Refusal to Take Sick Leave after Being Diagnosed with a Communicable Disease as an Estimate of the Phenomenon of Presenteeism in Poland.

OBJECTIVE: The purpose of this study was to estimate the prevalence of presenteeism in patients with communicable diseases in Poland. SUBJECT AND METHODS: This study was based on data from the medical records of 2,529 patients aged 19-64 years. All of the patients were diagnosed with communicable diseases. The inclusion criteria were based on implementing decision concerning communicable diseases made by the Commission of the European Union. Associations between refusal to take sick leave and patients' age, gender, and diagnosis in terms of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) were tested. Linear regression analysis of the data acquired from the patients who agreed to take sick leave was further used to estimate the possible length of sick leave in patients who refused to take it. RESULTS: The number of patients who refused to take sick leave was 18.1%. The presenteeism rate was related to the age of patients (periods of sick leave were longer in older patients) and the ICD-10 diagnosis (largely in bacterial intestinal infections and measles). The estimated number of days spent on sick leave in patients who refused to take it, assuming that they made a different decision and complied with it, was in the range of 4-6 days. CONCLUSION: The prevalence of presenteeism in the case of communicable diseases in Poland is lower than in the general population. However, as the refusals to take sick leave took place in the case of potentially contagious diseases, the negative impact on productivity may be significant.

[Therapy delays among women with diagnosed breast cancer and chosen sociodemographic factors]. / Opóznienia w leczeniu kobiet z rozpoznaniem raka piersi a wybrane czynniki demograficzne i spoleczne.

BACKGROUND: Up to now, there have been very few studies concerning delay issues in the treatment of breast cancer in Poland. The aim of the study was to determine the time and causes of delay in the treatment of women diagnosed with breast cancer and the importance of demographic and social factors on the occurrence of delays in the implementation of therapy. MATERIAL AND METHODS: The study was conducted in 2015-2016 in the Podkarpackie Oncology Centre in Brzozów for a group of 231 women. The time criterion of the delays in the treatment of women suffering from breast cancer was more than 1 month from the first oncological consultation to therapy initiation. The diagnostic poll method and medical documentation analysis were used. Research tools included a survey questionnaire and research protocol. The collected material was subjected to the statistical analysis using the χ2 test. The values of p < 0.05 were considered statistically significant. RESULTS: Delays were noted in 62.8% of the study participants and the mean delay time took 12.6 weeks. The main causes of the delays were: fear that the diagnosis would be confirmed, long waiting time for specialist investigations and their results, age, marital status and professional activity. No statistically significant correlation was found between profession, education level and the place of residence with therapy delays. CONCLUSIONS: Delays in the treatment of breast cancer patients were noted in the majority of study participants. A correlation was observed between the delays and chosen sociodemographic factors. Med Pr. 2019;70(1):89-98.

Causes of delays in breast cancer diagnosis in Poland.

Breast cancer is the most common malignant tumor in women. The results of breast cancer treatment to a large extent depend on the time of the primary diagnosis of the disease. AIM: The aim of this study was to determine the most common causes of the delay and the delay time in the diagnosis of breast cancer in Polish women. MATERIALS AND METHODS: The study was performed using a diagnostic survey and analysis of medical documentation from the Subcarpathian Regional Oncology Center, Poland. A total of 231 patients with diagnosed breast cancer were recruited to the study. RESULTS: Delays in diagnosing of breast cancer were found in 83.1% of all the patients. The average time from the first symptom observation by a woman to the first medical consultation was on average 61.7 days. The most common cause of the delay in medical consultation in the examined group was a fear of diagnosing cancer (31.2%). CONCLUSIONS: The examined women require permanent health education in the field of breast cancer and the importance of early diagnosis of the disease for the effectiveness of treatment and prognosis.

Evaluation of the analgesic effect of morphine on models of acute nociceptive pain in rats with a central noradrenergic system lesion.

