Efficacy of nonpharmacological interventions for severe radiation-induced oral mucositis among head and neck cancer patients: A network meta-analysis of randomised controlled trials

AIMS AND OBJECTIVES

To assess the effectiveness of different nonpharmacological treatments for severe radiation-induced oral mucositis in patients with head and neck cancer.

BACKGROUND

Radiation-induced oral mucositis is highly prevalent in patients with head and neck cancer. Current medications for radiation-induced oral mucositis are limited in effectiveness and susceptible to side effects, and while there is an increasing adoption of nonpharmacological interventions, the optimal one remains unclear.

DESIGN

Systematic review and network meta-analysis based on the PRISMA-NMA guidelines.

METHODS

Six databases were searched. Two authors independently performed the literature screening, data extraction and methodological quality assessment of the included studies. Traditional pairwise meta-analysis was performed by R Studio. A network meta-analysis was then conducted to assess the effects of nonpharmacological interventions for severe radiation-induced oral mucositis in patients with head and neck cancer.

RESULTS

Fifty-two studies involving seven types of nonpharmacological interventions were enrolled. The network meta-analysis indicated that natural plant-based therapies might be the most effective, health education interventions might be the second most effective, and honey might be the third most effective interventions for reducing the incidence of severe radiation-induced oral mucositis. For reducing the incidence of severe oral mucositis-related pain, the pairwise meta-analysis showed that only natural plant-based therapies and health education interventions were effective.

CONCLUSIONS

Nonpharmacological interventions are effective in the management of severe radiation-induced oral mucositis among patients with head and neck cancer.

RELEVANCE TO CLINICAL PRACTICE

Nonpharmacological interventions are a category of safe and effective adjunctive therapies that should be encouraged in clinical practice.

TRIAL REGISTRATION DETAILS

CRD42023400745.

Effects of Face Mask Mandates on COVID-19 Transmission in 51 Countries: Retrospective Event Study

BACKGROUND

The question of the utility of face masks in preventing acute respiratory infections has received renewed attention during the COVID-19 pandemic. However, given the inconclusive evidence from existing randomized controlled trials, evidence based on real-world data with high external validity is missing.

OBJECTIVE

To add real-world evidence, this study aims to examine whether mask mandates in 51 countries and mask recommendations in 10 countries increased self-reported face mask use and reduced SARS-CoV-2 reproduction numbers and COVID-19 case growth rates.

METHODS

We applied an event study approach to data pooled from four sources: (1) country-level information on self-reported mask use was obtained from the COVID-19 Trends and Impact Survey, (2) data from the Oxford COVID-19 Government Response Tracker provided information on face mask mandates and recommendations and any other nonpharmacological interventions implemented, (3) mobility indicators from Google's Community Mobility Reports were also included, and (4) SARS-CoV-2 reproduction numbers and COVID-19 case growth rates were retrieved from the Our World in Data-COVID-19 data set.

RESULTS

Mandates increased mask use by 8.81 percentage points (P=.006) on average, and SARS-CoV-2 reproduction numbers declined on average by -0.31 units (P=.008). Although no significant average effect of mask mandates was observed for growth rates of COVID-19 cases (-0.98 percentage points; P=.56), the results indicate incremental effects on days 26 (-1.76 percentage points; P=.04), 27 (-1.89 percentage points; P=.05), 29 (-1.78 percentage points; P=.04), and 30 (-2.14 percentage points; P=.02) after mandate implementation. For self-reported face mask use and reproduction numbers, incremental effects are seen 6 and 13 days after mandate implementation. Both incremental effects persist for >30 days. Furthermore, mask recommendations increased self-reported mask use on average (5.84 percentage points; P<.001). However, there were no effects of recommendations on SARS-CoV-2 reproduction numbers or COVID-19 case growth rates (-0.06 units; P=.70 and -2.45 percentage points; P=.59). Single incremental effects on self-reported mask use were observed on days 11 (3.96 percentage points; P=.04), 13 (3.77 percentage points; P=.04) and 25 to 27 (4.20 percentage points; P=.048 and 5.91 percentage points; P=.01) after recommendation. Recommendations also affected reproduction numbers on days 0 (-0.07 units; P=.03) and 1 (-0.07 units; P=.03) and between days 21 (-0.09 units; P=.04) and 28 (-0.11 units; P=.05) and case growth rates between days 1 and 4 (-1.60 percentage points; P=.03 and -2.19 percentage points; P=.03) and on day 23 (-2.83 percentage points; P=.05) after publication.

CONCLUSIONS

Contrary to recommendations, mask mandates can be used as an effective measure to reduce SARS-CoV-2 reproduction numbers. However, mandates alone are not sufficient to reduce growth rates of COVID-19 cases. Our study adds external validity to the existing randomized controlled trials on the effectiveness of face masks to reduce the spread of SARS-CoV-2.

Cost effectiveness of nonpharmacological prevention programs for diabetes: A systematic review of trial-based studies

Trial-based economic value of prevention programs for diabetes is inexplicit. We aimed to review the cost-effectiveness of nonpharmacological interventions to prevent type-2 diabetes mellitus (T2DM) for high-risk people. Six electronic databases were searched up to March 2022. Studies assessing both the cost and health outcomes of nonpharmacological interventions for people at high-risk of T2DM were included. The quality of the study was assessed by the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. The primary outcome for synthesis was incremental cost-effectiveness ratios (ICER) for quality-adjusted life years (QALYs), and costs were standardized in 2022 US dollars. Narrative synthesis was performed, considering different types and delivery methods of interventions. Sixteen studies included five based on the US diabetes prevention program (DPP), six on non-DPP-based lifestyle interventions, four on health education, and one on screening plus lifestyle intervention. Compared with usual care, lifestyle interventions showed higher potential of cost-effectiveness than educational interventions. Among lifestyle interventions, DPP-based programs were less cost-effective (median of ICERs: $27,077/QALY) than non-DPP-based programs (median of ICERs: $1395/QALY) from healthcare perspectives, but with larger decreases in diabetes incidence. Besides, the cost-effectiveness of interventions was more possibly realized through the combination of different delivery methods. Different interventions to prevent T2DM in high-risk populations are both cost-effective and feasible in various settings. Nevertheless, economic evidence from low- and middle-income countries is still lacking, and interventions delivered by trained laypersons and combined with peer support sessions or mobile technologies could be potentially a cost-effective solution in such settings with limited resources.

Preoperative anxiety management in pediatric patients: a systemic review and meta-analysis of randomized controlled trials on the efficacy of distraction techniques

Background

This study addresses the pervasive issue of heightened preoperative anxiety in healthcare, particularly among pediatric patients. Recognizing the various sources of anxiety, we explored both pharmacological and nonpharmacological interventions. Focusing on distraction techniques, including active and passive forms, our meta-analysis aimed to provide comprehensive insights into their impact on preoperative anxiety in pediatric patients.

Methods

Following the PRISMA and Cochrane guidelines, this meta-analysis and systematic review assessed the efficacy of pharmaceutical and distraction interventions in reducing pain and anxiety in pediatric surgery. This study was registered on PROSPERO (CRD42023449979).

Results

This meta-analysis, comprising 45 studies, investigated pharmaceutical interventions and distraction tactics in pediatric surgery. Risk of bias assessment revealed undisclosed risks in performance and detection bias. Distraction interventions significantly reduced preoperative anxiety compared to control groups, with notable heterogeneity. Comparison with Midazolam favored distraction techniques. Subgroup analysis highlighted varied efficacies among distraction methods, with a notable reduction in anxiety levels. Sensitivity analysis indicated stable results. However, publication bias was observed, suggesting a potential reporting bias.

Conclusion

Our study confirms distraction techniques as safe and effective for reducing pediatric preoperative anxiety, offering a valuable alternative to pharmacological interventions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=449979, PROSPERO [CRD42023449979].

