Reflections on the Past Decade in Evidence-Based Practice Within the Children's Oncology Group.

Background: The Children's Oncology Group (COG) is the only National Cancer Institute-supported clinical trials organization focused exclusively on childhood and adolescent cancer research. The COG Nursing Discipline Committee has embedded the tenets of evidence-based practice (EBP) into clinical trials nursing in order to standardize the nursing care delivered to children enrolled on these trials. The COG nursing EBP initiative is aimed at developing evidence-based clinical resources and tools to provide guidance to clinicians regarding topics relevant to the provision of cancer treatment for patients enrolled on COG clinical trials from diagnosis through survivorship. A rigorous, evidence-based process designed to guide development of the evidence-based clinical tools and resources within the COG nursing discipline was developed and was implemented with the first nurse expert team beginning in 2012. Method: The standardized process included (a) selecting EBP projects and nursing expert teams (NETs), (b) providing leadership, mentoring, and championship for NETs; (c) approving clinical content developed through the NETs; and (d) providing guidance and oversight over planned dissemination of the COG EBP projects. Results: The COG Nursing EBP Subcommittee has developed 15 publications to date that include 90 authors. Eleven of these authors contributed to multiple publications. Discussion: On this 10th anniversary of the development of the EBP within the COG nursing discipline, we recognize its contributions to the professional growth of many of the discipline's members and to advances in nursing care for children enrolled in pediatric cancer clinical trials.

Evidence-Based Recommendations for Education Provided to Patients and Families Regarding the Adverse Events of ALK and MEK Inhibitors: A Systematic Review From the Children's Oncology Group.

Background: Pediatric oncology patients receive multiple modalities of therapy to treat their malignancies. These modalities have the potential for acute toxicity and late effects. In the last decade, a new modality known as targeted biological therapy, has become an integral part of treatment for pediatric cancers. As targeted therapy use has increased, adverse events specific to these targeted agents have emerged, requiring a new effort focused on providing education to patients and families regarding how best to report, monitor, and manage these adverse events. Method: A clinical question was developed to guide the systematic literature review. Anaplastic lymphoma kinase (ALK) and mitogen-activated protein kinase kinase (MEK) inhibitors were selected for review due to their frequency of use in pediatric oncology. The search was conducted to identify relevant articles published between January 1, 2000 and May 5, 2020. Articles were screened by two team members for inclusion/exclusion criteria using the web-based systematic review tool, Rayyan. Results: Twenty-seven articles met the eligibility criteria for inclusion and were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation criteria. Adverse events for ALK and MEK inhibitors included manifestations of the gastrointestinal, hematologic, dermatologic, musculoskeletal, neurological, cardiovascular, and ocular systems. Recommendations for patient/family education were made for ALK and MEK inhibitors based on the reported adverse events. Conclusions: Adverse events of ALK and MEK inhibitors differ from the more common adverse events experienced with conventional treatment modalities used in pediatric oncology. It is important for nurses to include information regarding potential adverse events in patient/family education for children receiving these targeted agents.

Feasibility of a universal suicidality tool for adolescents.

BACKGROUND: The suicide rate among adolescents has been increasing rapidly over the past several years. LOCAL PROBLEM: Adequate screening for suicide risk in this population, particularly youth of color, is lacking. METHODS: The Ask Suicide-Screening Questions (ASQ) tool was implemented at two adolescent-focused health clinics in a large U.S. city. INTERVENTIONS: This project followed the Ottawa Model of Research Use. Participating clinicians were surveyed before and after receiving an educational module on suicide risk screening, the ASQ tool, and clinical pathways. Clinicians were also asked about the feasibility and acceptability of the ASQ tool in their practice. An electronic medical records software was used to gather data on patients newly screened for suicide risk using the ASQ tool. RESULTS: Among eligible patients, 40.2% were screened using the ASQ tool during the 4-month duration of the project. Most clinicians reported that using the tool was feasible within their practice (66%) and 100% endorsed its acceptability (i.e., reporting that they were comfortable screening for suicide and that the ASQ was easy to use). CONCLUSIONS: The ASQ may be a promising screening tool for clinicians to use to address the mental health needs of at-risk youth. This project supports the universal acceptability and feasibility of its use in inner-city primary care clinics.

