Construct validity of functional status scores of patients with lymphedema.

During treatment of lymphedema, routine use of patient-reported outcomes measures (PROMs) is recommended to monitor patient progress; however, the validity functional status (FS) PROMs in these patients is unknown. Our aims were to examine construct validity of the shoulder computerized adaptive testing (CAT) and the foot-and-ankle CAT, as a measure of FS for patients selecting the shoulder or the foot-and-ankle as their main body part affected by their lymphedema. We assessed the ability of the FS scores to distinguish between patient groups in clinically expected ways at admission and discharge from physical therapy. At admission (n=1600), patients who were younger and had more acute symptoms, less severe lymphedema, less co-morbidities, no relevant surgical history, did not use medications for chronic conditions, and exercised regularly, had higher FS. At discharge (n=611), patients who were younger and had less advanced lymphedema, fewer co-morbidities, no relevant surgical history, did not use medications for chronic conditions, exercised regularly, and had more acute symptoms had higher FS change, after controlling for their baseline FS score. Low participation rates in FS outcomes data collection could have biased results. Overall, the CAT-based FS PROMs used in this study discriminated between patient groups in clinically logical ways both at intake and at discharge from lymphedema treatment.

Effectiveness of compression bandaging education for wound care nurses.

OBJECTIVE: Compression bandaging is an essential component in the treatment of venous leg ulcers (VLUs). An adequate pressure and stiffness is needed in order for the treatment to be successful. The aim of this study was to evaluate the effectiveness of a training workshop on compression bandaging among wound care nurses who had no previous experience in application of compression bandages, immediately post-training and six months after training. METHOD: A quasi-experimental design, conducted at Maccabi Healthcare Services, in which nurses underwent a four-hour educational session, including practising with a device that measures sub-bandage pressure. RESULTS: We assessed 37 nurses. Before training, 5.4% of nurses bandaged in the optimal range; after training, 58% bandaged in optimal range, and six months post-training, 37% bandaged in optimal range. At post- and six months post-training, no nurse bandaged 'too low' (≤20mmHg). Stiffness of the bandage was achieved in only 5.4% of nurses before training; 62% immediately after, and 75% six months after training. CONCLUSION: We conclude that the proposed educational session using a device that measures the pressure applied is an effective way to teach wound care nurses how to use compression bandages. However, more practise is needed to achieve an optimal range of pressure over time.

A systematic review of care delivery models and economic analyses in lymphedema: health policy impact (2004-2011).

A project of the American Lymphedema Framework Project (ALFP), this review seeks to examine the policy and economic impact of caring for patients with lymphedema, a common side effect of cancer treatment. This review is the first of its kind undertaken to investigate, coordinate, and streamline lymphedema policy initiatives in the United States with potential applicability worldwide. As part of a large scale literature review aiming to systematically evaluate the level of evidence of contemporary peer-reviewed lymphedema literature (2004 to 2011), publications on care delivery models, health policy, and economic impact were retrieved, summarized, and evaluated by a team of investigators and clinical experts. The review substantiates lymphedema education models and clinical models implemented at the community, health care provider, and individual level that improve delivery of care. The review exposes the lack of economic analysis related to lymphedema. Despite a dearth of evidence, efforts towards policy initiatives at the federal and state level are underway. These initiatives and the evidence to support them are examined and recommendations for translating these findings into clinical practice are made. Medical and community-based disease management interventions, taking on a public approach, are effective delivery models for lymphedema care and demonstrate great potential to improve cancer survivorship care. Efforts to create policy at the federal, state, and local level should target implementation of these models. More research is needed to identify costs associated with the treatment of lymphedema and to model the cost outlays and potential cost savings associated with comprehensive management of chronic lymphedema.

Self-reported information sources and perceived knowledge in individuals with lymphedema.

Currently, a limited number of studies have been conducted that examine sources of information and knowledge level in individuals with lymphedema. This study aimed (1) to examine self-reported information sources and perceived lymphedema knowledge among individuals with lymphedema; and (2) to examine differences in self-reported information sources and perceived lymphedema knowledge among individuals with primary or secondary lymphedema; and with upper or lower extremity lymphedema. The National Lymphedema Network (NLN) conducted a survey to collect self-report data from March 2006 to January 2010. Overall, participants preferred a variety of sources of information. Participants reported low levels of knowledge about the types of lymphedema, treatment approaches and methods, and self-administrated therapies. In comparison to participants with secondary or upper extremity lymphedema, participants with primary or lower extremity lymphedema reported lower knowledge level regarding causes of lymphedema, risks for and complications of lymphedema, treatment approaches and methods for lymphedema, and self-administered therapies. Opportunities exist to expand lymphedema information sources. Healthcare professionals should focus on delivering high quality information about treatment and self-care management to individuals with lymphedema.

Intermittent pneumatic compression therapy: a systematic review.

