Exploring the mechanisms of change in the chronic disease self-management programme: secondary analysis of data from a randomised controlled trial

Objective

The Chronic Disease Self-Management Programme (CDSMP) has been shown to be clinically and cost effective; however the specific mechanisms by which benefits are achieved are not well understood. We investigate what aspects of the course are associated with different outcomes.

Methods

Post-hoc analysis of data from participants in a randomised controlled trial of the CDSMP using evaluations after 6 months for all patients and longer term outcomes at 12 months for a sub-set of patients. Data were analysed using univariate and multivariate regressions.

Results

All course quality variables apart from the venue predicted satisfaction with CDSMP. The best predictors were ratings of the group process and course content. Group process was also significantly associated with self-care behaviour and long-term group outcomes (such as maintaining contact). Few associations between course ratings and patient health outcomes were found.

Conclusion

The most consistent predictor of CDSMP outcomes was the rating of the group process, highlighting the importance of group dynamics, however the complexity of mechanisms by which the CDSMP works cautions against giving primacy to any single factor.

Practice implications

Taking measures to ensure group processes are of high quality and effective within CDSMP are important in maximising patient satisfaction and self-care behaviour change.     

The Taxonomy of Everyday Self-management Strategies (TEDSS): A framework derived from the literature and refined using empirical data

Objective

To extend our understanding of self-management by using original data and a recent concept analysis to propose a unifying framework for self-management strategies.

Combining mHealth and health-coaching for improving self-management in chronic care. A scoping review

BackgroundSelf-management approaches are widely used to improve chronic care. In this context, health care professionals call for efficient tools to engage patients in managing their illness. Mobile health (mHealth), defined by WHO as medical and public health practice supported by mobile devices, is demonstrated to enhance self-management and health-coaching as an engaging tool in supporting behaviour change. Nevertheless, it is unclear how health-coaching and mHealth can benefit from each other.ObjectiveWe conducted a scoping review to provide a literature-overview and identify any existing gaps in knowledge of mHealth in combination with health-coaching interventions for improving self-management in patients with chronic diseases.Patient involvementNo patients were involved in the review process.MethodsThe five-stage framework by Arksey and O'Malley was used. The review surveys; PubMed, CINAHL, Embase, Scopus, and PsycInfo. Two independent reviewers performed review selection and characterization.ResultsThe review points at two approaches; (i) coaching used to support mHealth and (ii) mHealth as support for coaching. The findings suggest that patients prefer physical interactions to telecommunication. mHealth was primarily used to facilitate telecommunication and to monitor disease aspects.DiscussionWe found that mHealth and health-coaching interventions benefit from each other. The review report on a considerable unclarity in the coaching-methods and that the patients were more satisfied with physical interactions than mHealth. We suggest to prioritize human contact and to explore more personalized health technology.Practical valueThis scoping review can provide a framework for researchers and care providers to support discussion and introduction of new approaches and technology in self-management for patients with chronic diseases, thereby improving patients’ quality of life.     

Empowerment-oriented strategies to identify behavior change in patients with chronic diseases: An integrative review of the literature

BackgroundChronic diseases in the Americas account for about 80 % (5.2 million) of all deaths. Instruments are needed to enhance knowledge, skills, behavior change and self-care attitudes drawing on patient autonomy.ObjectiveTo identify empowerment-oriented strategies focused on behavioral change in patients with chronic diseases.Patient InvolvementNone.MethodsThis is an integrative review of articles published from any period until June 2020 by journals indexed in the following databases: National Library of Medicine National Institutes of Health (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Biblioteca Virtual em Saúde (BVS).ResultsOut of 1,287 articles, 25 met our selection criteria. Reported health interventions were based on self-management and behavior change, shared decisions and a personalized collaborative process, peer support and self-confidence, as well as strategies involving educational media and health literacy.DiscussionOver 80 % of health interventions were patient-centered and focused on patient knowledge and skill development towards personal goal setting, including effective problem-solving strategy development. Behavior change is not only an outcome of education, but also implicates revisiting values, attitudes, and experiences. Knowledge is important to facilitate decision-making leading to positive outcomes in chronic disease management.Practical ValueEmpowerment-oriented strategies are important tools for providing trust and motivation to people with chronic diseases. Healthcare professionals should support and encourage patient empowerment as a strategy for behavior change and able to offer qualified care for shared decision making. Thus, patients will be able to participate more actively in their own health condition management and to make decisions to promote self-care.     

