Cross-Lagged Panel Network Analysis of Symptoms in Patients with Gastric Cancer Undergoing Postoperative Chemotherapy

OBJECTIVES

To develop temporal symptom networks at three postoperative chemotherapy time points and investigate the longitudinal relationships between 18 symptoms in patients with gastric cancer undergoing postoperative chemotherapy in China.

METHODS

Symptom prevalence and severity were measured using the M. D. Anderson Symptom Inventory (MDASI) and Gastrointestinal Cancer Module of the MDASI (MDASI-GI) at T1, T2, and T3 on the day after the first, third, and sixth chemotherapy sessions, respectively. Cross-lagged panel network (CLPN) models were employed to examine the temporal dynamics of the 18 symptoms and their interrelationships.

RESULTS

In total, 379 participants were included. Dry mouth had the highest out-prediction (r = 0.101) and out-strength (r = 0.863) values during T1→T2. The strongest direct effect was observed for the change in taste → lack of appetite (β = 0.38) during T2→T3. Feeling bloated had the highest values for out-strength (r = 0.910), out-prediction (r = 0.215), and bridge strength (r = 1.010) during the T2→T3 period. The two CLPNs showed medium to high stability based on the centrality stability coefficients of out-strength and in-strength.

CONCLUSIONS

Lack of appetite can be improved during chemotherapy by managing vomiting and taste changes. Attention should be paid to the dry mouth and feeling bloated, as they are the strongest predictors in the early and middle stages of treatment.

IMPLICATIONS FOR NURSING

Understanding the relationship between symptoms during chemotherapy in patients with postoperative gastric cancer can help clinicians identify targets for intervention at different times.

Validity and Reliability of the Korean Version of Supportive Care Needs Survey-Short Form 34 for Patients With Cancer: A Methodological Study

PURPOSE

The Supportive Care Needs Survey-Short Form 34 (SCNS-SF34) measures the perceived care needs of patients with cancer. This study aimed to evaluate the reliability and validity of the Korean version of the SCNS-SF34 (i.e., the SCNS-SF34-K).

METHODS

The SCNS-SF34 was translated into Korean following a World Health Organization translation guideline. We recruited 208 patients with cancer via an online survey in 2022. The data were analyzed using SPSS 27.0 and Amos 23.0, and the construct validity, known-group validity, and internal consistency were tested.

RESULTS

The SCNS-SF34-K validated the final five-factor model via confirmatory factor analysis. The SCNS-SF34-K's subscales demonstrated discriminant and convergent validity. In addition, known-group validity was confirmed using the Eastern Cooperative Oncology Group Performance Status Scale (t = -7.12), Patient Health Questionnaire-9 (t = -7.61), and Distress Thermometer (t = -9.22). McDonald's Omega coefficient for the total scale was .96, and each sub-domain ranged from .88 to .95.

CONCLUSION

This research provides initial findings on the validity and reliability of the SCNS-SF34-K, a tool for measuring the supportive care needs of Korean cancer patients. The SCNS-SF34-K demonstrates potential for evaluating various aspects of patient needs and may be valuable for both clinical oncology practice and research in Korea.

Nutritional Management of Lung Cancer Patients Undergoing Chemotherapy: A Qualitative Exploration of Patients' and Healthcare Professionals' Perspectives

OBJECTIVES

To describe the experiences of lung cancer patients undergoing chemotherapy in nutrition management and the problems in the process of implementing nutrition management for patients by healthcare professionals.

METHODS

This is a qualitative descriptive study. Qualitative data were collected through semistructured interviews with lung cancer patients undergoing chemotherapy (N = 16) and healthcare professionals (N = 24) from the oncology department at three tertiary grade A hospitals.

RESULTS

Three themes emerged from the patients' interviews: deficiency in nutritional management capabilities; barriers to implementing nutritional management; incentives to implementing nutritional management. Five themes emerged from the healthcare professionals' interviews: insufficient attention to nutritional management of lung cancer patients undergoing chemotherapy; lack of standardization in nutritional management; inadequate support for nutritional management; weak multidisciplinary awareness; poor compliance from patients and their families.

CONCLUSIONS

The nutritional management of lung cancer patients undergoing chemotherapy is a complicated and vital process that requires the joint efforts of healthcare professionals and patients. Formulating corresponding strategies from multiple perspectives is suggested to provide targeted nutritional guidance for patients.

IMPLICATION FOR NURSING PRACTICE

This study can help nurses better understand the nutritional management needs and challenges of patients to provide individualized nutritional guidance to patients. Meanwhile, the study also found the existing problems of nutrition management in clinical work, which can help nurses to reflect on and better participate in the nutrition management of patients.

Falls experienced by adult cancer survivors: a scoping review

PURPOSE

Accidental falls among adult cancer survivors are a health concern. Falls impose economic burdens and detrimental consequences to cancer survivors. This review aimed to synthesize findings from published research to explore the relationship between falls and cancer diagnosis and treatment among cancer survivors.

MATERIALS AND METHODS

A scoping review was conducted using four databases (Medline, EMBASE, CINAHL, and Scopus) for the years 2001-2021. A total of 425 abstracts were identified after removing duplicates. A second search for the years 2022-2023 was completed where 80 abstracts were identified. Abstract screening, full-text review, and data extraction were conducted. Study characteristics and key findings were extracted from full texts. Descriptive numerical summaries were presented, and narrative analyses were performed.

RESULTS AND CONCLUSIONS

A total of 42 articles were included in the scoping review which demonstrated (1) an increased prevalence of falls among cancer survivors, (2) the presence of cancer-specific fall risk factors, (3) a lack of cancer-specific fall prediction tools, and (4) few fall prevention interventions as part of usual care among cancer survivors. Younger cancer survivors were underrepresented. Cancer survivors should be aware of their risk of falls, and health professionals should ensure that fall prevention is part of usual care.

Translation and Validation of the Greek Version of the Breast Cancer Screening Beliefs Questionnaire

BACKGROUND

Breast cancer is the most prevalent cancer among women in Greece. It is crucial to have a simple, trustworthy and effective instrument for assessing the factors that impact cancer screening behaviors.

OBJECTIVE

This study aimed to translate and validate the Greek version of the Breast Cancer Screening Beliefs Questionnaire (BCSBQ).

METHODS

In this cross-sectional methodological study conducted from April to June 2024, 202 Greek women aged 21 to 69 years participated using a snowball sampling method. A backward-forward translation process was performed on the BCSBQ. The study evaluated the face, content, and constructs validity of the questionnaire. A confirmatory factor analysis was carried out to determine whether the data supported the 3-factor structure of the instrument. Additionally, the reliability of the BCSBQ was measured using Cronbach's alpha and intra-class correlation coefficients.

RESULT

The results of the confirmatory factor analysis demonstrated the presence of three distinct factors: attitude, knowledge, and barriers to screening. The three-factor model was supported by standard indices, with the following values: chi-square = 112.5, RMSEA = 0.079, SRMR = 0.057, CFI = 0.94, and NNFI = 0.942. The instrument also showed a satisfactory Cronbach's alpha of 0.814, while the Cronbach's alpha values for the three subscales ranged from 0.72 to 0.84. The mean scores observed on the three subscales in this study were remarkably high (Attitudes=76.7±23.9, Knowledge=80.9±20.1, Barriers=89.9±12.7).

CONCLUSION

The three-factor structure of the BCSBQ-12 demonstrated valid and reliable results among Greek women. Given its strong psychometric properties, this tool can be utilized in future studies to assess women's beliefs regarding breast cancer screening in Greece.

Diet and Physical Activity Behaviors of Breast Cancer Survivors: A Scoping Review

OBJECTIVES

This scoping review explored insight into the current evidence on adherence to health behavior guidelines, specifically diet and physical activity among breast cancer survivors.

METHODS

A scoping review was conducted through databases including PubMed, CINAHL, Scopus, Web of Science, and SPORTDiscus with Full Text in November 2022, following the JBI methodology. The search strategy combined the keywords i) diet OR nutrition OR eating OR exercise OR physical activity OR fitness and ii) breast cancer survivors OR patients with breast cancer.

RESULTS

Twelve original research studies were included; most were conducted in the United States (50%), followed by the European countries (33.34%). Most studies exclusively focused on physical activity (83.33%) and assessed adherence to the physical activity guidelines for Americans (30%), along with the American Cancer Society (20%) and American College of Sports Medicine (20%) guidelines. Overweight or obesity, comorbidity, race, and quality of life were reported as factors associated with physical activity. Independence of disease status was significantly associated with fruit and vegetable intake.

CONCLUSION

Studies reported a wide range of prevalence of adherence to dietary and physical activity recommendations among breast cancer survivors. Further studies are needed to explore diet and physical activity in the context of factors affecting these behaviors among cancer survivors to support the development of healthy behavior, improve health outcomes, and reduce the disease burden among this population.

IMPLICATION FOR NURSING PRACTICE

Nurses have a key role in educating and coordinating multidiscipline teams to initiate and provide cancer survivorship care. These findings indicate that nurses should consider developing targeted strategies and education to promote dietary patterns and physical activity adherence among breast cancer survivors.

Shifting perspectives: an investigation of a virtual reality awe experience in people going through cancer treatment

PURPOSE

Evoking awe using virtual reality appears to be a promising intervention that has potential to positively impact physical and psychological well-being. The purpose of this exploratory study was to investigate the acceptability and potential benefits of a VR experience of awe for patients undergoing cancer treatment.

