Databases seached were MEDLINE, CINAHL, EMBASE, PsycINFO, CANCERLIT, Cochrane Library, PEDro, and SPORTDiscus through March 2005.

Fourteen randomized trials were included. Nonrandomized trials, pilot studies, and studies reported only in abstract form were excluded. Therapeutic exercise regimens addressing only specific impairments to shoulder and arm were not included. Studies with an additional treatment arm or combined intervention (e.g., exercise with diet modification) were included only if the effects of exercise could be isolated. Studies were required to have quality of life, cardiorespiratory fitness, or physical functioning as a primary outcome. Secondary outcomes of interest included symptoms of fatigue, body composition, and adverse events resulting from the exercise intervention. Methodologic quality of each included study was evaluated using eight quality criteria specified a priori.

Outcomes were quality of life, cardiorespiratory fitness, physical functioning, symptoms of fatigue, body composition, and adverse events resulting from the exercise intervention.

There was wide variability in the exercise interventions evaluated. Interventions included Tai Chi Chuan, aerobic exercise (walking, cycle ergometer, and arm ergometer), resistance training (weights and resistance bands), and mixed aerobic and resistance exercise. Exercise programs were of moderate or low intensity, and the interventions included a mixture of supervised and self-directed programs, delivered individually or in groups. Overall, study reports provided too little detail concerning the frequency, intensity, time, and type of exercise to allow for determination for an exercise dose-response. Similarly, limited detail about the adherence to the exercise program was provided, and few studies had been designed to include monitoring of activity in the comparison group, so that potential contamination could be gauged.

• A total of 717 participants were included, with sample sizes for individual studies ranging from 16 to 123 participants.
• Participants in the included studies were women with early to later stage (stage 0–III) breast cancer or who had undergone breast cancer surgery with or without adjuvant cancer therapy.
• Clinical heterogeneity in treatment (e.g., chemotherapy, radiation therapy, and hormonal therapy) was evident, particularly in trials of exercise during adjuvant treatment for breast cancer.

Six studies involving 319 patients assessed the effect of exercise on symptoms of fatigue. Although all of the studies showed improvements in symptoms of fatigue with exercise, only two reported statistically significant improvements. These two studies were also the only studies performed following breast cancer treatment. The pooled results from all six studies showed that exercise significantly improved symptoms of fatigue (standardized mean difference [SMD] = 0.46; 95% confidence interval [CI] [0.23, 0.70]). The pooled results from the four studies performed during adjuvant cancer treatment showed a nonsignificant effect on fatigue (SMD = 0.28; 95% CI [-0.02, 0.57]). Four studies reported adverse events; in one study, two of 23 participants reported that participation in the home-based exercise program (self-monitored walking program) resulted in worsening of fatigue.

• Of the 14 studies included in this review, the median score for methodologic quality was 3 (range 0–8). Only four of the 14 studies were considered high quality.
• The most common methodologic shortcomings included failure or inadequate blinding of outcome assessor and inadequate participant concealment of study group allocation.

PURPOSE: To review an article from a non-peer–reviewed journal on managing bleeding malignant skin lesions

• Twenty-one references specific to prevention of bleeding in malignant skin lesions
• Nonpharmacologic measures within non-peer–reviewed nursing journals

• Amorphous and alginate dressings discussed in wound management to keep wound moist
• Multiple-layer dressings recommended to prevent bleeding and prevent adherence and subsequent trauma to the wound and absorption
• Alginate dressings recommended to control light bleeding
• Topical epinephrine recommended to control profuse bleeding

The journal is not peer-reviewed.

To determine if providing, to hospice patients and caregivers, systematic feedback from standardized assessment tools improves the quality of hospice care

Hospice teams were formed, each with a similar composition. Patients were randomly assigned to receive standard care (control) or standard care plus systematic assessment. Patient-caregiver dyads were identified and screened, within 24–72 hours of admission, with the Short Portable Mental Status Questionnaire. Research assistants (RAs, an RN and a social worker) collected baseline data from both the patient and caregiver, respectively, and then collected data one and two weeks later, using identified tools. Verbal and written reports were given at two interdisciplinary team conferences after each data collection. RAs performed a chart audit for both groups during the study. The control group completed the same standardized assessments, but no reports were made to the interdisciplinary team.