Facilitating and Implementing a Process for the Delivery of Pediatric Oncology New Diagnosis Education Among Nursing Staff Through the Electronic Medical Record.

Background: An estimated 11,060 children between the ages of 1 and 14 years and 4,900 adolescents between the ages of 15 and 19 years are diagnosed with cancer in the United States. Parents with children newly diagnosed with cancer must acquire new knowledge related to the diagnosis, treatment plan, psychosocial care, and home management therapies to safely provide care following discharge. Expert consensus and review of current evidence demonstrate that utilizing a new diagnosis education checklist allows the delivery of essential information to patients and caregivers. The checklist divides educational topics into three sections: primary, secondary, and tertiary topics. This project followed the completion of an evidence-based fellowship through Children's Oncology Group focusing upon the feasibility and efficacy of implementing a standardized new diagnosis education checklist. The fellowship identified secondary topic documentation and an electronic medical record (EMR) checklist as areas of future work. Methods: This quality improvement project focused upon nursing staffs' documentation of secondary topics and the development/utilization of an EMR checklist. A pre-post survey design evaluated the outcomes of secondary topic documentation and EMR checklist implementation. Results: This nurse-led initiative created templates for primary and secondary topic checklists using Epic's SmartPhrase feature ".PHOPTED1" and ".PHOPTED2." Secondary topic completion and documentation increased 26% following implementation, and over 40% of the nursing staff indicated that they were very likely to continue to use the new templates. Discussion: Project templates are readily applicable to institutions that utilize Epic. Template examples and strategies to facilitate inpatient/outpatient checklist completion are discussed.

Long-term effects of spasticity treatment, including selective dorsal rhizotomy, for individuals with cerebral palsy.

AIM: To understand the long-term effects of comprehensive spasticity treatment, including selective dorsal rhizotomy (SDR), on individuals with spastic cerebral palsy. METHOD: This was a pre-registered, multicenter, retrospectively matched cohort study. Children were matched on age range and spasticity at baseline. Children at one center underwent spasticity treatment including SDR (Yes-SDR, n=35) and antispastic injections. Children at two other centers had no SDR (No-SDR, n=40 total) and limited antispastic injections. All underwent subsequent orthopedic treatment. Participants returned for comprehensive long-term assessment (age ≥21y, follow-up ≥10y). Assessment included spasticity, contracture, bony alignment, strength, gait, walking energy, function, pain, stiffness, participation, and quality of life. RESULTS: Spasticity was effectively reduced at long-term assessment in the Yes-SDR group and was unchanged in the No-SDR group. There were no meaningful differences between the groups in any measure except the Gait Deviation Index (Yes-SDR + 11 vs No-SDR + 5) and walking speed (Yes-SDR unchanged, No-SDR declined 25%). The Yes-SDR group underwent more subsequent orthopedic surgery (11.9 vs 9.7 per individual) and antispastic injections to the lower limbs (14.4 vs <3, by design). INTERPRETATION: Untreated spasticity does not cause meaningful impairments in young adulthood at the level of pathophysiology, function, or quality of life.

Evidence-Based Recommendations for Nurse Monitoring and Management of Immunotherapy-Induced Cytokine Release Syndrome: A Systematic Review from the Children's Oncology Group.

Children with B-precursor acute lymphoblastic leukemia and B-cell lymphoma, particularly those with relapsed or refractory disease, are increasingly enrolled on phase II and phase III clinical trials studying immunotherapies. These therapeutic agents may be associated with a high risk of cytokine release syndrome (CRS), and nurses lack standardized guidelines for monitoring and managing patients with CRS. Six studies and one clinical practice guideline were included in this systematic review that examined the evidence of CRS following administration of chimeric antigen receptor T-cell therapy or the bi-specific T-cell engager antibody, blinatumomab. Six nursing practice recommendations (five strong, one weak) were developed based on low or very low-quality evidence: three reflect preinfusion monitoring, one focuses on monitoring during and postinfusion, and three pertain to the nurse's role in CRS management.

