A Causal Model of Health-related Quality of Life Among Pakistani Older Persons with Multimorbidity (HRQL-OPM)

OBJECTIVES

Poor health-related quality of life (HRQOL) is common among older persons (OP) with multimorbidity. A model is proposed to examine how different factors influence HRQL-OPM.

METHODS

Participants included 410 hospitalized OP ≥ 60 years with multimorbidity. Structural equation modeling assessed hypothesized relationships between factors and HRQOL.

RESULTS

Activities of daily living (ADLs) and social support were directly related to HRQOL, while symptom burden, social support and depressive symptoms had indirect associations with HRQOL via ADLs as a mediator. Model fit was excellent (CMIN/DF = 4.23; TLI = 0.93; CFI = 0.96; RMSEA = 0.08).

CONCLUSION

Achieving optimum HRQL-OPM requires alleviating depressive symptoms and symptom burden while enhancing social support and improving ADLs. Ultimately, ADLs and social support determines an individual's level of HRQOL. Findings suggest the need to understand what kind of ADLs and ways of social support are required by those coping with multimorbidity.

Integrating the symptom experience and coping in patients with stage I-III breast cancer in China: A qualitative study

PURPOSE

To develop an in-depth understanding of the meaning of symptoms in the context of how women with stage I-III breast cancer in China cope with the effects of primary and adjuvant therapies for breast cancer.

METHOD

A qualitative descriptive approach was used. A purposive sample of women diagnosed with stage I-III breast cancer were recruited from the "Be Resilient to Breast Cancer" study between November 2023 and March 2024. Data was collected from in person interviews using a semi-structured interview guide. Interviews were audio-recorded and transcribed verbatim. The framework analysis method was used to generate codes and themes.

RESULTS

A sample of 17 women with breast cancer agreed to participate. The average age was 50.1 years (SD = 8.45), and the majority (65%) had stage III. The overarching theme was Confronting Physical and Psychological Symptoms. The four themes explaining the experience were Changed Identity, Uncertainty, Finding Meaning and Seeking Support and Solace. Changed Identity and Uncertainty reflected the challenges of coping with multiple symptoms from the treatment. The themes of Finding Meaning and Seeking Support and Solace captured how women adapted a positive perspective to cope with the experience.

CONCLUSIONS

This study contributed to the evidence of the integration of the symptom experience in coping with breast cancer treatment in the context of a collectivist Chinese culture. It enhanced the understanding of the physical and psychological symptom experience of curative intent breast cancer therapy and offered insight into how women from China cope in early survivorship.

Conceptualising TMD symptom burden in youths: Symptom duration, frequency, intensity and interference

OBJECTIVE

This study aimed to conceptualise Temporomandibular disorder (TMD) symptom burden and severity and explored their interrelationships with somatic symptoms and psychological distress.

METHODS

Participants were recruited from a local polytechnic. The quintessential five TMD symptoms (5Ts) of the Diagnostic Criteria for TMDs (DC/TMD) were appraised and extended to evaluate the duration, frequency, intensity and interference of discrete TMD symptoms. Global TMD severity (GS) was computed by totaling the points for all TMD symptoms and dimensions. TMD (TS) and somatic symptom (SS) burden were assessed based on the Somatic Symptoms Scale-8, while psychological distress was measured with the Depression, Anxiety and Stress Scales-21. Statistical analyses were performed using Kruskal-Wallis/Dunn tests and Spearman's correlation (α = .05).

RESULT

Of the 366 eligible participants (mean age 19.1 ± 2.3 years), 51.4% were 5Ts-negative and 48.6% were 5Ts-positive. Among the 5Ts-positive individuals, 25.3%/64.0% were 'bothered a little' whereas 4.5%/10.7% were 'bothered a lot' by TMD pain/headache. Correspondingly, 32.6%/12.4%/5.1% were 'bothered a little' while 2.8%/2.8%/1.1% were 'bothered a lot' by TMJ sounds/closed/open locking. TS burden was moderate-to-strongly correlated to aggregate symptom duration, frequency, intensity, interference, GS and SS burden (rs = .50-.88). While TS burden and GS were weakly associated with psychological distress (rs = .18-.36), SS burden was moderately related to depression, anxiety and stress (rs = .47-.53).

CONCLUSIONS

TS burden can serve as a proxy for global TMD severity and may be more meaningful than the mere presence of TMD symptoms in clinical and research settings.

