Age-related effects on symptom status and health-related quality of life in persons with HIV/AIDS.

Health-related quality of life (HRQOL) is linked to symptom status and may be related to age in HIV-positive persons. Data were collected in a multisite HIV-positive sample (N = 1,217) using an HIV-specific HRQOL and three symptom status instruments according to the Wilson and Cleary HRQOL model. Multiple stepwise linear regression analysis found that younger age predicted higher sexual function (ΔR(2) = .12, p < .01) and older age predicted greater provider trust (ΔR(2) = .04, p < .01). No significant differences were found in symptom status or the other seven HRQOL dimensions. Although older HIV-positive persons reported more comorbidities, they did not report more symptoms.

Does "asymptomatic" mean without symptoms for those living with HIV infection?

Throughout the history of the HIV epidemic, HIV-positive patients with relatively high CD4 counts and no clinical features of opportunistic infections have been classified as "asymptomatic" by definition and treatment guidelines. This classification, however, does not take into consideration the array of symptoms that an HIV-positive person can experience long before progressing to AIDS. This short report describes two international multi-site studies conducted in 2003-2005 and 2005-2007. The results from the studies show that HIV-positive people may experience symptoms throughout the trajectory of their disease, regardless of CD4 count or classification. Providers should discuss symptoms and symptom management with their clients at all stages of the disease.

Marijuana effectiveness as an HIV self-care strategy.

Persons living with HIV/AIDS use self-care for symptom management. This study assesses the use of marijuana as a symptom management approach for six common symptoms for persons living with HIV/AIDS--anxiety, depression, fatigue, diarrhea, nausea, and peripheral neuropathy. This sub-analysis of the efficacy of a symptom management manual encompasses the experiences of participants from sites in the U.S., Africa, and Puerto Rico. Baseline data are analyzed to examine differences in the use and efficacy of marijuana as compared with prescribed and over-the-counter medications as well as the impact on adherence and quality of life.

Fatigue in HIV/AIDS patients with comorbidities.

Fatigue has been identified as a key complaint among patients with HIV/AIDS. Although having more than one disease is expected to increase symptom severity, this relationship has not been explored extensively. We investigated differences in fatigue severity together with the impact of demographic factors and the number of comorbidities and symptoms among patients with and those without comorbidities at 18 international clinical and community sites. Specific comorbidities and the number of symptoms associated with increased fatigue severity. Only by distinguishing fatigue as to its causes and patterns will health care providers be able to intervene specifically and thus more effectively.

Effects of a home-based intervention program on anxiety and depression 6 months after coronary artery bypass grafting: a randomized controlled trial.

OBJECTIVE: The objective of this study was to evaluate the effects of a home-based intervention program (HBIP) on anxiety and depression 6 months after coronary artery bypass grafting (CABG). METHODS: In a prospective randomized controlled trial, 203 elective CABG patients were included. An HBIP structured for respondents in the intervention group was performed 2 and 4 weeks after surgery. Anxiety and depression symptoms were measured by the Hospital Anxiety and Depression Scale (HADS) in both patient groups before surgery, 6 weeks after surgery, and 6 months after surgery. RESULTS: A total of 185 patients completed the study: 93 patients in the intervention group and 92 patients in the control group. On 6-week and 6-month follow-ups, significant improvements in anxiety and depression symptoms were found in both groups. These improvements did not differ significantly between the groups. However, in a predefined subgroup of patients with anxiety and/or depression symptoms at baseline (n=65), improvement was significantly larger in the intervention group (n=29) than in the control group (n=36) after 6 months (P<.05). CONCLUSIONS: Patients experiencing high levels of psychological distress before CABG surgery benefited from a structured informational and psychological HBIP. Implementation of psychological screens of patients scheduled for CABG might serve to identify patients experiencing anxiety and/or depression. These patients could then be targeted to receive individualized HBIP.

Implementing communication systems in the community health services. The health care workers experiences.