OBJECTIVES: Stimulation of some noradrenergic system receptors demonstrates a synergistic anti-nociceptive effect with the opioid system at the level of peripheral tissues, spinal cord, and supraspinal structures. Furthermore, opioids stimulate the noradrenergic descending pathways originating from the substantia nigra by presynaptic inhibition of the GABA neuron ends. It is thus important to determine whether a disruption to the adrenergic transmission obtained via DPS-4 administration to neonatal rats impacts the perception of noxious stimuli mediated by 5-HT3-serotonin receptors at the level of spinal cords or higher tiers of the central nervous system. DESIGN & SETTING: The studies were conducted with neonatal and adult rats, males of the Wistar strain in which a central noradrenergic system lesion was induced with DSP-4 on days 1 and 3 of life. Next, the evaluation of the analgesic effect of morphine was performed on 8- to 10-week-old animals using the following models of acute nociceptive pain: the hot plate test and the tail immersion test as models of acute nociceptive pain induced by a thermal stimulus, and the paw withdrawal test as a model of nociceptive pain caused by a mechanical stimulus. RESULTS: Morphine was found to produce a longer-lasting analgesic effect in the tail immersion test in the control group than in rats. Similarly, in the paw withdrawal test, this substance generated a strong analgesic effect (with over 200% of analgesia) in the control group, whereas its action in the rats with DSP-4 lesions was statistically significant. Morphine induced analgesia at about 13-14% in the control rats when examined with the hot plate test. CONCLUSIONS: The disruption to the central noradrenergic system in an early stage of development resulted in a reduction of the analgesic effect of morphine in the models of acute pain in which the mechanisms of supraspinal perception are involved.

Migration Challenges and Their Impact on the Primary Healthcare System-A Qualitative Research.

In 2020 it is estimated that 281 million people were international migrants. Migrants constitute a potentially vulnerable population in terms of facing discrimination, poor living and housing conditions, and insufficient access to healthcare services. Due to the armed conflict in Ukraine in 2022, almost 10 million people crossed the Polish border within a year of the outbreak of the conflict. The objective of this paper is to present the use of primary healthcare services by people migrating from Ukraine to Poland and identify the barriers in access to healthcare by this group of persons. This study used a qualitative research technique in the form of an expert interview using individual in-depth interviews (IDI). The study group consisted of professionally active primary healthcare providers (doctors, nurses, and facility managers) in Poland. Research was carried out in the areas regarding the availability of healthcare, the potential threats and challenges, and possible system solutions. The results showed that the most common cause for doctor's appointments among migrants are respiratory infections, including COVID-19. Many cases were related to back pain, mainly resulting from the physical work of the patients. Additionally, some barriers to access and the provision of healthcare services for patients from Ukraine were identified. The majority (75%) of respondents indicated language as a significant barrier when providing services. Based on the study results, we recommend creating a dedicated website and telephone hotline for this group of persons as well as the use of traditional media to distribute information about access to healthcare services. It is also essential to focus on assistance for older people, since they may experience more difficulties with language and navigating the healthcare system.

Measuring the Intensity of Stress Experienced and Its Impact on Life in Patients with Diagnosed Alcohol Use Disorder.

Alcohol addiction is characterized by extensive alcohol consumption that dominates other behaviours previously important to a patient. According to data from The State Agency for Prevention of Alcohol-Related Problems, up to 900,000 people in Poland are addicted to alcohol. On average, approximately 9.7 L of pure alcohol per capita was consumed in 2021. Alcohol addiction may cause severe health problems and is one the key risk factors for various diseases. Stress plays an important role in the process of alcohol addiction and is also a predictor for lower enjoyment in life. On the other hand, sense of coherence may be a stronger protective factor. The aim of our study was to verify the relation between the level of perceived stress among patients with alcohol addiction and satisfaction with life. Because sense of coherence is a disposition that allows for managing stress effectively, the latter should be reflected in the results of multivariate analyses that take both the level of stress and sense of coherence into account. In the present study, sense of coherence and perceived stress were negatively correlated; therefore, strengthening internal resources for managing difficult and stressful situations is recommended.

Lung Cancer Screening-Trends and Current Studies.

Lung cancer is the leading cause of death among all the oncological diseases worldwide. This applies to both women and men; however, the incidence and mortality among women is on the rise. In 2020, lung cancer was responsible for 1.8 million deaths (18%). More than 90% of lung cancer cases and 77.1% of lung cancer deaths occur in countries with high and very high HDI (human development index) values. The aim of our study is to the present trends and most recent studies aimed at lung cancer screening. In the face of the persistently high mortality rate, conducting research aimed at extending already-implemented diagnostic algorithms and behavioural interventions focused on smoking cessation is recommended.

