[Caregiver Need Assessment: a questionnaire for caregiver demand]. / Caregiver Need Assessment: uno strumento di analisi dei bisogni del caregiver.

UNLABELLED: Many studies have focused on the importance of the informal care provided by caregivers and on its impact in terms of worsening quality of life and increased burden. The aim of the present study is to analyze the psychometric validity and reliability of the Caregiver Needs Assessment (CNA) questionnaire, which has been built to investigate the needs (related to assistance) perceived by caregivers of severely impaired patients, particularly in the first stages of their illness. METHODS: The CNA was administered to 226 family caregivers (24.3% males) of 197 patients (50.8% males) hospitalized for neuromotor rehabilitation after a stroke, head injury, Lateral Amyotrophic Sclerosis, Parkinson or other severely impairing diseases. RESULTS: The instrument was tested on a large sample (KMO = 0.83) of heterogeneous caregivers. Explorative and confirmatory factor analysis, performed on a two subgroup random subdivision of the sample, showed the presence of two factors with good internal consistency: the factor "needs of emotional and social support" (alpha = 0.765) and the factor "needs of information and communication" (alpha = 0.742). The structural equation modeling confirms the goodness of fit of the 2-factor structure (RMSEA = 0.073; SRMR = 0.1; CFI = 0.96). We observed a positive correlation (p < 0.01) between the factor "needs of emotional and social support" of the CNA and other questionnaires aimed at assessing psychological wellbeing, and between the factor "needs of information and communication" and the factor "needs for knowledge about the disease" of the Family Strain Questionnaire, showing good convergent validity. We also observed high Pearson correlation coefficients (0.942 and 0.965) between test-retest measurements of both factors in the CNA. CONCLUSION: The statistical analysis confirms the good psychometric properties of the CNA questionnaire. For its brevity and ease in compilation the CNA is promising practical tool aimed at assessing caregivers' needs in order to personalize a programme of psychological support, to measure it's outcome and to provide comparison of the different needs in different diseases.

[Contribution to the Italian validation of the IPQ-R]. / Contributo alla validazione italiana dell'IPQ-R.

Knowledge of patients' opinions and beliefs about their illness is fundamental in interdisciplinary health care interventions. The IPQ and its revised version (IPQ-R) are questionnaires designed to assess components of the mental representation of illness described in Leventhal's self-regulation model. To validate the IPQ-R in the Italian population, verifying its psychometric properties and focusing on Part II of the instrument (opinions about disease), we enrolled 277 inpatients (216 males and 61 females) affected by myocardial infarction (n=70), coronary artery by-pass graft surgery (n=52), chronic heart failure (n=47), valve replacement (n=20), obstructive sleep apnoea syndrome associated to obesity (n=53) and respiratory failure (n=35). All patients completed the Italian version of the IPQ-R obtained by means of 3 translations and a back version. IPQ-R scores were compared to patients' scores on the SF-36 and AD schedule (on anxiety and depression). Structural validity and reliability (both internal and test-retest) of the Italian IPQ-R were assessed. The validity of Part II of the IPQ-R was confirmed. As in the original version, 7 factors were extracted. ANOVA revealed statistically significant differences between the different diseases. Correlations between IPQ-R and, respectively, the SF-36 and AD schedule were statistically significant and coherent with the constructs analyzed. Finally statistically significant correlations emerged between the IPQ-R factors. The test-retest reliability and internal consistency of the questionnaire were confirmed. The psychometric properties of the Italian version of the IPQ-R were demonstrated to be robust. Hence, the Italian version of the IPQ-R, which resulted homogeneous with the original version, could be useful in assessing the cognitive factors involved in patients' adjustment to various chronic illnesses.

Adherence to treatment: assessment of an unmet need in asthma.

BACKGROUND: In asthma, as in other chronic conditions, poor adherence to treatment and to medical advice is common and contributes to substantial worsening of the disease and increased health care costs. OBJECTIVE: The aim of the present study was to evaluate patients' self-reported adherence to asthma medication regimens and to identify possible correlations between treatment adherence and depression, anxiety, and coping strategies. METHODS: Sixty-three asthmatic outpatients (27 men and 36 women; mean age +/- SD, 38.5 +/- 14.1) were consecutively enrolled during their routine control visit. Patients were asked to complete 3 different questionnaires: the Adherence Schedule in Asthma, the Hospital Anxiety and Depression Scale, and the Coping Orientations to Problem Experienced questionnaires. RESULTS: Depression was detected in 32.3% of patients and anxiety in 34.9%. A negative correlation was found between older age and perception of family support (rho = -0.33). The presence of anxiety displayed a positive correlation with difficulty in accepting the illness (rho = 0.33) and a negative correlation with acceptance of illness limitations (p = -0.30); it was also positively correlated with fear of the side effects of medication (rho = 0.37). The presence of depression was negatively correlated with acceptance of illness limitations (rho = -0.32), knowledge of the illness (p = -0.29), and with ability to identify worsening signs (rho = -0.31). CONCLUSION: This study shows how different factors may modulate adherence to asthma treatment. The opportunity to identify reasons for nonadherence through a simple assessment will allow a tailored intervention to be planned for each patient.

Impact of children's respiratory allergies on caregivers.

BACKGROUND: Despite the great attention that has been paid to HRQoL in children with respiratory allergy, few studies have addressed this aspect in relation to caregivers. The aim of our study was to evaluate the impact of childhood respiratory allergies on caregivers by means of a new method. METHODS: 119 parents of children suffering from allergies (75 suffering from asthma and 44 suffering from rhinitis) were recruited from three Italian Allergy Units. Parents were asked to complete the Disease Impact On Caregiver (DIOC), a new non disease specific questionnaire, validated on the Italian population. The questionnaire consists of 31 items grouped in four factors (Performance, Personal gratification, Psychophysical endurance, Socio-emotional domain) and covers the life aspects that could be affected by the assistance duties towards an ill family member. RESULTS: Child's asthma resulted to have a worse impact on many aspects of a parents' life than rhinitis. Differences resulted to be statistically significant in 19 aspects out of the 31 assessed. The worse impact of asthma versus rhinitis was confirmed in the following domains: Performance (24.0 +/- 18.2 vs 11.5 +/- 17.8), Personal gratification (26.3 +/- 20.5 vs 12.1 +/- 16.5) and Psychophysical endurance (35.0 +/- 24.8 vs 18.8 +/- 21.7). In the Socio-emotional domain no difference emerged. CONCLUSIONS: Compared to parents of rhinitics, parents of asthmatic children appear to be more compromised in their resistance to stress, mood, emotional stability, amount of spare time and leisure activities. Our results suggest the need of giving the due attention to these problems both in clinical practice and in research, in order to avoid possible interferences of the caregiver's distress in the optimization of treatment outcome.

Relationship between cognitive impairment and clinical status in chronic heart failure patients.

BACKGROUND: In spite of its clinical importance, cognitive functioning is not always taken into account in studies on patients with chronic heart failure. The aim of the present study is to analyse the relationship between cognitive impairment and cardiovascular variables in a sample of patients with chronic heart failure for assessment or candidated for heart transplant. METHODS: Sixty-four male patients with chronic heart failure in NYHA class I-III, in a stable clinical condition, underwent cardiological evaluation and neuropsychological assessment by means of a wide battery of tests: Spinnler and Tognoni's tests and WAIS scale. RESULTS: Compared to the normative group, only 9% of patients did not have impairment in any cognitive function. 26% of patients had impairment of one cognitive function, and 30% of four or more cognitive functions. The cognitive functions that were most often impaired were short-term verbal memory, short-term visual spatial memory, differed verbal memory and verbal learning and visual spatial logical ability. On the whole, no statistical significant relationship was found between cognitive scores and the considered cardiovascular variables. CONCLUSIONS: Our data support the need to take into account the risk of cognitive impairment in CHF patients, regardless of age, disease severity or functional status. The high prevalence of short-term verbal memory impairment has important implications in clinical practice, since CHF patients should be actively involved in the medical management of their disease. Memory deficits could compromise patient's adherence to treatment as well as doctor-patient interactions. The practical consequences of these difficulties require some changes in doctors' behaviour and suggest the need for specific medical staff member training.

The effects of a cognitive behavioural intervention in asthmatic patients.

There is evidence that educational programmes may improve patient's compliance with asthma treatment and control symptoms. Whilst medical parameters have been thoroughly studied, few data are available concerning psychological intervention. The aim of our open pilot study was to verify whether any difference in perceived illness and response style to asthma existed in the patients enrolled in an Asthma Rehabilitation Group (ARG) and in a Control Group (CG). Forty consecutive asthmatics were randomly enrolled, all of whom were diagnosed, treated and followed-up according to the International Guidelines. Both groups underwent a psychological assessment at baseline and after one year. A battery of questionnaires was used to obtain data relating to baseline characteristics (anxiety, depression, psychophysiological disorders), emotional reactions to asthma attacks (panic-fear, etc,) and cognitive variables (external control, psychological stigma, internal beliefs, external chance, etc.) involved in the perceived illness. In addition, the Asthma Rehabilitation Group patients underwent an educational programme and a cognitive-behavioural intervention. In both groups, a reduction of anxiety and depression scores was observed, as well as a significant improvement of the medical parameters evaluated. Only the Asthma Rehabilitation Group reported lower scores on the Psychophysiological Questionnaire and on the External Control Subscale after 1 year. The Control Group reported higher score on the External Chance Scale. The data of our study seem to confirm the effectiveness of psychological intervention on the cognitive skills involved in the perception and management of asthma. Larger scale studies on this topic are suggested.

[Rehabilitation day-hospital of the heart failure unit: structure and functions]. / Day-hospital riabilitativo nell'Unità per lo Scompenso Cardiaco: strutturazione e funzione.

Chronic heart failure has emerged as an important public health problem. The consequent increase in the sanitary services has induced an increased consumption of financial resources and conditioned the need to investigate new sanitary models that guarantee, by integrating the inpatient and outpatient health care delivery, the continuity of health assistance. Cardiac rehabilitation in the context of a day-hospital Heart Failure Unit allows for the organization of a rehabilitation program including various health approaches aimed at guaranteeing a multidisciplinary program and the relief continuity. This article describes the experience developed in the Heart Failure Unit of Montescano.

[Neuropsychological course of patients with craniocerebral injuries in rehabilitation]. / Percorso neuropsicologico del paziente con trauma cranio-encefalico in riabilitazione.

The aim of the present paper is to describe a neuropsychological assessment and intervention model in Traumatic Brain Injury (TBI) patients. The theoretical and methodological frameworks are described and the following diagnostic and rehabilitative flowchart is fully explained: 1. first visit with patient and his relatives; 2. clinical and testing assessment; 3. diagnostic balance and its communication to patient and his relatives; 4. neuropsychological rehabilitation and psychological counseling. Whenever necessary, patient's relatives are involved. Furthermore, TBI patients' health related quality of life is outlined as an important clinical and scientific issue deserving more attention, in spite of the objective methodological difficulties which its evaluation implies.

International Classification of Functioning, Disability and Health (ICF) core sets for osteoarthritis. A useful tool in the follow-up of patients after joint arthroplasty.

AIM: The first aim of this study was to verify the applicability of the International Classification of Functioning Disability and Health (ICF) core set for osteoarthritis (OA) as an outcome tool after the total hip arthroplasty (THA) and total knee arthroplasty (TKA), in order to follow the changes of the profile of functioning after joint arthroplasty. METHODS: Seventy-two OA inpatients were consecutively enrolled during the first three days of rehabilitation after THA (34.7%) or TKA (65.3%) and were evaluated of the ICF Core Set for OA. Patients were interviewed at the beginning of the study one month prior to surgery, at the end of the rehabilitation treatment lasting on average three weeks and three and six months after their discharge. RESULTS: The ICF core set data comparison showed many significant differences among the four evaluations with a significant improvement in many categories assessed. At the six months interview activity limitations and participation restrictions were still reported, even if with a lower percentage as compared to the first evaluation. CONCLUSION: The ICF core set for OA resulted an interesting outcome tool after the THA or TKA, even if more research is needed, mainly on data reliability and category definition. Even tough problems in the administration were encountered, the ICF core set allowed to focus on issues and aspects of patient's every day life usually not taken into account or not codified in the usual care assessment.

Randomized double-blind controlled study with sublingual carbamylated allergoid immunotherapy in mild rhinitis due to mites.

BACKGROUND: The clinical efficacy of sublingual immunotherapy (SLIT) in mite allergy and in mild disease is still a matter of debate, thus we performed a long-term clinical trial. METHODS: The study was randomized, double-blind and placebo-controlled. After a 1-year assessment, 68 patients with mild rhinitis with/without asthma due to mites were randomized to drugs + placebo or drugs + SLIT for 2 years. Sublingual immunotherapy was given as soluble tablets of monomeric carbamylated allergoid. Clinical scores for asthma and rhinitis (0, absent to 3, severe) and drug consumption were assessed by diary card in the period November-February. Quality of life was assessed before and after each observation period and pharmaco-economy data were evaluated as well. RESULTS: Fifty-six patients completed the study. The rate of dropouts was similar in the two groups. No relevant side effect was reported. There was a significant reduction of total clinical scores (P < 0.05) in the active group vs placebo at the first year, but not at the second whereas nasal obstruction significantly improved in both years (P < 0.05). The reduction of drug intake score was significant only at the first year. No change was observed concerning most of the Short Form-36 items, because at baseline all patients displayed a normal profile. A significant change in SLIT group was seen for the item 'change in health status'. The need for extra visits was significantly lower in the active group (25%vs 43%). CONCLUSIONS: Sublingual immunotherapy was clinically effective and safe in mite-induced mild disease.

Multiple learning tasks in patients with ideomotor apraxia.

The Authors studied a group of patients with ideomotor apraxia (LBD+) to verify if these patients had some difficulties in multiple learning tasks in respect to non-apraxic patients and normal control subjects. All five groups were submitted to gesture learning task, motor skill learning task, supra-span (Corsi) learning task. The results indicate that learning difficulties were present in LBD+ patients, as demonstrated by their low performance in gesture sequence, motor skill and score of block-tapping supra-span task. This fact may be seen as a basic learning deficit and therefore linked to memory impairment. On the other hand, this could be tied to an aspecific more diffuse deterioration of attention if we consider that our apraxic patients had a greater cerebral lesion than non-apraxic patients.

Quality of life in respiratory allergy.

The HRQL (Health Related Quality of Life) is considered a relevant aspect of pharmacological treatment, since it evaluates the outcomes from the patient's viewpoint. This article reviews the currently available information about HRQL as an outcome measure in Respiratory Allergy. Pertinent abstracts and articles were considered, showing strong evidence that HRQL assessment has emerged as an important parameter in both clinical practice and experimental trials. The different types of questionnaires used in HRQL assessment, the results of studies using those questionnaires and concomitant effect of pharmacologic treatments, are herein reviewed. Moreover, the impact of allergy specialists' care on patients with allergies and the new perspectives in HRQL are discussed.

Relationship between MPQ and VAS in 962 patients. A rationale for their use.

BACKGROUND: 1) To analyse the information provided both by the Visual Analogue Scale (VAS) and by the McGill Pain Questionnaire (MPQ) in a cross-sectional study with patients affected by different kinds of pain and to study the relationship between VAS and MPQ scores in the same patient sample. METHODS: 962 patients affected by different kinds of pain (i.e. neuropathic pain, acute post-traumatic pain, chronic musculo-skeletal pain, headache, and cancer pain) were enrolled into the study during the first visit for pain management. The horizontal 10cm VAS and the Italian version of the MPQ were administered. RESULTS: VAS scores proved to be significantly lower in acute post traumatic and in chronic musculo- skeletal pain compared to headache and neuropathic pain. VAS scores were signi- ficantly higher in neuropathic pain compared to cancer pain. MPQ total score (Pain Rating Index, PRI) related to neuropathic pain was significantly higher than scores reported in the other pain groups, with the exception of cancer pain. Cancer pain MPQ total score was higher than acute post-traumatic and chronic musculo-skeletal PRI pain scores. Different patterns of MPQ dimensions emerged within each pain group. The association between VAS and PRI, analysed by means of stepwise multiple regression analyses was significantly different among the groups (p<0.0001). The percentage of VAS variance explained by MPQ PRI score ranged from 6% (headache) to 32% (neuro-pathic pain). CONCLUSIONS: Several differences emerged among the pain groups. VAS and MPQ resulted to address pain aspects only partially overlapping. In some clinical conditions (headache and cancer) the MPQ can provide more detailed and clinically useful information about patients' pain experience.

Relationship between psychological profile and cardiological variables in chronic heart failure. The role of patient subjectivity.

AIM: To analyse the relationships between the psychological profile, the satisfaction profile and cardiological variables in patients with chronic heart failure. MATERIAL AND METHODS: One hundred and fifty-two male patients with chronic heart failure in a stable clinical condition underwent cardiological evaluation and psychological assessment by means of two instruments: the Cognitive Behavioural Assessment 2.0 Battery and the Satisfaction Profile. RESULTS: Patients scored higher than healthy subjects in terms of psychophysiological disorders and depression. Patients in NYHA class III reported higher anxiety and depression scores and had more frequent problems in daily life than patients in NYHA classes I and II. Class III patients also reported lower satisfaction levels in many aspects of psychological and physical functioning. Pulmonary resistances >2.5 Wood units, pulmonary capillary wedge pressure >0. 18 mmHg and a diagnosis of ischaemic cardiomyopathy were associated with low satisfaction levels in the Satisfaction Profile 'physical functioning' factor. To be listed for heart transplantation and a history of more than three hospitalizations were related to low satisfaction levels in many items of the Satisfaction Profile. Finally, stepwise multiple regression showed that NYHA class, depression score and pulmonary capillary resistance accounted for 32% of the variance in the Satisfaction Profile physical functioning factor score. CONCLUSION: On the basis of chronic heart failure diagnosis only, a generic pattern of psychological distress can be predicted, common to many severe chronic diseases. Shifting from objective mental health measures towards the domain of subjective satisfaction, the only link which emerges is between objective cardiological data and satisfaction with physical functioning. Satisfaction in terms of other life aspects does not seem to be related to cardiological variables. These results support the importance of subjectivity in health related quality of life, as well as objective measures.

[Heart failure unit: 1 year experience]. / Unità per lo scompenso cardiaco: un anno di esperienza.

Many factors such as aging and pharmacologic and surgical progress contribute to the growing of organizational problems of health care for patients with severe chronic heart failure. Since March 16, 1992, in the Medical Center of Montescano, an experimental model (Heart Failure Unit) of health assistance has been in development, taking into account the assistance and observational needs of such patients. During the first year of activity, 173 patients were treated in the Unit, for a total of 307 admissions. In-hospital complications were 5 deaths, 91 severe heart decompensations, 25 severe ventricular tachyarrhythmias, 17 infections, 11 severe bradyarrhythmias, 6 instances of acute heart failure due to atrial arrhythmias, 5 unstable angina episodes, 3 thromboembolisms, and 3 neuropsychiatric disorders. During the follow-up until August 15, 1993, 27 patients died and 19 underwent heart transplantation. Our experience focused on realizing the following goals: 1) to organize a fit hospital environment and adequate nursing; 2) to pursue the autonomy and independence of the patients; 3) to routinely cooperate in a multidisciplinary team; 4) to offer continuity of care to patients.

[The psychological side of chronic heart failure. A pluriannual experience]. / Il versante psicologico dello scompenso cardiaco cronico. Considerazioni da un'esperienza pluriennale.

The present study summarizes the authors' experience reached in the last four years with chronic heart failure patients', particularly referring to the psychological aspects. The 218 male patients (age 51.7 +/- 8.3) psychological profile (obtained by means of the CBA 2.0 Primary Scales) has shown higher scores in the anxiety, depression and psychophysiological disorders scales and lower scores in some of the fear scales, compared with the reference normative group. The CBA 2.0 Schedule 4 has enlightened suicidal ideas, eating and sleep disorders, economic and sexual problems. The comparison between the psychological and the many cardiological variables taken into account, has not allowed to highlight significant relationships on the whole. Our data support the necessity to introduce other--likely subjective--variables in the studies aimed at analyzing the relationships between psychological and cardiological factors in the chronic heart failure patients.