Factors influencing access to nonpharmacological interventions for community-dwelling seniors with mild-to-moderate dementia: An integrative review

WHAT IS KNOWN ON THE SUBJECT

Research has shown effectiveness of nonpharmacological interventions in improving or maintaining cognition, mood, functioning, self-efficacy and quality of life for persons with mild-to-moderate dementia (PWDs). These interventions are critical during the earlier stages of dementia. However, Canadian and international literature report underutilization of and difficulty accessing the interventions.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

To our knowledge, this is the first review that explored factors influencing seniors' utilization of nonpharmacological interventions in the earlier stages of dementia. This review contributed to the discovery of unique factors such as PWDs' beliefs, fears, perceptions, and acceptability of nonpharmacological interventions and environmental influences on intervention provision. PWDs' intervention uptake may appear as a matter of personal choices related to individuals' knowledge, beliefs and perceptions. However, the analysis of the research evidence suggests that PWDs' choices are shaped by environmental factors such as formal and informal caregiver support, acceptability and accessibility of nonpharmacological interventions, dementia care workforce, community's attitudes towards dementia and funding. The complex interplay among factors highlights the importance of targeting health promotion strategies at both individuals and their environments.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

The review findings feature opportunities for healthcare practitioners, including mental health nurses, in advocating for PWDs' evidence-informed decision-making and access to desired nonpharmacological treatments. Involvement of patients and families in care-planning through ongoing assessment of health and learning needs, as well as enablers and barriers to using interventions, continuing information provision, and personalized referrals to appropriate services can promote PWDs' rights to healthcare.

ABSTRACT

INTRODUCTION: Despite the significance of nonpharmacological interventions in optimal management of mild-to-moderate dementia, it remains unclear in the literature how persons with mild-to-moderate dementia (PWDs) view, understand and access nonpharmacological interventions.

AIM

The purpose of this review was to explore the extent and nature of evidence concerning factors that influence the use of nonpharmacological interventions for community-dwelling seniors with mild-to-moderate dementia.

METHOD

An integrative review was undertaken following Toronto and Remington (A step-by-step guide to conducting an integrative review, 2020)'s instruction which expanded Torraco (Human Resource Development Review, 2016, 15, 404)'s and Whittemore and Knafl (Journal of Advanced Nursing, 2005, 52, 546)'s guidance.

RESULTS

The review of 16 studies suggests that PWDs' use of nonpharmacological interventions is shaped by a complex interplay of various personal, interpersonal, organizational, community and political influences.

DISCUSSION

The findings highlight the complex, interrelated relationships among multiple factors and subsequent limitations of behaviour-oriented health promotion strategies. To assist PWDs in making healthier choices, health promotion strategies need to direct attention to both individuals' behaviours and environmental conditions impacting the behaviours.

IMPLICATIONS FOR PRACTICE

The findings of this review can inform multidisciplinary health practitioners' (including mental health nurses) practice with seniors living with mild-to-moderate dementia. We recommend actionable ways in which they can empower patients and their families in dementia management.

Preparing for pragmatic trials in dementia care: Health equity considerations for nonpharmacological interventions

Inequities with regard to brain health, economic costs, and the evidence base for dementia care continue. Achieving health equity in dementia care requires rigorous efforts that ensure disproportionately affected populations participate fully in-and benefit from-clinical research. Embedding-proven interventions under real-world conditions and within existing healthcare systems have the potential to examine the effectiveness of an intervention, improve dementia care, and leverage the use of existing resources. Developing embedded pragmatic controlled trials (ePCT) research designs for nonpharmacological dementia care interventions involves a plethora of a priori assumptions and decisions. Although frameworks exist to determine whether interventions are "ready" for ePCT, there is no heuristic to assess health equity-readiness. We discuss health equity considerations, case examples, and research strategies across ePCT study domains of evidence, risk, and alignment. Future discussions regarding health equity considerations across other domains are needed.

Nonpharmacological tactile activity interventions for reducing behavioural and psychological symptoms of dementia in the acute hospital setting: An integrative review

AIM

To review existing research on nonpharmacological tactile activity interventions for reducing behavioural and psychological symptoms of dementia in the acute hospital setting.

BACKGROUND

When people living with dementia are admitted to hospital, they often experience an exacerbation of behavioural and psychological symptoms of dementia. Pharmacological interventions are often used to manage behavioural and psychological symptoms of dementia despite the low success rate and the heightened risk of morbidity and mortality. Low-cost alternatives that are implementable at the bedside are nonpharmacological interventions such as tactile activity interventions.

DESIGN

An integrative review of the literature.

METHODS

Four databases were searched using the PRISMA framework to guide the search and screening. Eligible studies were identified and the quality of each was evaluated using the Mixed Method Appraisal Tool. Thematic analysis was conducted to identify and analyse key themes across all articles. The PRISMA checklist was used to evaluate the current study.

RESULTS

Seven studies examined the use of tactile activity interventions to reduce the behavioural and psychological symptoms of dementia and the barriers and facilitators to implementation.

CONCLUSION

There is limited evidence exploring tactile activity interventions for reducing behavioural and psychological symptoms of dementia in acute hospital settings. Individualised approaches in combination with staffing expertise appear central to implementation.

RELEVANCE TO CLINICAL PRACTICE

Acute hospital settings can result in increased behavioural and psychological symptoms of dementia which can be distressing for patients and family and challenging for nursing staff. Tactile activity interventions may offer a low resource bedside option to support people with dementia in acute health settings.

PATIENT OR PUBLIC CONTRIBUTION

No direct patient or public contribution to the review.

An Auditory Sonic Sleep Treatment for Individuals Living With Dementia in a Memory Care Setting: A Quality Improvement Program Evaluation

BACKGROUND

The absence of a cure for dementia, combined with the increased longevity of the baby boom generation, is resulting in a dramatic increase in the number of people living with dementia. Aging-related changes coupled with dementia-related behavioral symptoms pose unique challenges for those living with dementia as well as those who provide care. There is evidence that improved sleep can improve health and well-being. Research also supports using auditory interventions as a form of nonpharmacological therapy.

OBJECTIVE

This study evaluated the effects of a customized auditory (sonic) treatment during sleep on the mood, behavior, quality of life, functional ability, and health condition of individuals living with the symptoms of dementia. Workforce outcomes were evaluated as a secondary outcome.

METHODS

A controlled before-after design with a mixed-method approach was used to evaluate the impact of the sonic sleep treatment during baseline, intervention, and discontinuation time frames.

RESULTS

Statistically significant improvements were observed in participants' cooperation with care (p = .0249) and daytime drowsiness (p = .0104). Other nonstatistically significant improvements included bed mobility, appetite, bathing self-performance, toilet use, incidence of falls, following requests and instructions, and nighttime insomnia. While workforce outcomes remained unchanged, staff were supportive of resuming the sonic sleep treatment after the discontinuation time frame.

CONCLUSIONS

The sonic sleep treatment demonstrated improved outcomes for individuals living with dementia. This supports using an appropriate auditory stimulus as a fundamental component of care for individuals living in memory care settings.

Topical Cellular/Tissue and Molecular Aspects Regarding Nonpharmacological Interventions in Alzheimer's Disease-A Systematic Review

One of the most complex and challenging developments at the beginning of the third millennium is the alarming increase in demographic aging, mainly-but not exclusively-affecting developed countries. This reality results in one of the harsh medical, social, and economic consequences: the continuously increasing number of people with dementia, including Alzheimer's disease (AD), which accounts for up to 80% of all such types of pathology. Its large and progressive disabling potential, which eventually leads to death, therefore represents an important public health matter, especially because there is no known cure for this disease. Consequently, periodic reappraisals of different therapeutic possibilities are necessary. For this purpose, we conducted this systematic literature review investigating nonpharmacological interventions for AD, including their currently known cellular and molecular action bases. This endeavor was based on the PRISMA method, by which we selected 116 eligible articles published during the last year. Because of the unfortunate lack of effective treatments for AD, it is necessary to enhance efforts toward identifying and improving various therapeutic and rehabilitative approaches, as well as related prophylactic measures.

