Self-care strategies for symptom management in patients with chronic heart failure

BACKGROUND

The troublesome symptoms experienced by patients with chronic heart failure are associated with diminished quality of life, frequent hospitalizations, and mortality.

OBJECTIVES

To describe the symptoms experienced by patients with heart failure, to detail the self-care strategies used by these patients in managing their symptoms, and to categorize the self-care strategies.

METHODS

Six focus groups were used with 23 patients who had heart failure, along with six focus groups with 18 family members of the patients. Data analysis was performed by transcription of audiotape recordings of the group sessions and review of field notes.

RESULTS

The patients reported a large number of troublesome symptoms, many consistent with past empirical findings, but some not reported in previous studies. Self-care strategies to manage the symptoms clustered into 11 categories.

CONCLUSIONS

Results from this study provided direction for future studies to (a) identify the prevalence, severity, and etiologies of the commonly reported symptoms, particularly cognitive impairment, loss of balance, and depression; (b) evaluate the emotions reported by women with heart failure; and (c) test the strategies as part of an intervention program to improve symptom management in patients with heart failure.

Urethral diverticula

Urethral diverticula are a common cause of chronic genitourinary symptoms in women. They occur in three percent of women overall with higher frequencies in selected populations of symptomatic women. The peak incidence is between the ages of 25-45 but they affect all ages. The classical presentation is with recurrent urinary tract infections and post micturition dribbling but almost any urinary symptom may be a presenting feature. Reported cure rates following surgery approach 70% for recurrent urinary tract infection and almost 100% for local symptoms such as dyspareunia. However, despite this and the availability of effective diagnostic techniques diagnosis is often delayed. This is partly due to a lack of awareness among clinicians and partly because the condition overlaps the traditional territories of gynaecologists and urologists.

Timing a one-handed catch. II. Adaptation to telestereoscopic viewing

A pre-exposure, exposure, post-exposure design was used to assess the adaptation of the timing of a one-handed catch during telestereoscopic viewing. More specifically, it was examined whether the adaptation involved: (1) ignoring binocular sources of information and selecting other information, or (2) a recalibration of the coupling between the effected binocular information and the catching movement, and (3), if it is recalibration, whether it is restricted to the manipulated binocular information. To test these hypotheses, subjects (n=16) were assigned to one of two groups, each group performing three blocks of 15 trials in the dark with only the ball visible. In the exposure condition, both groups were required to catch balls under binocular telestereoscopic viewing. In the pre-exposure and post-exposure conditions, subjects performed under binocular and monocular viewing, respectively. Kinematics of the grasping movement were recorded. It was predicted that, in the case of a selection process, no after effects would occur in the post-exposure condition, whereas, in the case of recalibration, aftereffects would occur. Moreover, if the recalibration is restricted to the manipulated information, only the group that was provided with binocular vision during the pre- exposure and post-exposure conditions would show aftereffects. Significant condition (pre-exposure, exposure, post-exposure) by block (first three trials, last three trials) effects were found for the moments of grasp onset, peak opening velocity and hand closure, indicating that the hand was opened and closed earlier in the first three trials of telestereoscopic viewing. This coincided with an increase in catching failures. In addition, for the moments of hand closure and peak closing velocity, negative aftereffects were found in the post-exposure condition. The hand was closed later in the first three trials after removal of telestereoscope. With respect to the presence of the aftereffects, no differences were found between the groups. It was concluded that adaptation to telestereoscopic viewing in the timing of a one-handed catch is due to the recalibration of the coupling between information and movement, rather than a selection of another source of information. Moreover, it is likely that the recalibration was not restricted to the single, manipulated information. Rather, the recalibration involves multiple binocular and monocular optical and oculomotor sources of information.

