Self-managed Treatment Research Articles

Performance of full-scale rural wastewater treatment plants in the reduction of antibiotic-resistant bacteria and antibiotic resistance genes from small-city effluents

The main objective of this study was to evaluate the performance of full-scale rural wastewater treatment plants (WWTPs) in the reduction of antibiotic-resistant bacteria (ARB) and antibiotic resistance genes (ARGs) from small-city effluents. Twenty full-scale WWTPs in rural Chile with different biological treatment technologies (vermifiltration (VF), activated sludge (AS) and biodisc (BD)) and disinfection treatments (chlorination (Cl) and UV irradiation (UV)) were monitored and studied in two campaigns: Campaign 1 (20 WWTPs) and Campaign 2 (6 WWTPs). In both campaigns, the rural WWTPs improved the water quality of the effluents very significantly (90%, 70%, and 40% reductions in TU, COD, and NH4+-N, respectively) and reduced ARB and ARG loads by 2–4 log units. All three biological treatments contributed to the final quality of the effluents, especially in terms of microbiological parameters, with statistically indistinguishable efficiencies between them. These results show the importance of rural WWTPs in improving the water quality of urban effluents while reducing microbiological risk and the spread of antibiotic resistance into the environment. The study demonstrates the utility of a non-centralized, self-managed wastewater treatment scheme that can be implemented in many sparsely populated areas around the world.

A feasibility study of a novel computer-based treatment for sentence production deficits in aphasia, delivered by a combination of clinician-led and self-managed treatment sessions

ABSTRACT Background There is increasing evidence that face-to-face treatments for verb and sentence production deficits in aphasia can be effective. However, very few studies have investigated supplementing such treatments with self-managed computer-based home practice. Given the increasing importance of computer-based aphasia treatment, it is imperative that the feasibility of this mode of delivering verb and sentence treatments is explored. Aims This study explored the feasibility and preliminary effectiveness of a novel computer-based treatment for sentence production deficits in aphasia, delivered by a combination of face-to-face and self-managed treatment sessions. The effect of treatment on verb and sentence production, discourse and functional communication was assessed. Methods & Procedures The study used a pre-post design with six single cases: three males and three females aged 49 – 81 years. The Sentence Production Treatment (SPT) was developed based on the evidence from systematic reviews of verb-in-isolation and sentence treatments respectively. The SPT was low dose (8 hours) and clinician delivered, supplemented by a minimum set level (16 hours) of self-managed computer-based treatment. The feasibility of the SPT was investigated by: monitoring recruitment and retention of participants; logging any technical issues; assessing the fidelity of face-to-face treatment delivery using checklists; and monitoring compliance with self-delivered treatment. Outcomes & Results The SPT was found to be feasible and acceptable to the six participants. Treatment effects were noted on trained verb production and sentence production for five participants each. Generalisation to untrained verb and sentence targets and discourse was more limited, however four participants perceived functional communication improvements. Conclusions The study represents the first preliminary evidence that a computer-based sentence level treatment for sentence production deficits in aphasia, which included a self-managed component, is feasible and can be effective. Given these overall positive findings of feasibility and benefit, further feasibility testing is warranted, exploring intervention refinement and candidacy.

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study.

