Jill R. Quinn

Symptom Clusters in Acute Myocardial Infarction: A Secondary Data Analysis

Background: Early recognition of acute myocardial infarction (AMI) symptoms and reduced time to treatment may reduce morbidity and mortality. People having AMI experience a constellation of symptoms, but the common constellations or clusters of symptoms have yet to be identified. Objectives: To identify clusters of symptoms that represent AMI. Methods: This was a secondary data analysis of nine descriptive, cross-sectional studies that included data from 1,073 people having AMI in the United States and England. Data were analyzed using latent class cluster analysis, an atheoretical method that uses only information contained in the data. Results: Five distinct clusters of symptoms were identified. Age, race, and sex were statistically significant in predicting cluster membership. None of the symptom clusters described in this analysis included all of the symptoms that are considered typical. In one cluster, subjects had only a moderate to low probability of experiencing any of the symptoms analyzed. Discussion: Symptoms of AMI occur in clusters, and these clusters vary among persons. None of the clusters identified in this study included all of the symptoms that are included typically as symptoms of AMI (chest discomfort, diaphoresis, shortness of breath, nausea, and lightheadedness). These AMI symptom clusters must be communicated clearly to the public in a way that will assist them in assessing their symptoms more efficiently and will guide their treatment-seeking behavior. Symptom clusters for AMI must also be communicated to the professional community in a way that will facilitate assessment and rapid intervention for AMI.

Living with advanced heart failure or COPD: Experiences and goals of individuals nearing the end of life

The last phase of life of patients with end-stage heart failure (HF) or chronic obstructive pulmonary disease (COPD) is marked by high symptom burden and uncertainty about the future. Few enroll in hospice, and their preferences for care remain unknown. The purpose of this qualitative study was to describe the experiences and goals for care of patients with end-stage HF and COPD who were recently discharged from the hospital. Forty semi-structured interviews were completed with 20 participants. Despite conditions considered life-threatening by clinicians, participants believed they still had time. They hoped that their illnesses would remain stable, although specific experiences made them think they might be worsening. All expected that their doctors would tell them when their illnesses became life-threatening.

Towards a Personal Health Management Assistant

We describe design and prototyping efforts for a Personal Health Management Assistant for heart failure patients as part of Project HealthDesign. An assistant is more than simply an application. An assistant understands what its users need to do, interacts naturally with them, reacts to what they say and do, and is proactive in helping them manage their health. In this project, we focused on heart failure, which is not only a prevalent and economically significant disease, but also one that is very amenable to self-care. Working with patients, and building on our prior experience with conversational assistants, we designed and developed a prototype system that helps heart failure patients record objective and subjective observations using spoken natural language conversation. Our experience suggests that it is feasible to build such systems and that patients would use them. The system is designed to support rapid application to other self-care settings.

Effect of leisure activities on inflammation and cognitive function in an aging sample

Cardiovascular disease risk factors (CVDRFs) increase the risk of dementia. The purpose of this study was to examine whether leisure activities (mental, physical, and social activities) modified the effect of CVDRFs on inflammatory markers and cognitive function in middle and old age. A secondary-data analysis study was conducted using data from 405 middle-age participants (40-59 years) and 342 old-age participants (60-84 years) who participated in the Survey of Midlife Development in the United States (MIDUS). CVDRFs were obtained from a combination of self-report medical history and blood-based biomarkers. Three CVDRF groups (≤1, 2, and ≥3 CVDRFs) were identified. More CVDRFs were significantly associated with higher levels of inflammatory markers in both age groups, and associated with lower levels of executive function (EF) in the old age group. CVDRFs were not related to the frequency of leisure activities in either age group. After controlling for covariates, higher levels of physical activities were significantly associated with lower levels of inflammatory markers, and higher levels of mental activities were associated with higher levels of cognitive function. In the old age group, physical activities also moderated the effect of CVDRFs on episodic memory (EM), and mental activities moderated the effect of CVDRFs on interleukin-6 (IL-6). Multiple CVDRFs may be associated with poorer cognitive function and higher inflammatory markers, but middle-age and older adults with CVDRFs may not engage in frequent physical and cognitive activities that may be protective. It is important to develop strategies to facilitate engagement in these activities from midlife.

“That Don’t Work for Me”: Patients’ and Family Members’ Perspectives on Palliative Care and Hospice in Late-Stage Heart Failure

Experts in both heart failure and palliative care recommend collaboration between the two disciplines as a mechanism to improve late-stage heart failure care. However, referral rates of heart failure patients to palliative care services remain low. The purpose of this study was to describe the perspectives of heart failure patients and their family members regarding the barriers to palliative care in late-stage heart failure care. We used qualitative content analysis to identify themes from 40 semistructured interviews with 24 hospitalized late-stage heart failure patients and 16 designated family members. Results indicated that participants often refused or deferred palliative care services if they viewed hospice and palliative care as synonymous. They perceived that a set of hospice “rules” existed and that they were “deal breakers” for heart failure patients as they impeded the goals of aggressively managing troubling symptoms and/or providing comfort at end of life. The findings from this study underscore the need to examine the current hospice guidelines and for clinicians to view palliative care as a philosophy of care that allows for the unpredictable trajectory of heart failure.

