Activity pacing is associated with better and worse symptoms for patients with long-term conditions

Background: Activity pacing has been associated with both improved and worsened symptoms, and its role in reducing disability among patients with long-term conditions has been questioned. However, existing studies have measured pacing according to unidimensional subscales, and therefore the empirical evidence for pacing as a multifaceted construct remains unclear. We have developed a 26-item Activity Pacing Questionnaire (APQ-26) for chronic pain/fatigue containing 5 themes of pacing: activity adjustment, activity consistency, activity progression, activity planning, and activity acceptance. Objective: To assess the associations between the 5 APQ-26 pacing themes and symptoms of pain, physical fatigue, depression, avoidance, and physical function. Methods: Cross-sectional questionnaire study design. Data analyzed using multiple regression. Participants: A total of 257 adult patients with diagnoses of chronic low back pain, chronic widespread pain, fibromyalgia, and chronic fatigue syndrome/myalgic encephalomyelitis. Results: Hierarchical multiple regression showed that activity adjustment was significantly associated with increased physical fatigue, depression, and avoidance, but decreased physical function (all Ps≤0.030). Activity consistency was associated with decreased pain, physical fatigue, depression, and avoidance, but increased physical function (all Ps≤0.003). Activity planning was associated with reduced physical fatigue (Ps=0.025) and activity acceptance was associated with increased avoidance (Ps=0.036). Conclusions: Some APQ-26 pacing themes were associated with worse symptoms and others with symptom improvement. Specifically, pacing themes involving adjusting/reducing activities were associated with worse symptoms, whereas pacing themes involving undertaking consistent activities were associated with improved symptoms. Future study will explore the causality of these associations to add clarification regarding the effects of pacing on patients’ symptoms

Exploring patients’ opinions of activity pacing and a new activity pacing questionnaire for chronic pain and/or fatigue:a qualitative study

Objective: Despite the frequent recommendation of activity pacing as a coping strategy for patients with chronic pain and/or fatigue, pacing is interpreted in different ways and there is an absence of a widely accepted pacing scale. We have developed a new Activity Pacing Questionnaire(APQ). The aims of this study were to explore patients’ views and beliefs about the concept of pacing, together with the acceptability of the APQ. Design: Qualitative pragmatic study using semi-structured telephone interviews. Data were analysed using Framework analysis. Participants 16 adult patients attending secondary care physiotherapy out-patient departments were recruited via purposive sampling. Diagnoses included chronic low back pain, chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalomyelitis. Findings: Pacing emerged as a multifaceted concept from participants’ descriptions. The implementation of pacing was influenced by participants’ age, the presence of co-morbidities and participants’ emotions. The APQ was found to be generally acceptable in comparison to two existing pacing subscales. Participants undertook activities using quota/symptom-contingent approaches. Four behavioural typologies emerged: Task avoidance, Task persistence, Task fluctuation (boom-bust) and Task modification (activity pacing). Conclusions: The APQ appears to be easy to complete, and acceptable to patients who are attending physiotherapy for the management of long-term conditions. It emerged that individual patients implemented different pacing facets to varying degrees, and that different behavioural typologies were apparent. The relationships between behavioural typologies and facets of pacing warrant further investigation to facilitate the development of effective tailored pacing interventions

Psychosocial predictors of health-related quality of life and health service utilisation in people with chronic low back pain

