An intervention to improve caregiver self-efficacy and contribution to self-care does not affect caregiver anxiety, depression, quality of life and sleep. Secondary outcome analysis of MOTIVATE-HF RCT

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Center of Excellence for Nursing Scholarship (CECRI), Rome, Italy.

Background

Caregiver contribution (CC) to self-care can improve patient outcomes in heart failure (HF). However, caring for a person with HF can be a burdensome experience for caregivers. Experimental studies aimed at improving caregiver self-efficacy and CC to HF self-care are scarce. Moreover, it is underexplored if interventions aiming to improve caregiver self-efficacy and CC to HF self-care consequently affect caregiver anxiety, depression, quality of life and sleep.

Purpose

To evaluate if the delivery of a Motivational Interviewing intervention aimed at improving caregiver self-efficacy and CC to HF self-care affects caregiver anxiety, depression, quality of life, and sleep.

Methods

Secondary outcome analysis of the MOTIVATE-HF randomized controlled trial. Participants were recruited from three centers in Italy, and they were randomized into three arms: Arm 1 (Motivational Interview for patients), Arm 2 (Motivational Interview for patients and caregivers), Arm 3 (standard care). The intervention consisted in one face-to-face MI session, plus three telephone contacts within two months from enrollment with patients (Arm 1) or with patients and caregivers (Arm 2). Data were collected at baseline and after 3, 6, 9, 12 months. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale, quality of life was measured with the 12-Item Short-Form Health Survey, and sleep was evaluated with the Pittsburgh Sleep Quality Index.

Results

A total of 510 patient and caregiver dyads were enrolled. Caregiver median age ranged between 53 and 57, they were mainly female (76%), married (72%), spouses (37%), educated at high school or university level (55%), employed (73.5%), and living with the patient (60%). At baseline, anxiety, depression, quality of life and sleep scores were comparable among the three Arms. Over the year of follow-up, anxiety, depression, and sleep disturbances decreased, while quality of life slightly increased in all the three Arms. However, these changes were not significant in any of the study arms. When comparing these changes between Arm 2 and Arm 1 and 3, we did not observe any significant difference.

Conclusion

Delivering Motivational Interview to caregivers to improve their self-efficacy and contribution towards patient self-care did not increase caregivers’ own levels of anxiety and depression and did not decrease their quality of life and sleep. This may help tailoring future interventions for caregivers knowing that such an intervention does not worsen caregivers’ conditions and wellbeing.

Motivational Interviewing improves caregiver self-efficacy in heart failure: a secondary outcome analysis of the MOTIVATE-HF trial

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Center of Excellence for Nursing Scholarship, Rome, Italy.

Background

Caregiver self-efficacy, which is caregiver confidence in her own abilities to help the patient in performing self-care, directly influences caregiver contribution (CC) to self-care, while acting as a mediator between predictors of CC to self-care and CC to self-care itself. Although caregiver self-efficacy is associated with patient and caregiver outcomes, evidence on interventions aiming to improve this variable, as well as CC to self-care, is scarce.

Purpose

To evaluate the effect of Motivational Interviewing (MI) on caregiver self-efficacy and CC to self-care in heart failure.

Methods

Secondary outcome analysis of the MOTIVATE-HF RCT. A total of 235 caregivers and 238 patients completed the study. Participants were recruited from three centres in Italy and randomized into Arm 1 (MI for patients), Arm 2 (MI for patients and caregivers), Arm 3 (standard care). The intervention consisted in one face-to-face MI session followed by three telephone contacts delivered to patients (Arm 1) or to patients and caregivers (Arm 2). Caregiver self-efficacy and CC to self-care were assessed with the Caregiver Contribution to Self-Care of HF Index. Data were collected at baseline, before the intervention, and after 3, 6, 9, 12 months from enrolment.

Results

Among the three arms, caregivers median age was 55 years, they were mainly female (76%), married (72%), spouses (37%), employed (73.5%), with a high school level or higher education (55%), and living with the patients (60%). Patients median age was 74 years, they were mainly male (58%), retired (76%), in NYHA Class II (61.9%). Over the year of the study, caregiver self-efficacy significantly improved in all arms, and was significantly higher in Arm 2 compared to Arm 3 at 9-month follow-up (difference: 8.36, 95% CI (3.13; 13.59), p = 0.002). At 12-month follow-up, caregiver self-efficacy was still higher in Arm 2 compared to Arm 3, but this difference only approached statistical significance (difference: 6.59, 95% CI (-0.41; 13.60), p = 0.064). The longitudinal mixed linear model on self-efficacy, accounting for time, living with the patient, randomization arm and their interaction, confirmed a significantly higher improvement of caregiver self-efficacy in Arm 2 compared to Arm 3 (β ̂ = 1.39, 95% CI (0.02; 2.75), p = 0.046). CC to self-care significantly improved over time in all Arms, but without significant differences among the three Arms.