BackgroundAlthough the efficacy of high-dose speech-language therapy (SLT) for individuals with poststroke aphasia has been established in the literature, there is a gap in translating these research findings to clinical practice. Therefore, patients continue to receive suboptimal amounts of SLT, with negative consequences for their functional communication recovery. Recent research has identified self-managed digital health technology as one way to close the dosage gap by enabling high-intensity therapy unrestricted by clinician availability or other practical constraints. However, there is limited empirical evidence available to rehabilitation professionals to guide dose prescriptions for self-managed SLT despite their increasing use in the COVID-19 era and likely beyond.ObjectiveThis study aims to leverage real-world mobile health data to investigate the effects of varied dosage frequency on performance outcomes for individuals with poststroke speech, language, and cognitive deficits following a 10-week period of self-managed treatment via a commercially available digital health platform.MethodsAnonymized data from 2249 poststroke survivors who used the Constant Therapy app between late 2016 and 2019 were analyzed. The data included therapy tasks spanning 13 different language and cognitive skill domains. For each patient, the weekly therapy dosage was calculated based on the median number of days per week of app use over the 10-week therapy period, binned into groups of 1, 2, 3, 4, or ≥5 days per week. Linear mixed-effects models were run to examine change in performance over time as a function of dosage group, with post hoc comparisons of slopes to evaluate the performance gain associated with each additional day of practice.ResultsAcross all skill domains, linear mixed-effects model results showed that performance improvement was significantly greater for patients who practiced 2 (β=.001; t15,355=2.37; P=.02), 3 (β=.003; t9738=5.21; P<.001), 4 (β=.005; t9289=7.82; P<.001), or ≥5 (β=.005; t6343=8.14; P<.001) days per week compared with those who only practiced for 1 day per week. Post hoc comparisons confirmed an incremental dosage effect accumulating with each day of practice (ie, 1 day vs 2 days, 2 days vs 3 days, and 3 days vs 4 days), apart from 4 days versus ≥5 days of practice per week. The result of greater improvement for higher versus lower dosage frequency groups was true not only across all domains but also within a majority of individual subdomains.ConclusionsThe findings from this study demonstrated that increased dosage frequency is associated with greater therapy gains over a 10-week treatment period of self-managed digital therapy. The use of real-world data maximizes the ecological validity of study results and makes the findings more generalizable to clinical settings. This study represents an important step toward the development of optimal dose recommendations for self-managed SLT.

Applying adaptive distributed practice to self-managed computer-based anomia treatment: A single-case experimental design

IntroductionThere is a pressing need to improve computer-based treatments for aphasia to increase access to long-term effective evidence-based interventions. The current single case design incorporated two learning principles, adaptive distributed practice and stimuli variability, to promote acquisition, retention, and generalization of words in a self-managed computer-based anomia treatment. MethodsTwo participants with post-stroke aphasia completed a 12-week adaptive distributed practice naming intervention in a single-case experimental design. Stimuli variability was manipulated in three experimental conditions: high exemplar variability, low exemplar variability, and verbal description prompt balanced across 120 trained words. Outcomes were assessed at 1-week, 1-month, and 3-months post-treatment. Statistical comparisons and effect sizes measured in the number of words acquired, generalized, and retained were estimated using Bayesian generalized mixed-effect models. ResultsParticipants showed large and robust acquisition, generalization, and retention effects. Out of 120 trained words, participant 1 acquired ∼77 words (trained picture exemplars) and ∼63 generalization words (untrained picture exemplars of treated words). Similarly, participant 2 acquired ∼57 trained words and ∼48 generalization words. There was no reliable change in untrained control words for either participant. Stimuli variability did not show practically meaningful effects. ConclusionsThese case studies suggest that adaptive distributed practice is an effective method for re-training more words than typically targeted in anomia treatment research (∼47 words on average per Snell et al., 2010). Generalization across experimental conditions provided evidence for improved lexical access beyond what could be attributed to simple stimulus-response mapping. These effects were obtained using free, open-source flashcard software in a clinically feasible, asynchronous format, thereby minimizing clinical implementation barriers. Larger-scale clinical trials are required to replicate and extend these effects.

Computational Modeling of Deep Tissue Heating by an Automatic Thermal Massage Bed: Predicting the Effects on Circulation.

Automatic thermal and mechanical massage beds support self-managed treatment, including reduction of pain and stress, enhanced circulation, and improved mobility. As the devices become more sophisticated (increasing the degrees of freedom), it is essential to identify the settings that best target the desired tissue. To that end, we developed an MRI-derived model of the lower back and simulated the physiological effects of a commercial thermal-mechanical massage bed. Here we specifically estimated the tissue temperature and increased circulation under steady-state conditions for typical thermal actuator settings (i.e., 45–65°C). Energy transfer across nine tissues was simulated with finite element modeling (FEM) and the resulting heating was coupled to blood flow with an empirically-guided model of temperature-dependent circulation. Our findings indicate that thermal massage increases tissue temperature by 3–8°C and 1–3°C at depths of 2 and 3 cm, respectively. Importantly, due to the rapid (non-linear) increase of circulation with local temperature, this is expected to increase blood flow four-fold (4x) at depths occupied by deep tissue and muscle. These predictions are consistent with prior clinical observations of therapeutic benefits derived from spinal thermal massage.

