Monica Pettersson

Prospective follow-up of sexual function after elective repair of abdominal aortic aneurysms using open and endovascular techniques

OBJECTIVES Surgical intervention in the treatment of abdominal aortic aneurysms (AAA) can affect sexual functions, resulting in a negative impact on the quality of life. The aim of this study was to investigate the preoperative information given about sexual functions and to compare the functional changes after open (OR) and endovascular repair (EVAR) for patients with AAA during one year after treatment. METHODS Seventy-six patients participated in the study (40 OR and 36 EVAR). A questionnaire was used to measure the sexual function preoperatively, and then after one month and one year following surgical interventions. Four aspects related to sexual function were studied: interest in sex, quality of erection, ability to achieve orgasm, and ejaculation. Two questions about the preoperative information covering the sexual function and another two questions about the patients concern for their sexual activities were also added. Fishers exact test was used to test for significant relative changes within each group of treatment for the variables studied. RESULTS Ninety-one percent reported that they did not receive any preoperative information about the risk for any possible negative impact on the sexual function. None of the EVAR patients were given such information. Forty-two percent of all patients felt some anxiety about having sex before the operation, which decreased to 7% after one year. About 22% reported having strong/moderate ability of their erection and 54% reported this as being weak/very weak preoperatively. Patients who preoperatively had reported some form of sexual interest had experienced a significant impairment in sex (P < .039) one year after the interventions. Patients treated with EVAR reported a significant impairment in the quality of erection (P < .033) and their ability to achieve ejaculation (P < .047) one year after the operation. A similar tendency was seen in the OR group, but did not achieve statistical significance. CONCLUSION Few patients were given or understood any preoperative information concerning the risk and possibility of a negative impact on their sexual function following surgical interventions. This was especially reported by patients in the EVAR group. Following the operation, the reported sexual interest and ability was decreased among patients in both groups. When only those patients who had reported some form of interest in sexual activity before the intervention were analyzed, a small significant impairment in quality of erection and achieving ejaculation could be found during the one year follow-up in the EVAR group.

Opening Pandora's box: The experiences of having an asymptomatic aortic aneurysm under surveillance

Abdominal aortic aneurysm (AAA) is a ballooning-out of the aorta that does not normally give any symptoms. Undetected and untreated an aortic aneurysm can rupture, which in most cases is fatal. Mass screening of 65-year old men for the early detection of AAA and, in selected cases, operation seem to reduce mortality due to rupture, although, screening has not reduced the overall mortality in this group. In Västra Götaland, the southwest part of Sweden, screening for AAA amongst 65-year old men started in 2009. There are controversies within the medical community about the benefits and adverse effects of screening. In order to explore mens experiences of being screened and knowing they had an aortic aneurysm, we undertook a qualitative interview study with 15 men who in the screening programme were identified as having an aortic aneurysm and who were to be followed-up with annual ultrasonic examinations for an indeterminate number of years. The interviews were analysed for categories and themes using content analysis. The study found that the men were ambivalent about the knowledge that they had an AAA and about the follow-up monitoring. They appreciated having the knowledge but it was accompanied by worry, feelings of anxiety and existential thoughts about the fragility and finiteness of life. We recommend that before a screening programme is implemented, the psycho-social consequences should be thoroughly investigated. Participants should be given adequate and understandable information about the consequences of screening so that they can make an informed choice whether to participate or not.