慢性肾功能衰竭患者筛查甲状腺素结果分析

目的通过慢性肾功能衰竭患者(chronic renal failure,CRF)筛查甲状腺素结果分析,了解慢性肾功能衰竭患者甲状腺素水平在不同时期的变化。方法根据甲状腺功能测定结果,住院CRF患者135例,按慢性肾功能衰竭分期:代偿期69例,失代偿期20例,肾衰竭期11例,尿毒症期35例。选取同一时期健康体检人群共95名为对照组。采用免疫放射法(IRMA)检测血清促甲状腺素(TSH);游离三碘甲状腺原氨酸(FT 3 )、游离甲状腺素(FT 4 )、总三碘甲状腺原氨酸(TT 3 )、总甲状腺素(TT 4 )检测使用放射免疫法(RIA);同时用电化学发光法(ECLIA)检测抗甲状腺过氧化物酶抗体(TPOAB)和甲状腺球蛋白抗体(TGAB)。结果 CRF组的FT 3 、FT 4 和TT 3 、TT 4 显著低于对照组( P <0.01),TSH、TGAB和TPOAB显著高于对照组( P <0.01)。肾功能失代偿期的患者与其他三组比较,血清甲状腺激素水平FT 3 、FT 4 和TT 3 、TT 4 最低,而血清TSH、TPOAB和TRAB较其他三组则显著升高。结论血清甲状腺素水平降低与肾功能损害程度密切相关,血清甲状腺素异常变化往往发生在肾功能失代偿期阶段。因此,血清甲状腺素水平的监测对CRF患者具有一定的临床价值,在治疗过程中应予以适当关注。     

慢性肺疾病早产鼠BALF及肺组织中脂质过氧化的同步研究

目的为探讨高氧致早产儿慢性肺疾病(CLD)发生中支气管肺泡灌洗液(BALF)及肺组织中脂质过氧化的变化规律及相互间关系.方法采用高浓度氧致早产鼠CLD模型为研究对象,应用分光光度计比色法同步测定BALF和肺组织超氧化物岐化酶(SOD)活性及脂质过氧化产物丙二醛(MDA)的含量.结果两组的BALF及肺组织中SOD活性均无差异(P>0.05);而实验组,BALF及肺组织中MDA的水平呈同相变化,即吸高氧3d明显升高(P<0.05),7d达高峰(P<0.01),持续1w后逐渐下降,21d仍高于正常水平(P<0.05).结论肺组织的氧自由基损伤贯穿高氧致CLD发生、发展全过程中;BALF中MDA水平可间接反应肺组织的氧自由基损伤程度.     

Effect of chronic psychosocial stress on nonalcoholic steatohepatitis in mice

Nonalcoholic fatty liver disease (NAFLD) is characterized by hepatic lipid accumulation which may progress towards inflammation (nonalcoholic steatohepatitis (NASH)). NAFLD is regarded as a consequence of a sedentary, food-abundant lifestyle which, in the modern world, often coincides with chronically high levels of perceived psychosocial stress. Here, we aimed to characterize the effect of chronic psychosocial stress on the development of NAFLD/NASH in male mice either fed with standard chow or NASH-inducing high fat diet. Chronic psychosocial stress was induced by chronic subordinate colony housing (CSC), a pre-clinically validated paradigm relevant for human affective and somatic disorders. Single housed (SHC) mice served as controls. Under standard chow conditions CSC mice revealed lower hepatic triglyceride levels but higher hepatic TNFα, MCP-1 and HMOX mRNA expression, while serum transaminase levels did not significantly differ from SHC mice. Under the NASH-inducing high-fat diet CSC and SHC mice showed similar body weight-gain and serum levels of glucose and adiponectin. Moreover, liver histology as well as TNFα, MCP-1 and HMOX expression were similar in CSC and SHC mice fed with HFD. Surprisingly, CSC showed even significantly lower transaminase levels than SHC mice fed with the same NASH-inducing diet. Together, these data indicate that under normal dietary conditions the CSC model induces noticeable hepatic oxidative stress and inflammation without causing manifest hepatocellular injury. In contrast, CSC exhibited a protective effect on hepatocellular injury in a dietary NASH-model. Identification of the underlying mechanisms of this phenomenon may lead to novel therapeutic strategies to prevent progression of NAFLD.     