Cost Effectiveness of Patient Self-Managed Warfarin Compared with Direct Oral Anticoagulants in Atrial Fibrillation: An Economic Evaluation in a Danish Healthcare Sector Setting.

BackgroundPatient self-managed anticoagulant treatment with warfarin (PSM) has been proposed as an alternative to direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF); however, direct evidence on the cost effectiveness of PSM compared with DOACs is lacking. We aimed to evaluate the cost effectiveness of PSM versus DOACs for NVAF patients in the Danish healthcare setting using a model-based cost-utility analysis.MethodsA cost-utility analysis was performed using a decision-analytic model including two treatment alternatives: continuous PSM and DOACs. The analysis was performed from an extended Danish healthcare sector perspective, including patient-paid costs of medication related to the anticoagulant treatment, with a lifetime horizon. Inputs for the model comprised of probabilities of events, costs in Danish estimates, when possible, and effect in utilities. The probabilities of events are primarily based on real-life data from a direct comparison of PSM and DOACs. The results are presented as the incremental cost-effectiveness ratio (ICER) with an assumed cost-effectiveness threshold of £20,000/quality-adjusted life-year (QALY). Both deterministic and probabilistic sensitivity analyses were performed to investigate the robustness of the results.ResultsThe base-analysis showed that PSM was dominant, with a decreased cost of £8495 and an increased QALY accumulation of 0.23 per patient (ICER = −£36,935/QALY). All deterministic sensitivity analyses indicated that PSM was dominant or at least cost effective. The probabilistic sensitivity analysis showed that 95% of the iterations were cost effective.ConclusionsThe present study found that PSM is dominant (i.e., both more effective and cost saving) compared with DOACs, adding to the scarce evidence of the comparative cost effectiveness of PSM and DOACs in NVAF.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-022-00337-3.

Effect of self-managed lifestyle treatment on glycemic control in patients with type 2 diabetes

The lack of effective, scalable solutions for lifestyle treatment is a global clinical problem, causing severe morbidity and mortality. We developed a method for lifestyle treatment that promotes self-reflection and iterative behavioral change, provided as a digital tool, and evaluated its effect in 370 patients with type 2 diabetes (ClinicalTrials.gov identifier: NCT04691973). Users of the tool had reduced blood glucose, both compared with randomized and matched controls (involving 158 and 204 users, respectively), as well as improved systolic blood pressure, body weight and insulin resistance. The improvement was sustained during the entire follow-up (average 730 days). A pathophysiological subgroup of obese insulin-resistant individuals had a pronounced glycemic response, enabling identification of those who would benefit in particular from lifestyle treatment. Natural language processing showed that the metabolic improvement was coupled with the self-reflective element of the tool. The treatment is cost-saving because of improved risk factor control for cardiovascular complications. The findings open an avenue for self-managed lifestyle treatment with long-term metabolic efficacy that is cost-saving and can reach large numbers of people.

Effect of Digital Lifestyle Management on Metabolic Control and Quality of Life in Patients with Well-Controlled Type2 Diabetes.

