The choreographies of the elimination of faeces:An ethnographic study of the institutionalized body care practices of older people in different health care settings

AimTo explore the choreographies of the elimination of faeces of older people to gain insight into the institutionalized practices of body care of older people in hospitals and long-term care settings.DesignA qualitative ethnographic study, drawing on a perspective of socio-material theory. Reported in accordance with the Standards for Reporting Qualitative Research.MethodsA total of, 30 women and 11 men aged 80 years and above needing assistance with body care in a hospital ward, 2 nursing homes and home care and 32 care workers participated. Four individual interviews with older people and three focus group interviews with care workers were conducted, in addition to 135 h of participant observations, from December 2020 to September 2021. Data were analysed using a situational analysis approach.ResultsThe assistance with the elimination of faeces is a multiplicity of ongoing dynamic practices where different actors interrelate. Dominating actors are time, space, materialities, different ideals and professional knowledge. The choreographies aim at order the elimination of faeces to happen at the right time at the right place, to provide dignified care.ConclusionTo assist older people with the elimination of faeces is complex institutionalized practices. The study argues for a greater focus on the ongoing relations between human and non-human actors to provide new understandings of an underexplored phenomenon in nursing

Body care of older people:An ethnographic study of body care practices in different institutionalized settings in Danish healthcare