Modulating Stress Proteins in Response to Therapeutic Interventions for Parkinson's Disease

Parkinson's disease (PD) is a neurodegenerative illness characterized by the degeneration of dopaminergic neurons in the substantia nigra, resulting in motor symptoms and without debilitating motors. A hallmark of this condition is the accumulation of misfolded proteins, a phenomenon that drives disease progression. In this regard, heat shock proteins (HSPs) play a central role in the cellular response to stress, shielding cells from damage induced by protein aggregates and oxidative stress. As a result, researchers have become increasingly interested in modulating these proteins through pharmacological and non-pharmacological therapeutic interventions. This review aims to provide an overview of the preclinical experiments performed over the last decade in this research field. Specifically, it focuses on preclinical studies that center on the modulation of stress proteins for the treatment potential of PD. The findings display promise in targeting HSPs to ameliorate PD outcomes. Despite the complexity of HSPs and their co-chaperones, proteins such as HSP70, HSP27, HSP90, and glucose-regulated protein-78 (GRP78) may be efficacious in slowing or preventing disease progression. Nevertheless, clinical validation is essential to confirm the safety and effectiveness of these preclinical approaches.

Protocol for a quasi-experimental study to ascertain the effectiveness of using eKnee School approach to impart self-care education to patients suffering from knee osteoarthritis during COVID-19 pandemic

BACKGROUND

Knee osteoarthritis (KOA) patients seek improvement in their quality of life by attaining independence in activities of daily living. Literature recommends nonpharmacological intervention as first-line treatment for KOA. The study aims to ascertain the effectiveness of online supervised nonpharmacological intervention sessions of virtual knee school (eKS) training among mild and moderate KOA patients in comparison to routine care during COVID-19 pandemic and assessment of cost-effectiveness of eKS against the routine care for KOA patients during COVID-19 pandemic.

MATERIALS AND METHODS

A quasi-experimental pre-post with control group, enrolling 50 participants each in two groups: usual/routine KOA care or usual care plus KS interventions via virtual mode. Our primary outcome measures are pain, quality of life, and incremental cost-effectiveness ratio. Secondary outcomes include performance-based tests (30-second chair test, timed up and go test, 6-minute walk test) and patient satisfaction. Intervention fidelity will be assessed with a priori checklist tailored to eKS assessing adherence, dose, quality, and user engagement in the key components. Quantitative data collection will be conducted at baseline and 6 months. Descriptive data analysis will be carried for quantitative data. For qualitative data, the thematic analysis will be performed; we propose to undertake a deterministic and probabilistic sensitivity analysis to address the issue of uncertainty in the present cost-effectiveness analysis model.

CONCLUSION

The management of KOA through virtual mode emphasizes the concepts of patient-as-person, family-centered, with socially interactive approach. The study will provide information on the effectiveness of nonpharmacological interventions for improving the quality of life of patients suffering from KOA through virtual knee school. Nevertheless, pitfalls in running eKS will be noted, which will help improve all aspects of online medical communications in the future.

Effect of using eye masks and earplugs in preventing delirium in intensive care patients: A single-blinded, randomized, controlled trial

BACKGROUND

Delirium, which is frequently encountered in intensive care patients, can be prevented with multicomponent nursing interventions, and thus the negative consequences can be reduced.

AIM

To examine the effect of using eye masks and earplugs in preventing delirium in intensive care units (ICUs).

STUDY DESIGN

A randomized, controlled, single-blind intervention study. This study was conducted in the medical and surgical ICUs of a tertiary hospital, and nurses were given pre-study training on delirium risks, diagnosis, prevention, and management. Data were collected using the patient information form, the Nursing Delirium Screening Scale, the Richard-Campbell Sleep Scale, and the daily follow-up form. Various environmental modifications were made in the ICUs for all patients, and evidence-based nonpharmacological nursing interventions were applied to the patients in both groups during the day and night shifts for 3 days. In addition, the patients in the intervention group were provided with eye masks and earplugs for three nights.

RESULTS

The study included a total of 60 patients (30 in the intervention group and 30 in the control group). There was a statistically significant difference in the development of delirium between the intervention and control groups (night of the 2nd day, p = .019; day of the 3rd day p < .001; night of the 3rd day p ≤ .001). The average total sleep quality score of the intervention group was found to be significantly higher than the control group (p ≤ .001 for three nights). Staying in the internal medicine ICU affected (odds ratio [OR], 11.84; 95% confidence interval [CI], 3.00-46.66; p = .017) more on the development of delirium than in coronary ICU, being in the age group of 65 and over, having a hearing impairment, coming to ICU from the operating room, and education level had an effect.

CONCLUSIONS

The earplugs and eye masks used by the intensive care patients overnight were found to be effective in increasing sleep quality and preventing delirium.

RELEVANCE TO CLINICAL PRACTICE

The use of eye masks and earplugs is recommended for ICUs in preventing delirium.

The Impact of Head-Up Tilt Sleeping on Orthostatic Tolerance: A Scoping Review

To systematically summarize the evidence of head-up tilt sleeping (HUTS) on orthostatic tolerance, we conducted a systematic, predefined search in PubMed, OVID Embase, Cochrane and Web of Science. We included studies assessing the effect of HUTS on orthostatic tolerance and other cardiovascular measures and rated the quality with the American Academy of Neurology risk of bias tool. We included 10 studies (n = 185) in four groups: orthostatic hypotension (OH; 6 studies, n = 103), vasovagal syncope (1 study, n = 12), nocturnal angina pectoris (1 study, n = 10) and healthy subjects (2 studies, n = 58). HUTS duration varied (1 day-4 months) with variable inclinations (5°-15°). In two of six OH studies, HUTS significantly improved standing systolic blood pressure. Orthostatic tolerance was consistently enhanced in OH studies with higher angles (≥12°), in 2 out of 3 with smaller angles (5°) but also in one studying horizontal sleeping. In vasovagal syncope, HUTS significantly augmented resilience to extreme orthostatic stress. One study was rated as a class II risk of bias, one of Class II/III and eight of Class IV. The evidence favouring HUTS to improve orthostatic tolerance is weak due to variable interventions, populations, small samples and a high risk of bias. Despite this, we found some physiological signs suggesting a beneficial effect.

Precious but convenient means of prevention and treatment: physiological molecular mechanisms of interaction between exercise and motor factors and Alzheimer's disease

Disproportionate to the severity of Alzheimer's disease (AD) and the huge number of patients, the exact treatment and prevention of AD is still being explored. With increasing ageing, the search for means to prevent and treat AD has become a high priority. In the search for AD, it has been suggested that exercise may be one of the more effective and less costly means of preventing and treating AD, and therefore a large part of current research is aimed at exploring the effectiveness of exercise in the prevention and treatment of AD. However, due to the complexity of the specific pathogenesis of AD, there are multiple hypotheses and potential mechanisms for exercise interventions in AD that need to be explored. This review therefore specifically summarises the hypotheses of the interaction between exercise and AD from a molecular perspective, based on the available evidence from animal models or human experiments, and explores them categorised according to the pathologies associated with AD: exercise can activate a number of signalling pathways inhibited by AD (e.g., Wnt and PI3K/Akt signalling pathways) and reactivate the effects of downstream factors regulated by these signalling pathways, thus acting to alleviate autophagic dysfunction, relieve neuroinflammation and mitigate Aβ deposition. In addition, this paper introduces a new approach to regulate the blood-brain barrier, i.e., to restore the stability of the blood-brain barrier, reduce abnormal phosphorylation of tau proteins and reduce neuronal apoptosis. In addition, this paper introduces a new concept." Motor factors" or "Exerkines", which act on AD through autocrine, paracrine or endocrine stimulation in response to movement. In this process, we believe there may be great potential for research in three areas: (1) the alleviation of AD through movement in the brain-gut axis (2) the prevention and treatment of AD by movement combined with polyphenols (3) the continued exploration of movement-mediated activation of the Wnt signalling pathway and AD.

