Host genetic susceptibility to Clostridium difficile infections in patients undergoing autologous stem cell transplantation: a genome-wide association study.

BACKGROUND: Clostridium difficile infection (CDI) is the most common hospital-acquired infection. Unfortunately, genes that identify CDI-susceptible patients have not been well described. We performed a genome-wide association study (GWAS) to determine genetic variants associated with the development of CDI. METHODS: A cohort study of Caucasian patients undergoing autologous stem cell transplantation for multiple myeloma was performed. Patients were genotyped using Illumina® Whole Genome Genotyping Infinium chemistry. We then compared CDI-positive to CDI-negative patients using logistic regression for baseline clinical factors and false discovery rate (FDR) for genetic factors [single nucleotide polymorphisms (SNPs)]. SNPs associated with CDI at FDR of p < 0.01 were then incorporated into a logistic regression model combining clinical and genetic factors. RESULTS: Of the 646 patients analyzed (59.7% male), 57 patients were tested CDI positive (cases) and were compared to 589 patients who were tested negative (controls). Hemoglobin, albumin, and hematocrit were lower for cases (p < 0.05). Eight SNPs on five genes (FLJ16171, GORASP2, RLBP1L1, ASPH, ATP7B) were associated with CDI at FDR p < 0.01. In the combined clinical and genetic model, low albumin and three genes RLBP1L1, ASPH, and ATP7B were associated with CDI. CONCLUSION: Low serum albumin and genes RLBP1L1 and ASPH located on chromosome 8 and ATP7B on chromosome 13 were associated with CDI. Of particular interest is ATP7B given its copper modulatory role and the sporicidal properties of copper against Clostridium difficile.

GWAS of 972 autologous stem cell recipients with multiple myeloma identifies 11 genetic variants associated with chemotherapy-induced oral mucositis.

PURPOSE: High-dose chemotherapy and autologous stem cell transplant (ASCT) to treat multiple myeloma (MM) and other cancers carries the risk of oral mucositis (OM) with sequelae including impaired nutritional and fluid intake, pain, and infectious complications. As a result of these problems, cancer treatment may have to be interrupted or delayed. In this study, we looked beyond OM's known risk factors of renal function and melphalan dose with a genome-wide association study (GWAS) to evaluate whether genetic variants in conjunction with clinical risk factors influence predisposition for OM. METHODS: Genotyping was performed using Illumina HumanOmni1-Quad v1.0 BeadChip and further assessed for data quality. We tested 892,589 germline single-nucleotide polymorphisms (SNPs) for association with OM among 972 Caucasian patients treated with high-dose melphalan and ASCT in Total Therapy clinical trials (TT2, TT3, TT4) for newly diagnosed MM. Statistical analyses included t tests, stepwise regression modeling, and logistic regression modeling to find baseline clinical factors and genotypes associated with OM. RESULTS: We found that 353 (36.3 %) patients had grades 2-4 OM. Type of treatment protocol, baseline estimated glomerular filtration rate, and melphalan dose along with baseline serum albumin and female gender predicted 43.6 % of grades 2-4 OM cases. Eleven SNPs located in or near matrix metalloproteinase 13, JPH3, DHRS7C, CEP192, CPEB1/LINC00692, FBN2, ALDH1A1, and DMRTA1/FLJ35282 were associated with grades 2-4 OM. The addition of these SNPs increased sensitivity in detecting grades 2-4 OM cases to 52 %. CONCLUSIONS: These SNPs may be important for their roles in inflammatory pathways, epithelial healing, and chemotherapy detoxification.

Effect of certification in oncology nursing on nursing-sensitive outcomes.

The study compared certified nurses with noncertified nurses for symptom management of nausea, vomiting, and pain; patient satisfaction; and nurse satisfaction to determine the effect of certification in oncology nursing on those nursing-sensitive outcomes. A total of 93 nurses-35 (38%) of them certified in oncology nursing-and 270 patients completed surveys. Chart audits provided additional data on symptom management. Certified nurses scored higher than noncertified nurses on the Nurses' Knowledge and Attitudes Survey Regarding Pain as well as the Nausea Management: Nurses' Knowledge and Attitudes Survey. The chart audits showed that certified nurses followed National Comprehensive Cancer Network guidelines for chemotherapy-induced nausea and vomiting (CINV) management more often than noncertified nurses. The study demonstrated that job satisfaction is fairly high for oncology nurses and patient satisfaction is high. In general, cancer pain and CINV were managed well but improvements can be made. Nurses and physicians continuously should be educated on evidence-based guidelines for symptom management of cancer pain and CINV, and a CINV knowledge and attitude assessment tool should be developed.

Understanding Lynch syndrome: implications for nursing.

Colorectal cancer (CRC) is the second-leading cause of cancer-related death in the United States. Approximately 10% of CRC is hereditary, and hereditary nonpolyposis CRC (HNPCC), or Lynch syndrome I, is the most common form. Lynch syndrome I is characterized by onset at an early age, poor differentiation, predominance of proximal tumors, and an excess of synchronous and metachronous tumors. In Lynch syndrome II, patients exhibit Lynch syndrome I features and also have extracolonic cancers. Lynch syndrome is an inherited autosomal dominant disorder caused by a germline mutation in one of several genes responsible for DNA mismatched repair. Amsterdam I criteria, Amsterdam II criteria, and Bethesda guidelines are the international diagnostic criteria for Lynch syndrome. Nursing care for patients with Lynch syndrome includes identifying patients who would benefit from genetic counseling, providing education, and assessing and meeting patient psychosocial needs.

Obtaining family histories from patients with cancer.

Information obtained from family history data can provide valuable insight into the biologic and environmental etiologies of an individual's personal and family history of disease. The purpose of this article is to provide a brief introduction to cancer genetics and discuss ways to obtain accurate family histories in a time-efficient manner to identify families with a hereditary cancer syndrome. The focus is on gathering family history information, which should be a standard component of the initial intake for any patient and updated regularly to keep the information current.

Short Functional Dependence Scale: development and pilot test in older adults with cancer.

The purpose of this study was to develop and pilot test an instrument, the Short Functional Dependence Scale (SFDS), to measure functional dependence in the older adult receiving cancer treatment. Patients from 2 oncology clinics affiliated with a teaching hospital participated in this descriptive, quantitative study. Participants consisted of older adults (N = 26; mean age 71, SD = 5; 54% female; 85% Caucasian) receiving chemotherapy intravenously for solid tumor cancer. Patients, nurses, oncologists, and social workers helped select instrument items and establish content validity. Measurements using the SFDS included baseline and follow-up visits. Data analysis included Cronbach alpha to determine internal consistency and repeated measures to evaluate SFDS scores and associated variables. Cronbach alpha ranged from 0.737 to 0.919 for the 12 items of the SFDS. Functional dependence increased with age, surgery, radiation therapy, and lower hemoglobin levels. Compared to participants with other types of cancer, participants with lung cancer were more dependent in basic activities of daily living, but participants with breast cancer had the highest degree of overall functional dependence. The SFDS has content validity and internal consistency. Pilot testing showed that the instrument performed well in differentiating the functional dependencies of patients receiving chemotherapy according to variables of interest.

An analysis of telephone interview data collected in 1992 from 820 women who reported problems with their breast implants to the food and drug administration.

How health care providers deal with concerns and feelings of women who have problems with their breast implants affects the women's satisfaction with their breast implants, yet in 1992 little was known about the concerns and feelings of these women. A qualitative analysis of in-depth telephone interviews conducted in 1992 with 820 women from all regions of the United States who reported problems with their breast implants to the Food and Drug Administration and responded to an invitation to be interviewed provided data. Respondents were primarily 40 to 69 years of age at the time of interview, Caucasian, married, and educated beyond high school. The sample was almost equally divided in reason for breast implants, with 65 percent being dissatisfied with their breast implants. Nearly all of the women had heard of problems with silicone gel-filled implants. Their main sources of information were television, newspapers, and magazines rather than their physicians or the breast implant manufacturers. Some women tried to avoid hearing the reports, and many tried to put the reported problems out of their minds. However, a majority (88.7 percent) wanted more information. The women expressed feelings of anger, regret, and worry, and repeatedly said they needed more information. Women who contacted the Food and Drug Administration about breast implant problems needed accurate and honest information from health care professionals. They wanted their physicians to explore their symptoms, fears, and concerns.

Exercise decisions within the context of multiple myeloma, transplant, and fatigue.

This constructivist (naturalistic) study explored the decision-making strategies of patients with multiple myeloma who were implementing a home-based exercise program intended to decrease cancer-related fatigue during therapy. A purposive nonprobability sample of 21 patients who were undergoing an aggressive tandem transplant protocol provided data through face-to-face and follow-up telephone interviews. Salient themes derived from the data through content analysis and constant comparison included intrinsic and extrinsic facilitators and barriers that influenced the participants' day-to-day decisions about exercise. Intrinsic factors that facilitated exercise adherence included a belief that exercise would be beneficial, a personal moral/ethical philosophy with regard to honoring a commitment and/or taking responsibility for one's health, and personal strategies such as keeping a routine and setting goals. Extrinsic facilitators included having a good support system and receiving prophylactic epoetin alfa. The experience of chemotherapy and related side effects were intrinsic barriers, while environmental factors such as weather, travel, and employment could be either facilitators or barriers. The delicate balance within the matrix of facilitators and barriers influenced participants' daily decisions about starting, interrupting, stopping, or resuming their workouts.

Symptom management and successful outpatient transplantation for patients with multiple myeloma.

This retrospective descriptive study compared symptoms and symptom management in patients who completed autologous peripheral blood stem cell transplantation without hospital admission with those of patients who required unplanned hospital admission during the transplantation period. The sample consisted of 87 patients with multiple myeloma treated as outpatients during a 16-month period. Medical records and electronic database records review for each patient provided data on patient characteristics, medical factors, and symptoms/symptom management. Neither age, gender, religion, payer source, treatment on or off protocol, nor positive blood culture made a difference in hospital admission. The percentage of outpatient visits that included documented teaching on self-care made a significant difference (P = .008). Longitudinal analyses of patients' documented symptoms before admission compared with nonadmitted patients captured changes over time in symptoms/symptoms management. Overall, the patients' symptoms were managed well. Significant differences were fatigue, measured as the percentage of usual energy (P = .017), and the amount of oral hydration in a 24-hour period (P < .001). Results call attention to the role that fatigue and the amount of oral hydration may have in unplanned hospital admissions and to the importance of teaching on self-care.

Feasibility of exercise during treatment for multiple myeloma.

Fatigue and insomnia are problems for patients with cancer. Research findings show that aerobic exercise decreases cancer-related fatigue. Because patients with cancer who have skeletal muscle wasting may not obtain maximum benefit from aerobic exercise training, exercise programs may need to include resistance training. Thus far, testing exercise as an intervention for fatigue has focused on patients with breast cancer and excluded patients with bone metastasis. There is a need to test the feasibility and effectiveness of exercise for patients with other types of cancer and with bone involvement. The effect of aerobic and strength resistance training on the sleep of patients with cancer has not been tested. A pilot/feasibility study with a randomized controlled design was conducted to investigate home-based exercise therapy for 24 patients receiving high-dose chemotherapy and autologous peripheral blood stem cell transplantation as treatment for multiple myeloma. None of the patients injured themselves. Because of the small sample size in the feasibility study, the effect of exercise on lean body weight was the only end point that obtained statistical significance. However, the results suggest that an individualized exercise program for patients receiving aggressive treatment for multiple myeloma is feasible and may be effective for decreasing fatigue and mood disturbance, and for improving sleep.

An evaluation of standardized patients in improving clinical breast examinations for military women.

There is a need to improve the quality of clinical breast examination (CBE) and breast cancer screening for women. The purpose of this study was to determine whether instructions from a standardized patient to military healthcare providers would increase the quality of CBE and breast cancer screening for military women. The study used a 2-group pretest and posttest experimental design with random assignment by study site. Before and after the intervention, the providers completed a 13-item survey to assess their current breast cancer screening practices and the standardized patient used an investigator-developed checklist to assess the providers' breast cancer screening performance. The survey of breast cancer screening practice scores and the interview and CBE performance scores were analyzed using analysis of covariance with the pretest scores as covariates. Results showed the experimental group made significantly more improvement than did the control group in their total scores on the observational checklist of interview and CBE skills (F = 19.18, P < .001, observed power = 0.99). In conclusion, this method of continuing education was effective with military healthcare providers.

Facilitating exercise adherence for patients with multiple myeloma.

Physical exercise is becoming an accepted part of therapy for many patients with cancer. Exercise may alleviate patients' fatigue and improve physical performance and psychological outlook. Much of the research is limited to women with breast cancer and excludes patients with bone metastases. This article reports on the authors' work in facilitating exercise adherence for patients with multiple myeloma (MM) and bone lesions while they were enrolled in a feasibility/pilot exercise study as they were receiving treatment for their disease in an outpatient treatment program. The exercise program for these patients receiving high-dose chemotherapy and stem cell transplantation consisted of aerobic and strength-building components. The program was home based, and patients performed exercises without direct supervision. On average, the patients completed the six-month exercise prescription 75% of the time. Overall trends showed that all 14 patients in the exercise group improved in several areas of testing, and the test results of all 10 patients in the usual-care group declined. Flexibility and simplicity are essential when designing exercise programs for patients, and encouragement and support also are needed to help patients adhere to prescribed exercise.

Developing and testing lay literature about breast cancer screening for African American women.

Written materials about breast cancer screening for African American women with low literacy skills are needed. Available materials were not at or below third-grade reading levels, were not culturally sensitive, and were not accurate in illustrating correct breast self-examination (BSE) techniques. Focus groups representing the target population helped the authors design a pamphlet describing how to perform BSE and a motivational picture book to help women overcome barriers to screening. The authors chose a food theme for the cover of the pamphlet written at a third-grade level and suggested a photographic version. In the motivational book, two women address barriers to screening and replace myths and fears with facts and actions. Data from 162 women showed that they learned from both the photographic and illustrated versions. Women in the photographic group found significantly more lumps in the silicone models, so the authors chose that version to use in final testing. Finally, nurses pretested a group of patients before they reviewed the materials and post-tested another group after they reviewed them. The group who had reviewed the materials had greater knowledge of and intent to follow the guidelines and received higher scores on BSE techniques.

Exploring measures of functional dependence in the older adult with cancer.

An aging population and increased incidence of cancer in older adults indicate the need to assess functional status within cancer treatment planning. This type of assessment could affect decisions about treatment options, nursing interventions, and community services for elders with cancer.

The dirty bomb: management of victims of radiological weapons.

A "dirty bomb," a conventional explosive packed with radioactive material, kills or injures through the initial blast and by airborne radiation and contamination. Adult-health nurses need an understanding of the consequences of blast injuries and radiation exposure, and the management of victims.

An overview of cancer in the older adult.

With the number of elders rising and the incidence of cancer increasing with age, a discussion of cancer in older adults is critical for medical-surgical nurses. An understanding of how aging affects cancer incidence, etiology, biology, diagnosis, treatment, and patient response will help medical-surgical nurses provide quality, comprehensive care to elders with cancer. This includes the ability to assess age-related limitations and initiate intervention strategies as appropriate for older adults with cancer.

Personal financial effects of multiple myeloma and its treatment.

BACKGROUND: Improvements in some treatment programs for multiple myeloma (MM) are increasing survival. As patients live longer with MM as a chronic disease, the personal financial effects of MM treatment become a serious concern. OBJECTIVE: The objective of this study was to identify the personal financial effects of MM and its treatment in 5 areas: employment, disability, health/medical and life insurance, retirement, and out-of-pocket expenses. METHODS: We mailed a questionnaire about financial issues to 1015 patients who had received intensive treatment for MM at the study site. Data analysis included descriptive statistics and comparisons using independent t tests. RESULTS: Our sample (n = 762; mean age, 61 [SD, 9.26] years) experienced issues with employment (66% employed at diagnosis and treatment; 33% employed at questionnaire time), disability (35% applied), health/medical and life insurance (29% lost coverage and 8% changed coverage), retirement (13% retired during treatment), and out-of-pocket expenses (36% of income in first treatment year and 28% of income during most recent 12 months). CONCLUSIONS: Issues of employment, disability, health insurance, retirement, and out-of-pocket costs for treatment are major challenges for patients. IMPLICATIONS FOR PRACTICE: In the midst of assessing physical needs during clinical trials for chemotherapy and stem cell transplants, healthcare providers must keep sight of patients' personal financial needs so that we can intervene promptly with referrals to social work, rehabilitation therapy, and other healthcare professions to help patients decrease the personal financial effects of MM and its treatment.