Intermittent pneumatic compression (IPC) therapy is an effective modality to reduce the volume of the lymphedematous limbs alone or in conjunction with other modalities of therapy such as decongestive therapy. However, there is no consensus on the frequency or treatment parameters for IPC devices. We undertook a systematic review of contemporary peer-reviewed literature (2004-2011) to evaluate the evidence for use of IPC in the treatment of lymphedema. In select patients, IPC use may provide an acceptable home-based treatment modality in addition to wearing compression garments.

Symptom burden and infection occurrence among individuals with extremity lymphedema.

Currently, there is a lack of data related to differences in symptoms and infection across different types and anatomical sites of lymphedema. The objective of this study was to examine differences in symptoms and infection status among individuals with lymphedema of the upper or lower extremities. The National Lymphedema Network initiated an online survey of self-report lymphedema data from March 2006 through January 2010. Descriptive statistics, Mann-Whitney tests, and Chi-square tests were used to analyze data. 723 individuals with upper extremity lymphedema and 1114 individuals with lower extremity lymphedema completed the survey. Individuals with extremity lymphedema experienced high symptom burden and infectious complications. Compared with individuals with upper extremity lymphedema, individuals with lower extremity lymphedema experienced more frequent and more severe symptoms (p<.001), infection episodes (p<.001), and infection-related hospitalizations (p<.001). No statistically significant differences of symptom burden and infection status were identified between individuals with lower extremity primary and secondary lymphedema. Individuals with extremity lymphedema experience substantial symptom burden and infectious complications; however, those with lower extremity lymphedema have more severe symptoms and more infections than those with upper extremity lymphedema.

Post-breast cancer lymphedema: incidence increases from 12 to 30 to 60 months.

Breast cancer survivors are at life-time risk of developing lymphedema (LE). Quantification of LE has been problematic as the criteria used to identify lymphedema use various methods to assess changes in the volume of the affected limb. In part because of difficulties and variability in measurement and diagnosis, the reported incidence of LE varies greatly among women treated with surgery and radiation for breast cancer. The goal of this research was to describe the trends for LE occurrence over three points in time (12, 30, and 60 months) among breast cancer survivors using four diagnostic criteria based on three measurement techniques. Participants were enrolled following diagnosis of breast cancer but before surgery. Baseline limb volume and symptom assessment data were obtained. Participants were followed every 3 months for 12 months, then every 6 months thereafter for a total of 60 months. Limb volume changes (LVC) in both limbs were measured using three techniques: objectively by (a) circumferences at 4 cm intervals and (b) perometry and subjectively by (c) symptom experience via interview. Four diagnostic criteria for LE most often reported in the literature were used: (i) 2 cm circumferential change; (ii) 200 mL perometry LVC; (iii) 10% perometry LVC; and (iv) signs and symptoms (SS) report of limb heaviness and swelling, either 'now' or 'in the past year' (diagnostic criteria i-iii define increases/differences in limb volume from baseline and/or between the affected and non-affected limb). Standard survival analysis methods were applied to identify when the criteria corresponding to LE were met. Trends in LE occurrence are reported for preliminary analysis of data from 236 participants collected at 6-, 12-, 18-, 24-, 30-, and 60-months post-op. At 60 months post-treatment, LE incidence using the four criteria ranged from 43% to 94%, with 2 cm associated with the highest frequency for lymphedema occurrence and SS the lowest. Sixty-month trends are compared to earlier trends at 12- and 30-months, per criterion. These preliminary findings provide additional evidence that breast cancer survivors are at risk for developing LE beyond the first year following treatment. Cases of lymphedema continue to emerge through 60-months post-breast cancer surgery. This 60-month analysis supports the previous 12- and 30-month analyses in finding the 2 cm criteria to be the most liberal definition of LE. The self-report of heaviness and swelling, along with 10% LVC, represent the most conservative definitions (41% and 45%, respectively). Furthermore, the variety of criteria used to identify LE, along with the absence of baseline (pre-treatment) measurements, likely contribute to the wide range of LE incidence rates reported in the literature.

Minimal limb volume change has a significant impact on breast cancer survivors.

We sought to define the incidence, risk factors, symptoms, and quality of life (QOL) outcomes associated with various degrees of postoperative limb volume change (LVC). A prospective cohort study was performed obtaining serial limb volume measurements using a perometer on 269 women undergoing surgery for breast cancer. Four groups were created based on maximum LVC: none < 5.0%, mild 5.0-9.9%, moderate 10.0-14.9%, and severe 15.0%. Symptoms and QOL were assessed. 81 (30.1%), 70 (26.0%), and 14 (5.2%) women developed mild, moderate, and severe LVC, respectively. Increases in body mass index (p < 0.001) and post-operative complications (p = 0.002) were associated with increasing LVC. Lower QOL scores were associated with a moderate LVC (OR = 3.72, 95% CI, 1.29-10.73, p = 0.015) and postoperative infections (OR = 5.04, 95% CI, 1.73-14.70, p = 0.003). LVC at 5.0% occurs in up to 61.3% of breast cancer survivors and is associated with a significant increase in symptoms and a change in reported quality of life.