Reengineering of the workplace through Information Technology is an important strategic issue for today's community health care. The computer-based patient record (CPR) is one technology that has the potential to profoundly modify the work routines of the care unit. This study investigates a CPR project, Gerica aimed at allowing the health care workers in the community health care to work in a completely electronic environment. The focus of our analysis was the use of Gerica, and the health care workers interpretations of it. The rationale behind the introduction of this technology was based on its alleged capability to both enhance quality of care and control costs. This is done by better managing the flow of information within the organization. Theory of structuration is used as the conceptual vehicle to aid in widening the search to the socially constructured nature of these meaning: how people constructed their conceptions in their work setting. The present study analyzed the implementation of CPR conducted in the community health services in Trondheim, Norway. Interviews with Gerica users demonstrate that individual interpretations vary considerably, also between users of the same application. User-resistance was not the problem. This project was a good opportunity to understand better the intricate complexity of introducing technology in professional work where the usefulness of information is short lived and where it is difficult to predetermine the relevancy of information. Profound misconceptions in achieving a tighter fit (synchronization) between care processes and information processes were the main problems.

Self-care management of anxiety and fear in HIV disease.

The purpose of this study is to describe the frequency and correlates of self-reported anxiety and fear and the self-care behaviors used to manage these symptoms. Data were collected in a convenience sample (N = 422) of HIV-positive subjects. Demographic and disease-related variables were compared for those who did and did not report anxiety and fear. Anxiety and fear were the most frequently reported symptoms (17.3%, n = 73). There were significant differences on gender, level of education, and the use of antiretroviral medications. Self-care behaviors (n = 212) for anxiety and fear were grouped into seven categories: using activities for distraction = 25%, talking to others = 21%, using alternative/complementary therapies = 18%, taking prescribed medications = 10%, using self-talk = 9%, using substances = 9%, and using avoidance behaviors = 7%. Anxiety and fear are commonly experienced by people with HIV/AIDS. Self-care strategies are imperative in the management of these clinical manifestations.

Complementary therapy use in persons with HIV/AIDS.

The purpose of this study was to describe the frequency and correlates of complementary and alternative medicine (CAM) therapies used by people with HIV/AIDS to manage illness and treatment-related symptoms. Data were collected from a convenience sample (N = 422) of people living with HIV disease. Demographic variables (e.g., education, age, and gender) were compared for those who reported using at least one CAM therapy. There were significant differences for gender (chi2 = 4.003, df = 1, p = .045) and for ethnicity (chi2 = 6.042, df = 2, p = .049). Females and African Americans used CAM more frequently. More than one third of the participants used CAM, and there were a total of 246 critical incidents of nontraditional treatment use. It is possible that these nonallopathic interventions may positively affect health-related quality of life in persons with HIV by ameliorating or reducing the side effects associated with the disease and its treatments.

Patients' experiences with symptoms and needs in the early rehabilitation phase after coronary artery bypass grafting.

BACKGROUND: The first month after discharge for Coronary artery bypass graft (CABG) is particularly challenging for the patients. A larger interview study is warranted to elicit CABG patients' detailed experiences, and give direction for future clinical practice. AIM: To explore the CABG patients' symptoms and needs in the early rehabilitation phase. METHODS: A qualitative, mixed method design integrating qualitative and quantitative approaches was used. Ninety-three CABG patients aged 39-77, participated in interviews at home after 2 and 4 weeks. The semi-structured interview guide covered: experiences of relief of angina pectoris after surgery, experiences with prescribed discharge medications, psychological experiences: anxiety, depression, sexuality, health professional contact persons, and patient defined experiences. RESULTS: Two weeks after CABG the patients symptoms and needs were characterised by a substantial amount of uncertainty and worries related to what to expect and what was normal for postoperative pain, assessment and sensation of surgical site, different experiences with physical activity/exercise, uncertainty about medications, difficulties with sleep pattern, irritability, postoperative complications,uncertainty about return to work, and insufficient information at discharge. Four weeks after surgery the patients' symptom level was decreased, and they experienced life beginning to return back to normal. Patency with grafts after CABG, decision to drive a car, impotence (erectile dysfunction), and a missing link to the hospital remained challenges. CONCLUSION: CABG patients' experiences indicate a need to extend the hospital's discharge care to the first month after surgery for specific themes to promote rehabilitation outcomes.

