Effectiveness of Internet-based interventions in managing chemotherapy-related symptoms in patients with cancer: a systematic literature review.

PURPOSE: The aims of this review were to (1) examine the effectiveness of Internet-based interventions on cancer chemotherapy-related physical symptoms (severity and/or distress) and health-related quality of life (HRQOL) outcomes and (2) identify the design elements and processes for implementing these interventions in oncology practices. METHODS: A systematic review was performed. The Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, CINAHL, and PsycINFO were searched for studies dating from January 2000 through to October 2016. Based on pre-determined selection criteria, data was extracted from eligible studies. Methodological quality of studies was assessed using an adapted version of the Cochrane Collaboration Back Review Group checklist. RESULTS: The literature search yielded 1766 studies of which only six RCTs fulfilled the eligibility criteria. Although the content, duration, and frequency of interventions varied considerably across studies, commonly used elements included tailored information, education, self-management support, and communication with clinicians. Five studies measured symptom distress and four of them reported statistically significant differences between study groups. Of the three studies that measured HRQOL, two reported improvement (or no deterioration over time) for the intervention group. However, several methodological issues including high attrition rates, poor adherence to interventions, and use of non-validated measures affect confidence in the strength of evidence. CONCLUSION: Despite the evidence in support of using the Internet as a worthwhile tool for effective patient engagement and self-management of chemotherapy-related symptoms outside clinic visits, methodological limitations in the evidence base require further well-planned and quality research.

Effects of the community-based Wellspring Cancer Exercise Program on functional and psychosocial outcomes in cancer survivors.

PURPOSE: In this study, we examined the effects of a 30-week community-based exercise program on cancer-related fatigue, quality of life, and other health-related outcomes in a sample of adults with mixed cancer diagnoses. METHODS: This prospective cohort study looked at outcomes for participants involved in the Wellspring Cancer Exercise Program in southern Ontario. The program consisted of an initial phase of two supervised sessions weekly for 10 weeks and a transition phase of one supervised session weekly for the subsequent 20 weeks. Outcomes were measured at baseline and every 10 weeks throughout the intervention, as well as at 16 weeks after program completion. RESULTS: During a period of 13 months, 229 of the 355 cancer survivors who enrolled in the exercise program consented to participate in the study. Participants attended 71% of the supervised exercise sessions in the initial phase and 49% in the transition phase. From baseline to the end of the initial phase, significant improvements in cancer-related fatigue, 6-minute walk test, social well-being, systolic blood pressure, balance, and physical activity volume were observed. During the transition phase, health-related quality of life and emotional well-being improved significantly. CONCLUSIONS: The Wellspring Cancer Exercise Program is associated with clinically meaningful improvements in cancer-related fatigue and functional aerobic capacity. Several other aspects of well-being in cancer survivors also improved for participants in the program. Community-based cancer exercise programs such as the Wellspring Cancer Exercise Program can improve well-being for cancer survivors and can provide an effective option that enhances sustainability and accessibility to exercise services for this population.

Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice.

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.

Case Studies of Fraud Associated with the Use of Radiation Sources: Practical Avoidance Strategies Based on Lessons Learned.

ABSTRACT: Periodically the radiation protection profession has experienced purposeful deception practices that remained undetected for some time. Upon discovery, the cases of fraud revealed gaps in confirmation or validation practices that the radiation protection community should note. Summarized here is a convenience sample of actual cases of fraud involving radiation sources along with the exploited process vulnerabilities. Recommended process improvements that the radiation safety community may consider are presented to improve the collective fidelity of radiation protection processes.

Help-seeking behaviour in patients with lymphoma.