Conclusion

Our results show that MI was effective in improving caregiver self-efficacy, but not CC to self-care. This may indicate that MI was able to improve how well caregivers were supporting patients, as showed by improvements in self-efficacy, but not how much they were doing it, as showed by the lack of improvement in CC to self-care. Further studies need to better understand how caregiver self-efficacy affects CC to self-care, how caregiver self-efficacy can be further improved, and the necessary intensity of MI to improve CC to self-care.

Self-care recommended by clinicians in patients with heart failure or type 2 diabetes: a Delphi study

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Australian Catholic University, Australia

Background

Patients with heart failure or type 2 diabetes often experience bothersome symptoms (e.g., swelling, dizziness) and need clinical support with symptom management to reduce the impact of these symptoms. Knowledge about recommended self-care management behaviors by experienced clinicians can help to guide the development of more effective self-care interventions.

Purpose

To develop a list of common bothersome symptoms of heart failure and type 2 diabetes and of self-care management behaviors that clinicians recommend to patients to reduce the impact of these symptoms.

Methods

A two-round Delphi study among a panel of 37 nurses and physicians (heart failure only n=14; type 2 diabetes only n=11 and both heart failure and type 2 diabetes n=12) from Italy, the Netherlands, Sweden and the US was performed. Online surveys were used to identify common and bothersome symptoms and related self-care management behaviors that they recommend to patients with heart failure or type 2 diabetes. Self-care management behaviors that received at least 75% agreement were retained and similar self-care management behaviors were discussed and merged to reduce redundancy.

Results

For heart failure, the final list included 12 common bothersome symptoms (e.g., fatigue/tiredness, shortness of breath) and 51 related self-care management behaviors (e.g., balance rest & activity, check body weight & swelling). For type 2 diabetes, 11 common bothersome symptoms (e.g., hypo- and hyperglycemia symptom clusters, foot wounds) and 25 related self-care management behaviors (e.g., check blood sugar, take insulin, contact podiatrist) were included in the final list. Consensus was reached on the vast majority (70%) of recommended behaviors.

Conclusion

The lists of common bothersome symptoms and self-care management behaviors reflect consensus but also discrepancies between clinicians’ recommendations and current guidelines. Efforts to enhance and align the use of proven effective self-care management behaviors to reduce symptom impact in routine care by clinicians should be considered.

A motivational interviewing intervention improves the burden of physical symptoms in patients with heart failure: A secondary outcome analysis of a randomized clinical trial

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Center of Excellence for Nursing Scholarship, Rome, Italy

Background. Patients with heart failure (HF) experience a variety of physical symptoms. Symptoms are perceived by patients as burdensome and, as such, negatively affect  quality of life. Besides, physical symptoms are among the first reasons for seeking emergency care and hospitalization. Findings from the MOTIVATE-HF trial show that motivational interviewing (MI) leads to better self-care. However, whether MI also reduces the burden of physical symptoms is not yet known.

Purpose. To evaluate the effectiveness of MI on the burden of physical symptoms in patients with HF.

Methods. Secondary outcome analysis of the MOTIVATE-HF trial. The study was a three-arm, multicenter randomized controlled trial with a 12-month follow-up. Patients with HF and their informal caregivers were enrolled and randomly divided into three arms: MI performed only with patients (Arm 1); MI performed both with patients and caregivers (Arm 2); usual care (Arm 3). Patients with a diagnosis of HF in NYHA functional class II-IV were recruited in three Italian centers. Participants underwent one face-to-face MI session, followed by three phone calls within two months from enrollment. Physical symptoms were measured with the Heart Failure Somatic Perception Scale (HFSPS) with the dimensions of dyspnea, chest discomfort, early and subtle, and edema. Higher scores at the HFSPS and its dimensions indicate worse physical symptom. Data were collected at baseline, and 3 (T1), 6 (T2), 9 (T3) and 12 (T4) months after enrollment. T-test was used to compare differences in HFSPS scores in Arms 1 and 2 versus Arm 3 at each follow-up. Changes over time were analyzed with mixed linear longitudinal models.

