Besoins non satisfaits en soins de soutien chez les survivants du cancer de la prostate à un stade avancé : exploration par méthodes mixtes

But : Les hommes souffrant d’un cancer avancé de la prostate connaissent un large éventail d’effets secondaires découlant du cancer et de ses traitements qui nuisent à leur qualité de vie (QDV). Peu d’études ont évalué les besoins de soins de soutien chez ces personnes. Cette étude a été réalisée pour effectuer une évaluation globale des besoins en soins de soutien chez ces survivants en se fondant sur un cadre de soins de soutien en oncologie (Supportive Care Framework for Cancer Care, ou SCFCC). Méthodes : Dans le cadre d’une recherche menée selon une approche mixte, parallèle et convergente, des survivants du cancer de la prostate à un stade avancé (n = 188) ont répondu à un questionnaire d’enquête transversale. Quelques-uns de ces survivants (n = 20) ont participé à un entretien afin de mieux évaluer leurs besoins non satisfaits. Résultats : Les survivants ont déclaré des besoins non satisfaits de soins de soutien dans tous les domaines du cadre d’évaluation utilisé. Pas moins de 95,2 % des survivants avaient au moins un besoin non satisfait, avec une moyenne de 14,9 besoins (fourchette : 0–42). Plusieurs domaines de convergence entre les données quantitatives et qualitatives (fatigue, dysfonctionnement sexuel, domaines pratique et émotionnel/psychologique) et de divergence (domaines informationnel et spirituel, dépression, dysfonctionnement urinaire) ont été trouvés durant le processus d’intégration. Conclusion : Cette étude confirme que les survivants du cancer de la prostate à un stade avancé présentent des taux élevés de besoins non satisfaits en soins de soutien. Les résultats soulignent également une grande diversité dans ces besoins non satisfaits. Ces résultats pourraient contribuer au développement de plans de soins de soutien centrés sur le patient, adaptés aux besoins particuliers de ce groupe vulnérable de survivants du cancer. Mots-clés : cancer de la prostate; stade avancé; survivants; soins de soutien; besoins non satisfaits; qualité de vie; méthodes mixtes

Unmet supportive care needs in prostate cancer survivors with advanced disease: A mixed-methods exploration

Purpose: Men with advanced prostate cancer experience a wide range of side effects from the cancer and its therapies, which have a negative effect on their quality of life (QOL). Few studies have evaluated supportive care needs in these individuals. The purpose of this study was to conduct a holistic supportive care needs assessment among these survivors guided by the Supportive Care Framework for Cancer Care. Methods: Using a convergent parallel mixed-methods approach, prostate cancer survivors with advanced disease (n = 188) completed a cross-sectional survey. A subset of these survivors (n = 20) participated in an interview to further explore their experience of unmet needs. Results: Survivors reported unmet supportive care needs in every domain of the framework. Up to 95.2% of the survivors had at least one unmet need, with a mean of 14.9 (range: 0–42). Several areas of convergence among the quantitative and qualitative data (fatigue, sexual dysfunction, practical, and emotional/psychological domains), as well as divergence (informational and spiritual domains, depression, urinary dysfunction) were found through the integration process. Conclusions: This study confirms that prostate cancer survivors with advanced disease experience high rates of unmet supportive care needs. The findings also highlight the diversity of those unmet needs. These results may assist with future development of patient-centered supportive care interventions that better meet the specific needs of this vulnerable group of cancer survivors. Keywords: prostate cancer; advanced disease; survivors; supportive care; unmet needs; quality of life; mixed-methods

The symptom phenotype of oncology outpatients remains relatively stable from prior to through 1 week following chemotherapy

Some oncology outpatients experience a higher number of and more severe symptoms during chemotherapy (CTX). However, little is known about whether this high risk phenotype persists over time. Latent transition analysis (LTA) was used to examine the probability that patients remained in the same symptom class when assessed prior to the administration of and following their next dose of CTX. For the patients whose class membership remained consistent, differences in demographic and clinical characteristics, and quality of life (QOL) were evaluated. The Memorial Symptom Assessment Scale (MSAS) was used to evaluate symptom burden. LTA was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of the MSAS symptoms. Of the 906 patients evaluated, 83.9% were classified in the same symptom occurrence class at both assessments. Of these 760 patients, 25.0% were classified as Low-Low, 44.1% as Moderate-Moderate and 30.9% as High-High. Compared to the Low-Low class, the other two classes were younger, more likely to be women and to report child care responsibilities, and had a lower functional status and a higher comorbidity scores. The two higher classes reported lower QOL scores. The use of LTA could assist clinicians to identify higher risk patients and initiate more aggressive interventions.