Self-reported symptom burden in postural orthostatic tachycardia syndrome (POTS): A narrative review of observational and interventional studies

BACKGROUND AND OBJECTIVE

Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic health condition affecting mostly women of childbearing age, and significantly impacting their health and quality of life. It is currently poorly understood with no approved licensed treatments. The aim of this systematic review was to contextualize the symptom burden of POTS, and review factors associated with this burden that may guide future treatments. The specific questions were (1) How does symptom burden in POTS compare to the burden in other long term conditions (LTCs), (2) Which factors are associated with POTS symptom burden, and (3) Which interventions show promise in reducing symptom burden in POTS.

DATABASES AND DATA TREATMENT

Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, APA PsycArticles, OpenGrey) were searched from inception to January 2022 for observational studies reporting on the association between any biological, psychological or social factors and symptom burden, and randomized controlled trials reporting on interventions for symptom burden in adults with POTS. Two reviewers independently conducted eligibility screening, data extraction and quality assessment. A narrative synthesis was undertaken.

RESULTS/CONCLUSION

5159 entries were screened for eligibility. Twenty-nine studies were included (1372 participants with POTS of a total sample size of 2314, 17 High-, 12 Medium-quality), seventeen were observational and twelve were randomized controlled experimental and intervention trials. Overall methodological quality of the evidence was medium-high but heterogeneity was high and sample sizes modest, allowing moderately robust conclusions. Orthostatic symptom burden was higher in POTS than other LTCs. Serum activity against adrenergic α1 receptors, physical functioning, depression, catastrophizing, prolonged cognitive stress testing and anxiety were significantly associated with symptom burden in medium-high quality studies. Preliminary medium-high quality evidence from predominantly proof-of-concept (n = 11) studies and one 3-month 2 × 2 factorial design trial suggest that compression garments, propranolol, pyridostigmine, desmopressin, and bisoprolol may hold promise in reducing symptom burden. Directions for future research include investigating associated factors over time, the development of complex interventions which address both biological and psychosocial factors associated with symptom burden, and effectiveness trials of these interventions.

SIGNIFICANCE

POTS symptom burden is high, particularly in relation to orthostatic intolerance when compared to other long-term conditions (LTCs). Despite this burden, there are no effectiveness randomized controlled trials of treatment to reduce symptoms in POTS. This review provides a starting point to understanding researched biological and psychosocial factors associated with this burden. There was however inconsistency in the measurement of symptom burden, lowering the confidence of cross-study inferences. A coherent definition of POTS symptom range, severity and impact along with a validated and reliable POTS-specific instrument is currently lacking. A standardized questionnaire to assess POTS symptom burden as a core outcome measure will help clarify future research and clinical practice.

Change in worry over time among Hispanic women with thyroid cancer

PURPOSE

The purpose of this study is to assess change in worry over time in Hispanic women with thyroid cancer.

METHODS

Worry about recurrence, quality of life, family at risk, death, and harm from treatments was assessed in 273 Hispanic women with thyroid cancer diagnosed in 2014-2015. Subjects were recruited from Surveillance, Epidemiology, and End Results (SEER) Los Angeles. Participants were surveyed at two points in time (time 1: 2017-2018 and time 2: 2019). Multivariable logistic regression was used to determine correlates with high worry (somewhat, quite a bit, very much) versus low worry (not at all, a little) at time 2.

RESULTS

For the five worry items, 20.1-39.6% had high worry at both time 1 and time 2. An additional 7.6-13.4% had low worry at time 1 that became high worry at time 2. In multivariable logistic regression controlling for age, recurrence status, education level, and number of complications or side effects symptoms, younger age (20-39) as compared to older (40-79) was associated with high worry about thyroid cancer recurrence (OR 2.16, 95% CI 1.12-4.17). History of recurrent or persistent disease was associated with high worry about harms from treatment (OR 2.94, 95% CI 1.29-6.67). Greater number of complications or side effects of symptoms was associated with more worry across all five items.

CONCLUSIONS

Some Hispanic women with thyroid cancer have persistently high worry, with young adult Hispanic women vulnerable to worry about recurrence.

IMPLICATIONS FOR CANCER SURVIVORS

Hispanic women with thyroid cancer may benefit from targeted psychosocial support during survivorship, with interventions informed by patient and cancer characteristics.

An appraisal of emerging second line therapies for metastatic colorectal cancer

INTRODUCTION

Despite a significant improvement in overall survival over the last 15 years, colorectal cancer remains a major public health problem worldwide. Much effort has been made to develop an optimal choice of first-line treatments, but after progression the therapeutic possibilities and the criteria for choice are different.

AREAS COVERED

The purpose of this literature review is to discuss the different possibilities of second-line treatment and to specify the criteria for choice. Biological subgroups requiring specific therapeutic decisions will be described. We conducted a systematic review for randomized controlled trials published since 1995. A non-exhaustive review of published phase II studies, cohort studies, and international guidelines was also given and future leads were discussed.

