Patients with chronic hepatitis C undergoing watchful waiting: Exploring trajectories of illness uncertainty and fatigue

Adjusting to living with chronic liver disease among patients who continue regular healthcare visits for hepatocellular carcinoma surveillance: A grounded theory study

AIM

To explore patients' process of living with chronic liver disease while continuing regular healthcare visits for hepatocellular carcinoma surveillance.

METHODS

Semistructured interviews and participant observations were conducted in this qualitative constructivist grounded theory study. The participants included 11 patients undergoing regular hepatocellular carcinoma surveillance every 1-6 months for 2-30 years. Data were analyzed using coding, memo-writing, theoretical sampling, and constant comparison.

RESULTS

The participants incorporated regular healthcare visits into their living cycle. The cycle's core comprised two categories ("inferring my liver condition" and "desiring status quo"). The cycle underwent a transition described by three phases ("seeking ways to live with my chronic liver disease," "being overwhelmed by living with my chronic liver disease," and "reconstructing my life to live with my chronic liver disease"). This transition involved adjusting to living with chronic liver disease while continuing regular healthcare visits. The relative importance of the cycle's core progressively shifted from "inferring my liver condition" to "desiring status quo."

CONCLUSIONS

This study revealed the transition phases of patients' living cycles in adjusting to living with chronic liver disease while continuing regular healthcare visits. Understanding the different phases in which patients are and the psychological impact of healthcare visits can help them look forward to recuperative actions. Furthermore, patients who have a sense of ownership experience loneliness because of regular healthcare visits. A support system including nurses as part of regular hepatocellular carcinoma surveillance should be established to help ease patients' sense of loneliness by utilizing their sense of ownership.

Prevalence and trajectories of neuropsychological post-COVID-19 symptoms in initially hospitalized patients

OBJECTIVE

To investigate the prevalence and trajectories of post-COVID-19 neuropsychological symptoms.

DESIGN

Prospective longitudinal multicentre cohort study.

SUBJECTS

A total of 205 patients initially hospitalized with SARS-CoV-2 (COVID-19).

METHODS

Validated questionnaires were administered at 9 months (T1) and 15 months (T2) post-hospital discharge to assess fatigue, cognitive complaints, insomnia, anxiety, depression, and post-traumatic stress symptoms.

RESULTS

Analyses included 184 out of 205 patients. Approximately 50% experienced high cognitive complaints at T1 and T2, while severe fatigue affected 52.5% at T1 and 55.6% at T2. Clinically relevant insomnia scores were observed in 25% of patients at both time-points. Clinically relevant anxiety scores were present in 18.3% at T1 and 16.7% at T2, depression in 15.0% at T1 and 18.9% at T2, and PTSD in 12.4% at T1 and 11.8% at T2. Most symptoms remained stable, with 59.2% of patients experiencing at least 1 persistent symptom. In addition, 31.5% of patients developed delayed-onset symptoms.

CONCLUSION

Post-COVID-19 cognitive complaints and fatigue are highly prevalent and often persist. A subgroup develops delayed symptoms. Emotional distress is limited. Screening can help identify most patients experiencing long-term problems. Future research should determine risk factors for persistent and delayed onset symptoms.

Classification of patient- and clinician-generated secure messages using a theory-based taxonomy

BACKGROUND

As secure electronic message exchange increases between patients and clinicians, we must explore and understand how patients and clinicians use those messages to communicate between clinical visits.

OBJECTIVE

To present the application of a taxonomy developed specifically to code secure message content in a way that allows for identification of patient and clinician communication functions demonstrated to be associated with patients' intermediate and health outcomes.

METHOD

We randomly sampled 1031 patients who sent and received 18 309 messages and coded those messages with codes from our taxonomy. We present the prevalence of each taxon (ie, code) within the sample.

RESULTS

The most common taxon among initial patient-generated messages were Information seeking (29.09%), followed by Scheduling requests (27.91%), and Prescription requests (23.09%). Over half of subsequent patient-generated messages included responses to clinic staffs' questions (58.31%). Six in 10 clinic staff responses included some form of Information sharing with process-based responses being most common (32.81%). A third of all clinician-generated messages (36.28%) included acknowledgement or some level of fulfilment of a patient's task-oriented request. Clinic staff sought information from patients in 20.54% of their messages.

