Postdischarge Nausea and Vomiting and Co-occurring Symptoms in Women Following Breast Cancer Surgery.

PURPOSE: The purpose of this study was to investigate the influence of potential co-occurring symptoms, including fatigue, sleep disturbance, anxiety, depressive symptoms, and pain, on the incidence of postdischarge nausea (PDN) measured two days following discharge to home after surgery for breast cancer. DESIGN: This study used a prospective, cross-sectional, observational design. METHODS: The sample was 334 women aged 27 to 88 years of age. Demographic data were collected from the patient and the medical record before surgery. Symptom data were collected 48 hours following surgery using the Patient Reported Outcome Measurement System (PROMIS) and numerical nausea and pain scales. FINDINGS: Eighty-five (25.4%) of study participants reported some nausea two days after discharge. Study participants who experienced PDN frequently described that it occurred after they left the hospital to drive home following their surgery. Unadjusted odds ratios showed the presence of co-occurring symptoms of anxiety, fatigue, sleep disturbance, and pain were all significantly associated with the presence of nausea 48 hours following surgery. Other significant factors associated with (PDN) were history of motion sickness, history of pregnancy-induced nausea, use of opioids, and type of surgery. CONCLUSIONS: Same-day surgery nurses providing postoperative education for women following surgery for breast cancer should explain to patients that nausea may occur after they are discharged, especially those with known motion sickness. In addition, patients should be informed that other symptoms, especially fatigue, sleep disturbance, and anxiety, may co-occur.

Older Women and Opioid Analgesia after Breast Cancer Surgery.

PURPOSE: To explore which factors influence opioid analgesia use in older women during the 48-hour period after hospital discharge following initial breast cancer surgery. DESIGN: This cross-sectional, descriptive study involved a cohort (n = 57) of older women recruited for a larger study of breast cancer patients. METHODS: We gathered patient-reported data pertinent to perioperative and post-discharge pain control. Data were analyzed using linear regression to explore those characteristics that had the greatest influence on the amount of post-discharge opioid analgesia required. RESULTS: After hospital discharge, 29 older women (51%) with breast cancer avoided opioid analgesia for various reasons. The number of prescribed opioid tablets each woman self-administered determined the total dosage of analgesia required 48 hours post-discharge. CONCLUSIONS: The majority of this sample of older women with early-stage breast cancer experienced adequate pain relief after surgery and required little or no postoperative or postdischarge opioid analgesia. Optimization of the pain control experience for older women with breast cancer requires thorough pain assessment from diagnosis through survivorship through the end of life. This can be achieved by equipping women in this population to advocate for their pain control needs in real time. Future studies that elucidate preferences, beliefs, and current pain control practices before, during, and after breast cancer surgery will improve safety and efficacy of pain control for this fast-growing population.

Examining the effect of 5-HTTLPR on depressive symptoms in postmenopausal women 1 year after initial breast cancer treatment.

BACKGROUND: Depression following the diagnosis of breast cancer has been well documented, and occurs in as many as 40% of women. The serotonin transporter gene SLC6A4 and its functional polymorphism 5-HTTLPR have been extensively studied as factors in the development of depression. Many research studies have demonstrated conflicting results, and the contribution of 5-HTTLPR to depression is unclear. PURPOSE: The purpose of this study was to compare the relationship between depressive symptoms and serotonin transporter gene polymorphisms between women with early-stage breast cancer 1 year following initial diagnosis and surgery and matched controls. METHODS: Participants (N = 125), included postmenopausal women following breast cancer surgery (n = 80) and age-and education-matched healthy controls (n = 45). The genetic elements of interest were the long (LA) and short (S) alleles of 5-HTTLPR, as well as the single nucleotide polymorphism rs25531 A > G within the L-allele (LG). DNA was extracted from either blood or saliva and analyzed for the SLC6A4 polymorphisms. The outcome measures for this longitudinal study included Beck Depression Inventory scores and physical function domain scores from the Medical Outcome Study Short Form 36. RESULTS: Women with breast cancer demonstrated greater depressive symptomatology and decreased physical function compared to healthy controls. The LA/LA genotype was associated with increased depressive symptomatology in the overall sample and within the controls. The LA/LA genotype appeared with greater frequency in the experimental group, but the relationship with increased depressive symptoms was not observed. Physical function was a significant (p < 0.00) predictor of depressive symptoms in both groups at 12 months. CONCLUSION: The relationship between 5-HTTLPR and depressive symptomatology in breast cancer patients remains unclear. A potential clinical application includes monitoring physical function and addressing increased depressive symptoms as physical function declines.

