Gonella, S., di Pasquale, T., & Palese, A. (2015). Preventive measures for cyclophosphamide-related hemorrhagic cystitis in blood and bone marrow transplantation: An Italian multicenter retrospective study. Clinical Journal of Oncology Nursing, 19, E8–E14.
To determine the incidence of early onset hemorrhagic cystitis (EOHC) and identify the effectiveness of preventive measures upon EOHC
This retrospective study evaluated the effects of hyperhydration, diuresis alkalization, mesna, fluoroquinolone antibiotic prophylaxis, urethral catheterization, and CBI on 158 patients in two centers undergoing BMT regime upon EOHC. EOHC was defined as HC occurring within the 21 days after transplantation.
Groups were compared using the Mann-Whitney U test (for continuous variables) and Yates’ correction (for categorical variables). Logistic regression was used to identify factors contributing to the development of EOHC, including gender, age, smoking habits, type of transplantation, stem-cell donor, Cytoxan dose, urethral catheterization, and CBI. A multivariate regression model using a backward stepwise selection algorithm was employed.
Thirty-one patients (all allogeneic transplantations) developed EOHC. Female gender (p = 0.24) and the dose of cytoxan (p = 0.016) were identified as independent risk factors for EOHC. The daily dose of mesna was the only significant measure (p = 0.01) identified between those who developed EOHC (median = 4.463) and those who did not (3.701).
Univariate analysis does not support the current standard, prophylactic catheterization and CBI, for prevention of EOHC. The best practice includes hyperhydration association with diuresis alkalization and mesna infusions.
Nurses caring for patients at risk of HC may need to reassess current standards for prophylactic treatment of HC.
Gonella, S., Garrino, L., & Dimonte, V. (2014). Biofield therapies and cancer-related symptoms: A review. Clinical Journal of Oncology Nursing, 18, 568–576.
PHASE OF CARE: Active antitumor treatment
APPLICATIONS: Palliative care
Interventions considered to be BT were healing touch, Reiki, and therapeutic touch. The effect on pain was examined in seven studies. There were some mixed findings, but most showed a reduction in pain over short time periods. Fatigue was assessed in five studies. These demonstrated fatigue reduction post-treatment, but data were conflicting over a longer period of four to eight weeks. Anxiety and depression were examined in seven studies. All but one found a significant reduction in mood disorders, but a study comparing Reiki, sham Reiki, and usual care found no difference between the sham and actual Reiki groups. Most studies were of descriptive or quasi-experimental design; potential confounding variables were not examined, and placebo effects could not be ruled out.
Studies using biofield therapies for relief of pain, anxiety, fatigue, and depression generally showed benefit; however, the evidence is not strong due to the limitations of the studies included.
Low-quality design studies and the short duration of study follow-up
BT therapies have not demonstrated effectiveness in well-designed clinical studies; however, though it is weak, evidence suggests potential benefit. There were no adverse effects of these interventions reported. Biofield therapies are not expensive and are low-risk, so they can be considered in the management of cancer-related symptoms. Well-designed clinical trials are needed to establish efficacy.
Gomutbutra, P., O'Riordan, D.L., & Pantilat, S.Z. (2013). Management of moderate-to-severe dyspnea in hospitalized patients receiving palliative care. Journal of Pain and Symptom Management, 45, 885–891.
To describe the management of moderate to severe dyspnea in patients receiving palliative care
A retrospective study was conducted using the records of patients who were consulted by a palliative care service over a five-year period. Information about medications prescribed was collected for patients who self-reported moderate to severe dyspnea at their initial evaluations by the palliative care service. Follow-up assessments of dyspnea were conducted by the palliative care service within 24 hours of the initial assessment. Data extraction was completed by a physician.
Retrospective chart review of patients with moderate or severe dyspnea
Most patients reported an improvement in dyspnea within of 24 hours after palliative care service consultation. Most patients with dyspnea received opioids but only the combination of benzodiazepines and opioids was independently associated to improve dyspnea.
Because dyspnea is a common symptom in patients receiving palliative care, the authors conducted a study that reviewed the records of patients with moderate or severe dyspnea. The study found that opioids given with benzodiazepines were associated with improvements in dyspnea. Additional research to determine whether the use of benzodiazepines alone or in combination with opioids is more effective is necessary to to lead to improvements in dyspnea treatments.