Long-term functional outcomes after an external femoral derotation osteotomy in individuals with cerebral palsy.

BACKGROUND: It is unknown how a femoral derotation osteotomy (FDO) during childhood affects functional outcomes in adulthood among individuals with bilateral cerebral palsy (CP). RESEARCH QUESTIONS: How do long-term functional outcomes after an FDO compare to matched individuals who did not have an FDO? How do outcomes change over time? METHODS: We queried the gait laboratory database for individuals who underwent an external FDO in childhood and were currently ≥25 years old. Participants returned for a long-term analysis (gait, physical examination, functional tests, imaging, questionnaires). The matched non-FDO group included only individuals in Gross Motor Function Classification System levels I-II, yielding three groups (non-FDO I-II, FDO I-II, FDO III-IV). RESULTS: Sixty-one adults (11 non-FDO, 34 FDO I-II, 16 FDO III-IV) returned 13-25 years after baseline (non-FDO) or surgery (FDO). The non-FDO and FDO I-II groups were matched at baseline on most variables, except the FDO group had weaker hip abductors. At long-term, groups were similar on gait variables (median long-term hip rotation [primary outcome], non-FDO: -4°, FDO I-II: -4°, FDO III-IV: -5°), hip abduction test, fear of falling, and most pain measures despite anteversion being 29° greater in the non-FDO group. The FDO I-II group reported more falls than the non-FDO group. All groups improved on hip rotation, foot progression, and hip abductor strength. Speed and step length decreased/tended to decrease for all three groups. Hip abduction moment and gait deviation index did not change. Improvements in the FDO groups were maintained from short- to long-term. SIGNIFICANCE: These results challenge the notion that an FDO is necessary to correct mean stance hip rotation for higher functioning individuals since nearly identical results were achieved by adulthood in the non-FDO I-II group. However, an FDO provides improvement earlier and maintenance from short- to long-term. This should factor into the shared decision-making process.

Implementing and Evaluating a Standardized New Diagnosis Education Checklist: A Report From the Children's Oncology Group.

When a child is newly diagnosed with cancer, parents report feeling overwhelmed with the amount of information that they must process in order to safely care for their child at home. The Children's Oncology Group (COG) Nursing Discipline has focused on examining current practices for educating families of children newly diagnosed with cancer, and developing tools to enhance the process of patient/family education at the time of diagnosis, including development of a COG Standardized Education Checklist, which classifies education into primary, secondary, and tertiary topics. The COG Nursing Discipline awarded nursing fellowships to two doctorally prepared nurses practicing at two distinct COG institutions to evaluate the checklist implementation. This project addressed the primary topics on the checklist essential to safely care for the child at home following the first hospital discharge. Checklist feasibility was determined by the proportion of checklists completed. Checklist fidelity was determined by review of documentation on the checklist regarding educational topics covered, learner preferences, and methods used. Checklist acceptability was assessed through parent/caregiver and nurse feedback. Project implementation occurred over a 5-month period and involved 69 newly diagnosed families. Implementation of the checklist was feasible (81%), with moderate fidelity to checklist topics taught across the two sites. Verbal instruction and written documentation were the most prevalent form of education. The return rate for the parent/caregiver and nurse acceptability questionnaires was moderate to low (68% and 12%, respectively), parent/caregiver feedback was positive and acceptability among responding nurses was high, with 92% of nurses identifying the primary checklist as useful.

Commonly Reported Adverse Events Associated With Pediatric Immunotherapy: A Systematic Review From the Children's Oncology Group