Mothers' Attitudes Towards Breastfeeding in Terms of Health Safety and Professional Lactation Education: A National Survey of Women.

Introduction and Objective: An important role in building opinions and attitudes regarding breastfeeding by mothers is played by the medical staff taking care of the mother woman expecting a baby. Breastfeeding is a standard in infant nutrition. The knowledge and support of the medical staff can help a woman make the decision to breastfeed. At the same time, it creates conditions for an optimal working environment for medical staff, affecting the quality of care. The aim of the study was identify mothers' attitudes towards breastfeeding in the context of health safety and professional lactation education. Materials and Methods: Data for the study were obtained on the basis of a proprietary questionnaire and a standardized research tool, which was the questionnaire for assessing knowledge and attitudes towards breastfeeding The Iowa Infant Feeding Attitude Scale designed by Arlene De la Mora (IIFAS). The study involved 439 women who gave birth to a child in the last 5 years. Results: Extensive knowledge about the benefits of breastfeeding for the child's body is declared by 67.9% of women. The vast majority of respondents (94.1%) pointed to supporting the development of the immune system. Most women (85%) obtained information on breastfeeding from the Internet, and 58.5% from medical personnel. Most respondents (88.8%) assessed their partner's attitude towards breastfeeding as positive. The result, The Iowa Infant Feeding Attitude Scale was equal to 50.97, which proves the positive attitude of women to breastfeeding. Conclusion: Promoting the best way to feed children, which is breastfeeding, plays an important role in building mothers' opinions and attitudes about breastfeeding.

Relationship between the components of disability definition and the effectiveness of rehabilitation measures as a process.

INTRODUCTION AND OBJECTIVE: The number of disabled persons is most often only estimated. The disabled require multidirectional, effective support in almost every field of functioning. There is no arbitrarily accepted definition of disability, and those currently available outline the ranges of support for which rehabilitation measures are necessary. OBJECTIVE: The aim of the review is to present the problem areas that contribute to the definition of disability and their interdependence and effectiveness in relation to rehabilitation interventions, as well as identification of the most frequent medical and social problems interdependent on the quality and feasibility of rehabilitation interventions. REVIEW METHODS: Scientific literature in Polish and English for 1993-2023 and legal acts concerning the definition of disability, definition of rehabilitation and the problem of employment were reviewed. The following key words were used to search the NIZP-PZH, MZ, JAHEE and ISAP databases: disabled persons, definitions of disability, rehabilitation as a process, synchronization of thematic groups of disability definitions with the rehabilitation process. BRIEF DESCRIPTION OF THE STATE OF KNOWLEDGE: Disability is a public health problem. The actual determination of the extent, medical and social needs of people with disabilities involves methods and measures for classifying people as disabled. The effects of treatment and rehabilitation are assessed by the level of functioning of the disabled in society. SUMMARY: The multiplicity of characteristics included in the definitions of disability account for all problems in health and social terms. In view of the social, environmental and cultural changes, the scope of needs of people with disabilities is also changing, which can be seen in newly-developed definitions, including rehabilitation.

Patient satisfaction with oncological care during the virus pandemic - SARS-CoV-2 taking into account social and demographic factors.

INTRODUCTION AND OBJECTIVE: The aim of the study was to examine the perception of medical services by oncological patients during the pandemic, identifying the key factors influencing it. The assessment of patient satisfaction with the treatment and care provided by doctors and other hospital staff provides important information on the quality of health services. MATERIAL AND METHODS: The study involved 394 patients diagnosed with cancer treated as inpatients in five oncology departments. The diagnostic survey method was used with a proprietary questionnaire and the standardized EORTC IN-PATSAT32 questionnaire. Calculations were carried out using Statistica 10.0 with p≤0.05 s considered statistically significant. RESULTS: Overall patient satisfaction with cancer care was 80.77/100. Higher values were shown for the competences of nurses than for doctors, especially for their interpersonal skills (79.34 - nurses vs. 74.13 - doctors) and availability (80.11 - nurses vs. 75.6 - doctors). It was also shown that the level of satisfaction with cancer care increased with age; women rated cancer care lower than men (p = 0.031), particularly its aspect related to the competences of doctors. A lower degree of satisfaction was observed among rural residents (p=0.042). Other demographic data, such as marital status and education, determined satisfaction with cancer care on the selected scale although it did not affect the overall level of satisfaction. CONCLUSIONS: The analysed socio-demographic factors, primarily age, gender and place of residence, determined some of the scales concerning patient satisfaction with cancer care during the COVID-19 pandemic. The results of this and other studies of a similar profile should be used in the formation of health policy, particularly in implementing programmes to improve the quality of cancer care in Poland.

