Neutropenia: State of the Knowledge Part II

Nondrug Intervention for Opportunistic Infections in Individuals With Hematological Malignancy: Systematic Review

BACKGROUND

Hematological malignancies disturb the blood, lymph nodes, and bone marrow. Taking medications for treating opportunistic infections (OIs) in these individuals may enhance the risk of medication interaction as well as adverse drug reactions.

OBJECTIVE

This review aims to evaluate the effectiveness of nondrug interventions in reducing OIs among patients with hematological cancers.

METHODS

The PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), and Embase databases were searched on December 26, 2022, for all randomized controlled trials (RCTs). The primary endpoint was OIs. The quality of included studies was assessed by the Cochrane Risk-of-Bias tool.

RESULTS

A total of 6 studies were included in this review with 4 interventions: (1) types of mouthwash received, (2) presence of coating on central venous catheters (CVCs), (3) use of well-fitted masks, and (4) types of diet consumed. The results were presented in 8 different comparisons: (1) chlorhexidine-nystatin versus saline mouth rinse, (2) chlorhexidine versus saline mouth rinse, (3) nystatin versus saline mouth rinse, (4) chlorhexidine silver sulfadiazine-coated CVCs versus uncoated catheters, (5) well-fitted masks versus no mask, (6) amine fluoride-stannous fluoride versus sodium fluoride mouthwash, (7) low-bacterial diet versus standard hospital diet, and (8) herbal versus placebo mouthwash. No clear differences were reported in any of the outcomes examined in the first 3 comparisons. There were also no clear differences in the rate of catheter-related bloodstream infection or insertion site infection between the use of chlorhexidine silver sulfadiazine-coated CVCs versus uncoated catheters in the patients. Further, no significant differences were seen between patients who used a well-fitted mask and those without a mask in the incidence of OI. The all-cause mortality and mortality due to OI were similar between the 2 groups. There was no clear difference in all-cause mortality, although common adverse effects were reported in patients who used sodium fluoride mouthwash compared with those using amine fluoride-stannous fluoride mouthwash. There was no evidence of any difference in the incidence of possible invasive aspergillosis or candidemia between patients who consumed a low-bacterial diet and a standard diet. For the last comparison, no significant difference was seen between patients who received herbal and placebo mouthwash.

CONCLUSIONS

Very limited evidence was available to measure the effectiveness of nondrug interventions in hematological cancers. The effectiveness of the interventions included in this review needs to be evaluated further in high-quality RCTs in a dedicated setting among patients with hematological malignancies.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020169186; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=169186.

Shapley-Additive-Explanations-Based Factor Analysis for Dengue Severity Prediction using Machine Learning

Dengue is a viral disease that primarily affects tropical and subtropical regions and is especially prevalent in South-East Asia. This mosquito-borne disease sometimes triggers nationwide epidemics, which results in a large number of fatalities. The development of Dengue Haemorrhagic Fever (DHF) is where most cases occur, and a large portion of them are detected among children under the age of ten, with severe conditions often progressing to a critical state known as Dengue Shock Syndrome (DSS). In this study, we analysed two separate datasets from two different countries- Vietnam and Bangladesh, which we referred as VDengu and BDengue, respectively. For the VDengu dataset, as it was structured, supervised learning models were effective for predictive analysis, among which, the decision tree classifier XGBoost in particular produced the best outcome. Furthermore, Shapley Additive Explanation (SHAP) was used over the XGBoost model to assess the significance of individual attributes of the dataset. Among the significant attributes, we applied the SHAP dependence plot to identify the range for each attribute against the number of DHF or DSS cases. In parallel, the dataset from Bangladesh was unstructured; therefore, we applied an unsupervised learning technique, i.e., hierarchical clustering, to find clusters of vital blood components of the patients according to their complete blood count reports. The clusters were further analysed to find the attributes in the dataset that led to DSS or DHF.

Acute leukaemia: making sense of a complex blood cancer

Acute leukaemia represents a diverse group of blood cancers that affect both children and adults. Treatment schedules for these haematology cancers are often prolonged, with many associated side effects and complications. Nurses caring for patients with acute leukaemia require an anticipatory approach, where care is aimed at minimizing the side effects of treatment and being constantly vigilant for any impending adverse effects. Moreover, patients require support for the psychosocial issues that can arise for patients during their illness. This article provides an overview of acute lymphoblastic leukaemia and acute myeloid leukaemia. Nursing considerations in the care of patients being treated for acute leukaemia are also explored.

Implementation of an evidence-based order set to impact initial antibiotic time intervals in adult febrile neutropenia

PURPOSE/OBJECTIVES

To evaluate the impact of the implementation of a standardized order set on the time interval in initiation of antibiotic therapy for adult patients with cancer and febrile neutropenia.

DESIGN

Practice change.

SETTING

The oncology unit of an urban hospital in the south-eastern United States.

SAMPLE

Adult patients with cancer and febrile neutropenia admitted six months prior to (n = 30) or during the three months following (n = 23) implementation of the order set.