BACKGROUND: Immunotherapy is a new and promising approach to treating pediatric cancers. These types of therapies have unique mechanisms of action for identifying and fighting cancer, as compared with traditional chemotherapy, and therefore are associated with different therapy-related adverse events (AEs). The purpose of this systematic review was to review available evidence to: (a) identify commonly reported AEs associated with immunotherapy agents frequently used in pediatric oncology and (b) generate recommendations for nursing practice. METHOD: A clinical question was developed and used to guide the systematic literature review. Five immunotherapy agents (dinutuximab, blinatumomab, rituximab, inotuzumab ozogamicin, brentuximab vedotin) were selected for inclusion secondary to their high relevance to pediatric oncology. A literature search was conducted to locate articles published between January 1, 2003 and October 31, 2018. RESULTS: Seventeen articles met eligibility criteria for inclusion and were evaluated using the Grading of Recommendations Assessment, Development, and Evaluation criteria. The most commonly reported AEs for the selected immunotherapy agents were identified and summarized. Strong recommendations are made for nurses to become familiar with the unique AE profiles associated with individual immunotherapy agents. Agent-specific recommendations for nursing practice regarding AEs associated with dinutuximab and rituximab were generated. CONCLUSIONS: Immunotherapy is rapidly emerging as an effective therapy for pediatric cancers. Nurses need to be aware of the breadth of agent-specific, immunotherapy-related AEs to appropriately monitor and manage patients receiving these therapies. Additional work is needed to confidently profile immunotherapy-related AEs in pediatric oncology and to develop agent-specific educational materials for patients/families.

Alcohol use is not a significant contributor to myelodysplastic syndromes.

PURPOSE: Myelodysplastic syndromes (MDS) are a class of clonal neoplastic disorders of largely unknown etiology, and published data remain inconclusive regarding the association between lifetime alcohol consumption and MDS risk. In these analyses, data from a population-based case-control study were used to investigate this association. METHODS: Eligible cases of MDS were identified through the Minnesota Cancer Reporting System; controls were matched by sex and age-decile. A central review process was used to confirm MDS diagnosis and classify subtypes. Unconditional and polytomous logistic regression were used to calculate odds ratios (OR) and 95% confidence intervals (CI). Kaplan-Meier curves were used to compare survival by category of lifetime alcohol consumption. RESULTS: In total, 398 cases of MDS and 698 controls were included. Alcohol consumption at 23-30, 31-49, and 50-65 years of age, recent consumption 1 year before diagnosis/interview, and lifetime consumption were not found to be significantly associated with MDS in males (OR range 0.63-0.99) or females (OR range 0.58-1.70). Analysis by MDS subtype further suggested there was not a significant association between recent alcohol consumption and odds of disease by subtype (OR range 0.39-1.13). Lifetime alcohol consumption was not significantly associated with survival after diagnosis of MDS CONCLUSIONS: Previously reported associations between alcohol consumption and MDS risk were inconsistent. Results from our analyses by sex and disease subtype do not support alcohol as a significant contributor to risk of MDS.

Evidence-Based Recommendations for the Appropriate Level of Sedation to Manage Pain in Pediatric Oncology Patients Requiring Procedures: A Systematic Review From the Children's Oncology Group [Formula: see text].

Repeated invasive and painful procedures are often necessary components of pediatric cancer treatment. Adequate pain control during procedures is essential; however, procedure-related pain may be underestimated and undertreated. Currently, there is not a standard approach for the appropriate level of sedation to manage procedure-related pain in children with cancer. A team was assembled to review the evidence and develop recommendations to determine the appropriate level of sedation necessary for pain control in patients undergoing pediatric oncology procedures. After a systematic search of the literature, 15 research-based articles were synthesized and critically appraised. A recommendation was made related to the level of sedation utilized for bone marrow aspirates and bone marrow biopsies. There is a need for further research related to the necessary level of sedation for patients undergoing pediatric oncology procedures.

Perspectives on Cancer Pain Assessment and Management in Children.

OBJECTIVE: To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer. DATA SOURCES: Published research and clinical guidelines. CONCLUSION: Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management. IMPLICATIONS FOR NURSING PRACTICE: Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.

Implementation of a Survivorship Care Plan Program in a Community-Based Oncology Clinic.