Measurement of dyspnea in patients treated with mechanical ventilation

BACKGROUND: Dyspnea, or difficult breathing, is common in patients receiving mechanical ventilation; however, dyspnea is not routinely or systematically measured. OBJECTIVE: The primary purpose of this methodological study was to evaluate the test-retest reliability of 5 dyspnea rating scales and the criterion validity of 4 dyspnea rating scales in patients receiving mechanical ventilation. The secondary purpose was to examine the correlations between each of these 5 rating scales and physiological measures of respiratory function. METHODS: The convenience sample consisted of 28 patients on mechanical ventilation during their hospitalization in the intensive care units of a large, inner-city hospital. Patients rated their dyspnea twice at 30-minute intervals on the visual analogue scale, the vertical analogue dyspnea scale, the modified Borg scale, the numerical scale, and the faces scale. Test-retest reliability was computed by using the intraclass correlation coefficient. Criterion validity was evaluated by using the Spearman rank-order correlation coefficient. RESULTS: The 5 rating scales had acceptable test-retest reliabilities, with intraclass correlation coefficients ranging from 0.81 to 0.97. Criterion validity of the 4 scales also was acceptable, with Spearman rank-order correlation coefficients from 0.76 to 0.96. The rating scales were not correlated with most of the physiological variables. At least half of the patients reported moderate to severe dyspnea. CONCLUSION: The scales showed acceptable reliability and validity, and they will be useful in quantifying dyspnea experienced by patients receiving mechanical ventilation. Further work is needed to evaluate the extent and the severity of dyspnea in such patients in order to evaluate the effectiveness of interventions.

Measurement of dyspnea in patients treated with mechanical ventilation

BACKGROUND

Dyspnea, or difficult breathing, is common in patients receiving mechanical ventilation; however, dyspnea is not routinely or systematically measured.

OBJECTIVE

The primary purpose of this methodological study was to evaluate the test-retest reliability of 5 dyspnea rating scales and the criterion validity of 4 dyspnea rating scales in patients receiving mechanical ventilation. The secondary purpose was to examine the correlations between each of these 5 rating scales and physiological measures of respiratory function.

METHODS

The convenience sample consisted of 28 patients on mechanical ventilation during their hospitalization in the intensive care units of a large, inner-city hospital. Patients rated their dyspnea twice at 30-minute intervals on the visual analogue scale, the vertical analogue dyspnea scale, the modified Borg scale, the numerical scale, and the faces scale. Test-retest reliability was computed by using the intraclass correlation coefficient. Criterion validity was evaluated by using the Spearman rank-order correlation coefficient.

RESULTS

The 5 rating scales had acceptable test-retest reliabilities, with intraclass correlation coefficients ranging from 0.81 to 0.97. Criterion validity of the 4 scales also was acceptable, with Spearman rank-order correlation coefficients from 0.76 to 0.96. The rating scales were not correlated with most of the physiological variables. At least half of the patients reported moderate to severe dyspnea.

CONCLUSION

The scales showed acceptable reliability and validity, and they will be useful in quantifying dyspnea experienced by patients receiving mechanical ventilation. Further work is needed to evaluate the extent and the severity of dyspnea in such patients in order to evaluate the effectiveness of interventions.

Cost of hospitalizations for heart failure: sodium retention versus other decompensating factors

OBJECTIVE

To determine the cost of heart failure-related hospital admissions and to compare the cost of admissions for sodium retention with the cost of admissions for other decompensating factors.

DESIGN

Retrospective, non-experimental, cost analysis.

SETTING

Midwestern university-affiliated, tertiary care, medical center.

SAMPLE

Two hundred seven heart failure-related admissions, 117 (57%) of which were for sodium retention leading to volume overload.

OUTCOME MEASURES

Cost of hospitalization.

PROCEDURE

Data obtained from the patient and financial records of patients hospitalized for heart failure in 1992 were analyzed using the ratio of cost-to-charge accounting procedure.

RESULTS

The total cost was $2,442,720 for the 207 heart failure-related admissions; the average cost was $12,400 per admission. Approximately half of the cost of the hospitalizations was expended in the 4 cost centers comprising routine and critical care services, which incorporate room charges and nursing care. Another one third of the cost was for supplies, medications, and laboratory tests. Admissions as a result of sodium retention had lower costs than admissions as a result of other factors.

CONCLUSION

The cost of hospitalization for heart failure is high. Routine services, supplies, medications, and laboratory tests used by these patients contribute to the high cost of care. Improved outpatient management strategies are necessary to reduce hospital admissions as a result of sodium retention.

Reforming higher specialist training in the United Kingdom--a step along the continuum of medical education

OBJECTIVES

The requirement to align the arrangements for postgraduate training in the United Kingdom with those elsewhere in the European Community provided the opportunity to review and reform our arrangements for higher specialist training. This paper describes the case for change--the strengths and deficiencies of the traditional pattern of postgraduate medical training, demographic influences in the medical workforce and the need for a more structural or planned approach to training.

