Protocol for evaluating and implementing a pragmatic value-based healthcare management model for patients with inflammatory arthritis:A Danish population-based regional cohort and qualitative implementation study

Introduction The provision of healthcare for patients with inflammatory arthritis occurs in the context of somewhat conflicting targets, values and drivers. Therefore, there is a need for introducing 'value-based healthcare' defined as the value of patient relevant health outcomes in relation to costs. This term is a central part of tomorrow's healthcare sector, especially for rheumatic diseases, yet the transition is a huge challenge, as it will impact the development, delivery and assessment of healthcare. Aims The aim of this study is to compare medical and patient evaluated impact of the traditional settlement and financing production (DAGS) controlled healthcare setting with a value-based and patient-centred adjunctive to standard care. Methods and analysis Patients with inflammatory arthritis receiving treatment in routine care at the outpatient clinics in the Capital Region of Denmark will prospectively and consecutively be enrolled in a Non-Intervention-Study framework providing a pragmatic value-based management model. A Danish reference cohort, used for comparison will be collected as part of routine clinical care. The enrolment period will be from 1 June 2018 until 31December 2023. Baseline and follow-up visits will be according to routine clinical care. Registry data will be obtained directly from patients and include personal, clinical and outcomes information. The study results will be reported in accordance with the STROBE statement. Ethics and dissemination The study has been notified to the Danish Data Protection Agency and granted authorisation for the period June 2018 to January 2025 (pending). Informed consent will be obtained from all patients before enrolment in the study. The study is approved by the ethics committee, Capital Region of Denmark (H-18013158). Results of the study will be disseminated through publication in international peer-reviewed journals

Emotional Responses and Support Needs of Healthcare Professionals after Adverse or Traumatic Experiences in Healthcare—Evidence from Seminars on Peer Support

The aim of this study was to identify (i) emotions experienced by healthcare professionals (HCPs) after adverse or traumatic events and (ii) needs for support after adverse or traumatic events. Data for this qualitative, descriptive study were collected at 27 seminars for 198 HCPs introducing a peer-support programme after adverse or traumatic events (The Buddy Study). Through interactive exercises, participants shared their experiences, and this study reports on the responses of an exercise identifying emotions and needs after an adverse or traumatic event. The top five emotions were anger, guilt, impotence, grief, and frustration and anxiety, and the top five needs were to be met with understanding, recognition, listening, care, and respect. Ten categories of emotions experienced by HCPs after adverse or traumatic events were constructed, and the five categories with the highest number of mentions were anger and impotence, fear and insecurity, negative self-evaluation, guilt and shame, and alone and overloaded. Nine categories relating to needs for support after adverse or traumatic events were constructed, and the five categories with the highest number of mentions were: being seen and understood, compassion, being respected, time to recover, and organisational support. The emotional disclosure promoted at the peer seminars of the Buddy Study revealed that all participants share the same emotional distress, being either second victims or potential second victims. Moreover, the support needed was of a human-to-human nature that all participants felt capable of providing as a “buddy” for a colleague. Both the identified emotions and needs for support identified in this study may contribute to qualifying the development of the content of support programmes for HCPs after traumatic or adverse events

Aging affects the transcriptional regulation of human skeletal muscle disuse atrophy

Important insights concerning the molecular basis of skeletal muscle disuse-atrophy and aging related muscle loss have been obtained in cell culture and animal models, but these regulatory signaling pathways have not previously been studied in aging human muscle. In the present study, muscle atrophy was induced by immobilization in healthy old and young individuals to study the time-course and transcriptional factors underlying human skeletal muscle atrophy. The results reveal that irrespectively of age, mRNA expression levels of MuRF-1 and Atrogin-1 increased in the very initial phase (2-4 days) of human disuse-muscle atrophy along with a marked reduction in PGC-1α and PGC-1β (1-4 days) and a ~10% decrease in myofiber size (4 days). Further, an age-specific decrease in Akt and S6 phosphorylation was observed in young muscle within the first days (1-4 days) of immobilization. In contrast, Akt phosphorylation was unchanged in old muscle after 2 days and increased after 4 days of immobilization. Further, an age-specific down-regulation of MuRF-1 and Atrogin-1 expression levels was observed following 2 weeks of immobilization, along with a slowing atrophy response in aged skeletal muscle. Neither the immediate loss of muscle mass, nor the subsequent age-differentiated signaling responses could be explained by changes in inflammatory mediators, apoptosis markers or autophagy indicators. Collectively, these findings indicate that the time-course and regulation of human skeletal muscle atrophy is age dependent, leading to an attenuated loss in aging skeletal muscle when exposed to longer periods of immobility-induced disuse