Evaluation of Nutritional Status and the Impact of Nutritional Treatment in Patients with Pancreatic Cancer.

Patients with pancreatic cancer who develop irreversible cancer cachexia have a life expectancy of less than 3 months. Therefore, it is extremely important to evaluate the patient's nutritional status as early as possible and to implement an appropriate nutritional intervention in order to reduce the risk of further weight loss and/or muscle loss, which affect the outcomes of cancer treatment and the correct nutritional treatment in patients with pancreatic cancer. A literature review was performed by using the PubMed and Cochrane quick search methodology. The main purpose of this review was to present the current approach to nutritional treatment in pancreatic cancer. The review included publications, most of which concerned clinical nutrition as part of the phase of treatment of patients with pancreatic cancer, nutritional and metabolic disorders in pancreatic cancer, and the period after pancreatic resection. Some of the publications concerned various nutritional interventions in patients with pancreatic cancer undergoing chemotherapy or surgical treatment (nutritional support before surgery, after surgery, or during palliative treatment). There is an unmet need for integrated nutritional therapy as a key part of the comprehensive care process for PC patients. Nutritional counseling is the first line of nutritional treatment for malnourished cancer patients, but pancreatic enzyme replacement therapy also constitutes the cornerstone of nutritional treatment for relieving symptoms of indigestion and maintaining or improving nutritional status.

How A Patient with Resectable or Borderline Resectable Pancreatic Cancer should Be Treated-A Comprehensive Review.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease with high morbidity and mortality in which long-term survival rates remain disastrous. Surgical resection is the only potentially curable treatment for early pancreatic cancer; however, the right patient qualification is crucial for optimizing treatment outcomes. With the rapid development of radiographic and surgical techniques, resectability decisions are made by a multidisciplinary team. Upfront surgery (Up-S) can improve the survival of patients with potentially resectable disease with the support of adjuvant therapy (AT). However, early recurrences are quite common due to the often-undetectable micrometastases occurring before surgery. Adopted by international consensus in 2017, the standardization of the definitions of resectable PDAC (R-PDAC) and borderline resectable PDAC (BR-PDAC) disease was necessary to enable accurate interpretation of study results and define which patients could benefit from neoadjuvant therapy (NAT). NAT is expected to improve the resection rate with a negative margin to provide significant local control and eliminate micrometastases to prolong survival. Providing information about optimal sequential multimodal NAT seems to be key for future studies. This article presents a multidisciplinary concept for the therapeutic management of patients with R-PDAC and BR-PDAC based on current knowledge and our own experience.

Treatment Costs and Social Burden of Pancreatic Cancer.

(1) Background: Pancreatic cancer is the cancer with the third-highest mortality rate, and forecasts indicate its growing share in morbidity. The basis of treatment is inpatient chemotherapy and there is a strong focus on palliative care. (2) Methods: A literature review was conducted based on the rapid review methodology in PubMed and Cochrane databases. The search was supplemented with publications from the snowball search. Qualitative assessment of included publications was performed using AMSTAR2 modified scheme. (3) Results: The review included 17 publications, of which majority concerned direct costs related to the adopted treatment regimen. Most of the publications focused on comparing the cost-effectiveness of drug therapies and the costs of palliative treatment. Other publications concerned indirect costs generated by pancreatic cancer. They particularly focused on the economic burden of lost productivity due to sickness absence. (4) Conclusion: The increase in the incidence of pancreatic cancer translates into an increase in the costs of the health care system and indirect costs. Due to the significant share of hospitalization in the health care structure, direct costs are increasing. The inpatient treatment regimen and side effects translate into a loss of productivity for patients with pancreatic cancer. Among gastrointestinal cancers, pancreatic cancer generates the second largest indirect costs, although it has a much lower incidence rate than the dominant colorectal cancer. This indicates a significant problem of the economic burden of this cancer.