There is conflicting evidence from the small number of randomized controlled trials (RCTs) that have assessed the benefit of survivorship care plans (SCPs) on improving patient outcomes. Yet, published quasi-experimental and descriptive studies provide preliminary evidence suggesting that using survivorship care plans in practice may improve patient knowledge, decrease worry and anxiety, and lead to patient and primary care physician satisfaction. Given the conflicting evidence and the paucity of RCTs, further research is needed to more fully explore the effect of SCP on patient outcomes. To address this knowledge gap, an SCP program was implemented in a community-based oncology clinic and used quality improvement methodology to assess the effect on patient knowledge of diagnosis, treatment, and follow-up, and to understand patients' satisfaction with the current SCP program. A total of 30 cancer patients were recruited in Southeast Michigan to participate in an SCP quality improvement project and completed surveys to evaluate the SCP program. Data were collected between December 2017 and March 2018. We observed a statistically significant (p = .028) difference between pre- and postintervention (survivorship care plan visit) knowledge scores about cancer diagnosis, treatment received, and follow-up recommendations. Moreover, participants were satisfied with the survivorship care plan and visit.

Nephrotoxicity: Evidence in Patients Receiving Cisplatin Therapy

BACKGROUND: Cisplatin has been used as a chemotherapeutic agent to treat many different cancers. A well-known side effect of cisplatin is nephrotoxicity, which is the primary dose-limiting toxicity. Hydration in conjunction with appropriate diuresis can decrease the incidence of nephrotoxicity. OBJECTIVES: This article aims to identify best practices in supportive therapy for patients receiving cisplatin therapy. METHODS: A team was assembled to review research-based evidence and summarize recommendations to address appropriate hydration regimens and forced diuresis for patients receiving cisplatin chemotherapy. FINDINGS: After a systematic search of the literature, only one pediatric study was found. The remaining 22 research-based studies of adults were synthesized and critically appraised. Hydration is necessary to prevent nephrotoxicity with cisplatin administration. In addition, the administration of magnesium and mannitol may assist in maintaining renal function and reducing nephrotoxicity in adults receiving cisplatin. Additional research is needed to evaluate outcomes of these interventions in the pediatric population.

Implementing a Daily Maintenance Care Bundle to Prevent Central Line-Associated Bloodstream Infections in Pediatric Oncology Patients.

Eliminating central line-associated bloodstream infection (CLABSI) is a national priority. Central venous catheter (CVC) care bundles are composed of a series of interventions that, when used together, are effective in preventing CLABSI. A CVC daily maintenance care bundle includes procedural guidelines for hygiene, dressing changes, and access as well as specific timeframes. Failure to complete one of the components of the care bundle predisposes the patient to a bloodstream infection. A nurse-led multidisciplinary team implemented and, for six months, sustained a daily maintenance care bundle for pediatric oncology patients. This quality improvement project focused on nursing staffs' implementation of the daily maintenance care bundle and the sustainment of the intervention. The project used a pre-post program design to evaluate outcomes of CVC daily maintenance care bundle compliancy and CLABSI. A statistically significant increase between the pre- and post-assessments of the compliance was noted with the CVC daily maintenance care bundle. CLABSI infection rates decreased during the intervention. Strategies to implement practice change and promote sustainability are discussed.

Nonhatching Decapsulated Artemia Cysts As a Replacement to Artemia Nauplii in Juvenile and Adult Zebrafish Culture.

Feeding Artemia nauplii as the main nutrition source for zebrafish is a common practice for many research facilities. Culturing live feed can be time-consuming and requires additional equipment to be purchased, maintained, and cleaned. Nonhatching decapsulated Artemia cysts (decaps) are a commercially available product that can be fed directly to fish. Several other ornamental fish species have been successfully cultured using decaps. Replacing Artemia nauplii with decaps could reduce the overall time and costs associated with the operation of a zebrafish facility. The objective of this study was to determine if decaps could be a suitable replacement to Artemia nauplii in juvenile and adult zebrafish culture. Wild-type zebrafish were fed one of three dietary treatments: decaps only, nauplii only, or a standard consisting of nauplii plus a commercially prepared pellet food. Survival, growth (length and weight), and embryo production were analyzed between the treatments. Fish receiving the decap diet demonstrated a significantly higher growth and embryo production when compared to the fish receiving the nauplii-only diet. When comparing the decap fish to the standard fish, no significant difference was found in mean survival, mean weight at 90 days postfertilization, or mean embryo production. It was determined that nonhatching decapsulated Artemia cysts can be used as a suitable replacement to Artemia nauplii in juvenile and adult zebrafish culture.