IntroductionThe lack of effective, scalable solutions for lifestyle treatment is a global clinical problem, causing severe morbidity and mortality. Digital tools could enable broad utility, but long-term metabolic outcomes and the influence on quality of life are unclear.MethodsWe developed a new method for lifestyle treatment that promotes self-reflection and iterative behavioural change, provided as a digital tool, and evaluated its effect on glycaemic control in patients with type 2 diabetes with HbA1c below 52 mmol/mol (n = 297). As a secondary analysis, its effect on quality of life (using SF-12) was examined in both participants with and without diabetes (total n = 1914). The tool was evaluated during a 12-week randomization period to assess the existence of effect, with a subsequent open-label follow-up to study long-term outcomes.ResultsParticipants were randomized to wait or access the intervention tool. The mean difference in HbA1c was 2 mmol/mol (95% CI − 4 to 0; P = 0.02) after 12 weeks in participants with type 2 diabetes. The groups were then merged to enable all participants to use the tool. The mean HbA1c reduction from baseline in patients with type 2 diabetes using the tool was 2 mmol/mol compared with matched controls (95% CI − 3 to 0; P = 0.005). In users with HbA1c above 45 mmol/mol, the mean difference between the groups was 4 mmol/mol (95% CI − 7 to − 2). The improvements were sustained during the follow-up of 1 year on average. Users of the tool also had improved quality of life from baseline to 6 months, mainly observed in non-diabetic participants.ConclusionThe tool does not require in-person reinforcement or increased healthcare resources, and the marginal cost is fundamentally lower than pharmacological treatment and most existing lifestyle interventions. The results therefore open a new means for self-managed lifestyle treatment with long-term metabolic efficacy that can benefit large numbers of people.Trial RegistrationClinicalTrials.gov NCT04624321 and NCT05006508.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13300-022-01214-2.

Home used, patient self-managed, brain-computer interface for the management of central neuropathic pain post spinal cord injury: usability study

BackgroundCentral Neuropathic Pain (CNP) is a frequent chronic condition in people with spinal cord injury (SCI). Previously, we showed that using laboratory brain-computer interface (BCI) technology for neurofeedback (NFB) training, it was possible to reduce CNP in people with SCI. In this study, we show results of patient self-managed treatment in their homes with a BCI-NFB using a consumer EEG device.MethodsUsers: People with chronic SCI (17 M, 3 F, 50.6 ± 14.1 years old), and CNP ≥4 on a Visual Numerical Scale. Location: Laboratory training (up to 4 sessions) followed by home self-managed NFB. User Activity: Upregulating the EEG alpha band power by 10% above a threshold and at the same time downregulating the theta and upper beta (20-30 Hz) band power by 10% at electrode location C4. Technology: A consumer grade multichannel EEG headset (Epoch, Emotiv, USA), a tablet computer and custom made NFB software. Evaluation: EEG analysis, before and after NFB assessment, interviews and questionnaires.ResultsEffectiveness: Out of 20 initially assessed participants, 15 took part in the study. Participants used the system for 6.9 ± 5.5 (median 4) weeks. Twelve participants regulated their brainwaves in a frequency specific manner and were most successful upregulating the alpha band power. However they typically upregulated power around their individual alpha peak (7.6 ± 0.8 Hz) that was lower than in people without CNP. The reduction in pain experienced was statistically significant in 12 and clinically significant (greater than 30%) in 8 participants. Efficiency: The donning was between 5 and 15 min, and approximately 10–20% of EEG data recorded in the home environment was noise. Participants were mildly stressed when self-administering NFB at home (2.4 on a scale 1–10). User satisfaction: Nine participants who completed the final assessment reported a high level of satisfaction (QUESQ, 4.5 ± 0.8), naming effectiveness, ease of use and comfort as main priorities. The main factors influencing frequency of NFB training were: health related issues, free time and pain intensity.ConclusionPortable NFB is a feasible solution for home-based self-managed treatment of CNP. Compared to pharmacological treatments, NFB has less side effects and provides users with active control over pain.Trial registrationGN15NE124, Registered 9th June 2016.

EEG Correlates of Self-Managed Neurofeedback Treatment of Central Neuropathic Pain in Chronic Spinal Cord Injury.