Psychological and social factors have been shown, separately, to predict outcome in individuals with chronic low back pain. Few previous studies, however, have integrated both psychological and social factors, using prospective study of clinic populations of low back pain patients, to identify which are the most important targets for treatment. One hundred and eight patients with chronic low back pain, newly referred to an orthopaedic outpatient clinic, completed assessments of demographic characteristics, details of back pain, measures of anxiety and depression (Hospital Anxiety and Depression Scale, HADS), fearful beliefs about pain (Fear Avoidance Beliefs Questionnaire), social stresses (Life Events and Difficulties Schedule) and physical aspects of health‐related quality of life [SF‐36 Physical Component summary Score scale (PCS)]. Six months later subjects completed the SF‐36 PCS and the number of healthcare contacts during follow‐up was recorded. Independent predictors of SF‐36 PCS at 6‐month follow‐up were duration of pain [(standardised regression coefficient (β) = −0.18, p = 0.04), HADS score (β) = −0.27, p = 0.003] and back pain related social difficulties (β = −0.42, p < 0.0005). Number of healthcare contacts over the 6 months ranged from 1 to 29, and was independently predicted by perceived cause of pain [Incident Rate Ratio (IRR) = 1.46, p = 0.03], Fear Avoidance Beliefs about work (IRR = 1.02, p = 0.009) and back pain related social difficulties (IRR = 1.16, p = 0.03). To conclude, anxiety, depression, fear avoidance beliefs relating to work and back pain related stresses predict impairment in subsequent physical health‐related quality of life and number of healthcare contacts. Interventions targeting these psychosocial variables in clinic patients may lead to improved quality of life and healthcare costs

Use of ultra-low dose computed tomography versus abdominal plain film for assessment of stone-free rates after shock-wave lithotripsy: implications on emergency room visits, surgical procedures, and cost-effectiveness

The aims of this investigation were: (1) to compare residual stone-fragment (RSF) detection rates of ultra-low dose computed tomography (ULD-CT) and abdominal plain film (KUB) in urolithiasis patients undergoing shock-wave lithotripsy (SWL), and (2) to evaluate the downstream sequelae of utilizing these two disparate imaging pathways of differing diagnostic fidelity. A retrospective chart-review of patients undergoing SWL at two high-volume surgical centers was undertaken (2013-2016). RSF diagnostic rates of ULD-CT and KUB were assessed, and the impact of imaging modality used on subsequent emergency room (ER) visits, unplanned procedures, and cost-effectiveness was investigated. Adjusted analyses examined association between imaging modality used and outcomes, and Markov decision-tree analysis was performed to identify a cost advantageous scenario for ULD-CT over KUB. Of 417 patients studied, 57 (13.7%) underwent ULD-CT while the remaining 360 underwent KUB. The RSF rates were 36.8% and 22.8% in the ULD-CT and KUB groups, respectively (p = 0.019). A 5.6% and 18% of the patients deemed stone-free on ULD-CT and KUB, respectively, returned to the ER (p = 0.040). Similarly, 2.8% and 15.1% needed an unplanned surgery (p = 0.027). These findings were confirmed on multivariable analyses, Odds ratios CT-ULD versus KUB: 0.19 and 0.10, respectively, p \u3c 0.05. With regards to cost-effectiveness, at low ULD-CT charges, the ULD-CT follow-up pathway was economically more favorable, but with increasing ULD-CT charges, the KUB follow-up pathway superseded. ULD-CT seems to provide a more \u27true\u27 estimate of stone-free status, and in consequence mitigates unwanted emergency and operating room visits by reducing untimely stent removals and false patient reassurances. Further, at low ULD-CT costs, it may also be economically more favorable

Maintaining musculoskeletal health using a behavioural therapy approach : a population-based randomised controlled trial (the MAmMOTH Study)

Acknowledgements: The study was funded by Arthritis Research UK (now Versus Arthritis) grant number: 20748. Costs for delivery of the intervention were provided by NHS Grampian, NHS Greater Glasgow and Clyde, and NHS Highland. The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. We acknowledge the contribution of the trial steering committee to the successful conduct of the study. The members were Professor Ernest Choy (Cardiff University), Professor Tamar Pincus (Royal Holloway, University of London) and Gordon Taylor (Bath University). We thank Brian Taylor and Mark Forrest from the Centre for Healthcare Randomised Trials (CHaRT) at the University of Aberdeen for their technical assistance and Professor Graeme MacLennan, Director of CHaRT, for methodological input. Professor John Norrie (originally University of Aberdeen now University of Edinburgh) and Dr. Majid Artus (originally Keele University, now the Osmaston surgery, Derbyshire) were study investigators at the time of grant award but subsequently left the study. We thank Kathy Longley (a representative of Fibromyalgia Action UK) for her input to the grant application and the project as well as from members of the public on the University of Aberdeen College of Life Sciences and Medicine Research Interest Group. The prioritisation of “Prevention of chronic pain” arose from a 2012 meeting of the Arthritis Research UK Clinical Study Group in Pain to which patients contributed.Peer reviewedPostprintsupplementary_datasupplementary_dat