Effectiveness of Nonpharmacological Interventions in the Field of Ventilation: An Umbrella Review

This umbrella review aimed to determine the effectiveness of nonpharmacological interventions in pulmonary ventilation and their impact on respiratory function. An individual with impaired ventilation displays visible variations manifested in their respiratory frequency, breathing rhythm ratio (I:E), thoracic symmetry, use of accessory muscles, dyspnea (feeling short of breath), oxygen saturation, diaphragm mobility, minute ventilation, peak flow, walking test, spirometry, Pimax/Pemax, diffusion, and respiratory muscle strength. Any variation in these markers demands the need for interventions in order to duly manage the signs and symptoms and to improve ventilation.

METHOD

Systematic reviews of the literature published in English, Spanish, French, and Portuguese were used, which included studies in which nonpharmacological interventions were used as a response to impaired ventilation in adults in any given context of the clinical practice. The recommendations given by the Joanna Briggs Institute (JBI) for umbrella reviews were followed. This research took place in several databases such as MEDLINE, CINAHL Complete, CINHAL, MedicLatina, ERIC, Cochrane Reviews (Embase), and PubMed. The Joanna Briggs critical analysis verification list was used for the systematic review. The data extraction was performed independently by two investigators based on the data extraction tools of the Joanna Briggs Institute, and the data were presented in a summary table alongside the support text.

RESULTS

Forty-four systematic reviews, thirty randomized clinical essays, and fourteen observational studies were included in this review. The number of participants varied between n = 103 and n = 13,370. Fifteen systematic revisions evaluated the effect of isolated respiratory muscular training; six systematic revisions evaluated, in isolation, breathing control (relaxed breathing, pursed-lip breathing, and diaphragmatic breathing exercises) and thoracic expansion exercises; and one systematic review evaluated, in isolation, the positions that optimize ventilation. Nineteen systematic reviews with combined interventions that reinforced the role of education and capacitation while also aiming for their success were considered. The articles analyzed isolated interventions and presented their efficacy. The interventions based on respiratory exercises and respiratory muscular training were the most common, and one article mentioned the efficacy of positioning in the compromisation of ventilation. Combined interventions in which the educational component was included were found to be effective in improving pulmonary function, diffusion, oxygenation, and functional capacity. The outcomes used in each study were variable, leading to a more difficult analysis of the data.

CONCLUSIONS

The interventions that were the focus of the review were duly mapped. The results suggest that nonpharmacological interventions used to optimize ventilation are effective, with a moderate to high level of evidence. There is a strong foundation for the use of the chosen interventions. The lack of studies on the intervention of "positioning to optimize ventilation" points out the need for a deeper analysis of its effects and for studies with a clear focus. This study supports the decisions and recommendations for the prescription of these interventions to patients with impaired ventilation.

Nonpharmacological Interventions for Preventing Rehospitalization Among Patients with Heart Failure: A Systematic Review and Meta-Analysis

Background

Heart failure (HF) is the most common condition for rehospitalization among people aged ≥65 years in the United States, with 35,197,725 hospitalizations between 2014 and 2017. Hospitalized patients with HF have the highest 30-day readmission rate (25%). Overall, HF management, despite its progress, remains a challenge. Although several studies have evaluated interventions designed to reduce HF-related hospital readmissions, research comparing their effectiveness remains insufficient.

Purpose

This systematic review and meta-analysis focused on studies that investigated the effectiveness of nonpharmacological interventions (NPIs) on reducing rehospitalization among patients with HF.

Methods

This review conformed to the preferred reporting items for systematic reviews and meta-analyses guidelines, used four databases: Cumulative index to Nursing and Allied Health Literature, PubMed, Cochrane, and Web of Science. Studies were included in the review according to the following criteria: (a) included only randomized control trials (RCTs), (b) included participants with HF who were over 18 years of age, (c) peer-reviewed, (d) written in English, and (e) rehospitalizations occurring within 30-day, 90-day, and 1 year of discharge from the initial hospitalization.

Results

Fourteen studies were included, with a total of 2,035 participants. Meta-analysis showed that rehospitalization was different between the intervention and usual care groups. The odds ratio was 0.54 (95% confidence interval [0.36, 0.82, p < 0.01]).

Conclusions/Implications for Practice

NPIs designed to increase HF knowledge and self-management may effectively reduce rehospitalization among HF patients. NPIs can be delivered at the patient's home through visits, phone calls, or digital platforms and technologies.

Value of Nonpharmacological Interventions for People With an Acquired Brain Injury: A Systematic Review of Economic Evaluations

OBJECTIVES

Acquired brain injury (ABI) has long-lasting effects, and patients and their families require continued care and support, often for the rest of their lives. For many individuals living with an ABI disorder, nonpharmacological rehabilitation treatment care has become increasingly important care component and relevant for informed healthcare decision making. Our study aimed to appraise economic evidence on the cost-effectiveness of nonpharmacological interventions for individuals living with an ABI.

METHODS

This systematic review was registered in PROSPERO (CRD42020187469), and a protocol article was subject to peer review. Searches were conducted across several databases for articles published from inception to 2021. Study quality was assessed according the Consolidated Health Economic Evaluation Reporting Standards checklist and Population, Intervention, Control, and Outcomes criteria.

RESULTS

Of the 3772 articles reviewed 41 publications met the inclusion criteria. There was a considerable heterogeneity in methodological approaches, target populations, study time frames, and perspectives and comparators used. Keeping these issues in mind, we find that 4 multidisciplinary interventions studies concluded that fast-track specialized services were cheaper and more cost-effective than usual care, with cost savings ranging from £253 to £6063. In 3 neuropsychological studies, findings suggested that meditated therapy was more effective and saved money than usual care. In 4 early supported discharge studies, interventions were dominant over usual care, with cost savings ranging from £142 to £1760.

CONCLUSIONS

The cost-effectiveness evidence of different nonpharmacological rehabilitation treatments is scant. More robust evidence is needed to determine the value of these and other interventions across the ABI care pathway.

The effect of nonpharmacological interventions on pain and sleep quality after percutaneous nephrolithotomy: A protocol for systematic review and network meta-analysis

BACKGROUND

Various nonpharmacological interventions have been applied to alleviate pain and improve sleep quality after percutaneous nephrolithotomy. However, evidence to compare their efficacy is scant. This study aims to evaluate the efficacy of different nonpharmacological interventions on alleviating pain and improving sleep quality in patients after percutaneous nephrolithotomy through a network meta-analysis .

METHODS

Randomized controlled trials reporting the efficacy of nonpharmacological interventions on alleviating pain and improving sleep quality in patients after percutaneous nephrolithotomy will be searched in online databases, including the Chinese Scientific Journal Database, China National Knowledge Infrastructure Database, Wanfang, China Biomedical Literature Database, Pubmed, Web of Science, Embase, and Cochrane Library. After quality assessment and date extraction, network meta-analysis will be performed using Stata 14.0 and R software.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSIONS

This study will provide systematic and comprehensive evidence-based support for the effects of nonpharmacological interventions on alleviating pain and improving sleep quality after percutaneous nephrolithotomy.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms.

REGISTRATION NUMBER

DOI 10.17605/OSF.IO/B4DHW.