What is spiritual care? Professional perspectives on the concept of spiritual care identified through group concept mapping

Objectives The overall study aim was to synthesise understandings and experiences regarding the concept of spiritual care (SC). More specifically, to identify, organise and prioritise experiences with the way SC is conceived and practised by professionals in research and the clinic.Design Group concept mapping (GCM).Setting The study was conducted within a university setting in Denmark.Participants Researchers, students and clinicians working with SC on a daily basis in the clinic and/or through research participated in brainstorming (n=15), sorting (n=15), rating and validation (n=13).Results Applying GCM, ideas were identified, organised and prioritised online. A total of 192 unique ideas of SC were identified and organised into six clusters. The results were discussed and interpreted at a validation meeting. Based on input from the validation meeting a conceptual model was developed. The model highlights three overall themes: (1) ‘SC as an integral but overlooked aspect of healthcare’ containing the two clusters SC as a part of healthcare and perceived significance; (2) ‘delivering SC’ containing the three clusters quality in attitude and action, relationship and help and support, and finally (3) ‘the role of spirituality’ containing a single cluster.Conclusion Because spirituality is predominantly seen as a fundamental aspect of each individual human being, particularly important during suffering, SC should be an integral aspect of healthcare, although it is challenging to handle. SC involves paying attention to patients’ values and beliefs, requires adequate skills and is realised in a relationship between healthcare professional and patient founded on trust and confidence

Immobility induced skeletal muscle atrophy results in an age-specific decrease in Akt and ribosomal protein S6 phosphorylation.

<p><b>A.</b> Western blotting of whole muscle protein homogenates of phosphorylated Akt and total Akt. <b>B.</b> Immobility decreased levels of phosphorylated Akt/total Akt ratio (p-Akt/Akt) at the early (2–4 days) phase of immobility in young but not aged skeletal muscle. * Time effect, p<0.05, compared to pre. # Age effect, p<0.001 young compared to old within time point. Due to lack of muscle tissue n = 6 (3 young and 3 old) in these analyses. <b>C.</b> Western blotting of whole muscle protein homogenates of total and phosphorylated S6 ribosomal protein. <b>D.</b> The percentage of the total number of subjects at each time point where p-S6 could be detected. Chi-square: Young p<0.001, Old p = 0.44. In a high number of especially young subjects phosphorylated S6 ribosomal protein (but not total S6 ribosomal protein) became non detectable after immobilization which made an exact quantification impossible.</p

Immobility-induced skeletal muscle atrophy causes an age-specific decline in muscle size.

<p><b>A.</b> Scheme of experimental setup, including the time points of muscle biopsy procedure. <b>B</b>. Percentage decreases in muscle size (mean muscle fiber area) after 4 days of immobility in young (n = 11) and old (n = 9) as well as after 14 days of immobilization in young (n = 11) and old (n = 12), respectively. * Time effect, p<0.05 compared to pre, # Age effect, p<0.05 young compared to old within time point. Group mean data ± SEM. Mean myofiber area was assessed in the quadriceps femoris muscle, by muscle biopsy sampling. <b>C.</b> Muscle histology from resting state (pre) and immobility (14 d) was analyzed by myofibrillar ATPase at pH 10.3 preincubations demonstrating type I (white) and type II muscle fibers (black) <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051238#pone.0051238-Brooke1" target="_blank">[52]</a>.</p

Immobility increases the transcriptional status of Bax, BCL2L1 and p53 and the immunodetection of TUNEL.

<p><b>A–C</b>. The mRNA level of Bax, BCL2L1 and p53 was determined using qRT-PCR and significant increases were found in the early phase (0–4 days) as well as later phase (14 days) of disuse-muscle atrophy <b>D.</b> Skeletal muscle cryosections were immunostained for nNOS (red), DAPI (blue) and TUNEL (green). <b>E.</b> Total numbers of TUNEL-positive nuclei were quantified for both young and old muscle and significant increases of TUNEL-positive nuclei were detected in old muscle in the early phase of immobility (1–2 days) and in both young and old after 4 days of immobility. <b>F.</b> Double immunohistochemical staining for TUNEL and the muscle satellite cell marker Pax7 did not reveal any TUNEL-positive muscle satellite cells. Additional green fluorescent expression on the shown image is due to autofluorescence by lipofusin and this is considered non-specific in our analysis. *Time effect, p<0.05 compared to pre. <u>*</u> Time effect, p<0.05 bar indicates young and old combined compared to pre. Data are means ± SEM.</p