Results. A sample of 510 patients (median 74 years, 58% male) and their caregivers (median 55 years, 75.5% female) were randomized to Arm 1 (n = 155), Arm 2 (n = 177) and Arm 3 (n = 178). Chest discomfort improved in Arms 1 and 2 versus Arm 3 at T4 (mean difference(Δ): -8.13, P = .014). Dyspnea also improved in Arms 1 and 2 than Arm 3 both at T3 and T4 (Δ: -7, P = .027 and Δ: -6.78, P = .038, respectively). HFSPS total score improved in Arms 1 and 2 versus Arm 3 at T3 (Δ: -4.55, P = .048). Over the year of observation, the mixed linear longitudinal models showed a significant improvement in Chest discomfort and total HFSPS score in Arm 2 versus Arm 3 (β = -2.61, P = .002 and, β = -1.35, P = .02).

Conclusions. The results of this secondary analysis indicate that MI may be effective in decreasing the burden of physical symptoms in HF patients, especially if also caregivers are involved in the intervention. Since symptom burden is among the first reasons for seeking emergency care and hospitalization in HF, MI might be a viable option to improve symptom burden via self-care.

Self-care research: How to grow the evidence base? (reprint)

BACKGROUND AND OBJECTIVE

The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field.

METHOD

During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research.

RESULTS

In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components.

CONCLUSION

Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each other's work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care.

Self-care interventions in patients with coronary artery disease: room for improvement

 

After a coronary artery event it is vital that patients perform self-care Self-care can be defined broadly as a process of maintaining health through treatment adherence and health-promoting practices (self-care maintenance), behavior and condition monitoring (self-care monitoring), and managing signs and symptoms when they occur (self-care management). For patients with coronary artery disease (CAD) essential self-care activities include adherence to medication, risk-factor management, symptom monitoring and preventive behavior. To advance the field of self-care in CAD patients, it is important to understand which self-care elements are currently addressed in interventions studies. The purpose of this study was to describe which behaviors are emphasized in self-care interventions for patients with CAD.

Methods

We conducted a systematic review of self-care interventions in chronic diseases. Four databases were search for randomized controlled trials with allocation to an intervention or to usual care or another intervention in adults with nine major symptomatic chronic conditions, one of which was coronary artery disease. Between 2008 and 2019 there were 9309 potential articles addressing self-care in chronic disease. After duplicates were removed and titles and abstracts were reviewed, 166 full-text articles on CAD studies evaluating a self-care intervention were assessed for eligibility and 15 studies remained after further assessment.

Results

Almost all studies (80%) in CAD patients included all three components of self-care (self-care maintenance, monitoring and management) in their interventions. Self-care maintenance behaviors addressed in these studies were mainly related to physical activity (73%) diet (60%) and medication management (33%) Another 40% included a psychosocial component, but only 4 studies (26%) were specially targeted at smoking behavior. With regard to self-care monitoring, most (60%) included monitoring of their physical activity level and 26% monitoring of symptoms. Self-care management behaviours were addressed rarely, but when addressed, focused on adapting activity level (60%), adapting diet (27%), medication changes (20%) and stress reduction (20%). Goal setting (60%), problem solving (40%) and feedback (33%) were the behavioural change techniques that were used most often to promote self-care. Only 1 study mentioned the use of social support. One study used reminders.

Conclusions

Most interventions that are tested to improve outcomes in patients with CAD address self-care maintenance, monitoring, management. The behavioural change techniques used are limited. There is a large variation in which behaviours are emphasized in research studies and the focus is primarily on changing traditional lifestyle factors, but not all life-style factors are addressed adequately in the interventions.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Australian Catholic University

An ortholog of Plasmodium falciparum chloroquine resistance transporter (PfCRT) plays a key role in maintaining the integrity of the endolysosomal system in Toxoplasma gondii to facilitate host invasion