Quality of Life in Patients with Pancreatic Cancer-A Literature Review.

Pancreatic cancer is the malignant disease with the highest mortality rate, and it ranks third in the world after lung and colon cancer. Identified factors that increase the risk of developing pancreatic cancer include chronic pancreatitis, radiation therapy to the pancreatic area due to another cancer, diabetes mellitus, obesity, smoking, and age. The objective of this study was to present the current state of knowledge on the quality of life of patients diagnosed with pancreatic cancer, factors that determine QoL, and ways of coping with the disease. The low curability and low survival rates of pancreatic cancer significantly affect the quality of life of patients, often in the form of significant deterioration, especially in terms of mental changes, cognitive functions, and coping with the disease. Cognitive decline with comorbid depression is also typical for patients with this type of cancer. Research has shown that the health-related quality of life of patients with pancreatic cancer is low, so further research is needed to improve the situation in this area.

Overview of Pancreatic Cancer Epidemiology in Europe and Recommendations for Screening in High-Risk Populations.

Pancreatic cancer is the seventh most common cause of death in the group of oncological diseases. Due to the asymptomatic course, early diagnosis is difficult. Currently, early detection methods are only used in high-risk groups. A literature review based on the available results of observational studies on patients with pancreatic cancer and people from high-risk groups was used to summarize the knowledge on risk factors. The GLOBOCAN 2020 data were used to assess the epidemiological situation in Europe. A summary of screening recommendations was prepared based on the available documents from medical organizations and associations. Pancreatic cancer risk factors are divided into two main groups: non-modifiable factors, e.g., hereditary factors and age, which increase the risk of developing this disease, and modifiable factors-BMI, smoking, and alcohol consumption. Hereditary factors account for 10% of pancreatic cancer cases. The highly specialized methods of early detection, (MRI, CT, or EUS) are used for screening high-risk populations. Of all the imaging methods, EUS is considered the most sensitive for pancreatic cancer and allows an accurate assessment of the size of even small lesions (<30 mm) and the extent of tumour infiltration into blood vessels. The available studies vary on the level of sensitivity and specificity of these methods for the diagnosis of pancreatic cancer. EUS, MRI, and CT are also expensive procedures and in some patients can be invasive, which is one of the arguments against the introduction of population screening programs based on imaging methods. Therefore, it is important to look for viable solutions that would improve early detection. This is important from the point of view of healthcare systems in Europe, where almost 29% of all global pancreatic cancer cases are reported.

Evaluation of Health Pattern and Stress Levels among Patients Undergoing Alcohol Addiction Treatment-A Cross Sectional Study.

Alcohol consumption is linked to over 200 diseases and injuries. It is also classified as a risk factor for several types of neoplasms as well as infectious diseases (i.e., HIV and tuberculosis). In 2019, among people aged 25 to 49, alcohol use was the leading risk factor for attributable burden of disease. There are many factors that affect alcohol drinking patterns such as social and economic status, social norms, cultural customs, availability of alcohol, etc. Stress also plays a significant role in the process of developing alcohol addiction. The aim of our study was to examine health patterns and stress levels among patients undergoing alcohol addiction treatment. The study sample consisted of 104 patients who were treated in a hospital ward due to alcohol dependence. Three standardized questionnaire tools were used to measure the sense of coherence and the level of stress among those patients. The main results suggest that the level of perceived stress correlated negatively with all dimensions of sense of coherence and all indicators of health behaviors, however, age was positively correlated with positive mental attitude, proper eating habits, and health behaviors. In conclusion, it is worth noting that developing patterns for positive health behaviors will make it possible to avoid alcohol dependence or reinforce the treatment results if alcohol dependence syndrome occurs.

Management of Metastatic Pancreatic Cancer-Comparison of Global Guidelines over the Last 5 Years.

Pancreatic cancer (PC) is usually diagnosed at an advanced stage of its development, which results in lower overall survival (OS). Prognosis is also poor even with curative-intent surgery. Approximately 80% of patients with localized PDAC have micrometastases at the time of diagnosis, which leads to a worse prognosis than in other cancers. The objective of this study is to present the progress in the treatment of metastatic pancreatic cancer based on the recommendations of oncological scientific societies, such as ESMO, NCCN, ASCO, NICE and SEOM, over the last 5 years. Combined FOLFIRINOX therapy is mostly a recommended therapy among patients with good performance statuses, while gemcitabine is recommended for more fragile patients as a first-line treatment. The newest guidelines suggest that molecular profiling of the tumor should be the first step in determining the course of treatment. The use of modern molecular therapies in patients with specific gene mutations should extend the survival of patients with this disease.