CONCLUSIONS

Over the past 5 years substantial progress has been made: the introduction of new regulatory arrangements and a new higher specialist training grade; the development of a managed and flexible system for delivering training to standards set by the Royal Colleges and which can accommodate the needs of those pursuing academic and research medicine; and the opportunity for trainees' progress to be measured against published curricula. The significant programme of change has been underpinned by careful workforce planning and the publication of comprehensive guidance. Significant reform of higher specialist training has been achieved. This paper also makes the case for a more strategic approach to planning and developing medical education across the continuum, from entry to medical school until retirement, which can guide medical education and improve patient care into the next millennium.

Ecotypic variation between and within two populations of Trifolium tomentosum (woolly clover) from Syria and Western Australia: its success as a colonising species

Ecotypic variation was studied between and within populations of Trifolium tomentosum (woolly clover) using seed that was collected from 2 semi-arid environments: Tel Hadya, Syria, and Pingrup, Western Australia. The seed was collected from 64 subplots within a 40-m2 grid at each site and the material was grown at the University of Western Australia Field Station at Shenton Park, Perth. Fifteen morphological characters were scored and were analysed using analysis of variance, principal components analysis, and discriminant function analysis. Material from the 2 sites was separated using multivariate analysis, with the seed from Tel Hadya containing more within-site variation. It is suggested that the lack of within-site variation observed at Pingrup is the result of a number of factors: a limited amount of genetic diversity being present in the original introduced material, a preference of T. tomentosum for alkaline soils rather than the acid soils predominantly occurring in Western Australia, the harsh selection pressures present in a semi-arid environment, and a limited time for genotypes to adapt to specific micro-niches within each environment. The results are used to contribute to our understanding of the success of colonising species in semi-arid environments.

Quality of life in women with heart failure

Persons with heart failure (HF) experience impaired quality of life (QOL). However, the majority of research conducted on QOL in persons with HF has been with men. The purpose of this descriptive pilot study was to describe the impact of symptoms of HF and examine the relationships among symptom impact, perceived health status, perceived social support, and overall QOL in 30 women who had recently been hospitalized for HF. The women reported high physical symptom impact, poor perceived physical health status, and impaired QOL. Physical symptom impact, perceived physical health status, and QOL were moderately to highly correlated with one another. Perceived social support was significantly, though not strongly, correlated with physical symptom impact. Emotional symptom impact and mental health status were significantly and negatively correlated with each other but were not significantly correlated with QOL. In this group of 30 chronically ill women, QOL was lower in those women who reported greater physical symptom impact and poorer perceptions of their physical health status.

Characterization of the precipitants of hospitalization for heart failure decompensation

BACKGROUND

The model for management of patients with heart failure may be a key determinant of morbidity and quality of life. Development of a better management strategy for these patients requires determination of the reasons for decompensation that leads to hospitalization.

OBJECTIVES

To ascertain and rank the principal reasons for hospitalization of patients who have heart failure.

METHODS

Retrospective audit of all 1992 admissions (N = 1031; 691 patients) coded for heart failure at a Veterans Affairs medical center and a tertiary care university medical center.

RESULTS

The diagnosis of heart failure was verified by preset criteria in 72% of the patients. Of the 496 patients with documented heart failure, worsening heart failure was a main reason for admission in 390 (79%). Despite different socioeconomic backgrounds, excessive sodium retention was the leading factor (55%) associated with decompensation in patients at both institutions. Other factors precipitated admission much less often.

CONCLUSIONS

Many hospitalizations for heart failure might be avoided by case management directed at lessening sodium overload. Increased use of medications known to be effective in persons with heart failure (angiotensin-converting enzyme inhibitors, digoxin, and adequate diuretic therapy) might reduce the likelihood of decompensation. Implementation of behavioral interventions to assist patients with self-monitoring signs of sodium retention and to improve compliance with medications and dietary sodium restrictions are strategies for further reducing the risk of decompensation.