Reducing cancer mortality is a priority for the UK Government and emphasis has been placed on introducing targets to ensure prompt diagnosis. Help seeking is the first step on the pathway to diagnosis and should occur promptly; however, patients with lymphoma take longer to seek help for symptoms than those with many other cancers. Despite this, the help seeking behaviour of these patients has not been investigated. This qualitative study examined the beliefs and actions about help seeking among 32 patients, aged 65 and over and newly diagnosed with lymphoma in West Yorkshire during 2000. Patients reported an extremely wide range of symptoms which were not always interpreted as serious or potentially caused by cancer. This, in association with a clear lack of knowledge about lymphoma, often led to help seeking being deferred. The range and characteristics of symptoms can largely be explained in terms of variations in the type, site and size of the lymphoma. The UK Government targets focus on the time after help seeking, yet for lymphoma it is also crucial to reduce the time taken to seek help. More education about the potential symptoms of this disease is needed among the general public.

Mass casualty incidents: are NHS staff prepared? An audit of one NHS foundation trust.

BACKGROUND: Lack of knowledge of an NHS trust's major incident policies by clinical staff may result in poorly coordinated responses during a mass casualty incident (MCI). AIM: To audit knowledge of the major incident policy by clinical staff working in a central London major acute NHS trust designated to receive casualties on a 24-h basis during a MCI. METHODS: A 12-question proforma was distributed to 307 nursing and medical staff in the hospital, designed to assess their knowledge of the major incident policy. Completed proformas were collected over a 2-month period between December 2006 and February 2007. RESULTS: A reply rate of 34% was obtained, with a reasonable representation from all disciplines ranging from nurses to consultants. Despite only 41% having read the policy in full, 70% knew the correct immediate action to take if informed of major incident activation. 76% knew the correct stand-down procedure. 56% knew the correct reporting point but less than 25% knew that an action card system was utilised. Nurses had significantly (p<0.01) more awareness of the policy than doctors. CONCLUSION: In view of the heightened terrorist threat in London, knowledge of major incident policy is essential. The high percentage of positive responses relating to immediate and stand-down actions reflects the rolling trust-wide MCI education programme and the organisational memory of the trust following several previous MCI in the capital. There is still scope for an improvement in awareness, however, particularly concerning knowledge of action cards, which are now displayed routinely throughout clinical areas and will be incorporated into induction packs.

Multidisciplinary approach to pseudoaneurysms complicating pancreatic pseudocysts. Impact of pretreatment diagnosis.

OBJECTIVE: To determine the effectiveness of thin-section, dynamic-contrast computed tomography and angiography in detecting the presence of pancreatic pseudoaneurysms. DESIGN: This case series consisted of 57 patients who were being examined for endoscopic drainage of pancreatic pseudocysts. SETTING: All patients were examined in a tertiary care, teaching hospital. PATIENTS: Fifty-seven consecutive patients were examined for 2 years. Follow-up ranged from 6 months to 2 years. INTERVENTIONS: All patients underwent thin-section, high-speed, dynamic-contrast computed tomography. Those patients with findings that were consistent with the presence of a pseudoaneurysm underwent angiography. Embolization was attempted if a pseudoaneurysm was present. Endoscopic retrograde cholangiopancreatography was used to determine pancreatic ductal anatomy before operation. MAIN OUTCOME MEASURE: No undetected pseudoaneurysm has complicated this series of endoscopically drained pseudocysts. RESULTS: Five patients had findings that were consistent with a pancreatic pseudoaneurysm on computed tomography. Angiographic findings confirmed a pseudoaneurysm in four patients, and angiographic embolization was successful in three. Four patients underwent resection, while one was treated with embolization and endoscopic stenting of a compressed pancreatic duct. There were no mortalities. CONCLUSIONS: Before endoscopic drainage of a pancreatic pseudocyst, a thin-section, high-speed, dynamic-contrast computed tomographic scan is essential. If there are findings consistent with the development of a pseudoaneurysm, angiography must be performed. This allows delineation of the arterial anatomy, as well as the option of performing angiographic embolization. While patients with pseudoaneurysms in the body and tail of the pancreas underwent resection, angiographic embolization alone was an acceptable alternative when the lesion was located in the head of the pancreas.

