The experience of fatigue for people living with hepatitis C

Fatigue in Patients with Chronic Hepatitis C

This study aimed to explore the factors associated with fatigue in chronic hepatitis C patients before and at 4, 8, 12, 16, 20, and 24 weeks after antiviral therapy. The study employed a prospective and repeated-measures design. The Chinese version of the brief fatigue inventory (BFI-C) and the Pittsburg sleep quality index (PSQI) were employed to collect data. Pegylated Interferon plus Ribavirin dosages and serum values (hemoglobin, alanine aminotransferase [ALT], and aspartate aminotransferase [AST]) were monitored before and during the antiviral therapy at 4, 8, 12, 16, 20, and 24 weeks. The study enlisted 115 patients as participants. Multivariate analysis indicated that gender, educational level, body mass index (BMI), and hemoglobin level were significant determinants of patients’ fatigue. When hemoglobin levels in the patients decreased in week 4 and continued to fall to the nadir at week 12, it prompted the healthcare providers to assess their fatigue levels and initiate proactive interventions as needed.

"Shaping the new freedom": A reflexive thematic analysis on patients' post cure needs after years of living with hepatitis C

BACKGROUND

Direct-acting antivirals present a treatment opportunity that provides high rates of sustained viral response even for people who have lived for years with hepatitis C virus (HCV) infection. While it is known that liver-related morbidity and mortality can be decreased and many symptoms reversed, this population's need for post-treatment professional support has not been extensively assessed. Therefore, our study aimed to describe the experiences of patients cured of chronic HCV infection and explore the meaning of these experiences regarding specific follow-up care needs within the context of the Swiss health system.

METHODS

For this qualitative study, we applied a reflexive thematic analysis approach with a social constructivist orientation. Twelve participants shared their experiences of being cured and their needs regarding follow-up care. Subsequently, the data were analysed in an iterative process based on Braun and Clarke's six phases of analysis.

RESULTS

In the overarching theme, participants summarised their new situation with the statement, "being cured feels like being released from a cage". They experienced striking health improvements with overwhelmingly positive influences on their everyday lives. This experience was characterised for all participants by important changes on three levels. We categorised these in three sub-themes: a) "the ball and chain have been lightened": this sub-theme illustrates the reduction of social limitations and emotional stress; b) "the gnawing at the liver has let up": this signifies relief from physical symptoms and strongly improved well-being. And under the third sub-theme, "shaping the new freedom", the participants described their new situation as a sometimes-stressful challenge because they had to reorient their self-management. They shared their concerns regarding the ongoing stigma of HCV infection, feeling insecure in their own health after being cured, and learning how to use their heightened sense of confidence and openness to enact behavioural changes that would improve their health-related lifestyles.

CONCLUSION

The findings of this study provide insights into treatment experiences of patients cured of chronic HCV infection and the need for follow-up care even after successful virus eradication. The results can sensitise healthcare professionals to patients' post-cure challenges and guide their care interventions. Some of these challenges, such as dealing with stigma, can be addressed during treatment; other needs, like providing motivation to engage in healthy behaviour, may warrant targeted follow-up.

Needs and Self-Care Efficacy for Cancer Patients Suffering from Side Effects of Chemotherapy

Background and Aim. Cancer is the leading cause of death in economically developed countries and is a threat to human lives. Cancer and chemotherapy side effects may affect the daily activity of cancer patients and their families on many levels confronted by changes in health status and lifestyles, leading to impaired self-care efficacy. Objective. To assess the needs and self-care efficacy for cancer patients suffering from side effects of chemotherapy. A descriptive cross-sectional design was conducted. A purposive sample of 150 adult cancer patients undergoing chemotherapy during the period from January to June 2020 was studied at the Oncology Outpatients Clinic at Al Rantisi Hospital in Gaza Strip. Tools. Tools of the study involved the following: structure interviewing questionnaire, patient assessment needs' tool, and self-care activity for side effects of chemotherapy; Part I: assessment of self-care efficacy and Part II: assessment of physical, psychological, social, and spiritual needs of patients and activity of daily living. The findings of this study indicated that, concerning the duration of illness, 44.5% of studied patients started complaining of symptoms of cancer for about two years, and more than one-third of them, 69.3%, started chemotherapy more than one year ago. More than half of the studied patients, 55.3%, had poor knowledge about cancer, side effects of chemotherapy, how to manage these side effects, and level of self-care efficacy. The majority of studied subjects, 87.3%, had a financial burden, and nearly two-thirds of patients, 61.3%, need reassurance to cope with illness. There was high statistical significance between self-care efficacy and daily living activity. Regarding physical problem, the most affected systems were the gastrointestinal and the dermatological system. Also, the majority of patients were independent in walking, dressing, toileting, and feeding, but more than two-thirds of them needed assistance toward the ability to handle finance, shopping, housekeeping, food preparation, and travelling.

Expert opinion on managing chronic HCV in patients with neuropsychiatric manifestations

Neurological manifestations of HCV infection appear to be under-recognized in clinical practice despite the majority of HCV-infected patients experiencing symptoms such as fatigue, depression and cognitive dysfunction. There is also growing evidence for a link between HCV infection and an increased risk of Parkinson's disease. The mechanism underpinning the association between HCV and these neuropsychiatric syndromes still requires further investigation. Here we review the pre-clinical and clinical evidence for a link between HCV and effects on the central nervous system leading to neuropsychiatric syndromes. Lastly, we describe how improvements in neuropsychiatric manifestations of HCV following treatment have been observed, which is subsequently reflected in an overall improvement in health-related quality of life.