Potential nonpharmacological interventions to prevent frailty among elderly in low- and middle-income countries: A protocol for systematic review

BACKGROUND

Frailty syndrome is a medical condition defined by a progressive loss of function that usually begins beyond 65 and necessitates assistance with daily activities. There are both pharmacological and nonpharmacological approaches to prevent frailty. The purpose of this systematic review is to investigate viable nonpharmacological therapies for reducing frailty among the elderly in low- and middle-income countries, to develop an appropriate guideline to determine the applicability of these nonpharmacological interventions in various feasible settings.

METHODS

Two independent researchers will explore 5 electronic databases for relevant and promising studies. The selected articles will be subjected to a full-text examination following the initial screening. Two independent authors will analyze the risk of bias using the Cochrane risk of bias assessment tool. The review findings on various nonpharmacological approaches to prevent frailty will be presented as a narrative synthesis. There will be a sensitivity analysis and an assessment of study heterogeneity if possible.

RESULTS AND CONCLUSION

The systematic review protocol has been evaluated and approved by the institutional review board of North South University. The preferred reporting items for systematic review and meta-analysis protocol recommendations for precisely reporting health care interventions and the Cochrane group standards will be strictly followed in this systematic review protocol.

PROSPERO REGISTRATION NUMBER

CRD42021290417.

Women's Lives Matter-The Critical Need for Women to Prioritize Optimal Physical Activity to Reduce COVID-19 Illness Risk and Severity

Physical activity (PA) is beneficial for the health and wellness of individuals and societies. During an infectious disease pandemic, such as the one caused by COVID-19, social distancing, quarantines, and lockdowns are used to reduce community spread of the disease. Unfortunately, such nonpharmacological interventions or physical risk mitigation measures also make it challenging to engage in PA. Reduced PA could then trigger physiological changes that affect both mental and physical health. In this regard, women are more likely to experience physical and psychological distress. PA is a safe and effective nonpharmacological modality that can help prevent and manage several mental and physical health problems when performed correctly. PA might even confer benefits that are directly related to decreasing COVID-19 morbidity and mortality in women. In this review, we summarize why optimal PA must be a priority for women during the COVID-19 pandemic. We then discuss chronic COVID-19 illness and its impact on women, which further underscores the need for worldwide preventive health strategies that include PA. Finally, we discuss the importance of vaccination against COVID-19 for women, as part of prioritizing preventive healthcare and an active lifestyle.

Evaluating the Aromatherapy Recommendation for Pain in the Holistic Nurses' Pain Relief Tools for Patients and Self-Care

Purpose of Study: The purpose of the study was to evaluate the usefulness of the aromatherapy (AT) recommendation in the American Holistic Nurses Association's (AHNA's) Holistic Nurses' Pain Relief Tools for Patients and Self-Care (Pain Tool). Methodology: An observational survey design was used and a purposeful sample of 55 nurses were invited to a two-part, 15-question survey administered via SurveyMonkey. The demographic data were analyzed with quantitative analysis and the open-ended questions were analyzed via content analysis. Results: A total of 55 registered nurses completed the survey and the mean age of participants was 53 years old. Lavender essential oil (EO) was used by 100% (N = 55) of participants and the inhalation method was favored (93%; n = 51). The AT recommendation was most helpful for educational purposes (29%; n = 16) and to reduce symptoms of pain (21%; n = 8). A majority of participants used the five holistic nursing core values (70%; n = 31) as well as promote more options for pain management (48%; n = 13) to improve outcomes (30%; n = 13). Respondents recommend the addition of more EOs and safety information (23%; n = 8). Finally, five recommendations were made to AHNA. Implication for Practice: Nurses who use AT (guideline) as a safe, cost-effective intervention for pain improve quality outcomes.

The Impact of Nonpharmacological Interventions on Patient Experience, Opioid Use, and Health Care Utilization in Adult Cardiac Surgery Patients: Protocol for a Mixed Methods Study

BACKGROUND

Despite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting.

OBJECTIVE

This trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention.

METHODS

To address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor's office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis.

RESULTS

This trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020.

CONCLUSIONS

Data generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study's findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21350.

Dementia in Latin America: Paving the way toward a regional action plan

Across Latin American and Caribbean countries (LACs), the fight against dementia faces pressing challenges, such as heterogeneity, diversity, political instability, and socioeconomic disparities. These can be addressed more effectively in a collaborative setting that fosters open exchange of knowledge. In this work, the Latin American and Caribbean Consortium on Dementia (LAC-CD) proposes an agenda for integration to deliver a Knowledge to Action Framework (KtAF). First, we summarize evidence-based strategies (epidemiology, genetics, biomarkers, clinical trials, nonpharmacological interventions, networking, and translational research) and align them to current global strategies to translate regional knowledge into transformative actions. Then we characterize key sources of complexity (genetic isolates, admixture in populations, environmental factors, and barriers to effective interventions), map them to the above challenges, and provide the basic mosaics of knowledge toward a KtAF. Finally, we describe strategies supporting the knowledge creation stage that underpins the translational impact of KtAF.

Comparative Efficacy of Pharmacological and Nonpharmacological Interventions for Acne Vulgaris: A Network Meta-Analysis

Acne has several effects on physical symptoms, but the main impacts are on the quality of life, which can be improved by treatment. There are several acne treatments but less evidence comparing their relative efficacy. Thus, we assessed the comparative efficacy of pharmacological and nonpharmacological interventions for acne. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to April 2019, to include randomized controlled trials for acne that compared topical antibiotics (TA), benzoyl peroxide (BPO), topical retinoids (TR), oral antibiotics (OA), lasers, light devices including LED device (LED), photodynamic therapy (PDT), and intense pulsed light, chemical peels (CP), miscellaneous therapies or complementary and alternative medicine (MTCAM), or their combinations. We performed Bayesian network meta-analysis with random effects for all treatments compared with placebo and each other. Mean differences (MDs) of lesions count and risk ratios of adverse events with their 95% credible intervals (CrIs) were calculated, and all interventions were ranked by the Surface Under the Cumulative Ranking (SUCRA) values. Additional frequentist additive network meta-analysis was performed to detect the robustness of results and potential interaction effects. Sensitivity analyses were carried out with different priors, and metaregression was to adjust for nine potential effect modifiers. In the result, seventy-three randomized controlled trials (27,745 patients with mild to moderate acne), comparing 30 grouped intervention categories, were included with low to moderate risk of bias. For adverse effects, OA had more risk in combination treatment with others. For noninflammatory lesions reduction, seventeen interventions had significant differences comparing with placebo and three interventions (TR+BPO: MD = −21.89, 95%CrI [−28.97, −14.76]; TR+BPO+MTCAM: −22.48 [−34.13, −10.70]; TA+BPO+CP: −20.63 [−33.97, −7.13]) were superior to others with 94, 94, and 91% SUCRA values, respectively. For inflammatory lesions reduction, nineteen interventions were significantly better than placebo, and three interventions (TR+BPO: MD = −12.13, 95%CrI [−18.41, −5.80]; TR+BPO+MTCAM: −13.21 [−.39, −3.04]; LED: −11.30 [−18.34, −4.42]) were superior to others (SUCRA: 81, 81, and 77%, respectively). In summary of noninflammatory and inflammatory lesions results, TR+BPO and TA+BPO were the best options compared to others. The frequentist model showed similar results as above. In summary, current evidence supports the suggestion that TR+BPO and TA+BPO are the best options for mild to moderate acne. LED is another option for inflammatory lesions when drug resistance occurs. All the combinations involved with OA showed more risk of adverse events than others. However, the evidence of this study should be cautiously used due to the limitations.