A longitudinal evaluation of oral mucositis in patients receiving radiation therapy (IMRT) with/without chemotherapy (CTX)

e20572

Background: Oral mucositis is a major side effect of RT ± CTX to the head and neck. A variety of instruments and techniques have been used to quantify oral cavity changes during treatment. Few studies have reported on the evaluation of oral mucositis using both subjective and objective methods. A secondary aim in our study testing an innovative mouthwash is to increase our understanding of using subjective and objective methods for measuring oral mucositis, functional status, and weight changes over time. Methods: Patients reported functional status, pain and investigators measured oral mucositis and weight at four times (beginning of RT [T1], onset of mucositis [T2], end of RT [T3], and healing of mucositis [T4]) over a 10 - 15 week period, using the Karnofsky Performance Status [KPS]) and the Oral Mucositis Assessment Scale (OMAS). The OMAS measures researcher-evaluated ulceration/pseudomembrane formation and erythema in specific sites in the mouth, and self-report by patients, rating severity of mouth pain, ability to swallow and chew. Results: Of 51 head and neck cancer patients enrolled, 3 never developed mucositis. Mean days to onset of mucositis was 15.58 (SD 6.85), and mean days to healing of mucositis was 77.86 (SD 40.1). Mucositis pain scores (possible range 0–45) were moderate at T2 (x=6.25, SD 3.5) and T3 (x=12, SD 5.0). Subjective pain, chewing, and swallowing scores were positively correlated with each other (r= .31 - .73, p<.05) and objective oral mucositis scores were positively correlated with each other (r= .49 - .77, p<.01), however, no significant correlations were obtained between the subjective and objective scores. In both the RT-only group as well as the RT+CTX group, weight significantly decreased from T1 to T4, and KPS significantly decreased from T1 to T3. RT+CTX patients showed lower KPS and greater weight loss from T1 to T4 (X=10lbs) compared to the RT-only group (X=3 lbs), but neither was significantly different. Conclusions: During RT+CTX, patients need more supportive care to maintain functional status and avoid weight loss. Lack of correlations between the subjective and objective scores is interesting in that they are measuring something quite different, which may provide some insight into underlying mechanisms.

No significant financial relationships to disclose.

Review article: self-report measures to evaluate constipation

BACKGROUND

Constipation is a subjective phenomenon, and as such must be evaluated using patient self-report. Valid and reliable measures of constipation are essential to standardize the diagnosis, assess the severity and evaluate the effectiveness of treatments.

AIM

To compare and contrast published self-report measures of constipation in terms of development, content, general characteristics, psychometric properties and clinical utility.

METHODS

MEDLINE (1966-2007), CINAHL (1980-2007), Cochrane (1993-2007) and Web of Science (1995-2007) were searched to identify self-report measures of constipation. Measures of constipation were selected if they: (i) were self-report measures that measured only constipation; (ii) had undergone psychometric testing; (iii) were used in adults and (iv) were written in English.

RESULTS

Seven self-report measures of constipation were identified. The content areas evaluated by these measures varied. Only two measures had adequate validity and reliability, sensitivity to change, or were tested in more than one sample.

CONCLUSIONS

Findings from this review suggest that the Chinese Constipation Questionnaire and the Patient Assessment of Constipation-Symptom Questionnaire demonstrate adequate psychometric properties for a constipation measure. Additional research is warranted to refine or develop a more comprehensive self-report measure to evaluate constipation in adults.

Biology of mucosal pain

Pain is experienced when injury to mucosal tissues occurs. Although the neurobiology of mucosal pain has not been fully elucidated, research has demonstrated that the oral mucosa contains primary afferent nociceptors that respond to thermal, mechanical, and chemical stimuli. Inflammation occurs during the initial phase of mucosal injury caused by stomatotoxic chemotherapy or radiation therapy. This article reviews the mechanisms that underlie acute pain in inflamed cutaneous tissue and summarizes the major mediators that activate and sensitize primary afferent nociceptors. Recommendations for future research to elucidate the neurobiology of mucosal pain throughout the gastrointestinal tract are presented.

Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management

PURPOSE

To evaluate oncology outpatients' level of adherence to their analgesic regimen during a 5-week period.

PATIENTS AND METHODS

A random sample of 65 adult oncology outpatients with a Karnofsky performance status score of >or= 50, an average pain intensity score of >or= 2.5, and radiographic evidence of bone metastasis were recruited for this longitudinal study from seven outpatient settings. On a daily basis, patients rated their level of pain intensity and recorded pain medication intake. Adherence rates for opioid analgesics prescribed on an around-the-clock (ATC) and on an as-needed (PRN) basis were calculated on a weekly basis.

RESULTS

Overall adherence rates for ATC opioid analgesics ranged from 84.5% to 90.8% and, for PRN analgesics, from 22.2% to 26.6%. No significant differences over time were found in either of these adherence rates.

CONCLUSION

One factor that seems to contribute to ineffective cancer pain management is poor adherence to the analgesic regimen.

Measurement of opioid-induced sedation

One of the major side effects of opioid analgesics is sedation. Despite the fact that neither a universal definition nor a gold standard for the measurement of opioid-induced sedation exists, various neurophysiologic and psychomotor measures are used to quantify the sedative effects of opioids. This report reviews the strengths and weaknesses of various approaches that are used to measure opioid-induced sedation. The first section summarizes various neurophysiologic measures (i.e., electroencephalogram, autonomic reflexes, and evoked responses), and the second section reviews psychomotor measures (i.e., visual analog scales, observer assessments, motor performance tests, tests of perceptual processes, tests of information processing, tests of memory, and composite tests) that are used to evaluate the sedative effects of opioids. Implications for future research on opioid-induced sedation are discussed.