Gomez-Hernandez, J., Orozco-Alatorre, A.L., Dominguez-Contreras, M., Oceguera-Villanueva, A., Gomez-Romo, S., Alvarez Villaseñor, A.S., . . . Gonzalez-Ojeda, A. (2010). Preoperative dexamethasone reduces postoperative pain, nausea and vomiting following mastectomy for breast cancer. BMC Cancer, 10, 692.
To evaluate the effectiveness of preoperative dexamethasone in reducing postoperative nausea, vomiting, and pain after mastectomy
Patients were randomized to receive either IV dexamethasone 8 mg or placebo 60 minutes prior to skin incision. All patients had the same standardized general anesthesia. The same surgical team performed each surgery. Pain was assessed on entry to the recovery room and at 6, 12, and 24 hours postoperatively. Analgesia was ketorolac 30 mg every 8 hours and IV tramadol infusion 50 mg as backup medication. Patients were followed for up to 30 days after surgery.
Double-blinded placebo-controlled randomized trial
Compared to patients in the placebo group, those receiving dexamethasone had significantly lower pain scale scores immediately after surgery (p = 0.004), at 6 hours (p < 0.0005), and at 12 hours (p = 0.04). Pain score differences between groups were approximately 1 point at these times. Authors noted no differences between groups at 24 hours after surgery. More patients in the placebo group than in the dexamethasone group required analgesics (p = 0.008), and the mean dose of IV tramadol was lower for those who received dexamethasone (p = 0.03). Incidence of nausea and vomiting was lower with dexamethasone; more patients in the placebo group required antiemetics (p = 0.01)
Compared to preoperative administration of placebo, preoperative administration of dexamethasone was associated with less short-term postoperative pain, nausea, and vomiting.
Findings suggest that preoperative dexamethasone administration can reduce short-term postoperative pain, nausea, and vomiting. In this study patients received specific anesthesia regimens. Findings may not be the same with different anesthetics. Further study in this area should identify optimal management of postoperative symptoms. The administration of a single corticosteroid dose prior to surgery can be a relatively low-risk intervention that seems to improve the patient’s experience.
Gomes, M.Z., Jiang, Y., Mulanovich, V.E., Lewis, R.E., & Kontoyiannis, D.P. (2014). Effectiveness of primary anti-Aspergillus prophylaxis during remission induction chemotherapy of acute myeloid leukemia. Antimicrobial Agents and Chemotherapy, 58, 2775–2780.
To analyze risk factors for breakthrough invasive fungal infection (IFI) in patients receiving remission-induction chemotherapy and evaluate effects of echinocandin versus triazole prophylaxis
Data were obtained from patients’ electronic medical records for antifungal use, documented IFI, type of chemotherapy, use of HEPA air filtration, duration of hospitalization, and neutropenia and mortality. Kaplan-Meier curves were used to estimate the probability of remaining IFI free based on prophylaxis strategy. Patient data were used up to IFI diagnosis, loss to follow-up, death, or completion of 120 days post-induction, whichever came first.
Those receiving echinocandin versus mold active triazole had higher incidence of IFI (0% in the triazole group, 8% in the echinocandin group, p = 0.09). All cause mortality did not differ between groups. Regimens containing clofarabine for induction was also an independent predictor of IFI (p = 0.004). Patients who died within 120 days of beginning induction chemotherapy were more likely to be female, had prior chemotherapy-related AML, had lung disease or infection, or had cardiovascular disease as a comorbid condition. Those receiving echinocandin also had more breakthrough yeast infections.
Findings suggest that primary antifungal prophylaxis during remission induction with echinocandin may be less effective in preventing IFI than prophylaxis with mold-active triazoles.
Patients with AML undergoing remission-induction chemotherapy are at high risk for developing IFIs, particularly mold infections. Findings from this study suggest that the class of antifungal prophylaxis agent used influences the patient’s risk of IFI. Nurses should be aware of the potential increased risk for fungal and yeast infections in patients getting echinocandin prophylaxis. Further research in this area is warranted given the limitations of this study.
Gomes, B., Calanzani, N., Curiale, V., McCrone, P., & Higginson, I.J. (2013). Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database of Systematic Reviews, 6, CD007760.