EXPERT OPINION

Some choices of second-line treatments are a direct result of the option chosen in the first line. Others are necessary because of the biological specificity of the tumor: immunotherapy for tumors with microsatellite instability, or the combination encorafenib cetuximab for mutated BRAF-V600E tumors. In many other circumstances, there are several options that require extensive involvement of multidisciplinary boards and the patient in the final therapeutic decision.

Associations Between Influencing Factors, Perceived Symptom Burden, and Perceived Overall Function Among Adults Living With HIV

With adherence to combination antiretroviral therapy, HIV infection is now a chronic, but manageable, disease with associated symptoms and complications. However, there is limited evidence on how symptom burden affects perceived overall function among people living with HIV (PLWH). Furthermore, there is no consensus on the factors that affect symptom burden in PLWH. We examined relationships between factors that may influence symptom burden and perceived overall function, and the association between symptom burden and overall function in 179 adult PLWH. This study was a cross-sectional, secondary analysis using the Theory of Unpleasant Symptoms (Lenz, Pugh, Milligan, Gift, & Suppe, 1997). We found strong evidence that symptoms, especially pain, tiredness, and depression, are prevalent in PLWH, and that symptoms were predicted by perceived social support and the number of comorbidities. Increased symptom burden predicts reduced overall function. Interventions are needed to reduce symptoms and strengthen social support in PLWH. Initiating symptom assessment and management strategies early is paramount.

What symptoms tell us: A multiple case study of oncology consultations

OBJECTIVES

While patients' symptom experiences have been widely investigated, there is a lack of contextualized studies investigating how symptoms circulate in the medical consultation, how patients present them, what they convey, how physicians respond, and how patients and physicians negotiate with each other to find ways to address them. The aim of this study is to explore patients and physicians handling of symptoms throughout oncological consultations with a multiple case study approach.

METHODS

Five consultations, purposively selected from an existing dataset of audiotaped consultations with patients with advanced cancer, were analyzed by means of an inductive analytical approach based on a sensitive framework from the literature.

RESULTS

Patients' symptoms showed multiple dimensions such as medical, cognitive, emotional, psychological, interactional, symbolic, experiential, and existential.

SIGNIFICANCE OF RESULTS

Different symptom dimensions remained unnoticed and unaddressed in the consultations. The physician-centered symptom approach that was observed leads to consumed time and missed opportunities for relationship building with the patient. Physicians showed a lack of sensitivity regarding the multiple dimensions of symptoms. Based on the findings, strategies for a more comprehensive symptom approach can be conceived.

A Randomized Clinical Trial Comparing the Impact of a Web-Based Multimedia Intervention Versus an Educational Pamphlet on Patient Outcomes in Breast Cancer Survivors with Chronic Secondary Lymphedema

Objective: The purpose of this study was to evaluate the effects of a Web-based Multimedia Intervention (WBMI) for breast cancer-related lymphedema (BCRL) patients on symptom burden, function, psychological well-being, costs, and arm volume. Methods: Women with BCRL were randomized to intervention (n = 80) or control (n = 80) groups. The WBMI offered 12 modules, each of which took about 30 minutes to complete. The Pamphlet took about 2 hours to read. Data on symptom burden, psychological well-being, function, and costs were collected preintervention; and 1, 3, 6, and 12 months postintervention. A subgroup of 45 regional patients had arm extracellular fluid measured by bioimpedance at baseline and at 3, 6, and 12 months postintervention. Intervention perceived value was also captured. Results: A statistically significant difference (p = 0.011) was observed for rates of intervention completion, WBMI (58%), and Pamphlet (77%). With the exception of the number of biobehavioral symptoms (mood), no statistically significant differences between groups in symptom reduction were apparent between baseline and 1 or 12 months (effect sizes = 0.05-0.28, p > 0.05) based on the Lymphedema Symptom Intensity and Distress Scale-Arm (LSIDS-A). No statistically significant differences between the groups were observed for changes in other variables. The WBMI was perceived as providing better self-care information than the Pamphlet (p = 0.001). Conclusions: WBMI participants experienced improved biobehavioral symptoms and higher perceived quality of information. The lack of significant differences on other variables may be due to the high percentage of participants who did not complete the WBMI.

'The Thing that Really Gets Me Is the Future': Symptomatology in Older Homeless Adults in the HOPE HOME Study

CONTEXT

The homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults.

OBJECTIVES

To characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults.

METHODS

We conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis.

RESULTS

We found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use.

CONCLUSION

Homelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.