• The original sample was composed of 709 participants: 350 dyads completed all three measurements, and 366 left the study at some point over the course of follow-up.
• Mean patient age was 74.05 years; mean caregiver age was 71.83 years.
• Mean age of all caregivers was 65.37 years: in the control group, mean caregiver age was 65.49 years; in the experimental group, mean caregiver age was 65.24 years.
• Mean age of all patients was 72.66 years: in the control group, mean patient age was 72.67 years; in the experimental group, mean patient age was 72.65 years.
• The caregiver sample was 26.4% male and 73.6% female. The patient sample was 56.3% male and 43.7% female.
• Patients had a cancer diagnosis and were receiving hospice care.
• Caregivers had to be older than age 18, able to read and understand English, and able to pass the mental status screening.
• Mean years of education was 13.21 years for caregivers and 12.14 years for patients. 
• Patients' mean Palliative Performance Scale score was 57.06; patients' mean Short Portable Mental Status Questionnaire score was 9.23.

• Multisite
• Home
• Two large, private not-for-profit hospices in Florida, United States

• Phase of care: end-of-life care
• Clinical applications: end-of-life and palliative care, late effects and survivorship

Randomized controlled trial 

• Palliative Performance Scale (PPS), to assess the physical condition and functional status of people receiving palliative care. The PPS includes three broad areas: mobility, intake, and level of consciousness in five categories. The scale, 0%–100%, is divided into 10% increments, with 0 meaning dead and 100 meaning normal. Validity and reliability were assessed.    
• Memorial Symptom Assessment Scale (MSAS), revised, to assess occurrence, intensity, and distress from symptoms. A total of 25 items are rated 0–4 for severity and distress, resulting in subscale scores for intensity and distress that range 0–100. Validity and reliability were assessed.
• Hospice Quality of Life Index–14 (HQLI-14). HQLI-14 is a shortened version of the validated HQLI. The HQLI-14 includes three aspects of overall quality of life (QOL): psycho-physiological well-being, functional well-being, and social-spiritual well-being. Fourteen items are scored 0–10, with 10 being the most favorable response. Item scores are added to obtain a total scale score ranging from 0 (worst QOL) to 140 (best QOL).
• Center for Epidemiologic Study Depression Scale (CESD), short form. The short form of the CESD is a 10-item true-false instrument validated for use in clinical settings. Items are either present or absent. Validity and reliability are strong.
• Spiritual Needs Inventory (SNI). The SNI assesses the extent to which individuals have spiritual needs and indicates which needs remain unmet. The SNI is a 17-item questionnaire with two main parts: The first rates items in response to a stem 1 (never) to 5 (always). Scores may range from 17 to 85, with a higher score representing a greater spiritual need. Individuals also choose yes or no to incide whether the need was met. Validity and reliability were assessed.
• Short Portable Mental Status Questionnaire (SPMSQ). The SPMSQ presents 10 items to measure cognitive impairment. Eight or more correct answers qualified patients and caregivers to remain in the study. Validity has been assessed.

The control and intervention groups were comparable in regard to every variable except patients' years of education. Attrition was greater than 51%. In dyads that completed the study, patients were older and had higher functional status scores at baseline. No other comparisons were statistically significant. Results showed improved patient depression (p < 0.001) as a result of the intervention and improvement in both groups in patients’ QOL (p < 0.001). No other patient outcomes (symptom distress, spiritual needs) or caregiver outcomes (depression, support and spiritual needs) were statistically significant.

The addition of the systematic assessment of depression to usual care probably had a greater effect because it is not a symptom on which hospice staff normally focus. Improving depression is an important way of improving overall QOL of patients and their families during hospice treatment. The lack of improvement in caregiver variables in either group over time may suggest the need for greater attention to this symptom.