针对晚期氧化蛋白产物的抗体制备与应用

目的:制备特异性识别晚期氧化蛋白产物(Advanced oxidation protein products,AOPP)的多克隆抗体,为研究AOPP的致病机理及与临床病情相关性提供有效工具。方法:用次氯酸氧化家兔血清白蛋白以获得AOPP-RSA,以此为免疫原免疫家兔,亲和层析纯化免疫血清,ELISA鉴定多克隆抗体的效价及特异性,Western blot检测慢性肾脏病(chronic kidney disease,CKD)患者血浆中AOPP,免疫组织化学方法检测肾组织中AOPP分布与定位。结果:获得效价达10-6的抗AOPP免疫血清,纯化抗体可特异地与不同种属来源的氧化修饰白蛋白结合,而与正常白蛋白及糖基化蛋白终产物无交叉反应。该抗体可识别人血浆中的AOPP,可特异地与大鼠CKD模型及各种炎症性CKD患者肾组织成份反应。结论:成功制备了可与不同种属AOPP结合的特异性多克隆抗体,并首次用于检测存在于CKD患者血浆、肾组织及模型动物肾组织中的AOPP,为深入研究AOPP的病理作用及其在组织定位提供了有效工具。     

Localizing sensory and cognitive systems for pre-attentive visual deviance detection: An sLORETA analysis of the data of Kimura et al. (2009)

Pre-attentive deviance detection in the visual environment has been known to be reflected by an event-related brain potential (ERP) component, deviant-related negativity. Recently, however, we demonstrated that deviant-related negativity comprises two, temporally and spatially overlapping ERP components, by using an experimental protocol consisting of oddball and equiprobable sequences [M. Kimura, J. Katayama, H. Ohira, E. Schröger, Visual mismatch negativity: new evidence from the equiprobable paradigm, Psychophysiology 46 (2009) 402–409]: (1) visual N1 that reflects a sensory, refractoriness-based deviance detection system and (2) visual mismatch negativity (MMN) that reflects a cognitive, memory-comparison-based deviance detection system. In the present paper, we further elucidated the neural generators of the visual N1 and visual MMN with standardized low-resolution brain electromagnetic tomography (sLORETA). Results showed that the visual N1 was involved in neural activations of the primary and nonprimary visual areas, while the visual MMN was involved in neural activations of the nonprimary visual areas and the prefrontal areas. These results suggest that the sensory and cognitive deviance detection systems subserved by distinct neural structures underlie our efficient pre-attentive visual deviance detection.     

Fatigue self-management education in persons with disease-related fatigue: A comprehensive review of the effectiveness on fatigue and quality of life

ObjectivesTo systematically synthesize the effectiveness of fatigue self-management education (SME) on fatigue and quality of life (QoL) in persons with disease-related fatigue, and to describe the intervention characteristics.MethodsWe systematically reviewed the literature on SMEs in people with disease-related fatigue. We included randomized controlled trials (RCT), which aimed to improve self-management skills for fatigue in daily life. We synthesized the effectiveness and mapped the intervention characteristics.ResultsWe included 26 RCTs studying samples from eight disease groups. At follow-up, 46% studies reported statistically significant improvements on fatigue and 46% on QoL. For persons with cancer 6/8 and multiple sclerosis 8/10 RCTs showed positive evidence in favor of SME. The range of effect sizes was wide (d: 0.0 ->0.8). Delivery modalities (inpatient, outpatient, home), interactions (individual, group, remote), and duration [range (h): 1–17.5] varied.ConclusionsThe overall evidence on the effectiveness of SMEs on fatigue and QoL is limited and inconsistent. For persons with cancer and multiple sclerosis, the evidence provides a positive effect. The RCTs with medium to large effect on QoL indicate the potential benefit of SMEs.Practical implicationDuration and peer interaction should be considered when tailoring SMEs to populations and contexts.     