Denne afhandling undersøger, hvordan kropspleje til ældre mennesker, der er afhængige af hjælp, konstitueres i forskning og i praksis, forskellige steder i det danske sundhedsvæsen.Baggrunden for undersøgelsen er at pleje af kroppen er en almenmenneskelig hverdagspraksis, som de fleste mennesker tager hånd om, uden behov for hjælp. Imidlertid vil en del mennesker få brug for hjælp til dette i en sundhedsinstitutionel kontekst, enten som følge af sygdom eller som følge af nedsatte funktioner, som potentielt følger med aldring. Derved bliver en hverdagspraksis, som det at pleje kroppen også et ældre menneskes møde med den danske velfærdsstat. Sundhedspolitisk og -fagligt har der de seneste årtier været et øget fokus på evidensbasering, personcentrering, aktiv aldring samt en af-institutionalisering af alderdommen. Samtidig er rehabilitering blevet et gennemgående paradigme i ældreplejen, hvor fokus har ændret sig fra passiv pleje til en pleje, hvor der er fokus på af bibeholde, genvinde eller udvikle funktioner.Indenfor sygeplejefaget, som traditionelt har anskuet pleje af kroppen som en central del af faget, er der de sidste ti år nationalt og internationalt kommet et øget fokus på den grundlæggende eller basale sygepleje. Det kan f.eks. være det at hjælpe ældre mennesker med at holde kroppen ren, komme i bad, eller hjælpe med at kroppens affaldsstoffer udskilles (f.eks. afføring og vandladning). Sygeplejefaglig forskningslitteratur dokumenterer, at ældre mennesker, der er afhængige af pleje, ikke får sygepleje af høj nok faglig kvalitet, med øget risiko for større sygelighed og dødelighed. Derfor argumenteres der for, at sygeplejen skal evidensbaseres samt være centeret om relationen mellem det menneske, der har brug for sygepleje, og det personale, der udfører sygeplejen.Afhandlingen undersøger, hvad der sker i de praksisser, hvor ældre mennesker får hjælp til at pleje kroppen i det danske sundhedsvæsen og hvordan denne kropspleje er formet af de institutionelle betingelser, blandt andet sundhedspolitiske ambitioner samt videns-former om krop, pleje og aldring, samt materialiteten som betingelse. Derudover udforsker afhandlingen, hvordan kropsplejepraksisserne har implikationer for hvem de ældre kan blive til som mennesker. Afhandlingen søger at bidrage med ny forskningsviden om, hvordan kropspleje til ældre mennesker konstitueres i praksis i det danske sundhedsvæ-sen samt i sygeplejeforskning. På baggrund af dette er det overordnede forskningsspørgsmål:Hvordan konstitueres kropspleje til ældre mennesker, i forskning og i praksis i forskellige institutionelle kontekster i sundhedsvæsenet.Dette spørgsmål er operationaliseret i nedenstående tre underspørgsmål:•Hvilke problematiseringer karakteriserer den sygeplejefaglige forskningslitteratur om kropspleje til ældre mennesker?•Hvordan praktiseres kropspleje i forskellige kontekster i det danske sundheds-væsen, og hvilken betydning har de institutionelle, kropslige og materielle betin-gelser for praktiseringen af kropspleje?•Hvilke muligheder for subjektivering tilbydes de ældre mennesker i kropspleje-praksisserne?Afhandlingen placerer sig inden for en kritisk humanistisk og samfundsvidenskabelig sundhedsforskningstradition og er informeret af poststrukturalistiske forskningstraditioner. Dermed rettes blikket mod kropspleje til ældre mennesker som noget der bliver til i et komplekst netværk af multiple konstituerende kræfter. Kropspleje til ældre mennesker anskues således ikke som et stabilt fænomen, men som noget, der bliver til og praktiseres i de daglige praksisser, i de forskellige institutionaliserede kontekster.Empirien er genereret i perioden december 2020 til januar 2022 via etnografisk feltarbejde på en hospitalsafdeling, to plejecentre og to hjemmeplejeteams. Empirigenereringen består af deltagerobservationer af kropsplejesituationer, individuelle interviews med de ældre mennesker og fokusgruppeinterviews med personale.Afhandlingens analyser omfatter tre artikler.Første artikel, Body care of older people in different institutionalized settings: A systematic mapping review of international nursing research from a Scandinavian perspective, undersøger international sygeplejefaglig forskningslitteratur omhandlende kropspleje til ældre mennesker fra 2010-2020 for at undersøge konstitueringerne i forskningsfeltet. Artiklen er et systematisk mapping review og søger at identificere, hvad der karakteriserer forskningslitteraturen. Derudover er der tilføjet en problematiseringsanalyse for at undersøge, hvordan kropsplejen til ældre mennesker konstitueres gennem problematiseringer. Reviewet viser, at de inkluderede artikler overvejende har en biomedicinsk forskningstilgang med fokus på evidensbaseret pleje. En anden del af litteraturen baseres på humanvidenskabelige tilgange, hvor fokus er de subjektive erfaringer og oplevelser samt personcentrede tilgange. Artiklen viser, at kropspleje til ældre mennesker konstitueres som en praksis, der skal være evidensbaseret og fokusere på relationen mellem de to subjekter i plejerelationen. Derudover viser artiklen, at der reproduceres dualismer mellem kroppen som objekt og kroppen som oplevet; samt mellem subjekt og objekt. Artiklen peger på, at sygepleje-forskningen om kropspleje til ældre mennesker er indlejret i magt-videns relationer, hvor biomedicinske vidensformer synes at være dominerende.Anden artikel, The choreographies of the elimination of faeces: An ethnographic study of the institu-tionalized body care practices of older people in different health care settings, undersøger hvordan plejen koreograferes så udskillelse af afføring, som en del af kropsplejen, ikke bliver matter out of place. Artiklen anskuer kropspleje som sociomaterielle praksisser og er ligeledes in-spireret