Barriers and enablers to delivering opportunistic behaviour change interventions during the COVID-19 pandemic: A qualitative study in healthcare professionals

Background

In line with public health policy, healthcare professionals (HCPs) working in the UK's National Health Service (NHS) are encouraged to deliver opportunistic health behaviour change interventions during routine consultations. The impact of the COVID-19 pandemic on healthcare delivery has been wide-ranging, but little is known about how the pandemic has affected the delivery of health behaviour change interventions. The present study aimed to examine the barriers and enablers to delivering opportunistic behaviour change interventions during the COVID-19 pandemic.

Methods

Twenty-five qualitative semi-structured interviews were conducted in January 2022 with a range of patient-facing healthcare professionals (including nurses, physiotherapists, dieticians, doctors and midwives) working in the NHS. Data were analysed using reflexive thematic analysis.

Results

Two overarching themes were generated: (1) the healthcare system's response to COVID-19, and (2) maintaining good HCP-patient relationships: reluctance and responsibility. COVID-19-related barriers included exacerbated staffing pressures and a perceived inability to use IT equipment to facilitate conversations about health behaviour change (due to poor internet connectivity or ill-equipped platforms). COVID-19-related enablers included the use of video consultations enabling less awkward and more honest conversations about health behaviours. However, some barriers and enablers remained the same as pre-pandemic, such as issues of role responsibility for discussing health behaviour change with patients, balancing holistic wellbeing advice with maintaining positive patient-HCP relationships, and reluctance to deliver opportunistic behaviour change interventions.

Discussion

The increased use of remote consultations may facilitate the delivery of opportunistic health behaviour change interventions by healthcare professionals. However, there is also a strong need to improve staffing levels, in order that staff have the psychological and physical capabilities to engage patients in these conversations.     

Examining the efficacy of social-psychological interventions for the management of fatigue in end-stage kidney disease (ESKD): a systematic review with meta-analysis

Fatigue affects between 42% and 89% of end-stage kidney disease (ESKD) patients, with significant repercussions on quality of life and clinical outcomes. Fatigue management revolves around pharmacotherapy or exercise, which have only modest and short-term improvements. The aim of this systematic review was to investigate whether social-psychological interventions are effective at reducing fatigue in ESKD. Databases were searched to identify randomized controlled trials (RCTs) and quasi-RCTs that determined the effect of social-psychological interventions on fatigue (primary or secondary outcome), in the renal patient population. A meta-analysis was conducted. Sixteen RCTs (N = 1536) were included, predominantly among dialysis patients. Fatigue was a primary outcome in only two studies. The meta-analytic findings showed a significant improvement in fatigue following social-psychological interventions (standardised mean difference, SMD = 0.37, p = .001; 95% CI 0.15 to 0.59, I² = 69.1%, p < .001). There was evidence for greater effectiveness of interventions including stress-management/relaxation techniques, evaluated among fatigued samples meeting diagnostic thresholds, against passive/non-active comparison groups. The studies were generally of poor quality, with high heterogeneity, particularly with the number of sessions ranging from 2 to 96. Development and evaluation of a fatigue-specific social-psychological intervention is warranted in this setting.     

The nucleobase adenine as a signalling molecule in the kidney

In 2002, the first receptor activated by the nucleobase adenine was discovered in rats. In the past years, two adenine receptors (AdeRs) in mice and one in Chinese hamsters, all of which belong to the family of G protein‐coupled receptors (GPCRs), were cloned and pharmacologically characterized. Based on the nomenclature for other purinergic receptor families (P1 for adenosine receptors and P2 for nucleotide, e.g. ATP, receptors), AdeRs were designated P0 receptors. Pharmacological data indicate the existence of G protein‐coupled AdeRs in pigs and humans as well; however, those have not been cloned so far. Current data suggest a role for adenine and AdeRs in renal proximal tubules. Furthermore, AdeRs are suggested to be functional counterplayers of vasopressin in the collecting duct system, thus exerting diuretic effects. We are only at the beginning of understanding the significance of this new class of purinergic receptors, which might become future drug targets.     

Impact of hospital-acquired acute kidney injury on Covid-19 outcomes in patients with and without chronic kidney disease: a multicenter retrospective cohort study