Psychometric properties of the disease-specific health-related quality of life instrument VascuQoL in a Swedish setting

BackgroundTraditional outcome measures in peripheral arterial disease (PAD) provide insufficient information regarding patient benefit. It has therefore been suggested to add patient-reported outcome measures. The main aim of this study was to validate the Swedish Vascular Quality of Life questionnaire (VascuQoL) version, a patient-reported PAD-specific health-related quality of life (HRQoL) instrument.MethodsTwo-hundred PAD patients were consecutively recruited from two university hospitals. Out of the 200 subjects, 129 had intermittent claudication and 71 had critical limb ischemia. Mean age was 70 ± 9 y and 57% of the participants were male. All patients completed SF-36 and VascuQoL at the vascular outpatient clinic, when evaluated for invasive treatment. Risk factors and physiological parameters were registered. Construct validity was tested by correlation analysis versus SF-36 and was also assessed with multitrait/multi-item scaling analysis (MTMI). Sensitivity analysis regarding disease severity identification was performed. Reliability was assessed with Cronbachs alpha and responsiveness by standardized response mean (SRM) calculations.ResultsSignificant correlations were demonstrated between relevant subscales of VascuQoL and SF-36. MTMI showed acceptable construct validity, but some scaling-errors. VascuQoL significantly (p < 0.001) discriminated claudicants from critical limb ischemia patients. Cronbachs alpha was 0.94 and SRM 1.02 (sum score).ConclusionsThe Swedish version of VascuQoL is valid and quantifies central aspects of HRQoL in PAD patients. Sensitivity analysis showed high ability to differentiate between disease severity and SRM illustrated excellent responsiveness. The relative abundance of items however makes use in the everyday clinical setting somewhat difficult.

Structure and content in consultations with patients undergoing surgery for colorectal cancer

PURPOSE To explore the structure and content of pre-planned consultations as part of the care and treatment of patients undergoing surgery for colorectal cancer. METHODS The study was based on 50 transcripts of audio-recorded pre-planned consultations between seven patients and 36 healthcare professionals from the time of diagnosis, pre-operative consultation, discharge consultation and pathology report in a colorectal unit. RESULTS The spread of consultation time between professions was considerable. Total mean consultation time for patients during the care process (7 consultations/patient) was 111 min (range 83-191). The mean consultation time for surgeons was 18 min (7-40), anaesthesiologists 12 min (5-18) and nurses 14 min (5-49). Patients took up 40% of the word space, healthcare professionals used 59% and significant others 1%. Word space changed in such a way that the patient became more active towards the final consultation. Neither during the diagnosis consultation nor during the pre-operative consultation did the patients meet the operating surgeon. Six major subjects emerged: general health, diagnosis, surgical procedure, pre-operative preparations, recovery and treatment and follow-up. CONCLUSIONS There is a need for clearer structure in the consultations. Most consultations lacked a clear introduction to the subject of the conversation. The study makes it possible to develop methods and structure for supporting conversations in which the patient is given space to help with the difficult issues present after undergoing surgery for colorectal cancer. The study also contributes to providing knowledge of how to organise surgical consultations in order to optimise person-centeredness, teamwork and clinical efficiency.

The drama of being diagnosed with an aortic aneurysm and undergoing surgery for two different procedures: Open repair and endovascular techniques

The purpose of this study is to describe and interpret what it means for patients to be diagnosed with an abdominal aortic aneurysm (AAA) and how they experience treatment. AAA is usually asymptomatic and often discovered coincidentally in conjunction with a diagnostic workup for other medical problems. Twenty patients who had undergone 2 different surgical procedures were sequentially invited for interviews 1 month following surgery. A hermeneutic approach was used. For all patients three themes emerged: an inability to come to terms with a life-threatening condition, a sense of living on borrowed time, and a sense of being granted a new lease on life. The theme that emerged for patients with open repair was that diagnosis with AAA was an ordeal to endure, while the theme for patients who underwent endovascular treatment was a sense of gratitude, security, and insecurity. Once the aneurysm was discovered patients were convinced that they were both blessed and saved, along with a sense of gratitude. Pre- and postoperative nursing care strategies can be developed based on the findings from this study.

Safety Hazards During Intrahospital Transport: A Prospective Observational Study

OBJECTIVE To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. DESIGN A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. SETTING The study was undertaken at two ICUs in one university hospital. PATIENTS Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4-10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. CONCLUSIONS Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety.Objective: To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. Design: A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. Setting: The study was undertaken at two ICUs in one university hospital. Patients: Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. Interventions: None. Measurements and Main Results: Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4–10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. Conclusions: Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety.