Definition of and mechanism for opioid-induced sedation

Although sedation is acknowledged to be one of the most common side effects of opioid analgesics, the mechanisms and characteristics of this phenomenon remain elusive, and research in this area is extremely limited. This report integrates research findings on the mechanism of action of opioids with research findings on the phenomenon of consciousness to develop a model of how opioids may act in the central nervous system to produce sedation. Based on this integration, a definition of opioid-induced sedation is proposed to encourage dialogue and research on this perplexing and clinically significant phenomenon.

A comparison of the affective state and quality of life of chemotherapy patients who do and do not develop chemotherapy-induced oral mucositis

The purpose of this longitudinal study was to compare the quality of life and affective state of patients receiving chemotherapy who developed oral mucositis to patients who did not. Outpatients had their mouths assessed at the beginning of their chemotherapy, completed the Multidimensional Quality of Life scale, Cancer version (MQOLS-CA) and the Profile of Mood States (POMS). Patients again completed the MQOLS-CA and POMS if they developed mucositis during their three cycles (monthly), or if they did not and were exiting the study. Seventy-seven outpatients completed the study; 28 patients developed mucositis and 49 did not. The MQOLS-CA total scores for the entire sample decreased significantly over time (F(1,75) = 25.44, P < 0.001), but there was no group by time interaction, i.e., the change in MQOLS-CA total scores did not depend on mucositis status. While the POMS Total Mood Disturbance scores for the entire sample increased significantly over time (F(1,75) = 19.55, P < 0.001), there was a significant group by time interaction (F(1,75)= 4.85, P = 0.03). Patients who developed mucositis had a significant increase in mood disturbance compared to patients who did not. Further, the POMS subscales of depression and anger showed the same pattern of significant increases. In conclusion, the development of mucositis adversely affected the outpatients' affective states, but not their QOL.

Monitoring and improving pain management practices. A quality improvement approach

The development of a multidisciplinary pain management committee is a critical step in monitoring and improving pain management practices. The systematic evaluation of the quality of pain management using the principles of QI establishes a process that can lead to improvements in the care that patients receive. Clinicians need to develop a 1- to 2-year plan to improve the quality of pain management. Changes in clinicians' behaviors occur slowly; thus, members of pain management committees should not become discouraged but continue to move forward one step at a time.

Symptom clusters and their effect on the functional status of patients with cancer

PURPOSE/OBJECTIVES

To determine the effect of the symptom cluster of pain, fatigue, and sleep insufficiency on functional status during three cycles of chemotherapy.

DESIGN

Prospective, longitudinal.

SETTING

23 outpatient offices and clinics.

SAMPLE

93 patients with cancer. The typical participant was female (72%), married/partnered (65%), white (87%), and middle-aged (55.4 years), with an average of 14.8 years of education.

METHODS

The Quality of Life-Cancer (QOL-CA) version instrument and the Karnofsky Performance Scale (KPS) were completed by 93 outpatients receiving chemotherapy at baseline (Time 1) and at the end of the third cycle (Time 2). Three items (pain, tires easily, sleeps enough to meet needs) from the QOL-CA questionnaire were used to measure the symptom cluster.

MAIN RESEARCH VARIABLES

Symptom cluster, outcome, functional status, chemotherapy.

FINDINGS

A hierarchical multiple regression model explained 48.4% of the variance in functional status. The KPS at Time 1 explained 30.8% of the variance in KPS at Time 2 (p < 0.001). After KPS at Time 1 was partialled out from KPS at Time 2, the four independent variables entered in the next step were considered predictors of the change in functional status between Time 1 and Time 2. Age explained 11.8% of the change (p = 0.001), pain explained 10.7% of the change (p = 0.002), and fatigue explained 7.3% of the change (p = 0.011). Sleep insufficiency statistically was not significant, only explaining 1% of the change (p = 0.344).

CONCLUSION

This study provides beginning insights into the effect of a symptom cluster on patients' functional status.

IMPLICATIONS FOR NURSING PRACTICE

Healthcare professionals need to be aware of the presence of symptom clusters and their possible synergistic adverse effect on patients' future morbidity.

New approaches for evaluating the quality of cancer pain management in the outpatient setting

Both retrospective and prospective methods can be used to evaluate the quality of cancer pain management in the outpatient setting. Retrospective evaluations of the quality of cancer pain management in the outpatient setting provide benchmark data that can be used to change clinical practice for groups of patients or for specific types of cancer pain problems. Prospective evaluations of the quality of cancer pain management with patient diaries in the outpatient/home care setting can help clinicians do "real-time" evaluations and modify the pain management plan for individual patients. This report provides practical suggestions for evaluating the quality of cancer pain management in the outpatient setting.