CONCLUSION

This taxonomy is the first step toward examining whether secure messaging communication can be associated with patients' health outcomes. Knowing which content is positively associated with outcomes can support training of, and targeted responses from, clinicians with the goal of generating message content designed to improve outcomes.

PATIENT CONTRIBUTION

This study is based on analyses of patient-initiated secure message threads.

The Relationship Between Uncertainty in Illness and Quality of Life in Patients With Heart Failure: Multiple Mediating Effects of Perceived Stress and Coping Strategies

BACKGROUND

Previous investigators have demonstrated that uncertainty in illness is associated with quality of life (QoL) in patients with chronic illness. However, little is known about the mechanism underlying the relationship in patients with heart failure.

OBJECTIVE

The aim of this study was to examine the multiple mediating effects of perceived stress and coping strategies on the relationship between uncertainty in illness and QoL in patients with heart failure.

METHODS

We conducted a cross-sectional study in 302 patients with heart failure recruited at a general hospital in China from October 2016 to September 2017. Uncertainty in illness, perceived stress, coping strategies, and QoL were assessed using self-reported questionnaires. The multiple mediation model was tested using the PROCESS macro for SPSS.

RESULTS

Of the 302 patients, 51.7% had poor physical QoL and 45.7% had poor mental QoL (physical component summary or mental component summary score of <50 points). Uncertainty in illness had a significantly negative indirect effect on mental QoL through perceived stress and acceptance-resignation (indirect effect, -0.02; 95% confidence interval, -0.04 to -0.01). Uncertainty in illness also had a significantly negative indirect effect on mental QoL via perceived stress only (indirect effect, -0.18; 95% confidence interval, -0.26 to -0.09).

CONCLUSIONS

Poor QoL is prevalent in patients with heart failure. Perceived stress and acceptance-resignation are important mediating factors between uncertainty in illness and mental QoL in patients with heart failure. Interventions aimed at reducing perceived stress and acceptance-resignation coping may be beneficial for improving mental QoL in patients with heart failure.

Early Treatment Uptake and Cost Burden of Hepatitis C Therapies Among Newly Diagnosed Hepatitis C Patients with a Particular Focus on HIV Coinfection

BACKGROUND

Despite the high efficacy and safety associated with direct-acting antivirals (DAAs), access to HCV treatment has been frequently restricted because of the high DAA drug costs.

OBJECTIVES

To (1) compare HCV treatment initiation rates between HCV monoinfected and HCV/HIV coinfected patients before (pre-DAA period) and after (post-DAA period) all-oral DAAs became available; and to (2) estimate the HCV treatment costs for payers and patients.

RESEARCH DESIGN AND METHODS

A retrospective analysis of the MarketScan® Databases (2009-2016) was conducted for newly diagnosed HCV patients. Multivariable logistic regression was used to estimate the odds ratio (OR) of initiating HCV treatments during the pre-DAA and post-DAA periods. Kruskal-Wallis test was used to compare drug costs for dual, triple and all-oral therapies.

RESULTS

A total of 15,063 HCV patients [382 (2.5%) HIV coinfected] in the pre-DAA period and 14,896 [429 (2.9%) HIV coinfected] in the post-DAA period were included. HCV/HIV coinfected patients had lower odds of HCV treatment uptake compared to HCV monoinfected patients during the pre-DAA period [OR, 0.59; 95% confidence interval (CI), 0.45-0.78], but no significant difference in odds of HCV treatment uptake was observed during the post-DAA period (OR, 1.08; 95% CI, 0.87-1.33). From 2009 to 2016, average payers' treatment costs (dual, $20,820; all-oral DAAs, $99,661; p < 0.001) as well as average patients' copayments (dual, $593; all-oral DAAs $933; p < 0.001) increased significantly.

CONCLUSIONS

HCV treatment initiation rates increased, especially among HCV/HIV coinfected patients, from the pre-DAA to the post-DAA period. However, payers' expenditures per course of therapy saw an almost fivefold increase and patients' copayments increased by 55%.

