Uncertainty in Illness

The middle-range nursing theory of uncertainty in illness is presented from both a theoretical and empirical perspective. The theory explains how persons construct meaning for illness events, with uncertainty indicating the absence of meaning. A model of the uncertainty theory displaying the concepts and their relationships forms the basis for the theoretical and empirical material. Discussion of the theory is organized around three major themes: the antecedents of uncertainty, the process of uncertainty appraisal and coping with uncertainty.     

Brain natriuretic peptide at discharge as a predictor of 6-month mortality in acute decompensated heart failure

Background

Brain natriuretic peptide (BNP) is well established in detecting acute decompensation of heart failure (ADHF). The role of BNP at discharge in predicting mortality is less established. Accumulating evidence suggests that inflammatory cytokines play an important role in the development of heart failure. We aimed to examine the contribution of BNP, interleukin 6, and procalcitonin to mortality in ADHF.

Methods

A cohort of 33 patients with ADHF was identified between March 2009 and June 2010 at Rambam Health Care Campus, Haifa, Israel. The cohort was followed up for all-cause mortality during 6 months after hospital discharge. Cox proportional hazard model was used to assess the association between BNP, interleukin-6 and procalcitonin and all-cause mortality.

Results

As compared to BNP at admission, BNP at discharge was more predictive for all-cause mortality. The area under the curve for BNP at admission and discharge was 0.810 (P = .004) and 0.864 (P = .001) respectively. Eleven patients (33.3%) patients who died during the follow-up period had higher BNP levels, median 2031.4 (IQR, 1173.4-2707.2), than those who survived; median 692.5 (IQR, 309.9-1159.9), (P = .001). On multivariate analysis, BNP remained an independent predictor for 6 month all-cause mortality HR 9.58 (95% CI, 2.0-45.89) for levels above the median compared to lower levels, (P = .005). Albumin, procalcitonin and interleukin 6 were not associated with all-cause mortality.

Conclusions

BNP at discharge is an independent predictor for all-cause mortality in patients with ADHF. Compared with BNP at admission, BNP at discharge has slightly higher predictive accuracy with regard to 6-month all-cause mortality.     

Economic and disease burden of breast cancer associated with suboptimal breastfeeding practices in Mexico

Purpose

Exclusive breastfeeding and longer breastfeeding reduce women’s breast cancer risk but Mexico has one of the lowest breastfeeding rates worldwide. We estimated the lifetime economic and disease burden of breast cancer in Mexico if 95% of parous women breastfeed each child exclusively for 6 months and continue breastfeeding for over a year.

Methods

We used a static microsimulation model with a cost-of-illness approach to simulate a cohort of Mexican women. We estimated breast cancer incidence, premature mortality, disability-adjusted life years (DALYs), medical costs, and income losses due to breast cancer and extrapolated the results to 1.116 million Mexican women of age 15 in 2012. Costs were expressed in 2015 US dollars and discounted at a 3% annual rate.

Results

We estimated that 2,186 premature deaths (95% CI 2,123–2,248), 9,936 breast cancer cases (95% CI 9,651–10,220), 45,109 DALYs (95% CI 43,000–47,217), and $245 million USD (95% CI 234–256) in medical costs and income losses owing to breast cancer could be saved over a cohort’s lifetime. Medical costs account for 80% of the economic burden; income losses and opportunity costs for caregivers account for 15 and 5%, respectively.

Conclusions

In Mexico, the burden of breast cancer due to suboptimal breastfeeding in women is high in terms of morbidity, premature mortality, and the economic costs for the health sector and society.

     

What is the function of psychosocial factors in predicting length of time since last dental visit? A secondary data analysis

Aim: To conduct a secondary analysis of the Adult Dental Health Survey, UK (ADHS.UK) data to investigate the function of psychosocial factors (costs, dental anxiety, communication) and whether their interaction mediates the relationship between perception of need and length of time since last dental visit. Materials and methods: The data used from the ADHS.UK interview questionnaires included demography, costs, perception of treatment need, communication, dental anxiety and reported dental attendance. The data were subjected to χ²‐analysis and hierarchical logistic regression analysis. Results: Time since last dental visit was significantly associated with all demographic and psychosocial variables. The hierarchical logistic regression analysis tested three models. Model 1 examined the demography and explained 2% of the variance. Model 2 showed that those in intermediate (e.g. clerical staff) and routine (e.g. agriculture workers) occupations and those who were unemployed/never worked had a greater likelihood of increased interval between dental visits, explaining an additional 2% of the variance of the time interval between dental visits. Model 3 provided an additional 10% of the variance, which included costs, perceived need, communication and dental anxiety. The interaction of the perception of need by extreme dental anxiety (OR = 0.52; 95% CI: 0.40, 0.69) improved the fit of the model [χ² (df1) = 22.85, P < 0.001]. Conclusion: This study revealed that dental anxiety, communication and treatment costs acted as barriers to accessing dental care. Dental anxiety acted as a mediator in the relationship between perception of need and increased time interval between dental visits.     

Uncertainty in illness theory: a replication of the mediating effects of mastery and coping

The purpose of this investigation was to replicate a test of the mediating functions of mastery and coping and to determine whether the relationships found in the initial test of the model would hold with a sample more heterogenous than the original sample. One hundred women receiving treatment for gynecological cancer participated in the investigation. Of the 14 relationships in the model, only 5 replicated significant paths and had overlapping confidence intervals. Two moderators were proposed to explain the differences between the initial and replication tests of the model and to improve the specificity of the theory.     