METHODS

Twenty cancer patients viewed a 5-min VR nature experience designed to induce awe and completed questionnaires assessing anxiety, symptom distress, spirituality, and connectedness to nature. Qualitative interviews assessed acceptability and ways to improve the intervention.

RESULTS

The VR experience effectively induced awe. Following the experience, participants reported decreased anxiety and symptom distress and increased feelings of spirituality and connectedness to nature. Participants enjoyed the experience and said they would use it again and would recommend it to others.

CONCLUSION

VR nature interventions that induce awe are worthy of future investigation as a psychological approach to support cancer patients undergoing treatment.

Unmet Needs and Health-Related Quality of Life Among Patients With Relapsed/Refractory Indolent Non-Hodgkin Lymphoma: A Mixed-Methods Study

OBJECTIVE

Patients with relapsed or refractory (r/r) indolent non-Hodgkin lymphoma (iNHL) live with incurable disease for a long-term, experiencing multiple relapses and treatments that impair their health-related quality of life (HRQOL). We aimed to better understand the unmet needs and HRQOL of patients with r/r iNHL.

METHODS

This convergent mixed-methods study evaluated patients with r/r iNHL who received treatment. Unmet needs and HRQOL were assessed quantitatively using self-administered questionnaires and analyzed statistically. Qualitative data were collected through face-to-face semi-structured interviews for reflexive thematic analysis. Quantitative and qualitative findings were integrated through narrative discussion and joint display.

RESULTS

Questionnaire respondents (50 participants, mean age: 72.42 years) reported unmet needs in the health system and information and psychological domains and a negative association between unmet needs and HRQOL. Interviews (20 participants, mean age: 72.75 years) identified four themes: "unremarkable symptoms," "anxiety of progression in the near future," "make the best of life," and "means to live with uncertainty." Integration revealed that participants accepted their low HRQOL and attempted to make the best of life, influencing their perception of unmet needs.

CONCLUSIONS

Throughout the long course of r/r and repeated treatment, patients with iNHL accepted their low HRQOL, valued their current situations, and endeavored to make the best of life. In this situation, support in the psychological and health system and information domains is crucial. Support for the unmet needs of patients with r/r iNHL is essential as they strive to live their best lives while maintaining a favorable HRQOL.

Feasibility and Acceptability of a Palliative Care Intervention among Older Adults with Advanced CKD and Their Caregivers

Background

In non-nephrology settings, specialty palliative care (PC) improves decision making, patient's quality of life (QoL), advance care planning, and certain indicators of the quality of end-of-life (EoL) care. This pilot randomized control trial (RCT) explored the feasibility and acceptability of a PC intervention, CKD-EDU, for adults aged 75 years and older with eGFR ≤25 ml/min and their caregivers.

Methods

Participants randomized to the control group received standard nephrology care and routine kidney therapy education, whereas those randomized to CKD-EDU received a decision aid and met with a PC clinician up to three times to discuss kidney therapy decisions and EoL planning. Patients were assessed at baseline, 4–6, 12–14, and 24–26 weeks. Main outcomes included intervention feasibility and acceptability, decision conflict, and patient QoL. The mediating effects of reduced decision conflict on improved QoL were explored, as were the effects of CKD-EDU on advance care planning, EoL treatment intensity, and 6-month hospitalization. Statistical analyses encompassed descriptive analyses, adjusted repeated-measure models, mediation analyses, and logistic regression models.

Results

Among the 127 eligible patients screened, 58 (46%) consented: 30 were randomized to CKD-EDU and 28 to the control arm. All patients completed baseline assessments and 89% completed at least 1 intervention session (n=26/29), underscoring intervention adherence and feasibility. Similarly, assessment completion rates at 4 (83%, n=45/54), 12 (93%, n=42/45), and 24 (95%, n=40/42) weeks were high. The intervention received over 85% acceptability ratings for all questions. Patients exposed to CKD-EDU exhibited significant improvement in Decisional Conflict Scale scores (P = 0.003) at 4–6 weeks and improvements in QoL at 24–26 weeks (P = 0.02). Exploratory analyses were not statistically significant in this pilot study, but all effect sizes were in the predicted direction.

Conclusions

This study demonstrates the feasibility and acceptability of CKD-EDU. A larger scale trial is warranted to assess its effectiveness in improving key outcomes important to patients and families.

Nutrition Security During Cancer: A Qualitative Investigation Among Patients With Cancer on Active Treatment From an Area of Persistent Poverty

OBJECTIVE

The objective of this paper was to qualitatively explore the eating habits and experience of nutrition security during cancer treatment among patients from an area of persistent poverty being treated in a safety net hospital oncology program.

METHODS

Eleven in-depth interviews were conducted with current individuals with cancer who were (1) undergoing active cancer treatment at LBJ Hospital, (2) over 18 years old, (3) English speaking, and (4) residing in an Acres Homes zip code. Reflexive thematic analysis was undertaken by four members of the study team, which brought together diverse expertise in health disparities, nutrition, food culture, and health communication.

RESULTS

Four main themes emerged from the data, including (1) food beliefs and eating behaviors in the context of cancer, (2) social and economic influences on food selection, procurement, and preparation, (3) lived experience of resiliency and coping with limited resources, and (4) the role of relationships (including social support, family, medical teams) in diet and food choice.

CONCLUSION

Findings from this study begin to fill a gap in knowledge regarding the complexities of managing nutritional needs among patients residing in an area of persistent poverty, which can inform the development of future health systems and community-based resources for those negotiating both cancer and chronically limited resources.

Symptoms among patients with breast cancer undergoing endocrine therapy: Application of latent profile analysis and network analysis

PURPOSE

To identify the subgroups and symptom networks associated with endocrine therapy in patients with breast cancer.

METHODS

This study was a cross-sectional design using convenience sampling to select patients from a tertiary hospital in China. A total of 406 patients were invited to complete demographic and clinical questionnaires and the Chinese Breast Cancer Prevention Trial Symptom Scale was used to assess their symptoms. Latent profile analysis was used to classify the symptom subgroups of patients with breast cancer undergoing endocrine therapy. Univariate and binary multivariate logistic regression analyses were used to analyze the influence of these factors on different subgroups. Network analysis was used to identify the core symptoms of different subgroups.

RESULTS

The analysis revealed two distinct subgroups: low symptom distress (74%; Class 1) and high symptom distress (26%; Class 2). Patients who were older, had a lower monthly family income per capita, and had not received radiotherapy were more likely to belong to Class 2. Furthermore, the network analysis results revealed that "difficulty concentrating" was a core symptom of the entire sample. The core symptom for Class 1 was "lack of energy," and the core symptom for Class 2 was "joint pain."

CONCLUSION

The symptoms of patients with breast cancer undergoing endocrine therapy were heterogeneous. Different subgroups exhibited different core symptoms. Therefore, targeted interventions should be provided according to the characteristics of the different symptom subgroups and their core symptoms to achieve precise and effective symptom management.

Development and pilot testing of a theory-driven and evidence-based advance care planning training programme for nurses in acute care settings

PURPOSE

To develop and pilot-test a novel training programme for nurses in acute care settings to improve their decision-making support skills, knowledge, attitudes, and confidence in conducting advance care planning (ACP).

METHODS

A single-group repeated measures design was employed. This study was conducted in two phases. In Phase 1, a theory-driven and evidence-based ACP training programme for nurses was developed based on the results of a prior systematic review and qualitative interviews. In Phase 2, a pilot study was conducted to assess the feasibility and acceptability of the ACP training programme according to the Tickle-Degnen typology and to explore the programme's preliminary effects.

RESULTS

Guided by the theory of planned behaviour and the experiential learning model, a multi-media experiential ACP training programme, the MEACP, was developed, comprising a 10-module mobile application and a 2-h, nurse-led skill-building workshop. The study had a high recruitment rate (91%), with 20 nurses consenting to participate in the MEACP. The nurses remained attentive and active during the workshop and were highly satisfied with the programme. The outcome evaluation results demonstrated preliminary positive effects of the MEACP in terms of improving the nurses' decision-making support skills, knowledge, attitudes, and confidence in conducting ACP.

CONCLUSIONS

The MEACP could feasibly be introduced in acute care settings and was found to be an acceptable educational intervention. This work contributes to nursing practice by providing information about the design of an innovative ACP training programme. Finding will highlight the importance of a paradigm shift regarding ACP in acute care settings.

Regional economic level moderates the impact of patients' and family carers' cancer-related work changes and hospital level on financial toxicity in China: A multi-centre cross-sectional study

PURPOSE

To explore how regional economic levels moderate the relationships between cancer-related financial toxicity (FT) and its associated risk factors.

METHODS

A secondary analysis was conducted using data from a cross-sectional survey of 1208 adult patients with cancer, conducted in six tertiary and six secondary hospitals across three Chinese provinces from February to October 2022. The interactions between the regional economic level-categorised as high- or low-/middle-income based on the gross domestic product per capita- and 13 previously identified risk factors for FT were examined via moderation analysis using the PROCESS macro for SPSS software.

RESULTS

Regional economic level moderated the impacts of both patients' and family carers' negative work changes due to cancer and the hospital level on FT (all p-values for interaction effect <0.05). Job changes had more severe effects on FT in high-income regions (patients: B = -2.07, standard error [SE] = 0.67, p = 0.002; carers: B = -1.58, SE = 0.66, p = 0.017), while treatment in tertiary hospitals had a stronger negative impact on FT in low-/middle-income regions (B = 1.81, SE = 0.87, p = 0.037).