Predictors of uncertainty in parents of children living with chronic conditions

BACKGROUND

Uncertainty in illness implies no meaning has been attributed to an illness event. Although many studies focus on this issue in adults, there is limited research into children with chronic illnesses. Parental uncertainty has been associated with increased risk of post-traumatic stress, which can in turn adversely affect child and parent coping strategies.

AIM

To identify the characteristics of parents who are at greater risk of uncertainty and the associated characteristics of their children's chronic illnesses.

METHOD

An exploratory, cross-sectional study design was adopted across three different sites in the United Arab Emirates. Data were collected from parents who accompanied their children, who were receiving treatment, using a validated, culturally adapted Parent Perception of Uncertainty Scale.

RESULTS

Scores for illness uncertainty ranged from 86.5 to 92.6, on a scale of 31-155, with higher scores indicating greater uncertainty. The highest scores were found in parents of children being cared for in ward settings who had previously been hospitalised, parents of children up to two years of age or those approaching adolescence, fathers, and parents whose first language was Arabic.

CONCLUSION

The groups of parents with the highest illness uncertainty may benefit most from interventions to improve communication and psychological support.

Incertidumbre ante la enfermedad crónica. Revisión integrativa

Este estudio tiene como objetivo integrar la evidencia acerca de la incertidumbre ante la enfermedad en el paciente con enfermedad crónica y su cuidador familiar, guiados por la teoría de la incertidumbre ante la enfermedad. Para esto se realizó una síntesis integrativa de la literatura durante los años 2007 a 2017. Se usaron las bases de datos Medline, Science Direct, Ovid Nursing, Scielo, Scopus, CINAHL y Psycinfo en los idiomas inglés y español. Para realizar la síntesis integrativa se incluyeron 46 publicaciones, con 21 estudios de tipo cualitativo, 19 cuantitativo, 2 mixtos y 4 revisiones. Los estudios se realizaron en su mayoría en pacientes con cáncer, enfermedades neurodegenerativas, fallos orgánicos, falla cardiaca, EPOC y en cuidados paliativos de distintas enfermedades. Dentro de las principales conclusiones del estudio se plantea que la persona con enfermedad crónica y su cuidador familiar desarrollan incertidumbre ante la enfermedad crónica debido a falencias en la educación acerca de la enfermedad y el cuidado, así como el soporte social que reciben del equipo de salud y de sus redes de apoyo.

Evaluating the Reliability and Validity of the Arabic Version of the Parents Perceptions of Uncertainty Scale (A-PPUS)

BACKGROUND

Uncertainty often accompanies illness and may be a major aversive component of the patients' treatment process. There is evidence that parental uncertainty has a negative impact on their own and on their child's coping strategies and may affect family functioning. Key to the provision of competent care, to address uncertainty, is the use of an appropriate validated assessment tool to understand key parental concerns. The 'Parent Perception of Uncertainty Scale' (PPUS) has been widely used for this purpose.

AIM

This study reports on the validity and reliability testing of the Arabic version of the Parents Perception of Uncertainty Scale (A-PPUS).

METHODS

The scale was translated to Arabic using the translation-back-translation method. Appropriate statistical tests were performed including measurements of internal consistency, item to total scale correlation, and univariate and multivariate analyses.

RESULTS

The study included 240 parents of children with chronic illnesses. Cronbach's alpha coefficient of the whole scale was 0.93. All the items were positively correlated to the total score. The univariate and multivariate analysis supported the previous tests and the assertion that the Arabic version of the PPUS provided a relevant measure of the uncertainty level.

CONCLUSION

This study has identified that the A-PPUS is a reliable tool for parent report of their uncertainty, in the UAE and Arabic population.

The importance of fatigue cognitions in chronic hepatitis C infection

Chronic Hepatitis C virus (HCV) infection is a source of significant public health burden worldwide. Fatigue is a cardinal patient reported consequence of the disease. HCV infection associated fatigue leads to significant impairment in the quality of life and day-to-day functioning. Despite its clinical significance, the factors that contribute to adverse impact of fatigue in HCV infection are largely unknown.

OBJECTIVES

This study evaluated the contributions of insomnia, depression symptoms, and fatigue-specific cognitions to fatigue-related functional impairment.

METHODS

Fatigue, insomnia, depression symptoms, as well as fatigue cognitions were assessed in participants (36% females; age>18 years, N=115) with chronic HCV infection at a tertiary hepatitis clinic.