Advancing the science of symptom management

Since the publication of the original Symptom Management Model (Larson et al. 1994), faculty and students at the University of California, San Francisco (UCSF) School of Nursing Centre for System Management have tested this model in research studies and expanded the model through collegial discussions and seminars.

AIM

In this paper, we describe the evidence-based revised conceptual model, the three dimensions of the model, and the areas where further research is needed.

BACKGROUND/RATIONALE

The experience of symptoms, minor to severe, prompts millions of patients to visit their healthcare providers each year. Symptoms not only create distress, but also disrupt social functioning. The management of symptoms and their resulting outcomes often become the responsibility of the patient and his or her family members. Healthcare providers have difficulty developing symptom management strategies that can be applied across acute and home-care settings because few models of symptom management have been tested empirically. To date, the majority of research on symptoms was directed toward studying a single symptom, such as pain or fatigue, or toward evaluating associated symptoms, such as depression and sleep disturbance. While this approach has advanced our understanding of some symptoms, we offer a generic symptom management model to provide direction for selecting clinical interventions, informing research, and bridging an array of symptoms associated with a variety of diseases and conditions. Finally, a broadly-based symptom management model allows the integration of science from other fields.

A pilot study of the relationship between discomfort and agitation in patients with dementia

People with dementia often have painful conditions that go unnoticed because of their communication problems. Signs of pain in this population may include agitation and observable behaviors associated with discomfort. Agitation, discomfort, and severity of dementia were evaluated in 33 Veterans Affairs nursing home patients using the Cohen-Mansfield Agitation Inventory, the Discomfort Scale, and the Global Deterioration Scale, respectively. Findings revealed statistically significant positive relationships between agitation and severity of dementia (r = 0.34, P = 0.01), discomfort and severity of dementia (r = 0.44, P = 0.01), and agitation and discomfort (r = 0.50, P = 0.003). In a multiple regression analysis, agitation was significantly associated with discomfort (R(2) =.14, P = 0.02) after controlling for dementia severity. These preliminary findings suggest that discomfort may be a source of agitation.

Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition

PURPOSE

This survey was designed to confirm the prevalence and duration of fatigue in the cancer population and to assess its physical, mental, social, and economic impacts on the lives of patients and caregivers. Patients and Methods. A 25-minute telephone interview was completed with 379 cancer patients having a prior history of chemotherapy. Patients were recruited from a sample of 6, 125 households in the United States identified as having a member with cancer. The median patient age was 62 years, and 79% of respondents were women. Patients reporting fatigue at least a few times a month were asked a series of questions to better describe their fatigue and its impact on quality of life.

RESULTS

Seventy-six percent of patients experienced fatigue at least a few days each month during their most recent chemotherapy; 30% experienced fatigue on a daily basis. Ninety-one percent of those who experienced fatigue reported that it prevented a "normal" life, and 88% indicated that fatigue caused an alteration in their daily routine. Fatigue made it more difficult to participate in social activities and perform typical cognitive tasks. Of the 177 patients who were employed, 75% changed their employment status as a result of fatigue. Furthermore, 65% of patients indicated that their fatigue resulted in their caregivers taking at least one day (mean, 4.5 days) off work in a typical month. Physicians were the health care professionals most commonly consulted (79%) to discuss fatigue. Bed rest/ relaxation was the most common treatment recommendation (37%); 40% of patients were not offered any recommendations.

CONCLUSIONS

Cancer-related fatigue is common among cancer patients who have received chemotherapy and results in substantial adverse physical, psychosocial, and economic consequences for both patients and caregivers. Given the impact of fatigue, treatment options should be routinely considered in the care of patients with cancer.

The PRO-SELF Program: a self-care intervention program for patients receiving cancer treatment

OBJECTIVES

To describe the development, testing, and refinement of the PRO-SELF Program as used in randomized clinical trials.

DATA SOURCES

Research studies and articles.

CONCLUSIONS

The PRO-SELF Program has made an important contribution in enhancing patients' self-care and reducing morbidity. It has the potential to contribute to self-care abilities of children and adolescents who have cancer.

IMPLICATIONS FOR NURSING PRACTICE

It is imperative that patients and their families have the essential information, skills, and support to carry out effective self-care symptom management.

Factors influencing oral mucositis in patients receiving chemotherapy

PURPOSE

Oral mucositis is a painful complication of chemotherapy and can greatly affect patients' morbidity and mortality. Findings from two previous studies suggested a decrease in the prevalence of chemotherapy-induced mucositis in patients with solid tumors. The purposes of this study were to follow a large cohort of outpatients to determine the prevalence of mucositis and to identify whether certain clinical factors were significant in the development of mucositis.

DESCRIPTION OF STUDY

In this prospective study, a convenience sample of 199 outpatients was followed for three cycles or until mucositis developed. The clinical factors monitored included the following: pretreatment dental examination/repair; initial standard chemotherapy dosage; prophylactic use of colony-stimulating factors; and use of preventive mouthwashes or other prophylactic measures.