Effects of early mother-infant intervention on outcomes in mothers and moderately and late preterm infants at age 1 year: a randomized controlled trial.

OBJECTIVE: There is a dearth of knowledge about the effects of early interaction-based interventions on parenting and infant communication skills in moderately and late preterm infants. AIMS: Assess in a RCT the effects of the Mother-Infant Transaction program (MITP) on maternal depression and stress, breastfeeding and mothers' perception of infant temperament; and MITP's impact on preterm infant communication skills at 12 months. METHODS: Mothers/preterm infants (30-36 weeks) were randomly assigned to MITP (intervention group) or standard care (control group). Mean gestational age in the intervention group was 33.3±1.5 (n=56) and in the control group (n=50) 33.0±1.6. Outcomes were assessed by CES-D, Parenting Stress Index; WHO breast-feeding categories, Infant Behavior Questionnaire and The Pictorial Infant Communication Scales. RESULTS: Intervention mothers reported significantly less postpartum depression one month after discharge (p=.04) and more breastfeeding at 9 months (p=.02). No significant group differences in favour of the intervention group were found on total parenting stress at 6 (p=.08) and 12 months (p=.46) or on perceived infant communication skills at 12 months (p=.86). The intervention mothers reported significantly less infant smile and laughter at 6 (p=.02) and 12 (p=.006) months and less motor activity at 12 months (p=.04). CONCLUSIONS: The results suggest that MITP reduced postpartum depression and extended the period of breastfeeding, but did not support any positive effects of the intervention on self-reported maternal stress and perceived infant communication.

Effect of early intervention on social interaction between mothers and preterm infants at 12 months of age: a randomized controlled trial.

In a randomized controlled trial at 12-months of age, the effect of the Mother Infant Transaction Program was tested on social interaction between mothers and moderately and late preterm infants with gestational age≥30.0 and <36 weeks. Ninety-three play sessions were videotaped and coded, 46 mothers-infants in the intervention group and 47 mothers-infants in the control group. The intervention mothers scored higher on maternal sensitivity/responsiveness (p=.05). Being a first-time mother was a moderator that enhanced the effects of the intervention. First-time mothers were more sensitive/responsive to their infant's cues (p=.01), and the dyads evinced higher level of synchrony (p=.02) as compared with experienced mothers. More positive mood was observed among their infants (p=.04). The findings suggest that the intervention contributes to better mother-infant interactions in moderately and late preterm infants of first-time mothers.

Predictors for physical and mental health 6 months after coronary artery bypass grafting: a cohort study.

BACKGROUND: Knowledge of predictors for health related quality of life (HRQoL) after coronary artery bypass grafting is limited. AIM: To identify preoperative and postoperative factors related to physical and mental health status 6 months after surgery. METHODS: 185 patients completed the Short Form-36 survey preoperatively and 6 months after surgery. Multiple linear regression was used to identify significant independent predictors for both physical and mental health component summary scores 6 months after surgery. RESULTS: Significant predictors for physical health were preoperative physical status (PCS), marital status, hospitalised with acute myocardial infarction and serum creatine kinase-MB (CK-MB) 1st postoperative day. Preoperative mental status (MCS and anxiety and/or depression symptoms) and postoperative pleural drainage were significant predictors of mental health 6 months after surgery. CONCLUSION: This study identified predictors that have an impact on CABG patients' HRQoL 6 months after surgery. These predictors could cause elevated risk for morbidity and mortality. Clinicians have the opportunity to improve the HRQoL of CABG patients by targeting counselling and/or interventions focusing on the identified predictors.

Health-related quality of life after coronary artery bypass grafting. The impact of a randomised controlled home-based intervention program.