Toxoplasma gondii is an apicomplexan parasite with the ability to use foodborne, zoonotic, and congenital routes of transmission that causes severe disease in immunocompromised patients. The parasites harbor a lysosome-like organelle, termed the "Vacuolar Compartment/Plant-Like Vacuole" (VAC/PLV), which plays an important role in maintaining the lytic cycle and virulence of T. gondii. The VAC supplies proteolytic enzymes that contribute to the maturation of invasion effectors and that digest autophagosomes and endocytosed host proteins. Previous work identified a T. gondii ortholog of the Plasmodium falciparum chloroquine resistance transporter (PfCRT) that localized to the VAC. Here, we show that TgCRT is a membrane transporter that is functionally similar to PfCRT. We also genetically ablate TgCRT and reveal that the TgCRT protein plays a key role in maintaining the integrity of the parasite’s endolysosomal system by controlling morphology of the VAC. When TgCRT is absent, the VAC dramatically increases in volume by ~15-fold and overlaps with adjacent endosome-like compartments. Presumably to reduce aberrant swelling, transcription and translation of endolysosomal proteases are decreased in ΔTgCRT parasites. Expression of subtilisin protease 1 is significantly reduced, which impedes trimming of microneme proteins, and significantly decreases parasite invasion. Chemical or genetic inhibition of proteolysis within the VAC reverses these effects, reducing VAC size and partially restoring integrity of the endolysosomal system, microneme protein trimming, and invasion. Taken together, these findings reveal for the first time a physiological role of TgCRT in substrate transport that impacts VAC volume and the integrity of the endolysosomal system in T. gondii.

Toxoplasma gondii is an obligate intracellular protozoan parasite that belongs to the phylum Apicomplexa and that infects virtually all warm-blooded organisms. Approximately one-third of the human population is infected with Toxoplasma. Toxoplasma invades host cells using processed invasion effectors. A lysosome-like organelle (VAC) is involved in refining these invasion effectors to reach their final forms. A T. gondii ortholog of the malarial chloroquine resistance transporter protein (TgCRT) was found to be localized to the VAC membrane. Although the mutated version of the malarial chloroquine resistance transporter (PfCRT) has been shown to confer resistance to chloroquine treatment, its physiologic function remains poorly understood. Comparison between the related PfCRT and TgCRT facilitates definition of the physiologic role of CRT proteins. Here, we report that TgCRT plays a key role in affecting the integrity and proteolytic activity of the VAC and adjacent organelles, the secretion of invasion effectors, and parasite invasion and virulence. To relieve osmotic stress caused by VAC swelling when TgCRT is deleted, parasites repress proteolysis within this organelle to decrease solute accumulation, which then has secondary effects on parasite invasion. Our findings highlight a common function for PfCRT and TgCRT in mediating small solute transport to affect apicomplexan parasite vacuolar size and function.

Selective microsurgical treatment of giant intracranial aneurysms

Giant intracranial aneurysms are defined as greater than 25mm in diameter. They share the same surgical challenges and strategies as so-called complex aneurysms, sometimes smaller in size but presenting with similar complex anatomy. The surgical difficulties arise from the size of the sack, the presence of intraluminal thrombus, the thickness of the arterial wall, and the complexity of arterial branching on the neck. Preoperative imaging gathers complementary information from magnetic resonance imaging, computed tomographic angiography, and rotational catheter-based angiography with three-dimensional reconstruction including balloon-test occlusion. The therapeutic decision-making needs a multidisciplinary approach including endovascular, neurosurgical and anesthesiological expertises. The microsurgical treatment needs a step-by-step preoperative planning with anticipation of possible pitfalls and alternative strategies. Classical principles of aneurysm surgery have to be tailored to face the difficulties arising from the size of the sack and from the arterial wall calcifications.

Quality of life one year post-Shiga toxin-producing Escherichia coli O104 infection--a prospective cohort study

BACKGROUND

In 2011, a major outbreak of hemolytic-uremic syndrome (HUS) and bloody diarrhea related to infections from Shiga toxin-producing Escherichia coli O104 (STEC) occurred in Germany. While previous research has focused on the medical components of this disease, we aimed to investigate the course of health-related quality of life (HrQoL) over 12 months including somatic and psychosocial risk factors. Furthermore, the influence of chronic fatigue (CF) on HrQoL was examined.

METHODS

A prospective cohort study with n = 389 patients completing self-report scales at baseline, after 6 months (participation rate: 79%) and after 12 months (participation rate: 77%). The courses of physical and mental HrQoL over the 12 month period were calculated by employing general linear mixed models.

KEY RESULTS

While the physical component score of HrQoL reached a score comparable to the general population, the mental component score remained below average 12 months after STEC infection. Female gender, prior psychiatric disorder, and prior traumatic events were risk factors for a worse HrQoL course after 12 months, while social support was identified to be protective. CF was associated with low HrQoL. In addition, the somatic symptom burden remained persistently high.