Uncertainty,appraisal and quality of life

This study evaluates the influence of different factors in the adaptation process activated by uncertainty in illness on health-related quality of life. The sample included 100 women (mean age = 52.1 years) receiving treatment for newly diagnosed (M=52.1 months) gynaecological cancer (38 cervical, 26 ovarian, 24 endometrial, 7 uterine, 4 vulvar, and 1 vaginal). Stepwise regression analyses identified mood states, ambiguity about illness-wellness state, dangerfocused appraisal and mastery as key predictors of four health-related quality of life scores. The variance accounted for by those variables is reflected in cumulative multipleR ² of 0.56 for total quality of life score, 0.57 for psychosocial well-being, 0.235 for physical well-being and 0.25 for disease/symptom distress. These variances do not reflect the contribution of age, time since diagnosis, metastasis and stage of cancer which were forced to enter the regression equation first. The latter set of variables accounted for a smaller portion of the variance in health-related quality of life (R ²=0.03–0.195). Coping strategy did not predict health-related quality of life. These findings provide beginning support for conceptualizing health-related quality of life as the outcome of an adaptation process explained by the uncertainty in illness theory. However, uncertainty in illness theory may not be sufficient to predict quality of life outcomes. Future research should consider the addition of discrepancy theory to guide the selection or development of a health-related quality of life measure, to account for the perceived discrepancy between actual experience and expected well-being.This study was supported by NCNR Grant No. 3NR011030451, Coping with Uncertainty in Gynaecological Cancer; by DRR Grant No. RR06014, Biomedical Research Support Grant.     

Depression burden, self-help interventions, and side effect experience in women receiving treatment for breast cancer

PURPOSE/OBJECTIVES: To describe effects of a set of Self-Help Intervention Project (SHIP) interventions with self-reported depression burden on the side effect experience of women receiving treatment for breast cancer. DESIGN: Repeated measures, experimental design. SETTING: Outpatient sites at a regional cancer center, private practices, and health maintenance organizations. SAMPLE: 169 women who completed data at all three data-collection points were used to answer the research questions. METHODS: Following random assignment, individuals in the treatment group participated in five different, but complementary, self-help interventions for six weeks. The control group received the usual care. Variables were measured at baseline after radiation, chemotherapy, or hormone therapies were started to allow for the side effects to emerge at six to eight weeks after treatment and three months following time 2. MAIN VARIABLES: Depression burden, fatigue burden, pain burden, nausea burden, difficulty concentrating burden, anxiety burden, number of side effects, severity of side effects, and participation in the interventions. FINDINGS: Self-reported depression burden was found to significantly influence severity of side effects, number of side effects, and the burdens of fatigue, difficulty concentrating, and anxiety. Depression burden did not significantly influence the side effect burdens of nausea or pain. Depression burden interacted with the self-help interventions over time for the side effect of fatigue, but the intervention effect on pain burden and nausea burden was not influenced by depression burden over time. No significant intervention effects were found for the burden of difficulty concentrating or anxiety, the number of side effects, or perceived severity of side effects. The interventions significantly reduced the fatigue, pain, and nausea burden in women with breast cancer. CONCLUSIONS: The interventions were particularly helpful, relative to their fatigue experience, for women reporting a high level of depression burden. Findings also contribute to conceptual clarification of essential aspects of the side effect experience and provide a basis for measure and intervention refinement. IMPLICATIONS FOR NURSING PRACTICE: Every woman who is undergoing cancer treatment should be assessed for depression and depression burden. Self-help interventions are effective and convenient treatments that reduce side effects and promote quality of life in women with breast cancer.     

Who makes the decision regarding the treatment of clinically localized prostate cancer–the patient or physician?

BACKGROUND:

The current study examined how patients' sociodemographic, cancer‐related, and subjective affective factors impacted their role in treatment decision‐making.

METHODS:

The patient sample (N = 788) was taken from a prospective follow‐up study of a population‐based cohort. Participants included 343 African American and 445 Caucasian‐American patients with clinically localized prostate cancer. Multinomial logistic regression was used to investigate relations between the explanatory variables and the nominal 3‐level decision‐making variable: patient‐only, patient‐physician shared, and physician‐only.

RESULTS:

Approximately 41% of patients reported patient‐only decision‐making, 45% reported shared decision‐making, and 13% reported physician‐only decision‐making. The odds of patient‐only over physician‐only decision‐making were greater for younger men (vs those aged ≥ 65 years) (odds ratio [OR], 1.68; 95% confidence interval [95% CI], 1.03‐2.74), and were less for men with high (vs low) cancer aggressiveness (OR,0.29; 95% CI, 0.15‐0.55). The odds of shared over physician‐only decision‐making were less for men with high (vs low) cancer aggressiveness (OR, 0.40; 95% CI, 0.22‐0.73). Greater odds of patient‐only and shared decision‐making also were found to be associated with greater concerns about the physical impact of treatment and having enough time for decision‐making and lower scores of receiving advice from others.

CONCLUSIONS:

The findings of the current study indicate that, to facilitate a more patient‐oriented decision‐making process regarding treatment in those with clinically localized prostate cancer, clinicians need to tailor their interventions according to patient age and cancer aggressiveness, help reduce patient concerns and misconceptions regarding the physical impact of treatments, allow sufficient time for patients to consider treatment options, and assist patients in balancing advice and information received from different sources. Cancer 2013. © 2012 American Cancer Society.