• Dyads might not have used the information provided.
• The study had a high level of attrition (greater than 51%).
• Only patients who remained functional throughout the whole course of study were selected.
• The information-only intervention may have been insufficient to lead to staff change.
• The control group may not have been valid in the sense that high-quality usual care may have been similar to the intervention: The number of visits did not change significantly in the intervention group.
• A study may have included a confounding effect: Hospice workers may have provided care of such good quality that results were affected by more than the intervention itself.

Hospice is an effective service, and efforts to improve hospice care should be a priority. Caregivers as well as patients should be a focus of hospice care. The study supports the systematic assessment of depression in hospice patients. The study also supports the need for greater attention, via research and systematic assessment, to caregivers in the hospice setting.

To determine if exercise interventions can effectively mitigate cancer-related fatigue (CRF)

DATABASES USED: PubMed, CINAHL, PsycINFO, ProQuest, SPORTDiscus

KEYWORDS: exercise, physical activity, exercise therapy, exercise training, aerobic exercise, resistance exercise, physical training, exercise prescription, cancer, oncology, malignancy, neoplasm cancer treatment, chemotherapy, radiotherapy, hormonal therapy, fatigue, CRF, QOL, depression

INCLUSION CRITERIA:

• Experimental, quasi-experimental, or pre-post design
• Data reported and available for meta-analysis
• Inclusion of exercise intervention to measure effects on CRF
• Control groups received care as usual with no prescribed physical activity

EXCLUSION CRITERIA:

• Interventions and measures focusing only on range of motion

TOTAL REFERENCES RETRIEVED = 948 articles initially identified

EVALUATION METHOD: No quality scoring of retrieved studies was described.

FINAL NUMBER STUDIES INCLUDED = 16 studies included in meta-analysis

SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Study sample sizes ranged from 22–242; 1,426 patients in treatment and control groups

KEY SAMPLE CHARACTERISTICS: Subjects were at various phases in cancer treatment, with some in active treatment of various modes and others post-treatment. Eight trials were in patients with breast cancer. Other studies included prostate cancer, mixed disease types, and acute myelogenous leukemia.

Overall effect of exercise on CRF showed a small but significant effect size with overall reduction in CRF ( SMD = 0.28, 95% CI 0.17–0.38, p <.001).

Subgroup analysis of exercise mode:

• Aerobic exercise had a small but significant positive effect (SMD = 0.25, 95% CI 0.12–0.38, p < .001)
• Resistance training had a small and insignificant effect (SMD =1.66, 95% CI 0.41–3.73, p > .05)
• Mixed aerobic and resistance exercise had a small and insignificant positive effect (SMD = 0.22, p > .05)

Interventions provided in a supervised setting (15 trials) significantly reduced CRF (SMD = 0.29, 95% CI 0.17–0.46, p < .001).

Unsupervised exercise showed a positive trend but no significant difference with exercise.

Effects in phase of treatment:

• Exercise caused a moderate and significant reduction in CRF when provided after completion of treatment (SMD = .31, 95% CI 0.6–14.03, p < .001).
• Exercise during treatment also resulted in reduced CRF (SMD = 0.24, 95% CI .12–.36, p < .001).

Effects in patients with cancer other than breast cancer:

• Subgroup analysis in trials with those patients with cancer other than breast cancer (four trials) showed that exercise significantly reduced CRF (SMD = 0.17, 95% CI .01–0.34, p < .05).

Exercise intervention produced improvement in aerobic fitness and musculoskeletal fitness (p < .001).

Findings from meta-analysis provide strong support for the positive effect of exercise on CRF. Effect sizes are small.

Findings suggest that various modes of exercise show a trend toward a positive impact on CRF in patients with breast cancer, as well as patients with other types of cancer.

There may be differences in effect based on mode of exercise.