Acceptance of Illness and Coping with Stress among Patients Undergoing Alcohol Addiction Therapy.

(1) Background: Acceptance of illness is a process in which a person with an illness accepts its presence and treats it as an integral part of their life. With regard to alcoholism, acceptance of illness is one of the important elements of the healing process. (2) Methods: The study group consisted of 104 residents in an addiction treatment ward. Questionnaires SOC-29, AIS and PSS-10 were used to check levels of coherence, stress and acceptance of illness. The analysis was based on regression analysis. Patient age was analysed as a moderator of correlations between perceived indicators. Moderation analysis was based on the simple moderation model. (3) Results: The level of perceived stress correlated negatively with all areas of the sense of coherence and with acceptance of illness. All areas of the sense of coherence correlated with acceptance of illness positively. (4) Conclusions: The acceptance of illness by the patient is a factor that can be motivating for further treatment, through a positive approach to illness and strengthening the sense of control in experiencing it. The combination of strengthening behavioural, cognitive and motivational resources can be used in the treatment of people experiencing the challenges of addiction to alcohol.

Research priorities in the domain of disability - correlation between health and social characteristics. A Polish example.

INTRODUCTION AND OBJECTIVE: In each society there functions a group of the disabled who need assistance. The number and character of dysfunctional consequences determine the types of support, characteristics of health, medical and social problems, where a part of them are interdependent. The interdependence of these needs determine the consistency of rehabilitation actions, which result in the improvement of quality of life of disabled persons in their living environment, especially among rural inhabitants. REVIEW METHODS: The scientific medical, and sociological literature, as well as binding legal Acts from 1978-2021 were reviewed. Materials from Polish and English databases were analysed. Key words related to disability, its definition, models of disability, disability discrimination, inequalities in medical and social care, health and social needs, maps of needs, satisfaction with medical and social care, and quality of life were used. BRIEF DESCRIPTION OF THE STATE OF KNOWLEDGE: Despite the fact that disability is a medical-social phenomenon, many reports concern only the treatment of the consequences of diseases, injuries, genetic/congenital or environmental defects. Disability is frequently identified with disease, which is inappropriate. Many researchers dealing with disability focus - quite rightly - on studies concerning social consequences, because they decide about the level of functioning of these persons in society and level of participation. SUMMARY: Disability is not only a medical and social problem. Treatment does not end the essence of disability. Only interdisciplinary studies can change the life of these persons regarding great possibilities for their participation.

Pain Management Strategies among Cancer Patients. Normalization of the CSQ (The Pain Coping Strategies Questionnaire) Form.

INTRODUCTION: Cancer is associated with chronic pain, which significantly reduces the quality of life. The level of pain depends on the dominant pain management strategy that the patient uses. OBJECTIVE: This study seeks to evaluate the application of the Pain Coping Strategies Questionnaire among cancer patients and develop norms allowing differentiation of patients with diagnosed cancer in terms of pain management strategies. MATERIAL AND METHODS: The study involved 1187 patients diagnosed with malignant cancer, who are under outpatient care of the Maria Sklodowska-Curie Institute-Oncology Center in Warsaw. The study used the Pain Coping Strategies Questionnaire (CSQ) elaborated by A.K. Rosentel and F.J. Keefe. RESULTS: Socioeconomic variables and medical factors affect pain management strategies chosen by patients. The area most strongly differentiated by the studied variables is praying/hoping. Factors that have the greatest impact on the choice of pain management strategies for cancer patients include education, income, and radiation therapy. Sten standards were developed to determine the severity of pain management strategies used in the low-average-high categories. CONCLUSIONS: The CSQ questionnaire should be used in cancer patients, and the result of the strategy used can be a prognostic factor for the expected effects of therapy. Knowledge of the variables most strongly affecting patients' choice of strategies that are not conducive to strengthening health attitudes and the ability to determine the severity of pain management strategies on standard scales allows us to focus psychotherapeutic activities on patients who need support most.