Impact of Co-occurring Cancer-Related and Wound-Specific Symptoms on Functional Performance Among Patients With Advanced Cancer and Malignant Fungating Wounds: An Exploratory, Observational Study.

PURPOSE: The purpose of this study was to examine the impact of co-occurring symptoms in patients with advanced cancer and malignant fungating wounds (MFWs) on palliative and functional performance, and the feasibility of collecting self-reported data in this population. DESIGN: This was an exploratory, observational study. Quantitative surveys and qualitative semistructured interviews using a phenomenological approach were employed. SUBJECTS AND SETTING: The sample comprised 5 adults with advanced breast, oral, and ovarian cancer and MFWs. Participants were recruited from an urban outpatient cancer center, hospice, and wound center located in the Northeastern United States. METHODS: Demographic and clinical characteristics were collected, and self-reported symptom and functional performance data measured. Descriptive statistics, T scores, confidence intervals, and standard deviation were calculated for quantitative data. One-to-one semistructured interviews were conducted by the first author to gain deeper understanding of participants' symptom experience. Qualitative data were analyzed using an iterative and inductive thematic data analysis method to identify major themes. RESULTS: The mean cancer-related and wound-specific symptom occurrence was 17 (SD = 5.56) and 4 (SD = 1.26), respectively. Distressing, extensive co-occurring symptom burdens were experienced by all participants; they also reported poor functional performance and diminished palliative performance. Qualitative findings supported quantitative results. CONCLUSIONS: Findings suggest that co-occurring cancer-related and wound-specific symptoms have incremental and negative impact on functional performance. The use of multiple data collection methods was feasible, including self-reported data in this advanced cancer population.

Curricular Quality Improvement in Midwifery: Simulating Unexpected Perinatal Loss.

INTRODUCTION: Caring for families experiencing perinatal loss is a fundamental component of midwifery practice, but little attention is paid to perinatal palliative care in midwifery curricula. Lack of educational preparation and self-care resources negatively impacts midwifery students and health care teams caring for families experiencing stillbirth. PROCESS: A private, urban university conducted a curricular quality improvement project to integrate perinatal palliative care into the midwifery curriculum using a high-fidelity, branching simulation pedagogy. Simulation objectives were developed from curricular gap analyses and the Core Competencies for Basic Midwifery Practice. Development of the Unexpected Perinatal Loss Simulation was guided by the International Nursing Association for Clinical Simulation and Learning Outcomes and Objectives and Design Standards. The Unexpected Perinatal Loss Simulation was revised based on qualitative data from student focus groups and expert content validation. OUTCOMES: Qualitative data yielded 4 key domains: presimulation, simulation skills, prior experience/personal reflections, and recommendations. Simulation procedures and scenario content were revised, after which 8 expert clinicians in the fields of midwifery, palliative care, and psychiatry validated the scenario content using the Lynn method. Two items did not meet the content validity index (CVI) threshold of 0.78, necessitating review by stakeholders; however, the overall scenario CVI threshold was met (0.82). DISCUSSION: Through this project, faculty integrated perinatal palliative care into the midwifery program using a novel approach of high-fidelity, branching simulation, structured debriefing, and an introductory self-care skills workshop. Potential clinical impact includes skillful perinatal palliative care with effective communication skills to mitigate how families experience and remember a traumatic loss and facilitate the grieving process. Students voiced insights into how they would process loss and seek support to mitigate their own grief as future midwives.

The Microbiome and Metabolome of Malignant Fungating Wounds: A Systematic Review of the Literature From 1995 to 2020.

PURPOSE: Malignant fungating wounds (MFWs) afflict up to 14% of patients with advanced cancer. The bacterial community structures of MFW may influence the development and severity of wound symptoms. The purpose of this systematic review was to evaluate existing evidence regarding the relationship between microbiome and symptoms of MFWs. METHODS: A systematic review of the published literature from January 1995 to January 2020 was conducted. An established quality assessment tool was used to assess the quality of the included studies. SEARCH STRATEGY: We searched 4 major electronic databases and retrieved 724 articles; 7 met inclusion criteria. FINDINGS/CONCLUSIONS: Seven studies were included; the overall quality of the included 7 studies was ranked as adequate. Findings from the studies provided an incomplete characterization of the microbiome and metabolome of MFW; none included modern genomic technologies. Twenty different species of aerobes and 14 species of anaerobes were identified, with inconsistent identification of biofilms and multi-drug-resistant bacteria. Symptom occurrence increased with the number of bacteria species (P = .0003) and the presence of at least 1 anaerobe (P = .0006) in malignant wound beds. Cancer wound-derived odor was associated with dimethyl trisulfide and 4 fatty acid volatiles. Periwound and moisture-associated skin damage were associated with higher putrescine levels in exudates. IMPLICATIONS: Understanding the role of microbiota of MFW in developing or amplifying the severity of wound symptoms is the first step toward development of more precise and effective topical interventions.

Real-time, simulation-enhanced interprofessional education in the care of older adults with multiple chronic comorbidities: a utilization-focused evaluation.

BACKGROUND: Interprofessional education (IPE) is a curricular requirement for all healthcare professional education standards. To foster learning about, from and with each other, consistent with the Interprofessional Education Consortium's Core Competencies, many graduate schools are integrating interprofessional (IP) simulation experiences throughout their educational curricula, providing multiple opportunities for health professional students to collaborate and practice together. High-fidelity, real-time simulations help students from diverse professional backgrounds to apply their classroom learning in realistic clinical situations, utilize mobile technology to access clinical decision support (CDS) software, and receive feedback in a safe setting, ensuring they are practice-ready upon graduation. METHODS: New York University Rory Meyers College of Nursing (NYU) and Long Island University College of Pharmacy (LIU) partnered for two consecutive years to create, coordinate and implement two interprofessional educational simulations involving patients with chronic cardiovascular disease. A utilization-focused evaluation of high-fidelity, simulation-enhanced IPE (Sim-IPE) was implemented to assess students' IP competencies before and after their participation in the IPE-simulation and their overall satisfaction with the experience. The Interprofessional Collaborative Competency Attainment Survey (ICCAS), a reliable instrument, was administered to both doctor of pharmacy students and primary care advanced practice nursing students before and after each simulation experience. Additionally, student satisfaction surveys were administered following the IPE-simulation. RESULTS: Aggregated means revealed statistically significant improvements in each of the six domains including communication, collaboration, roles and responsibilities, collaborative patient/family approach, conflict resolution and team functioning. Student ratings revealed positive experiences with the IPE-simulations. CONCLUSIONS: High-fidelity, real-time IPE-simulation is a powerful pedagogy to help graduate students from different professional backgrounds practice applying IP competencies in simulated experiences. Quality improvement studies and research studies are needed to assess the impact of high-fidelity, real-time simulations throughout graduate curricula with different types of patients to improve coordinated, team approaches to treatment.

Real-time decision-making in chronic illness branching simulation.

The United States (US) is facing a rapidly aging population that suffers from multiple chronic illnesses. To prepare nursing students to care for this increasingly complex, aging population nurse educators must develop curricula that incorporate both current technology and cutting-edge teaching pedagogies that facilitate development of real-time decision-making skills. Branching scenarios are simulations that mimic real-life; rapidly changing patient conditions unfold based on actual student decision-making. This challenges learners to adapt the nursing process based on subjective and objective assessments and utilize current technology to analyze multiple sources of patient data. As nursing students make decisions and act, the scenario branches, presenting them with immediate feedback on the outcomes. Branching simulation scenario designs incorporate multiple different mobile technologies with decision-support software that nursing students may access, such as real-time decision-support algorithms, evidence-based guidelines, telehealth, medication information resources, and electronic medical records (EMRs). Faculty at NYU Rory Meyers College of Nursing (NYU) have successfully incorporated mobile technology with decision-support software into branching simulations as a strategy to develop real-time clinical decision-making in the care of older adults with multiple chronic illnesses.

Symptoms of Malignant Fungating Wounds and Functional Performance among Patients with Advanced Cancer: An Integrative Review from 2000 to 2019.

Introduction: Malignant fungating wounds (MFWs), non-healing wounds caused by aggressive proliferation of malignant tumors, afflict 5%-14.5% of patients with advanced cancer. We conducted an integrative review to evaluate the level of evidence of peer-reviewed literature published from 2000 to 2019 on symptoms of MFWs, and the impact of the symptoms on functional performance among patients with advanced cancer. Methods: Four electronic databases were searched and 1506 articles were retrieved. A total of 1056 abstracts were screened for relevance and a full review of the 26 articles was performed. A total of 12 articles met inclusion criteria. An established quality assessment tool was used to rate the quality of the included studies. Results: The overall quality of the included 12 studies was adequate. This integrative review of the literature provided strong evidence that patients with MFWs suffered multiple symptoms, including pain, odor, exudate, bleeding, pruritus, perceived wound status, perceived bulk effect and lymphedema. Quantitative research was not able to capture the occurrence and characteristics of all the identified symptoms. There was a lack of quantitative research on the impact of MFWs and symptoms on patients' functional performance. Yet, qualitative studies provided vivid description of how the symptoms negatively affected patients' functional performance. Future research should develop a clinical tool that enables the comprehensive assessment of symptoms of MFWs. Well-designed quantitative research is needed to delineate the impact of symptoms of MFWs on patients' functional performance to ensure quality palliative care.

The Microbiome, Malignant Fungating Wounds, and Palliative Care.

Malignant fungating wounds present in 5-14% of advanced cancer patients in the United States and are a result of cancerous cells infiltrating and proliferating in the skin. Presentation of malignant fungating wounds often occurs in the last 6 months of life and therefore become symbols of impending death for patients and their families. Due to the incurable and severe nature of these wounds, patients require palliative care until death to minimize pain and suffering. Symptoms associated with these chronic wounds include malodor, pain, bleeding, necrosis, large amounts of exudate, increased microbial growth, and more. Limited research using culture-based techniques has been conducted on malignant fungating wounds and therefore no optimal approach to treating these wounds has been established. Despite limited data, associations between the cutaneous microbiome of these wounds and severity of symptoms have been made. The presence of at least one strain of obligate anaerobic bacteria is linked with severe odor and exudate. A concentration of over 105/g bacteria is linked with increased pain and exudate. Bacterial metabolites such as DMTS and putrescine are linked with components of malignant fungating wound odor and degradation of periwound skin. The few but significant associations made between the malignant fungating wound microbiome and severity of symptoms indicate that further study on this topic using 16S rRNA gene sequencing may reveal potential therapeutic targets within the microbiome to significantly improve current methods of treatment used in the palliative care approach.