CONCLUSIONS

These findings highlight the need for region-specific FT mitigation strategies. In high-income regions, more attention could be paid to managing the adverse work-related effects of cancer on patients and their families. In low-/middle-income regions, increased awareness and management of cancer-related FT in tertiary hospitals is needed. Future research should explore other risk factors associated with FT that may be moderated by regional economic levels.

Health Beliefs, Breast Cancer Awareness, and Prevention Behaviors of Turkish Nursing Students: A Cross-Sectional Study

Purpose: This study was conducted to examine the relationship between nursing students' breast cancer (BC) awareness, health beliefs, and BC prevention behaviors. Methods: This study sample consisted of 256 female students. Descriptive Information Form, Breast Cancer Awareness Scale (B-CAS), the Factors Affecting Breast Cancer Prevention Behaviors of Women (FABCPB) Scale, and the Champion's Health Belief Model Scale (CHBMS) were used to collect the data. Results: Breast self-examination was performed in 53.9% of the nursing students. The mean B-CAS score was 1.35 ± 0.58 and the mean FABCPB score was 102.84 ± 9.62. The mean scores of the sub-dimension scores of the CHBMS of nursing students were as sensitivity perception 7.93 ± 2.13, seriousness perception 22.58 ± 5.26, benefit perception 17.25 ± 3.17, obstacle perception 22.89 ± 6.24, confidence 37.71 ± 7.53, and health motivation 26.47 ± 4.41 points. A significant correlation was found between the scores of the nursing students on the B-CAS, FABCPB, and CHBMS scales. Conclusions: Nursing students' scores on the B-CAS and FABCPB were moderate, CHBMS sensitivity and obstacle perception sub-dimension scores were low, severity perception scores were moderate, and benefit perception, trust, and health motivation sub-dimension scores were high. As the BC awareness of nursing students increased, their cancer prevention behaviors and health beliefs increased.

Comorbidities And Reducing InEquitieS (CARES): Feasibility of self-monitoring and community health worker support in management of comorbidities among Black breast and prostate cancer patients

Background

Black individuals with cancer have a higher prevalence of comorbidities and a worse cancer prognosis than other racial groups in the US. As part of a quality improvement project, we aimed to demonstrate feasibility of self-monitoring and community health worker (CHW) support among managing comorbidities for Black individuals with breast or prostate cancer.

Methods

In a single arm, pre-post study, we enrolled patients with diabetes and/or hypertension who identified as Black and were diagnosed with 1) stage 0-IV breast cancer, or 2) prostate cancer and on long-term androgen-deprivation therapy. Participants received a home-monitoring device linked to a mobile app and worked with a CHW over six months to track their blood pressure (BP) and/or blood glucose (BG). PROMIS surveys assessed support and self-efficacy.

Results

Between May 2021-December 2022, 61 patients with breast or prostate cancer comorbid with hypertension (79 %) or hypertension and diabetes (21 %) enrolled. Once weekly self-recording of BP and BG was achieved in 92 % of individuals (with hypertension) and 77 % of individuals (with diabetes and hypertension). Participants (n = 47) who reported ≥4 readings in Months 1 and 6 demonstrated improved BP control (mean reduction = 4.07 mmHg); too few BG readings were collected to assess change. We observed a slight decrease in PROMIS scores for informational (mean 3.2, sd 8.0) and instrumental support (mean 3.6, sd 8.3).

Conclusions

A self-monitoring and CHW intervention is a feasible approach to monitor hypertension among Black cancer patients. Modifications are needed to improve BG monitoring and patient reported outcomes.

Perceived Learning Needs of Hospitalised Cancer Patients and Nurses

AIM

To understand the differences in perceived learning needs between cancer patients and nurses.

DESIGN

A cross-sectional descriptive design.

METHODS

Data were collected from 1147 cancer patients and 1000 nurses using a convenience sampling method from February 2022 to June 2023. Sociodemographic data of patients and nurses were collected through a self-designed general information questionnaire. Patients and nurses completed the Revised Chinese version of the Patient Learning Needs Scale to identify their perceptions of the learning needs and the difference between patient and nurse knowledge of needs.

RESULTS

According to cancer patients and nurses, the top learning needs were information on complications and symptoms. In contrast, patients perceived the lowest priority learning needs to be disease-related issues, while nurses perceived the lowest priority learning needs to be daily treatment and activities.

CONCLUSIONS

Patients and nurses have different views on the essential contents to be learned, highlighting the importance of considering these two aspects in formulating health education programmes.

PATIENT OR PUBLIC CONTRIBUTION

Participating cancer patients and nurses took the time to complete the questionnaire during the data collection phase and answered the questions sincerely.

To get through to survive: Exploring the symptom cluster management process during oncological treatment from the perspective of patients with lung cancer - A grounded theory study

PURPOSE

To explore the symptom cluster management process from the perspective of patients with lung cancer within the oncological care context.

METHODS

We used a constructivist grounded theory methodology to collect and analyze rich data from 15 patients with lung cancer via individual interviews and a two-dimensional symptom assessment scale.

RESULTS

A situational theoretical model describes the symptom cluster management process through the main category 'To get through to survive', with the category 'Handling symptom clusters' together with six sub-categories concerning the patients' management strategies and the category 'Living with symptom clusters,' together with two sub-categories describing the outcome in their daily life. Impacting conditions are incorporated in the model.

CONCLUSIONS

Patients often feel left to their own devices to deal with symptom clusters and may not understand or foresee problematic circumstances as they manage their situations on a day-to-day basis. When symptoms are normalized and accepted, patients do not ask for support, or support is not being offered to them. Healthcare professionals should consider the peril of normalizing symptoms and the patients' altered time perspective that stems from their approach of living one day at a time, in further development of nursing interventions and person-centered care for this population.

The effectiveness of art-based interventions for cancer patients: A systematic review and meta-analysis

PURPOSE

This study aimed to examine the effectiveness of art-based interventions on anxiety, depression, fatigue, and overall quality of life (QoL), including its physical, psychological, and social dimensions in cancer patients.

METHODS

The literature search included all studies published up to March 2024. Searches were conducted in the MEDLINE, Web of Science, EBSCO, and PubMed databases considering the updated Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The quality of the studies was assessed using the Revised Cochrane Risk of Bias Tool (RoB 2) and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) developed by the Cochrane Collaboration. Data were analysed using the MAJOR package in JAMOVI 2.3.28.

RESULTS

Fifteen studies conducted with 1113 cancer patients were identified and included in this study. Ten of the studies included women with breast cancer. The remaining studies involved chemotherapy patients with various cancers (n = 3), cancer patients in a blood and marrow transplantation unit (n = 1), and nasopharyngeal cancer patients (n = 1). Meta-analysis indicated that art-based interventions had a significant effect on anxiety, depression and physical aspects of QoL but no significant impact on fatigue, overall QoL, or the psychological and social dimensions of QoL.

CONCLUSIONS

This study provided clinical support for pursuing art-based research on anxiety, depression, and the physical QoL in cancer patients. However, the effect of art-based interventions on cancer patients' fatigue and their overall QoL, including its social and psychological dimensions, was insignificant.

REGISTRATION

The study protocol was registered in advance in the PROSPERO (CRD42024531397/April 13, 2024).

Cancer Survivorship and the Significance of an Integrated Diachronic Life Course Perspective

Standardised health care is primarily focused on remediation and delivered episodically through costly and fragmented health-care systems. Such an approach is untenable, given the diversity and complexity of peoples' health-care needs, increasing prevalence of chronic disease and existing heath inequities. A life course perspective fundamentally challenges our current understanding of health care and has great potential to promote innovation in health-care practice, systems and policy. However, the way that health develops and manifests across the life course is a highly complex process underpinned by a plethora of causal antecedents, consequences and interdependencies that have yet to be adequately captured and articulated in current life course frameworks. The field of cancer survivorship and its recent rise to prominence provides a highly relevant and compelling case example to inform development and refinement of existing life course frameworks. Cancer survivorship exemplifies what can be described as an integrated diachronic life course perspective, which serves as a conceptual framework to enhance our understanding of health development across the life course and guide health-care practice, systems and policy to meet the increasingly complex health-care needs of current and future generations.

Therapeutic strategies for fungating and ulcerating breast cancers: A systematic review and narrative synthesis

BACKGROUND

To identify optimal therapeutic strategies for managing fungating, large or ulcerating breast tumors and highlight existing gaps in the literature.

METHODS

We conducted a systematic search of Medline, Embase, APA, PsycInfo, CAB abstracts, Scopus, and Web of Science from inception to June 30, 2024, including studies on patients with fungating, large, or ulcerating breast cancers.

RESULTS

The search identified 7917 studies, with 79 meeting the inclusion criteria: 62 case reports, 7 case series, and 10 cohort studies. Owing to high heterogeneity, a narrative synthesis was performed, categorizing treatment by year, molecular subtype, histology, and staging. We found that treatment modalities increased, from an average of two in luminal-B cancers to three in HER2-positive cases, with over half achieving complete response. Triple-negative breast cancers averaged two modalities, with around half showing only partial response. Cohort analysis revealed a significant positive correlation between metastasis rate and radiotherapy use (Spearman's rho = 0.828, p = 0.042) and between chemotherapy and hormonal therapy use (rho = 0.69, p = 0.04). Median survival was positively correlated with surgical treatment (rho = 0.82, p = 0.046).