Categorization and Characterization of Activities Designed to Help Health-care Professionals Involved in Hepatitis Care Increase Their Awareness of the Disease: The Classification of Hepatitis Medical Care Coordinators

Objective This study aimed to investigate the current state of the activities performed by hepatitis medical care coordinators, categorize coordinators according to the activities they perform, and determine the backgrounds of these coordinators. Methods A self-administered questionnaire survey was completed by 414 coordinators. The surveyed items included gender, occupation, activity items performed, and barriers that inhibited the performance of these activities. A hierarchical cluster analysis was applied, and cases were classified based on the contents of the activities in question. Results The coordinators were classified into four groups (A-D). Group A, consisting primarily of public health nurses, was classified as "the type that conducted activities aimed at providing information and recommendations." Group B, which included registered dieticians and clerks, was classified as "the type that uses multidisciplinary collaboration to perform their tasks." Group C, which included clinical nurses, was classified as "the type that was more likely to perform activities as leaders in an organization." Group D, consisting primarily of pharmacists, was classified as "the type that promoted activities centered on providing instructions regarding medication dosage and administration." Conclusion Our study showed that coordinators' professional skills and abilities are reflected in the contents of the activities they conduct, and that, to adequately perform their roles, they must acquire skills in addition to those required in their original occupations. To implement high-quality hepatitis countermeasures, there is a need to foster an environment that facilitates cooperation between coordinators, as well as relationship-building.

Improving hepatitis C direct-acting antiviral access and uptake: A role for patient-reported outcomes and lived experience

Hepatitis C virus contributes to substantial and growing mortality and morbidity. Fortunately, the advent of highly effective interferon-free direct-acting antiviral (DAA) medications and new diagnostic tests has the potential to dramatically alter the epidemiologic trajectory of hepatitis C, particularly for "hard-to-reach" populations. Treatment advances and cure will also likely alter the individual experience of living with hepatitis C. However, it is not yet known in what capacity. This paper provides an overview of the population-level impact of DAA treatment, highlighting the need to further our understanding of the impact of treatment on behaviour, health and wellbeing through lived experience and more sensitive patient-reported outcome measures.

Multidimensional Fatigue Inventory in People With Hepatitis B Infection: Cross-cultural Adaptation and Psychometric Evaluation of the Persian Version

There is no valid and well-established tool to measure fatigue in people with chronic hepatitis B. The aim of this study was to translate the Multidimensional Fatigue Inventory (MFI) into Persian and examine its reliability and validity in Iranian people with chronic hepatitis B. The demographic questionnaire and MFI, as well as Chronic Liver Disease Questionnaire and EuroQol-5D (to assess criterion validity), were administered in face-to-face interviews with 297 participants. A forward-backward translation method was used to develop a culturally adapted Persian version of the questionnaire. Cronbach's α was used to assess the internal reliability of the scale. Pearson correlation was used to assess criterion validity, and known-group method was used along with factor analysis to establish construct validity. Cronbach's α for the total scale was 0.89. Convergent and discriminant validities were also established. Correlations between the MFI and the health-related quality of life scales were significant (p < .01). The scale differentiated between subgroups of persons with the hepatitis B infection in terms of age, gender, employment, education, disease duration, and stage of disease. Factor analysis indicated a four-factor solution for the scale that explained 60% of the variance. The MFI is a valid and reliable instrument to identify fatigue in Iranians with hepatitis B.

Effect of psychiatric symptoms and quality of life on cognitive performance in HCV patients

OBJECTIVE

Reduced performance in several cognitive domains has been repeatedly related to hepatitis C virus (HCV). Nevertheless, there is no consensus about the severity or cognitive profile. Moreover, other possible influential variables are scarcely controlled. The aim of this study is to define the specific cognitive profile in HCV after controlling for confounding variables.

METHODS

Forty-two HCV patients were distributed in 2groups according to the presence of co-infection with human immunodeficiency virus; a third group with 22 healthy controls was also included. The neuropsychological assessment included tests that assess processing speed, executive functioning, verbal memory, visual memory and working memory. Measures of depression (BDI), anxiety (HAM-A), fatigue (MAF), anhedonia (PAS), insomnia (ISI), quality of life (SF-36) and history of drug abuse (DAST-20) were taken in order to explore differences among groups and to control for their possible influence on cognitive performance.

RESULTS

HCV patients (including human immunodeficiency virus-coinfection) performed significantly worse in all cognitive measures. However, when the effect of BDI, HAM-A, MAF, ISI, SF-36 & DAST-20 was controlled, only verbal memory of HCV patients differed among groups. Coinfected patients performed worse in verbal memory.

CONCLUSIONS

According to previous studies verbal memory is the unique cognitive domain related to the effect of HCV. The present study does not support that the neurovirulence effect of HCV is decreasing cognitive performance in HCV patients. Nevertheless, the present study cannot relate the fronto-striatal disruption with the cognitive performance in HCV patients.

A comprehensive assessment of patient reported symptom burden, medical comorbidities, and functional well being in patients initiating direct acting antiviral therapy for chronic hepatitis C: Results from a large US multi-center observational study

BACKGROUND

Symptom burden, medical comorbidities, and functional well-being of patients with chronic hepatitis C virus (HCV) initiating direct acting antiviral (DAA) therapy in real-world clinical settings are not known. We characterized these patient-reported outcomes (PROs) among HCV-infected patients and explored associations with sociodemographic, liver disease, and psychiatric/substance abuse variables.

METHODS AND FINDINGS

PROP UP is a large US multicenter observational study that enrolled 1,600 patients with chronic HCV in 2016-2017. Data collected prior to initiating DAA therapy assessed the following PROs: number of medical comorbidities; neuropsychiatric, somatic, gastrointestinal symptoms (PROMIS surveys); overall symptom burden (Memorial Symptom Assessment Scale); and functional well-being (HCV-PRO). Candidate predictors included liver disease markers and patient-reported sociodemographic, psychiatric, and alcohol/drug use features. Predictive models were explored using a random selection of 700 participants; models were then validated with data from the remaining 900 participants. The cohort was 55% male, 39% non-white, 48% had cirrhosis (12% with advanced cirrhosis); 52% were disabled or unemployed; 63% were on public health insurance or uninsured; and over 40% had markers of psychiatric illness. The median number of medical comorbidities was 4 (range: 0-15), with sleep disorders, chronic pain, diabetes, joint pain and muscle aches being present in 20-50%. Fatigue, sleep disturbance, pain and neuropsychiatric symptoms were present in over 60% and gastrointestinal symptoms in 40-50%. In multivariable validation models, the strongest and most frequent predictors of worse PROs were disability, unemployment, and use of psychiatric medications, while liver markers generally were not.