Systematic Review and Meta-analysis of Nonpharmacological Interventions for Lung Cancer Fatigue

Fatigue is one of the most common adverse effects of lung cancer, and the efficacy of nonpharmacological interventions on fatigue in lung cancer patients is still unclear. We aimed to assess the effectiveness of nonpharmacological interventions on lung cancer-induced fatigue. A systematic review and meta-analysis were performed on studies retrieved from the PubMed, Embase Ovid, Cochrane Central Register of Controlled Trials, and Web of Science databases from inception to June 2020. A total of 18 of randomized controlled trials with three intervention categories were identified, comprising 1,446 patients. We observed that fatigue was significantly affected by physical therapies (standard mean difference [SMD] = -1.26, 95% confidence intervals [CI]: -2.05 to -0.47, p = .002), but not by exercise interventions (SMD = -0.52, 95% CI: -1.46 to 0.43, p = .29) or education and psychological interventions (SMD = -0.39, 95% CI: -0.92 to 0.14, p = .15). More research with robust methodology is needed to justify these findings.

Non-Pharmacological Interventions for Post-Stroke Fatigue: Systematic Review and Network Meta-Analysis

Post-stroke fatigue (PSF) is one of the most serious sequelae, which often interferes with the rehabilitation process and impairs the functional recovery of patients. Due to insufficient evidence, it is unclear which specific pharmacological interventions should be recommended. Therefore, in this paper, we compare the effectiveness of non-pharmacological interventions in PSF. A systematic review and network meta-analysis of randomized controlled trials were performed using EMBASE, MEDLINE, CINAHL, Cochrane library, ClinicalTrials.gov, CNKI, and CQVIP, from inception to January 2018, in the English and Chinese languages. RCTs involving different non-pharmacological interventions for PSF with an outcome of fatigue measured using the Fatigue Severity Scale were included. Multiple intervention comparisons based on a Bayesian network are used to compare the relative effects of all included interventions. Ten RCTs with eight PSF non-pharmacological interventions were identified, comprising 777 participants. For effectiveness, most interventions did not significantly differ from one another. The cumulative probabilities of the best non-pharmacological intervention for fatigue reduction included Community Health Management (CHM), followed by Traditional Chinese Medicine (TCM) and Cognitive Behavioral Therapy (CBT). Network meta-analysis based on data from the selected RCTs indicated that the eight PSF non-pharmacological interventions shared equivalent efficacy, but CHM, TCM, and CBT showed potentially better efficacy. In the future, fatigue needs to be recognized and more accurate assessment methods for PSF are required for diagnosis and to develop more effective clinical interventions.

Feasibility of Conducting Nonpharmacological Interventions to Manage Dementia Symptoms in Community-Dwelling Older Adults: A Cluster Randomized Controlled Trial

This study assessed the feasibility of conducting 3 nonpharmacological interventions with older adults in dementia, exploring the effects of chair yoga (CY), compared to music intervention (MI) and chair-based exercise (CBE) in this population. Using a cluster randomized controlled trial (RCT), 3 community sites were randomly assigned 1:1:1 to CY, MI, or CBE. Participants attended twice-weekly 45-minute sessions for 12 weeks. Thirty-one participants were enrolled; 27 safely completed the interventions and final data collection (retention rate of 87%). Linear mixed modeling was performed to examine baseline and longitudinal group differences. The CY group improved significantly in quality of life compared to the MI group (CY mean = 35.6, standard deviation [SD] = 3.8; MI mean = 29.9, SD = 5.3, P = .010). However, no significant group differences were observed in physical function, behavioral, or psychological symptoms (eg, for mini-PPT: slopetime = 0.01, standard error [SE] = 0.3, P = .984 in the CBE group; slopetime = -0.1, SE = 0.3, P = .869 in the MI group; slopetime = -0.3, SE = 0.3, P = .361 in the CY group) over the 12-week intervention period. Overall, this pilot study is notable as the first cluster RCT of a range of nonpharmacological interventions to examine the feasibility of such interventions in older adults, most with moderate-to-severe dementia. Future clinical trials should be conducted to examine the effects of nonpharmacological interventions for older adults with dementia on health outcomes.

Complementary and Alternative Medicine in Patients With Breast Cancer: Exploratory Study of Social Network Forum Data

Background

Patients and health care professionals are becoming increasingly preoccupied in complementary and alternative medicine (CAM) that can also be called nonpharmacological interventions (NPIs). In just a few years, this supportive care has gone from solutions aimed at improving the quality of life to solutions intended to reduce symptoms, supplement oncological treatments, and prevent recurrences. Digital social networks are a major vector for disseminating these practices that are not always disclosed to doctors by patients. An exploration of the content of exchanges on social networks by patients suffering from breast cancer can help to better identify the extent and diversity of these practices.

Objective

This study aimed to explore the interest of patients with breast cancer in CAM from posts published in health forums and French-language social media groups.

Methods

The retrospective study was based on a French database of 2 forums and 4 Facebook groups between June 3, 2006, and November 17, 2015. The extracted, anonymized, and compiled data (264,249 posts) were analyzed according to the occurrences associated with the NPI categories and NPI subcategories, their synonyms, and their related terms.

Results

The results showed that patients with breast cancer use mainly physical (37.6%) and nutritional (31.3%) interventions. Herbal medicine is a subcategory that was cited frequently. However, the patients did not mention digital interventions.

Conclusions

This exploratory study of the main French forums and discussion groups indicates a significant interest in CAM during and after treatments for breast cancer, with primarily physical and nutritional interventions complementing approved treatments. This study highlights the importance of accurate information (vs fake medicine), prescription and monitoring of these interventions, and the mediating role that health professionals must play in this regard.

Identifying Frameworks for Validation and Monitoring of Consensual Behavioral Intervention Technologies: Narrative Review

BACKGROUND

Changing health behaviors, such as smoking, unhealthy eating, inactivity, and alcohol abuse, may have a greater impact on population health than any curative strategy. One of the suggested strategies is the use of behavioral intervention technologies (BITs). They open up new opportunities in the area of prevention and therapy and have begun to show benefits in the durable change of health behaviors in patients or those at risk. A consensual and international paradigm was adopted by health authorities for drugs 50 years ago. It guides their development from research units to their authorization and surveillance. BITs' generalization brings into question their upstream evaluation before being placed on the market and their downstream monitoring once on the market; this is especially the case in view of the marketing information provided by manufacturers and the scarcity and methodological limits of scientific studies on these tools.

OBJECTIVE

This study aims to identify and categorize the frameworks for the validation and monitoring of BITs proposed in the literature.

METHODS

We conducted a narrative literature review using MEDLINE, PsycINFO, and Web of Science. The review items included the following: name, publication year, name of the creator (ie, first author), country, funding organization, health focus, target group, and design (ie, linear, iterative, evolutive, and/or concurrent). The frameworks were then categorized based on (1) translational research thanks to a continuum of steps and (2) the three paradigms that may have inspired the frameworks: biomedical, engineering, and/or behavioral.

RESULTS

We identified 46 frameworks besides the classic US Food and Drug Administration (FDA) five-phase drug development model. A total of 57% (26/46) of frameworks were created in the 2010s and 61% (28/46) involved the final user in an early and systematic way. A total of 4% (2/46) of frameworks had a linear-only sequence of their phases, 37% (17/46) had a linear and iterative structure, 33% (15/46) added an evolutive structure, and 24% (11/46) were associated with a parallel process. Only 12 out of 46 (26%) frameworks covered the continuum of steps and 12 (26%) relied on the three paradigms.