CONCLUSIONS

Local treatment is crucial for symptomatic palliation in fungating or ulcerating breast tumors, and histology should guide therapeutic choices. While local treatments remain primary, emerging systemic therapies show promise and may soon become first-line options. As the first systematic review on this topic, our study faced considerable source heterogeneity, precluding a meta-analysis. Instead, we analyzed treatment trends by demographics and tumor characteristics, providing a comprehensive overview and encouraging further research in this area.

Weight and Blood-Based Markers of Cachexia Predict Disability, Hospitalization and Worse Survival in Cancer Immunotherapy Patients

BACKGROUND

Cancer-associated cachexia can inhibit immune checkpoint inhibitor (ICI) therapy efficacy. Cachexia's effect on ICI therapy has not been studied in large cohorts of cancer patients aside from lung cancer. We studied associations between real-world routinely collected clinical cachexia markers and disability-free, hospitalization-free and overall survival of cancer patients.

METHODS

A retrospective study was conducted of electronic health records (EHR) of patients with lung, renal cell, melanoma and other cancers treated with ICI therapy at Northwestern Medicine of Chicago, IL, United States, between March 2011 and January 2022. Weight, body mass index, absolute neutrophil and lymphocyte counts, albumin and C-reactive protein (CRP) measures were analysed to calculate the Fearon consensus criteria for cachexia, weight loss grading system (WLGS) score, neutrophil-lymphocyte ratio (NLR), Prognostic Nutritional Index (PNI) and modified Glasgow Prognostic Score (mGPS) at ICI therapy initiation. Kaplan-Meier and Cox proportional hazards analyses were used to determine associations between these metrics and disability-free, hospitalization-free and overall survival.

RESULTS

EHR analysis uncovered 3285 cancer patients on ICI therapy (54% > 65 years of age, 50.7% male, 77.7% White). At ICI therapy initiation, 1282 (39.0%) patients had cachexia (consensus criteria), 1641 (50.0%) had a WLGS score ≥ 2, 1806 (55.0%) had an NLR > 3, 1087 (33.1%) had albumin < 3.5 g/dL and 1318 (40.1%) had a PNI < 44. Missing measurements included CRP missing for 98.2% and mGPS missing for 98.6% of patients. Disability-free (n = 1373), hospitalization-free (n = 2374) and overall survival (n = 1599) events were analysed with 1-year rates of 65% (64%-67%), 35% (34%-37%) and 65% (63%-66%), respectively. Multivariate Cox model analyses showed hazard ratios (HR) for cachexia at 1.58 (95% CI 1.38-1.80), 1.47 (95% CI 1.33-1.63) and 1.97 (95% CI 1.75-2.23) for disability, hospitalization and death, respectively. HRs for WLGS ≥ 2 were 1.45 (95% CI 1.28-1.66), 1.37 (95% CI 1.24-1.51) and 1.91 (95% CI 1.69-2.17). HRs for NLR > 3 were 1.57 (95% CI 1.35-1.83), 1.40 (95% CI 1.25-1.58) and 1.95 (95% CI 1.67-2.27). HRs for albumin < 3.5 g/dL were 1.33 (95% CI 1.15-1.54), 1.67 (95% CI 1.50-1.86) and 2.09 (95% CI 1.84-2.36). HRs for PNI < 44 were 1.60 (95% CI 1.39-1.84), 1.46 (95% CI 1.31-1.63) and 2.07 (95% CI 1.80-2.37).

CONCLUSIONS

Fearon consensus criteria, WLGS, NLR, albumin and PNI were routinely collected at ICI initiation in regular clinical practice and predictive of worse disability-free, hospitalization-free and overall survival in cancer patients receiving ICI therapy. These routine clinical measures may aid prognostication and decision-making in cancer patients with cachexia.

Use of a Smartphone Application to Promote Adherence to Oral Medications in Patients With Breast Cancer

PURPOSE

Medication nonadherence is common among patients with breast cancer (BC) and increases BC mortality and complications from comorbidities. There is growing interest in mobile health interventions such as smartphone applications (apps) to promote adherence.

METHODS

Use of Medisafe, a medication reminder and tracking app, was tested over 12 weeks among patients on BC treatment and at least one oral medication. Study participants were instructed to generate adherence reports every 4 weeks through Medisafe and were deemed to have completed the intervention if >50% of reports were generated. The primary end point was feasibility of the intervention, defined as a completion rate of ≥75% of consented patients. Secondary end points included changes in self-reported nonadherence from baseline to 12 weeks and patient-reported outcomes including reasons for nonadherence and satisfaction with Medisafe. We conducted univariable and multivariable analyses to evaluate demographic and clinical factors associated with intervention completion.

RESULTS

Among 100 patients enrolled, 78 (78.0%) completed the intervention. Age, race, ethnicity, clinical stage, and type of medication were not associated with odds of intervention completion. Self-reported nonadherence rates did not improve from baseline to postintervention in the overall study population. However, among patients with self-reported nonadherence at baseline, 26.3% reported adherence postintervention; these patients frequently reported logistical barriers to adherence. Study participants reported high levels of satisfaction with Medisafe, noting that the app was highly functional and provided high-quality information.

CONCLUSION

Smartphone apps such as Medisafe are feasible and associated with high patient satisfaction. They may improve adherence in nonadherent patients and those who face logistical challenges interfering with medication-taking. Future trials of mobile health interventions should target patients at high risk for medication nonadherence.

Feasibility trial of STRONG: A digital intervention to improve nutritional management for individuals with esophageal and gastroesophageal junction cancer

Introduction

Individuals with esophageal and gastroesophageal junction (GEJ) cancers are at especially high risk of malnutrition. However, most patients with malnutrition do not receive adequate nutritional support. We conducted a single-arm trial to test the implementation of Support Through Remote Observation and Nutrition Guidance (STRONG), a multilevel digital intervention to improve nutritional outcomes for patients with locally advanced esophageal and gastroesophageal junction cancer.

Methods

Participants received five nutritional counseling sessions with a dietitian, logged daily food intake through the Fitbit app, and completed five study assessments related to patient malnutrition, nutrition-related symptoms, and quality-of-life outcomes. We assessed the feasibility, acceptability, and usability of STRONG against a priori benchmarks.

Results

Participants (N = 17) had a median age of 68 years, and 71 % were male. Feasibility benchmarks were met for participants completing the baseline assessment (94 %), completing four out of five assessments (82 %), and participant retention (85 %). Among participants who only received an oral diet during the study period, adherence to dietetic appointments (89 %) and food intake tracking (78 %) were high. Participant recruitment rate (47 %) was slightly below the benchmark (50 %). All participants found the intervention to be acceptable. Usability of the intervention was high, with 69 % and 92 % of participants reporting high satisfaction with tracking food intake through the Fitbit and the dietitian-led nutrition counseling sessions, respectively.

Conclusion

Our study demonstrated that STRONG could be implemented with high feasibility, acceptability, and usability for esophageal and GEJ cancer patients. Findings from this study can guide a future efficacy study to assess the impact of STRONG on patient outcomes.

Clinical trial registration

The Support Through Remote Observation and Nutrition Guidance Program for Gastroesophageal Cancer Patients (STRONG-GEC) study was registered on clinicaltrials.gov (NCT05438940) in June 2022 prior to participant enrollment.

The Effect of Cervical Cancer and Human Papillomavirus Vaccine Education on Vaccination Perception in University Students: A Quasi-Experimental Controlled Educational Intervention

Purpose: The study investigated the impact of cervical cancer and human papillomavirus (HPV) vaccine education on university students' vaccination perceptions. Methods: This research was conducted with pre- posttest and quasi-experimental design with students enrolled in the department of health services of a university. The sample of the study consisted of 87 students (n = 43 in the intervention group, n = 44 in the control group). Research data were collected between June 29 and July 22, 2022, using the Introductory Information Form and HPV Information Scale. An informative training program about cervical cancer and HPV was applied to the intervention group. This training program was carried out in two separate sessions. In the first session, information was given about the prevalence, pathology, and risk factors of cervical cancer. In the second session, general information about HPV, details about the vaccine, and vaccination programs were given. Training sessions are organized as small group discussions and seminars covering relevant topics. Results: In our study, the average age of our students was 20.7 ± 2.5 years, and in both groups, the proportion of students who did not know about HPV, which can cause cervical cancer, was quite high (74.4%, 68.2%). The majority of the control and intervention groups needed health education about STDs. There were statistically significant differences between the control and intervention groups in terms of the pre-test and posttest Knowledge of HPV Scale scores (p < 0.05). Conclusion: It was found that the education on cervical cancer and HPV positively affected the perspectives of the students on vaccination. Interactive and group-oriented education increases knowledge sharing by encouraging interaction among students. In this way, a broader knowledge base about cervical cancer and HPV can be created, and misinformation can be corrected.

The inequalities and challenges of prehabilitation before cancer surgery: a narrative review

INTRODUCTION

Prehabilitation seeks to enhance functional capacity and preparedness before surgery with the aim of improving outcomes; it is generally based on exercise, diet and psychological interventions. While there is obvious appeal to this approach in terms of patient experience and resource use, the interventions are complex and the evidence base for prehabilitation before cancer surgery is heterogeneous. Prehabilitation requires patient understanding and motivation as well as commitment of resources. Programmes are challenging to design and implement, and can generate 'intervention-based inequalities' based on the capacity of patients to engage. We present a narrative review on the inequalities and challenges of prehabilitation before cancer surgery.