af antropologen Mary Douglas’ begreb matter out of place. Artiklen viser hvordan multiple aktører er konstituerende, når ældre mennesker skal have hjælp til udskillelse af afføring. Artiklen viser, at kroppe, materialitet, teknologier, viden om hygiejne og mave-tarmsystemet samt etiske idealer er dominerende aktører, som forhandles, ordnes og distribueres tidsligt og rumligt. Artiklen viser, at matter out of place er forskelligt i de forskellige kontekster og tæt forbundet med de vidensformer, etiske idealer og materialitet, der er i de pågældende kontekster. Artiklen konkluderer, at det at yde hjælp til udskillelse af afføring er komplekse og institutionaliserede praksisser, hvor den institutionelle kontekst for plejen, spiller en aktiv rolle i kropsplejepraksisserne.Tredje artikel, “I’m not ill, I’m just old”-negotiations of risk- an ethnographic study of the subjectification of older people in assisted body care practices in institutionalized homes, undersøger den subjek-tivering, der finder sted, når ældre mennesker får hjælp til pleje af kroppen i en hjemlig kontekst. Artiklen er inspireret af en foucauldiansk forståelse af diskursive praksisser og subjektivering. Analyserne viser, hvordan de ældre mennesker subjektiveres som værende i -risiko og ikke i -risiko. Denne subjektivering er ikke kun afhængig af en biomedicinsk og gerontologisk diskurs. Herskende diskurser om aktiv aldring og hjem og hjemlighed in-teragerer med disse diskurser og destabiliserer subjektpositionerne. Artiklen viser, hvor-dan de ældre mennesker navigerer i og forhandler, de positioner de tilbydes i kropspleje-praksisserne på forskellig vis. En afvisning af positionen som aktiv eller en afvisning af at ville engagere sig i forebyggelse af risici synes at sedimentere positionen som værende i- risiko og dermed også som problematisk og med manglende handlekraft. Artiklen kon-kluderer, at det stærke fokus på aktiv aldring og hjem og hjemlighed på paradoksal vis potentielt rummer muligheden for at ekskludere aldringens materielle processer samt subjektive oplevelser af kroppe og hjem.Samlet set viser afhandlingen, at kropspleje konstitueres igennem komplekse processer, hvor de konstituerende kræfter er multiple og hvor både humane og non-humane aktører interagerer. Afhandlingen viser, at kropsplejen er indlejret i magtfulde diskurser om krop, aktiv aldring, hjem og hjemlighed, som bliver medkonstituerende for, hvordan kropspleje praktiseres og dermed for de ældre menneskers handlemuligheder, ønsker og måder at leve på. Derudover peger afhandlingen på, hvordan kroppe, teknologier, materialitet, vidensformer samt politiske og etiske idealer omhandlende aldring og pleje, forhandles, distribueres og ordnes tidsligt og rumligt, hvilket konstituerer kropsplejen på multiple måder. Afhandlingen konkluderer, at det fokus der er på evidensbasering i sygeplejen samt det politiske fokus der er på rehabilitering, aktiv aldring og hjemlighed potentielt kan ende med at tavsliggøre vigtig viden om kropsplejepraksisserne og de ældre menneskers kropslige hverdagspraksisser og- viden.This PhD thesis examines how body care of older care dependent people is constituted in research and practice in various settings in the Danish healthcare system.The background to this is that body care is a mundane everyday practice most people perform without needing help. However, due to illness or decreased functioning which potentially comes with old age, some older people might need assistance with body care in an institutionalized healthcare setting. Thus, a daily practice like body care is also the older people’s encounter with the Danish Welfare state. In recent decades, in healthcare- and polices there has been an increased focus on evidence-based- and person-centered care, active aging, and a de-institutionalization of old age. Moreover, reablement has become a dominating paradigm in eldercare, changing the focus from passive care to a care aiming at maintaining, regaining, or developing functions.In the last decade within nursing, which traditionally is grounded in the care of the body, nationally and internationally, there has been an increased focus on fundamental care needs. This includes e.g. assisting care- dependent people keeping their bodies clean, bathe, or assist with the elimination of bodily wastes (defecation and urination). Nursing research demonstrates that older care-dependent people do not receive high quality nurs-ing care, leading to increased morbidity and mortality. Therefore, it is argued that nursing should be based on evidence and centered on the relationship between the person needing care and the care worker providing care.The thesis explores the body care practices of older people and how this care is shaped by the institutional context, for example health policy ambitions, different knowledge forms regarding the body, care, and aging, as well as materiality. Moreover, the thesis explores how the body care practices have implications for the older people’s subjectivity. The thesis aims to contribute with new knowledge on how body care of older people is constituted in practice in the Danish healthcare system and in nursing research. With this background the overarching research question of the thesis is:How is body care of older people constituted in research and practice in different institutional contexts in the healthcare system?The research question is divided into the three following sub-questions:•What is problematized in nursing research literature on body care of older peo-ple?•How is body care practiced in different contexts in the Danish healthcare system, and how do institutional, bodily and material conditions shape the practices?