A Prospective Study of Nausea and Vomiting After Breast Cancer Surgery.

PURPOSE: Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) continue to be common and disturbing complications experienced after surgery, particularly in women and especially in women undergoing breast cancer surgery. The purpose of this study was to assess the incidence and risk factors associated with PONV and PDNV from preoperative to 48 hours postoperatively in 97 women scheduled for breast cancer surgery. DESIGN: Prospective, comparative design. METHODS: After informed consent was obtained, women scheduled for breast cancer surgery were evaluated for incidence of vomiting, as well as the presence and severity of nausea from the preoperative holding area for 48 hours following surgery. Vomiting was assessed as both a nominally scaled, binary variable (Yes/No) and as a continuous variable to measure separate emetic events. Nausea was measured on an 11point verbal numeric scale with 0 being the absence of nausea and 10 representing the highest level of nausea ever experienced. RESULTS: Twenty-nine (29.8%) women experienced nausea, and nine (9%) women experienced nausea and vomiting while in the post-anesthesia care unit despite close attention to the need for prophylactic antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experience PONV. Women who received intravenous acetaminophen did not experience less PONV in this study. PDNV occurred more frequently than PONV, with 34 women (35%) reporting occurrence after discharge. About 13 women who did not experience PONV while in the PACU subsequently experienced PDNV after leaving the hospital, evidence for the importance of patient discharge teaching regarding these symptoms. Although clinical guidelines are necessary, our observation is that nurses in the PACU setting continuously challenge themselves to individualize the combination of medications and activities for each patient to reduce PONV after surgery.

The Psychoneurologic Symptom Cluster and Its Association With Breast Cancer Genomic Instability.

OBJECTIVES: To phenotype the psychoneurologic (PN) symptom cluster in individuals with metastatic breast cancer and associate those phenotypes with individual characteristics and cancer genomic variables from circulating tumor DNA. SAMPLE & SETTING: This study included 201 individuals with metastatic breast cancer recruited in western Pennsylvania. METHODS & VARIABLES: A descriptive, cross-sectional design was used. Symptom data were collected via the MD Anderson Symptom Inventory, and cancer genomic data were collected via ultra-low-pass whole-genome sequencing of circulating tumor DNA from participant blood. RESULTS: Three distinct PN symptom phenotypes were described in a population with metastatic breast cancer: mild symptoms, moderate symptoms, and severe mood-related symptoms. Breast cancer TP53 deletion was significantly associated with membership in a moderate to severe symptoms phenotype (p = 0.013). IMPLICATIONS FOR NURSING: Specific cancer genomic changes associated with increased genomic instability may be predictive of PN symptoms. This finding may enable proactive treatment or reveal new therapeutic targets for symptom management.

Oncology Nurses' Role in Promoting Patient Self-Advocacy.

Teaching patients with cancer the skill of self-advocacy shifts the focus of their cancer care onto what is important to them, leading to optimized patient-centered care. As oncology nurses, providing support to patients as they self-advocate to get their needs met fosters a collaborative relationship, creating an environment in which patients feel comfortable verbalizing their needs and concerns.

Symptom Science: Omics and Response to Non-Pharmacological Interventions.

Incorporating omics into non-pharmacological intervention research design could provide a better understanding of the variability in response to these interventions. It would also provide evidence for precision-based non-pharmacological interventions, including interventions focused on symptoms. The purpose of this manuscript was to present examples of studies that have used omics to examine response to non-pharmacological intervention. Using the interventions of exercise, diet (related to obesity), cognitive based therapy, and alternative mind-body practices (meditation, yoga, and tai chi), PubMed was searched to identify studies that incorporated genomic or other omic approaches as part of a non-pharmacological intervention. The review identified genes associated with the effectiveness of each of the interventions. Although there were no genes that were associated with all four interventions, there were nine genes that were the focus of more than one intervention (ACE, BDNF, COMT, CXCL8, IL6, SL6A4, TNF, GSTM1, PTGER3). All nine of these genes were either directly or indirectly biologically related to one another, suggesting that this cadre of genes could serve as an initiation point for investigations using omic approaches to better understand response to non-pharmacological interventions.

Critical thinking ability of new graduate and experienced nurses.

AIM: This paper is a report of a study to identify critical thinking learning needs of new and experienced nurses. BACKGROUND: Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. In order to improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize. METHODS: In 2004-2006, a consecutive sample of 2144 newly hired nurses in a university-affiliated healthcare system completed the Performance Based Development System Assessment consisting of 10 videotaped vignettes depicting change in patient status. Results were reported as meeting or not meeting expectations. For nurses not meeting expectations, learning needs were identified in one of six subcategories. RESULTS: Overall, 74.9% met assessment expectations. Learning needs identified for nurses not meeting expectations included initiating independent nursing interventions (97.2%), differentiation of urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), providing relevant rationale to support decisions (62.6%) and problem recognition (57.1%). Controlling for level of preparation, associate (P=0.007) and baccalaureate (P<0.0001) nurses were more likely to meet expectations as years of experience increased; a similar trend was not seen for diploma nurses (P=0.10). Controlling for years of experience, new graduates were less likely to meet expectations compared with nurses with >or=10 years experience (P=0.046). CONCLUSION: Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as the Performance Based Development System can provide information about learning needs and facilitate individualized orientation targeted to increase performance level.

Symptom Science: Omics Supports Common Biological Underpinnings Across Symptoms.

For precision health care to be successful, an in-depth understanding of the biological mechanisms for symptom development and severity is essential. Omics-based research approaches facilitate identification of the biological underpinnings of symptoms. We reviewed literature for omics-based approaches and exemplar symptoms (sleep disruption, cognitive impairment, fatigue, gastrointestinal [GI] distress, and pain) to identify genes associated with the symptom or symptoms across disease processes. The review yielded 27 genes associated with more than one symptom. ABCB1 (MDR1), APOE, BDNF, CNR1, COMT, DAT1 (SLC6A3), DRD4, ESR1, HLA-DRB1, IL10, IL1B, IL6, LTA, PTGS2 (COX-2), SLC6A4, and TNF were associated with cognitive impairment and pain, which had the most genes in common. COMT and TNF were related to all symptoms except sleep disruption. IL1B was associated with all symptoms except cognitive impairment. IL10, IL1A, IL1B, IL1RN, IL6, and IL8 (CXCL8) were linked with all the exemplar symptoms in various combinations. ABCB1 (MDR1) and SLC6A4 were associated with cognitive impairment, GI distress, and pain. IL10 and IL6 were linked to cognitive impairment, fatigue, and pain. APOE and BDNF were associated with sleep disruption, cognitive impairment, and pain. The 27 genes were associated with canonical pathways including immune, inflammatory, and cell signaling. The pathway analysis generated a 15-gene model from the 27 as well as 3 networks, which incorporated new candidate genes. The findings support the hypothesis of overlapping biological underpinnings across the exemplar symptoms. Candidate genes may be targeted in future omics research to identify mechanisms of co-occurring symptoms for potential precision treatments.

Primer in Genetics and Genomics, Article 1: DNA, Genes, and Chromosomes.

Precision medicine refers to the practice of determining a patient's unique genetic, biomarker, and other characteristics for the purpose of improving his or her clinical outcomes. Not all patients with the same clinical diagnosis respond equally to identical treatment regimens. By examining patients at the molecular level, health-care providers will be better able to apply the most effective therapies that each individual requires. To understand precision medicine, nurses must have a solid understanding of genomics and proteomics. The purpose of this article is to (1) provide a historical review of what and how we have learned about the genome, particularly in the past century, (2) explain the processes whereby genetic information in cellular DNA is transcribed to messenger RNA and translated to protein, and (3) introduce genetic and epigenetic mechanisms that regulate gene expression.

Exploring the multifactorial nature of postoperative nausea and vomiting in women following surgery for breast cancer.

BACKGROUND: Postoperative nausea and vomiting (PONV) are two of the most frequent and distressing complications following surgical procedures, with as many as 80% of patients considered to be at risk. Despite recognition of well-established risk factors and the subsequent use of clinical guidelines, 20-30% of women do not respond to antiemetic protocols, indicating that there may be a genetic risk. OBJECTIVE: The purpose of this pilot study was to describe the incidence and explore the risk factors associated with PONV after surgery in women diagnosed with early stage breast cancer. METHODS: A prospective cohort design was employed to measure PONV in women recruited prior to surgery. DNA was extracted from saliva samples collected prior to discharge. Polymorphisms for seven candidate genes with a known role in one of the neural pathways associated with PONV were included in this study; serotonin receptor (HTR3A), serotonin transport (SLC6A4), tryptophan (TPH), dopamine receptors (DRD2/ANKK and DRD3), catechol-O-methyltransferase (COMT) and histamine (H1). RESULTS: Twenty-nine (29.8%) women experienced nausea and 10 (11%) experienced nausea and vomiting while in the PACU despite administration of multiple antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experienced PONV. Odds ratios demonstrated that alleles for the COMT, DRD3, and TPH genes were associated with decreased PONV. CONCLUSION: The understanding of the multifactorial nature of PONV and the recognition of genetic risk will ultimately lead to the development of personalized interventions to manage these frequent and often debilitating symptoms.

Beyond BRCA: A Pilot Program to Assess and Improve Knowledge of Pharmacogenomic Testing Among Advanced Practitioners in a Breast Cancer Treatment Setting.

To provide the best available evidence-based care to their patients, advanced practitioners (APs) must become proficient in genomic competencies and remain informed regarding the availability of pharmacogenomic tests. Databases, such as the Centers for Disease Control and Prevention's "Genomic Testing," provide guidance about pharmacogenomic testing, but many APs are not aware of these resources. This study employed a quasi-experimental pretest/posttest design using a convenience sample of APs in a large clinical outpatient breast cancer clinic to assess the knowledge base, beliefs, attitudes, and barriers regarding pharmacogenomic testing among front-line APs and increase knowledge through a targeted educational intervention. The objectives of the educational intervention were to (1) increase knowledge of the clinical indication for testing; (2) increase collaboration among the interprofessional team; and (3) identify correctly when the plan of care should be modified based on pharmacogenomic test results to optimize patient outcomes. Responses showed that these oncology APs possess a strong foundation in genetics and support the addition of new pharmacogenomic tests to their practice.

Association between serotonin transport polymorphisms and postdischarge nausea and vomiting in women following breast cancer surgery.

PURPOSE/OBJECTIVES: To examine the association of the serotonin transport gene and postdischarge nausea and vomiting (PDNV) in women following breast cancer surgery. DESIGN: A cross-sectional study. SETTING: A comprehensive cancer center in Pittsburgh, PA. SAMPLE: 80 post-menopausal women treated surgically for early-stage breast cancer. METHODS: Data were collected using standardized instruments after surgery but before the initiation of chemotherapy. Blood or saliva were used for DNA extraction and analyzed following standardized protocols. Data were analyzed using descriptive statistics and logistic regression. MAIN RESEARCH VARIABLES: Serotonin transport gene (SLC6A4), nausea, vomiting, pain, and anxiety. FINDINGS: Women who inherited the LA/LA genotypes were at greater risk for nausea and vomiting when compared to women who carried any other combination of genotypes. Twenty-one percent of women reported nausea and vomiting an average of one month following surgery and prior to initiation of adjuvant therapy. Those women who experienced PDNV reported significantly higher anxiety and pain scores. CONCLUSIONS: Findings of this study suggest that variability in the genotypes of the serotonin transport gene may help to explain the variability in PDNV in women following breast cancer surgery and why 20%-30% of patients do not respond to antiemetic medications. IMPLICATIONS FOR NURSING: Nurses need to be aware that women who do not experience postoperative nausea and vomiting following surgery for breast cancer continue to be at risk for PDNV long after they have been discharged from the hospital, and this frequently is accompanied by pain and anxiety.

The association of CYP2D6 genotype and postoperative nausea and vomiting in orthopedic trauma patients.

The CYP2D6 gene encodes for an enzyme that is involved in the metabolism of more than 25% of all medications, including many opioids and antiemetics. It may contribute to the risk of postoperative nausea and vomiting (PONV), a common surgical complication. However, little research has been conducted in this area. The purpose of this study was to explore the association of CYP2D6 genotypes with PONV in adult surgical trauma patients. Data from 112 patients (28% female) with single extremity fractures, aged 18-70 years, were analyzed. PONV was defined as present if patients reported nausea, were observed vomiting, or received medication for PONV. Saliva samples collected for DNA extraction and Taqman(®) allele discrimination and quantitative real time polymerase chain reaction (qRT-PCR) were used to collect genotype data that were then used to assign CYP2D6 phenotype classification. The incidence of PONV was 38% in the postanesthesia care unit and increased to 50% when assessed at 48 hr. CYP2D6 classification results were 7 (6%) poor metabolizers, 34 (30%) intermediate metabolizers, and 71 (63%) extensive metabolizers. No ultrarapid metabolizers were identified. Patients who were classified as poor metabolizers had less PONV and higher pain scores. Gender and history of PONV, but not smoking, were also significant risk factors. Findings suggest variability in CYP2D6 impacts susceptibility to PONV.