What is symptom meaning? A framework analysis of communication in palliative care consultations

OBJECTIVE

There is a limited understanding of symptom meaning and its significance to clinical practice within symptom experience literature. This study aims to qualitatively explore the ways in which symptom meanings are discussed by patients and responded to by palliative care physicians during consultations.

METHODS

Framework analysis was conducted with 40 palliative care consultation transcripts.

RESULTS

55% of consultations discussed symptom meaning. Six themes regarding patients' symptom meanings emerged while four themes conveyed physicians' responses to these utterances. Key symptom meanings included symptoms representing diminished function and uncertainty about symptom cause or future. Physicians usually gave scientific medical responses concerning symptom cause and treatment, versus reassurance or empathy.

CONCLUSION

This study has provided greater insight into the different symptom meanings that exist for palliative care patients. Physicians' responses highlight their reliance on medical information when patients are distressed. Future studies should explore the impact of different responses on patient outcomes, and health practitioners' views about optimal responses.

PRACTICE IMPLICATIONS

Physicians could explore symptom meanings with their patients, looking out for those identified here. Apart from information-giving and treatment, active listening to these concerns as they present in consultations may help improve the therapeutic relationship and better guide optimal care.

Quality of Life of Patients with Advanced Chronic Kidney Disease Receiving Conservative Care without Dialysis

With the evidence that dialysis may not necessarily be beneficial for older adults with advanced chronic kidney disease (CKD), there is a growing interest in promoting conservative care without dialysis as a viable treatment option for these individuals. This review summarizes the current empirical evidence of symptom experiences and quality of life of patients receiving conservative care. Data suggest that conservative care may yield symptom experiences and quality of life that are compatible with those of patients on dialysis. However, these data are exclusively from studies conducted outside of the United States in which there were often no comparison groups or study designs that could provide high quality evidence. There is an urgent need for further research and developing a conservative care model suitable for CKD populations in the U.S.

To adjust and endure: a qualitative study of symptom burden in older people with multimorbidity

CONTEXT

Older people with multimorbidity are vulnerable and often suffer from conditions that produce a multiplicity of symptoms and a reduced health-related quality of life.

OBJECTIVES

The aim of this study is to explore the experience of living with a high symptom burden from the perspective of older community-dwelling people with multi-morbidity.

METHOD

A qualitative descriptive design with semi-structured interviews, including 20 community-dwelling older people with multi-morbidity and a high symptom burden. The participants were 79-89 years old with a mean of 12 symptoms per person. Data were analyzed using content analyses.

RESULTS

The experience of living with a high symptom burden revealed the overall theme, "To adjust and endure" and three sub-themes. The first sub-theme was "To feel inadequate and limited". Participants reported that they no longer had the capacity or the ability to manage, and they felt limited and isolated from friends or family. The second sub-theme was "To feel dependent". This was a new and inconvenient experience; the burden they put on others caused a feeling of guilt. The final sub-theme was "To feel dejected". The strength to manage and control their conditions was gone; the only thing left to do was to sit or lie down and wait for it all to pass.

CONCLUSION

This study highlights the importance of a holistic approach when taking care of older people with multi-morbidity. This approach should employ a broad symptom assessment to reveal diseases and conditions that are possible to treat or improve.

Symptom burden in community-dwelling older people with multimorbidity: a cross-sectional study

Background

Globally, the population is ageing and lives with several chronic diseases for decades. A high symptom burden is associated with a high use of healthcare, admissions to nursing homes, and reduced quality of life. The aims of this study were to describe the multidimensional symptom profile and symptom burden in community-dwelling older people with multimorbidity, and to describe factors related to symptom burden.

Methods

A cross-sectional study including 378 community-dwelling people ≥ 75 years, who had been hospitalized ≥ 3 times during the previous year, had ≥ 3 diagnoses in their medical records. The Memorial Symptom Assessment Scale was used to assess the prevalence, frequency, severity, distress and symptom burden of 31 symptoms. A multiple linear regression was performed to identify factors related to total symptom burden.

Results

The mean number of symptoms per participant was 8.5 (4.6), and the mean total symptom burden score was 0.62 (0.41). Pain was the symptom with the highest prevalence, frequency, severity and distress. Half of the study group reported the prevalence of lack of energy and a dry mouth. Poor vision, likelihood of depression, and diagnoses of the digestive system were independently related to the total symptom burden score.

Conclusion

The older community-dwelling people with multimorbidity in this study suffered from a high symptom burden with a high prevalence of pain. Persons with poor vision, likelihood of depression, and diseases of the digestive system are at risk of a higher total symptom burden and might need age-specific standardized guidelines for appropriate management.