STUDY PURPOSE: To review the evidence regarding effectiveness of home palliative care services for patients and their caregivers
TYPE OF STUDY: Meta-analysis and systematic review
DATABASES USED: 12 electronice databases were searched up to November 2012—Cochrane Central Register of Controlled Trials (CENTRAL); EMBASE; MEDLINE; Cochrane Pain, Palliative, and Supportive Care (PaPaS) Trials Register; Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register; CINAHL; EURONHEED; PsycINFO; Cochrane Database of Systematic Reviews (CDSR); Database of Abstracts of Reviews of Effectiveness (DARE); Health Technology Assessment (HTA) Database; and NHS Economic Evaluation Database (NHS EED)
KEYWORDS: An extensive listing of search strategies is provided.
INCLUSION CRITERIA: Randomized controlled trials, time series, and pre-post trials; patients older than 18 years and/or their caregivers
EXCLUSION CRITERIA: Services provided in settings other than the home
PHASE OF CARE: End-of-life care
APPLICATIONS: Palliative care
Strong evidence suggests that home palliative care services increase the likelihood of patients dying at home and decrease symptom burden for patients. Evidence regarding effects for caregivers is conflicting and inconclusive. Evidence regarding cost and cost-effectiveness is insufficient to draw conclusions.
Findings provide strong evidence that home palliative care services result in increased deaths at home and reduced symptom burden for patients. The effect for informal caregivers is uncertain. Caregiver burden can be higher in situations with more patient symptoms to manage, so one could expect that reducing patient symptom burden could have some benefit for the caregiver.
Gollins, S., Gaffney, C., Slade, S., & Swindell, R. (2008). RCT on gentian violet versus a hydrogel dressing for radiotherapy-induced moist skin desquamation. Journal of Wound Care, 17, 268–275.
To compare hydrogel dressing to gentian violet (GV) for healing moist desquamation
Patients were referred after a nurse or radiographer identified moist desquamation. They were randomly assigned to GV or hydrogel. Patients were given instruction on how to apply GV or hydrogel at home and were assessed by radiographers on alternate days until the healing occurred. Tracing of the moist desquamation area on to polythene sheets was done randomly on different days with different patients.
The study took place at a single site in the United Kingdom.
The study used a randomized controlled trial design.
The study could not support or refute the value of hydrogel dressings.
Goldschmidt, N., Ganzel, C., Attias, D., Gatt, M., Polliack, A., & Tadmor, T. (2014). Pegfilgrastim prophylaxis for cladribine-induced neutropenia in patients with hairy-cell leukemia. Acta Haematologica, 132, 118–121.
To evaluate the efficacy of primary prophylactic pegfilgrastim compared to on-demand daily G-CSF after treatment with cladribine in patients with hairy-cell leukemia (HCL)
This was a retrospective chart review of 40 patients with HCL (1991–2012) treated with cladribine (0.1 mg/kg per day) for five to seven days either subcutaneously (SC) or IV, receiving a total of 40 courses of therapy treated with filgrastim (300 mcg per day) on demand until the patients' absolute neutrophil counts (ANCs) were > 2.0 x 109 compared to nine courses of therapy with primary pegfilgrastim prophylaxis (6 mg SC for 24 hours after the completion of chemotherapy).
Retrospective, historical control study of patients with HCL prescribed cladribine determining the effect of IV pegfilgrastim versus filgrastim on neutropenia, hospitalization, 20 FN, severity of infection, and ANC nadir
The median follow-up was 94 months (range = 12–312 months). No significant difference was found between primary prophylaxis with pegfilgrastim versus on-demand filgrastim for patients with HCL treated with cladribine for the variables of incidence of neutropenia, number days of hospitalization because of FN, severity of infection, or the number of days from the last day therapy till ANC recovery.
This retrospective study demonstrated no difference in the clinical effectiveness of primary pegfilgrastim versus on-demand filgrastim after cladribine therapy for patients with HCL.
This study demonstrated no difference in the incidence of neutropenia, FN, or infections requiring hospitalization between the use of pegfilgrastim versus filgrastim after treatment with cladribine. Large, prospective, randomized trials need to be conducted to validate this study's results. Nurse-sensitive interventions remain critical in the prevention of infection for patients with HCL and prolonged neutropenia caused by disease and treatment.
