Styczynski, J., Gil, L.; & EBMT Paediatric Diseases Working Party. (2008). Prevention of infectious complications in pediatric HSCT. Bone Marrow Transplantation, 42, S77–S81.
To analyze the current guidelines and recommendations for the prevention of infectious complications in adults and children undergoing hematopoietic stem cell transplantation (HSCT).
This resource is a guideline. A mini-review of evidence-based recommendations was conducted on the prevention of infections after HSCT in children. These recommendations were rated based on the strength of the recommendation and supporting evidence quality. The evidence-based system (A-E, I-III) was used to establish the strength of the recommendations and the quality of the supporting evidence.
Databases searched were not stated. The authors stated that they reviewed current guidelines, but the guidelines were not specifically identified.
Search keywords were prophylaxis, infection, hematopoietic SCT, strategy, and vaccination.
Studies were included in the review if they reported adults and children undergoing HSCT. The exclusion criteria were not reported.
The study has clinical applicability for pediatrics.
In the hospital environment, cleaning all surfaces to prevent dust accumulation, separating patient wards from outside air, and housing patients in rooms with high-efficiency particulate absorption filters were category AII recommendations. Having patients wear masks when going to unprotected areas and providing rooms with positive pressure were category BIII recommendations. Hand washing to minimize hospital-acquired candidal and bacterial infections was rated AIII. Antibacterial prophylaxis for all patients from conditioning through engraftment was strongly recommended (AI), with ciprofloxacin, levofloxacin, and amoxicillin-clavulanate. Fungi prophylaxis was recommended with fluconasole, voriconazole, posaconazole, or (BII) itraconazole for all patients. Cytomegalovirus prophylaxis with ganciclovir was recommended (AI) for high-risk patients. Herpes simplex virus prophylaxis for IgG-positive patients was recommended (AI) with valacyclovir. Varicella-zoster virus prophylaxis was recommended for IgG-positive patients. Vaccinations were not supported by any AI recommendations. Annual inactivated influenza viral vaccine and conjugated Streptococcus pneumonia vaccine for all patients undergoing HSCT both received a category AII recommendation. Viral polio inactivated, hepatitis B, bacterial conjugated Haemophilus influenzae B, toxoid tetanus, toxoid diphtheria, and polysaccharide S. pneumonia vaccines all received category recommendations. (See Table 1 for the evidence-based rating.)
Table 1 (as shown in the article)
“Category definition to determine strength of recommendation:
Category definitions to determine quality of supporting evidence
Table 2 provides antimicrobial prophylaxis type, indication, first and second recommendation using A-E, I–III ratings, and when to begin and end therapy. Table 3 lists recommendations for vaccinations after HSCT by delineating viral and bacteria vaccines, type of vaccine, time to begin, number of doses, indications, and recommendations using A-E, I–III categories.
Conflict of Interest: Jan Styczynski and Lidia Gil have received speakers’ fees from Medagro and MSD.
Cotrimoxazole or quinolones antibacterial prophylaxis has demonstrated efficacy for patients with cancer who are neutropenic and after autologous HSCT (category AI), but well-designed clinical trials specifically for patients undergoing allogeneic HSCT are not available. Studies with mostly adults receiving fluoroquinolones for HSCT were analyzed to deem the safety for children. Using fluoroquinolones safely in children is based on one double-blind, placebo-controlled, randomized pediatric clinical trial using amoxicillin clavulanate, and patients undergoing HSCT were not included. High- and intermediate-risk patients should be offered antifungal prophylaxis. Fluconazole, micafungin (both category AI), and itraconazole (category BI) are recommended during pre-engraftment for antifungal prophylaxis. In adults with severe acute or extensive chronic graft-versus-host disease, oral posaconazole has been shown to be effective in reducing invasive mycoses. No data on dose and schedule were reported for pediatric dosing. Oral valganciclovir has been shown to be effective when compared to intravenous ganciclovir, but no pediatric data were available, and the drug was not available in liquid suspension, which is often desirable for children. Vaccination against influenza and S. pneumoniae for HSCT was strongly recommended (category AII for both). Live tuberculosis should never be offered (EII). Other vaccinations have the potential for decreasing post-HSCT risks for vaccine-preventable infections. High quality supporting evidence used in this guideline was based on as little as one randomized, controlled trial, with no discussion of sample size, risk of bias, etc., making this a relatively low threshold for highly rated evidence.
