Evidence-based management approaches for patients with severe chronic obstructive pulmonary disease (COPD): A practice review

Background: Patients with chronic obstructive pulmonary disease (COPD) face limited treatment options and inadequate access to palliative care. Aim: To provide a pragmatic overview of clinical guidelines and produce evidence-based recommendations for severe COPD. Interventions for which there is inconsistent evidence to support their use and areas requiring further research were identified. Design: Practice review of guidelines supported by scoping review methodology to examine the evidence reporting the use of guideline-recommended interventions. Data sources: An electronic search was undertaken in MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Database of Systematic Reviews, complemented by web searching for guidelines and publications providing primary evidence (July 2021). Guidelines published within the last 5 years and evidence in the last 10 years were included. Results: Severe COPD should be managed using a multidisciplinary approach with a holistic assessment. For stable patients, long-acting beta-agonist/long-acting muscarinic antagonist and pulmonary rehabilitation are recommended. Low dose opioids, self-management, handheld fan and nutritional support may provide small benefits, whereas routine corticosteroids should be avoided. For COPD exacerbations, systematic corticosteroids, non-invasive ventilation and exacerbation action plans are recommended. Short-acting inhaled beta-agonists and antibiotics may be considered but pulmonary rehabilitation should be avoided during hospitalisation. Long term oxygen therapy is only recommended for patients with chronic severe hypoxaemia. Short-acting anticholinergic inhalers, nebulised opioids, oral theophylline or telehealth are not recommended. Conclusions: Recommended interventions by guidelines are not always supported by high-quality evidence. Further research is required on efficacy and safety of inhaled corticosteroids, antidepressants, benzodiazepines, mucolytics, relaxation and breathing exercises

One size does not fit all - stroke survivor's views on group self-management interventions

INTRODUCTION: Stroke is the main cause of complex disability in the UK. Many stroke survivors feel abandoned when rehabilitation ends and more than half are left with long-term unmet needs. There is now emerging interest in whether group self-management programs (SMP) specifically for stroke survivors could help. However, more work is required to understand the acceptability of group SMPs to stroke survivors and the factors of concern that could impact efficacy. PURPOSE: The purpose of this study is to explore stroke survivor's views on (1) possible benefits of a group SMP, (2) possible challenges of a group SMP, and (3) when/where to implement a SMP in an individual's stroke journey. METHOD: Fourteen stroke survivors took part in semi-structured interviews, which were analyzed using an inductive thematic approach. RESULTS: Three main themes were identified in the data: (1) a space to share support, (2) it is not a one size fits all problem, and (3) how is it all going to happen? CONCLUSION: A varied group of stroke survivors can provide valuable insight and ideas about how group SMP's should be constructed. To the best of our knowledge, this is the first patient engagement study that explores group SMPs for stroke. In future work, researchers may find it helpful to consider the findings from this study to inform the design of group SMPs. Implications for Rehabilitation There is interest in whether unmet needs after stroke could be addressed through a group self-management program (SMP). Stroke survivors can provide valuable insight and ideas about how group SMPs should be constructed. Group SMPs should carefully consider: how to create a safe space in which stroke survivors feel comfortable, the impact of the facilitators, tailoring the group to the individual, the presence of carers, and the emotional impact of a group SMP

Plaque Rupture in Coronary Atherosclerosis Is Associated With Increased Plaque Structural Stress.

OBJECTIVES: The aim of this study was to identify the determinants of plaque structural stress (PSS) and the relationship between PSS and plaques with rupture. BACKGROUND: Plaque rupture is the most common cause of myocardial infarction, occurring particularly in higher risk lesions such as fibroatheromas. However, prospective intravascular ultrasound-virtual histology studies indicate that 135 kPa was a good predictor of rupture in higher risk regions. CONCLUSIONS: PSS is determined by plaque composition, plaque architecture, and lumen geometry. PSS and PSS variability are increased in plaques with rupture, particularly at proximal segments. Incorporating PSS into plaque assessment may improve identification of rupture-prone plaques.This work was supported by British Heart Foundation grants CH/20000003/12800, FS/13/33/30168, and FS/15/26/31441; Heart Research UK grant RG2638/14/16 and MRC Confidence in Concepts award; and the NIHR Cambridge Biomedical Research Centre