Multi-joint foot kinetics during walking in people with Diabetes Mellitus and peripheral neuropathy

Neuropathic tissue changes can alter muscle function and are a primary reason for foot pathologies in people with Diabetes Mellitus and peripheral neuropathy (DMPN). Understanding of foot kinetics in people with DMPN is derived from single-segment foot modeling approaches. This approach, however, does not provide insight into midfoot power and work. Gaining an understanding of midfoot kinetics in people with DMPN prior to deformity or ulceration may help link foot biomechanics to anticipated pathologies in the midfoot and forefoot. The purpose of this study was to evaluate midfoot (MF) and rearfoot (RF) power and work in people with DMPN and a healthy matched control group. Thirty people participated (15 DMPN and 15 Controls). An electro-magnetic tracking system and force plate were used to record multi-segment foot kinematics and ground reaction forces during walking. MF and RF power, work, and negative work ratios were calculated and compared between groups. Findings demonstrated that the DMPN group had greater negative peak power and reduced positive peak power at the MF and RF (all p≤0.05). DMPN group negative work ratios were also greater at the MF and RF [Mean difference MF: 9.9%; p=0.24 and RF: 18.8%; p<0.01]. In people with DMPN, the greater proportion of negative work may negatively affect foot structures during forward propulsion, when positive work and foot stability should predominate. Further study is recommended to determine how both MF and RF kinetics influence the development of deformity and ulceration in people with DMPN.

A Place to Get Worse: Perspectives on Avoiding Hospitalization from Patients with End-Stage Cardiopulmonary Disease.

Much of what is known about delay in seeking medical care has been from patients with acute coronary syndromes. Less is known about why patients living with chronic cardiopulmonary illnesses delay seeking care for worsening symptoms. The aim of this study was to describe the perspectives of patients with end-stage heart failure or chronic obstructive pulmonary disease about their timing in seeking medical care for worsening symptoms. Two semistructured interviews were conducted with 20 participants and were audio recorded and transcribed verbatim. Avoiding the hospital was the central theme among participants in this study. Returning to the hospital invoked an underlying fear, symbolizing negative things. These included a perceived hassle and setback associated with hospitalization and a fear of not returning home following another admission, either from loss of independence or death. This study sheds light on findings from previous research that delay results from the inability to recognize worsening symptoms. Participants in this study clearly recognized worsening symptoms, yet waited to seek care until it was unbearable in effort to avoid the hospital. The incorporation of palliative alongside disease-driven care within this population would alleviate symptoms, which could decrease the need for emergent care and subsequent hospitalization.

Reasons for Use of Hormone Replacement Therapy in Women Undergoing Coronary Angiography

The recommendation has been made that all women be counseled about the risks and benefits of hormone replacement therapy (HRT). Use of HRT among women undergoing coronary angiography was explored to assess whether patterns of use were similar to data drawn from community samples. Using a descriptive design, a convenience sample of 414 postmenopausal women was interviewed. Fifty-eight percent had never used HRT, 18.3% were past users, and 23.7% were currently using HRT. The primary reason given for ever using HRT was for symptoms of menopause. Less than 14% of women cited coronary heart disease (CHD) or osteoporosis as their primary reason for using HRT. The most common reasons for stopping HRT were side effects and fear of cancer. The most common reasons given for never having used HRT were that their healthcare provider had never talked about it and that they had never thought about it. Use of HRT among women undergoing coronary angiography is similar to that found in community samples. The challenge is to promote patient-provider interactions that include information about HRT based on the scientific model as well as attention to womens individual concerns.

Kansas City Cardiomyopathy Questionnaire Administered to Hospitalized Patients With Heart Failure.

Background and Purpose: The psychometric properties of the Kansas City Cardiomyopathy Questionnaire (KCCQ) have been examined primarily in community-dwelling patients with heart failure (HF). The objective of this research was to examine the properties of the KCCQ administered to patients hospitalized with HF (N = 233). Methods: Confirmatory factor analysis, Cronbach’s alphas, and correlations were performed to examine the scale’s dimensions, reliability, and validity. Results: Confirmatory factor analysis indicated a 5-factor solution (63.6% of the variance). The Cronbach’s alpha levels were greater than .70, except for the self-efficacy dimension (.60). Convergent validity was not verified between the KCCQ and several illness severity measures. Conclusions: The psychometric properties of the KCCQ may be different based on the population in which the KCCQ is administered, which may have clinical implications.

Who Is Attending? End-of-Life Decision Making in the ICU (318-C)

Who Is Attending? End-of-Life Decision Making in the ICU (318-C) Judith Baggs, PhD RN FAAN, Oregon Health & Science University, Portland, OR. Madeline Schmitt, PhD RN, University of Rochester, Rochester, NY. Thomas Prendergast, MD, Portland VA Medical Center, Portland, OR. Sally Norton, PhD RN FPCN, University of Rochester, Rochester, NY. Craig Sellers, PhD RN ANP-BC GNP, University of Rochester, Rochester, NY. Jill Quinn, PhD RN CS-ANP FNAP FAHA FAANP, University of Rochester, Rochester, NY. (All authors listed above for this session have disclosed no relevant financial relationships with the following exception: Baggs is an editor for Wiley-Blackwell Publishers and receives an honorarium.)