Sturtzel, B., & Elmadfa, I. (2008). Intervention with dietary fiber to treat constipation and reduce laxative use in residents of nursing homes. Annals of Nutrition and Metabolism, 52(Suppl. 1), 54–56.
To determine whether the addition of oat bran to the diets of older adult residents of a long-term care facility would lead to a reduction in laxative use.
The control group (15 patients assigned) received usual diet.
The intervention group had oat fiber containing 8.3 g of nondigestible fermentable fiber and 9.7 g of nondigestible nonfermentable fiber per 100 g incorporated into their diet for 12 weeks.
Single ward of a long-term care facility in Vienna, Austria
The study has clinical applicability to older adult care.
This was a controlled, parallel, blind intervention trial.
Fiber supplementation with oat bran may be an alternative to laxatives for treating constipation in an older adult population.
Increasing fiber supplementation with oat bran may be an alternative to laxative use for treating constipation in older adults. Additional study is warranted in a larger population that includes patients with cancer.
Sturm, I., Baak, J., Storek, B., Traore, A., & Thuss-Patience, P. (2014). Effect of dance on cancer-related fatigue and quality of life. Supportive Care in Cancer, 22, 2241–2249.
To evaluate the effect of dance on relieving fatigue in patients with cancer undergoing active cancer treatment
This study consisted of two groups, one with supportive consultation, fatigue counseling, nutrition counseling, psychooncology, and 10 60-minute dance classes for five weeks, and the other with everything except the dance class.
Nonrandomized intervention
Fatigue was measured at baseline and at the end of the study for both groups. There was significant reduction in fatigue in the dance group while fatigue essentially was unchanged in the control group. The study also demonstrated improved scores on the social and emotional functioning scales and in physical performance in the dance group.
Dance could be an appropriate, multidimensional approach for the treatment of cancer-related fatigue.
To encourage exercise or movement, this study offers a less monotonous approach compared to conventional fitness programs addressing cancer-related fatigue. Replication and a randomized study is needed to establish effectiveness.
Sturgeon, M., Wetta-Hall, R., Hart, T., Good, M., & Dakhil, S. (2009). Effects of therapeutic massage on the quality of life among patients with breast cancer during treatment. Journal of Alternative and Complementary Medicine, 15, 373–380.
To test hypotheses regarding the effect of massage on anxiety, pain, nausea, sleep, and quality of life (QOL).
Patients were referred by their physicians and were provided a physician order for massage. Patients completed self-administered instruments prior to massage therapy and one week after therapy. Massage treatments lasted 30 minutes and were provided during treatment with chemotherapy and/or radiation therapy (RT) once per week for three weeks.
Patients were undergoing the active treatment phase of care.
The study used a pre-/posttest design.
STAI scores were lower after massage therapy (p = 0.03). Sleep scale items that showed improvement with massage were soundness of sleep (p = 0.05), time from settling down to sleeping (p = 0.02), and overall sleep satisfaction (p = 0.01). FACT-B scores also showed improvement in several areas after massage therapy (p < 0.05). Effect sizes in these areas were moderate (≥0.3).
Provision of massage therapy during treatment for breast cancer may reduce anxiety and improve sleep and aspects of QOL.
Massage therapy may assist women undergoing breast cancer treatment to better tolerate the impact of treatment, reduce anxiety, and improve sleep during active treatment.
Stuiver, M.M., Ten Tusscher, M.R., Agasi-Idenburg, C.S., Lucas, C., Aaronson, N.K., & Bossuyt, P.M. (2015). Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy. Cochrane Database of Systematic Reviews, 2, CD009765.
STUDY PURPOSE: To assess the effects of conservative (nonsurgical and nonpharmacologic) interventions on lymphedema after breast cancer treatment
TYPE OF STUDY: Systematic review
DATABASES USED: Cochrane Breast Cancer Group’s (CBCG) Specialized Register, CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro, PsycINFO, and the World Health Organization International Clinical Trials Registry Platform in May 2013 (reference lists of included trials and other systematic reviews were searched)
PHASE OF CARE: Late effects and survivorship
The evidence from this review was insufficient to draw firm conclusions.
All included studies were deemed to be of low or very low quality.
The quality of the evidence regarding interventions for reducing the risk of lymphedema remains low. More research is needed.