Receiving Preferred Treatment not Associated with Positive Outcome in a Randomized Trial

Background: In a randomized trial of treatments for chronic widespread pain (CWP), participants were asked their treatment preference just prior to randomisation (baseline). This analysis examined whether treatment preference was associated with baseline factors and whether receiving a preferred treatment affected outcomes. Methods: The MUSICIAN trial was a 2 × 2 randomized trial of cognitive behavioural therapy (CBT) or exercise for people with CWP. Participants were randomly allocated to one of three active treatments [CBT (n = 112), exercise (n = 109), both exercise and CBT (n = 112)] or usual care (n = 109). Before allocation participants were asked, if they had a choice, which active treatment they would choose. A positive outcome was self-reported improvement in health of much or very much better 6, 9 and 30 months after entering the study. Associations between preference and baseline characteristics were examined, including age, gender, chronic pain grade (CPG), passive and active coping, fatigue, psychological distress, sleep problems and kinesiophobia. Differences in gender and CPG between preferences were tested by chi-square tests. For continuous variables, comparison was by analysis of variance and, where a difference was observed, Tukey’s honest significant difference was used to identify which preferences differed and then the standardized mean difference (d) with 95% CIs were calculated. Among those allocated to active treatments, logistic regression was used to calculate odds ratios, adjusted for factors associated with preference, with 95% CIs of positive outcome in those receiving their preferred treatment and not receiving preferred treatment as the referent group. Results: Of 442 participants, 144 (33%) expressed preference for exercise, 20 (5%) for CBT, 199 (45%) for combined exercise and CBT and 79 (18%) expressed no preference. Compared with females, males were more likely to prefer exercise only (44 vs 28%) and less likely to prefer combined treatment (35 vs 50%). Those preferring CBT, compared with those preferring exercise, were higher in passive coping [d = 0.9 (95% CI 0.41, 1.37)], fatigue [0.8 (0.34, 1.31)], psychological distress [0.7 (0.26, 1.21)], sleep problems [0.7 (0.18, 1.12)] and kinesiophobia [0.6 (0.17, 1.12)]. Those preferring CBT also had greater scores on passive coping than those preferring combined treatment [0.6 (95% CI 0.11, 1.03)] or no preference [0.5 (−0.01, 0.98)] and greater kinesiophobia than those with no preference [0.5 (−0.05, 0.95)]. Of participants allocated to CBT, exercise or combined treatment, 7, 39 and 50%, respectively, had a preference for their allocated treatment. There was no clear association between achieving a positive outcome and whether or not someone received their preferred treatment (see Table 1). Conclusion: Exercise and exercise combined with CBT were the most preferred treatments. Participants with specific preferences differed from each other with respect to factors which might influence outcome. However, receiving preferred treatment did not appear to influence treatment response. Disclosure statement: M.B. has received funding for the MUSICIAN Study from Arthritis Research UK. G.J.M. has received funding for the MUSICIAN Study from Arthritis Research UK. All other authors have declared no conflicts of interest

The impact of prior care experience on nursing students' compassionate values and behaviours: A mixed methods study