METHODS

We searched databases of peer-reviewed research to identify appropriate articles. We used the results in combination with iterative searches based on citation tracking, grey literature (e.g. patient information resources) and articles from personal libraries, to develop our discussion.

RESULTS

We describe the uncertainties in the evidence base for prehabilitation before cancer surgery, and the challenges and barriers for healthcare providers, systems and patients. Key findings include that prehabilitation is under-researched in many cancers and that people with lower health literacy, from minority ethnic groups and socio-economically disadvantaged backgrounds, are less likely to engage, despite often having worse peri-operative outcomes.

DISCUSSION

Prehabilitation must be implemented carefully to avoid widening inequalities. More research is needed, both in terms of the impact of interventions and to understand how prehabilitation should account for the social determinants of health.

Early Feeding After Free Flap Reconstruction for Oral Cavity Cancer: A Single Institution Retrospective Review

OBJECTIVE

Patients undergoing free flap reconstruction of the oral cavity have traditionally received nothing by mouth for 6-14 days postoperatively to limit the risk of wound complications. Growing evidence suggests that initiation of oral intake may not increase the morbidity. This study further investigates the utility of "early feeding."

METHODS

This was a retrospective cohort study conducted at a large, urban tertiary healthcare system. Patients who underwent free flap reconstruction for oral cavity cancer between June 1, 2020, and October 31, 2022, were grouped as early feeding (oral intake on or before Postoperative Day 5) or late feeding (LF) (oral intake after Postoperative Day 5). Outcomes included rate of orocutaneous fistula, development of other local or systemic complications, and hospital length of stay (LOS).

RESULTS

Sixty six patients were studied, with 26 belonging to the LF group and 40 to the early feeding (EF) group. The LF group was significantly older (median age 64.5 vs. 80 years, p = 0.027) and more likely to have a defect extending beyond the oral cavity (25.0% vs. 50.0%, p = 0.037). No significant differences were found in orocutaneous fistula formation between the LF and EF groups (7.7% vs. 0%, p = 0.152), but the rate of total complications was significantly higher in the LF group (38.5% vs. 12.5%, p = 0.014). LOS was significantly longer in the LF group (12.5 vs. 6 days, p < 0.001).

CONCLUSION

These findings suggest that in the correctly suggested patient population, early postoperative oral intake may facilitate earlier hospital discharge without increasing the risk of postoperative complications.

Development of A Caregiver-Reported Scale for Pediatric Cancer Financial Toxicity (CRS-PCFT)

BACKGROUND

Financial toxicity is common among families of pediatric patients with cancer. However, the availability of survey and/or screening instruments specific to pediatric family financial toxicity is limited.

METHODS

A two-round cross-sectional survey was conducted in Shandong Province, China. We combined classical test theory (CTT) and item response theory (IRT) to validate items of the caregiver-reported scale for pediatric cancer financial toxicity (CRS-PCFT) after Delphi. The scale structure, reliability, and validity were determined and validated by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The threshold was discussed based on the correlations between CRS-PCFT and socio-factors.

FINDINGS

A 16-item initial scale was determined after Delphi. The data from 206 pilot survey samples was used to select and validate items, and a 10-item CRS-PCFT was developed. The scale showed satisfactory reliability and validity based on data from 398 formal survey samples. When the CRS-PCFT scores were into high and low toxicity groups by the median, they were significantly correlated with education (r = -0.284, p < 0.0001), household income (r = -0.253, p < 0.0001), work status (r = -0.173, p = 0.001), and cancer stages (r = 0.147, p = 0.003).

INTERPRETATION

CRS-PCFT demonstrates robust reliability and validity and makes it more accurate to obtain the pediatric cancer financial toxicity conditions. Additional research should be done to validate CRS-PCFT.

The critical role of education in shaping nurses' attitudes and intentions towards neonatal palliative care: A network analysis

BACKGROUND

Neonatal palliative care is an essential component of comprehensive neonatal care; however, its implementation remains challenging worldwide, particularly in low- and middle-income countries due to limited resources, cultural barriers, and lack of training.

OBJECTIVES

The aim of this study was to investigate the structural characteristics of neonatal nurses' attitudes towards neonatal palliative care and their intention to provide such care using network analysis to identify key influencing factors and interrelationships.

DESIGN

A multi-center cross-sectional study.

SETTING

The setting was 92 hospitals across 28 provinces in mainland China.

PARTICIPANTS

A convenience sampling method was employed to recruit 893 neonatal nurses from October 2023 to February 2024.

METHODS

The web-based survey included a sociodemographic questionnaire, the simplified Chinese version of the Neonatal Palliative Care Attitude Scale (NiPCAS), and a single question gauging participants' intention to provide neonatal palliative care. Network analysis techniques were used to examine the structural characteristics of the attitude network.

RESULTS

A total of 767 valid questionnaires were received. The estimated network comprised 26 nodes representing individual NiPCAS items, with 150 non-zero edges out of a possible 325 connections. In-service education experience emerged as the most central and influential node, demonstrating the highest centrality (strength = 2.511; bridge strength = 3.144) and predictability (R2 = 0.475). This was followed by the ideal palliative care environment and staff support for palliative care. On average, 29.3 % of each item's variance could be accounted for by surrounding items. The strongest associations with the intention to provide neonatal palliative care were observed with beliefs about the necessity of palliative care in neonatal nurse education (edge weight = 0.29).

CONCLUSIONS

The findings highlight the pivotal role of in-service education experience in shaping nurses' attitudes towards neonatal palliative care, suggesting that educational interventions may significantly influence overall attitudinal structures. The strong associations between the intention to provide neonatal palliative care, and beliefs about the necessity of palliative care in neonatal nurse education, further reinforce the critical role of education in fostering positive attitudes and intentions. The significance of organizational and resource-related factors suggests that efforts to improve neonatal palliative care should focus on enhancing staff support and creating supportive work environments.

The utility and feasibility of incorporating death cafes in undergraduate education: A qualitative exploration of medical and nursing students' perspectives

BACKGROUND

The current medical and nursing curricula place little emphasis on palliative and end-of-life care. Consequently, students are less comfortable in communicating about topics related to death and dying when providing palliative and end-of-life care. Death cafés utilizes a facilitator-led small group to encourage conversations about death and dying to take place alongside food and beverages in a safe environment. In light of the presence of death taboos, there is a need to understand how medical and nursing students perceive the incorporation of a death café within the undergraduate program.

OBJECTIVES

This study aimed to explore the perceptions of medical and nursing students regarding the utility and feasibility of incorporating death cafés into their undergraduate education.

DESIGN

A qualitative study was conducted.

METHODS

This study was conducted in one medical school in a university in Singapore. Participants above the ages of 18 years, pursuing a full time undergraduate medical or nursing program were invited. A purposive sampling approach using the maximum variation sampling technique to enhance representativeness was used to select the participants based on their sociodemographic and academic variables. A total of 32 medical and nursing students were included in the study. Online individual interviews were conducted. The interviews were then transcribed and analyzed using qualitative content analysis.

RESULTS

Three main categories were developed from the content analysis: (1) Perceptions of death cafés, (2) Features of a death café, and (3) Contents of a death café conversation. Participants viewed the death café as a platform for conversations surrounding death and dying. Several features such as the presence of a facilitator and discussions to be held in small groups were surfaced. The proposed topics to be discussed ranged from communication skills, coping with death encounters, and understanding more about the concepts of palliative care.

CONCLUSION

Medical and nursing students view death cafes as a feasible and potential approach in learning pallative and end-of-life care. The use of a faciliator-guided small group discussion on topics such as coping with death, communication techniques and concepts of palliative care are proposed. Further work is needed to examine how the death café method can potentially impact students' confidence and skills in managing palliative and end-of-life care.

Nonpharmacological Management of Cancer-Related Cachexia: A Systematic Review

OBJECTIVES

Cancer-related cachexia affects approximately 50% to 80% of cancer patients and contributes significantly to cancer-related mortality, accounting for 20% of deaths. This multifactorial syndrome is characterized by systemic inflammation, anorexia, and elevated energy expenditure, leading to severe weight loss and muscle wasting. Understanding the underlying mechanisms is critical for developing effective interventions. While progress has been made over the past decade, most therapeutic approaches have centered on pharmacological agents or nutritional supplements. This systematic review seeks to address a critical gap by examining interventional studies that focus on nonpharmacological, nonsupplement, and nonparenteral strategies for managing cancer-related cachexia.

METHODS

A systematic review followed the guidelines provided by PRISMA 2020. The review was conducted to identify clinical trials on the nonpharmacological, nonsupplement, and nonparenteral management of cancer-related cachexia. The literature search encompassed PubMed, CINAHL, and Scopus, targeting studies published between 2014 and 2024. Inclusion criteria required studies to be written in English, involve human participants aged 18 years or older, and focus on individuals diagnosed with active solid tumors. Studies involving participants with hematological malignancies were excluded due to the unique dietary requirements associated with these conditions.

RESULTS

The search identified 2,949 articles, of which 10 met the eligibility criteria. The nonpharmacological interventions examined included acupuncture, nutritional advice, education and support, informational booklets, behavior change support, and exercise. Significant heterogeneity was observed in both the types of interventions and the sample sizes across the studies. Most participants were outpatients. Commonly, assessed outcomes included body weight, body mass index, quality of life (QoL), and muscular strength. This variation highlights the need for more standardized approaches to better evaluate the impact of such interventions.