RESULTS

Oral mucositis developed in 50 patients (25.1%). Prechemotherapy dental examination/repair and initial standard chemotherapy dosage were equivalent among both groups. Of the 48 patients in whom mucositis developed, 10 (20.8%) received prophylactic colony-stimulating factors. Of 134 patients in whom mucositis did not develop, 46 (34.3%) received prophylactic colony-stimulating factors. This difference was statistically nonsignificant.

CLINICAL IMPLICATIONS

Differences in the clinical factors investigated could not explain the lower prevalence of oral mucositis among the current patient cohort. The reason for the diminishing prevalence of this side effect remains unclear, and additional parameters, particularly detailed oral hygiene practices, should be evaluated. In the meantime, oncology clinicians should consider the teaching of patients and urging them to use good oral hygiene practices as necessary and potentially preventive measures against chemotherapy-induced mucositis.

The impact of age on a patient's perception of pain and ways it can be managed

The elderly population is one of the fastest growing groups in the United States. Pain is a significant problem for community-dwelling elders and for elderly persons in residential facilities. Numerous barriers exist to effective pain management in the elderly. Clinicians, however, can overcome many of these barriers through careful assessments of pain that accommodate many of the physiologic changes that occur with aging. Effective pain management of elderly individuals requires knowledge of the pharmacokinetic and pharmacodynamic changes that occur with aging. Both pharmacologic and nonpharmacologic approaches should be used to manage pain in the elderly.

The symptom experience of angina in women

Angina is the symptom of myocardial ischemia and the most common presentation of women with coronary artery disease. Women have delayed responses to angina and postpone seeking care more than men. Myocardial ischemia is life threatening and timeliness of treatment is critical. Understanding the symptom experience is important to patients and health care providers alike to reduce morbidity and mortality rates. This article reviews current knowledge of the symptom experience to identify gaps in knowledge and provide a basis for future research and interventions. The symptom experience component of the Symptom Management Model is used as an organizing framework. In terms of chest pain perception, biopsychosocially oriented studies are inconsistent. Data suggest that women use different pain descriptors than men and that diabetes, somatic awareness, and hormonal status probably play a role in attenuating or altering anginal pain. In evaluating symptoms, findings suggest that if anginal symptoms were experienced as expected and/or were evaluated as cardiac in origin, response was more appropriate. Even when it is known that the symptoms are related to cardiac disease, women's responses are still delayed because of a need to self-treat to maintain control. If a patient recognizes symptoms to be cardiac in origin, an appropriate evaluation of the urgency of the situation was made more often, and a rapid response was more likely. Therefore, the larger problem may be the accurate perception of the symptom and the recognition that the symptom is cardiac in origin. This article has implications for future research dealing with improved responses.

Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis

OBJECTIVE

To test the effectiveness of 3 mouthwashes used to treat chemotherapy-induced mucositis. The mouthwashes were as follows: salt and soda, chlorhexidine, and "magic" mouthwash (lidocaine, Benadryl, and Maalox).

STUDY DESIGN

A randomized, double-blind clinical trial was implemented in 23 outpatient and office settings. Participants were monitored from the time they developed mucositis until cessation of the signs and symptoms of mucositis, or until they finished their 12-day supply of mouthwash. All participants followed a prescribed oral hygiene program and were randomly assigned a mouthwash. Nurses used the Oral Assessment Guide for initial assessment and taught patients how to assess their own mouths, then phoned the patients every other day to gather status reports.

RESULTS

In 142 of 200 patients, there was a cessation of the signs and symptoms of mucositis within 12 days. No significant differences in time for the cessation of the signs and symptoms were observed among the 3 groups.

CONCLUSIONS

Given the comparable effectiveness of the mouthwashes, the least costly was salt and soda mouthwash.

Plasma norepinephrine levels, vagal tone index, and flexor reflex threshold in premature neonates receiving intravenous morphine during the postoperative period: a pilot study

OBJECTIVE

The goal of this study was to evaluate the effects of a single dose of intravenous morphine on postoperative pain in extremely premature neonates after thoracotomy.

DESIGN

Descriptive correlational study.

PATIENTS

Twenty-four critically ill mechanically ventilated premature neonates with a mean gestational age of 26.1 +/- 2.1 (SD) weeks and a postnatal age of 13.8 +/- 8.1 (SD) days.

OUTCOME MEASURES

Plasma norepinephrine (NE) levels, vagal tone index (VTI), and flexor reflex threshold were measured preoperatively, immediately before, and 20 and 60 minutes after the administration of the first postoperative dose of morphine (0.1 mg/kg).

RESULTS

One-way repeated-measures ANOVA revealed no significant change in plasma NE levels from baseline levels (df[2,32] = 2.40, p = 0.11). Pre- and postmorphine VTI values were significantly lower than preoperative values (df[3,60] = 6.04, p = 0.0012), but no significant differences were found between pre- and postmorphine VTI values. Neonates (n = 10) who had a flexor reflex response during the postoperative period demonstrated no significant differences in the force required to elicit a flexor reflex across the four measurements (df[3,27] = 0.76, p = 0.53); however, the flexor reflex responses were significantly less vigorous during the postoperative period than at baseline.