Background/aim Hospital-acquired acute kidney injury (HA-AKI) may commonly develop in Covid-19 patients and is expected to have higher mortality. There is little comparative data investigating the effect of HA-AKI on mortality of chronic kidney disease (CKD) patients and a control group of general population suffering from Covid-19.Materials and methodsHA-AKI development was assessed in a group of stage 3–5 CKD patients and control group without CKD among adult patients hospitalized for Covid-19. The role of AKI development on the outcome (in-hospital mortality and admission to the intensive care unit [ICU]) of patients with and without CKD was compared.Results Among 621 hospitalized patients (age 60 [IQR: 47–73]), women: 44.1%), AKI developed in 32.5% of the patients, as stage 1 in 84.2%, stage 2 in 8.4%, and stage 3 in 7.4%. AKI developed in 48.0 % of CKD patients, whereas it developed in 17.6% of patients without CKD. CKD patients with HA-AKI had the highest mortality rate of 41.1% compared to 14.3% of patients with HA-AKI but no CKD (p < 0.001). However, patients with AKI+non-CKD had similar rates of ICU admission, mechanical ventilation, and death rate to patients with CKD without AKI. Adjusted mortality risks of the AKI+non-CKD group (HR: 9.0, 95% CI: 1.9–44.2) and AKI+CKD group (HR: 7.9, 95% CI: 1.9–33.3) were significantly higher than that of the non-AKI+non-CKD group.ConclusionAKI frequently develops in hospitalized patients due to Covid-19 and is associated with high mortality. HA-AKI has worse outcomes whether it develops in patients with or without CKD, but the worst outcome was seen in AKI+CKD patients.     

Online resources for family caregivers of cognitively competent patients: A review of user-driven reputable health website content on caregiver communication with health professionals

ObjectiveMost patients want their family involved in consultations and decisions, however some family caregivers report feeling overwhelmed and unsure of their role. As caregivers are increasingly looking to medical websites for guidance, this study aimed to review reputable web-resources available to inform family caregivers on how to be involved in medical consultations and decisions.MethodsGoogle searches were performed using lay search strings, to imitate how a cancer caregiver may locate information. Relevant webpages were included if they were directed at caregivers and from a reputable health organisation. Qualitative content analyses were performed on the included webpages.Results22 webpages were included and 8 were directed at caregivers of cancer patients. Six key categories of information were identified: preparing for consultations, helping during consultations, advocating for the patient, decision-making, communicating in hospital settings, and communicating with family and friends.ConclusionA range of online resources were found to guide family caregivers, particularly cancer caregivers, on involvement in consultations. However, few provided information to caregivers on complex situations such as treatment decision-making, advocating for patient’s needs, and communicating in a hospital setting.Practice implicationsClinicians can actively refer family caregivers to online resources that support caregiver communication in medical settings.     

Clinical application of neutrophil gelatinase-associated lipocalin in the revised chronic kidney disease classification

Background: A revised classification of chronic kidney disease (CKD) was proposed by the Kidney Disease: Improving Global Outcomes (KDIGO) in 2012. Neutrophil gelatinase-associated lipocalin (NGAL) was considered as one of the most promising biomarkers in clinical nephrology. The aim of this study was to examine the level of NGAL in patients with different impairment of GFR based on the new classification, and to evaluate whether NGAL in serum or urine was associated with different risk categories in CKD patients. Methods: A cross-sectional study was performed in 240 patients with CKD. NGAL, serum cystatin C, β₂-macroglobulin (β₂-MG), urine α₁-macroglobulin (α₁-MG) and albuminuria were tested in patients with various degrees of renal impairment. Results: Good correlation was found between the NGAL and the cystatin C, β₂-MG and the α₁-MG (r > 0.7). The level of sNGAL in CKD stage 3b was more than that in CKD stage 3a (P = 0.025). The concentration of the NGAL increased progressively with the increasing of risk categories (proposed by the revised CKD classification). The cutoff value of NGAL was calculated from stage 2 to stage 5. ROC analysis showed good AUC (sNGAL > 0.8, uNGAL > 0.7) and high specificity (sNGAL > 87%, uNGAL > 90%) on the cutoff value of NGAL. Conclusion: The results confirm NGAL as a useful biomarker in clinical nephrology which is helpful to diagnosis and evaluate the categories for CKD proposed by the KDIGO.     

Absence of ULK1 decreases AMPK activity in the kidney,leading to chronic kidney disease progression

AMP-activated protein kinase (AMPK) inactivation in chronic kidney disease (CKD) leads to energy status deterioration in the kidney, constituting the vicious cycle of CKD exacerbation. Unc-51-like kinase 1 (ULK1) is considered a downstream molecule of AMPK; however, it was recently reported that the activity of AMPK could be regulated by ULK1 conversely. We demonstrated that AMPK and ULK1 activities were decreased in the kidneys of CKD mice. However, whether and how ULK1 is involved in the underlying mechanism of CKD exacerbation remains unknown. In this study, we investigated the ULK1 involvement in CKD, using ULK1 knockout mice. The CKD model of Ulk1^−/− mice exhibited significantly exacerbated renal function and worsening renal fibrosis. In the kidneys of the CKD model of Ulk1^−/− mice, reduced AMPK and its downstream β-oxidation could be observed, leading to an energy deficit of increased AMP/ATP ratio. In addition, AMPK signaling in the kidney was reduced in control Ulk1^−/− mice with normal renal function compared to control wild-type mice, suggesting that ULK1 deficiency suppressed AMPK activity in the kidney. This study is the first to present ULK1 as a novel therapeutic target for CKD treatment, which regulates AMPK activity in the kidney.     