CONCLUSIONS

Exercise interventions improved lean mass, QoL, and fatigue. Complementary interventions like acupuncture have demonstrated promising benefits in managing cancer-related cachexia. These include improved appetite, enhanced Karnofsky Performance Status (indicating better functional ability), and reduced weight loss. While some studies suggest nutritional interventions may positively impact weight or dietary habits, the evidence remains inconclusive. This highlights the importance of initiating interventions early in the course of care, just after the diagnosis and the start of treatment to maximize potential benefits. Additionally, actively involving patients in their care is crucial, as this can enhance adherence, personalize strategies, and address individual needs more effectively.

IMPLICATIONS FOR NURSING PRACTICE

The assessment and nonpharmacological management of cancer-related cachexia play a vital role in enhancing the QoL for cancer patients. Individualized nutritional interventions, educational programs, exercise routines, and tailored lifestyle advice have shown the potential to positively impact food intake, body composition, fatigue levels, and overall patient satisfaction during anticancer treatments. These approaches not only address the physical challenges of cachexia but also support the psychological and emotional well-being of patients, contributing to a more comprehensive and patient-centered care strategy.

Effects of Wab-WPPEP on post-intensive care syndrome-family in family caregivers of heart valve replacement patients: A randomized controlled trial

OBJECTIVES

To evaluate the effects of a WeChat applet-based whole process psychological empowerment program (Wab-WPPEP) on post-intensive care syndrome-family in family caregivers of heart valve replacement patients.

DESIGN

Two-arm, parallel, randomized controlled clinical trial.

SETTINGS

A tertiary general hospital in Fuzhou, China.

METHODS

Participants were randomly assigned to two groups. The intervention group received Wab-WPPEP, while the control group received routine care. The intervention was implemented from ICU admission to one month post-discharge. The primary outcome was anxiety, while secondary outcomes included depression, post-traumatic stress disorder (PTSD), and quality of life. Outcomes were assessed at baseline (T0), before ICU transfer (T1), pre-discharge (T2), and one month post-discharge (T3) using standardized questionnaires. Generalized estimating equations were used to analyze the repeated-measures data.

RESULTS

The intervention group exhibited greater improvements in anxiety (T1: β = -1.92, 95 % CI: -2.35 to -1.49, P < 0.001; T2: β = -1.66, 95 % CI: -2.03 to -1.29, P < 0.001; T3: β = -3.98, 95 % CI: -4.34 to -3.62, P < 0.001), depression (T1: β = -1.32, 95 % CI: -1.79 to -0.85, P < 0.001; T2: β = -1.70, 95 % CI: -2.08 to -1.32, P < 0.001), and quality of life (T2: β = 31.16, 95 % CI: 21.35 to 40.98, P < 0.001) compared to the routine-care group. PTSD scores were also significantly lower in the intervention group (t = -6.454, P < 0.001).

CONCLUSIONS

Wab-WPPEP significantly reduced anxiety and depression, improved quality of life, and alleviated PTSD symptoms in family caregivers of heart valve replacement patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Comprehensive psychological interventions should be implemented throughout the ICU stay and recovery period to improve family caregiver well-being.

Disparities in Global Authorship and Data Source in the Pediatric Blood and Cancer Journal 2011-2021: Realities and Strategies for Improvement

BACKGROUND

Research expands knowledge and improves outcomes. Research is needed in all settings, but most often occurs in high-income countries (HIC) compared to low- and middle-income countries (LMICs). Publication in scientific peer-reviewed journals and authorship position are important for academic/clinical advancement. We explored the current state of global authorship and data source distribution for publications in the Pediatric Blood and Cancer (PBC) journal.

PROCEDURE

LMIC-affiliated author inclusion and position in selected article categories of the PBC (2011-2021) were recorded. Articles with at least one LMIC-affiliated author (first-listed affiliation) and 5% of exclusively HIC-authored articles were verified. Descriptive statistical analysis was performed.

RESULTS

Of 4504 articles reviewed, 593 (13%) included at least one LMIC-affiliated author (517/593 [87%] as first author and 488/593 [82%]) as senior author. In a subset of articles with LMIC-sourced data, 148/675 (22%) included exclusively HIC authors. Within the LMIC-sourced data subset, 81/675 (12%) articles were mixed HIC/LMIC affiliation and 446/675 (66%) were exclusively LMIC-affiliated. The frequency of LMIC-affiliated authors as first or senior author within HIC/LMIC-affiliated collaborations was 31/81 (38%) and 9/81 (11%), respectively.

CONCLUSION

As more than 80% of children live in LMICs and the WHO Global Initiative for Childhood Cancer is increasingly engaged across LMICs, all researchers/clinicians must justly be given an opportunity to conduct, write, publish, and be recognized for their research. PBC is uniquely poised to promote equitable publishing practices and opportunities for professional recognition by drawing on emerging best practices for equitable authorship, including potentially restructuring authorship guidelines and requirements.

Health promotion nursing interventions for female breast cancer survivors: A scoping review

AIM

Map the existing health promotion nursing interventions for female breast cancer survivors (BCS) to describe the approaches used and the characteristics of these interventions in the available studies.

DESIGN

A scoping review.

DATA SOURCE

Five electronic databases were systematically searched for eligible studies, published between 2002 and 2022.

METHODS

Following the Joanna Briggs Institute's methodology, two reviewers independently used Covidence to screen the title, abstract and full text of evidence against the inclusion criteria and extracted data using an extraction table. The PRISMA Extension for Scoping Reviews (PRISMA-ScR) guided the reporting. No patient or public contribution was necessary.

RESULTS

This review included 22 studies on nursing health promotion interventions for BCSs, primarily conducted in specialized care centres. In 20 of 22 studies, nurses employed the educational approach to promote the health of BCSs. Many interventions aimed to support survivors in adopting healthy lifestyles, improving their sexual health, promoting overall well-being and addressing their individual needs by equipping them with self-care skills. Nurses utilized self-monitoring, health education materials and technologies to support survivors' health.

CONCLUSION

The review concludes that the nurse used various approaches and interventions with different characteristics to improve the health of BCSs. This review also emphasizes that a limited number of determinants of health have been considered by nurses in the development of health promotion interventions.

IMPACT

The review highlights the important role that nurses can play in enhancing the health of female BCSs after cancer treatments. This review can guide future research for developing nursing health promotion interventions in primary care settings for female BCSs. Additionally, the review offers insights to support future research, education and training on diverse approaches and characteristics that nurses can utilize to establish interventions that enhance the health of female BCSs.

Family members' conceptions of their supportive care needs across the colorectal cancer trajectory - A phenomenographic study

AIM

To describe the variations of family members' conceptions of their supportive care needs (SCN) across the colorectal cancer (CRC) trajectory.

DESIGN

A descriptive qualitative study with a phenomenographic approach.

METHOD

Individual semi-structured interviews were conducted from May 2022 to October 2022 with 23 family members of persons diagnosed with colorectal cancer. The interviews were analysed using phenomenographic analysis following the Consolidated criteria for reporting qualitative research (COREQ) checklist.

RESULTS

The phenomenographic analysis resulted in five categories. Not of importance describes family members' needs as unimportant due to the good prognosis and the organization of care and in relation to the needs of others. Only satisfiable by professionals describes information possessed by the healthcare professionals as key, as well as the need for professional counselling for the family members to process their emotions. Managed by themselves describes family members preferring to manage their SCN themselves by turning to the appropriate social support and/or by using coping skills. Understood retrospectively describes SCN as only understandable when things have calmed down and as requiring one's own experience to understand. Left unmet describes SCN as unnoticed by the healthcare professionals or not brought to light by the family members, or family members not knowing where to turn for support.

CONCLUSION

Supportive care should involve individualized information, proactive and repeated assessments of needs across the trajectory, as well as encouragement of family members to reflect on their needs and to accept support when needed.

IMPACT

There is a gap in the literature regarding family members' SCN across the CRC trajectory which this study addresses. Findings show five categories of family members' conceptions of their SCN. Those findings could serve as a basis for the development of clinical colorectal supportive care across the cancer trajectory.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Findings show that to offer family members of persons diagnosed with colorectal cancer support only at the time of diagnosis is insufficient. Instead, the healthcare team is recommended to proactively and repeatedly try to identify those in need and the characteristics of their needs. In addition, it is important to offer individualized information and strive to encourage family members to reflect on their situation and to not suppress their own needs if emerging.

REPORTING METHOD

Reporting adheres to the consolidated criteria for reporting qualitative research (COREQ) checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Spiritual Care Experiences of Nurses Caring for Gynecologic Cancer Patients in Türkiye: A Qualitative Research

The study aimed to examine the spiritual care experiences of nurses caring for gynecologic cancer patients. The study was conducted using a phenomenological design, one of the qualitative research methods. Nurses caring for gynecologic cancer patients were included in the study. In sample selection, the criterion sampling method, one of the purposeful sampling methods, was used, and the sample size was ten nurses. A semi-structured interview guide was used to collect the data. Content analysis was performed using the MAXQDA package program. The study was written based on the COREQ checklist. The nurses' statements determined themes, sub-themes, and codes in line with the research findings. Accordingly, four themes were identified as "spiritual care practices," "emotional effects of spiritual care," "factors affecting spiritual care," and "recommendations to improve spiritual care". In line with the findings obtained, it is recommended that in-service training should be provided to nurses caring for gynecologic cancer patients to provide spiritual care at a professional level. Moreover, the excessive workload caused by working conditions should be reduced, and regulations and institutional policies should be established to increase the number of nurses.