CONCLUSIONS

To date, 46 frameworks of BIT validation and surveillance coexist, besides the classic FDA five-phase drug development model, without the predominance of one of them or convergence in a consensual model. Their number has increased exponentially in the last three decades. Three dangerous scenarios are possible: (1) anarchic continuous development of BITs that depend on companies amalgamating health benefits and usability (ie, user experience, data security, and ergonomics) and limiting implementation to several countries; (2) the movement toward the type of framework for drug evaluation centered on establishing its effectiveness before marketing authorization to guarantee its safety for users, which is heavy and costly; and (3) the implementation of a framework reliant on big data analysis based on a posteriori research and an autoregulation of a market, but that does not address the safety risk for the health user, as the market will not regulate safety or efficacy issues. This paper recommends convergence toward an international validation and surveillance framework based on the specificities of BITs, not equivalent to medical devices, to guarantee their effectiveness and safety for users.

Nonpharmacological Interventions for Depressive Symptoms in End-Stage Renal Disease: A Systematic Review

Depressive symptoms are common in patients with end-stage renal disease, which can affect treatment and prognosis. We aimed to evaluate the effects of nonpharmacological interventions for depressive symptoms in end-stage renal disease. Eligible studies were identified using PubMed, Web of Science, the Cochrane Library, Embase, and PsycNET (up to March 2019). We identified 24 studies including 1,376 patients. We found that psychological intervention (-0.60, 95% confidence interval [CI] = [-0.87, -0.33]), exercise (-1.13, 95% CI = [-1.56, -0.69]), and manual acupressure (-0.26, 95% CI = [-0.50, 0.03]) were associated with a significant effect on depressive symptoms. However, few studies reported adverse events, and conclusions about safety should be drawn cautiously. While the available data show that nonpharmacological interventions are potential strategies to alleviate depressive symptoms of patients with end-stage renal disease, recommendation of the most efficacious interventions for this population will require future randomized controlled trials with large-scale, long-term intervention.

Barriers to Behavioral Treatment Adherence for Headache: An Examination of Attitudes, Beliefs, and Psychiatric Factors

BACKGROUND/OBJECTIVES

Nonpharmacological interventions, such as biofeedback, cognitive behavioral therapy, and relaxation techniques are Level-A evidence-based treatments for headache. The impact of these interventions is often equivalent to or greater than pharmacological interventions, with fewer side effects. Despite such evidence, the rate of participation in nonpharmacological interventions for headache remains low. Once obstacles to optimizing use of behavioral interventions, such as local access to nonpharmacological treatment and primary headache providers are traversed, identification of barriers contributing to low adherence is imperative given the high levels of disability and cost associated with treating headache disorders. In this review of factors in adults associated with underuse of nonpharmacological interventions, we discuss psychological factors relevant to participation in nonpharmacological treatment, including attitudes and beliefs, motivation for change, awareness of triggers, locus of control, self-efficacy, acceptance, coping styles, personality traits, and psychiatric comorbidities associated with treatment adherence. Finally, future prospects and approaches to optimizing treatment matching and minimizing adherence issues are addressed.

METHODS

An interdisciplinary team conducted this narrative review. Neuropsychologists conducted a literature search during the month of July 2017 using a combination of the keywords ("headache" or "migraine") and ("adherence" or "compliance") or "barriers to treatment" or various "psychological factors" discussed in this narrative review. Content experts, a psychiatrist, and a complementary and integrative health specialist provided additional commentary and input to this narrative review resulting in integration of additional noteworthy studies, book chapters and books.

RESULTS

Various psychological factors, such as attitudes and beliefs, lack of motivation, poor awareness of triggers, external locus of control, poor self-efficacy, low levels of acceptance, and engagement in maladaptive coping styles can contribute to nonadherence.

CONCLUSIONS

To maximize adherence, clinicians can assess and address an individual's level of treatment acceptance, beliefs that may present as barriers, readiness for change, locus of control, self-efficacy and psychiatric comorbidities. Identification of barriers to adherence as well as the application of relevant assessment and intervention techniques have the potential to facilitate adherence and ultimately improve treatment success.

Reducing Burden for Caregivers of Older Adults With Mild Cognitive Impairment: A Systematic Review

BACKGROUND/RATIONALE

This systematic review aims to evaluate the efficacy of the nonpharmacological interventions reducing burden, psychological symptoms, and improving quality of life of caregivers of individuals with mild cognitive impairment (MCI).

METHOD

Databases reviewed included Medline, Cochrane Library, Embase, PsycNet, AgeLine, and ProQuest Dissertations and Theses. Studies using an experimental/quasi-experimental design including nonpharmacological intervention were included. Four studies were included, and no meta-analysis was conducted.

RESULTS

Calendar training and note-taking (cognitive intervention) significantly decreased caregiver's depressive symptoms and prevented worsening of subjective burden 6 months posttreatment. Daily engagement of meaningful activity combined with problem-solving therapy and educational material reduced depressive symptoms 3 months posttreatment. Moreover, educational intervention and social conversation phone calls decreased caregiver burden 3 months posttreatment.

CONCLUSION

Studies suggest that nonpharmacological interventions can support caregivers of older adults with MCI, but the few published articles present some bias and are inconclusive. Randomized-controlled trials targeting specifically caregivers are needed to determine the most efficient type of interventions for those individuals.

Evaluation of the efficacy of randomized controlled trials of sensory stimulation interventions for sleeping disturbances in patients with dementia: a systematic review

OBJECTIVE

The current review aims to evaluate the sensory stimulation interventions in terms of reducing sleeping disturbances in patients with dementia. The nonpharmacological interventions seem to be an efficient, inexpensive, and easy tool for family caregivers. Moreover, sleeping disorders increase caregivers' distress and may lead to hospitalization.

METHODS

A systematic literature search was performed. Eleven randomized controlled trials have been found. Among these eleven trials, one referred to massage therapy and acupuncture, and the other ten studies referred to bright light therapy.

RESULTS

The results demonstrated that there are no relevant randomized controlled trials of music therapy, aromatherapy, and multisensory environment/Snoezelen referring to sleeping disturbances. Several studies have been conducted about the effect of the bright light therapy, and there is also another study that combines massage therapy and acupuncture therapy.

CONCLUSION

Sensory stimulation interventions are inexpensive and practical for dementia caregivers; however, only bright light therapy seems to be useful to reduce sleeping problems in dementia. The other sensory stimulation interventions lack evidence, and there is a strong need for further research.

Innovation and pragmatism required to reduce seclusion practices

Seclusion may be harmful and traumatic to patients, detrimental to therapeutic relationships, and can result in physical injury to staff. Further, strategies to reduce seclusion have been identified as a potential method of improving cost-effectiveness of psychiatric services. However, developing alternative strategies to seclusion can be difficult. Interventions to reduce seclusion do not lend themselves to evaluation using randomized controlled trials (RCTs), though comprehensive literature reviews have demonstrated considerable non-RCT evidence for interventions to reduce seclusion in psychiatric facilities. In the UK, a recent 5-year evaluation of seclusion practice in a high secure UK hospital revealed reduced rates of seclusion without an increase in adverse incidents. To assess the effect of a novel intervention strategy for reduction of long-term segregation on a high secure, high dependency forensic psychiatry ward in the UK, we introduced a pilot program involving stratified levels of seclusion ("long-term segregation"), multidisciplinary feedback and information sharing, and a bespoke occupational therapy program. Reduced seclusion was demonstrated and staff feedback was mainly positive, indicating increased dynamism and empowerment on the ward. A more structured, stratified approach to seclusion, incorporating multidisciplinary team-working, senior administrative involvement, dynamic risk assessment, and bespoke occupational therapy may lead to a more effective model of reducing seclusion in high secure hospitals and other psychiatric settings. While lacking an evidence base at the level of RCTs, innovative, pragmatic strategies are likely to have an impact at a clinical level and should guide future practice and research.