BackgroundNeurofeedback (NFB) is a neuromodulatory technique that enables voluntary modulation of brain activity in order to treat neurological condition, such as central neuropathic pain (CNP). A distinctive feature of this technique is that it actively involves participants in the therapy. In this feasibility study, we present results of participant self-managed NFB treatment of CNP.MethodsFifteen chronic spinal cord injured (SCI) participants (13M, 2F), with chronic CNP equal or greater than 4 on the Visual Numeric Scale, took part in the study. After initial training in hospital (up to 4 sessions), they practiced NF at home, on average 2–3 times a week, over a period of several weeks (min 4, max 20). The NFB protocol consisted of upregulating the alpha (9–12 Hz) and downregulating the theta (4–8 Hz) and the higher beta band (20–30 Hz) power from electrode location C4, for 30 min. The output measures were pain before and after NFB, EEG before and during NFB and pain questionnaires. We analyzed EEG results and show NFB strategies based on the Power Spectrum Density of each single participant.ResultsTwelve participants achieved statistically significant reduction in pain and in eight participants this reduction was clinically significant (larger than 30%). The most successfully regulated frequency band during NFB was alpha. However, most participants upregulated their individual alpha band, that had an average dominant frequency at αp = 7.6 ± 0.8 Hz (median 8 Hz) that is lower than the average of the general population, which is around 10 Hz. Ten out of fifteen participants significantly upregulated their individual alpha power (αp ± 2 Hz) as compared to 4 participants who upregulated the power in the fixed alpha band (8–12 Hz). Eight out of the twelve participants who achieved a significant reduction of pain, significantly upregulated their individual alpha band power. There was a significantly larger increase in alpha power (p < 0.0001) and decrease of theta power (p < 0.04) in participant specific rather than in fixed frequency bands.ConclusionNeurofeedback is a neuromodulatory technique that gives participants control over their pain and can be self-administered at home. Regulation of individual frequency band was related to a significant reduction in pain.

Effectiveness and safety of self-managed oral anticoagulant therapy compared with direct oral anticoagulants in patients with atrial fibrillation

We compared the effectiveness and safety of direct oral anticoagulants (DOAC) vs patient self-managed warfarin therapy (PSM) in patients with atrial fibrillation. We linked prospectively registered data from university hospital clinics to nationwide Danish health registries. Primary effectiveness and safety outcomes were ischaemic stroke (incl. systemic embolism) and major bleeding. All-cause mortality and all-cause stroke were secondary outcomes. An inverse probability of treatment propensity-weighted approach was applied to adjust for potential confounding. The study cohorts included 534 patients treated with PSM and 2,671 patients treated with DOAC. Weighted rates of ischaemic stroke were 0.46 and 1.30 percent per year with PSM vs DOAC, hazard ratio (HR) 0.27 (95% confidence interval 0.11–0.68) with 2.5 years follow-up. Rates of major bleeding were 2.32 and 2.13 percent per year (HR 1.06 [0.69–1.63]). All-cause mortality was not statistically different (HR 0.67 [0.39–1.17]), whereas the incidence of all-cause stroke was significantly lower among patients treated with PSM with rates of 0.61 vs 1.45 percent per year (HR 0.36 [0.16–0.78]). In patients with atrial fibrillation, self-managed oral anticoagulant treatment was associated with a significantly lower risk of all-cause and ischaemic stroke compared to treatment with DOAC, whereas no significant differences were observed for major bleeding and mortality.

How can technology enhance elderly adherence to self-managed treatment plan?

Patient non-compliance with treatment care is one of the leading causes of increasing healthcare costs and hospital readmissions. Elderly patients, those 65 years and older, are especially prone to losing motivation to adhere to treatment, particularly when self-management is required and they are infrequently checked by providers. This study investigates the effect of information systems on retaining motivation to adhere to self-management and satisfaction with treatment. Drawing upon goal-setting and control theories, we found that clearly defined and revisited goals are more likely to be followed by elderly patients if progress is monitored and regular and timely feedback is provided by their provider.

THE USE OF SELF-MANAGED TREATMENT STRATEGIES IN A PREDOMINANTLY LOW-INCOME, AFRICAN-AMERICAN SAMPLE OF WOMEN LIVING WITH HIV.