Findings suggest positive effects in supervised and unsupervised exercise programs, but only those that were supervised demonstrated statistical significance in this study. It is unclear if this represents a real difference in effectiveness, or the fact that there were only four studies of unsupervised exercise included.

Findings support the use of exercise to reduce CRF during and after completion of cancer treatment. Subgroup analyses in this study begin to provide additional useful information regarding the modes and types of exercise interventions that may be most effective. Further research comparing effectiveness of various approaches is warranted.

Effect sizes of exercise are small, suggesting that studies that include patients with very low fatigue or interventions to prevent fatigue may not readily show significant changes.

To evaluate whether adding a brief problem-solving intervention (i.e., COPE) to caregivers of patients receiving hospice cancer care would be superior to either standard hospice care alone or standard hospice care with emotional support

Intervention group: In addition to standard hospice care, the intervention involved giving three training sessions to caregivers using the COPE problem-solving technique as a coping skill to manage caregiving stress. COPE involves training caregivers how to use Creativity, Optimism, Planning, and obtaining Expert information when needed as well as how to use a homecare guide for advanced cancer. The intervention was done during visits to the caregiver by a trained nurse while a home health aide stayed with the patient. The visits were conducted within seven to nine days of recruitment, but the schedule was not clearly reported.

Control group II: Caregivers and patients received standard hospice care and supportive visits that focused on emotional support only. These visits were scheduled at the same times and frequencies as the COPE training occurred in the intervention group.

• The sample started with 329 caregiver/patient dyads but decreased at different data collection points.
• Mean caregiver age was 60 years (SD = 15.27); mean patient age was 70.12 years (SD = 12.58).
• The caregiver sample was 14.5% male and 85.5% female (average for three groups).
• Caregivers had to be providing care to adult patients with advanced cancer newly admitted to hospice.
• The average educational level of participants was slightly above high school education. 
• No systematic demographics were found among participants in the three groups. 

• Single site
• Inpatient setting
• Large, nonprofit, community-based hospice in southeastern United States

• End-of-life care phase
• Elder care, palliative care

A three-group randomized controlled trial design was used.

• Caregiver quality of life (QOL) was assessed using the Caregiver Quality of Life Index–Cancer (CQOL-C).
• To assess caregiver symptom-related burden, the authors adapted the patient Memorial Symptom Assessment Scale (MSAS) by asking caregivers to rate their distress associated with 24 patient symptoms.  
• Caregiver general mastery was assessed using a six-item scale where caregivers reported their feelings of control and confidence in caregiving.  
• Caregiver burden and mastery specific to caregiving tasks was assessed using the Caregiver Demands Scale (CDS) to obtain scores for caregiving task burden and caregiving task mastery.

Results of random effect regression models showed significant interactions (time by group) in the intervention group for three of the caregivers’ measured outcomes.

• Caregiver QOL (p = 0.054)
• Caregiver symptom-related burden (burden related to patients’ symptoms) (p = 0.001)
• Caregiving task burden (p = 0.021), with main effect for time (p = 0.014), where increases in task burden scores increased over time

There were statistically significant group by time effects, showing that caregiver QOL was higher in the COPE (p = 0.033) and support groups, and symptom burden was lower in the COPE (p < 0.001) and support groups when compared to the usual care group.

Overall, the study findings show strong evidence of effectiveness of the COPE treatment among caregivers of patients in hospice care. In this group of caregivers, COPE improved caregivers’ overall QOL and caregiver symptom-related burden.

• The intervention might be expensive, impractical, or require training needs.*
• Subject withdrawals were ≥ 10%.
• Other limitations/*explanation: Details about the COPE  intervention that were given in the study were insufficient, which is possibly a result of publication space limitations, but additional detail would have made it easier to fully understand the nature of this intervention (e.g., how long did the COPE training sessions last? When specifically were the sessions conducted with the caregivers? Exactly where did the sessions take place?). However, the authors mentioned that the intervention manual is available upon request to those who may wish to replicate the study or use the intervention in caring for caregivers. The differences between the usual care and support group interventions were not clear.

