Prophylactic recombinant erythropoietin therapy and thalidomide are predictors of venous thromboembolism in patients with multiple myeloma: limited effectiveness of thromboprophylaxis.

BACKGROUND: Venous thromboembolism (VTE) is a significant but poorly understood complication in patients with newly diagnosed multiple myeloma (NDMM). As a result, most patients receive thromboprophylaxis with low molecular weight heparin (LMWH). The purpose of this retrospective study was to identify risk factors for VTE in NDMM and evaluate the effectiveness of LMWH. METHODS: A total of 604 patients with newly diagnosed myeloma completed 3 induction cycles with multiagent chemotherapy with up-front randomization to thalidomide between 1998 and 2004. Prophylactic enoxaparin was given to thalidomide recipients beginning in June 2001, and 122 subjects received prophylactic epoetin alfa (EPO) as part of an exercise trial. The primary study endpoint was grades 3-4 VTE. RESULTS: A total of 72 patients (11.9%) developed VTE (mostly deep venous thrombosis), with a higher incidence among EPO recipients (P = .001), although only significant for upper extremity DVT (P = .0002). The EPO-treated patients had higher hemoglobin (Hb) levels throughout the study (P < .0005), although no relationship between higher Hb levels and increasing incidence of VTE could be shown. A history of VTE was a strong predictor of VTE on univariate analysis (P < .000005). Enoxaparin did not reduce the rate of VTE (P = .158). Logistic regression analysis identified thalidomide therapy (P = .001; odds ratio [OR], 2.428; 95% confidence interval [CI], 1.418-4.159) and prophylactic EPO (P = .002; OR, 2.488; 95% CI, 1.432-4.324) as risk factors for VTE. Myeloma response and survival were not negatively affected by prophylactic EPO or VTE. CONCLUSIONS: Prophylactic EPO, thalidomide therapy, and VTE history, but not higher Hb levels, were found to increase the risk of VTE among NDMM patients receiving multiagent chemotherapy. This risk was not found to be reduced in this population by LMWH thromboprophylaxis.

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.

Back to basics: assessment, communication, caring, and follow-up: a lesson from a couple's journey with multiple myeloma.

Ian was a patient with multiple myeloma. His wife, Judi, chronicled their journey and experiences with myeloma and the healthcare system. Through her own eyes, Judi provides a view of the positive and negative consequences of actions or omissions by the healthcare team. The other authors, oncology nurses affiliated with a myeloma treatment center, collaborated with Judi to tell her story and remind oncology nurses that they can and do make a difference when focus is placed on the basics: assessment, communication, caring, and follow-up.

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.

Effects of exercise on fatigue, sleep, and performance: a randomized trial.

PURPOSE/OBJECTIVES: To compare usual care with a home-based individualized exercise program (HBIEP) in patients receiving intensive treatment for multiple myeloma (MM)and epoetin alfa therapy. DESIGN: Randomized trial with repeated measures of two groups (one experimental and one control) and an approximate 15-week experimental period. SETTING: Outpatient setting of the Myeloma Institute for Research and Therapy at the Rockfellow Cancer Center at the University of Arkansas for Medical Sciences. SAMPLE: 187 patients with newly diagnosed MM enrolled in a separate study evaluating effectiveness of the Total Therapy regimen, with or without thalidomide. METHODS: Measurements included the Profile of Mood States fatigue scale, Functional Assessment of Cancer Therapy-Fatigue, ActiGraph® recordings, 6-Minute Walk Test, and hemoglobin levels at baseline and before and after stem cell collection. Descriptive statistics were used to compare demographics and treatment effects, and repeated measures analysis of variance was used to determine effects of HBIEP. MAIN RESEARCH VARIABLES: Fatigue, nighttime sleep, performance (aerobic capacity) as dependent or outcome measures, and HBIEP combining strength building and aerobic exercise as the independent variable. FINDINGS: Both groups were equivalent for age, gender, race, receipt of thalidomide, hemoglobin levels, and type of treatment regimen for MM. No statistically significant differences existed among the experimental and control groups for fatigue, sleep, or performance (aerobic capacity). Statistically significant differences (p < 0.05) were found in each of the study outcomes for all patients as treatment progressed and patients experienced more fatigue and poorer nighttime sleep and performance (aerobic capacity). CONCLUSIONS: The effect of exercise seemed to be minimal on decreasing fatigue, improving sleep, and improving performance (aerobic capacity). IMPLICATIONS FOR NURSING: Exercise is safe and has physiologic benefits for patients undergoing MM treatment; exercise combined with epoetin alfa helped alleviate anemia.

Fatigue, sleep, pain, mood, and performance status in patients with multiple myeloma.

