Magister Scientiae (Physiotherapy) - MSc(Physio) / The aim of this study was to investigate met and unmet palliative care needs for people living with HIV/AIDS in selected areas in Rwanda. The achieve this aim, the study, firstly, identified the palliative care needs of people living with HIV/AIDS, secondly, it identified the health care services available to meet these needs, and thirdly, it determined the extent to which palliative care needs were met. / South Africa

Student Number : 9201769X - M Med research report - School of Clinical Medicine - Faculty of Health Sciences / A PROSPECTIVE RANDOMIZED TRIAL OF TWO FRACTIONATION REGIMENS OF RADIATION THERAPY IN THE MANAGEMENT OF AIDSASSOCIATED KAPOSI SARCOMA OBJECTIVE: To compare a standard fractionation scheme with a hypofractionated scheme in the treatment of AIDS-associated Kaposi sarcoma with the aim of showing noninferiority of the shorter schedule. PATIENTS AND METHODS: HIV positive patients with histologically proven Kaposi sarcoma presenting consecutively to Radiation Oncology at Johannesburg Hospital were randomized between January 2003 and May 2004 to receive a standard regimen of 24 Gy in 12 fractions (ARM A) or the study regimen of 20 Gy in 5 fractions (ARM B). The radiation technique used was individualized for each site in accordance with departmental practice. Follow-up assessment was done at monthly intervals. Treatment response and toxicity were recorded at each follow-up visit. RESULTS: A total of 60 patients were recruited, of which 41 were male and 19 were female. The median age was 36 years (range: 23 – 55 years). Thirteen patients died prior to receiving treatment. The remaining 47 patients were treated to 65 sites, of which 35 sites received 24 Gy in 12 fractions (ARM A) and 30 sites received 20 Gy in 5 fractions (ARM B). The main indications for treatment were pain (n=71), oedema (n=44), functional impairment (n=35), cosmesis (n=14) and bleeding (n=4). At the time of reporting 28 patients were alive and 32 patients have died. The overall survival of the whole group was 37% at 1 year. A complete response was recorded at 28 sites, a partial response at 19 sites and stable disease at 3 sites. The mean time to maximum objective response was 3 months (range: 1 – 14 months). The response rates were equal in the 2 treatment arms (p=0.73). Local control was equal in the 2 treatment arms with a median local recurrence free survival of 150 days for ARM A and 455 days for ARM B (p=0.11, log rank test). Acute skin toxicity occurred at 27 sites. Moist desquamation developed at 7 sites while necrosis developed at 2 sites. Acute skin toxicity was equal in the 2 treatment arms (p=0.77). Acute mucosal toxicity occurred at 2 sites. Late skin reactions developed at 21 sites, of which necrosis or ulceration occurred at 5 sites. Chronic skin reactions were equivalent in the 2 treatment arms (p=0.24). Post radiation oedema developed at 5 sites. CONCLUSION: In our experience, 20 Gy in 5 fractions gave similar results to 24 Gy in 12 fractions in terms of treatment response, local recurrence free survival and toxicity in this small group of patients.

Changes in demographic patterns and the burden of chronic illness have challenged palliative care clinicians to engage populations other than those with malignant disease. This new paradigm has promoted the development of a population based approach to service delivery which aims to extend the reach of palliative care to hard to reach populations, including older people in residential aged care. In Australia, the high levels of disability and death experienced by older people in this care setting has resulted in policy promoting the delivery of a palliative approach to care. Achieving health care reform in this complex health care environment has traditionally been difficult to realise due to a range of workforce, training, funding, variable organizational philosophies and legal factors. The “Residential - Palliative Approach Competency” (R-PAC) Project aimed to collaboratively develop, implement and evaluate a sustainable model of care to facilitate the delivery of a palliative approach to care for older people admitted to residential aged care facilities, in regional Australian. Action research, with a focus on improving care and involving participants, was used to promote the delivery of a palliative approach in residential aged care facilities. The R-PAC Project was designed to follow the action research sequence of reflection, assessment, planning, action and observation. Nested within the action research method are eight distinct but interrelated studies in a mixed method design. Study A, a focused needs assessment undertaken as part of the preliminary investigations, confirms that older people in aged care have unmet palliative care needs. The three studies conducted during Phase One provide a greater understanding of delivering palliative care in the residential aged care setting. Study B, a chart audit identified the strengths and gaps in end-of-life care provision in the local aged care setting. While, Study C identified that aged care nurses and care assistants are committed and compassionate about delivering palliative care but desired greater palliative care competencies. The palliative care attitudes, values and learning needs of aged care providers were explored in greater depth in Study D. The data from these investigations guided the development and implementation of a multifaceted intervention during Phase Two. Following the implementation of the multi-faceted intervention and during Phase Three another series of investigations was undertaken to measure the impact of the collaborative intervention. Focus groups were used to determine the perceptions of aged care providers toward the multi-faceted intervention (Study E) and to seek the views of general practitioners (Study F). These data revealed that aged care nurses and general practitioners wanted to establish a more collaborative approach to care planning and delivery. The survey (Study G) and chart audits (Study H) were repeated in Phase Four in order to measure the impact of the action. The findings of the survey of aged care nurses and care assistants shown an increase in palliative care competencies, while the chart audit demonstrated positive trends in improving end-of-life care. Although, some aspects of care, particularly advance care planning and routine use of pain assessment tools required ongoing attention. This data propel the R-PAC Project into Phase Five and the development of a model of care to promote the delivery of a palliative approach, which was informed by the research findings. The R-PAC Project use of the action research method has facilitated a cascade of engagement and participation of all residential aged care facilities in this regional community and enabled practice innovation. The project has seen the sharing of valuable insights into usual practice and collaboratively engaging aged care nurses, care assistants and general practitioners in developing practical solutions to end-of-life care. This process has allowed for the acknowledgement and validation of the role of aged care providers, fostered personal empowerment and identified the importance of collaboration. This research has provided greater insight into the palliative care needs of people in residential aged care and collaboratively developed an intervention to improve the outcomes of older people. Study findings have also identified important issues requiring ongoing evaluation, particularly multidisciplinary team meetings and care planning. / Doctor of philosophy (PhD)