Blended face-to-face and online/computer-based education approaches in chronic disease self-management: A critical interpretive synthesis

ObjectiveTo review the literature on chronic disease self-management programs that blend face-to-face and online/computer-based education design and delivery.MethodsA critical interpretive synthesis was conducted. Studies that described blended chronic disease self-management programs were reviewed. Two reviewers performed independent database searches, eligibility screening, and data extraction. Findings were synthesized using a conceptual mapping process.ResultsTwelve articles were included in the final review. Studies focused on patients with diagnoses of diabetes, asthma, and chronic obstructive pulmonary disorder. Factors influencing the design and delivery of programs focused on patient characteristics (such as disease prognosis, time since diagnosis, social determinants of health, health literacy, and proficiency with online/computer-based technologies).ConclusionsBlended learning self-management programs should consider the suitability of programs in light of health conditions and patient characteristics. Individual patient needs can be identified through clinician-driven assessments, including collaborative goal setting and the selection of pertinent educational tools.Practice ImplicationsWhen considering the design and delivery of chronic disease self-management education programs, healthcare providers should consider three factors: 1) patient characteristics, 2) learning perspectives, and 3) design technology options that best meet patient abilities, clinician expertise, and administrative capacity.     

正常老中青少年1468例和慢阻肺患者168例用力呼气弦线时间常数的初步探讨

本文在正常老青少年1486例和慢阻肺(COPD)患者168例的最大呼气流量—容积(MFFV)曲线上,用Knudson的弦线法于高中低肺容积处的弦线时间常数,τch75、τch50、τch25和本文采用的容积校正的比时间常数(Sτ) 1/75、1/50、1/25进行了系统探讨。在IBM-PC/XT计算机上建立青少年组和成年组各指标的回归方程。应用COPD患者各指标实测值占预计值的百分数和t检验,以估计疾病改变的程度。结果表明,各τch均随年龄而延长;青少年τch随肺内容积的衰减而缩短,老年人则随其衰减而延长。1/在青少年中随年龄而缩短,成年以后则随年龄而延长,1/在老中青少年中均随肺内容积的衰减而延长。COPD患者τch和1/的改变为:肺心病>300％,肺气为170～280％,慢支为110～180％。较MEFV曲线更为敏感,具有临床应用前景。本文讨论了上述指标的生理及临床意义。     

Organ-protective effect of angiotensin-converting enzyme 2 and its effect on the prognosis of COVID-19

This article reviews the correlation between angiotensin-converting enzyme 2 (ACE2) and severe risk factors for coronavirus disease 2019 (COVID-19) and the possible mechanisms. ACE2 is a crucial component of the renin-angiotensin system (RAS). The classical RAS ACE-Ang II-AT1R regulatory axis and the ACE2-Ang 1-7-MasR counter-regulatory axis play an essential role in maintaining homeostasis in humans. ACE2 is widely distributed in the heart, kidneys, lungs, and testes. ACE2 antagonizes the activation of the classical RAS system and protects against organ damage, protecting against hypertension, diabetes, and cardiovascular disease. Similar to SARS-CoV, SARS-CoV-2 also uses the ACE2 receptor to invade human alveolar epithelial cells. Acute respiratory distress syndrome (ARDS) is a clinical high-mortality disease, and ACE2 has a protective effect on this type of acute lung injury. Current research shows that the poor prognosis of patients with COVID-19 is related to factors such as sex (male), age (>60 years), underlying diseases (hypertension, diabetes, and cardiovascular disease), secondary ARDS, and other relevant factors. Because of these protective effects of ACE2 on chronic underlying diseases and ARDS, the development of spike protein-based vaccine and drugs enhancing ACE2 activity may become one of the most promising approaches for the treatment of COVID-19 in the future.     