CONCLUSIONS

This large multi-center cohort study provides a comprehensive and contemporary assessment of the symptom burden and comorbid medical conditions in patients with HCV treated in real world settings. Pain, fatigue, and sleep disturbance were common and often severe. Sociodemographic and psychiatric markers were the most robust predictors of PROs. Future research that includes a rapidly changing population of HCV-infected individuals needs to evaluate how DAA therapy affects PROs and elucidate which symptoms resolve with viral eradication.

TRIAL REGISTRATION

(Clinicaltrial.gov: NCT02601820).

Novel patient-reported outcomes (PROs) used in a pilot and feasibility study of a Cognitive Behavioral Coping Skills (CBCS) group intervention for patients with chronic hepatitis C

Background

Patients with chronic hepatitis C virus (HCV) experience reduced quality of life, HCV-associated symptoms, comorbid conditions, and treatment side effects. The Cognitive Behavioral Coping Skills group intervention for HCV (CBCS-HCV) was developed using the Stage Model of Behavioral Therapies Research. Intervention development and initial feasibility testing in wave 1 participants were previously reported. The primary objective of this subsequent pilot with wave 2–3 participants was to investigate the effect sizes and clinical improvements in patient-reported outcomes (PROs) and trial and intervention feasibility.

Methods

A pilot feasibility two-arm randomized controlled trial using block randomization to assign patients to CBCS-HCV or standard of care was conducted. Participants attended nine group sessions: four before HCV treatment and five during treatment. PRO data were collected at five time points: before the CBCS intervention (T1), immediately before HCV treatment (T2), during HCV treatment (T3, T4), and 1 month post-intervention/post-HCV treatment (T5). PROs included quality of life, perceived stress, HCV symptoms, and medication adherence. Cohen’s d was used to estimate within-group changes (WGCs) and between-group differences (BGDs), with d > 0.35 considered potentially clinically significant. Potential mechanisms of change were also evaluated.

Results

Several WGCs and BGDs (ES > .35) suggest that the CBCS-HCV may promote improvements in PROs: psychological stress, depression, anger, anxiety, sleep disturbance, and fatigue. The intervention did not appear to impact social functioning, pain, or medication adherence. Cognitive behavioral skills and group therapy dynamics, but not HCV treatment self-efficacy, may mediate improvements in PROs. Most aspects of the study trial, including intervention implementation, were feasible. Patient acceptance and retention were exceptional. The greatest feasibility challenge was due to patients needing to initiate treatment as soon as medications were obtained, but often before a full block could be created in wave 3. Challenges with PRO data collection were identified that will be resolved in future studies.

Conclusions

The CBCS-HCV intervention warrants future investigation in an efficacy trial to evaluate improvements in selected PROs. The next step is to pilot test the CBCS-HCV delivered via telehealth to an expanded pool of patients to reduce patient barriers, hone technical logistics, and improve intervention reach and effectiveness.

Trial registration

NCT03057236 Retrospectively registered.

Hepatitis C in a new therapeutic era: Recontextualising the lived experience

AIMS AND OBJECTIVES

To explore the experience of adults living with hepatitis C in a new era of interferon-free treatment.

BACKGROUND

Hepatitis C is a leading cause of morbidity and mortality worldwide, posing a significant challenge to global public health. Historically, the treatment of hepatitis C was poorly efficacious and highly demanding; however, more effective and tolerable therapies have become available in high-income nations in recent years. This is the first study to explore how these significant developments in the treatment of hepatitis C may have influenced the experience of those living with the virus, and their understanding of the disease.

DESIGN

A qualitative study underpinned by social phenomenological theory.

METHODS

Data were generated through semi-structured interviews with a purposive sample of 20 hepatitis C positive adults living in a large city in Scotland.

RESULTS

Thematic analysis identified three overriding themes. "Positioning hepatitis C" illustrated how the disease was understood within wider sociocultural, medical and politico-economic contexts. "Beyond a physical burden" emphasised the emotional aspect of infection, and "a new uncertainty" revealed participants' cautious response to the advances in hepatitis C therapy.

CONCLUSIONS

Interthematic discourse portrayed the new era of hepatitis C treatment as holding little sway over constructions of the illness, as narratives resonated with previous studies. Such unmoving "lay" understandings of hepatitis C may pose potential barriers to the new therapeutic era from reaching its full potential.

RELEVANCE TO CLINICAL PRACTICE

How people living with the virus perceive and understand hepatitis C can have an adverse impact on their engagement with care and treatment. Whilst global medical discourse eulogises the arrival of a new era of therapy, there remain significant challenges for nurses engaging those with hepatitis C in therapeutic pathways.

Living with Hepatitis C Virus: A Systematic Review and Narrative Synthesis of Qualitative Literature

Background and Aims. The lived experience of HCV has not been well documented in the literature. The aim of this systematic review was to understand the experiences of living with Hepatitis C Virus (HCV). Methods. Five databases were searched from inception until January 19, 2015. Studies were included if they focused on adults diagnosed with HCV; reported experience living with HCV; and described original research. Results. 46 studies were included. Studies found that participants had reduced quality of life due to physical symptoms. Due to physical symptoms and discrimination, many participants switched to part-time work or quit their jobs. Many individuals reported negative experiences with the healthcare system; themes of feeling unsupported, not having adequate information, and not feeling involved in decisions were reported. Stigma significantly impacted those living with HCV. Conclusions. Published literature indicates that those with HCV often feel stigmatized and unsupported in their care, relationships, and work environments, while simultaneously coping with physical and psychological symptoms. This synthesis points to areas where greater education, compassion, and patient-centered healthcare could improve the experience of people living with HCV.

Hepatitis C virus infection, and neurological and psychiatric disorders - A review

An association between hepatitis C virus infection and neuropsychiatric symptoms has been proposed for some years. A variety of studies have been undertaken to assess the nature and severity of these symptoms, which range from fatigue and depression to defects in attention and verbal reasoning. There is evidence of mild neurocognitive impairment in some patients with HCV infection, which is not fully attributable to liver dysfunction or psychosocial factors. Further evidence of a biological cerebral effect has arisen from studies using magnetic resonance spectroscopy; metabolic abnormalities correlate with cognitive dysfunction and resemble the patterns of neuroinflammation that have been described in HIV infection. Recent research has suggested that, in common with HIV infection, HCV may cross the blood brain barrier leading to neuroinflammation. Brain microvascular endothelial cells, astrocytes and microglia may be minor replication sites for HCV. Importantly, patient reported outcomes improve following successful antiviral therapy. Further research is required to elucidate the molecular basis for HCV entry and replication in the brain, and to clarify implications and recommendations for treatment.