Stubblefield, M.D., Vahdat, L.T., Balmaceda, C.M., Troxel, A.B., Hesdorffer, C.S., & Gooch, C.L. (2005). Glutamine as a neuroprotective agent in high-dose paclitaxel-induced peripheral neuropathy: A clinical and electrophysiologic study. Clinical Oncology, 17, 271–276.
The study examined the neuroprotective effect of glutamine.
Seventeen patients received 10 g of glutamine administered three times daily for a total of four days beginning 24 hours after completion of paclitaxel. The remaining 29 patients made up the control group. Neurologic assessments and electrodiagnostic (nerve conduction) studies were carried out at baseline and at least two weeks (median 32 days) after treatment by a neurologist. Neurologic signs and symptoms also were assessed.
The study sample consisted of 46 patients who received high-dose paclitaxel prior to stem cell transplantation.
The study had a retrospective, non-randomized design.
Patients who received glutamine developed less weakness, less loss of vibratory sensation, and less toe numbness compared to those in the control group. A trend toward reducing symptoms of finger numbness was noted. In the comparison group, three patients developed foot drop and four patients developed tibialis weakness.
The mechanism of neuroprotection conferred by glutamine is unclear; some evidence suggests a correlation between treatment-induced reduction in nerve growth and severity of neurotoxicity.
The limitations of this study include it not being randomized or blinded as well as the fact that no placebo control group was used.
Results of this study should be interpreted with caution because of the small sample size and the non-randomized, retrospective design.
Stubblefield, M.D., Burstein, H.J., Burton, A.W., Custodio, C.M., Deng, G.E., Ho, M., . . . Von Roenn, J.H. (2009). NCCN task force report: Management of neuropathy in cancer. Journal of the National Comprehensive Cancer Network, 7(Suppl., 5), S1–S26.
This study outlines the common antineoplastic agents known to cause neuropathy and provides information on incidence, onset dosages, the signs and symptoms, and general course and patterns of resolution. Agents identified include platinum compounds, vinca alkaloids, taxanes, bortezomib, ixabepilone, thalidomide, and lenalidomide. In addition to outlining the mechanisms of neuropathy development in cancer, the study discusses neurophysiologic and objective testing, noting that findings on electromyographic (EMG) and nerve conduction studies (NCS) can lag behind clinical symptoms. The study also identifies commonly used physician-based grading systems, including the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) and Eastern Cooperative Oncology Group (ECOG) systems, and notes that these two grading systems lack inter-rater reliability. Patient-based instruments for assessment include the Functional Assessment of Cancer Treatment (FACT) and the Patient Neurotoxicity Questionnaire (PNQ). The authors note that the routine assessment of pain secondary to neuropathy, using instruments such as the Brief Pain Inventory (BPI), is useful.
Routine assessment should be conducted and continued throughout therapy. Key points in assessment that should be included are:
Proposed agents for prevention of CIPN identified include:
Agents used for pain management:
Current literature is inconclusive on the benefits of neurostimulation in treating CIPN. The authors note that evidence is scarce on efficacy of complimentary and alternative medicine (CAM) therapies and the need for appropriately powered and controlled studies in this area. However, acupuncture was identified as a promising adjunct option. The article also provides safety tips and issues for management of functional deficits in PIN, including situations in which to avoid or discontinue physical training, footwear selection, orthosis, and safety aspects of the household environment. Finally, the article addresses how autonomic neuropathy from chemotherapy occurs, but has not been well documented or studied.
The article provides a comprehensive review of current knowledge about CIPN and common approaches toward assessment, prevention, and management. The authors do not make specific recommendations for treatment, research to validate evaluation tools, and exploration of combinations and scheduling of pain medications. In addition, testing of the safety and effectiveness of therapeutic interventions and dietary supplements are needed.
Strong, V., Waters, R., Hibberd, C., Murray, G., Wall, L., Walker, J., . . . Sharpe, M. (2008). Management of depression for people with cancer (SMaRT oncology 1): a randomised trial. Lancet, 372, 40–48.
To determine the effectiveness of integrating a depression management program into the care of patients with cancer and major depressive disorder (MDD).
Patients were randomized into the treatment group or the usual care group. The treatment group received up to 10 individual one-to-one 45-minute sessions over a three-month period; some occurred via telephone or in the patients' homes, as needed. The intervention consisted of education about depression and its treatment, problem-solving and coping strategies, and collaboration with each patient’s oncologist and primary care provider. Two repeat sessions were offered to persons whose Patient Health Questionnaire-9 (PHQ-9) scores were increasing. No further intervention occurred after six months, but a progress-monitoring interview was conducted at 12 months.