胱抑素C评价早中期慢性肾脏病患者肾功能损害的临床价值

目的探讨血清胱抑素C（CysC）评价早中期慢性肾脏病（CKD）患者肾功能损害的临床价值。方法以2008年1月至2010年12月深圳市第六人民医院肾内科住院治疗的221例CKD1～3期患者为观察对象,测定CysC、血肌酐（SCr）、血尿素氮（BUN）、血尿酸（BUA）及血白蛋白（Alb）,与MDRD公式计算的肾小球滤过率（GFR）进行比较。结果 CKD1～3期患者CysC随着GFR的下降而升高,各组间比较差异有统计学意义（P〈0.05）;血清CysC水平与SCr、BUN及BUA水平呈明显正相关（r=0.650,P=0.000;r=0.631,P=0.000;r=0.309,P=0.000）,与GFR水平呈明显负相关（r=-0.717,P=0.000）。CKD2期患者CysC异常检出率为32.8%,SCr为0;CKD3期患者CysC异常检出率为73.0%,SCr为58.4%,CKD3期患者CysC、SCr的异常检出率差异有统计学意义（P〈0.05）。CysC评估GFR的接受者操作特征曲线下面积（AUCROC）为0.853,敏感性为0.780,特异性为0.817;SCr的AUCROC为0.924,敏感性为0.793,特异性为0.958;联合CysC和SCr后,AUCROC上升至0.940,敏感性为0.853,特异性为0.950。结论 CysC是评估早中期CKD患者肾功能损害的敏感指标,联合应用CysC和SCr可提高对早中期慢性肾功能不全患者的诊断效能。     

Integrated medicine in the management of chronic illness: a qualitative study

Background

Complementary and alternative medicine (CAM) is popular with patients, yet how patients use CAM in relation to orthodox medicine (OM) is poorly understood.

Aim

To explore how patients integrate CAM and OM when self-managing chronic illness.

Design of study

Qualitative analysis of interviews.

Method

Semi-structured interviews were conducted with individuals attending private CAM practices in the UK, who had had a chronic benign condition for 12 months and were using CAM alongside OM for more than 3 months. Patients were selected to create a maximum variation sample. The interviews were analysed using framework analysis.

Results

Thirty five patient interviews were conducted and seven categories of use were identified: using CAM to facilitate OM use; using OM to support long-term CAM use; using CAM to reduce OM; using CAM to avoid OM; using CAM to replace OM; maximising relief using both CAM and OM; and returning to OM. Participants described initiating CAM use following a perceived lack of suitable orthodox treatment. Participants rejecting OM for a specific condition never totally rejected OM in favour of CAM.

Conclusion

Patients utilise CAM and OM in identifiably different ways, individualising and integrating both approaches to manage their chronic conditions. To support patients and prevent potential adverse interactions, open dialogue between patients, OM practitioners, and CAM practitioners must be improved.     

Improving the uptake of pulmonary rehabilitation in patients with COPD:: qualitative study of experiences and attitudes

Background

Pulmonary rehabilitation can improve the quality of life and ability to function of patients with chronic obstructive pulmonary disease (COPD). It may also reduce hospital admission and inpatient stay with exacerbations of COPD. Some patients who are eligible for pulmonary rehabilitation may not accept an offer of it, thereby missing an opportunity to improve their health status.

Aim

To identify a strategy for improving the uptake of pulmonary rehabilitation.

Design of study

Qualitative interviews with patients.

Setting

Patients with COPD were recruited from a suburban general practice in north-east Derbyshire, UK.

Method

In-depth interviews were conducted on a purposive sample of 16 patients with COPD to assess their concerns about accepting an offer of pulmonary rehabilitation. Interviews were analysed using grounded theory.

Results

Fear of breathlessness and exercise, and the effect of pulmonary rehabilitation on coexisting medical problems were the most common concerns patients had about taking part in the rehabilitation. The possibility of reducing the sensation of breathlessness and regaining the ability to do things, such as play with their grandchildren, were motivators to participating.

Conclusion

A model is proposed where patients who feel a loss of control as their disease advances may find that pulmonary rehabilitation offers them the opportunity to regain control. Acknowledging patients'' fears and framing pulmonary rehabilitation as a way of ‘regaining control’ may improve patient uptake.     