CONCLUSIONS & INFERENCES

Our results show high somatic and psychosocial burden in patients 12 months after STEC infection. We recommend considering the risk factors and protective factors of poor HrQoL early in the treatment of STEC or similar diseases. Patients who are suffering from persisting somatic symptoms, CF, and impaired HrQoL may require specific aftercare.

Evidence-based chronic heart failure management programs: reality or myth?

BACKGROUND

Chronic heart failure management programmes (CHF-MPs) have become part of standard care for patients with chronic heart failure (CHF).

OBJECTIVE

To investigate whether programmes had applied evidence-based expert clinical guidelines to optimise patient outcomes.

DESIGN

Prospective cross-sectional survey was used to conduct a national audit.

SETTING

Community setting of CHF-MPs for patients after discharge.

SAMPLE

All CHF-MPs operating during 2005-2006 (n = 55). 10-50 consecutive patients from 48 programmes were also recruited (n = 1157).

MAIN OUTCOME MEASURES

(1) Characteristics and interventions used within each CHF-MP and (2) characteristics of patients enrolled into these programmes.

RESULTS

Overall, there was a disproportionate distribution of CHF-MPs across Australia. Only 6.3% of hospitals nationally provided a CHF-MP. A total of 8000 post-discharge CHF patients (median, 126; IQR, 26-260) were managed via CHF-MPs representing only 20% of the potential national case load. Significantly, 16% of the case load comprised patients in functional New York Heart Association class I with no evidence of these patients having had previous echocardiography to confirm a diagnosis of CHF. Heterogeneity of CHF-MPs in applied models of care was evident with 70% of CHF-MPs offering a hybrid model (a combination of heart failure outpatient clinics and home visits), 20% conducting home visits and 16% an extended rehabilitation model of care. Less than half (44%) allowed heart failure nurses to titrate medications. The main medications that were titrated in these programmes were diuretics (n = 23, 96%), beta-blockers (n = 17, 71%), ACE inhibitors (n = 14, 58%) and spironolactone (n = 9, 38%).

CONCLUSION

CHF-MPs are being implemented rapidly throughout Australia. However, many of these programmes do not adhere to expert clinical guidelines for the management of patients with CHF. This poor translation of evidence into practice highlights the inconsistency and questions the quality of health-related outcomes for these patients.

Variable Very-High-Energy Gamma-Ray Emission from the Microquasar LS I +61 303

Microquasars are binary star systems with relativistic radio-emitting jets. They are potential sources of cosmic rays and can be used to elucidate the physics of relativistic jets. We report the detection of variable gamma-ray emission above 100 gigaelectron volts from the microquasar LS I 61 + 303. Six orbital cycles were recorded. Several detections occur at a similar orbital phase, which suggests that the emission is periodic. The strongest gamma-ray emission is not observed when the two stars are closest to one another, implying a strong orbital modulation of the emission or absorption processes.

Symptomatic vasospasm after subarachnoid haemorrhage: assessment of brain damage by diffusion and perfusion-weighted MRI and single-photon emission computed tomography

Our purpose was to assess the usefulness of diffusion- and perfusion-weighted MRI for the detection of ischaemic brain damage in patients with suspected vasospasm after subarachnoid haemorrhage (SAH). We studied 11 patients admitted with a ruptured aneurysm of the anterior circulation and suspected of intracranial vasospasm on clinical examination and transcranial Doppler sonography (TCD). All were investigated by technetium-hexamethyl-propylene amine oxime (Tc-HMPAO) single photon emission computed tomography (SPECT) and diffusion and perfusion-weighted MRI (DWI, PWI) within 2 weeks of their SAH. Trace images and TTP maps were interpreted by two examiners and compared with clinical and imaging follow-up. PWI revealed an area of slowed flow in seven patients, including four with major and three with minor hypoperfusion on SPECT. In two patients, PWI did not demonstrate any abnormality, while SPECT revealed major hypoperfusion in one and a minor deficit hypoperfusion in the other. Two patients with high signal on DWI had a permanent neurological deficit.

[Follow-up study of head-injured children]

The authors reviewed in a retrospective study 61 cases of severely head injury children who where admitted in the rehabilitation centre to evaluate the outcome 1 and 5 years after the brain injury. Neurologic and neuropsychologic status of children was assessed ad admission, 1 and 5 years later. Duration on intubation and age at time of head trauma were the worst functional prognosis.