CONCLUSIONS

Findings from this pilot study suggest that the dose of morphine commonly used to treat postoperative pain in premature neonates does not affect NE, VTI, and flexor reflex threshold values within 1 hour of administration.

Recent developments in understanding the immune response to human papilloma virus infection and cervical neoplasia

PURPOSE/OBJECTIVES

To provide an overview of the immune system and describe the systemic and local immune response to human papilloma virus (HPV) infection in the cervix and to the development of cervical dysplasia.

DATA SOURCES

Historical and current medical and nursing literature, current gynecologic oncology texts.

DATA SYNTHESIS

The immune system provides protection against a wide variety of pathogens and plays a role in the response of the body to neoplastic cells. The immune system orchestrates the functions of various immune cells and proteins to fight against invading pathogens. Mucosal immunity is one of the key functions of the immune system and has unique features. Humoral and cytotoxic responses in the cervix and in the peripheral blood are seen during clearance of an HPV infection.

CONCLUSIONS

The functional status of the immune system is associated closely with the development of cervical dysplasia and cancer in women with HPV infection. Clinicians must assist women in maintaining proper functioning of immune responses.

IMPLICATIONS FOR NURSING PRACTICE

A better understanding of local and systemic immune responses to HPV infection may help nurses who provide care to women with cervical disease and women at high risk for cervical cancer to deliver better care and clearer information to patients.

Review of research studies that evaluated the impact of treatment for childhood cancers on neurocognition and behavioral and social competence: nursing implications

ISSUES AND PURPOSE

Given the increasing incidence of childhood cancer, increasing survivor rates, and documented incidence of sequelae, nurses need evidence on which to base interventions for families at risk. The authors review and critique research studies that evaluated the impact of treatment for childhood cancers. Implications for nursing practice are discussed.

CONCLUSIONS

Research to evaluate the effects of treatment on neurocognition and behavioral and social competency of children with cancer has produced conflicting results. Most studies found deleterious effects on all three areas associated with childhood cancer treatment. Some studies, however, found no differences between childhood cancer survivors and children on therapy compared to normative data or healthy controls.

PRACTICE IMPLICATIONS

Knowledge of the short- and long-term impact of treatment for childhood cancer on neurocognition and behavioral and social competence allows nurses to design interventions that mitigate neurocognitive effects, decrease behavioral problems, and improve social competence.

The kappa opioid nalbuphine produces gender- and dose-dependent analgesia and antianalgesia in patients with postoperative pain

Nalbuphine, pentazocine, and butorphanol, mixed agonist/antagonist opioids that induce analgesia by acting predominantly at kappa opioid receptors, have recently been shown in single-dose studies to have greater analgesic efficacy in women than in men. In the current experiments, the first placebo controlled dose response study of opioid analgesic efficacy that examines for gender differences, nalbuphine (5, 10, or 20 mg) and placebo were evaluated in 62 men and 69 women for the treatment of moderate to severe postoperative pain following extraction of impacted wisdom teeth. In a randomized, open injection, double blind experimental design, pain intensity was recorded on a 10 cm visual analog scale (VAS) immediately prior to drug administration (baseline) and at 20 min intervals thereafter. Although responses to placebo were similar in men and women, for all doses of nalbuphine women exhibited significantly greater analgesic response than men, compatible with our previous results. Unexpectedly, men receiving the 5 mg dose of nalbuphine experienced significantly greater pain than those receiving placebo; only the 20 mg dose of nalbuphine in men produced significant analgesia compared to placebo. While a similar antianalgesic effect was not observed in women, only the 10 mg dose of nalbuphine produced significant analgesia compared to placebo. These results suggest that the optimal analgesic dose of nalbuphine for women is lower than the highest dose that can be safely administered. In contrast, the antianalgesic effect of nalbuphine suggests avoidance of its routine use for postoperative analgesia in men until further studies clarify this issue. Because gender differences in other mixed kappa agonists/antagonists (i.e. pentazocine and butorphanol) have previously been shown, these results may generally apply to this class of opioid analgesics.

Relationship between fatigue and quality of life in patients with glioblastoma multiformae

PURPOSE/OBJECTIVES

To evaluate changes in fatigue at the time of diagnosis (Time 1) and two weeks after the completion of radiation therapy (Time 2) and to determine the relationship between fatigue and quality of life (QOL) at each time interval in patients with glioblastoma multiformae (GBM).

DESIGN

Descriptive study to evaluate fatigue and QOL.

SETTING

Neuro-oncology clinic for accrual. Clinic, home, or office for patients interviews.

SAMPLE

60 adult patients diagnosed with GBM who received radiation therapy.

METHODS

Participants completed a demographic data sheet, the Profile of Mood States, and the Multidimensional Quality of Life Scale-Cancer Version 2 at both time points.

MAIN RESEARCH VARIABLES

Fatigue and QOL.

FINDINGS

Fatigue significantly increased from Time 1 to Time 2 (t = -2.69, p = 0.009). Increases in fatigue were associated with significant decreases in QOL at Time 1 (r = -0.57) and Time 2 (r = -0.60).