Nonpharmacological Interventions for Children with Attention Deficit Hyperactivity Disorder in India: A Comprehensive and Comparative Research Update

The nonpharmacological treatments for children with attention deficit hyperactivity disorder (ADHD) have witnessed a sea change from a rudimentary and haphazard psychosocial to cognitive interventions to social and behavioral skills to body oriented interventions to more sophisticated neurocognitive interventions. As the objective of each treatment varied, the method or procedure of each treatment also differed across studies. Indian research although not very rigorous, did witness changes emphasizing on exploring interventions in reducing symptoms and improving overall behavior. The research literature between 2005 and 2015 was searched using PubMed, Google Scholar, IndMED, MedIND, ResearchGate, and other indexed databases. Results of 110 studies were organized into five broad categories of themes of interventions such as psychosocial, body-focused, cognitive/neuro-cognitive, and cognitive behavioral. Effects of ADHD on cognitive, academic, and behavioral outcomes were also highlighted before the themes of intervention to establish linkage with discussion. However, a limited number (n = 9) of reported Indian studies focusing either on the impact of ADHD on the function of children or on interventions were found, suggesting a huge gap between global and Indian research in the area of children with ADHD. It also highlights the need for development and efficacy testing of indigenous intervention program in different areas of intervention for research and clinical practice.

A Control-Based Multidimensional Approach to the Role of Optimism in the Use of Dementia Day Care Services

We examined whether grounded optimism and external locus of control are associated with admission to dementia day care centers (DCCs). A total of 130 informal caregivers were recruited from the Alzheimer's Association in Salamanca (northwest Spain). All caregivers completed an assessment protocol that included the Battery of Generalized Expectancies of Control Scales (BEEGC-20, acronym in Spanish) as well as depression and burden measures. The decision of the care setting at baseline assessment (own home vs DCC) was considered the main outcome measure in the logistic regression analyses. Grounded optimism was a preventive factor for admission (odds ratio [OR]: 0.34 and confidence interval [CI]: 0.15-0.75), whereas external locus of control (OR: 2.75, CI: 1.25-6.03) increased the probabilities of using DCCs. Depression mediated the relationship between optimism and DCCs, but this effect was not consistent for burden. Grounded optimism promotes the extension of care at home for patients with dementia.

The use and utility of specific nonpharmacological interventions for behavioral symptoms in dementia: an exploratory study

OBJECTIVE

This study compares different nonpharmacological interventions for persons with behavioral symptoms and dementia on frequency of use and perceived efficacy in terms of change in behavior and interest.

METHODS

Participants were 89 nursing home residents from six Maryland nursing homes with a mean age of 85.9 years (SD: 8.6 years). Research assistants presented interventions tailored to the participants' needs and preferences in a pre-intervention trial phase and in an intervention phase. The impact of each intervention on behavioral symptoms and on the person's interest was rated immediately after the intervention by a research assistant.

RESULTS

The most utilized interventions in both trial and treatment phases were the social intervention of one-on-one interaction, simulated social interventions such as a lifelike doll and respite video, the theme intervention of magazine, and the sensory stimulation intervention of music. In contrast, the least utilized interventions in both phases were sewing, fabric book, and flower arrangement. Interventions with the highest impact on behavioral symptoms included one-on-one social interaction, hand massage, music, video, care, and folding towels. Other high impact interventions included walking, going outside, flower arranging, food or drink, sewing, group activity, book presentation, ball toss, coloring or painting, walking, and family video.

CONCLUSIONS

The results provide initial directions for choosing specific interventions for persons with dementia and also demonstrate a methodology for increasing knowledge through ongoing monitoring of practice.

Implication of the nutritional and nonnutritional factors in the context of preservation of cognitive performance in patients with dementia/depression and Alzheimer disease

It has been postulated that Alzheimer disease (AD) is a systemic process, which involves multiple pathophysiological factors. A combination of pharmacotherapy and nonpharmacological interventions has been proposed to treat AD and other dementia. The nonpharmacological interventions include but are not limited to increasing sensory input through physical and mental activities, in order to modify cerebral blood flow and implementing nutritional interventions such as diet modification and vitamins and nutraceuticals therapy to vitalize brain functioning. This article highlights the recent research findings regarding novel treatment strategies aimed at modifying natural course of the disease and delaying cognitive decline through simultaneous implementation of pharmacological and nonpharmacological modulators as standardized treatment protocols.

Managing agitation using nonpharmacological interventions for seniors with dementia

Approximately 36 million people have Alzheimer's disease worldwide, and many experience behavioral issues such as agitation. The purpose of this study was to investigate the perceptions of long-term care (LTC) staff regarding the current use of nonpharmacological interventions (NPIs) for reducing agitation in seniors with dementia and to identify facilitators and barriers that guide NPI implementation. Qualitative methods were used to gather data from interviews and focus groups. A total of 44 staff from 5 LTC facilities participated. Findings showed that both medications and NPIs are used for the management of agitation. The use of NPIs was facilitated by consistency in staffing, and the ability of all the staff members to implement them. Common barriers to NPI use included the perceived lack of time, low staff-to-resident ratios, and the unpredictable and short-lasting effectiveness of NPIs. This study offers insight into perceived factors that influence implementation of NPIs and the perceived effectiveness of NPIs.

Recreational Activities to Reduce Behavioural Symptoms in Dementia

Few clinicians have an educational grounding in the use of nonpharmacological therapies for people with dementia. In this article, we explore the utility of recreational activities as one nonpharmacological intervention that has demonstrated effectiveness for reducing the behavioural symptoms of dementia. The implementation of effective recreational activities involves three components: understanding the evidence for this approach; acknowledging the need to reduce medications that have the potential to interfere with activity effectiveness; and individualizing activities so that the maximum benefit from the intervention is obtained.

Do interventions bringing current self-care practices into greater correspondence with those performed premorbidly benefit the person with dementia? A pilot study

This article assessed whether bringing current self-care practices into greater correspondence with those performed before the onset of dementia benefits the dementia patient. Participants were 20 nursing home residents with dementia, their spouses, and nursing assistants. Past and current self-care routines were determined by proxy responses of spouses and nursing assistants, respectively, using the Self-maintenance Habits and Preferences in Elderly questionnaire. Interventions were proposed based on current practices that were inconsistent with those practiced in the past and that had been important to residents. Residents showed engagement with the interventions, as these resulted in significantly more positive than negative or neutral responses. There was no effect on agitation. Incorporating prior preferences into care routines can contribute to the quality of life of dementia patients.

Challenges of implementing intervention research in persons with dementia: example of a glider swing intervention

Intervention studies for persons with dementia present many challenges. This article describes challenges encountered in conducting a glider swing intervention study for persons with dementia and the strategies used to manage the problems encountered. The overall purpose of a quasi-experimental study was to explore the effects of a glider swing intervention on emotions, relaxation, and aggressive behaviors in nursing home residents with dementia. Suggestions for investigators conducting intervention studies for persons with dementia are provided.

Binocular visual processing in the owl's telencephalon

Single neurons recorded from the owl's visual Wulst are surprisingly similar to those found in mammalian striate cortex. The receptive fields of Wulst neurons are elaborated, in an apparently hierarchical fashion, from those of their monocular, concentrically organized inputs to produce binocular interneurons with increasingly sophisticated requirements for stimulus orientation, movement and binocular disparity. Output neurons located in the superficial laminae of the Wulst are the most sophisticated of all, with absolute requirements for a combination of stimuli, which include binocular presentation at a particular horizontal binocular disparity, and with no response unless all of the stimulus conditions are satisfied simultaneously. Such neurons have the properties required for 'global stereopsis', including a receptive field size many times larger than their optimal stimulus, which is more closely matched to the receptive fields of the simpler, disparity-selective interneurons. These marked similarities in functional organization between the avian and mammalian systems exist in spite of a number of structural differences which reflect their separate evoluntionary origins. Discussion therefore includes the possibility that there may exist for nervous systems only a very small number of possible solutions, perhaps a unique one, to the problem of stereopsis.