OBJECTIVE: The aim of this study was to evaluate the impact of a home based intervention program (HBIP) on health related quality of life (HRQoL) after coronary artery bypass grafting (CABG). To strengthen the clinical interpretation, HRQoL data were compared to the general population. METHODS: In a randomised controlled trial (RCT), a total of 185 CABG patients (93 vs 92) completed the study. The intervention group received a HBIP 2 and 4 weeks after surgery. HRQoL was measured by the Seattle Angina Questionnaire (SAQ) and the Short Form 36 (SF-36) in both patient groups before surgery, at 6 weeks and 6 months after surgery. RESULTS: Significant improvements were found in both groups for the majority of subscales of HRQoL at 6-week and 6-month follow-up. However, these improvements did not differ significantly between the groups. Compared to the general population, significant differences (P < 0.05) were found for the SF-36 subscales: role physical, role emotional and bodily pain. CONCLUSIONS: HRQoL after CABG improved markedly over time, but no significant or clinically important differences were found when compared with controls. Thus, work to further develop and test the effect of a HBIP on HRQoL in patients undergoing rehabilitation following CABG is warranted.

Prayer as a complementary health strategy for managing HIV-related symptoms among ethnically diverse patients.

Data were analyzed from an ethnically diverse convenience sample comprising 1071 adults participating in a multisite study. Older African Americans, Hispanics, and females were more likely to use prayer as a complementary health strategy for HIV-related anxiety, depression, fatigue, and nausea. Implications for future studies are discussed.

Self-care strategies for depressive symptoms in people with HIV disease.

AIM: This paper reports a study with people living with HIV to examine the experience of depressive symptoms, self-care symptom management strategies, symptom outcomes in response to those strategies, and sources from which the strategies were learned. BACKGROUND: Depressive symptoms are common, under-diagnosed and under-treated in people living with HIV. These symptoms have been associated with lower medication adherence, risky behaviours and poorer health outcomes. METHODS: The study was based on the model of symptom management developed by the University of California San Francisco School of Nursing Symptom Management Faculty. Thirty-four HIV+ men and women from a larger study of symptom self-care strategies (n = 422) reported experiencing depressive symptoms. Data were collected from this subset on the Web, by mail and in-person using the critical incident technique. RESULTS: Depressive symptoms were described using 80 words and phrases clustered into eight categories: futility, sadness, loneliness/isolation, fatigue, fear/worry, lack of motivation, suicidal thoughts and other. A total of 111 self-care strategies were coded into six categories: practising complementary/alternative therapies, talking to others, using distraction techniques, using antidepressants, engaging in physical activity, and using denial/avoidant coping. Sources of information for strategies used were trial and error (31%), healthcare providers (28%), family and friends (20%), classes/reading (8%), clergy (8%), support groups (4%) and other (3%). Overall, 92% of the self-care strategies used were reported as helpful, 4% were sometimes helpful and 4% were not helpful. CONCLUSIONS: People living with HIV use numerous effective self-care strategies to manage depressive symptoms. Further study is needed to validate the use of these strategies across populations, to standardize dose, duration and frequency, and to measure their effectiveness.

High technology and nursing: ethical dilemmas nurses and physicians face on high-technology units in Norway.

Results from two studies of ethical dilemmas nurses and doctors experience on two high-technology units are compared and discussed. The qualitative comparative methodology of grounded theory was used to generate theoretical frameworks grounded in the empirical realities of the units. The ethical dilemmas they faced were related to: treating the one vs. the common good; end of life questions; and resource allocations with inadequate staffing. Similarities were related to intensity and urgency of nursing care and patient treatment, clear nursing ideologies based on treating humans within a framework of hope, embracing technology and scarce resources. Differences between the two study units were patient diagnosis, hierarchical structure on one unit while one had a vertical structure and decision-making processes, and finally how nursing knowledge and autonomy were used. The two studies demonstrated that clinical, ethical and administrative interactions and decisions are highly compounded, stressful and intertwined.