Endoscopic management of pseudocysts of the pancreas.

Endoscopic pseudocyst management should not be regarded as an exercise in applied technology. Rather, it is of vital importance for the clinician to be thoroughly aware of the many considerations in patient selection and to understand the available treatment alternatives prior to undertaking such a venture. Despite these considerations, it is our opinion that endoscopic pseudocyst management at present is the method of choice in the majority of patients requiring drainage of symptomatic pseudocysts.

Advancing the quality of oncology nursing care: Interlink Community Cancer Nurses' model for reflective practice.

Since 1996, Interlink Community Cancer Nurses have been using reflective practice as a team to share knowledge and experience amongst peers. The use of reflective practice enables the nurse to examine decision-making in patient situations and uncover the knowledge and artistry that is embedded in nursing practice. This article describes how reflection is practised by specialist cancer nurses to advance the quality of caregiving. The use of a structured framework for reflection which incorporates ways of knowing in nursing is an essential feature of the Interlink model for reflection. The development of a process for reflection within the Interlink program has at times been challenging. However, the Interlink nurses' experience with reflection is believed to be critical to the ongoing development of the program and the individual nurse. Interlink nurses have found that guided reflection, the creation of an environmental milieu for reflection and personal knowing, and self-evaluation are critical to the process of becoming a self-reflective practitioner.

A mixed-method evaluation of nurse-led community-based supportive cancer care.

GOALS OF WORK: The study purpose was to evaluate a nurse-led supportive care clinical case management program in the community using multi-methods to delineate care processes prior to outcome evaluation. MATERIALS AND METHODS: Multiple data sources including program service records, chart reviews and interviews with nurses and key interdisciplinary informants were used to identify population served (coverage and reach), processes of care (implementation), and providers' perceptions of the effectiveness of the nurse-led program (reaction). MAIN RESULTS: The program provided care to over 700 cancer patients in a 1-year period. Nurse-led support interventions were focused on direct care inclusive of teaching/coaching for symptom management, counseling and support, and mobilization of services through system navigation based on an initial comprehensive assessment of supportive care needs. CONCLUSIONS: Nurse-led models of supportive care have the potential to reduce unmet supportive care needs, improve continuity of care, and overall health-related quality of life that should be tested in future trials.

Referral pathways and diagnosis: UK government actions fail to recognize complexity of lymphoma.

To gain survival advantages potentially associated with prompt diagnosis, the UK government introduced identical waiting-time targets for all cancers, and guidelines to ensure that general practitioners make appropriate hospital referrals. For lymphoma, the evidence guiding these actions is limited. This study examined referral pathways in patients with lymphoma and variations in time to diagnosis by discipline of first referral. A case series study was conducted including all patients aged over 25 years, newly diagnosed with lymphoma in the UK county of West Yorkshire, during 2000. Data were extracted from primary care and hospital records of 189 patients. Referral pathways were described, and the number of days between first referral and diagnosis calculated. A distinct referral pathway did not exist; patients were initially referred to many disciplines. Surgical referrals predominated, and only 12% of patients were sent directly to haematology. Time to diagnosis varied by discipline and was shorter for patients sent to haematology than for most other common disciplines. UK government actions to ensure the prompt diagnosis of patients with lymphoma are not evidence-based. The complexity of the referral pathway in patients with lymphoma, which affects time to diagnosis, has been underestimated. Further government actions should be evidence-based, ensuring prompt diagnosis of lymphoma from whatever discipline patients originate.

Lymphoma: variations in time to diagnosis and treatment.

This study examines illness trajectories of patients with lymphoma and assesses whether UK government targets to reduce waiting time for diagnosis and treatment are achievable and appropriate. One hundred and ninety-four patients, residents in West Yorkshire, aged more than 25 years and newly diagnosed with lymphoma during 2000 were included. Data collected from interviews, primary care and hospital records were used to examine time between critical events on the illness trajectory and characteristics of patients not meeting proposed targets. Forty-two per cent of patients did not receive a hospital appointment within 2 weeks of general practitioner referral, 26% were not treated within 1 month of diagnosis and 64% were not treated within 2 months of referral. Target achievement differed by diagnostic group, and trends were seen by age and deprivation. The interval from onset of symptoms to treatment averaged more than 1 year and approximately half of this occurred before first medical contact. Results suggest that significant improvements are needed to achieve targets. Although existing targets particularly address referral and treatment intervals, these were the shortest intervals on the trajectory. Generalized targets may be inappropriate and unachievable for lymphoma as they do not consider individual disease characteristics or allow for variations in the urgency with which treatment is needed.

The renal manifestations and outcome of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in adults.

Thrombotic thrombocytopenic purpura/Hemolytic uremic syndrome (TTP/HUS) is generally regarded to be a rare disease. The present study was undertaken to identify presenting features, prognostic variables, pathological features and outcome associated with TTP/HUS. The present study is a retrospective chart review of 68 patients treated with plasmapheresis for TTP/HUS at a single tertiary referral medical institution from 1980-1992. The annual number of patients with TTP/HUS treated with plasmapheresis increased from an average of one case per year in 1980 to nine cases per a year in 1992. The in-hospital mortality for patients presenting with TTP/HUS was 25%. Forty four percent of patients presented with an elevated serum creatinine, and 16% required hemodialysis support. Of the seven patients who survived and required hemodialysis support only two patients continued on dialysis. None of the patients presenting with a normal serum creatinine required dialysis at any time in their course. Patient age, sex, presenting platelet count, white blood cell count, hemoglobin level and presence of neurological disease were not significantly associated with death or need for dialysis. The histopathological features of TTP/HUS (fibrin/platelet thrombi in renal vessels and glomeruli, fibrinoid necrosis of vessel walls) were found in all five cases autopsied. The incidence of TTP/HUS may be increasing. Alternative possibilities for the increased frequency of cases seen include greater diagnostic suspicion and referral bias. Despite the use of plasmapheresis, mortality during the initial hospital admission was almost 25%. In retrospect prognosis could not be predicted based on admission biochemical or clinical variables. The majority of patients who developed acute renal failure and survived to hospital discharge recovered renal function and became independent of dialysis.

Endoscopic management of tumors of the major duodenal papilla: Refined techniques to improve outcome and avoid complications.

BACKGROUND: Adenomas of the major duodenal papilla have malignant potential and are traditionally treated by pancreaticoduodenectomy. This is a report of our experience with endoscopic management and a description of techniques for decreasing complications and enhancing efficacy. METHODS: Forty-one patients were referred for endoscopic management of papillary tumors. If there was no duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy with pancreatic duct stent placement was performed. If the lesion could be elevated by injection of an epinephrine solution, piecemeal resection was performed. The base of the lesion was thermally ablated as needed. Resection/ablation together with stent removal was performed 1 month later. RESULTS: Nine patients (22%) had lesions other than papillary adenoma or cancer. Malignant appearance, ductal stricturing, or extension into the ducts was found in 16 of 41 patients (39%) in whom biopsy specimens alone were obtained. Three patients with adenomas (7%) did not undergo endoscopic resection (because of extremely large lesions and/or comorbid illnesses). Thirteen patients with adenomas (32%) had endoscopic resection; 12 (92%) were lesion-free after 32 ERCPs (mean 2.7). Endoscopic management was unsuccessful in 1 patient (8%). Pancreatitis developed in 1 patient. CONCLUSIONS: Endoscopically treatable papillary neoplasms can be identified on the basis of endoscopic, radiographic, and biopsy features. Preresection sphincterotomy, stent placement, elevation by epinephrine injection, and piecemeal resection may reduce complications and permit more aggressive treatment.