The challenges of conducting clinical research: one research team's experiences

Conducting clinical research is an exciting and a rewarding endeavor. Each project is unique and, because of this uniqueness, research studies require considerable planning. Regardless of all the upfront planning, challenges will occur throughout the life of the study. Clinical research projects are rife with obstacles that range from the lack of administrative and physician support to subject attrition. Some of the challenges, such as subject dropout, are not unexpected, whereas other unanticipated issues can blindside a research team. This case study examines several such challenges experienced in one longitudinal study and presents the solutions engineered by the research team to keep the project on track.

Thoughts, feelings, and motivations of bystanders who attempt to resuscitate a stranger: a pilot study

BACKGROUND

Rates of bystander cardiopulmonary resuscitation remain low nationwide. Possibly, low rates can be explained by examining the reactions of laypersons who attempt to resuscitate a stranger.

OBJECTIVE

To examine the thoughts, feelings, and motivations of laypersons who have attempted to resuscitate a stranger.

METHOD

Survey methods were used to do a qualitative study of 12 laypersons who had provided bystander resuscitation. A 36-item questionnaire of predominately open-ended questions was used to elicit retrospective information about the laypersons' thoughts, feelings, and motivations during several stages of the resuscitation event. Data were analyzed by using content analysis.

RESULTS

Thoughts about the event included curiosity, questioning of personal capability, and recognition of differences between classroom training and real-life events. Feelings included hope, euphoria, pride, relief, satisfaction, hopelessness, doubt, agitation, anger, sadness, and fear. Primary motivations were duty and responsibility, guilt and social pressure, and altruism. All participants reported that they had excellent recall of the event.

CONCLUSION

These results provide insight into a population that acts on behalf of the medical community.

Thoughts, feelings, and motivations of bystanders who attempt to resuscitate a stranger: a pilot study

BACKGROUND: Rates of bystander cardiopulmonary resuscitation remain low nationwide. Possibly, low rates can be explained by examining the reactions of laypersons who attempt to resuscitate a stranger. OBJECTIVE: To examine the thoughts, feelings, and motivations of laypersons who have attempted to resuscitate a stranger. METHOD: Survey methods were used to do a qualitative study of 12 laypersons who had provided bystander resuscitation. A 36-item questionnaire of predominately open-ended questions was used to elicit retrospective information about the laypersons' thoughts, feelings, and motivations during several stages of the resuscitation event. Data were analyzed by using content analysis. RESULTS: Thoughts about the event included curiosity, questioning of personal capability, and recognition of differences between classroom training and real-life events. Feelings included hope, euphoria, pride, relief, satisfaction, hopelessness, doubt, agitation, anger, sadness, and fear. Primary motivations were duty and responsibility, guilt and social pressure, and altruism. All participants reported that they had excellent recall of the event. CONCLUSION: These results provide insight into a population that acts on behalf of the medical community.

Testing a predictive model of what makes a critical thinker

The goal of nursing education is to help individuals become self-determining, independent thinkers. Cognitive development may be the outcome that best characterizes such a thinker. The purpose of this study was to test a model of cognitive development in which four independent variables--knowledge base, critical thinking skills, critical thinking dispositions, and experience--were used to predict cognitive development. Data were analyzed from 232 practicing registered nurses. Three hierarchical levels of cognitive development were examined: dualism, relativism, and commitment. Critical thinking skill was a significant contributor only to the dualistic level of cognitive development. Critical thinking dispositions contributed to all three levels of cognitive development. Experience contributed only to the commitment level. The results of this study suggest that the development of a critical thinker may require time and experience. These findings can be used to examine current policy regarding the criteria used to evaluate nursing education.

Self-care abilities of patients with heart failure

BACKGROUND

Self-care is difficult for patients with heart failure (HF) because early symptoms are subtle and the treatment regimen is complex. The primary purpose of this study was to describe HF self-care abilities and the difficulties that patients have in achieving success in self-care. A secondary purpose was to compare self-care abilities in patients experienced with HF with those patients who are newly diagnosed.

METHODS

Descriptive, cross-sectional, comparative surveys were conducted to assess demographic and clinical factors that may interfere with self-care and lifestyle changes made to accommodate the diagnosis of HF. Symptoms the patients had and self-care responses to those symptoms were assessed by using the Self-Management of Heart Failure questionnaire.