The Experience of Fatigue Across Long-Term Conditions: A Qualitative Meta-Synthesis

CONTEXT

Fatigue is a common and debilitating symptom associated with many long-term conditions and is reported to cause significant levels of distress for those individuals. There is a substantial body of literature related to the nature of fatigue; however, this has not been drawn together and compared across conditions.

OBJECTIVES

The aim of this review was to synthesize data on the nature of fatigue across long-term conditions.

METHODS

The review was designed as a qualitative meta-synthesis and followed the Joanna Briggs Institute guidelines for synthesizing qualitative research. The following databases were searched for the period January 1980 to January 2016, Ovid (Medline, Embase, CINAHL, and PsycINFO) and manual searching from the reference lists from articles identified by electronic search. Fifty-seven studies were included in the review, and findings related to the nature of fatigue were extracted and findings meta-synthesized.

RESULTS

The perceived nature of fatigue across long-term conditions was encompassed in one synthesis; the fatigue experience is without precedent, with four categories: a different fatigue to any experienced before, the intensity of fatigue is overwhelming, the trajectory of fatigue, and impact on sleep and sleep disturbance. Just over half of the participants in the included studies were diagnosed with cancer. Patterns in the experience of fatigue by condition were found for cancer-related fatigue and post-stroke fatigue where data were able to be synthesized.

CONCLUSION

Although similarities in the nature of the fatigue experienced were found across conditions, differences were also evident and could be mapped for cancer-related fatigue and post-stroke fatigue. Further qualitative research on the experience of fatigue across a wide range of chronic conditions would further contribute to understanding similarities and differences across conditions and inform both research and practice in relation to assessment and management.

Effects of Viral Eradication With Ledipasvir and Sofosbuvir, With or Without Ribavirin, on Measures of Fatigue in Patients With Chronic Hepatitis C Virus Infection

BACKGROUND & AIMS

Fatigue is a disturbing symptom of chronic hepatitis C virus (HCV) infection. We assessed the effects of sustained virologic response 12 weeks after the end of therapy (SVR12) on fatigue.

METHODS

We performed a retrospective analysis of 100 patients with chronic HCV infection who achieved an SVR12 after treatment with ledipasvir and sofosbuvir, with or without ribavirin. Data were collected on fatigue-related patient-reported outcomes (PROs) and assessed by using the Functional Assessment of Cancer Therapy-Fatigue scoring system and the Vitality subscale of Short Form 36. We measured levels of cytokines and growth factors in frozen serum samples collected at baseline, week 12 of treatment, and 4 weeks after treatment. Central fatigue and peripheral or muscle fatigue (PF) were determined by using items from PROs. Serum levels of cytokines, growth factors, serotonin, alanine aminotransferase, and aspartate aminotransferase were measured by using the Bio-Plex, enzyme-linked immunosorbent, and enzymatic assays.

RESULTS

Compared with baseline, 4 weeks after the end of treatment, all fatigue-associated PROs improved significantly. Baseline PROs correlated inversely with serum level of interferon-γ; level of platelet-derived growth factor correlated with PF, central fatigue, and total fatigue score. Only PF correlated with serum level of serotonin. At baseline, high PF scores correlated with high serum levels of serotonin and low levels of interleukin-10 and tumor necrosis factor-α. In multivariate analysis, serum level of interleukin-8 was associated with greater fatigue (P < .02). Reductions in levels of chemokine (C-C motif) ligand 2 (also called monocyte chemotactic protein 1) were associated with fatigue after treatment (P = .0165).

CONCLUSIONS

In an analysis of data from patients with chronic HCV infection participating in a clinical trial of ledipasvir and sofosbuvir, SVR12 was associated with reduced fatigue, compared with baseline. High baseline serum levels of interferon-γ were associated with fatigue. Reductions in levels of chemokine (C-C motif) ligand 2 were associated with persistent fatigue after SVR12. Central and peripheral fatigue each associated with different biomarkers, suggesting different pathogenic pathways.

Fatigue in chronic hepatitis C infection: Understanding patients' experience from a cognitive-behavioural perspective

OBJECTIVES

Fatigue is a leading concern of patients with chronic hepatitis C virus (HCV) infection. Despite its clinical significance, fatigue in HCV is poorly understood and therefore invariably under-treated. A cognitive-behavioural approach offers a framework to understand and treat fatigue, but the characteristics of fatigue in chronic HCV infection have not been documented from a cognitive-behavioural perspective. This study captured the common and unique aspects of fatigue from a cognitive-behavioural perspective in individuals with HCV infection and clinically significant fatigue.

DESIGN

Cross-sectional, qualitative using a critical realism approach.

METHODS

Fourteen individuals (64% women; age >18 years) participated in semi-structured interviews. The interviews documented the features, course, and perceived antecedents of fatigue; fatigue-specific cognitions; fatigue management behaviours; and the functional impact of fatigue.

RESULTS

Participants' descriptions included the aspects of fatigue that have been targets of cognitive-behavioural therapy in other medical conditions, including attributing fatigue to the illness; expectation of chronicity; low control; and fatigue-driven coping. There were also components of fatigue experience that appear to be unique characteristics of fatigue related to HCV, including predominantly physical fatigue; high acceptance of fatigue; and liver-protective diet as a fatigue management behaviour.

CONCLUSIONS

This was the first study to document the experience of fatigue in chronic HCV infection in a cognitive-behavioural framework. The findings suggest that the cognitive-behavioural approach can be applied to fatigue in chronic HCV infection. This would open an avenue to alleviate fatigue and thus improve the primary patient-reported outcome of the disease.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Fatigue is a key patient-reported outcome measure of chronic hepatitis C virus (HCV) infection. Fatigue management is not part of the standard care, because fatigue is poorly characterized in this population. What does this study add? A cognitive-behavioural approach can be applied to understand fatigue in HCV infection. Identified aspects of fatigue (antecedents, consequences, cognitions, behaviours) that can be treatment targets. Cognitive-behavioural therapy would open a new treatment avenue to alleviate fatigue in HCV infection.