CONCLUSIONS

Patients with GBM experience increases in fatigue after radiation therapy. Increases in fatigue are associated with decreases in almost all aspects of patients' QOL.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must provide patients with information about the occurrence of fatigue during radiation therapy and recommend interventions to deal with this devastating symptom.

Risk factors for chemotherapy-induced oral mucositis: dental appliances, oral hygiene, previous oral lesions, and history of smoking

Oral mucositis is one of the dose-limiting toxicities of several chemotherapy (CTX) agents. There are suggested risk factors that could influence the development of mucositis. The presence of dental appliances, history of oral lesions, or smoking have the potential to irritate the oral mucosa and produce breaks in the integrity of the mucosa. The purposes of this study were to determine if there were differences in the incidence, severity, and time to onset of CTX-induced mucositis in oncology outpatients who wore dental appliances, had a history of oral lesions, had varying oral hygiene/care practices, and had a history of smoking and those who did not. Patients who were initiated a course of CTX that included stomatotoxic agents were followed for three complete cycles of CTX. They were instructed on how to examine their mouths for mucositis, to contact, and then visit their outpatient settings if it occurred. Clinicians corroborated the presence of mucositis, and the Eiler's Oral Assessment Guide was used by clinicians to determine the severity. Of 332 outpatients, almost half (46%) wore some type of dental appliance, 32% had a history of oral lesions, 10% were currently smoking, and 63% had a history of smoking. Oral hygiene/care practices varied: 81% brushed their teeth two or more times a day, 29% flossed at least daily, 11% had visited their dentist within 2 months of beginning CTX, and 10% had their teeth professionally cleaned within two months of beginning CTX. There was a 31% (n = 104) incidence of CTX-induced mucositis. No significant differences were found in the incidence between patients who wore dental appliances, had a history of oral lesions, had a history of smoking, and practiced different hygiene/care and patients who did not. Of 104 patients who developed mucositis, the average severity rating was 13.05 +/- 2.88 (+/-SD) (a normal mouth is rated at 8) and the average time to onset was 22.3 +/- 21.46 days. There were no significant differences found in severity or time to onset of mucositis between patients who wore dental appliances, had a history of oral lesions, had a history of smoking, and practiced different dental hygiene/care and patients who did not. Although not significant, there were interesting differences in the time to onset across the suggested risk factors (e.g., patients who had visited a dentist or who had their teeth professionally cleaned within 2 months before beginning before CTX developed mucositis 7.4 and 10.6 days sooner, respectively, than patients who did not). These findings suggest that risk factors for the development of CTX-induced mucositis are not as simple and direct as clinicians may believe.

Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: a pilot study

Pain and fatigue are two of the most common problems experienced by oncology patients. This study evaluated 24 oncology patients who were receiving radiation therapy for bone metastases to (1) describe the patterns of pain intensity and fatigue severity over a 48-hour period; (2) evaluate for sleep disturbances; (3) describe the relationships between these symptoms and various treatment characteristics; and (4) describe the self-care strategies used by patients to manage pain and fatigue. Patients reported moderate amounts of pain and fatigue. Average pain scores did not vary significantly over a 48-hour period. However, patients reported significantly lower fatigue scores in the morning compared to the evening. In addition, patients experienced significant sleep disturbances, with a mean sleep efficiency index of 70.7% (estimated using wrist actigraphy). Patients with lower Karnofsky Performance Status scores reported more sleep disturbances. In addition, patients who had received a higher percentage of their radiation treatment reported more sleep disturbances. Patients used a variety of self-care strategies to manage pain and fatigue. Additional research is warranted to describe more completely the patterns of pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy.

Anesthesia-based pain services improve the quality of postoperative pain management

Anesthesia-based pain services are facilitating improvements in the quality of care of surgical patients by developing and directing institution-wide perioperative analgesia programs that include interdisciplinary collaborations. However, the impact of anesthesia-based pain services has not been evaluated in a systematic fashion. This prospective multisite study (n = 23 hospitals) utilized a standardized approach to evaluate the quality of pain care provided to patients who were and who were not cared for by an anesthesia-based pain service. A total of 5837 patients were evaluated using a standardized survey that consisted of a medical record review and a patient interview. The data were collected as part of the hospitals' quality improvement activities. Forty-nine percent of the patients were cared for by an anesthesia-based pain service. Patients who received pain service care reported significantly lower pain intensity scores; had lower levels of pain in the postoperative period; had a lower incidence of pruritus, sedation, and nausea; and experienced significantly less pain than expected. In addition, these patients were more likely to receive patient education about postoperative pain management; were more satisfied with their postoperative pain management; and were discharged sooner from the hospital. The findings from this study demonstrate that the care provided by anesthesia-based pain services has a significant impact on patient outcomes.