While low-income and ethnic minority women represent a growing proportion of new HIV cases in the United States, little is known about how they manage their antiretroviral medication regimens. Using a predominantly low-income, African-American sample (N = 85), this study examined medication self-management strategies among HIV seropositive women undergoing antiretroviral therapy in a major metropolitan area. Most study participants (95%; n = 81) reported employing a specific medication management strategy during the previous week. Pillboxes, use of daily activities, and receiving reminders from another person were the most common strategies. Most participants (80.2%) employed two or more strategies. Age, education, and motivation were associated with alarm, pillbox, and visual aid usage.

The reliability and validity of the Japanese version of the Diabetes Family Behavior Checklist (DFBC) for assessing the relationship between Type 2 diabetes mellitus patients and their families with respect to adherence to treatment regimen

AimsAn appropriate questionnaire for assessing family support of self-management behavior of Japanese Type 2 diabetes patients has yet to be developed. We produced a Japanese version of the Diabetes Family Behavior Checklist (DFBC) and tested its reliability and validity. MethodsThe study enrolled Japanese patients with Type 2 diabetes mellitus who were living with their families: 158 patients in the Insulin Group and 169 in the Oral Hypoglycemic Agents Group. The external validity of the DFBC was tested with questionnaires of self-managed dietary and exercise behaviors, the Appraisal of Diabetes Scale (ADS), and HbA1c. ResultsThe DFBC comprised two components: “Negative” and “Positive” feedbacks. Cronbach's alpha in the subcategories was ≥0.93, and the test–retest showed an intraclass correlation coefficient of 0.89. “Positive” and “Negative” scores correlated with self-managed dietary and/or exercise behaviors, the ADS scores in the both Groups. For patients having HbA1c levels of ≤6.8% there was a correlation between their “Positive” and “Negative” scores and the scores of their families in both Groups. ConclusionThe DFBC showed evidence of validity and reliability and may be a useful tool for quick assessment of self-managed treatment behavior of Japanese Type 2 diabetes patients and support received from their family.

Computer Therapy Compared With Usual Care for People With Long-Standing Aphasia Poststroke

The purpose of this study was to test the feasibility of conducting a randomized controlled trial to study the effectiveness of self-managed computer treatment for people with long-standing aphasia after stroke. In this pilot single-blinded, parallel-group, randomized controlled trial participants with aphasia were allocated to self-managed computer treatment with volunteer support or usual care (everyday language activity). The 5-month intervention period was followed by 3 months without intervention to investigate treatment maintenance. Thirty-four participants were recruited. Seventeen participants were allocated to each group. Thirteen participants from the usual care group and 15 from the computer treatment group were followed up at 5 months. An average of 4 hours 43 minutes speech and language therapy time and 4 hours volunteer support time enabled an average of 25 hours of independent practice. The difference in percentage change in naming ability from baseline at 5 months between groups was 19.8% (95% CI, 4.4-35.2; P=0.014) in favor of the treatment group. Participants with more severe aphasia showed little benefit. Results demonstrate early indications of cost-effectiveness of self-managed computer therapy. This pilot trial indicates that self-managed computer therapy for aphasia is feasible and that it will be practical to recruit sufficient participants to conduct an appropriately powered clinical trial to investigate the effectiveness of self-managed computer therapy for people with long-standing aphasia. Clinical Trial Registration- www.controlled-trials.com. Unique identifier: ISRCTN91534629.

Factors Determining Community Support Leading to the Success of Communal Self-Managed Wastewater Treatment System: A Case Study of Low-Income Communities in Bangkok

Factors Determining Community Support Leading to the Success of Communal Self-Managed Wastewater Treatment System: A Case Study of Low-Income Communities in Bangkok

The Perpetually Sick Self

The Perpetually Sick Self

Depot combined with oral antipsychotic medication in schizophrenia: A parachute for the patient in prodromal phase

Optimal treatment with antipsychotic medication in combination with psychosocial interventions are the main ingredients of a strategy for the prevention of psychotic relapses by continuous minimal effective medication, by low dose of doctor-prescribed depot neuroleptics, and intermittent self-managed oral antipsychotic psychopharmacological treatment.□ Combined strategy, Depot neuroleptics, Oral antipsychotic medication, Relapse prevention, User participation.