The experience of hepatitis C treatment for people with a history of mental health problems: An interpretative phenomenological analysis

This qualitative study explores the experience of hepatitis C virus treatment for people with pre-existing mental health problems within a large city hospital. Four men and four women with pre-existing mental health problems who had received hepatitis C virus treatment took part in semi-structured interviews which were analysed using interpretative phenomenological analysis. A central theme of ‘Self, stigma and change’ was identified which interlinked with three other main themes of ‘Coping and responding to treatment’, ‘Connectedness to others’ and ‘The impact of information’. These themes and their sub-themes are discussed in relation to existing literature and clinical practice guidelines.

Meanings of fatigue for women with Parkinson's disease

The existing knowledge of women's experiences of living with Parkinson's disease and fatigue is limited. To gain first-hand knowledge, we interviewed 11 women using a phenomenological hermeneutic interpretation. The results indicate that the familiar daily routines of women with Parkinson's disease had changed in the sense that their bodily attachment to the world had been altered. The body no longer provided smooth access to the surrounding world; rather, the body served as a barrier to daily living. In practice, understanding this barrier can be significant in recognizing how to create positive conditions that support the women's experiences and how to formulate their care in congruence with their needs.

Fatigue before, during and after antiviral therapy of chronic hepatitis C: results from the Virahep-C study

BACKGROUND & AIMS

Fatigue is the most frequent and often debilitating symptom of chronic hepatitis C. It is unclear whether successful therapy of hepatitis C leads to its clinical improvement. In the Virahep-C study, patients with hepatitis C virus (HCV) genotype 1 infection were treated with peginterferon alfa-2a and ribavirin for up to 48 weeks while undergoing assessment of viral kinetics and clinical symptoms.

METHODS

Fatigue measurements were conducted, before, during and after therapy, as 'presence' (yes/no) and 'severity' (visual analog scale: 0-100mm). The clinical, histologic, and virologic features that correlated with the presence and degree of fatigue were assessed focusing upon changes associated with sustained virological response (SVR).

RESULTS

At baseline, 52% (n=401) of participants reported having fatigue, which was more common in women than men (59% vs. 48%, p=0.02) and slightly more severe (30 vs. 22 mm, p=0.056). Fatigue was frequent and worse in cirrhotics versus those with lesser fibrosis (66% vs. 49%; 34 vs. 24 mm). Fatigue did not correlate with other parameters. The proportion of patients and median fatigue scores increased on treatment (52-78%; 25-40 mm, p<0.0001) with higher fatigue noted amongst those who ultimately achieved SVR (p<0.0001). On achieving SVR, there was a significant decrease in both frequency and severity of fatigue compared to their baseline (53-33%; 27-13 mm, both p<0.0001).

CONCLUSIONS

Fatigue is common in patients with chronic hepatitis C but is poorly associated with biochemical parameters. Sustained response is accompanied by substantial improvement of fatigue.

Review of patient-reported outcome measures in chronic hepatitis C

BACKGROUND

Chronic hepatitis C (CHC) and its treatment are associated with a variety of patient-reported symptoms and impacts. Some CHC symptoms and impacts may be difficult to evaluate through objective clinical testing, and more easily measured through patient self-report. This literature review identified concepts raised by CHC patients related to symptoms, impacts, and treatment effects, and evaluated integration of these concepts within patient-reported outcome (PRO) measures. The goal of this work was to provide recommendations for incorporation of PRO measurement of concepts that are relevant to the CHC experience into CHC clinical trial design.

METHODS

A three-tiered literature search was conducted. This included searches on concepts of importance, PRO measures used in clinical trials, and existing PRO measures. The PRO Concept Search focused on reviewing issues raised by CHC patients about CHC symptoms, disease impact, and treatment effects. The CHC Trials with PRO Endpoints Search reviewed clinical trials with PRO endpoints to assess differences between treatments over time. The PRO Measure Search reviewed existing PRO measures associated with the concepts of interest.

RESULTS

This multi-tiered approach identified five key concepts of interest: depression/anxiety, fatigue, flu-like symptoms, cognitive function, insomnia. Comparing these five concepts of interest to the PRO measures in published CHC clinical trials showed that, while treatment of CHC may decrease health-related quality of life in a number of mental and physical domains, the PRO measures that were utilized in published clinical trials inadequately covered the concepts of interest. Further review of 18 existing PRO measures of the concepts of interest showed only four of the 18 were validated in CHC populations.

CONCLUSIONS

This review identified several gaps in the literature regarding assessment of symptoms and outcomes reported as important by CHC patients. Further research is needed to ensure that CHC clinical trials evaluate concepts that are important to patients and include measures that have evidence supporting content validity, reliability, construct validity, and responsiveness.

Patients' perceptions of information and support received from the nurse specialist during HCV treatment

AIM

To identify patients' perceptions of support received from the nurse specialist during Hepatitis C virus (HCV) treatment.

BACKGROUND

HCV is a worldwide health problem. However, it is a treatable disease and treatment success rates are high. Unfortunately, treatment comes with a multitude of adverse side effects and patients require informational and psychological support from specialist nurses while on treatment. To date, there is little nursing research on support received from this specialist nursing care.

DESIGN

This study used a quantitative descriptive design.

METHOD

A 59-item questionnaire collected data from 106 patients with a diagnosis of HCV attending a HCV outpatient clinic.

RESULTS

Overall, patients were very satisfied with support received. Advice on contraception was well received. However, many patients did not feel supported with regard to advice on sleep management. There were no statistically significant differences between overall satisfaction and gender, age, genotype and risk factor. However, there were significant correlations found between support received and reported genotype. Those patients presenting with genotype 1, who are mostly infected through blood or blood products, indicated that they require more support in relation to information on side effects of treatment, quality of life and support groups. Specific approaches to support and advice for this cohort may need to be incorporated into current services.

CONCLUSION

Results of this study reinforce the need for the ongoing use of specialist nurse services and development of this service where no such facilities exist. In addition, the service may need to further recognise and support the information and psychological needs of patients with differing modes of HCV infection.

RELEVANCE TO CLINICAL PRACTICE

Findings provide information to practising nurse specialists about patient's views of information and support received from nurse specialists in HCV treatment centres and identify where deficits exist.

