysis of found themes. In addition, the Critical Appraisal Skills Programme (CASP) has been used to visualize meta-synthesis and meta-analysis results and overall quality of included literature. Results This review encompasses relevant information regarding the implementation and adoption of ATT for PwD and their caregivers from five continents and sixty-five countries. It is a true global representation of the growing challenge of ageing. In total, 32 publications were included for review. Identified primary promotors for the implementation and adoption of ATT were as follows: personalized (tailored) training and co-designed solutions, safety for the PwD, involvement of all relevant stakeholders (multi-faceted approach including PwD), ease of use and support (design and follow up), and cultural relevance. Main barriers for the implementation and adoption of ATT included: unintended adverse consequences, timing and disease progress, technology anxiety, system failures (connectivity, errors, etc.), digital divide and lack of access to or knowledge of available ATT. Conclusions The most crucial elements for the adoption of ATT in the future will be a focus on co-design, improved involvement of both the PwD and their caregivers, and the adaptability (tailoring related to context) of ATT solutions over time (disease process). 94% of the literature presented in the review comes from high income countries. There is a significant need for more quality research to be conducted in the regions of the world where population growth and prevalence of dementia is expected to grow most rapidly over the next 30 years.M.Phil. in Global Health - ThesisINTH395AMAMD-GLO

Gaps in care and support for patients with advanced breast cancer: a report from the Advanced Breast Cancer Global Alliance

PURPOSE Although new therapeutic options continue to improve disease-related outcomes in advanced breast cancer (ABC), enhanced focus is needed to improve quality of life for patients currently living with ABC. METHODS In November 2019, a multidisciplinary workshop to explore patient perceptions of their information and support needs was held at the ABC Global Alliance Annual Meeting in Lisbon, Portugal. Ninety-two attendees from 27 countries participated in the workshop. RESULTS Several key unmet needs were identified and discussed in the workshop, including the following: (1) Significant patient knowledge gaps exist related to the diagnosis and management of ABC, and the availability of patient-focused information to support these gaps in knowledge remains limited. (2) The development of meaningful relationships between patients and health care professionals, and the role of patients in decision making, is often overlooked for patients with ABC. (3) Multidisciplinary care approaches are crucial for patients with ABC; however, these often lack effective coordination. (4) Access to clinical trials for ABC also remains limited. (5) Caregivers, friends, and family members do not receive sufficient guidance to support patients with ABC and manage their own well-being. CONCLUSION The variety of unmet needs explored in the workshop demonstrates that patients with ABC still face considerable challenges related to quality of care and support, which will not be resolved until tangible action is taken. Issues highlighted in the workshop should be prioritized by working groups to shape the development of community-based solutions. There is a need for the global community to act proactively to maximize awareness of these ongoing unmet needs and existing resources, while socializing and building new initiatives and resources that will help to close these gaps for patients

NPC1 deficiency impairs cerebellar postnatal development of microglia and climbing fiber refinement in a mouse model of Niemann-Pick disease type C.

Little is known about the effects of NPC1 deficiency in brain development and whether these effects contribute to neurodegeneration in Niemann-Pick disease type C (NPC). Degeneration of cerebellar Purkinje cells occurs at an earlier stage and to a greater extent in NPC; therefore, we analyzed the effect of NPC1 deficiency on microglia and on climbing fiber synaptic refinement during cerebellar postnatal development using th

Cytokine Combination Therapy with Erythropoietin and Granulocyte Colony Stimulating Factor in a Porcine Model of Acute Myocardial Infarction

PurposeErythropoietin (EPO) and granulocyte colony stimulating factor (GCSF) have generated interest as novel therapies after myocardial infarction (MI), but the effect of combination therapy has not been studied in the large animal model. We investigated the impact of prolonged combination therapy with EPO and GCSF on cardiac function, infarct size, and vascular density after MI in a porcine model.MethodsMI was induced in pigs by a 90 min balloon occlusion of the left anterior descending coronary artery. 16 animals were treated with EPO+GCSF, or saline (control group). Cardiac function was assessed by echocardiography and pressure-volume measurements at baseline, 1 and 6 weeks post-MI. Histopathology was performed 6 weeks post-MI.ResultsAt week 6, EPO+GCSF therapy stabilized left ventricular ejection fraction, (41 ± 1% vs. 33 ± 1%, p < 0.01) and improved diastolic function compared to the control group. Histopathology revealed increased areas of viable myocardium and vascular density in the EPO+GCSF therapy, compared to the control. Despite these encouraging results, in a historical analysis comparing combination therapy with monotherapy with EPO or GCSF, there were no significant additive benefits in the LVEF and volumes overtime using the combination therapy.ConclusionOur findings indicate that EPO+GCSF combination therapy promotes stabilization of cardiac function after acute MI. However, combination therapy does not seem to be superior to monotherapy with either EPO or GCSF

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

Genetic mechanisms of critical illness in COVID-19.

Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, P = 1.65 × 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, P = 2.3 × 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, P = 3.98 ×  10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, P = 4.99 × 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication