Wake-up Call: Night Shifts Adversely Affect Nurse Health and Retention, Patient and Public Safety, and Costs.

The purpose of this mini review is to (1) summarize the findings on the impact of night shift on nurses' health and wellness, patient and public safety, and implications on organizational costs and (2) provide strategies to promote night shift nurses' health and improve organizational costs. The night shift, compared with day shift, results in poorer physical and mental health through its adverse effects on sleep, circadian rhythms, and dietary and beverage consumption, along with impaired cognitive function that increases nurse errors. Nurse administrators and health care organizations have opportunities to improve nurse and patient safety on night shifts. Low-, moderate-, and higher-cost measures that promote night nurses' health and well-being can help mitigate these negative outcomes. The provided individual and organizational recommendations and innovations support night shift nurses' health, patient and public safety, and organizational success.

CE: Nurses Are More Exhausted Than Ever: What Should We Do About It?

ABSTRACT: For nurses, the challenges posed by demanding work environments and schedules often lead to fatigue, and this can be exacerbated during crises like the COVID-19 pandemic. In this article, the authors discuss causes and challenges of nurse fatigue and consider several evidence-based strategies and solutions for individual nurses and organizations. Barriers to implementation, including a negative workplace culture and inadequate staffing, are also described, and several resources are presented.

Palliative care, Version 1.2014. Featured updates to the NCCN Guidelines.

The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. These NCCN Guidelines Insights summarize the NCCN panel's discussions and guideline updates from 2013 and 2014. These include modifications/additions to palliative care screening and assessment protocols, new considerations for discussing the benefits and risks of anticancer therapy, and approaches to advance care planning. Recent updates focus on enhanced patient-centered care and seek to promote earlier integration of palliative care and advance care planning in oncology.

Adult cancer pain.

Pain is a common symptom associated with cancer and its treatment. Pain management is an important aspect of oncologic care, and unrelieved pain significantly comprises overall quality of life. These NCCN Guidelines list the principles of management and acknowledge the range of complex decisions faced in the management oncologic pain. In addition to pain assessment techniques, these guidelines provide principles of use, dosing, management of adverse effects, and safe handling procedures of pharmacologic therapies and discuss a multidisciplinary approach for the management of cancer pain.

Palliative care.

These guidelines were developed and updated by an interdisciplinary group of experts based on clinical experience and available scientific evidence. The goal of these guidelines is to help patients with cancer experience the best quality of life possible throughout the illness trajectory by providing guidance for the primary oncology team for symptom screening, assessment, palliative care interventions, reassessment, and afterdeath care. Palliative care should be initiated by the primary oncology team and augmented by collaboration with an interdisciplinary team of palliative care experts.

A spicamycin derivative (KRN5500) provides neuropathic pain relief in patients with advanced cancer: a placebo-controlled, proof-of-concept trial.

CONTEXT: Neuropathic pain in patients with cancer can be difficult to treat effectively. OBJECTIVES: The purpose of the study was to determine safety and efficacy of KRN5500, a novel, spicamycin-derived, nonopioid analgesic agent, in patients with advanced cancer and neuropathic pain of any etiology. METHODS: The study was a Phase 2a, multicenter, double-blind, placebo-controlled, dose escalation clinical trial. Patients with refractory neuropathic pain and advanced cancer were randomly assigned 2:1 to receive a maximum of eight single escalating doses of KRN5500 or placebo, ranging from 0.6 to 2.2 mg/m(2). The primary objective was safety and tolerability. The secondary objective was efficacy, measured by change in average pain intensity on a 0-10 numeric rating scale administered one week after the patient's final dose. RESULTS: Nineteen patients received treatment (KRN5500 n=12; placebo n=7). The most frequently reported adverse events were gastrointestinal symptoms, which were more frequent and severe with KRN5500 than placebo; two (17%) KRN5500 patients discontinued the study because of nausea and vomiting. At study endpoint, KRN5500 exhibited a significant median decrease in pain intensity from baseline of 24% compared with 0% for placebo (P=0.03). The median for largest weekly reduction in target pain intensity was 29.5% for KRN5500 and 0% for placebo patients (P=0.02). CONCLUSION: This proof-of-concept study for KRN5500 in patients with advanced cancer and any type of neuropathic pain found gastrointestinal adverse events to be the predominant safety concern. The results also provided the first indication of clinical and statistical efficacy in reducing pain intensity.

Fentanyl pectin nasal spray in breakthrough cancer pain.

Abstract Fentanyl pectin nasal spray (FPNS) is being developed to improve analgesic onset, treatment efficacy, and satisfaction/acceptability in treating breakthrough cancer pain (BTCP). Patients (n = 114) were entered into a randomized, placebo-controlled, double-blind, multicenter study. Patients who successfully titrated (n = 83) entered a double-blind phase; 10 episodes of BTCP were treated with the effective dose (7) or placebo (3). Pain intensity (11-point scale) and pain relief (5-point scale) were assessed between 5 and 60 minutes. Use of rescue medications was recorded, and acceptability assessments were conducted 30 and 60 minutes post dose. Only 6% of patients failed to titrate to an effective dose of FPNS due to lack of efficacy and 5% due to adverse events. A total of 91% of randomized patients completed the study. Episode analysis (FPNS, n = 459; placebo, n = 200) revealed that compared with placebo, 33% of FPNS episodes showed an onset of improvement in pain intensity at 5 minutes (P < 0.05); 33% of episodes by 10 minutes had clinically meaningful pain relief (> or = 2 point decrease in pain intensity; P < 0.0001). Satisfaction with the convenience and ease of use of FPNS was reported by 70% and 68% of patients, respectively; 87% of patients elected to continue treatment post study. FPNS provided rapid analgesia in BTCP and was well accepted by patients.

Factor V Leiden: impact on infusion nursing practice.

As one whose family has been affected by factor V Leiden since 1980, the author knows firsthand the impact of this disease process on patients, outcomes, and practice. In today's healthcare environment, genetic screening for the factor V mutation is routine among pregnant women. Preoperative testing is often done on those "at risk." This article addresses the genetics, the occurrence, the treatment, and practice implications.

A new extended release formulation (OROS) of hydromorphone in the management of pain.

Opioid analgesics are essential in the treatment of moderate to severe cancer-related pain. Opioids are also recognized as important in the management of other severe, persistent refractory painful conditions, such as sickle cell disease and arthritis. In the clinical practice of pain management, stable opioid dosing generally depends on achieving maximal analgesia with tolerable side effects typical of opioid analgesics. There is a wide interindividual variability of responsiveness to exogenous opioids both in terms of analgesic efficacy and side effects. Optimizing pain management for the individual patient may require sequential trials of opioid medications until the regimen with the most favorable therapeutic ratio of efficacy to side effects is determined.

Fentanyl buccal tablet for the treatment of breakthrough pain in opioid-tolerant patients with chronic cancer pain: A long-term, open-label safety study.

BACKGROUND: This study assessed the long-term safety and tolerability of fentanyl buccal tablet (FBT) in opioid-tolerant patients with cancer and breakthrough pain (BTP) who were either naive to FBT or had completed 1 of 2 previous double-blind, placebo-controlled FBT studies (rollover patients). METHODS: Patients who were FBT-naive underwent titration to find a successful FBT dose. Rollover patients used a previously identified successful dose of FBT. Patients who achieved a successful dose were eligible to enter a maintenance phase (>or=12 months). Safety assessments included adverse events (AEs), physical and neurologic examinations, and clinical laboratory tests. RESULTS: Two hundred thirty-two patients were enrolled. A total of 112 entered titration; 79 identified a successful FBT dose, and 77 of these patients entered the maintenance phase along with 120 rollover patients (n = 197). AEs resulted in discontinuation of therapy for 33% of patients. The most common AEs were generally typical of opioids administered to cancer patients. All serious AEs were considered to be related to the patients' underlying conditions, except for 1 incident of FBT-related drug withdrawal syndrome. Sixty patients died after enrollment because of disease progression. Fifteen (6%) patients experienced >or=1 application-site AE, all of which were considered by investigators to be related to FBT. CONCLUSIONS: FBT was generally well tolerated and had a favorable safety profile in the long-term (>or=12 months) management of patients with persistent cancer pain and BTP. No unexpected AEs occurred. Safety and tolerability was similar to that observed in short-term studies.

Certification and credentialing to define competency-based practice.

One of the challenges that healthcare organizations face today is how to effectively establish, document, and evaluate competency in intravenous practice. The process used to define practice parameters based on national certification and credentialing versus organizational policies is described. Key attributes, the role of mentoring, and adverse outcomes are addressed.

Multicenter, open-label, prospective evaluation of the conversion from previous opioid analgesics to extended-release hydromorphone hydrochloride administered every 24 hours to patients with persistent moderate to severe pain.

BACKGROUND: Hydromorphone hydrochloride is a mu-opioid agonist with dose-dependent analgesic properties. Extended-release hydromorphone hydrochloride (ER hydromorphone HCl) capsules have been developed for administration every 24 hours. OBJECTIVES: This prospective evaluation focused on the first (ie, conversion) phase of 2 identically designed, randomized, controlled studies that compared the safety and efficacy of once-daily ER hydromorphone HCl capsules with immediate-release hydromorphone hydrochloride (IR hydromorphone HCl) tablets administered 4 times daily in the treatment of persistent moderate to severe cancer- and noncancer-related pain. METHODS: Patients being treated with opioid analgesics for persistent moderate to severe pain were converted to ER hydromorphone HCl using an 8:1 conversion ratio. The dose was titrated to attain an average pain intensity (API) score < or = 4 on a 0- to 10-point numeric rating scale. Supplemental oral IR hydromorphone HCl tablets were used as rescue medication at a dose of one eighth to one sixth of the daily ER hydromorphone HCl dose. RESULTS: A total of 343 patients (272 [79%] with cancer pain; mean age, 57.8 years) were enrolled and converted to ER hydromorphone HCl from their previous opioids. About half (51%) were women. At baseline, the mean (SD) API score was 5.3 (2.1). Mean (SD) API scores were 4.7 (2.0) after the first 48 hours and 3.4 (2.1) by the end of titration. After 4 to 21 days of titration, 239 (70%) patients reached stabilization defined as a > or = 48-hour period with an API score of < or =4, unchanged ER hydromorphone HCl dose, and < or = 2 rescue doses per day. The stabilized patients had mean (SD) API scores of 2.7 (1.1) at the end of titration. At stabilization, 102 (43%) of 239 patients remained at their initial conversion dose, 129 (54%) had a dose increase, and 8 (3%) had a dose decrease. Frequent (> or =10% of patients) adverse events that occurred within the first 48 hours after conversion and during the entire titration phase were nausea, somnolence, headache, constipation, vomiting, and dizziness. CONCLUSION: In this prospective evaluation of the conversion and titration phase of 2 randomized, controlled studies, a conversion ratio of 8:1 mg of oral morphine to oral ER hydromorphone HCl was found to be clinically useful in patients with persistent moderate to severe cancer-related or noncancer-related pain.

Management of pain associated with spinal tumor.

Metastatic spinal disease is common in cancer patients, and it is a frequent source of pain and disability. Expert management of the patient's pain and neurologic dysfunction is required. Neurosurgical advances have afforded the patient the opportunity to have improved symptom management and improved quality-of-life outcomes. Patients and their families are best served by the provision of supportive care by specialty pain medicine and palliative care services (especially neurology based) working with the primary neurosurgical team in an integrated model.