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. 2023 Feb 22;18(2):e0281998.
doi: 10.1371/journal.pone.0281998. eCollection 2023.

Symptom severity trajectories and distresses in patients undergoing video-assisted thoracoscopic lung resection from surgery to the first post-discharge clinic visit

Affiliations

Symptom severity trajectories and distresses in patients undergoing video-assisted thoracoscopic lung resection from surgery to the first post-discharge clinic visit

Tomohito Saito et al. PLoS One. .

Abstract

This study aimed to characterize patients' symptom severity trajectories and distresses from video-assisted thoracoscopic lung resection to the first post-discharge clinic visit. Seventy-five patients undergoing thoracoscopic lung resection for diagnosed or suspected pulmonary malignancy prospectively recorded daily symptom severity on a 0-10 numeric scale using the MD Anderson Symptom Inventory until the first post-discharge clinic visit. The causes of postoperative distresses were surveyed, and symptom severity trajectories were analyzed using joinpoint regression. A rebound was defined as a statistically significant positive slope after a statistically significant negative slope. Symptom recovery was defined as symptom severity of ≤3 in two contiguous measurements. The accuracy of pain severity on days 1-5 for predicting pain recovery was determined using area under the receiver operating characteristic curves. We applied Cox proportional hazards models for multivariate analyses of the potential predictors of early pain recovery. The median age was 70 years, and females accounted for 48%. The median interval from surgery to the first post-discharge clinic visit was 20 days. Trajectories of several core symptoms including pain showed a rebound from day 3 or 4. Specifically, pain severity in patients with unrecovered pain had been higher than those with recovered pain since day 4. Pain severity on day 4 showed the highest area under the curve of 0.723 for predicting pain recovery (P = 0.001). Multivariate analysis identified pain severity of ≤1 on day 4 as an independent predictor of early pain recovery (hazard ratio, 2.86; P = 0.0027). Duration of symptom was the leading cause of postoperative distress. Several core symptoms after thoracoscopic lung resection showed a rebound in the trajectory. Specifically, a rebound in pain trajectory may be associated with unrecovered pain; pain severity on day 4 may predict early pain recovery. Further clarification of symptom severity trajectories is essential for patient-centered care.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. CONSORT flow diagram of the study population and schedule for symptom severity recording.
A: Flow diagram depicting the selection process of participants eligible for data analysis. B: The in-hospital recording of symptom severity/interference was scheduled once preoperatively; once daily during the first postoperative week; and if applicable, every 2 days during the second postoperative week and once a week during the third postoperative week. The post-discharge recording of symptom severity/interference was scheduled daily until the first outpatient clinic visit. MDASI: MD Anderson Symptom Inventory; VATS: Video-assisted thoracoscopic surgery.
Fig 2
Fig 2. Symptom severity/interference trajectories and the models using the joinpoint regression analysis.
A: The symptom severity of pain, disturbed sleep, drowsiness, and fatigue was significantly higher on day 1 than on day 5, day 10, day 15 and day 20 (pain, P < 0.0001, P < 0.0001, P < 0.0001, and P = 0.017; disturbed sleep, P < 0.0001 in all comparisons; fatigue, P < 0.0001, P < 0.0001, P = 0.0002, and P = 0.047; drowsiness, P < 0.0001, P < 0.0001, P < 0.0001, and P = 0.0004). However, the symptom severity of shortness of breath and that of numbness and tingling on day 1 showed no significant difference compared to that on day 5, day 10, day 15 and day 20 (shortness of breath, P = 0.18, P = 0.74, P = 0.41, and P > 0.99; numbness and tingling, P = 0.19, P = 0.82, P = 0.94, and P = 0.20). B: Joinpoint analysis revealed that pain, fatigue, and numbness and tingling showed a rebound in the trajectories. C: The interference level of general activity, enjoyment of life, walking and mood was higher on day 1 than on day 5, day 10, day 15, and day 20 (general activity, P < 0.0001, P < 0.0001, P < 0.0001, and P = 0.0003; enjoyment of life, P = 0.0001, P < 0.0001, P < 0.0001, and P = 0.011; walking, P < 0.0001, P < 0.0001, P < 0.0001, and P = 0.0016; mood, P < 0.0001, P < 0.0001, P = 0.0001, and P = 0.016. The symptom interference of work and relationship with other people on day 1 was higher than that on day 5, but showed no significant difference compared to that on day 10, day 15 and day 20 (work, P = 0.0072, P = 0.20, P = 0.056, and P = 0.33; relationship with other people, P = 0.012, P = 0.11, P = 0.053, and P = 0.48). D: Symptom severity trajectories of general activity, walking, and mood showed a rebound pattern.