Solving ethically difficult care situations in nursing homes.

Patients in nursing homes sometimes give accounts of episodes in which they feel their autonomy and/or self-respect are violated as a result of the care they receive from nursing staff. In these ethically difficult care situations nurses use strategies such as negotiation, explanation and, in some cases, restraint. This study investigates how nurses apply these strategies to resolve ethical dilemmas in such a way that patients experience respect rather than violation. Critical issues that will be discussed include the definition of ethically difficult care situations in nursing homes and the identification of strategies for resolving such situations. Examples of the use of three strategies are presented. The use of negotiation, restraint and explanation are discussed in order to ensure respect for patients' autonomy and thus to optimize health care outcomes.

Ethics in nursing homes: experience and casuistry.

The purpose of the study was to further explore the methods that nurses use to solve ethically difficult care situations in nursing homes while the aim of this article was to present a model for nursing practice in such situations. Fourteen nurses from three nursing homes in Norway were observed and interviewed in order to discern the strategies they used to deal with ethically difficult care situations. To analyse this information, we used a constant comparative method until a grounded theory emerged. The nurses' principal strategy was to apply earlier experiences while striving for the best outcome for the elderly patients. This article discusses this strategy and compares it to a theory of ethics called casuistry. We suggest that by using the method of experiences combined with casuistry in a more systematic way, nurses can develop acceptable solutions for difficult care situations in nursing homes.

Ethical issues after the disclosure of a terminal illness: Danish and Norwegian hospice nurses' reflections.

This research explored the ethical issues that nurses reported in the process of elaboration and further disclosure after an initial diagnosis of a terminal illness had been given. One hundred and six hospice nurses in Norway and Denmark completed a questionnaire containing 45 items of forced-choice and open-ended questions. This questionnaire was tested and used in three countries prior to this study; for this research it was tested on Danish and Norwegian nurses. All respondents supported the ethics of ongoing disclosure to terminally ill patients based on ethical principles embedded in their country's Patients' Rights Acts. Truth, as an intrinsic value, proved foundational to patient autonomy, the most frequent ethical principle these nurses reported to justify their ethical position on information disclosure to terminally ill people. Telling the truth about a diagnosis was not the end of ethics in hospice care, but rather the beginning because what occurs ethically in dealing with prognosis issues became central to these hospice nurses, the patients and their families. Coupled with truth-telling, compassionate interaction and care become extensions of patients' rights.

Self-care for fatigue in patients With HIV.

PURPOSE/OBJECTIVES: To identify when fatigue is reported as a problem by people who are HIV positive, what the perception of fatigue is, and which self-care behaviors are used and with what efficacy. DESIGN: Multisite descriptive study. SETTING: University-based AIDS clinics, community-based organizations, and homecare agencies located in cities across the United States, in Norway, and through a university Web site. SAMPLE: Convenience sample of 422 self-identified people who are HIV positive. MAIN RESEARCH VARIABLES: Symptom description, symptom relief, symptom help, and self-care strategies. FINDINGS: The sixth most reported symptom in this study, fatigue, was treated with a variety of self-designed strategies. In only three instances was consultation with a healthcare provider (i.e., physician) or an injection (medication not defined) mentioned. The most frequently used interventions were supplements, vitamins, and nutrition followed by sleep and rest; exercise; adjusting activities, approaches, and thoughts; distraction; and complementary and alternative therapies. In addition to self-designed strategies, the media and friends and family were sources of information. CONCLUSIONS: Fatigue was reported less frequently in this study than in other HIV-, AIDS-, or cancer-related studies. This may be an artifact of the study design. The use of informal networks for assistance, let alone the prevalence of unrelieved fatigue, indicates the need for more attention to this problem among people with AIDS. IMPLICATIONS FOR NURSING: Careful assessment of the pattern of fatigue and its onset, duration, intervention, and resolution is required if the varied types of fatigue are to be identified and treated successfully.