Epitopes recognized by CBV4 responding T cells: effect of type 1 diabetes and associated HLA-DR-DQ haplotypes

The present study aimed at characterizing the epitopes recognized by coxsackievirus B4 (CBV4)-specific T-cell lines established from 23 children with type 1 diabetes (T1D) and 29 healthy children with T1D risk-associated HLA genotypes. Responsiveness to VP1 region was dependent on the specific infection history as 55% of the T-cell lines from donors with neutralizing antibodies to CBV serotypes responded to VP1 peptides compared to none of the T-cell lines from other donors (P = 0.01). The pattern of recognized peptides was dependent of the HLA genotype. Forty-two percent of the T-cell lines from donors carrying the HLA-(DR4)-DQB1*0302 haplotype responded to VP1 peptides 71-80 compared to none of the T-cell lines from donors without this haplotype (P = 0.02). No evidence for the existence of diabetes-specific epitopes was found. Only few epitopes were exclusive recognized by T cells from diabetic children, and in each case only one or two T-cell lines were responding.     

Hepatocellular carcinoma in nonalcoholic fatty liver disease mimicking benign hemangioma: two case reports and literature review

Objective: To study the clinical features of nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC). Methods: The clinical manifestations, imaging features, pathological subtypes and treatment outcome of two cases with NAFLD-associated HCC were analyzed. Results: In these two cases, both were young, obese male patients, with contrast enhanced CT scan of hemangioma-like features. They had undergone surgical resection and both were reported as well-differentiated HCC pathologically. They were followed-up respectively up to 46 and 36 months post-operatively with no evidence of recurrence or metastasis. Conclusions: NAFLD-associated HCC has different radiological presentations from typical HCC. Incidental finding of any liver occupying lesions in NAFLD patients should raise immediate clinical attention.     

雷公藤甲素治疗异基因骨髓移植后aGVHD的实验研究

目的：探素雷公藤甲素（TWH）对异基因HSCT中aGVHD的治疗作用及其机制，并研究雷公藤甲素对移植物抗肿瘤（GVT）作用的影响和对移植物植入的影响。方法：（1）以B6为供者，致死性照射的CB6F1为受者，建立基因半相合移植动物模型；以CB6F1为受者，皮下接种S180细胞并照射，建立基因半相合移植荷瘤aGVHD模型；BALB／c小鼠背部皮下注射S180细胞并照射，建立同基因移植荷瘤动物模型。各组动物分别给予不同剂量TWH及CsA。观察TWH对GVHD、GVT的影响。（2）MTT法测定TWH抑制脾淋巴细胞增殖作用和TWH的体外抑瘤作用。（3）ELISA法测定移植后动物血清IL-4、IFN-γ水平。（4）甲基纤维素半固体培养基检测CFU-GM生成率。结果：（1）小剂量TWH（〈1μg/d）降低aGVHD发病率，延长动物生存时间；小剂量TWH与小剂量CsA在预防GVHD方面有协同作用。（2）TWH在抑制aGVHD的同时，保留GVT作用，延长了荷瘤动物生存时间，而无GVHD的同基因移植荷瘤动物生存期缩短。（3）TWH可抑制脾细胞增殖，降低血清IFN-γ水平。（4）一定剂量TWH（〈1μg／d）不影响干细胞植入和CFU-GM的产率。结论：TWH具有抑制aGVHD保留GVT的作用，可与CsA协同作用预防异基因HSCT中aGVHD。     

Disease Surveillance: The Bedrock for Control and Prevention

How to cite this article: Krishna B. Disease Surveillance: The Bedrock for Control and Prevention. Indian J Crit Care Med 2021;25(7):745–746.