Oral hygiene improvement: a pragmatic approach based upon risk and motivation levels

Good oral hygiene has always been the cornerstone of public and private dental health promotion. However, this has often been based upon incorrect assumptions. The public is not always willing and does not always need to change its oral health behavior to the same extent as that expected by the dental profession. The present commentary emphasizes the need to modify oral hygiene instruction according to specific risk and motivation levels. Dentistry needs to be flexible in accepting new evidence-based modalities of oral health promotion. Dentists, dental hygienists and the entire health care team need to accept that the traditional methods of oral health education are not always effective

Conceptualising effective symptom management in palliative care: a novel model derived from qualitative data

Background Pain, breathlessness and fatigue are some of the most challenging symptoms to manage in patients with advanced disease. Specialist palliative care leads to better symptom management, but factors contributing to successful symptom management in this context have not been explored. Our aim was to understand what facilitates effective symptom management in specialist palliative care within UK hospices and investigate what barriers are experienced. Methods This was a grounded theory study using qualitative semi-structured focus groups and interviews. Participants were recruited from multidisciplinary specialist palliative care teams (doctors, nurses, healthcare assistants, physiotherapists, occupational therapists, complementary therapists, social workers and chaplains) working in inpatient, outpatient and community services provided by five hospices in the United Kingdom. Results We present a novel qualitative data-derived model of effective symptom management in specialist palliative care. We describe a co-ordinated, multi-faceted, sequential approach involving a process of engagement, partnership, decision-making, and delivery. Interventions to manage symptoms are less effective in psychologically distressed patients. Our data highlights that families of patients have a key role in determining effectiveness of symptom management interventions A holistic approach by a co-ordinated, multi-disciplinary team, including support to recognise and minimise psychological distress might facilitate more effective symptom management. Barriers to symptom management include team discordance and lack of understanding about symptom management by patient and families. Conclusions Shared decision-making between patients and professionals and co-ordination of care by a multi-disciplinary team are key components of effective symptom management. Actions to address psychological distress and evaluate the understanding and expectations of patients and their families would enable more effective symptom management. A more effective multi-disciplinary approach would be facilitated by discussion within teams about role competencies and boundaries

Relationships of the Psychological Influence of Food and Barriers to Lifestyle Change to Weight and Utilization of Online Weight Loss Tools

Abstract: Introduction: The psychological influence of food (PFS) and perceived barriers to lifestyle change (PBLC) were considered as predictors of body mass index and website tool utilization (TU) in an online weight loss program. Materials and Methodology: An archival analysis of all (N = 1361) overweight/obese (BMI M = 31.6 + 6.24 kg/m 2), adult (M = 42.0 + 10.72 years) users (82.4 % female) of an evidence-based, multidisciplinary Internet weight loss program was performed. Predictor variables included: PFS and PBLC, age, and longest maintained weight loss in relation to 1) BMI 2

Practice review: Evidence-based and effective management of fatigue in patients with advanced cancer

Background: Fatigue affects most patients living with advanced cancer and is a symptom that healthcare professionals can find difficult to manage. Aim: To provide healthcare professionals with a pragmatic overview of approaches to management of fatigue in patients with advanced cancer that are commonly recommended by guidelines and to evaluate evidence underpinning them. Design: Scoping review methodology was used to determine the strength of evidence supporting use of interventions recommended in management of fatigue in patients with advanced cancer. Data sources: National or international guidelines were examined if they described the management of fatigue in adult cancer patients and were written within the last 6 years (2015–2021) in English. The Cochrane Database of Systematic Reviews (January 2011–December 2021) was searched for ‘cancer’ AND ‘fatigue’ in title, abstract or keywords. A PubMed search was also made. Results: Evidence indicates physical exercise interventions are effective and patients may benefit from energy conservation tactics. Evidence does not support use of psychostimulants such as methylphenidate. Limited data were found on efficacy of corticosteroids, psychological interventions, nutritional intervention, sleep optimization or complementary therapies for management of fatigue in advanced cancer. Conclusion: We recommend regular assessment, review and acknowledgement of the impact of fatigue. Exercise and energy conservation should be considered. Pharmacological interventions are not endorsed as a routine approach. Many interventions currently recommended by guidelines are not supported by a robust evidence base and further research on their efficacy is required