Comparison of upper limb volume measurement techniques and arm symptoms between healthy volunteers and individuals with known lymphedema.

Lymphedema is a problem for breast cancer survivors. The proliferation of limb measurement techniques makes it difficult to know how best to measure an at-risk limb. Using a sample of healthy volunteers and individuals with lymphedema, this study: 1) examined the relationship between more commonly used circumferential limb measurement methods and newer measurement methods of infrared laser perometry and bioelectrical impedance; 2) compared self-reported arm symptoms in healthy volunteers and breast cancer survivors with known lymphedema; and 3) explored the relationships among self-reported arm symptoms and circumferential tape measurement, infrared laser (perometry), and single and multi-frequency bioelectrical impedance. Lymphedema index ratios were calculated to allow comparison among measurement methods. Measurement methods correlated strongly with each other. Fourteen symptoms were reported by one or more participants in the lymphedema group while participants in the healthy volunteer group reported only eight symptoms over the same time frames. Using p < 0.001, all measurement methods correlated with self-reported arm swelling in the past year, while only circumferential and impedance measurements correlated with firmness. Future research needs to include serial arm measurements to explore arm volume variation in healthy and lymphedema volunteers and to further investigate possible lymphedema index ratios cut points as lymphedema diagnostic criteria.

An inside view. NP/MD perceptions of collaborative practice.

The pressing dilemma in this era of health care reform is how to provide cost-effective, high quality health care for all Americans. At the present time, due to a number of complex factors, including attrition and economic disincentives, a shortage of primary care physicians exists in certain medically underserved areas of the country. At the same time, however, primary care nurse practitioners are increasing in number.

The church family and kin: an older rural black woman's support network and preferences for care providers.

Although kin and church are considered premier support sources for rural elders, few scholars have undertaken descriptive studies to explore the nature of rural Black elders' support networks and their preferences for in-home service providers. In the case study described in this article, methods of support network analysis and descriptive phenomenology were used to analyze data from five lengthy, open-ended interviews with a 94-year-old rural Black woman. The various groups and individuals of her network are labeled in her words, the network's supportive functions are described, and preferences for providers are noted. In addition, the varying structures of her home care experience with the support network members are described. Her attempts to voice and exercise her preferences for in-home service providers are explained in terms of two contrasting processes: preference uptake and preference suppression. Based on these findings, implications for appraising the appropriateness of rural elders' in-home services are discussed.

Missouri responds to the advanced practice nurse role.

A randomly-drawn statewide sample of 891 consumers revealed overall support for the advanced practice nurse role to be greater than 75 percent. Seeking health care consumers' reactions to proposed alternatives is a crucial step in planning and implementing a program of health care reform that will meet current and future health needs.

An exploration of factors influencing adjustment among relocating rural elders.

The aim of this preliminary qualitative study was to examine factors influencing the adjustment of 34 elderly people relocating to an age-segregated planned housing unit in a rural community. Factors identified as affecting urban relocation were explored as a basis for developing a greater understanding of rural elders. Data from open-ended interviews were analyzed through sorting into categories by themes. Inclusion of factors reported to influence relocation among urban-dwelling elders in rural relocation research was validated through the template analytic technique. Content analysis resulted in support for the variables of predictability, controllability, social support and interaction, recency of loss, and prior life satisfaction as potential influences on post-relocation adjustment. Health professionals can ease adjustment through increased understanding of the factors that affect adjustment to relocation. Based on these preliminary findings, a more comprehensive study of relocation among the rural aged is warranted.

Affectivity and mental health among elderly religious.

Fifty elderly Catholic nuns from the Midwest were interviewed in a descriptive study to obtain information regarding affectivity and mental health. Lawton's Philadelphia Geriatric Center affectivity instrument was used to determine frequency of positive versus negative emotions and 10 dimensions of affectivity. Overall, these subjects reported positive emotional experiences to be more common than negative ones. The nuns were shown to be strongest in the affectivity dimensions of duration of feelings, affective dissimulation, and emotional adaptation. They scored lowest on sensation seeking, variability of feelings, and emotional maturity. The mean scores of these subjects demonstrated statistically stronger emotional experiences than did Lawton's subjects. In response to an open-ended question on definition of health, evidence of a multidimensional perception of health was present among these elderly nuns. This research provides the foundation for further work designing and implementing interventions aimed at promoting optimal mental health among members of cultural minority groups.

A public health nurse's guide to reading meta-analysis research reports.

Meta-analysis research reports are increasingly found in the public health literature. Meta-analysis is a quantitative method for summarizing existing studies. Although it is often advocated to synthesize research, nurses must be able to read these reports critically to determine applicability to practice.