Nursing care of caregivers of patients in hospice should involve focused interventions that extend beyond emotional support. COPE is an intervention that can be used with caregivers of patients with cancer in general, hospice or otherwise. This intervention is very promising. The fact that it improved some caregivers’ outcomes in hospice suggests that it can also be very effective under different contexts. 

The COPE method involves the following four interventions.

• Creativity (viewing problems from different perspectives to develop new strategies for solving caregiving problems)
• Optimism (having a positive but realistic attitude toward the problem-solving process)
• Planning (setting reasonable caregiving goals and thinking out, in advance, the steps necessary to reach those goals)
• Expert information (what nonprofessionals need to know about the nature of a problem and when to get professional help and what family caregivers can do on their own to deal with the problem)

The COPE intervention was delivered by nurses, and a home health aide was present for each visit to provide respite so that caregivers could focus on the intervention. No specific data were given on length of intervention, although it was inferred to occur over two weeks. The study was divided into three arms.

• Group 1 was hospice standard care only (n = 109).
• Group 2 was hospice standard care plus supportive visits from the intervention nurse and home health aide made on the same schedule as the COPE intervention group (same amount of time per session as group 3, nurse provided individual support and discussed feelings) (n = 108).
• Group 3 was hospice standard care plus intervention visits by a nurse who taught them the problem-solving method (n = 111).
   

• The sample (N = 328) included adults with cancer in a hospice program and their caregivers (caregivers identified by hospice without having cancer themselves).
• Patients had at least a sixth-grade education and were cognitively intact.

• Home

A properly designed randomized, controlled trial with three arms was used.

• Caregiver demands scale (to measure burden)
• Caregiver Quality-of-Life Index–Cancer Memorial Symptom Assessment Scale (measures burden of cancer symptoms)
• Caregiver mastery
• Brief COPE scale (to measure use of problem-focused versus emotion-focused coping strategies)

Significant group by time interactions were found between the standard group and the COPE group (group 3) in quality of life, symptom burden, and caregiving task burden. No significant differences were found between the standard group and the support condition (group 2) in quality of life, symptom burden, or caregiving task burden. The COPE group had significant improvements in symptom burden over time, whereas the usual care group did not. Mastery and coping skills were not significantly different among groups.

Although substantial attrition occurred across all three groups longitudinally, researchers examined for differences. The only significance found was that completers were initially older than noncompleters. No effects of attrition by group were significant.

• No specific information was given regarding how many intervention sessions were delivered, what happened at each session, or what the total length of the intervention was (although it is inferred to be within two weeks).

To examine the hypothesis that following an emotionally focused therapy (EFT), the intervention group for patients with metastatic cancer and their caregivers would demonstrate a greater increase in marital functioning postintervention when compared to the control group

To examine whether the intervention group would have a greater decrease in depression, hopelessness, and spousal caregiver burden scores and greater increase in patients’ perceptions of spousal caregiver empathic behaviors as compared to the control group

Potential participants included those who had requested a psychosocial referral for couple distress or those whom doctors had referred to the Psychosocial Oncology and Palliative Care Program. Couples were assigned to the EFT intervention or the control standard of care group. Randomization was stratified by sex.

The EFT intervention, which was adapted for use with couples experiencing metastatic cancer, was delivered over eight sessions. The modified manualized EFT addressed particular issues that challenge such couples and were used in prior research. These included ways to facilitate marital relationships by changing habitual and distressing patterns of interaction, increase mutual understanding and emotional engagement, and strengthen the marital bond. Couples had a one-hour weekly session delivered by a trained psychologist in a clinic outpatient or other convenient location over a period of two to three months.

The control group received standard of care from the institutional Psychosocial Oncology and Palliative Care Program. Social work consultation in that facility accounts for two-thirds of psychosocial care and usually involves practical and instrumental care or supportive interactions to relieve patient and family psychological distress. Patients and their partners facing metastatic cancer may be followed by a multidisciplinary team on a weekly, biweekly, or until end-of-life basis and as defined by patient/clinician assessment.