RESULTS

The 139 patients were primarily elderly, male, retired, unmarried, and earning less than $20,000 annually. Hearing and eyesight were impaired and most patients were functionally compromised. Most of the group had multiple HF symptoms during the past year, yet their knowledge of the importance of signs and symptoms was poor and many misperceptions were evident. Recognition of changes in signs and symptoms was difficult for most patients, but easier for those more experienced with HF. Experienced patients were more likely to use appropriate self-care remedies than newly diagnosed patients. Few patients were comfortable evaluating the effectiveness of their self-care actions and most had low self-confidence in their ability to perform self-care.

CONCLUSIONS

With the low level of self-care ability and the number of difficulties these patients face, it is not surprising that rehospitalization rates remain high. Specific recommendations for the teaching and delivery of care are provided.

[Recombinant hirudin in neurosurgery]

We report the case of a 70-year-old woman with paraplegia resulting from spinal cord compression secondary to an epidural haematoma. Because of an arrhythmia, a mitral valve replacement and the high risk of venous thrombosis, an anticoagulant treatment was introduced postoperatively. The patient having previously developed an type II heparin-induced thrombocytopaenia, a treatment by lepirudine was established successfully.

Comparison of anxiety assessments between clinicians and patients with acute myocardial infarction in cardiac critical care units

BACKGROUND

Although anxiety is common after acute myocardial infarction and can adversely affect physical recovery, it is not part of the routine clinical assessment of patients with myocardial infarction. Furthermore, evidence suggests that patients and clinicians differ significantly in their assessments of patients' anxiety levels.

OBJECTIVES

To determine the extent to which clinicians assess anxiety in patients with acute myocardial infarction and to compare patients' self-ratings with their clinicians' assessments.

METHODS

In a prospective, descriptive study, 101 patients used the Spielberger State Anxiety Index to assess their anxiety during the first 48 hours after admission for acute myocardial infarction. Patients' scores were compared with nurses' and physicians' assessments of the patients' anxiety as reported in the medical record.

RESULTS

Only 45 patients (45%) had anxiety assessments noted in the record. Of those 45, 26 patients (58%) were described simply as anxious without any further description of the level of anxiety. Eleven (24%) of those 45 patients had behaviors of anxiety recorded, again without any indication of the level of anxiety. No association between patients' self-assessments and their clinicians' assessments was apparent (lambda = .03; P > .05).

CONCLUSIONS

Anxiety was not routinely assessed, despite nearly half the patients reporting moderate to extreme anxiety when asked. When clinicians assessed anxiety, their assessments did not match patients' self-ratings of anxiety. A simple, easy-to-use instrument for discriminating levels of anxiety is needed.

Comparison of anxiety assessments between clinicians and patients with acute myocardial infarction in cardiac critical care units

BACKGROUND: Although anxiety is common after acute myocardial infarction and can adversely affect physical recovery, it is not part of the routine clinical assessment of patients with myocardial infarction. Furthermore, evidence suggests that patients and clinicians differ significantly in their assessments of patients' anxiety levels. OBJECTIVES: To determine the extent to which clinicians assess anxiety in patients with acute myocardial infarction and to compare patients' self-ratings with their clinicians' assessments. METHODS: In a prospective, descriptive study, 101 patients used the Spielberger State Anxiety Index to assess their anxiety during the first 48 hours after admission for acute myocardial infarction. Patients' scores were compared with nurses' and physicians' assessments of the patients' anxiety as reported in the medical record. RESULTS: Only 45 patients (45%) had anxiety assessments noted in the record. Of those 45, 26 patients (58%) were described simply as anxious without any further description of the level of anxiety. Eleven (24%) of those 45 patients had behaviors of anxiety recorded, again without any indication of the level of anxiety. No association between patients' self-assessments and their clinicians' assessments was apparent (lambda = .03; P > .05). CONCLUSIONS: Anxiety was not routinely assessed, despite nearly half the patients reporting moderate to extreme anxiety when asked. When clinicians assessed anxiety, their assessments did not match patients' self-ratings of anxiety. A simple, easy-to-use instrument for discriminating levels of anxiety is needed.

Predictors of self-care in persons with heart failure

OBJECTIVE

The objective of this study was to test a model of individual patient characteristics, covering symptom severity, comorbidity, social support, education, age, socioeconomic status, and gender, derived from Connelly's Model of Self-Care in Chronic Illness as predictors of self-care in heart failure.

DESIGN

This was a nonexperimental correlational study.

SETTING

The study took place in 6 hospitals in southern California.