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

We identified trajectories of illness uncertainty in chronic hepatitis C patients and examined their association with fatigue levels during 12 months of disease monitoring without treatment (watchful waiting). Sixty-two men and 63 women completed uncertainty and fatigue measures. Groups were formed by uncertainty scores (high, medium, and low) at baseline. Baseline fatigue levels were higher in the high uncertainty group than in the medium and low groups. Over time, uncertainty levels did not change. Fatigue levels in the low uncertainty group remained constant, increased in the medium, and decreased in the high groups. Findings suggest that uncertainty and fatigue do not remit spontaneously. Being aware of this may help nurses identify those patients needing support for these two concerns.

Socio-demographic and clinical features of Irish iatrogenic hepatitis C patients: a cross-sectional survey

BACKGROUND

A discrete sub-group of iatrogenically-acquired hepatitis C virus (HCV)-infected individuals exists in the Irish population on whom limited current research data is available. The aim of this study was to establish a current profile of the socio-demographic and clinical characteristics of the Irish iatrogenic hepatitis C population and to determine factors predicting symptoms experienced.

METHODS

An anonymous, national, cross-sectional survey was conducted to explore this populations' self-reported health and social attributes. Data were collected on 290 respondents.

RESULTS

Mean time since infection was 26 years. Eighty-four percent (n = 237) of respondents were female (mean age = 55.9 +/- 9.6 years). Hepatic and extra-hepatic symptoms were common (62% and 99% respectively). Fatigue and pain were frequent complaints while 89% reported diagnosed co-morbid disease. On logistic regression, female gender, age and co-morbid disease emerged as independent predictors of self-reported symptoms.

CONCLUSION

This study describes the current status of the iatrogenically infected patient cohort in Ireland, adding to existing knowledge regarding the clinical course and consequences of HCV infection. Changing healthcare needs were shown by comparison with earlier surveys in this same population, in terms of disease progression, development of co-morbid disease and ageing.

The multidimensional burden of hepatitis C and its treatment: a case study

The purpose of this case study was to gain an in-depth understanding of the mental, physical, and emotional burden of being infected with the hepatitis C virus (HCV) from the perspective of an individual living with the disease and undergoing antiviral treatment. Interviews were conducted during and after antiviral therapy with 1 participant chosen from a Midwest HCV clinic population. Interviews were audio recorded, transcribed verbatim, and coded. Content analysis and thematic analysis were performed. The participant reviewed and validated the themes and the interpretation of the themes. Ten categories were identified, which were subsequently integrated in 4 themes: (1) transition or process of change, (2) maintaining control over one's life, (3) social support and communication, and (4) side effects. The results of this study can assist healthcare providers to understand what individuals experience in the course of HCV infection and its treatment. This knowledge will assist them to provide effective patient-centered care. To provide such care, it is imperative that healthcare providers understand the physical, psychological, social, and professional impact that the diagnosis of HCV infection and antiviral therapy has on individuals.

Chronic Fatigue

Because of the widespread nature of chronic fatigue, health care providers need a common understanding of chronic fatigue to enable effective communication. To aid this understanding a concept analysis was undertaken using a modified version of Rodger’s evolutionary method of concept analysis. The literature review yielded many resources focused on defining fatigue and relating it to many diverse chronic conditions. This article also discusses the differences between chronic fatigue and acute episodes of fatigue. Chronic fatigue is a subjective, unpleasant, changeable, and exhausting experience that adversely affects quality of life. Whereas rest or sleep often relieves acute fatigue, chronic fatigue is unrelenting. Chronic fatigue has multiple antecedents and is a component of a diverse array of chronic diseases.

Future directions for investigation of fatigue in chronic hepatitis C viral infection

Fatigue is a common and often debilitating symptom for people living with chronic hepatitis C viral infection. Numerous published reports in the past decade have attempted to address the nature and aetiology of fatigue in chronic hepatitis C; however, this field is plagued with lack of clarity about how hepatitis C virus (HCV)-related fatigue occurs and when it is experienced by the infected person. Consequently, both patients and clinicians alike are unclear about how to mediate or prevent the negative consequences of HCV-related fatigue. In the following article, the authors identify areas of ambiguity and incongruity that have evolved primarily from the underlying assumptions and methodological decisions of researchers in the field of HCV-related fatigue. Research related to fatigue in chronic illness is drawn upon to suggest future directions for investigations and interventions in the field of HCV-related fatigue. Future research needs to move beyond the subjective symptomatology of HCV-related fatigue and begin to account for the multidimensional and contextualised nature of the fatigue experience.

Uncertainty, symptoms, and quality of life in persons with chronic hepatitis C

BACKGROUND

Chronic hepatitis C (CHC) is the most common blood-borne infection in the United States, but little is known about illness uncertainty in these patients.

OBJECTIVE

The authors examined the constructs of illness uncertainty.

METHOD

In this cross-sectional study, Mishel's Uncertainty in Illness Scale was used to examine these constructs (ambiguity, complexity, inconsistency, unpredictability) and their relationships with fatigue, pain, depressive symptoms, comorbidity, and quality of life (QOL) in 126 CHC patients undergoing a watchful-waiting protocol.

RESULTS

The Ambiguity subscale had the strongest relationships with depressive symptoms, QOL, and fatigue, and three of the four subscales were significantly correlated with pain.

CONCLUSION

The results suggest targets for patient self-management interventions.

Living with hepatitis C: qualitative interviews with hepatitis C-infected veterans

BACKGROUND

Chronic hepatitis C (HCV) infection affects millions of people in the USA and prevalence rates are higher in US veterans. The consequences of HCV infection include reduced quality of life, liver damage, and reduced longevity.

OBJECTIVE

Our objective was to describe the experiences of US veterans living with chronic HCV infection and use this information in the development of an HCV self-management intervention.

METHODS

Twenty-two male HCV-infected veterans completed qualitative interviews. Participants were recruited via flyers and hepatitis C clinic providers at a major VA medical center. Participants were asked about their medical history, being diagnosed with HCV, and general experiences living with HCV.

RESULTS

The study gathered the following findings: the impact of HCV on interpersonal relationships was pronounced, recovery from substance use disorders and getting care for HCV were connected, receiving the HCV diagnosis was more troubling to non-IV drug users, participants had misconceptions about HCV and its treatment, psychological problems were prevalent as were barriers to participating in antiviral treatment and HCV care in general.