Characterization of the precipitants of hospitalization for heart failure decompensation

BACKGROUND: The model for management of patients with heart failure may be a key determinant of morbidity and quality of life. Development of a better management strategy for these patients requires determination of the reasons for decompensation that leads to hospitalization. OBJECTIVES: To ascertain and rank the principal reasons for hospitalization of patients who have heart failure. METHODS: Retrospective audit of all 1992 admissions (N = 1031; 691 patients) coded for heart failure at a Veterans Affairs medical center and a tertiary care university medical center. RESULTS: The diagnosis of heart failure was verified by preset criteria in 72% of the patients. Of the 496 patients with documented heart failure, worsening heart failure was a main reason for admission in 390 (79%). Despite different socioeconomic backgrounds, excessive sodium retention was the leading factor (55%) associated with decompensation in patients at both institutions. Other factors precipitated admission much less often. CONCLUSIONS: Many hospitalizations for heart failure might be avoided by case management directed at lessening sodium overload. Increased use of medications known to be effective in persons with heart failure (angiotensin-converting enzyme inhibitors, digoxin, and adequate diuretic therapy) might reduce the likelihood of decompensation. Implementation of behavioral interventions to assist patients with self-monitoring signs of sodium retention and to improve compliance with medications and dietary sodium restrictions are strategies for further reducing the risk of decompensation.

Psychosocial variables and hospitalization in persons with chronic heart failure

Persons with chronic heart failure (HF) must cope not only with the physical impairment of their disease but with the associated emotional distress. The primary purpose of this prospective study was to examine whether the psychosocial variables of symptom impact measured at baseline--health perception, social support and coping--differed between a group of adults with chronic HF who were hospitalized and a group who were not hospitalized during the following six months of the study. A secondary purpose was to examine indices of left ventricular dysfunction that might influence hospitalization. Within the six-month period following baseline data collection, 23 of 62 (37%) patients who completed the study were hospitalized at least once for problems pertaining to HF. Patients in the hospitalized group reported significantly more baseline symptom impact, particularly in the areas of emotional symptoms and deficits of attention and memory. Social support and coping did not differ significantly between hospitalized and nonhospitalized patients. Extent of myocardial dysfunction, age and demographic variables were not significantly different between the two groups. Heart failure decompensation requiring inpatient management was presaged by increased anxiety and disorders of mentation, suggesting that health care providers need to be sensitive to these reported symptoms and their impact, because they might be clues to impending hospitalization.

Beliefs about medication and dietary compliance in people with heart failure: an instrument development study

BACKGROUND

Sodium retention is often a precursor to hospitalization in people with heart failure (HF). Lack of compliance with medications and with dietary sodium restrictions affects sodium retention.

OBJECTIVES

The purpose of this study was to evaluate the reliability and validity of the Beliefs about Medication Compliance Scale and the Beliefs about Dietary Compliance Scale.

METHODS

The Beliefs about Medication Compliance Scale and the Beliefs about Dietary Compliance Scale are instruments we developed specifically to measure beliefs about compliance with behaviors that affect sodium retention in persons with HF. The scales, based on the Health Belief Model, were designed from a review of literature and from self-reports of people with HF. A convenience sample of 101 people with HF completed the scales.

RESULTS

Internal consistency reliability was satisfactory. Factor analysis provided initial support for construct validity of the scales.

CONCLUSIONS

Future testing of the scales is needed in more diverse populations. The scales can then be used to test interventions tailored to individual subjects' beliefs about compliance.

Genetic variation between and within two populations of Trifolium glomeratum (cluster clover) in Western Australia

Genetic variation between and within populations of Trifolium glomeratum (cluster clover) was studied using seed collected from 2 sites in Western Australia: Mount Barker in the south and Kwelkan in the wheatbelt. Seed was collected at 64 subplots within each site and the material was grown at the University Field Station at Shenton Park, Perth. Seventeen morphological characters were scored and the results were analysed using analysis of variance, principal components analysis, and cluster analysis. Within-site variation was much greater than had previously been shown, and a considerable amount of between-site variation was present. It is suggested that within-site variation is due to a small amount of heterozygosity, as a result of limited outbreeding, being present in each population. The 2 populations are shown to be distinct from each other, with the population from Mount Barker containing more within-site variation. It is suggested that this is a result of climatic stress influencing and reducing the amount of variation being maintained in the Kwelkan population.

Development of an instrument to measure threat related to cardiac events

The purpose of this study was to evaluate the reliability and validity of the Cardiac Event Threat Questionnaire (CTQ). The CTQ is a 31-item instrument specific for cardiac events that was developed from a literature review and self-reports of persons who had experienced a recent cardiac event. A convenience sample (N = 270) of persons hospitalized for angina, myocardial infarction, or cardiac surgery completed the CTQ. Satisfactory internal consistency and test-retest reliabilities were found. Results of confirmatory factor analysis and correlation with the Profile of Mood States provide initial support for construct validity of the CTQ.