PATIENTS

The study included 209 patients diagnosed with heart failure by their physicians. The typical study participant was age 73 years, Class III, married, grade-school educated, and earning an income of less than $20,000 per year. The genders were almost equally represented.

OUTCOME MEASURE

Self-care was measured by the Evaluating the Change subscale of the Self-Management of Heart Failure Instrument.

RESULTS

The model of 7 variables, analyzed by using multiple regression analysis, explained 10.3% of the variance in self-care. Only 2 of the variables were significant predictors of self-care: education (P =.009) and symptom severity (P =.046); 89.7% of the variance remained unexplained.

CONCLUSIONS

Persons with higher education and those who are symptomatic may be more likely to engage in self-care than those who are poorly educated or asymptomatic. Further research is needed to confirm these Results and identify other predictors of self-care.

Which patients with heart failure respond best to multidisciplinary disease management?

BACKGROUND

Multidisciplinary disease management approaches have been shown to decrease resource use in selected samples of patients with heart failure. We remain uncertain regarding the effectiveness of this approach in a general heart failure population and who can be expected to benefit most. The purpose of this study was to test the effectiveness of a multidisciplinary disease management intervention in an unselected population of patients with heart failure and to determine if subgroups could be identified in which the intervention is most effective.

METHODS AND RESULTS

Two hundred forty patients with heart failure who were matched on preadmission functional status, comorbidity, and age participated in a quasi-experimental clinical trial. Half (n = 120) were given a multidisciplinary disease management intervention, whereas the other half (n = 120) received usual care. Data on acute care resource use were collected 3 and 6 months after enrollment. No intervention effect was seen in the primary analysis. When the data were analyzed by preadmission functional status (I to IV), acute care resource use was lower in the class II intervention patients. Class I intervention patients had a 288% increase in total costs and a 14-fold increase in heart failure costs. A model of predictor variables explained 17.2% of the variance in heart failure readmission at 3 months.

CONCLUSIONS

An intervention of this type and intensity is recommended primarily for functional class II heart failure patients. Increases in cost in class I patients may have resulted from improved access to care.

Patient teaching to promote behavioral change

Nurses are taught that patient teaching is an essential component of their professional role. This article describes the research on which effective patient teaching should be based.

Development and testing of a clinical tool measuring self-management of heart failure

BACKGROUND

Self-management is a primary goal of treatment for heart failure. Yet no measure of self-management in this patient group currently exists.

OBJECTIVES

To develop a clinically useful measure of the abilities of patients with heart failure to manage their disease. Self-management in this context was defined as a cognitive decision-making process undertaken in response to signs and symptoms of heart failure. A panel of experts agreed that the process involved 4 distinct stages: recognizing a change, evaluating the change, implementing a treatment strategy, and evaluating the treatment. The tool was developed to reflect this process.

METHODS

Face validity of the process model was assessed in a sample of 25 patients with heart failure and used to develop a 65-item tool with 6 subscales. The subscales measure the 4 stages as well as the patients' ease in evaluating the signs and symptoms and their self-efficacy. The tool was pilot tested with 2 samples of patients with heart failure (N = 17; N = 129). Psychometrics of the final tool were then tested in a sample of 127 patients with heart failure.

RESULTS

Face and content validity of the tool were demonstrated adequately through this study. Internal consistency scores of the 6 subscales of the Self-Management of Heart Failure instrument ranged from 0.79 (ease of evaluating treatment) to 0.92 (evaluating the change). Reliability could not be calculated for 1 subscale (evaluating the treatment) because of missing data that resulted from patients skipping sections because they had not experienced a symptom.

CONCLUSION

Clinicians interested in evaluating the self-management abilities of their patients with heart failure are encouraged to use this tool and to contribute to additional testing.

Implementation of a multidisciplinary disease management program for heart failure patients

Institutions across the country are considering the feasibility of a disease management program for heart failure (HF) patients. Published reports suggest that such programs can save money and improve outcomes. However, the design of a disease management program can be challenging. This paper describes the structure and function of a successful disease management program for heart failure patients. The program is supported by a multidisciplinary team of nurses, pharmacists, dietitians, social workers, and physicians who approach the problem from a self care perspective. Program components include standardized educational materials, reinforcement of educational contacts, monthly support groups, and a quarterly newsletter. Existing staff built the program with few additional resources and staff. The program, which costs only approximately $330/patient for a 6 month intervention, has decreased hospital readmissions (29%) and days in the hospital (43%) significantly. (c)1999 by CHF, Inc.