The effects of Omega-3 fatty acids and vitamin D supplementation on the quality of life and blood inflammation markers in newly diagnosed breast cancer women: An open-labelled randomised controlled trial

BACKGROUND AND AIMS

Nutritional intervention is one of the primary steps to improvement of health status and quality of life (QoL) in patients with cancer treated by chemotherapy. There is limited evidence on the potential nutritional intervention to complement active oncological treatment strategies in breast cancer (BC) patients in developing countries. The aim of the present study was to assess the effects of omega-3 fatty acids (ω3) and vitamin D3 (VitD) supplementations on the QoL and blood inflammation markers of tumor necrosis factor-alpha (TNF-α) and high-sensitive C-reactive protein (hsCRP) assessed among women newly diagnosed with BC in the Gaza Strip, Palestine.

METHODS

A total of 88 BC women were randomly assigned into one of four groups: i) omega-3 fatty acid (ω3) group; ii) vitamin D (VitD) group; iii) ω3+VitD group, and iv) the control. Participants were received either two 300 mg ω3 capsules daily, or one 50,000IU VitD tablet weekly, or both supplementation for 9-weeks. The QoL status was assessed by the European Organization for Research and Treatment of Cancer (EORTC) instruments of QLQ-C30 and QLQ-BR23 tools, while blood inflammatory markers of TNF-α hsCRP were used. All measurements were taken from baseline to the end of the intervention period. The detailed procedures of the present study were registered on ClinicalTrial.gov with the identifier NCT05331807.

RESULTS

At the end of the trial, participants in the ω3+VitD group showed a significant increase in overall global health status (p < 0.01) compared to other groups. Additionally, this group showed significantly higher functional scores (all p < 0.05) and lower scores for fatigue (p < 0.01), nausea and vomiting, pain, and appetite loss (all p < 0.05) at the end of the trial compared to baseline. Furthermore, comparisons between the intervention groups revealed a significant difference in blood concentrations of TNF-α and hsCRP (p < 0.05). These significant differences were identified in hsCRP between ω3 and control groups (p < 0.01). The ω3+VitD group demonstrated a significant reduction in both hsCRP and TNF-α levels (both p < 0.05) from baseline. No significant changes in blood inflammatory markers were observed within the ω3 or VitD groups alone.

CONCLUSION

Participants receiving daily ω3 and weekly VitD supplementation for 9 weeks showed a significant improved in QoL and blood inflammation markers among the newly diagnosed BC during their chemotherapy treatment.

Machine learning models for risk prediction of cancer-associated thrombosis: a systematic review and meta-analysis

BACKGROUND

Although the number of models for predicting the risk of cancer-associated thrombosis has been rising, there is still a lack of comprehensive assessment for machine learning prediction models.

OBJECTIVES

This study aimed to critically appraise and quantify the performance studies using machine learning to predict cancer-associated thrombosis.

METHODS

We conducted searches on PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and other related databases for the related publications (from inception to December 1, 2023). The Prediction Model Risk of Bias Assessment Tool checklist was employed to evaluate the risk of bias and applicability. The Grading of Recommendations Assessment, Development and Evaluation system was used to evaluate the quality of evidence in systematic reviews. Meta-analyses were conducted using R (version 4.3.2).

RESULTS

A total of 32 studies were included. Mostly included literature exhibited a high risk of bias, and the applicability of the prediction models was deemed acceptable. The 21 included studies in the meta-analysis demonstrated the high predictive capacity of the machine learning models for cancer-associated thrombosis.

CONCLUSION

Most of the prediction models included in the study showed good applicability and excellent prediction performance, but there was a high risk of bias.

Exploring factors influencing body acceptance in women with breast cancer: A cross-sectional study

PURPOSE

Body acceptance in women with breast cancer is a crucial factor related to their physical, psychological health, and quality of life. However, research on the factors influencing body acceptance in this population is lacking. This study aims to identify these factors to provide insights for developing tailored interventions.

METHODS

We conducted a cross-sectional study with 258 participants via an online survey in September 2023. Variables measured included general and disease-related characteristics, self-esteem, resilience, social support, objectified body consciousness, and body acceptance. We analyzed the data using descriptive statistics, frequency analysis, independent t-test, one-way ANOVA, Scheffé's test, Pearson's correlation coefficient, and hierarchical regression analysis.

RESULTS

Among participants' characteristics, we identified age, religion, menstruation status, elapsed period after diagnosis, cancer stage at diagnosis, and current treatment as factors influencing body acceptance. Additionally, higher resilience (β = 0.35, p < .001), increased social support (β = 0.13, p = .037), and lower objectified body consciousness (β = -0.31, p < .001) positively influenced body acceptance. Collectively, these variables accounted for 78.9% of variance in body acceptance.

CONCLUSION

This study offers valuable insights into the factors affecting body acceptance in women with breast cancer. The findings highlight the need for tailored interventions that enhance resilience, foster social support, and address objectified body consciousness. Future research should validate these findings across diverse populations and refine personalized care strategies in clinical practice.

Effect of Technology-Based Psychological Empowerment Interventions on Psychological Well-Being of Parents of Pediatric Cancer Patients: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

In recent years, technology-based interventions have emerged as effective approaches to provide psychological support for the parents of children with cancer. Despite their increasing use, evidence on the effectiveness of technology-based empowerment interventions remains limited, largely due to the heterogeneity in intervention designs and measured outcomes.

AIM

This meta-analysis aims to evaluate the effectiveness of technology-based psychological empowerment interventions on the psychological well-being of parents of pediatric cancer patients.

METHODS

A comprehensive literature search was conducted databases including Scopus, Medline, PubMed, Embase, Cochrane Library, Web of Science, APA PsycINFO, CINAHL Complete, and the Ovid Nursing Database Scopus, Medline, and PubMed identified 8020 studies, from which 9 RCTs involving 698 parents of children with cancer were included. The risk of bias was assessed using the revised Cochrane Risk of Bias (RoB 2) tool. Data analysis was assessed using a random effects model with standardized mean difference (SMD) using Review Manager Version 5.4. Heterogeneity was assessed using the chi-square test and I2 statistic. Subgroup analyses and sensitivity analyses were performed.

RESULTS

The meta-analysis revealed significant improvements in psychological outcomes, including decreases in distress (SMD: -0.42, 95% CI [-0.70, -0.13], p = 0.005), depression (SMD: -0.92, 95% CI [-1.56, -0.27], p = 0.005) and anxiety (SMD: -1.47, 95% CI [-2.50, -0.44], p = 0.005) immediately after the intervention. Follow-up analyses showed maintained decreases in depression (SMD: -0.39, 95% CI [-0.61, -0.17], p = 0.005) and anxiety (SMD:-0.32, 95% CI [-0.58, -0.07], p = 0.01). Additionally, significant increases were observed coping (SMD: 4.31, 95% CI [1.19, 7.44], p = 0.007) and resilience (SMD: 4.68, 95% CI [1.23, 8.13], p = 0.008) immediately after the intervention. However, no significant effect was found on health-related quality of life (SMD: 0.02, 95% CI [-0.25, 0.29], p = 0.88).

CONCLUSION

This meta-analysis provides evidence that technology-based psychological empowerment interventions dramatically improve the psychological well-being of parents of children with cancer. By effectively decreasing distress, depression, and anxiety while enhancing coping skills and resilience, these interventions are emerging as essential components of psychosocial support programs. These findings underscore the transformative potential of technology-driven approaches in addressing the unique and multifaceted needs of families, paving the way for more accessible and personalized support systems.

A visualized and bibliometric analysis of cancer vocational rehabilitation research using CiteSpace

BACKGROUNDThere are numerous publications on cancer vocational rehabilitation, visual techniques can help medical researchers and social workers be more familiar with the state of this field.OBJECTIVETo summarize cancer vocational rehabilitation research, we applied visualized and bibliometric analysis to enable medical workers and social workers to identify evolving patterns of knowledge among articles and research trends, understand the current research status of vocational rehabilitation of cancer, and carry out further research on hot topics.METHODSBased on a review of 933 papers on cancer vocational rehabilitation published in the Web of Science Core Collection, this study used Citespace software to systematically and objectively describe cancer vocational rehabilitation.RESULTSSince 2003, the field of cancer vocational rehabilitation began to sprout. The most published and most cited country, institution, author and cited journal were the United States, University of Amsterdam, Angela G. E. M. de Boer, and Psycho-Oncology, respectively. The three most frequently cited keywords were breast cancer, quality of life and cancer survivor. The three keywords with the largest spike in citations were cohort, absence and symptom. Conducting randomized controlled trials or prospective cohort studies to help cancer survivors return to work, and using qualitative methods to understand the vocational rehabilitation experiences or perceptions of cancer survivors or medical staff are hotspots in this field.CONCLUSIONSCancer vocational rehabilitation has attracted the attention of researchers all over the world. Future studies may focus on other cancer types and explore more high quality interventions.

Does Adjuvant Radiotherapy Enhance Survival in Intracranial Solitary Fibrous Tumor Patients?

OBJECTIVE

Intracranial solitary fibrous tumor is a rare central nervous system tumor that lacks a reliable prognostic clinical model. Uncertainty persists regarding the treatment outcomes of surgery and adjuvant radiotherapy (ART). To address this, we investigated the efficacy of ART and applied machine learning (ML) to develop accurate prognostic models.