Patients were undergoing the active treatment and transitional phases of care.
The study was a randomized trial with a control (usual care) group.
Measurements revealed no statistically significant differences in the two groups at baseline, including differences in the use of antidepressant medication. However, at three and six months, more patients in the intervention group than in the control group were using a therapeutic level of antidepressants. Depression scores on the SCL-20 decreased between baseline and three months in both groups, but the scores decreased more in the intervention group. More patients in the intervention group had a depression score that decreased by at least 50% from baseline to the three-month follow-up (p = 0.0008). In addition, several patients in the intervention group no longer met the criteria for MDD at three months and had reduced anxiety and fatigue. The study showed no significant changes in pain or physical functioning at three or six months. In addition, at six and 12 months, the study showed a significant improvement in quality of life for patients in the intervention group.
Supplementation of usual care with a nurse-delivered intervention for the management of depression reduced the symptoms of depression, anxiety, and fatigue more than usual care alone. There were no significant improvements in pain or physical functioning. The authors noted the close relationship of anxiety and fatigue to depression as a possible rationale for the cluster of improvements.
A cost-effective, patient-acceptable, nurse-delivered intervention can support the management of depression, anxiety, and fatigue in patients with cancer and MDD. At 12 months, the evidence showed a sustained effect of the three-month intervention.
Stricker, C. T., Drake, D., Hoyer, K. A., & Mock, V. (2004). Evidence-based practice for fatigue management in adults with cancer: exercise as an intervention. Oncology Nursing Forum, 31, 963–976.
Databases searched were MEDLINE, CINAHL, and Database of Abstracts of Reviews of Effects (DARE) through October 2003. Proceedings of the annual meetings of the American Society of Clinical Oncology, American College of Sports Medicine, and Oncology Nursing Society were also searched.
Twenty experimental studies (nine randomized, clinical trials and 11 quasiexperimental studies) were included. The outcome was fatigue. Treatment evaluated physical activity or group or individual exercise.
There is strong evidence to support the effectiveness of home-based exercise programs performed by middle-aged women undergoing adjuvant chemotherapy or radiation therapy for nonmetastatic breast cancer and some evidence that exercise may be equally beneficial in other cancer populations, including individuals with solid tumors and hematologic malignancies and cancer survivors. Based on current evidence, low-intensity exercise individualized to patient comfort is the only type of exercise that can be considered safe for patients in palliative care settings. Evidence supports the efficacy of aerobic laboratory-based interval training in individuals receiving peripheral blood stem cell transplantation.
All studies had some design limitations, including
Streckmann, F., Zopf, E., Lehmann, H., May, K., Rizza, J., Zimmer, P., . . . Baumann, F. (2014). Exercise intervention studies in patients with peripheral neuropathy: A systematic review. Sports Medicine, 44, 1289–1304.
PHASE OF CARE: Multiple phases of care
Five studies assessed the influence of balance training on the side effects of PNP and showed a significant impact on balance control. Two studies also showed improved gait parameters. Improved motor, sensory, and metabolic symptoms was observed with tai chi. Combinations of endurance, balance, and strengthening exercises showed a positive effect on motor performance only if exercises were performed standing or walking. One RCT in chemotherapy-induced PNP showed that exercise (sensorimotor, endurance, and resistance training) can reduce quality of life, level of activity, and sensitivity. Only three studies in the cohort of those with PNP from various causes showed they were able to achieve improvements through the exercise regimen. The other three studies in this group showed no significant changes after intervention. None of the studies reported serious adverse effects, although one of the diabetic neuropathy studies reported one calf strain from treadmill walking.
Evidence for exercise interventions in those with PNP has improved, although study quality is diverse. Overall, the quality of studies included in this review was 2b with the best evidence in those with diabetes and PNP. Current data suggest that exercise is feasible, safe, and beneficial. Exercise compliance was overall good, and only mild adverse events were reported. Specific treatment for nerve damage was not available, and the efficacy of pharmaceutical interventions is questionable.
Patient cohorts were very heterogeneous. Because of the heterogeneity, the results are not very generalizable. Eighteen studies were included (small sample).
More research is needed on exercise interventions, particularly in regard to the patients with cancer who have other symptoms to contend with as well. Nurses should educate patients about PNP and encourage enrollment in clinical trials if available.