•What are the possibilities for subjectification in the body care practices for the older people?The thesis is carried out within a critical humanistic and social science health research tradition and is informed by poststructuralist research traditions. Thus, attention is directed towards body care for older people as practices emerging in a complex network of multiple constitutive forces. Body care for older people is not seen as a stable phenomenon but as something that is constituted and practiced in daily practices in different institutionalized contexts.The empirical data was generated from December 2020 to January 2022 through ethnographic fieldwork in a hospital ward, two nursing homes, and two home care teams. Data generation consists of participant observations of body care situations, individual interviews with the older people, and focus group interviews with staff.The analysis in the thesis consists of three parts which are presented in the form of three articles.The first article, "Body care of older people in different institutionalized settings: A systematic mapping review of international nursing research from a Scandinavian perspective", examines international nursing research literature on body care of older people from 2010-2020 to explore how body care of older people is constituted in the nursing research field. The article is a systematic mapping review aiming to identify the characteristics of the research literature. Furthermore, a problematization analysis perspective is applied to examine how body care of older people is constituted through problematizations. The review shows that the included articles predominantly adopt a biomedical research approach focusing on evidencebased care. Another part of the literature is based on humanistic approaches focusing on subjective experiences and person-centered care practices. The article reveals that body care of older people is constituted as a practice that should be evidence-based as well as focus on the relationship between the two subjects in the care relationship. The article also illuminates how dualisms between the body as an object and the body as experienced as well as between subjects and objects, are reproduced. The article points to how nursing research on body care of older people is embedded in power-knowledge relations where biomedical knowledge forms seem to be dominating.The second article, "The choreographies of the elimination of faeces: An ethnographic study of the institutionalized body care practices of older people in different health care settings", explores how care is choreographed to ensure that the elimination of feces as part of body care does not become matter out of place. The article draws on an understanding of care as ongoing socio-material practices as well as it draws on the anthropologist Mary Douglas' concept of dirt as ‘matter out of place’. The article illuminates how bodies, materialities, tech-nologies, different ethical ideals and professional knowledge on hygiene and the digestive system are dominating actors in the choreographies, which are negotiated, ordered and distributed spatially and temporally. Matter out of place varies across the contexts and is closely linked to the knowledge forms, ethical ideals, and materiality present in the different contexts. Moreover, the article demonstrates how care is choreographed differently in the different institutionalized settings. The article concludes that the assistance with the elimination of faeces are complex and deeply institutionalized practices, where the institutionalized context of care plays an active role in shaping body care practices.The third article, "'I'm not ill, I'm just old' - Negotiations of risk: An ethnographic study of the subjectification of older people in assisted body care practices in institutionalized homes", examines the subjectification processes in the body care practices in the context of home. The article draws on a Foucauldian understanding of discursive practices and subjectification. The analyses show how the older people are subjectified as being at -risk or not at- risk. The subjectification is not only dependent on biomedical and gerontological discourses. Hegemonic discourses of active aging and home and homeliness are interacting with these discourses destabilizing the subject positions. The article shows how the older people navigate and negotiate the subject positions offered in the body care practices in different ways. A rejection of the position as active and a rejection to engage in prevention of biomedical risks related to old age, seems to sediment a position as at-risk and thus non-agentic and problematic. The article concludes that the strong focus on active ageing and home paradoxically holds the potential to exclude the material processes of ageing as well as the subjective experiences of bodies and home.Overall, the thesis shows that body care is constituted through complex processes, where the constitutive forces are multiple, and where both human and non-human actors interact. The thesis demonstrates how body care is embedded in powerful discourses about the body, aging, and home, which become constitutive of how body care is practiced and having thorough implications for the older people’s agency, longings and everyday life. Furthermore, the thesis points to how bodies, technologies, materiality, knowledge forms, and political and ethical ideals about aging and care are negotiated, distributed and ordered spatially and temporally, constituting body care in multiple ways. The dissertation concludes that the focus on evidence-based care in nursing and the political focus on reablement and active aging potentially silence important knowledge about body care practices and the older people's everyday bodily practices