Very little work has been undertaken that explores pain as a part of human existence and the inherent knowledge that accompanies it. What pain means to people and how they know their own pain is the subject of this research study.The research sought to identify ways of knowing cancer pain of six participants, each receiving palliative care at the time of this study. The themes of, balancing conflict, living with threat, always there and making sense are identified and examined to provide understanding of the ways these people know their pain. A new model of pain assessment is offered that incorporates an ontological way of knowing, and the meaning that the findings have for nursing practice is explored. Implications for nursing practice and education that are derived from the study are offered. The rigour of the study is promoted through an audit process / Doctor of Philosophy (PhD)

Heart failure is a cause of significant burden to both individuals and society. Individuals live with a disease where there is a decline in physical functioning, the experience of a range of symptoms including breathlessness and pain, frequent hospitalisations and death. The frequent hospital admissions that are usually precipitated by shortness of breath places an economic burden on the current health system. This burden of heart failure is expected to increase in the coming years due to factors such as the ageing population and improved survival from acute cardiac events. This current and predicted continuing burden has been recognised by the health system and has resulted in significant improvement in the pharmacotherapy and nonpharmacotherapy treatment of heart failure. Despite this improvement and with the exception of those few who receive cardiac transplantation, there is no cure for heart failure. Whist the advances in therapy have promoted significant improvements in heart failure management, symptoms including breathlessness (dyspnoea) remain a major issue. The Management of Dyspnoea in Advanced Heart Failure project explored and assessed the current therapeutic management of dyspnoea in advanced heart failure and examined two potential therapeutic options namely nebulised frusemide and long-term oxygen therapy. Following a comprehensive review of the nebulised frusemide literature, The Haemodynamic Effects of Nebulised Frusemide in Heart Failure study showed that nebulised frusemide did have an impact on the haemodynamic parameters of participants. Whilst many consider oxygen therapy as a common sense approach for breathlessness, the lack of scientific evidence for its use in chronic breathlessness with people who have normal or mildly low oxygen levels has prevented funding to supply oxygen therapy to this group of patients. The O2 Breathe Study is a palliative care study that is testing long-term home oxygen therapy versus medical air in patients who do meet the current funding arrangements. The analysis of the screening data showed that the symptom burden as a result of dyspnoea is similar to that seen in cancer and respiratory patients, and heart failure patients had lower levels of physical functioning than the respiratory group. Whilst the design of the studies in this thesis will not allow conclusions to be made regarding their efficacy for dyspnoea management in heart failure, they have provided preliminary data and hypotheses to be tested in the future. / Doctor of Philosophy (PhD)

Title from PDF of title page (University of Missouri--Columbia, viewed on Feb 25, 2010). The entire thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file; a non-technical public abstract appears in the public.pdf file. Dissertation advisor: Dr. Debra Oliver. Vita. Includes bibliographical references.

Thesis (Ph.D.) -- University of Adelaide, Dept. of Clinical Nursing, 1999. / Bibliography: leaves 252-270.

Thesis (Ph.D.) -- University of Western Sydney, 2005. / Includes bibliography.

Thesis (Ph.D.)--Edith Cowan University, 2006. / Submitted to the Faculty of Computing, Health and Science. Includes bibliographical references.

Thesis (Ph.D.)--Flinders University, School of Nursing and Midwifery. / Typescript bound. Includes bibliographical references: (leaves 266-297) Also available online.