• The sample included 42 patient/caregiver dyads (22 in the EFT group and 20 in the control group).
• Mean age of patients was 51 years; mean age of caregivers was 50 years.
• The patient sample was 45% male and 55% female; the caregiver sample was 55% male and 45% female.
• Patients mainly had breast (23%), blood (17%), gynecologic, (14%), and head and neck (10%) cancers.
• Of the patients, 42% had some college education or a college degree, spoke English, and were not in active treatment. Similar results were noted in caregivers.

• Outpatient
• Home setting
• Toronto, Ontario, Canada

• End-of-life phase
• Caregiver burden; depression; marital functioning

A randomized, controlled, two-group trial design was used.

• Beck Depression Inventory II: Used extensively in cancer populations; Cronbach’s alpha in prior studies = 0.92
• Beck Hopelessness Scale: Used in terminally ill populations; prior Cronbach’s alpha = 0.88
• Caregiver Burden Scale: “Demand” subscale prior Cronbach’s alpha = 0.92; “difficulty” subscale prior Cronbach’s alpha = 0.93
• Relationship-Focused Coping Scale: Measured patient’s perception of caregiver empathic behavior; prior Cronbach’s alpha = 0.89
• Revised Dyadic Adjustment Scale (RDAS): Used to screen couples for study inclusion; Cronbach’s alpha in current study = 0.90; has validity from prior studies  

Patients with metastatic disease and their spouses who received the modified EFT had significant improvements in martial functioning compared with those couples who received standard care (p < 0.0001). Additionally, patients in the EFT intervention group reported significant improvement in their assessment of perceived caregivers’ empathetic behaviors when compared with the control group (p = 0.02). On the basis of initial RDAS scores, 91% of the intervention patients improved RDAS scores as compared to 28% of control patients (p < 0.0001). Fifty percent of EFT caregivers improved their RDAS scores as compared to 11% of control caregivers (p = 0.01). The study had a high participation rate and retention of couples. After the EFT and control interventions, there was no difference between groups in caregiver burden, hopelessness, or depression.

A modified EFT intervention was beneficial for patients with advanced cancer and their caregivers and improved both quality of martial functioning and patients’ perceived experience of being empathically understood by their caregivers. There were no apparent effects on caregiver strain and burden.

• The study had a small sample.
• Couples were referred by their clinical team and met a cutoff for marital distress, thereby limiting generalizability (no attentional control).
• The control intervention standard of care varied because of clinician decision of care deemed suitable for the client.
• Participants were not blinded to the intervention.

Recent trends toward longer survival and home care for patients with advanced cancer place emotional, relationship, and physical demands (burden) on the primary caregiver, who in many cases is the spouse or partner. An intervention that improves martial functioning may impact terminal care and patient satisfaction with spousal care, as well as reduce caregiver burden. Nursing assessment of marital or patient–caregiver relationships and referral to relevant resources may enhance the quality of life of both patients and caregivers and meet a standard of care for holistic nursing care.

STUDY PURPOSE: To systematically review oral care interventions for the prevention and treatment of oral mucositis (OM) in patients undergoing cancer treatment

TYPE OF STUDY: Systematic review

DATABASES USED: Ovid MEDLINE

KEYWORDS: mucositis, stomatitis, cancer, oral care, oral care protocol, dental care, dental cleaning, oral decontamination, oral hygiene, saline, sodium bicarbonate, baking soda, chlorhexidine, magic/miracle mouthwash, calcium phosphate

INCLUSION CRITERIA: Primary research article, reflects a variety of research designs, rested the effects of intervention on severity of OM or mucositis-related symptoms

EXCLUSION CRITERIA: Review articles, clinical case reports, literature reviews, non-research articles

TOTAL REFERENCES RETRIEVED = 129

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Hadorn et al. criteria was used to assess the flaws in the selected publications, and levels of evidence were rated using the Somerfield schema.