Swedish Version of the Distress Thermometer: Validity Evidence in Patients With Colorectal Cancer

Background: The objective of this study was to validate the NCCN Distress Thermometer (DT), including the accompanying Problem List (PL), in a Swedish population of patients diagnosed with colorectal cancer (CRC). Methods: A total of 488 patients diagnosed with CRC completed the DT/PL and EORTC core quality-of-life questionnaire (QLQ-C30) before surgery. Construct validity of the PL was analyzed using a confirmatory factor analysis. Internal consistency reliability (ICR) was tested using Cronbachs alpha coefficient. Correlations between the reported PL areas and QLQ-C30 function scales were used to explore convergent validity. Discriminant validity was examined by evaluating associations between the DT and QLQ-C30 measures of overall health-related quality of life (HRQoL). Results: Findings showed that the Swedish translation of the DT/PL is consistent with the original English version. The DT has good ICR, with the total number of reported problems significantly correlating with DT scores (r=0.67; P<.001). Analysis of convergent validity indicated that the PL areas significantly correlated with QLQ-C30 function scales, with emotional problems showing the highest correlation (r=0.76; P<.001), and item-level correlation analyses showed significant correlations between symptoms. There was also good discriminant validity between the DT and the QLQ-C30 in terms of HRQoL, including overall health status (r=-0.49; P<.001) and overall quality of life (r=-0.57; P<.001). Furthermore, there was good discriminant validity between the DT and QLQ-C30 regarding poor, moderate, and excellent HRQoL. Conclusions: These findings provide validity evidence regarding the DT, including the PL. Findings also show that the DT has good potential for screening distress-related practical, family, emotional, and physical problems during the cancer trajectory in Swedish-speaking patients. Additionally, the DT seems to be an effective screening tool to detect patients with poor, moderate, and excellent HRQoL.

Consequences of screening in abdominal aortic aneurysm: development and dimensionality of a questionnaire

BackgroundIn interview studies, men under surveillance for screening-detected abdominal aortic aneurysms have reported ambivalence towards this diagnosis: the knowledge was welcomed together with worries, feelings of anxiety and existential thoughts about life’s fragility and mortality due to the diagnosis. Previous surveys about health-related quality of life aspects among men under surveillance for screening-detected aneurysm have all used generic patient-reported outcomes. Therefore, the aim of this study was to extend the core-questionnaire Consequences of Screening for use in abdominal aortic aneurysm screening by testing for comprehension, content coverage, dimensionality, and reliability.MethodsIn interviews, the suitability, content coverage, and relevance of the core-questionnaire Consequences of Screening were tested on men under surveillance for a screeningdetected abdominal aortic aneurysm. The results were thematically analysed to identify the key consequences of abnormal screening results. Item Response Theory and Classical Test Theory were used to analyse data. Dimensionality, differential item functioning, local response dependency and reliability were established by item analysis, examining the fit between item responses and Rasch models.ResultsThe core-questionnaire Consequences of Screening was found to be relevant for men offered regular follow-up of an asymptomatic screening-detected abdominal aortic aneurysm.Fourteen themes especially relevant for men diagnosed with a screening-detected abdominal aortic aneurysm were extracted from the interviews: ‘Uncertainty about the result of the ultra sound examination’, ‘Change in body perception’, ‘Guilt’, ‘Fear and powerlessness’, ‘Negative experiences from the examination’, ‘Emotional reactions’, ‘Change in lifestyle’, ‘Better not knowing’, ‘Fear of rupture’, ‘Sexuality’, ‘Information’, ‘Stigmatised’, ‘Self-blame for smoking’, ‘Still regretful smoking’. Altogether, 55 new items were generated: 3 were single items and 13 were only relevant for former or current smokers. 51 of the 52 items belonging to a theme were confirmed to fit Rasch models measuring fourteen different constructs. No differential item functioning and only minor local dependency was revealed between some of the 51 items.ConclusionsThe reliability and the dimensionality of a condition-specific measure with high content validity for men under surveillance for a screening-detected abdominal aortic aneurysm have been demonstrated. This new questionnaire called COS-AAA covers in two parts the psychosocial experience in abdominal aortic aneurysm screening.