Goldberg, R.M., Loprinzi, C.L., O’Fallon, J.R., Veeder, M.H., Miser, A.W., Mailliard, J.A., … Burnham, N.L. (1994). Transdermal clonidine for ameliorating tamoxifen-induced hot flashes. Journal of Clinical Oncology, 12, 155–158.
The study evaluated transdermal clonidine for alleviating tamoxifen-induced hot flashes in women with a history of breast cancer.
Four weeks of transdermal clonidine (equivalent to a daily oral dose of 0.1mg) was followed by four weeks of placebo patches or vice versa. Patches were changed weekly.
The study enrolled 116 women with a mean age of 54 years who were receiving tamoxifen for breast cancer experiencing hot flashes and requesting intervention; experiencing hot flashes for longer than one month and at least seven per week. One hundred ten (110) of the 116 completed the study. Participants were stratified by age, duration of hot flash symptoms, and the average frequency and severity of hot flashes.
This was a randomized, double-blind, crossover prospective study.
The study employed the following measures:
The study showed a statistically significant decrease in hot flashes (frequency and severity) (p < .0001), and clinically moderate decreases in frequency (20%) and severity (10%). Toxicities included dry mouth (p < .001) and constipation (p < .02).
Small study size limited the value of the outcomes.
Goldberg, G.R., & Morrison, R.S. (2007). Pain management in hospitalized cancer patients: A systematic review. Journal of Clinical Oncology, 25, 1792–1801.
To provide a systematic review of institutional interventions designed to improve management of pain in hospitalized patients with cancer
Databases searched were MEDLINE, Cochrane Library, and authors’ personal libraries.
Search keywords were pain, pain measurement, outcomes assessment, or quality assurance.
Inclusion criteria was not specifically stated, other than that studies involved patients with cancer.
Exclusion criteria was not specifically stated.
Total number of studies retrieved or initially evaluated is not provided.
Articles were reviewed and independently summarized by the authors, and any disagreements were discussed until consensus was achieved.
Studies were not exclusively for patients with cancer, but all did involve some cancer care cases.
Nursing educational interventions improve knowledge and correct misconceptions but have not shown improved pain or patient satisfaction.
Studies suggest that patient education and tailored counseling sessions directed at patients can improve pain scores and negative beliefs and misconceptions.
Routine pain assessment has been shown to improve staff and patient satisfaction; however, interventions have not been shown to improve overall pain scores or pain severity.
Provision of audit and feedback of patient pain scores to nursing staff improved pain assessment rates but had no effect on pain severity.
The study involving CDSS showed some improvement in prescribing practices, predominantly reducing use of meperidine, but did not demonstrate improved pain scores.
Meta-analysis of eight studies in the effect of a hospital-based palliative care team suggests that referral to such programs results in small but positive effects on pain, other symptoms, satisfaction, and reduction in length of stay compared to conventional care.
The major types of institution-wide interventions aimed at improving pain management include education, inclusion of pain assessment as a vital sign, auditing and staff feedback of pain scores, use of CDSS, and referral to palliative care specialists. Improved knowledge, assessment, and process of care measures have been demonstrated; however, no substantial effects on actual pain scores and severity have been demonstrated as a result of these interventions. From this review, the most promising interventions related to actual pain outcomes appear to be patient education and counseling and referral to palliative care specialists. The authors conclude that no generalizable interventions were identified.
Findings point to the difficulty of being able to demonstrate the effects of institutional interventions on patients’ measurable pain outcomes other than satisfaction with pain management. Most of these efforts are not necessarily appropriate in a randomized controlled trial type of design, leading to questions of methodological rigor in findings, and suggest that the patient’s experience of pain is complex and not readily determined by standardized processes.
Findings suggest that individual patient interventions including counseling and education are worth further investigation in order to have an effect on pain outcomes.
Involvement of palliative care specialists appears to be somewhat effective to improve pain outcomes; however, it is not clear that universal referrals to such groups for all pain management are practical. This raises the question of how such specialized knowledge, focus, and expertise might be shared and utilized in new ways to impact all patients. It is not clear that educational interventions for staff that have been studied are sufficient to improve knowledge of providers to the extent required to impact pain-related results.