FINAL NUMBER STUDIES INCLUDED = 52

SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Not stated

PHASE OF CARE: Active antitumor treatment

The guidelines are as follows.

• Oral care protocols: Oral care was suggested for the prevention of OM in adult and pediatric populations for all types of cancer therapies. No population-specific guidelines were recommended.
• Dental care (by a professional): No guidelines were recommended for dental care in the prevention of OM.
• Normal saline: No guidelines were recommended for normal saline for the prevention or treatment of OM.
• Sodium bicarbonate rinse: No guidelines were recommended for sodium bicarbonate for the prevention or treatment of OM.
• Chlorhexidine: No guidelines were recommended for chlorhexidine for the prevention or treatment of OM in patients receiving standard chemotherapy or hematopoietic stem cell transplantation. Guidelines suggest that chlorhexidine not be used to prevent OM in patients with head and neck cancer treated with radiotherapy.
• Mixed medication mouthwash: No guidelines were recommended for mixed medication mouthwash for the prevention or treatment of OM.
• Calcium phosphate: No guidelines were recommended for calcium phosphate for the prevention or treatment of OM.

Oral care protocols are recommended to patients for the prevention and treatment of OM. Chlorhexidine is not recommended for patients with head and neck cancer who receive radiotherapy treatment.

Evidence for interventions to prevent and treat OM are limited, making guideline recommendations difficult.

Nurses should teach patients appropriate oral care to help prevent OM.

To determine the success rate and duration of relief following repeat celiac plexus neurolysis (CPN) for pancreatic cancer pain

CPN was performed using either fluoroscopy or computed tomography (CT). All CPN and neurolytic procedures were performed under sterile conditions with IV sedation provided as needed at the discretion of the attending physician. The decision to use fluoroscopy versus CT was based on several factors, including patient condition, resource availability, and radiologic demonstration of tumor distribution. A diagnostic/prognostic block was performed first; in patients who obtained relief, subsequent neurolysis with 80%–100% ethanol was administered. Volume was variable and dependent on clinical circumstances. All procedures were performed in the prone position using a posterior approach. Patients were kept prone for 30 minutes to avoid spread to posterior nerves.

• N = 24
• MEAN AGE: Participants with negative outcome (defined as less than 50% pain relief in less than one month following repeat CPN procedure) = 52.4 years; those with positive response = 59 years
• MALES: 62.5%, FEMALES: 37.5%
• KEY DISEASE CHARACTERISTICS Pancreatic cancer (unresectable) with moderate-to-severe abdominal and/or back pain poorly controlled with pharmacotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: Severe, persistent pain; end-stage pancreatic cancer pain management
• EXCLUSION CRITERIA: Untreated coagulopathy, unstable medical illness, cognitive impairment that precluded an accurate response assessment

• SITE: Single site 
• SETTING TYPE: Outpatient
• LOCATION: Baltimore, MD

• PHASE OF CARE: Late/end-stage, end-of-life care
• APPLICATIONS: Elder care, palliative care

• Prospective, descriptive

• A successful procedure was defined as 50% or more pain relief for one month or longer after repeat CPN.
• Baseline 0–10 Numeric Rating Scale pain score

Those participants with a successful response to initial CPN were more likely to have pain symptoms in the back and abdomen and have a shorter time interval from diagnosis of pancreatic cancer to initial CPN. The overall success rate decreased from 67% after initial CPN to 29% following repeat CPN (p = 0.13). The mean duration of pain relief also decreased from 3.4 months following initial CPN to 1.7 months after repeat CPN (p = 0.03). The proportion of individuals with successful repeat CPN after unsuccessful initial CPN was 50% (four out of eight), which favorably compared to 19% (3 out of 16) in those who had successful initial CPN (p = 0.13). In multivariate analysis, the presence of metastases was associated with a 90% decrease in success rate. No statistically significant differences were found between repeat CPN success, and failure groups were observed for age, sex, baseline pain score, location of tumor, presence of metastasis, encasement of celiac axis, opioid use, peritoneal tumor involvement, use of repeat diagnostic block, radiologic guidance used for procedure, needle approach or technique used, or the use of sedation for the procedure. Disease progression on imaging and a longer period between blocks were contributors to treatment failure.