Background: Compassion is critical to the provision of high-quality healthcare and is foregrounded internationally as an issue of contemporary concern. Paid care experience prior to nurse training has been suggested as a potential means of improving compassion, which has been characterised by the values and behaviours of care, compassion, competence, communication, courage, and commitment. There is however a dearth of evidence to support the effectiveness of prior care experience as a means of improving compassion in nursing. Objective: To explore the impact of paid prior care experience on the values and behaviours of pre-registration nursing students indicated as characterising compassionate care. Design: Longitudinal mixed methods design employing a modified concurrent triangulation strategy, comprising two work packages. Work package 1 was qualitative, and work package 2 adopted a concurrent embedded strategy with a dominant quantitative component. Research is reported in accordance with the Good Reporting of a Mixed Methods Study framework. Setting(s): Three United Kingdom universities. Participants: Pre-registration nursing students attending one of three universities, and individuals who had previously participated in a Health Education England paid prior care experience pilot. Participant numbers at time point 1 were questionnaires n = 220, telephone interviews n = 10, and focus groups n = 8. Methods: Work package 1 consisted of longitudinal semi-structured telephone interviews. Work package 2 comprised validated online questionnaires measuring emotional intelligence, compassion satisfaction and fatigue, resilience, psychological empowerment, and career commitment (as proxies of compassionate values and behaviours), and focus groups. Qualitative data were thematically analysed. Quantitative data were analysed via Analysis of Variance in SPSS v 26. Results: Qualitative findings suggest that prior care experience has both positive and negative effects on students' compassionate values and behaviours, however positive effects do not extend to qualification. No statistically significant differences were found in any of the quantitative outcome measures between participants with and without paid prior care experience. A statistically significant increase in compassion fatigue was identified in both groups of participants post-qualification. Paid prior care experience did not prevent participants from experiencing reality shock on becoming a student or on qualification. Conclusions: There is insufficient evidence of longitudinal beneficial impact to recommend paid prior care experience as an effective intervention to foster nursing students' compassionate values and behaviours. These findings do not support mandating a period of paid care experience as a prerequisite for entry into nurse education. Registration: N/A. Tweetable abstract Insufficient evidence of longitudinal beneficial impact to recommend prior care experience as an effective intervention to foster nursing student compassion @PriorCareExp @Sarah_F_

Association study between the monoamine oxidase A gene and attention deficit hyperactivity disorder in Taiwanese samples

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a common and highly heritable disorder of childhood characterized by inattention, hyperactivity and impulsivity. Molecular genetic and pharmacological studies suggest the involvement of the dopaminergic, serotonergic and noradrenergic neurotransmitter systems in the pathogenesis of ADHD. Monoamine oxidase A (MAO-A) encodes an enzyme that degrades biogenic amines, including neurotransmitters such as norepinephrine, dopamine and serotonin. In this study we examined a 30 bp promoter variable number tandem repeat (VNTR) and a functional G/T single nucleotide polymorphism (SNP) at position 941 in exon 8 (941G/T) of MAO-A for association with ADHD in a Taiwanese sample of 212 ADHD probands. METHODS: Within-family transmission disequilibrium test (TDT) was used to analyse association of MAO-A polymorphisms with ADHD in a Taiwanese population. RESULTS: A nominally significant association was found between the G-allele of 941G/T in MAO-A and ADHD (TDT: P = 0.034. OR = 1.57). Haplotype analysis identified increased transmission of a haplotype consisting of the 3-repeat allele of the promoter VNTR and the G-allele of the 941G/T SNP (P = 0.045) to ADHD cases which the strong association with the G-allele drove. CONCLUSION: These findings suggest the importance of the 941G/T MAO-A polymorphism in the development of ADHD in the Taiwanese population. These results replicate previously published findings in a Caucasian sample

Zero Botnets: An Observe-Pursue-Counter Approach

Adversarial Internet robots (botnets) represent a growing threat to the safe use and stability of the Internet. Botnets can play a role in launching adversary reconnaissance (scanning and phishing), influence operations (upvoting), and financing operations (ransomware, market manipulation, denial of service, spamming, and ad click fraud) while obfuscating tailored tactical operations. Reducing the presence of botnets on the Internet, with the aspirational target of zero, is a powerful vision for galvanizing policy action. Setting a global goal, encouraging international cooperation, creating incentives for improving networks, and supporting entities for botnet takedowns are among several policies that could advance this goal. These policies raise significant questions regarding proper authorities/access that cannot be answered in the abstract. Systems analysis has been widely used in other domains to achieve sufficient detail to enable these questions to be dealt with in concrete terms. Defeating botnets using an observe-pursue-counter architecture is analyzed, the technical feasibility is affirmed, and the authorities/access questions are significantly narrowed. Recommended next steps include: supporting the international botnet takedown community, expanding network observatories, enhancing the underlying network science at scale, conducting detailed systems analysis, and developing appropriate policy frameworks.Comment: 26 pages, 13 figures, 2 tables, 72 references, submitted to PlosOn