Comprehensive review:Computational modelling of Schizophrenia

Computational modelling has been used to address: (1) the variety of symptoms observed in schizophrenia using abstract models of behavior (e.g. Bayesian models - top-down descriptive models of psychopathology); (2) the causes of these symptoms using biologically realistic models involving abnormal neuromodulation and/or receptor imbalance (e.g. connectionist and neural networks - bottom-up realistic models of neural processes). These different levels of analysis have been used to answer different questions (i.e. understanding behavioral vs. neurobiological anomalies) about the nature of the disorder. As such, these computational studies have mostly supported diverging hypotheses of schizophrenia's pathophysiology, resulting in a literature that is not always expanding coherently. Some of these hypotheses are however ripe for revision using novel empirical evidence.Here we present a review that first synthesizes the literature of computational modelling for schizophrenia and psychotic symptoms into categories supporting the dopamine, glutamate, GABA, dysconnection and Bayesian inference hypotheses respectively. Secondly, we compare model predictions against the accumulated empirical evidence and finally we identify specific hypotheses that have been left relatively under-investigated

Co-targeting CDK2 and CDK4/6 overcomes resistance to aromatase and CDK4/6 inhibitors in ER+ breast cancer

Resistance to aromatase inhibitor (AI) treatment and combined CDK4/6 inhibitor (CDK4/6i) and endocrine therapy (ET) are crucial clinical challenges in treating estrogen receptor-positive (ER+) breast cancer. Understanding the resistance mechanisms and identifying reliable predictive biomarkers and novel treatment combinations to overcome resistance are urgently needed. Herein, we show that upregulation of CDK6, p-CDK2, and/or cyclin E1 is associated with adaptation and resistance to AI-monotherapy and combined CDK4/6i and ET in ER+ advanced breast cancer. Importantly, co-targeting CDK2 and CDK4/6 with ET synergistically impairs cellular growth, induces cell cycle arrest and apoptosis, and delays progression in AI-resistant and combined CDK4/6i and fulvestrant-resistant cell models and in an AI-resistant autocrine breast tumor in a postmenopausal xenograft model. Analysis of CDK6, p-CDK2, and/or cyclin E1 expression as a combined biomarker in metastatic lesions of ER+ advanced breast cancer patients treated with AI-monotherapy or combined CDK4/6i and ET revealed a correlation between high biomarker expression and shorter progression-free survival (PFS), and the biomarker combination was an independent prognostic factor in both patients cohorts. Our study supports the clinical development of therapeutic strategies co-targeting ER, CDK4/6 and CDK2 following progression on AI-monotherapy or combined CDK4/6i and ET to improve survival of patients exhibiting high tumor levels of CDK6, p-CDK2, and/or cyclin E1

Charles Bonnet Syndrome:Evidence for a Generative Model in the Cortex?

Several theories propose that the cortex implements an internal model to explain, predict, and learn about sensory data, but the nature of this model is unclear. One condition that could be highly informative here is Charles Bonnet syndrome (CBS), where loss of vision leads to complex, vivid visual hallucinations of objects, people, and whole scenes. CBS could be taken as indication that there is a generative model in the brain, specifically one that can synthesise rich, consistent visual representations even in the absence of actual visual input. The processes that lead to CBS are poorly understood. Here, we argue that a model recently introduced in machine learning, the deep Boltzmann machine (DBM), could capture the relevant aspects of (hypothetical) generative processing in the cortex. The DBM carries both the semantics of a probabilistic generative model and of a neural network. The latter allows us to model a concrete neural mechanism that could underlie CBS, namely, homeostatic regulation of neuronal activity. We show that homeostatic plasticity could serve to make the learnt internal model robust against e.g. degradation of sensory input, but overcompensate in the case of CBS, leading to hallucinations. We demonstrate how a wide range of features of CBS can be explained in the model and suggest a potential role for the neuromodulator acetylcholine. This work constitutes the first concrete computational model of CBS and the first application of the DBM as a model in computational neuroscience. Our results lend further credence to the hypothesis of a generative model in the brain