METHODS

Literature regarding febrile neutropenia, use of order sets, and change process was reviewed. In addition, a retrospective and concurrent chart review was conducted for adult patients admitted with febrile neutropenia. Time intervals were analyzed using SPSS® software, version 18.

MAIN RESEARCH VARIABLES

Initial antibiotic times, order-set use, and length of stay.

FINDINGS

An overall reduction in time intervals for initiation of antibiotic therapy was observed for presentation (t = 2.25; degrees of freedom [df] = 37; p = 0.031) and order (t = 2.67; df = 40.17; p = 0.012) to antibiotic administration, with an order-set usage of 31% in the inpatient unit and 71% in the emergency department.

CONCLUSIONS

Findings in the presence of low order-set usage suggest that staff education and placement of the order-set antibiotics in unit-based medication dispensing machines helped reduce time intervals for initial antibiotic therapy.

IMPLICATIONS FOR NURSING

The use of an evidence-based approach to nursing care is essential to achieving the best outcomes for patients with febrile neutropenia. Incorporation of current evidence into an order set to guide clinical practice and comprehensive nurse, pharmacy, and physician education are needed for the successful implementation of evidence-based practice changes.

The Patient Care Monitor-Neutropenia Index: development, reliability, and validity of a measure for chemotherapy-induced neutropenia

PURPOSE/OBJECTIVES

To provide an initial evaluation of the psychometric properties of the Patient Care Monitor 1.0 Revised-Neutropenia Index (PCM-N), a symptom-based assessment tool designed to measure health-related quality-of-life (HRQOL) changes associated with chemotherapy-induced neutropenia.

DESIGN

Known-groups methodology and self-report instrument validation.

SETTING

A large community oncology practice in Memphis, TN.

SAMPLE

424 patients with cancer in four samples.

METHODS

All patients in the first three samples were assessed at baseline of chemotherapy administration and at a point analogous to midcycle. The fourth sample underwent a cross-sectional evaluation of the ability of the PCM-N to distinguish patients with febrile neutropenia, severe afebrile neutropenia, and no neutropenia.

MAIN RESEARCH VARIABLES

PCM-N score, grade of neutropenia, and febrile status.

FINDINGS

Internal consistency reliability and factor analysis supported the single additive scale structure of the 13 items of the PCM-N. The PCM-N demonstrated good known-groups validity and was able to distinguish patients with grades 3-4 neutropenia from those with grades 0-2. The tool also was able to distinguish patients with febrile neutropenia, severe afebrile neutropenia, and no neutropenia. Receiver operating characteristic analyses provided a psychometrically based threshold score.

CONCLUSIONS

The PCM-N is a reliable and valid instrument sensitive to changes in HRQOL associated with moderate-to-severe chemotherapy-induced neutropenia.

IMPLICATIONS FOR NURSING

Nurses can use the PCM-N as a rapid and cost-effective tool for monitoring symptoms of neutropenia in patients with cancer.

National Cancer Institute Cancer Center designation and 30-day mortality for hospitalized, immunocompromised cancer patients

PURPOSE

To examine 30-day mortality and National Cancer Institute (NCI) designation for cancer patients who are immunocompromised and hospitalized.

METHOD

Secondary analysis of 1998 and 1999 hospital claims, cancer registry, and vital statistics (n = 10,370) linked to survey and administrative data from 160 Pennsylvania hospitals. Logistic regression models estimated the effects of NCI designation on the likelihood of 30-day mortality.

RESULTS

NCI-designated centers were associated with a 33% reduction in the likelihood of death, after adjusting for patient, hospital, and nursing characteristics.

CONCLUSIONS

Immunocompromised cancer patients have lower mortality in NCI-designated hospitals. Identification and adoption of care processes from these institutions may improve mortality.

The EDUCATE Study: a continuing education exemplar for Clinical Practice Guideline Implementation

Cancer care is evolving from a solo practitioner care delivery system based on tradition and anecdotal experience to a multidisciplinary, collaborative, science-driven paradigm. Evidence-based practice facilitates optimal care quality for patients with cancer and is effected for medical and nursing practitioners through clinical practice guideline implementation. Clinician education based on principles of adult learning is one method of implementing clinical practice guidelines in clinical practice. However, research demonstrates that conventional static methods of education do little to change behavior; instead, effective education incorporates interactive formats, provides feedback, and includes reminder and reinforcement strategies. The EDUCATE (Educating Clinicians to Achieve Treatment Guideline Effectiveness) Study offers one model for clinical practice guideline implementation using educational methods. A faculty of nurse educators, together with practice champions, carried out an intensive educational intervention comprised of multiple teaching/learning activities during a 12-month period in community oncology practices throughout the United States. In addition to an overview of clinical practice guidelines and educational methods that can be used for implementation of clinical practice guidelines, the obstacles faced and lessons learned through the EDUCATE Study are presented, along with recommendations for implementation in the practice setting.