This study demonstrated that the magnitude and duration of pain relief following repeat CPN were significantly less than after the initial procedure. Results suggest that a subset of patients may benefit from repeat CPN. Thirty percent of individuals reported positive responses to repeat CPN, which warrants further analysis.

• Small sample (less than 30)
• Measurement/methods not well described
• Other limitations/explanation: Because of the infrequency with which repeat CPN is performed and the patient population involved, a randomized study was deemed impractical. This research did not contain any objective documentation of functional improvement or quality of life.

Evaluation of a repeat procedure may be warranted when pain levels begin to escalate following a successful initial procedure. However, this is a preliminary suggestion warranting more well-controlled studies. As patient advocates and proponents of pain management, nurses are in a position to further research regarding patient responses to pain management interventions and techniques, such as CPN and repeat CPN. In the outpatient setting, oncology nurses focus on pain management at every visit and direct patients to follow up with the appropriate interdisciplinary team member(s) to address as needed. Nurses are involved in every aspect of patient care, including pre-, post-, and during interventions (e.g., the various CPNs described here), and in outpatient, inpatient, hospice, and palliative settings.

To determine whether replacing a third of the normal diet with an elemental formula (E028) during the first three weeks of pelvic radiotherapy is feasible and effective in decreasing acute gastrointestinal (GI) toxicity

Patients with a gynecologic, urologic, or lower GI malignancy who were scheduled to receive radical or adjuvant radiotherapy to the pelvis were randomized to receive either an elemental diet, which involved replacing one normal meal per day with the elemental formula E028 Extra, or no intervention for the first three weeks of treatment.

• The study reported on 50 patients with a median age of 61.5 years.
• The median age of patients in the intervention group was 62.5 years with a range of 29–79.
• The median age of patients in the control group was 58 years with a range of 38–82.
• The intervention group had 17 female and 8 male patients. The control group had 12 female and 13 male patients.
• Patients had been diagnosed with gynecologic, urologic, or lower GI malignancies and were schedule to receive radical or adjuvant radiotherapy to the pelvis.

The study was conducted in an oupatient care setting in the United Kingdom.

Patients were undergoing the active treatment phase of care.

This was a prospective, randomized-controlled trial.

The Inflammatory Bowel Disease Questionnaire – Bowel specific sub-set (IBDQ-B), Vaizey Incontinence Questionnaire (VIQ), and Radiation Therapy Oncology Group (RTOG) tool were used.

• Intake of the elemental formula was lower than the prescribed volume required to provide a third of caloric requirements. 
• Bowel symptoms increased significantly in both groups as a result of pelvic radiotherapy. Symptom scores at weeks 3 and 5 were significantly higher than those at baseline for both groups. Changes in symptoms between baseline and week 3 were not significantly worse in the intervention group compared to the control group (p = 0.214).
• No significant differences were found between groups at baseline (p = 0.632) or at any other timepoints (p = 0.151).

Patients in the intervention group exhibited poor compliance, ingesting only 65% of the proposed oral elemental formula. The intervention group did not experience a reduction in bowel symptoms or fecal calprotectin compared to the control group.

• The sample size was small, with fewer than 100 patients.
• The study was not blinded.
• The intervention group included a greater proportion of patients with gynecologic malignancy, and the control group included a greater proportion of patients with urologic malignancy. Because the volume of small bowel in the targeted field and dose of radiotherapy differs according to cancer site, lack of stratification could have had an effect on outcome. Furthermore, results could have been affected by the fact that some of the patients with gynecologic cancers were receiving concomitant chemotherapy while those with urologic cancer were not.

This study did not show a benefit to ingesting elemental formula. Orally ingested elemental formulae are known to be unpalatable, and the intervention group had poor compliance with consuming the proposed amount of formula.