The PRO-SELF Mouth Aware program: an effective approach for reducing chemotherapy-induced mucositis

Many oncology patients receive chemotherapy drugs that have the potential to induce oral mucositis. If mucositis is not prevented, patients will have to manage the problems associated with mucositis: pain, local infection, and decreased ability to take fluids or food. At the time of this writing, clinical approaches for mucositis management are variable and generally ineffective. The mouth care program, PRO-SELF: Mouth Aware (PSMA), presented in this article, was found to be a significant component of a self-care program that may have reduced the incidence of chemotherapy-induced mucositis. The PSMA program has three dimensions: (a) didactic information, (b) development of self-care exercises (skills), and (c) supportive interactions with a nurse in the setting where the patients are receiving their treatment. This program focuses on decreasing the direct (i.e., incidence and severity of mucositis) and indirect morbidities of oral mucositis (i.e., number of local infections, level of discomfort/pain, and disruption in fluid and/or food intake). It provides the critical dimensions (i.e., specific information, self-care exercises, and nurse support) to promote the prevention of mucositis. The PSMA program is designed to provide patients with a definitive self-care repertoire to manage chemotherapy-induced mucositis in the home without the direct supervision of a health care provider.

Differences in outcomes among patients experiencing different types of cancer-related pain

PURPOSE/OBJECTIVES

To determine differences in pain characteristics, mood states, and quality of life (QOL) in outpatients with different types of cancer-related pain (i.e., somatic, visceral, or neuropathic) compared to outpatients who were pain-free.

DESIGN

Descriptive, comparative.

SETTING

Sixteen outpatient facilities that are part of the Oncology Nursing Research Network.

SAMPLE

A convenience sample of 129 outpatients who experienced cancer-related pain and 169 pain-free patients, all of whom were actively being treated for cancer.

METHODS

All patients completed a demographic questionnaire, the Multidimensional Quality of Life Scale-Cancer, and the Profile of Mood States, Patients with pain completed a Cancer Pain Questionnaire and the McGill Pain Questionnaire. Patients' medical records were reviewed.

MAIN RESEARCH VARIABLES

Types of cancer-related pain (i.e., somatic visceral, or neuropathic), pain intensity, pain duration, quality of pain, QOL, and mood states.

FINDINGS

No differences were found in any pain characteristics or any pain indices from the word descriptors of the McGill Pain Questionnaire. Patients with somatic and visceral pain had significantly higher fatigue scores than pain-free patients. In addition, patients with somatic and visceral pain had significantly lower physical well-being, nutrition, and total QOL scores and more symptom distress than pain-free patients.

CONCLUSIONS

The type of cancer-related pain appears to influence the mood states and QOL of outpatients with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses need fo determine the type of pain the patient is experiencing and the impact of the pain on the patient's mood and QOL.

Gender differences in the dimensions of quality of life

PURPOSE/OBJECTIVES

To explore gender differences and similarities in the dimensions of quality of life (QOL).

DESIGN

Secondary analysis of the Multidimensional Quality of Life Scale--Cancer Version (MQOLS--CA) data from two different research studies.

SETTINGS

Multiple outpatient oncology sites.

SAMPLE

The typical female participant (n = 254) was 58 years old (SD +/- 11.3) with 14 years of education, married/partnered (64%), Caucasian (88%), and diagnosed with breast (47%) or colorectal (16%) cancer. The typical male participant (n = 222) was 60 years old (SD +/- 14) with 14.3 years of education, married/partnered (69%), Caucasian (85%), and diagnosed with colorectal (31%) or prostate (13%) cancer.

METHODS

Factor analytic procedures and reliability testing.

MAIN RESEARCH VARIABLES

QOL as measured by the MQOLS-CA, gender.

FINDINGS

For women, two factors emerged from the analysis procedures-psychosocial well-being (7 items) and physical competence (6 items). For the men, two different factors emerged--vitality (8 items) and personal resources (4 items). None of the cancer-specific items from the MQOLS-CA loaded on any of the factors for either gender.

CONCLUSIONS

Measurement of QOL requires gender-specific questions to accurately address the dimensions of the concept of QOL in females and males.

IMPLICATIONS FOR NURSING PRACTICE

Additional research is warranted to replicate these findings. Gender-specific interventions could then be developed and tested to maximize the QOL of all patients.

Management of perioperative pain in hospitalized patients: a national survey

A survey was carried out to provide "benchmark" data on current practices of in-hospital perioperative pain management. The 59-item survey questionnaire incorporated all key points contained in the Agency for Health Care Policy and Research and the American Society of Anesthesiologists published guidelines concerning institutional policies as well as practice patterns. The questionnaire was mailed to designated pain specialists in a sample of 400 hospitals that were systematically stratified by bed size and geographic region. Of the 400 questionnaires mailed, 223 (56%) were returned. Of the 223 respondents, 85% were board-certified anesthesiologists. There was good to excellent overall adherence to most of the guideline recommendations; significant exceptions were the infrequent use of nonpharmacologic techniques for pain control and the relatively high frequency of intramuscular opioid use. In general, large hospitals have a greater adherence to the recommendations of the guidelines than do smaller hospitals. No noteworthy variations in institutional policies or practice patterns were evident. These results provide comprehensive baseline data against which future developments in the field of perioperative pain management can be assessed.