Relationships among selected antecedent variables and coping effectiveness in postmyocardial infarction patients

Selected theoretical relationships from Lazarus' (1966) model of stress were tested in a convenience sample of 81 postmyocardial infarction clients. Two hypothesized causal models were analyzed. Results from regression analyses indicated 63% of the variance in coping effectiveness was explained by marital status, length of time since hospitalization, perceived availability of social support, uncertainty, degree of threat, coping strategies, and emotions. A revised model that fit the data was proposed. Findings indicated that emotions were an outcome of threat, not coping; threat did not directly affect coping strategies; and coping strategies did not directly influence coping effectiveness.

Complications of transvaginal ultrasound-directed follicle aspiration: a review of 2670 consecutive procedures

PURPOSE

Complications following transvaginal ultrasound-directed follicle aspiration are rare, making it difficult to assess their true incidence. During a 4-year prospective study the complications arising from a series of 2670 consecutive procedures were monitored.

RESULTS

Vaginal hemorrhage occurred in 229 (8.6%) of the cases, with a significant loss (> 100 ml) in 22 (0.8%). Postoperative pelvic infection occurred in 18 (0.6%) of the cases. Hemorrhage from the ovary with hemoperitoneum formation was seen on two occasions and necessitated emergency laparotomy in one instance. A single case of pelvic haematoma formation from a punctured iliac vessel was also recorded; this settled without intervention. Of the 18 cases with infection, 9 were severe with pelvic abscess formation; microbiological examination of the pus from these cases suggests that the most common route of infection in such cases is probably by direct inoculation of vaginal organisms into the peritoneal cavity by the collecting needle.

CONCLUSION

The low incidence of pelvic infection questions the value of using prophylactic antibiotics. No increased risk of infection was demonstrated in cases with preexisting peritoneal damage.

Postmenopausal women. Factors in osteoporosis preventive behaviors

Osteoporosis is a serious health hazard mainly affecting postmenopausal and elderly women. Osteoporotic fractures are one of the leading causes of morbidity and death in the elderly population. Prevention of further loss of bone mass in postmenopausal women can be achieved if women take estrogen replacement therapy, consume adequate levels of calcium, exercise regularly, and practice healthy lifestyle behaviors. Elderly women need to follow the same strategies as postmenopausal women with more emphasis on prevention of falls.

Perceived threats of individuals recovering from myocardial infarction

Lazarus' phenomenological theory of stress and coping provided the basis for this descriptive study of perceived threats after myocardial infarction (MI). Sixty-four post-MI subjects enrolled in phase II cardiac rehabilitation programs identified threats they had experienced in the past month. Perceived threats were defined as situations that were difficult or troubling to the individual and were described by respondents in narrative form. Degree of threat was then measured by one item on which subjects indicated the degree of concern the threatening event had caused them. Responses to the one item were analyzed and categorized into the following five areas: physical problems; medical therapy/self-care; work/physical activity; interpersonal/family; and financial. The results provide an overview of the multiple concerns individuals deal with after a major life-threatening cardiac event.

The effects of lignocaine on human sperm motility

OBJECTIVE

The purpose of this study was to assess the motility of human sperm incubated with various concentrations of lignocaine.

METHODS

Eleven semen samples with a sperm density greater than or equal to 20 x 10(6) ml and progressive motility greater than or equal to 40% were prepared using a swim-up technique. Aliquots from each sample were incubated for 4 hr under capacitating conditions with lignocaine concentrations of 100, 10, 1, and 0.1 microgram/ml and without additional lignocaine as a control. Digital computerized motion analysis was performed on all samples at 1, 2, and 4 hr after the addition of lignocaine.

RESULTS

After 2 hr of incubation a significant (P less than 0.05) increase in the percentage of sperm with a curvilinear velocity greater than 100 microns/sec was observed in those samples incubated with 100 micrograms/ml lignocaine. This stimulatory effect was no longer apparent after a further 2 hr of incubation. No other significant changes were identified in any of the motility parameters examined.

CONCLUSIONS

No adverse effects on human sperm motility were identified during incubation with low concentrations of lignocaine. A transient stimulatory effect was observed at a lignocaine concentration of 100 micrograms/ml.