Scallop swimming kinematics and muscle performance: modelling the effects of "within-animal" variation in temperature sensitivity

Escape behaviour was investigated in Queen scallops (Aequipecten opercularis) acclimated to 5, 10 or 15 degrees C and tested at their acclimation temperature. Scallops are active molluscs, able to escape from predators by jet-propelled swimming using a striated muscle working in opposition to an elastic hinge ligament. The first cycle of the escape response was recorded using high-speed video ( 250 Hz) and whole-animal velocity and acceleration determined. Muscle shortening velocity, force and power output were calculated using measurements of valve movement and jet area, and a simple biomechanical model. The average shortening speed of the adductor muscle had a Q(10) of 2.04, significantly reducing the duration of the jetting phase of the cycle with increased temperature. Muscle lengthening velocity and the overall duration of the clap cycle were changed little over the range 5 - 15 degrees C, as these parameters were controlled by the relatively temperature-insensitive, hinge ligament. Improvements in the average power output of the adductor muscle over the first clap cycle ( 222 vs. 139 W kg(-1) wet mass at 15 and 5 degrees C respectively) were not translated into proportional increases in overall swimming velocity, which was only 32% higher at 15 degrees C ( 0.37m s(-1)) than 5 degrees C (0.28 m s(-1))

The effects of temperature and body mass on jump performance of the locust Locusta migratoria

Locusts jump by rapidly releasing energy from cuticular springs built into the hind femur that deform when the femur muscle contracts. This study is the first to examine the effect of temperature on jump energy at each life stage of any orthopteran. Ballistics and high-speed cinematography were used to quantify the energy, distance, and take-off angle of the jump at 15, 25, and 35°C in the locust Locusta migratoria. Allometric analysis across the five juvenile stages at 35°C reveals that jump distance (D; m) scales with body mass (M; g) according to the power equation D = 0.35M0.17±0.08 (95% CI), jump take-off angle (A; degrees) scales as A = 52.5M0.00±0.06, and jump energy (E; mJ per jump) scales as E = 1.91M1.14±0.09. Temperature has no significant effect on the exponent of these relationships, and only a modest effect on the elevation, with an overall Q10 of 1.08 for jump distance and 1.09 for jump energy. On average, adults jump 87% farther and with 74% more energy than predicted based on juvenile scaling data. The positive allometric scaling of jump distance and jump energy across the juvenile life stages is likely facilitated by the concomitant relative increase in the total length (Lf+t; mm) of the femur and tibia of the hind leg, Lf+t = 34.9M0.37±0.02. The weak temperature-dependence of jump performance can be traced to the maximum tension of the hind femur muscle and the energy storage capacity of the femur's cuticular springs. The disproportionately greater jump energy and jump distance of adults is associated with relatively longer (12%) legs and a relatively larger (11%) femur muscle cross-sectional area, which could allow more strain loading into the femur's cuticular springs. Augmented jump performance in volant adult locusts achieves the take-off velocity required to initiate flight.Edward P. Snelling, Christie L. Becker, Roger S. Seymou

Against strong pluralism

Strong pluralists hold that not even permanent material coincidence is enough for identity. Strong pluralism entails the possibility of purely material objects -- even if not coincident -- alike in all general respects, categorial and dispositional, relational and non-relational, past, present and future, at the microphysical level, but differing in some general modal, counterfactual or dispositional repscts at the macrophysical level. It is objectionable because it thus deprives us of the explanatory resources to explain why evident absurdities are absurd. A second objection is to the suggestion that cases involving artefacts can illustrate strong pluralism. This offends against the principle that gien a complex intrinsic microphysical property instantiated in some regiion, the number of material things possessing it in that region cannot depend on the existence and nature of intentional activity taking place outside it