Communicative and pedagogical strategies in nurses’ and surgeons’ discharge consultations with patients undergoing surgery for colorectal cancer

AIM To describe the structure, content, and the communicative and pedagogic strategies in discharge consultations between patients and professionals after colorectal cancer surgery. BACKGROUND Both nurses and surgeons play an important role in preparing patients for discharge from hospital following surgery for colorectal cancer (CRC). DESIGN An explorative quantitative and qualitative research based on analysis of transcriptions of 13 audio-taped discharge consultations between patients and nurses and patients and surgeons conducted between January - March 2012. METHODS In the quantitative analysis, the structure of each consultation was described in phases, subtopics, and main topics. The proportion of the main topics in relation to the whole conversation was counted in percentages. The text from the consultations was then analysed qualitatively with the support from Ricoeurs theory of interpretation. RESULTS The language constituted the essence in the consultations regardless of other communicative and pedagogical strategies. The pedagogic strategies used were explanation model, information transfer, task orientation, and dialogue. Topics occurring in the consultations were Operation, Symptoms, Medication, Thromboprophylaxis, Recovery after surgery, Bowel function, Spreading, and Follow-up. The surgeons and nurses used similar topics, but the surgeons used more communicative and pedagogic strategies. CONCLUSION Language was fundamental for communication and independent of the communicative and pedagogical strategies. Using preparedness communication more consistent in discharge consultation can help patients to better understand the recovery process after CRC surgery and regain control over their life. It is important that the consultations build on the patient as an active and learning person.

Validity and test retest reliability of the vascular quality of life Questionnaire-6: a short form of a disease-specific health-related quality of life instrument for patients with peripheral arterial disease

BackgroundMany existing patient-reported outcome measures are extensive regarding both patient burden and administration, and in terms of analysing and reporting results. The VascuQoL-6 (VQ6) – a short version of the original Vascular Quality of Life Questionnaire (VascuQoL), a disease-specific instrument for peripheral arterial disease – was recently developed. However, the VQ6 has not yet been empirical tested with regard to content validity, construct validity and test retest reliability. Our aim was, therefore, to explore both the validity and the reliability of the VQ-6 in a target population with established peripheral arterial disease.MethodsTwo hundred patients treated at two vascular centres were consecutively recruited for the survey. Administered questionnaires included VQ6 and the Short Form Health Survey-36 (SF-36). Out of the 200 patients, 150 also received a second VQ6 questionnaire for a test-retest assessment. Further, a purposive sample of 22 patients consented to participate in cognitive interviews. All included patients suffer from peripheral arterial disease. The questionnaire data was tested by both Rasch analysis and traditional psychometric methods, while the cognitive interviews were analysed descriptively.ResultsThe validity and reliability of the VQ6, as tested in a target population without the surrounding 19 items from the original VascuQoL, was high, in general, and a good fit to the Rasch model was observed. Further, an excellent internal consistency and significant correlations between comparable dimensions in SF-36 were demonstrated. In the test-retest analysis, the percentage agreement was somewhat poor (<70%) in the six items. However, no systematic disagreements between the two assessments were seen in any of the six items, and the test-retest assessment for the VQ6 sum score showed an acceptable intraclass correlation coefficient (0.86). Finally, all items in the VQ6 were considered as both understandable and relevant by the interviewed patients.ConclusionsThe VQ6 has acceptable to good psychometric properties with regard to data quality, scale assumptions, targeting, validity and reliability. Further, VQ6 seems to be easy to use and comprehend within the target population of patients with PAD.