Extensive lanthanum deposition in the gastric mucosa: The first histopathological report

Lanthanum carbonate is one of the new phosphate binders used for the treatment of hyperphosphatemia in patients with chronic kidney disease. It is poorly absorbed from the gastrointestinal tract, forms insoluble complexes within the lumen, and prevents the absorption of dietary phosphate. A 63‐year‐old female with a 7‐year history of peritoneal dialysis, who was treated with lanthanum carbonate for four years, underwent endoscopic submucosal dissection for intramucosal gastric cancer. Resected specimens showed massive accumulation of macrophages containing fine, granular, brown material in the lamina propria. This was confirmed as lanthanum deposition by scanning electron microscopy with energy dispersive x‐ray spectroscopy. Although lanthanum may be poorly absorbed, increased tissue accumulation of lanthanum, particularly in the liver and bone, has been reported in animals with chronic kidney disease. This report indicates enhanced gastrointestinal absorption of lanthanum in some patients or conditions, although its clinical significance awaits further studies.     

A longitudinal qualitative study to explore and optimize self-management in mild to end stage chronic kidney disease patients with limited health literacy: Perspectives of patients and health care professionals

ObjectivesLimited health literacy (LHL) is associated with faster kidney deterioration. Health care professionals (HCPs) promote self-management to maintain kidney function, which is difficult for patients with LHL. Evidence lacks on perceived barriers and best strategies to optimize their self-management. Our study aims to explore experiences with and barriers for self-management from the perspectives of LHL patients and HCPs to identify strategies to optimize self-management.MethodsWe performed a longitudinal qualitative study with semi-structured in-depth interviews and focus group discussions among CKD patients and LHL (n = 24) and HCPs (n = 37) from general practices and hospitals.ResultsFour themes arose among patients: (1) CKD elusiveness, (2) suboptimal intake of knowledge (3) not taking a front-seat role, and (4) maintaining change. Among HCPs, three themes emerged: (1) not recognizing HL problems, (2) lacking effective strategies, and (3) health care barriers.ConclusionWe suggest three routes to optimize self-management: providing earlier information, applying person-centered strategies to maintain changes, and improving competencies of HCPs.Practice implicationsHCPs need to explain CKD self-management better to prevent kidney deterioration. New interventions, based on behavioral approaches, are needed to optimize self-management. HCPs need training to improve recognition and support of LHL patients.     

Challenges that healthcare practitioners experience in the comprehensive assessment of patients with non-communicable diseases: a preliminary investigation

BackgroundResource allocation and access to comprehensive treatment in the public healthcare sector are always under pressure. This pressure takes the form of staff shortages, treatment models and the holistic care of patients, compromising basic healthcare in South Africa.ObjectivesThe study''s aim was to determine the challenges that healthcare practitioners experience while assessing patients with non-communicable diseases, in private and public healthcare sectors in the Gauteng Province of South Africa.MethodsThe research design was exploratory and contextual. Qualitative data were collected through focus groups and semi-structured interviews among healthcare practitioners (n = 12). Data analysis took place using Atlas.ti 8.4 Windows (2020). Inter-rater reliability (r = 93.68%) was calculated to ensure the rigour and validity of the results.ResultsFrom the discussion, four themes emerged: 1) limited consultation time; 2) overwhelming economic impact and healthcare cost for facilities and patients; 3) holistic patient care encompassing physical, mental and socioeconomic components; and 4) lack of patient education due to time constraints experienced by healthcare practitioners.ConclusionConsultation times are reduced due to a shortage of medical staff, patient numbers, equipment, and poor working conditions. By improving these conditions, patients across all socioeconomic groups will be better assisted, treated, and educated, benefiting from equal access and quality healthcare.     

The role of the immune system in kidney disease

The immune system and the kidneys are closely linked. In health the kidneys contribute to immune homeostasis, while components of the immune system mediate many acute forms of renal disease and play a central role in progression of chronic kidney disease. A dysregulated immune system can have either direct or indirect renal effects. Direct immune‐mediated kidney diseases are usually a consequence of autoantibodies directed against a constituent renal antigen, such as collagen IV in anti‐glomerular basement membrane disease. Indirect immune‐mediated renal disease often follows systemic autoimmunity with immune complex formation, but can also be due to uncontrolled activation of the complement pathways. Although the range of mechanisms of immune dysregulation leading to renal disease is broad, the pathways leading to injury are similar. Loss of immune homeostasis in renal disease results in perpetual immune cell recruitment and worsening damage to the kidney. Uncoordinated attempts at tissue repair, after immune‐mediated disease or non‐immune mediated injury, result in fibrosis of structures important for renal function, leading eventually to kidney failure. As renal disease often manifests clinically only when substantial damage has already occurred, new diagnostic methods and indeed treatments must be identified to inhibit further progression and promote appropriate tissue repair. Studying cases in which immune homeostasis is re‐established may reveal new treatment possibilities.     

Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study

Background

Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management.

Aim

To explore processes underpinning the implementation of CKD management in primary care.

Design and setting

Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester.

Method

Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data.

Results

A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions.

Conclusion

Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity.