Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management.

PURPOSE: To evaluate oncology outpatients' level of adherence to their analgesic regimen during a 5-week period. PATIENTS AND METHODS: A random sample of 65 adult oncology outpatients with a Karnofsky performance status score of >or= 50, an average pain intensity score of >or= 2.5, and radiographic evidence of bone metastasis were recruited for this longitudinal study from seven outpatient settings. On a daily basis, patients rated their level of pain intensity and recorded pain medication intake. Adherence rates for opioid analgesics prescribed on an around-the-clock (ATC) and on an as-needed (PRN) basis were calculated on a weekly basis. RESULTS: Overall adherence rates for ATC opioid analgesics ranged from 84.5% to 90.8% and, for PRN analgesics, from 22.2% to 26.6%. No significant differences over time were found in either of these adherence rates. CONCLUSION: One factor that seems to contribute to ineffective cancer pain management is poor adherence to the analgesic regimen.

Suspected malignant hyperthermia in a strabismus patient. A case report.

Malignant hyperthermia is an autosomal dominant disorder with variable expressivity that is caused by a membrane defect in the sarcolemma of myofibrils. A patient with strabismus (esotropia) had tachycardia and masseter muscle rigidity on exposure to succinylcholine chloride and halothane, but because of rapid recognition of the condition and discontinuation of the procedure, the potentially lethal complications of malignant hyperthermia did not develop. A serum creatine phosphokinase level showed a substantial increase above normal. Two weeks later, the patient underwent successful correction of the strabismus under general anesthesia, using morphine sulfate and thiopental sodium without complication. This condition is of interest to ophthalmologists because it occurs with increasing frequency in patients with strabismus and ptosis, and it may be triggered by certain local anesthetic agents often used by ophthalmologists.

Adult cystinosis. A case report.

A 41-year-old man, referred because of the suspicion of retinal detachment, was found to have retinoschisis, moderately severe renal disease, and adult cystinosis with crystals in the cornea and conjunctiva. Conjunctival crystals were demonstrated by light and electron microscopy, and chemical analysis confirmed the presence of excessive amounts of cystine. Studies of renal tissue showed changes that were interpreted as being due to hypertensive vascular disease. Light and electron microscopic examination of kidney tissue showed no cystine crystals, and chemical analysis indicated only trace amounts of cystine.

Post-mortem analysis of samples from a human victim of a fatal poisoning caused by the xanthid crab, Zosimus aeneus.

After ingestion of a specimen of the crab Zosimus aeneus (Xanthidae), an East Timorese adult male died within several hours. Xanthid crabs are known to harbour paralytic shellfish toxins (PSTs), tetrodotoxin and palytoxin. A post-mortem examination did not find any obvious pathological abnormalities. This absence of pathologies is more often associated with PSTs and tetrodotoxin intoxication. A second, yet uneaten specimen of Z. aeneus from the same meal, contained a significant amount of PSTs and these same toxins were identified in the gut contents, blood, liver and urine of the victim. Metabolism of the PSTs occurred with the ingested crab harbouring gonyautoxin 2, gonyautoxin 3 and saxitoxin (STX) whereas neoSTX, decarbamoylSTX and STX dominated the PSTs in the victim's urine. The PST composition in the gut contents, in both their identity and proportion, was intermediate between the eaten crab and the urine suggesting that toxin conversion commenced in the victim's gut. The dose consumed by the victim was calculated to be between 1 and 2 microg STX equivalents/kg based upon the concentration in the remains of the cooked crab. The victim's meal did not consist solely of the toxic crab eaten and the possibility of other food items acting in a synergistic manner with the consumed PSTs cannot be discounted.

Mood states of oncology outpatients: does pain make a difference?

The purposes of this study were to determine if there were significant differences in the mood states of oncology outpatients who had cancer-related pain and those who were pain free, and to evaluate the relationships between pain intensity and duration and mood states in those patients with pain. Two hundred (54.2%) patients experienced cancer-related pain during the previous month and 169 (45.8%) patients were pain free. Those patients who experienced cancer-related pain scored significantly higher on all of the subscale scores of the Profile of Mood States, except vigor, and had a significantly higher total mood disturbance (TMD) score than did pain-free patients. In addition, the subscale scores of tension, depression, anger, fatigue, confusion, and TMD scores were moderately correlated with increases in pain intensity. Also, depression, fatigue, confusion, and TMD scores were moderately correlated with increasing duration of pain. These data suggest that there is a relationship between pain and mood in oncology outpatients and that health-care professionals need to assess for mood disturbances in this population and develop appropriate treatment strategies.

A comparison of the affective state and quality of life of chemotherapy patients who do and do not develop chemotherapy-induced oral mucositis.

The purpose of this longitudinal study was to compare the quality of life and affective state of patients receiving chemotherapy who developed oral mucositis to patients who did not. Outpatients had their mouths assessed at the beginning of their chemotherapy, completed the Multidimensional Quality of Life scale, Cancer version (MQOLS-CA) and the Profile of Mood States (POMS). Patients again completed the MQOLS-CA and POMS if they developed mucositis during their three cycles (monthly), or if they did not and were exiting the study. Seventy-seven outpatients completed the study; 28 patients developed mucositis and 49 did not. The MQOLS-CA total scores for the entire sample decreased significantly over time (F(1,75) = 25.44, P < 0.001), but there was no group by time interaction, i.e., the change in MQOLS-CA total scores did not depend on mucositis status. While the POMS Total Mood Disturbance scores for the entire sample increased significantly over time (F(1,75) = 19.55, P < 0.001), there was a significant group by time interaction (F(1,75)= 4.85, P = 0.03). Patients who developed mucositis had a significant increase in mood disturbance compared to patients who did not. Further, the POMS subscales of depression and anger showed the same pattern of significant increases. In conclusion, the development of mucositis adversely affected the outpatients' affective states, but not their QOL.

Efficacy of proactive information on self-care in chemotherapy patients.

The purpose of this longitudinal experimental study was to test the efficacy of providing side effect management (SEM) information proactively for chemotherapy patients. The proactively experimental intervention consisted of presenting SEM information on all side effects the patient was susceptible to develop, prior to the development of any side effects. A control of like patients received the standard information provided in the setting. Sixty patients initiating chemotherapy (CT) were randomized into either the experimental or the control group. They recorded their experienced side effects of CT in their self-care behavior (SCB) logs. Measurements of state-trait anxiety (STAI) and locus of control occurred at the beginning and 6 weeks later. Patients receiving SEM proactively performed significantly higher scores on all of the SCB ratios and preventive activities. These patients did not initiate self-care with less delay or before the side effects became more severe than the control group patients. Performance status increased significantly for the experimental group patients between interviews (initial and 6 weeks). The findings are in contrast to a parallel study with radiation therapy patients and extend and enhance understanding of self-care practice.

Differences in nausea, vomiting, and retching between younger and older outpatients receiving cancer chemotherapy.

The purpose of this study was to determine whether there were differences in the side effects of nausea, vomiting, and retching (N, V, and R) between younger ( < 65 years, n = 102) and older ( > or = 65 years, n = 25) persons receiving outpatient chemotherapy. A longitudinal 4-month study was used for the 127 participants recruited from 18 settings. Participants completed two questionnaires (Inventory of N, V, and R and Behavior Checklist) over the course of the study. The pattern between the younger and older patients' N, V, and R subscale scores was consistent in that the younger patients' scores were consistently (except on one occasion) higher than the older patients' scores, but this difference was statistically insignificant. This study furthers our understanding of N, V, and R and has several clinical implications.

Comorbidity, nutritional intake, social support, weight, and functional status over time in older cancer patients receiving radiotherapy.

It is essential that nurses gain insight about the responses of older adults to standard anticancer therapies because there is ongoing concern about whether the elderly are affected adversely by the prescribed therapy. The purpose of this longitudinal prospective study was to describe selected outcomes and their relationships in a sample of 45 elderly (mean age 69.8 years; range 61-86) patients receiving radiotherapy for either breast (42%) or lung (58%) cancer. The outcome variables were weight and multidimensional functional status; moderator variables were co-morbidity, nutritional intake, estimated adequacy of intake, radiation dose, side effects, and social support. Data were collected at the beginning of radiation (T1), the middle of therapy (T2), the conclusion of therapy (T3), and three months post radiation (T4). Although 81.4% had some concurrent condition, those with a comorbid condition did not respond significantly differently from those without a comorbid condition on any of the major variables at any of the four times. At none of the four times was the caloric intake adequate to meet the estimated energy requirements for usual activity (range 67.9-71.5%). However, caloric intake was not significantly related to weight at any of the four times. There was a significant weight decrease from beginning of therapy to the middle of therapy and from the beginning of therapy to conclusion of therapy. The percentage of calories contributed by protein was significantly correlated with weight during radiotherapy, and protein calories consumed at the previous time were correlated with weight at T2 and T3. In contrast, the percentage of calories contributed by carbohydrate intake was significantly negatively correlated with two of the four functional status measures at each time, but was not related to weight. In addition carbohydrate calories consumed at the previous time also were related to one or more functional status measures at succeeding time points. Almost no relationships were found between social support and the outcome measures of weight and functional status. Scores on three of the four functional status measures suggest improvement over time from initiation of radiation to 3 months after therapy. Scores on the fourth measure, Overall Health Rating, suggest a slight decline; however, the average score reflects good overall health. These findings provide evidence that this group of elderly, the great majority of whom had at least one comorbid condition, tolerated the course of radiation with less than adequate intake for usual activity, a slight decrease in mean weight, but without major disruptions in functional status.(ABSTRACT TRUNCATED AT 400 WORDS)

The PRO-SELF Mouth Aware program: an effective approach for reducing chemotherapy-induced mucositis.

Many oncology patients receive chemotherapy drugs that have the potential to induce oral mucositis. If mucositis is not prevented, patients will have to manage the problems associated with mucositis: pain, local infection, and decreased ability to take fluids or food. At the time of this writing, clinical approaches for mucositis management are variable and generally ineffective. The mouth care program, PRO-SELF: Mouth Aware (PSMA), presented in this article, was found to be a significant component of a self-care program that may have reduced the incidence of chemotherapy-induced mucositis. The PSMA program has three dimensions: (a) didactic information, (b) development of self-care exercises (skills), and (c) supportive interactions with a nurse in the setting where the patients are receiving their treatment. This program focuses on decreasing the direct (i.e., incidence and severity of mucositis) and indirect morbidities of oral mucositis (i.e., number of local infections, level of discomfort/pain, and disruption in fluid and/or food intake). It provides the critical dimensions (i.e., specific information, self-care exercises, and nurse support) to promote the prevention of mucositis. The PSMA program is designed to provide patients with a definitive self-care repertoire to manage chemotherapy-induced mucositis in the home without the direct supervision of a health care provider.

The role of the oncology clinical nurse specialist in research.

Selected aspects of the role of the oncology clinical nurse specialist (OCNS) using the example of a randomized clinical trial are discussed in this paper. A conceptual framework for these aspects of the OCNS role is explicated at three levels of research involvement. Outcomes of this involvement are empiric testing of nursing interventions and demonstrating nursing's effectiveness.

Predictors of self-care: a test of Orem's model.

Despite advancements in self-care for people with cancer, a profile of individuals who perform self-care behaviors has not been determined. Without these data, interventions cannot be targeted to specific patient groups that demonstrate the most need. This study's investigators used Orem's model of self-care to determine predictors of self-care behavior. The sample consisted of 127 adults with cancer who were to receive their first dose of chemotherapy (e.g., doxorubicin, methotrexate, 5-fluorouracil, cyclophosphamide, or cisplatin, given alone or in combination). Data were collected from the subjects prior to the first cycle and at drug nadir for each of the four chemotherapy cycles. Potential predictors of self-care included demographic variables, performance status, affective state, social support, ability to manage a situation, self-care ability, and prior health-promoting activities. Self-care was measured using a 40-item behavior checklist. Multiple regression techniques were used to obtain four significant predictors of self-care, which accounted for 47% of the variance. Subjects with lower performance status, higher anxiety, less social support, and more education performed more self-care. These findings clarify Orem's model with this clinical population and provide a patient profile of self-care for practice.

Predicting self-care with patients and family members' affective states and family functioning.

People with cancer manage the side effects of treatment with the assistance of their family members. This study was designed to describe self-care behaviors (SCBs) initiated by patients and their family members and to determine the relationship between patients and family members' affective states and family functioning and SCBs. Using a longitudinal design, 42 patients and 40 family members were followed during 3 cycles of chemotherapy (12-16 weeks). The patients completed measures of affective state (POMS) each cycle; patients and family members completed a family functioning measure (F-COPES) at second cycle only; and the patients reported in an SCB log on an ongoing basis. The overall pattern of SCBs corroborated previous findings. The average number of SCBs initiated was 1.4 per side effect. Depression and vigor significantly predicted SCBs at Cycle 1 only. The severity of side effects consistently predicted SCB over the 3 cycles (r 2 = -0.39 to -0.46). Patients who experienced more severe side effects were at risk of diminished self-care.

The development and testing of a nursing model of morbidity in patients with cancer.

Although oncology nurses are concerned about patient morbidity associated with cancer and its treatment, a comprehensive morbidity model from the perspective of nursing has yet to be developed. The purpose of this study was to begin to develop a morbidity model relevant to patients with cancer receiving treatment in the ambulatory care setting. The model was empirically tested with a sample of 100 patients with cancer beginning chemotherapy. Three domains emerged from the model: physiologic/pathophysiologic, functional, and psychological. Indices of morbidity within each domain were tested to establish beginning reliability and validity of the model. The results that were obtained indicate significant correlations among many of the indices within each domain (e.g., performance status, mood disturbance, patients' ratings of their current health); other indices did not contribute significantly to the model (e.g., type of cancer, history of recurrent disease, and patients' assessments of their health prior to developing cancer). Although further testing and refinement of the model is indicated, these preliminary findings reflect the model's potential for significant clinical relevance. By using this model, nurses could more readily profile patients at risk for increased morbidity and target their interventions accordingly.

Symptom clusters and their effect on the functional status of patients with cancer.

PURPOSE/OBJECTIVES: To determine the effect of the symptom cluster of pain, fatigue, and sleep insufficiency on functional status during three cycles of chemotherapy. DESIGN: Prospective, longitudinal. SETTING: 23 outpatient offices and clinics. SAMPLE: 93 patients with cancer. The typical participant was female (72%), married/partnered (65%), white (87%), and middle-aged (55.4 years), with an average of 14.8 years of education. METHODS: The Quality of Life-Cancer (QOL-CA) version instrument and the Karnofsky Performance Scale (KPS) were completed by 93 outpatients receiving chemotherapy at baseline (Time 1) and at the end of the third cycle (Time 2). Three items (pain, tires easily, sleeps enough to meet needs) from the QOL-CA questionnaire were used to measure the symptom cluster. MAIN RESEARCH VARIABLES: Symptom cluster, outcome, functional status, chemotherapy. FINDINGS: A hierarchical multiple regression model explained 48.4% of the variance in functional status. The KPS at Time 1 explained 30.8% of the variance in KPS at Time 2 (p < 0.001). After KPS at Time 1 was partialled out from KPS at Time 2, the four independent variables entered in the next step were considered predictors of the change in functional status between Time 1 and Time 2. Age explained 11.8% of the change (p = 0.001), pain explained 10.7% of the change (p = 0.002), and fatigue explained 7.3% of the change (p = 0.011). Sleep insufficiency statistically was not significant, only explaining 1% of the change (p = 0.344). CONCLUSION: This study provides beginning insights into the effect of a symptom cluster on patients' functional status. IMPLICATIONS FOR NURSING PRACTICE: Healthcare professionals need to be aware of the presence of symptom clusters and their possible synergistic adverse effect on patients' future morbidity.

Family problems during cancer chemotherapy.

Although reports suggest that a cancer diagnosis affects all members of a family, limited descriptions are available of the types of problems families experience when a family member has cancer. Adult patients with cancer (n = 100) and their family members (n = 126) were interviewed in their homes at 1 1/2 weeks, 7 1/2 weeks, and 6 months following the initiation of chemotherapy. The Problem Centered Family Coping Interview, a semistructured tool with established content validity, was used to identify family problems that occurred in the previous month. Content analysis was performed on interviews using empirically based categories. Families reported from one to eight problems occurring in the previous month (mean = 3.4). Cancer-related health concerns accounted for 48%-52% of the problems identified at all three interviews. This study's findings enhance knowledge about the family's cancer experience.

The relationship of visual acuity, tactile sensitivity, and mobility of the upper extremities to proficient breast self-examination in women 65 and older.

The purpose of this study was to describe the relationship of visual acuity, tactile sensitivity, and mobility of the upper extremities to the performance of proficient breast self-examination (BSE) in women 65 and older. A convenience sample of 32 women, ages 66-89, met with the investigator to have their visual acuity, tactile sensitivity, and upper extremity mobility tested. Their ability to perform the visual, tactile, and upper extremity components of proficient BSE also was tested by using simulated breast models (SBMs). Thirty of the women had adequate visual acuity (< or = 20/40 Snellen equivalent) but were unable to visually detect the abnormalities on the SBM. Thirty of the women had tactile sensitivity of 10 mm (1 cm) or better on the static two-point discrimination test of the second, third, and fourth digits of each hand. Yet, only 13 of these women were able to locate the 1 cm lump; only 12 were able to locate the 5 mm lumps; and none were able to locate the 3 mm lump. The subjects' ability to pass the upper extremity mobility component of proficient BSE was significantly related to their ability to pass the upper extremity range of motion criteria. Limitations and deficits, mostly of the hands and shoulders, were revealed. When teaching BSE to older women, nurses are responsible for assessing limitations and deficits in their ability to perform proficient BSE and, if necessary, for intervening with alternatives. The need for further research in this area is indicated to improve assessment and education of older women regarding the use of proficient BSE for early detection of breast cancer.

Gender differences in the dimensions of quality of life.

PURPOSE/OBJECTIVES: To explore gender differences and similarities in the dimensions of quality of life (QOL). DESIGN: Secondary analysis of the Multidimensional Quality of Life Scale--Cancer Version (MQOLS--CA) data from two different research studies. SETTINGS: Multiple outpatient oncology sites. SAMPLE: The typical female participant (n = 254) was 58 years old (SD +/- 11.3) with 14 years of education, married/partnered (64%), Caucasian (88%), and diagnosed with breast (47%) or colorectal (16%) cancer. The typical male participant (n = 222) was 60 years old (SD +/- 14) with 14.3 years of education, married/partnered (69%), Caucasian (85%), and diagnosed with colorectal (31%) or prostate (13%) cancer. METHODS: Factor analytic procedures and reliability testing. MAIN RESEARCH VARIABLES: QOL as measured by the MQOLS-CA, gender. FINDINGS: For women, two factors emerged from the analysis procedures-psychosocial well-being (7 items) and physical competence (6 items). For the men, two different factors emerged--vitality (8 items) and personal resources (4 items). None of the cancer-specific items from the MQOLS-CA loaded on any of the factors for either gender. CONCLUSIONS: Measurement of QOL requires gender-specific questions to accurately address the dimensions of the concept of QOL in females and males. IMPLICATIONS FOR NURSING PRACTICE: Additional research is warranted to replicate these findings. Gender-specific interventions could then be developed and tested to maximize the QOL of all patients.

Influence of age on problems experienced by patients with lung cancer undergoing radiation therapy.

The purpose of this prospective, longitudinal study was to determine if patients with lung cancer who are 65 years of age or older experience problems differently than do patients younger than age 65 during and following radiation treatment. The moderator and outcome variables selected for study were recognized attendant problems that may develop during lung cancer treatment and that may influence the treatment regimen and response. No statistically significant differences were found between patients age 65 or older and those younger than age 65 on caloric intake, adequacy of energy intake, total radiation dose, concurrent illnesses, and social support at any of four data-collection periods. Similarly, there were no significant differences on weight, body mass index, and multidimensional functional status. The relationship between the social support subscales and functional status measures for the 65-or-older group suggested that those subjects with lower social support perceived themselves to have better functional status. There was no relationship between social support and two functional status measures for the under-65 group. The significant relationships between social support and the overall health rating were in opposite directions for the two age groups. The results suggest that chronologic age alone may not be a sufficient criterion to determine therapeutic regimen or to suggest that unique problems may result.

Informed consent: process and clinical issues.

PURPOSE/OBJECTIVES: To review the issues related to informed consent in a clinical cancer care setting and suggest strategies to improve the informed consent process. DATA SOURCES: Published books, journal articles, and clinical research experience. DATA SYNTHESIS: Clinicians and researchers are ethically obligated to maintain the informed consent process when treating participants in clinical cancer research. Nurse clinicians, clinical trial nurses, and nurse researchers often encounter dilemmas while ensuring proper informed consent. Nurses involved in pediatric cancer care must address specific consent issues relevant to children and youth. CONCLUSIONS: Informed consent does not end with a patient's signature on a form. Establishing and maintaining informed consent is a multidisciplinary effort in cancer clinical trials. Nurses can improve the informed consent process by ensuring adequate time for patient consideration and understanding and by reassessing consent during the study. IMPLICATIONS FOR NURSING PRACTICE: Clinical trial nurses and nurse investigators in both adult and pediatric oncology have a duty and obligation to maintain continued informed consent throughout a study and to be involved in all aspects of study planning and implementation.