Self-Management: A Comprehensive Approach to Management of Chronic Conditions

For both clinical and economic reasons, the increasing number of persons living with chronic conditions represents a public health issue of growing importance. Emphasizing patient responsibility, and acting in concert with the provider community, self-management represents a promising strategy for treating chronic conditions—moving beyond education to teaching individuals to actively identify challenges and solve problems associated with their illness. Self-management also shows potential as an effective paradigm across the prevention spectrum (primary, secondary, and tertiary) by establishing a pattern for health early in life and providing strategies for mitigating illness and managing it in later life. We suggest ways to advance research methods and practical applications of self-management as steps in its future development and implementation.Improvements in health care have resulted in greater numbers of people living with multiple chronic conditions for longer periods of time. With this change, chronic illness is now a major focus of health care.1 At the same time, increased attention has been concentrated on approaches to manage chronic symptoms to maintain patient independence and quality of life over longer periods of time. Approaches to managing chronic illness are shifting from the traditional provider–patient relationship to a paradigm in which individuals with chronic conditions play a key role in guiding their care, in partnership with health care providers.2,3Many prevalent chronic conditions, such as heart disease, diabetes, and arthritis, though unique in their own attributes and demands, share common challenges associated with their management. These include dealing with symptoms and disability; monitoring physical indicators; managing complex medication regimens; maintaining proper levels of nutrition, diet, and exercise; adjusting to the psychological and social demands, including difficult lifestyle adjustments; and engaging in effective interactions with health care providers.4,5The identification and elaboration of common patient-centric strategies to deal with these challenges is the focus of the field of self-management.6,7 Regardless of the chronic condition, the development of a generic set of skills has proven successful in allowing individuals to effectively manage their illness and improve health outcomes.8 A 2010 report by the Department of Health and Human Services included self-management as one of 4 goals in a strategic framework for improving the health status of individuals with multiple chronic conditions.9 More recently, the 2012 Institute of Medicine report “Living Well With Chronic Illness: A Call for Public Health Action” included self-management10 as one of several models of living well interventions, noting that self-management programs instill individual responsibility and offer tools for patients to use in caring for their chronic illness.10There is increasing recognition that chronic illness, including its prevention, treatment and management, represents a public health as well as a clinical issue.11,12 Indeed, the Institute of Medicine report noted that a population health perspective for developing strategies, interventions, and policies to combat chronic illness is critical.10 Community-based self-management intervention programs are one aspect of a population-based approach addressing the larger public health problem of chronic conditions in the United States and across the globe. There is an extensive body of literature related to self-management of chronic conditions, but our intent with this article is not to provide a comprehensive review, but rather to highlight the unique contribution of nurse scientists to the field.Nursing science has enhanced the care of individual patients and has tested interventions that can be scaled up for implementation at the population level. We present examples of nursing science that demonstrate effectiveness, promise sustainability and scalability, and set the foundation for implementing wide-reaching public health actions for managing chronic illness.12There is increased awareness of the need to promote conceptual clarity regarding self-management and its integration into clinical practice. Equally important is the requirement to develop more sophisticated models of self-management, tailored to various health conditions and situations. Fundamental to the development of such models and their practical application is the need to conduct research that informs self-management practice and contributes to health policy.The nursing community, comprising both researchers and clinicians, plays a crucial role in efforts to provide the evidence base for innovative self-management practices, and is ideally positioned to implement those advances in a practical manner. Over the course of its history, the National Institute of Nursing Research (NINR) at the National Institutes of Health (NIH) has promoted self-management science as one of its core areas of investigation, supporting research to improve and manage symptoms of acute and chronic illness.13 Recognizing that self-management represents a topic of ever-increasing importance, a goal of NINR is to advance the science of self-management and, ultimately, disseminate results widely for translation into clinical practice.Recently, a group of nurse scientist leaders assembled to discuss “The Science of Chronic Illness Self-Management” as the topic of the 2013 National Nursing Research Roundtable. The Roundtable is an annual meeting with the purpose of providing a regular forum of communication about the direction and conduct of nursing research. Discussions from this year’s meeting resulted in a set of recommended areas of focus and approaches to advance the field and practice of self-management (see the box on this page).

Recommended Areas of Focus and Approaches to Advancing Self-Management

Clinical rejection is distinguished from subclinical rejection by increased infiltration by a population of activated macrophages.