Fig 3
Fig 3. Symptom severity trajectories and the models using the joinpoint regression analysis for patients with recovered or unrecovered symptom at the first post-discharge clinic visit.
A: Patients with unrecovered pain had been experiencing more severe pain than those with recovered pain since day 4. Both, patients with recovered pain and those with unrecovered pain, showed a rebound in the severity trajectory. B: Patients with unrecovered fatigue tended to experience more severe fatigue than those with recovered fatigue following day 4. Both patients with recovered fatigue and those with unrecovered fatigue showed a rebound in the severity trajectory. C: Initially, numbness and tingling were more severe in patients with recovered numbness and tingling than those with unrecovered numbness and tingling. Following day 7, patients with unrecovered numbness and tingling experienced greater numbness and tingling than their counterparts. Only patients with unrecovered numbness and tingling showed a rebound in the severity trajectory. D: Patients with unrecovered general activity encountered greater interference than those with recovered general activity after day 4. Both, patients with recovered general activity and those with unrecovered general activity presented a rebound in the interference trajectory. E: Patients with recovered walking encountered greater interference than those with unrecovered walking on day 1. Following day 3, the interference rose higher among patients with unrecovered walking than those with recovered walking. Patients with recovered walking showed a rebound, whereas those with unrecovered walking showed a consistent positive slope over time in the interference trajectory. F: Unlike patients with recovered mood, those with unrecovered mood had been experienced a rebound and more severe interference in daily life since day 3. Patients with recovered mood did not present a rebound in the interference trajectory.
Fig 4
Fig 4. Symptom recovery to mild severity and distribution of symptom recovery status at the first post-discharge outpatient clinic visit.
A: The cumulative rates of symptom recovery to a mild level of pain, interfered general activity, disturbed sleep, interfered enjoyment of life, and interfered work were 57.6%, 53.4%, 82.0%, 64.1%, and 50.2%, respectively. B: The cumulative rates of symptom recovery to a baseline level of pain, interfered general activity, disturbed sleep, interfered enjoyment of life, and interfered work were 16.4%, 20.4%, 39.7%, 38.3%, and 28.2%, respectively. C: The distribution of symptom recovery status at the first post-discharge follow-up visit revealed a higher mean number of unrecovered symptoms/ interferences in patients with unrecovered pain, than those with recovered pain (5.8 vs 1.9, respectively, P < 0.0001).
Fig 5
Fig 5. The receiver operating characteristic (ROC) curves of pain severity level on days 1, 2, 3 and 4 for predicting recovery of pain to mild level at the time of the first post-discharge clinic visit.
The area under the ROC curve of pain severity level on day 1, 2, 3, and 4 were 0.502(P = 0.98), 0.549 (P = 0.48), 0.626 (P = 0.069), and 0.723 (P = 0.001), respectively. A pain scale value of 1 on day 4 was determined as the best cut-off level to predict symptom recovery to a mild level by the first post-discharge clinic visit.
Fig 6
Fig 6. Reported patients’ distresses and information needs during hospitalization and after hospital discharge.
A: Sixty-seven (89.3%) patients responded to the questionnaire for distress during the hospitalization; severity of symptoms, burden on the partner, and difficulties in management of symptoms were the three major distresses, accounting for 32.8%, 23.9%, and 20.9%. Of note, 31.3% of the questionnaire responses reported no distress during hospitalization. B: Twenty-one (28.0%) patients responded on concerning information needed during the hospitalization: duration of the symptoms was the leading concern accounting for 19.0% of participants. C: For distress after hospital discharge, 50 (66.7%) patients responded the questionnaire: duration of symptoms, decrease in physical strength, and impact of symptoms on daily life were the top three distresses, accounting for 70.0%, 54.0%, and 50.0%, respectively. No distress after hospital discharge was reported by only 8.0% of the patients responded the questionnaire. D: Seventeen (22.7%) patients responded the questionnaire on the information need after hospital discharge: duration of symptom was the leading concern accounting for 29.4%.

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