METHODS

The Surveillance, Epidemiology, and End Results database was used for this study's analysis. To identify the prognostic variables, we conducted Cox regression analysis and constructed prognostic models using 5 ML algorithms to predict 5-year survival. A validation method incorporating the area under the curve of the receiver operating characteristic curve was used to validate the accuracy and reliability of the models. We investigated the role of ART and surgery using Kaplan-Meier survival analysis, competing risk analysis, and Bias Reduction through Analysis of Competing Events method.

RESULTS

The study population comprised 747 patients. Among them are 316 patients with "surgery" and 431 patients with "surgery + ART." The therapeutic groups showed significant differences in overall survival. Multivariate Cox regression analysis revealed that older age and surgery alone were poor prognostic factors. The most significant prognostic factors were the local tumor excision, followed by lobectomy and age.

CONCLUSIONS

Although ART did not lead to a substantial decrease in cancer-specific deaths, it did improve overall survival. This underscores the broader health benefits of ART, including effective management of comorbid conditions. Caution is advised when interpreting these survival benefits because of potential confounding factors in patient health and treatment management. Our web tool and ML models aid in clinical decision-making.

Interventions for Prevention and Management of Gynecological Cancer-Related Lower Limb Lymphedema: A Systematic Scoping Review

OBJECTIVES

This scoping review aims to map out evidence on interventions for reducing lower limb lymphedema incidence and symptoms after gynecological cancer surgery.

METHODS

This scoping review followed the methods and protocol outlined by the Joanna Briggs Institute Methods Manual. Five databases, including Pubmed, Scopus, Web of Science, CINAHL, and PsycINFO were searched in January 2024.

RESULTS

The review included 15 interventions primarily designed to prevent and manage cancer-related lower extremity lymphedema. Most studies have examined the effect of interventions on the development of lymphedema-related symptoms and quality of life. Most studies tested complex decongestive therapy (CDT) (n = 6, 39.9%), including various techniques, such as manual lymphatic drainage, compression, exercise, and skincare. Of the interventions, 86.6% improved at least one outcome measurement, such as quality of life, lymphedema incidence, symptoms, and lower limb volume.

CONCLUSIONS

Limited evidence shows that the use of interventions appears to have the potential to reduce the risk and symptoms of lymphedema and improve the quality of life in women undergoing gynecological cancer treatment.

IMPLICATIONS FOR NURSING PRACTICE

Developing and testing comprehensive lymphedema education and management strategies in nursing practice is essential to optimize patient outcomes and enhance the quality of life for women undergoing gynecological cancer treatment.

Psychological resilience, dyadic coping, and dyadic adjustment in couples dealing with cervical cancer in Northwest China: A cross-sectional study

PURPOSE

To examine the relationship between dyadic coping and dyadic adjustment in patients with cervical cancer and their spouses in northwest China, and explore the mediating role of psychological resilience in this relationship.

METHODS

A cross-sectional study was conducted from June to October 2024 in two tertiary hospitals in Xinjiang Province, China; 260 patients with cervical cancer and their spouses were enrolled. Participants independently completed demographic and clinical questionnaires as well as Chinese versions of the Resilience Scale, Dyadic Coping Inventory, and Locke-Wallace Marital Adjustment Scale. The Actor-Partner Interdependence Model was employed to analyze dyadic data.

RESULTS

Patients with cervical cancer and their spouses both exhibited actor effects (β = 0.197, P < 0.001; β = 0.342, P < 0.001) and partner effects (β = 0.276, P < 0.001; β = 0.264, P < 0.001) in the association between dyadic coping and dyadic adjustment. Regarding the mediating role of psychological resilience, spouses' dyadic coping directly affected patients' psychological resilience, and patients' psychological resilience indirectly influenced their own dyadic adjustment (β = 0.061, 95% CI = 0.019, 0.121; β = 0.074, 95% CI = 0.019, 0.144).

CONCLUSIONS

Our findings suggested that psychological resilience plays an essential role in enhancing dyadic coping and cultivating dyadic adjustment among patients with cervical cancer and their spouses. Healthcare professionals should identify couples who have difficulty coping and adapting, and consider couple-centered dyadic resilience interventions to improve these behaviors.

A Rapid Review on Shared Decision Making in Pediatric Palliative Care and End-of-Life Care: Implications for Clinical Practice, Research, and Policy

Shared decision making is a concept essential to establishing meaningful goals of care that reflect one's preferences, values, beliefs, culture, and quality of life. This rapid review considered shared decision making from the perspective of seriously ill or medically complex children receiving inpatient palliative or end-of-life care, where shared decision making is made on behalf of and in the child's best interest. A total of 118 articles were screened, resulting in the selection of 12 articles using a systematic process. Emergent themes noted and discussed include the roles of family and clinicians, explorative communication, transparency, cultural implications, and ethical challenges.

Profiles of chemotherapy-induced peripheral neuropathy in breast cancer patients undergoing taxane-based chemotherapy: A latent class analysis

PURPOSE

This study aimed to identify the potential subgroups of chemotherapy-induced peripheral neuropathy (CIPN) in breast cancer patients undergoing taxane-based chemotherapy and examine the association of the latent subtype with patient characteristics.

METHODS

This multi-center, cross-sectional investigation was conducted between April 2022 and March 2023. CIPN was evaluated using the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity scale. Latent class analysis was employed to identify distinct CIPN subgroups, and multinomial logistic regression was used to analyze the associations between these subgroups and patient characteristics.

RESULTS

In total, 397 individuals were categorized into three subgroups: high symptoms with high dysfunction (Class 1; 25.4%), moderate symptoms with low dysfunction (Class 2; 39.2%), and low symptoms with low dysfunction (Class 3; 35.3%). Taxane type, chemotherapy cycles, fatigue, β-blocker use, and depression were significant predictors of the subgroups (P < .05).

CONCLUSION

CIPN symptoms in breast cancer patients are heterogeneous. Significant factors for the latent subgroups included taxane type, chemotherapy cycles, β-blocker use, fatigue, and depression. Identifying different subgroups of chemotherapy-induced peripheral neuropathy would help develop interventions tailored to the patients.

Explore Potential Profiles and Influencing Factors for Financial Toxicity in Patients with Colorectal Cancer Undergoing Chemotherapy: A Cross-Sectional Study

OBJECTIVES

To explore the potential financial toxicity (FT) profiles in patients with colorectal cancer (CRC) undergoing chemotherapy and analyze its influencing factors.

METHODS

A cross-sectional study was conducted on 373 CRC patients undergoing chemotherapy in southwest China from January 2024 to May 2024. We utilized the General Information Questionnaire, the FT based on Patient-Reported Outcome Measures (COST-PROM), the Brief Illness Perception Questionnaire (BIPQ), and the Family APGAR Index (APGAR). Latent profile analysis (LPA) by Mplus8.3 was used to identify the latent profiles of the FT. Multinomial logistic regression analysis was used to analyze the relevant factors in the different categories.

RESULTS

The patients with CRC undergoing chemotherapy were divided into four profiles: high FT group (44.5%), moderate FT-low psychological adaptation group (22.8%), moderate FT-high psychological adaptation group (18.0%), and low FT group (14.7%). Age, average monthly household income per capita, employment status, disease duration, round of chemotherapy, illness perception, and family function were the influencing factors for potential profiles of FT in CRC chemotherapy patients (P < 0.05).

CONCLUSIONS

There are four potential profiles of FT in patients with CRC undergoing chemotherapy. Healthcare providers should pay attention to patients with CRC undergoing chemotherapy aged 18 to 59 years old, employed and unemployed, with lower average monthly household income per capita, disease duration of less than 1 year, and more times of chemotherapy. Additionally, reducing patients' negative perceptions of the disease and improving family function can help lower the level of FT.

IMPLICATION FOR NURSING PRACTICE

This research can assist nurses in identifying patients at high risk of FT, enabling early intervention and the implementation of targeted psychological nursing interventions. Nurses can help patients develop positive perceptions of the disease and improve family relationships, thereby mitigating the negative effects of FT.

The longitudinal association between resilience and sleep quality in breast cancer

PURPOSE

To estimate the longitudinal association between resilience and sleep quality in patients with newly diagnosed breast cancer within the first 6 months.

METHOD

Between July 2023 and September 2023, 155 newly diagnosed BC patients were recruited to participate in the Be Resilience to Breast Cancer program (Abbreviated as BRBC). They completed the 10-item Connor-Davidson Resilience scale and Pittsburgh Sleep Quality Index Scale. The following three timepoints were set to collect the data, including 1 month after initial diagnosis (T0), 3 months (T1), and 6 months (T2). Data were analyzed using Cross-lagged Panel Model (CLPM), and Parallel Latent Growth Model (PLGM).

RESULTS

Excluded questionnaires with a large number of missing items and finally 125 patients were included, with the response rate of 83.3%. CLPM indicated that resilience at T1 predicted PSQI at T2 (r = -0.168, P < 0.001), and PSQI at T1 predicted resilience at T2 (r = -0.112, P< 0.001). PLGM demonstrated that changes in resilience was significantly associated with changes in PSQI (r = -0.874, P< 0.001).

CONCLUSION

A longitudinal association between resilience and sleep quality was confirmed in patients with newly diagnosed breast cancer. Resilience was a protective factor in the development of sleep quality.