CONCLUSION

The themes derived from our analysis indicate that affected veterans may benefit from interventions or support to improve HCV-related health education, social/relationship issues, psychological issues, and exploration of the connection between substance use recovery and motivation to get care for HCV infection.

Chronic fatigue: an evolutionary concept analysis

AIM

This paper is a report of a concept analysis of chronic fatigue.

BACKGROUND

Fatigue is a prevalent symptom encompassing both acute and chronic manifestations. It is chronic fatigue that is most problematic because of its duration and impact on life quality. The rise in prevalence of chronic conditions will result in a need to address coexistent symptoms, clarification of which is needed. Chronic fatigue is one of the most common symptoms in chronic illness. Clarification of the concept and an understanding of its use by discipline are needed.

DATA SOURCES

The evolutionary method of concept analysis was used to ascertain the attributes, antecedents, consequences and surrogate terms for chronic fatigue. A review of the literature published between 1966 and 2007 was carried out to determine the contextual use of the concept of chronic fatigue among disciplines. Sources used for this analysis included CINAHL, Medline, PsychINFO and Social Work Abstracts and the search yielded 66 papers.

RESULTS

The chronic fatigue experience is associated with a multitude of physical, psychological and social factors. The defining attributes of chronic fatigue are constancy, abnormality, whole-body experience, inexplicability and disabling. The antecedents of chronic fatigue are physical disease, psychopathology, female gender and a history of abuse. Consequences found include social isolation and stigmatization, physical inactivity, psychological disturbances and a reduced quality of life.

CONCLUSION

Further research is needed to identify the aetiology of chronic fatigue and to address the social context of living with this disabling symptom.

An exploration of the relationship between fatigue and physical functioning in patients with end stage renal disease receiving haemodialysis

AIM

To measure fatigue and physical functioning in patients with end stage renal disease (ESRD) receiving haemodialysis and to investigate the relationships between fatigue and physical functioning.

BACKGROUND

Fatigue and reduced physical functioning are among the most bothersome symptoms experienced by individuals receiving haemodialysis for ESRD. Research has shown that increasing activity levels has resulted in decreased fatigue levels and improved physical functioning in individuals with cancer. Establishing whether or not a relationship exists between both concepts in haemodialysis patients is a preliminary step in identifying potential fatigue reducing strategies necessary for improved wellbeing.

METHOD

A quantitative exploratory correlational design was used with 46 individuals completing the Multi-dimensional Fatigue Inventory, the Medical Outcomes Study Short-Form 36-item questionnaire and a Demographic Questionnaire.

RESULTS

Results indicated fatigue was prevalent with highest scores achieved for physical fatigue; reduced activity and general fatigue. Substantial limitations in physical functioning were found. A significant moderate negative relationship between general fatigue and physical functioning indicated that, as physical functioning levels increased, fatigue levels decreased. A significant difference was also found between general fatigue scores for males and females. Significant relationships were found between overall physical functioning, older age and employment status.

CONCLUSION

The research indicates the prevalence of fatigue and limitations in physical functioning in individuals with ESRD. However, as physical functioning increased fatigue decreased; a finding relevant to clinical nursing.

RELEVANCE TO CLINICAL PRACTICE

Understanding the levels of fatigue and the value of exercise is of relevance to clinical practice thus assessment of fatigue and physical functioning ability in the clinical setting is necessary.

A phenomenological study of fatigue in patients with primary biliary cirrhosis

AIM

This paper reports the findings of research on the lived experience of fatigue in patients with primary biliary cirrhosis - a type of chronic liver disease.

BACKGROUND

Fatigue is a universal phenomenon, commonly associated with both acute and chronic illness, but also seen in healthy individuals. However, it is not often addressed in healthcare encounters despite its disabling nature, perhaps because of the multitude of contributing factors and the lack of effective treatments. It is a common and debilitating symptom in patients with primary biliary cirrhosis. Despite the prevalence of fatigue in this condition, patients' experiences of this symptom have not been researched.

METHOD

An interpretive-phenomenological approach developed by van Manen was chosen and this combines features of descriptive and interpretive phenomenology. Eight participants were interviewed during 2005 about their fatigue experience. Thematic analysis was conducted.

FINDINGS

Five themes were identified: an unreliable body, fatigue as always present yet insidious, planning a life to conserve energy, struggling to maintain normality and emotional consequences. These themes reflected the unrelenting, intrusive nature of fatigue into the lives of those affected.

CONCLUSION

This research will provide empathic insight into the fatigue experience in this condition and generate communication about coping strategies. It will add to the body of research on fatigue in chronic conditions and may generate ideas for intervention research.

The patient experience of treatment for hepatitis C

This study has used qualitative hermeneutics to explore the patient's experience of treatment for hepatitis C. Hepatitis C treatment may pose numerous physical and emotional challenges. There is a need to understand the experience from a holistic nursing perspective in order to facilitate the patient's well-being. Individuals undergoing combination treatment for hepatitis C participated in a hermeneutic dialogue, which provided the investigators with an emic perspective. Dialogue content, reflection, and preunderstanding were hermeneutically analyzed. Similar treatment experiences elicited four common emotions (sadness, anger, fear, and frustration). Analyzing the similar experiences led to two emerging themes: (1) "That is not who I am," connoted by rejecting the notion of being a "typical" patient, seeing treatment as not so bad, being "different" during treatment, and feeling abandoned because of treatment; and (2) "looking beyond the experience" was noted by looking for faith beyond traditional healthcare and looking for understanding. The hepatitis C treatment experience was seen as a process: having a start, a middle, and an end, without being all-consuming. Implications for holistic nursing care are presented.

Women's experiences of fatigue in chronic illness

AIM

The aim of this paper is to add a qualitative dimension to the body of knowledge about fatigue by revealing the meaning given by women living with chronic illness to the experience of fatigue.

BACKGROUND

Fatigue is a common symptom experienced by people who live with chronic illness. It pervades every aspect of life and may be experienced in physical, psychological, emotional or social dimensions. Management of fatigue relies heavily on the individual's ability to employ self-care actions. The invisibility of fatigue is recognized as one of the most frustrating aspects, which can lead to lack of understanding and misunderstanding by others.