BACKGROUND: Cancer-related fatigue and insomnia are common distressing symptoms and may affect mood and performance status. OBJECTIVE: The objective of this study was to describe fatigue, sleep, pain, mood, and performance status and the relationships among these variables in 187 patients with newly diagnosed multiple myeloma (MM) and conduct an analysis using the correlates of fatigue. METHODS: Data were from baseline measures from the study, using the Profile of Mood States and the Functional Assessment of Cancer Therapy-Fatigue to assess fatigue, the actigraph to measure sleep, the Wong/Baker Faces Pain Rating Scale to assess pain, the Profile of Mood States to assess mood, and the 6-minute walk test along with a back/leg/chest dynamometer to test muscle strength to assess performance status. Data analysis consisted of descriptive statistics, Pearson and Spearman ρ correlations, and multiple regression analysis using fatigue as the dependent variable. All P values were 2-sided, and P<.05 was considered significant. RESULTS: Patients with newly diagnosed MM presented with fatigue, pain, sleep and mood disturbances, and diminished functional performance. The regression model, which included all of these variables along with age, sex, and stage of disease, was statistically significant with a large measure of effect. Mood was a significant individual contributor to the model. CONCLUSIONS: Among patients with MM, fatigue, pain, sleep, mood, and functional performance are interrelated. IMPLICATIONS FOR PRACTICE: Interventions are needed to decrease fatigue and pain and to improve sleep, mood, and functional performance.

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.

Effects of exercise in combination with epoetin alfa during high-dose chemotherapy and autologous peripheral blood stem cell transplantation for multiple myeloma.

PURPOSE/OBJECTIVES: To determine the effect of aerobic and strength resistance training and epoetin alfa (EPO) therapy on transfusions, stem cell collections, transplantation recovery, and multiple myeloma treatment response. DESIGN: Randomized clinical trial. SETTING: A myeloma research and therapy center in the south central United States. SAMPLE: 135 patients with multiple myeloma, 120 evaluable. METHODS: Random assignment to exercise or usual care groups. All patients received EPO based on an algorithm. Aerobic capacity, using the six-minute walk test, was assessed prior to induction chemotherapy, prior to stem cell mobilization, and following stem cell collection for all patients and before and after transplantation for patients continuing in the study. Data analysis included analysis of variance to compare other outcome variables by groups. MAIN RESEARCH VARIABLES: Number of red blood cell and platelet transfusions during transplantation, number of attempts at and total number of days of stem cell collection, time to recovery after transplantation, and response to intensive therapy for multiple myeloma. FINDINGS: Recovery and treatment response were not significantly different between groups after transplantation. The exercise group had significantly fewer red blood cell transfusions and fewer attempts at stem cell collection. Serious adverse events were similar in each group. CONCLUSIONS: Exercise with prophylactic EPO therapy reduces the number of RBC transfusions and attempts at stem cell collection for patients receiving intensive treatment for multiple myeloma. IMPLICATIONS FOR NURSING: Exercise is safe and has many physiologic benefits for patients receiving multiple myeloma treatment.

Keep moving: patients with myeloma talk about exercise and fatigue.

PURPOSE/OBJECTIVES: To learn about the feelings, beliefs, and experiences of patients with multiple myeloma implementing an exercise program in the context of an aggressive tandem peripheral stem cell transplant protocol. RESEARCH APPROACH: Qualitative naturalistic (constructionist). SETTING: International referral center for the treatment of multiple myeloma. PARTICIPANTS: Purposive nonprobability sample of 12 men and 9 women with multiple myeloma aged 38-70 enrolled in the exercise arm of a randomized trial of epoetin alfa with or without exercise as an intervention to decrease cancer-related fatigue. METHODOLOGIC APPROACH: Verbatim transcripts of tape-recorded, in-depth interviews analyzed for thematic content using content analysis and constant comparison. FINDINGS: Themes included (a) belief systems, which encompassed participants' beliefs about exercise and epoetin alfa, philosophy, and self-concept, (b) social context, which included life before cancer, social environment, and social system congruence, and (c) intersection between belief systems and social context, which were participants' experience appraisals. All participants believed that exercise could be helpful and would recommend exercise to other patients with cancer in a similar situation. Most believed that lack of activity contributed to decreased energy. MAIN RESEARCH VARIABLE: Patients' experience of implementing exercise in the context of treatment for multiple myeloma. CONCLUSIONS: Complex interactions between participants' beliefs and social context and experience appraisal influenced their ability to adhere to an exercise program during aggressive treatment for multiple myeloma. INTERPRETATION: Through careful assessment, clinicians can capitalize on belief and social systems that support adherence to exercise as an intervention to ameliorate fatigue for patients with cancer who are undergoing prolonged aggressive treatment.

General characteristics and experiences of specialized standardized patients: breast teaching associate professionals.

BACKGROUND: Standardized patients and teaching associates provide, reinforce, and evaluate the teaching of clinical skills to students and health care providers. As new needs and roles emerge for this method of teaching and evaluation, information is needed for recruitment, training, and retention. METHODS: This article addresses the general characteristics and experiences of 12 Breast Teaching Associate Professionals (BTAPs) in a two-year NCI-funded study aimed to improve breast cancer screening practices of rural primary health care providers in Eastern Arkansas. RESULTS: Areas of focus are demographic characteristics, motivations for serving as BTAPs, their perceptions of the advantages and disadvantages of the BTAP role, and the influence or impact the role had on their own health behaviors or personal lives. CONCLUSION: The evolving commitment to the value of this method of teaching and to health care education on this campus became stronger for many of the women as participation continued into other projects with further learning and specialization.