RESULTS

Sixty percent of participants reported clinically significant fatigue (Fatigue Severity Index FSS ≥ 4). Comorbidities and fatigue perceptions accounted for 61% of the variation of fatigue. Fatigue perceptions were the main predictors of adverse fatigue outcomes (B=.114, 95% CI=.054-.154). Patients with clinically significant fatigue were four-times more likely than less fatigued patients to believe that the main cause of their fatigue was the infection.

CONCLUSION

Patients' beliefs about their fatigue were the main predictors of adverse fatigue outcomes. These results suggest that fatigue associated with chronic hepatitis C infection can be conceptualized using a cognitive behavioral approach. This was the first study to evaluate the role of both comorbid mood/sleep and cognitive predictors of fatigue in a single model. Integrating the findings into existing treatment strategies could improve patient reported outcomes in chronic hepatitis C infection.

Living with hepatitis C: a phenomenological study

AIMS AND OBJECTIVES

To explore the experience of adults living with hepatitis C over time.

BACKGROUND

Hepatitis C virus is a growing problem affecting thousands of people worldwide. The majority of individuals infected develop chronic liver disease, but treatment is not always successful, leaving many to live with the virus indefinitely. Experiences of living with hepatitis C are poorly understood yet essential to meet the needs of an increasing number of affected people.

DESIGN

A qualitative study using a descriptive phenomenological methodology.

METHODS

Unstructured interviews were conducted with 23 hepatitis C-positive individuals in the East of England; participants were interviewed twice within a year.

RESULTS

Data analysis revealed six themes of the experience of living with hepatitis C: hepatitis C and self; hepatitis C, self and others; self and handling hepatitis C; self and handling hepatitis C treatment issues; living with the consequences of hepatitis C; self, hepatitis C and thoughts of the future.

CONCLUSIONS

Diagnosis of hepatitis C can disrupt people's sense of identity and trigger a life transition. A complex range of factors create uncertainty for people living with hepatitis C. Many struggle to make a healthy transition to life with the condition, instead living in a state of sustained uncertainty.

RELEVANCE TO CLINICAL PRACTICE

Nurses working within a chronic care framework of ongoing advice and support can improve experiences for those living with hepatitis C. Practice aimed at reducing both the disruptive effect of the diagnosis and the uncertainties it creates can help facilitate a transition to life with the disease.

Managing systemic symptoms in chronic liver disease

Improved medical management and the changing disease demographic mean that the majority of patients with chronic liver disease are living with the disease rather than dying from it. Historically, the perception has been that the impact of chronic liver disease is related entirely to the consequences of endstage liver disease; however, more recently a number of systemic symptoms have been recognised that can occur at any point in the natural history of chronic liver disease and which can be associated with functional impairment and reduced quality of life. The most characteristic of these systemic symptoms is fatigue, which frequently associates with sleep disturbance and autonomic dysfunction, particularly manifest as abnormality of blood pressure regulation. Cognitive symptoms can occur even in non-cirrhotic patients. Falls can present in patients with autonomic dysfunction, complicated by the presence of peripheral muscle strength problems. Importantly for clinicians managing chronic liver disease, the severity of these systemic symptoms is typically not related to liver disease severity, and therefore despite optimal liver disease management, patients can often continue to experience debilitating symptoms. The similarity in systemic symptoms between different chronic liver diseases (and indeed chronic inflammatory conditions affecting other organs) suggests the possibility of shared pathogenetic processes and raises the possibility of common management strategies, although further research is urgently needed to confirm this. In primary biliary cirrhosis, where our understanding of systemic symptoms is arguably most developed, structured management strategies have been shown to improve the quality of life of patients. It is highly likely that similar approaches will have comparable benefits for other chronic liver disease groups. Here, we review the current understanding of systemic symptoms in chronic liver disease and offer recommendations regarding the successful management of these symptoms. Critical for successful treatment is use of a structured and systematic approach to management in which all contributing factors are addressed in an organised fashion. We believe that such a systematic approach, when applied to research as well as to clinical management, will allow us to reduce the overall burden of chronic liver disease, improve quality of life and enhance functional ability.