METHOD

We report the findings of data from research in progress (2003-2005). Data were generated via email group conversations between us and 30 women who live with long-term illness.

FINDINGS

A recurring conversational thread has been women's experiences of fatigue when living with long-term illness. Although fatigue has been reported to be a major obstacle to maintaining usual daily activities and quality of life, few studies have explored this common symptom from the perspective of people themselves. Common themes found in the experience of fatigue as described by women are the meaning of fatigue, awareness as self-care, fatigue as invisible to others, seeking medical validation and accountability for self-care.

CONCLUSION

It is vital for healthcare workers to give opportunities for women to talk about fatigue, validate their experiences and provide support with self-care. Healthcare workers are encouraged to challenge their own meanings and expectations surrounding a person's report of fatigue so that opportunities for therapeutic intervention can be facilitated.

A review of cognitive impairment and cerebral metabolite abnormalities in patients with hepatitis C infection

Numerous studies have reported associations between chronic hepatitis C virus (HCV) infection and fatigue, depression and impairments in health-related quality of life, which are independent of the severity of liver disease. Although there are a large number of potential explanations for these symptoms, including a history of substance abuse and associated personality types, or the effect of the diagnosis of HCV infection itself, there has been recent interest in the possibility of a biological effect of HCV infection on cerebral function. There is emerging evidence of mild, but significant neurocognitive impairment in HCV infection, which cannot be wholly attributed to substance abuse, co-existent depression or hepatic encephalopathy. Impairments are predominantly in the domains of attention, concentration and information processing speed. Furthermore, in-vivo cerebral magnetic resonance spectroscopy studies in patients with hepatitis C and normal liver function have reported elevations in cerebral choline-containing compounds and reductions in N-acetyl aspartate, suggesting that a biological mechanism may underlie the cognitive findings. The recent detection of HCV genetic sequences in post-mortem brain tissue raises the intriguing possibility that HCV infection of the central nervous system may be related to the reported neuropsychological symptoms and cognitive impairment.

Factors Influencing the Development of a Hepatitis C Exercise Protocol

Chronic hepatitis C (HCV) varies greatly in its course and outcomes. Reports of fatigue and other symptoms are common during treatment and when patients are not receiving treatment. Exercise as a form of treatment for HCV-related fatigue has had little attention in research studies, yet data from studies in closely related chronic conditions consistently report the value of exercise for maintaining and improving health and reducing risk factors. This article examines the factors influencing the development of an exercise protocol as an adjunct to health promotion in patents with HCV. A review of the current literature summarizes findings from the areas of exercise in chronic illness states, exercise measures, and exercise prescription as treatment for chronic illnesses, with a focus on HCV. Nurses should consider these factors when developing an exercise protocol as an alternative treatment for side effects and symptoms related to hepatitis C and other chronic conditions. More research on specific exercise prescriptions should be undertaken and reported in the literature.

The meaning of fatigue for women with multiple sclerosis

AIM

This paper reports the findings of a study that aimed to elucidate the meaning of fatigue for women with multiple sclerosis (MS).

BACKGROUND

Living with chronic illness can involve giving up usual activities. MS is a chronic autoimmune disease of the central nervous system. Fatigue is a common experience among people with MS; however, little is known about the meaning of fatigue experienced by women with this condition.

METHOD

Ten women with MS were interviewed about their experience of fatigue. A phenomenological hermeneutic method influenced by Ricoeur was used to interpret the transcribed interviews.

FINDINGS

The findings were presented in two major themes with five subthemes; experiencing the body as a barrier and experiencing a different absence. Fatigue seemed to give rise to an experience of being absent and divided into two parts. This also led to a feeling of not being able to participate in the surrounding world. The feeling of being an outsider and lacking the ability as a healthy person is interpreted as a form of suffering. Although the fatigue had a great impact on the women's daily life, the women still hoped for some relief. Fatigue seemed to imply that instead of working as an implement to manage in the world the body has become an enemy of survival.

CONCLUSION

This study highlights the importance for nurses of understanding how women with MS experience fatigue, which is a prerequisite for communication based on a shared understanding. This awareness would enhance nurses' opportunities to alleviate suffering. More research is needed to investigate what kinds of interventions can help these women to manage their everyday lives and to maintain a sense of normality despite their fatigue and illness. Such interventions should be subject to empirical evaluation research.

Exploring risk perception and behaviour of homeless injecting drug users diagnosed with hepatitis C

Injecting drug users (IDUs) are at the greatest risk of hepatitis C infection by using any item of injecting equipment that has come into contact with contaminated blood. Alongside this, homeless IDUs have been identified as being at increased risk of harm in their illicit drug taking behaviour. This study interviewed 17 hepatitis C positive homeless IDUs about their injecting practices. In-depth interviews explored the impact of a positive hepatitis C diagnosis on their injecting and identified their risk behaviours and perceptions. The interviews were tape-recorded, transcribed and analysed using the framework approach. Homeless IDUs engaged in both high risk and unhygienic injecting practices, such as using drugs outside and in public places, sharing injecting equipment and re-using cleaned needles. Excessive needle reuse whilst in prison was also identified. However, the findings were not universally bleak as a positive diagnosis of hepatitis C did lead to some behaviour change towards safer injecting and some adopted other lifestyle and behaviour changes. It was, however, common for homeless people to devolve responsibility for preventing hepatitis C transmission to their peers, especially when injecting with others. Knowledge regarding possible transmission through injecting paraphernalia appeared to make users more careful to reduce it through these routes. Placing a continuous emphasis on health promotion is therefore important in educating IDUs about the hepatitis C transmission risks associated with injecting drug use. Information regarding safer and hygienic use, including accurate information regarding the most effective methods to clean used equipment, must be re-enforced by people working with homeless injecting drug users.

Hepatitis C virus

Hepatitis C virus is a common blood-borne pathogen that is now declining as a new infection in the population. However, women and men who were infected 2 to 3 decades ago are now developing liver damage. To prevent further damage, treatment with IFN and ribavirin is available. Because of adverse events, this treatment requires close supervision over 6 to 12 months, which is often provided by a clinic nurse in collaboration with the physician and pharmacist. Educational outreach to the public and health care providers may help identify patients earlier and promote screening of high-risk groups.