It has been reported previously that one-third of protocol renal biopsies in asymptomatic, biochemically stable renal transplant recipients in the first 6 mo show unsuspected subclinical graft rejection (both infiltrate and tubulitis) and that subclinical rejection is a risk factor for chronic renal dysfunction. This study was performed to determine whether differences in phenotype or activation status of graft-infiltrating cells underlie these different manifestations of acute rejection. Biopsies with normal histology (n = 10), subclinical rejection (n = 13), and clinical rejection (n = 9) were studied using immunohistochemistry and computerized image analysis. Subclinical and clinical rejections had similar histologic Banff scores. Univariate analysis showed a trend for a higher infiltration with CD8+ (P = 0.053) and CD68+(P = 0.06) cells in clinical rejection. Of the activation markers studied (CD25, perforin, tumor necrosis factor-alpha), only allograft inflammatory factor-1+-activated macrophages were significantly (P = 0.014) increased in the infiltrate of clinical rejection biopsies. These data suggest that activated macrophages or their products are responsible for acute renal dysfunction associated with clinical rejection episodes.     

Characterization of a herpesvirus isolated from domestic geese in Australia

A herpesvirus (GHV 552/89) associated with high mortality in a flock of domestic geese in Australia was compared with duck virus enteritis (DVE) herpesvirus by cross-protection studies in domestic geese, Muscovy ducks and commercial Pekin ducks. In DVE-vaccinated geese, Muscovy ducks and Pekin ducks, mortality levels of 100, 50 and 0%, respectively, were recorded following challenge with GHV 552/89. Conversely, in geese, Muscovy ducks and Pekin ducks immunized with inactivated GHV 552/89, 100% mortality was observed in the geese and Muscovy ducks, and 80% in the Pekin ducks following challenge with DVE virus. The isolate was also compared with six other avian herpesviruses using cross-neutralization tests in cell cultures. No detectable cross-neutralization occurred with any of the avian herpesviruses tested. Further characterization of GHV 552/89 was undertaken by comparing its genome with strains of DVE herpesvirus using restriction endonuclease analysis of the viral DNA and a polymerase chain reaction (PCR) test. Following digestion with HindIII, the DNA fragment pattern of GHV 552/89 was found to be completely different from the DVE viruses. Similarities were found between the digestion patterns of a UK and a US DVE isolate, but both were distinguishable from a UK vaccine strain. The results of the PCR analysis and comparison using two DVE-specific primer sets did not produce specific amplification products of expected molecular weights (603 and 446 base pairs) from the GHV 552/89 genome. The PCR products derived from the DVE strains were similar to those derived from the DVE control DNA. From the results of this study, it is concluded that the goose herpesvirus GHV 552/89 is antigenically and genomically distinct from DVE herpesvirus.     

Neurochemical effects of prenatal haloperidol exposure

The neurochemical effects of prenatal exposure to dopamine receptor antagonists are as yet poorly characterized. To further examine this problem, pregnant rats were given daily subcutaneous injections of vehicle, 2.5 or 5.0 mg/kg haloperidol over gestational days 6 through 20. Membrane binding of [3H]SCH-23390 (D1-specific) and [3H]spiroperidol (D2-specific in most brain areas) was measured in four regions of the cerebral dopamine system at postnatal day (PND) 30. Dopamine (DA) and 3,4-dihydroxyphenylacetic acid (DOPAC) levels were measured in caudate on PND 30 following a d-amphetamine challenge. Prenatal haloperidol exposure reduced [3H]SCH-23390 and [3H]spiroperidol binding in caudate in a dose-dependent manner. [3H]Spiroperidol binding was similarly reduced in nucleus accumbens, but only the low dose (2.5 mg/kg) group showed decreased [3H]SCH-23390 binding in this region. Binding of neither compound was significantly altered in amygdala or frontal cortex. Basal or drug-stimulated levels of caudate DA and DOPAC were unaltered. It is concluded that prenatal haloperidol exposure reduces D1 and D2 binding in some, but not all regions of the forebrain dopamine system.     

Frequency downconversion and phase noise in MIT

High-frequency (3-30 MHz) operation of MIT systems offers advantages in terms of the larger induced signal amplitudes compared to systems operating in the low- or medium-frequency ranges. Signal distribution at HF, however, presents difficulties, in particular with isolation and phase stability. It is therefore valuable to translate received signals to a lower frequency range through heterodyne downconversion, a process in which relative signal amplitude and phase information is in theory retained. Measurement of signal amplitude and phase is also simplified at lower frequencies. The paper presents details of measurements on a direct phase measurement system utilizing heterodyne downconversion and compares the relative performance of three circuit configurations. The 100-sample average precision of a circuit suitable for use as a receiver within an MIT system was 0.008 degrees for input amplitude -21 dBV. As the input amplitude was reduced from -21 to -72 dBV variation in the measured phase offset was observed, with the offset varying by 1.8 degrees. The precision of the circuit deteriorated with decreasing input amplitude, but was found to provide a 100-sample average precision of <0.022 degrees down to an input amplitude of -60 dBV. The characteristics of phase noise within the system are discussed.