The efficacy of honey or olive oil on the severity of oral mucositis and pain compared to placebo (standard care) in children with leukemia receiving intensive chemotherapy: A randomized controlled trial (RCT).

BACKGROUND: Oral mucositis (OM) is a significant complication occurring in approximately 40 to 80% of patients receiving chemotherapy regimens. Although a wide variety of agents have been tested to prevent OM or reduce its severity, none have provided conclusive evidence. OBJECTIVES: To determine the efficacy of honey or olive oil on the severity and OM pain in children with leukemia and suffering from OM compared to placebo (standard care) and, to assess which of the two interventions is more beneficial. METHODS: A single blind randomized controlled study (RCT) was used to evaluate the effect of Manuka honey or olive oil, in the treatment of chemotherapy-related OM in 42 children with leukemia. The primary outcome was the severity of mucositis, using the World Health Organization (WHO) scale and the secondary outcome was the pain assessed using the Visual analogue scale (VAS). RESULTS: Children who received the honey had less severe OM (assessed on the (WHO) scale), p = 0.00 and less pain (assessed on the VAS scale), p = 0.00, compared to the control group. Children who received the olive oil had less pain than the control group, p = 0.00), although not lower than the honey group. CONCLUSION: Manuka honey or olive oil can be used as alternative therapies by nurses to children with leukemia and suffering from OM, especially in low and middle-income countries where more expensive therapies may not be available or economical. PRACTICE IMPLICATIONS: Pediatric nurses may recommend Manuka honey to treat OM in children with leukemia as it is safe and inexpensive compared to other treatment modalities.

Effects of Exercise on Physiologic and Psychologic Outcomes in Patients with End Stage Kidney Disease on Hemodialysis: A Quasi-Experimental Study.

End stage kidney disease (ESKD), a public health concern, has overwhelming effects on individuals' holistic wellbeing. Hemodialysis, albeit a life-saving treatment for patients with ESKD, can lead to muscle atrophy, weakness, and decreased quality of life mostly due to an inactive lifestyle. This quasi-experimental, pre-post design was used to study the effects of exercise on physiologic and psychologic outcomes of patients with ESKD at a hemodialysis unit in Lebanon. Patients acted as their own controls and were assessed before and after introducing the exercise program. Data were collected on quality of life of patients as well as their dialysis adequacy. Results showed that while there was a significant improvement in the dialysis adequacy post-exercise intervention, quality of life was not affected.

A Nonrandomized Pretest Posttest Study on the Impact of an Educational Pain Management Program on Nurses' Knowledge and Attitudes Regarding Pain in a Middle Eastern Country.

BACKGROUND: Although nurse's knowledge and attitudes regarding pain management has been sufficiently studied worldwide, the impact of an educational intervention program in improving such attitudes and knowledge has not been likewise researched, especially in Middle Eastern countries. AIMS: To examine nurses' knowledge and attitudes regarding pain at a university hospital in Lebanon before and after the introduction of a pain management educational program. And to assess the relationship between the characteristic of nurses and their pain knowledge. METHODS: Design; A nonrandomized pretest posttest study design was used. Setting; A university hospital in Lebanon. Participants; Included 183 nurses using the Nurses' Knowledge and Attitudes Survey Regarding Pain questionnaire. The pain educational intervention was based on the principles of Ajzen's theory of planned behavior. RESULTS: A significant difference between the pre and post test scores was noted (p = .016). Questions answered correctly by 80% of participants were related to questions about pain, pain assessment and management, and questions related to medications, such as correct dosages and opioid side effects were not answered correctly by the majority of nurses. There were significant associations between test scores and the nurses' educational level, their age, and their years of experience. Nurses who worked in critical care units, the emergency department and oncology had higher scores than nurses who worked on general units. CONCLUSIONS: Despite the intensive pain education provided at our institution, the pain knowledge of nurses remains below that recommended level which indicates a dire need for more intensive and continuous education in order to provide a pain free environment.

The Impact of Therapeutic Exercises on the Quality of Life and Shoulder Range of Motion in Women After a Mastectomy, an RCT.

Breast cancer ranks highest in incidence and mortality among females and second among both genders. Lebanon has the second highest rate of breast cancer worldwide for those 35-39 years old and the highest for those 40-49. Mastectomy often results in deceased shoulder and arm mobility and decreased quality of life. The objective of this study was to assess the effect of an educational program of therapeutic exercises on the quality of life and functional ability in women after a mastectomy. Sixty women undergoing a mastectomy were randomly assigned to either an intervention or control group. The intervention group received extensive pre-surgery education as well as training on therapeutic exercises. Follow-up phone calls to the intervention group were made to ensure that the exercises were being done. Both groups were visited at home at two and four weeks to obtain the outcome variables. The Breast Cancer Patient Version was used to assess quality of life, and the "Goniometer" was used to assess the range of motion of the affected shoulder. At two and four weeks after surgery, women in the intervention group had significant improvements in their shoulder range of motion: flexion, extension, and abduction were significantly different between the control and intervention group at p = 0.04-0.00. For quality of life, physical, psychological, psychological, social, and spiritual well-being were significantly higher for the intervention group at both two and four weeks after surgery, p < 0.001. In a middle-income country, one-to-one education provided by a nurse, which included demonstrations, back demonstrations, and weekly phone calls had a positive impact on women's shoulder range of motion and quality of life. NCT04184102.

Translation, Cross-Cultural Adaptation, and Validation of the Adolescent Pediatric Pain Tool (APPT) for Multidimensional Measurement of Pain in Children and Adolescents.

BACKGROUND: Pain is subjective and multidimensional in nature. Its assessment is very challenging especially in the pediatric population. Adequate assessment of pain in children is the keystone for effective management. Accurate and comprehensive evaluation of the child's pain experience requires the use of multidimensional pain assessment tools such as the Adolescent Pediatric Pain Tool (APPT) which measures the intensity, location and quality of pain. AIMS: The aim of this study was to translate and culturally validate the APPT for use in Lebanese children and adolescents with cancer. METHODS: The instrument was translated and culturally adapted following the WHO four steps; 1) forward translation and back-translation, 2) expert panel, 3) pre-testing and 4) cognitive interviewing. The semantic validation of the pain quality descriptors was performed by healthy children and children with cancer aged 8-17 years, using the Q-sort method. RESULTS: A final Arabic version with 31 pain descriptors equivalent to the original tool was produced based on the results from the pilot study and the children's interviews. Children were able to differentiate between the different words they use to describe their pain. CONCLUSION: Our results showed that the Lebanese version of the APPT is a culturally sensitive tool to assess the location, intensity and quality of pain in Lebanese children with cancer. Health professionals are encouraged to use this tool to assess the pain characteristics in Lebanese children with cancer, hence leading to effective pain management.

Evidence on Nurse Staffing Ratios and Patient Outcomes in a Low-Income Country: Implications for Future Research and Practice.

BACKGROUND: Conclusive evidence on the effect of nurse staffing ratios on nurse-sensitive outcomes (NSOs) has not yet been achieved worldwide. AIMS: To describe the relationship between nurse staffing and NSOs at a Magnet designated, university hospital a low-income country. METHODS: A 48-month prospective study assessed the relationship between nurse staffing and six patient outcomes or NSOs in medical-surgical units and critical care units (CCUs). Nurse staffing was measured by nursing hours per patient day (NHPPD) and skill mix, whereas NSOs were total falls and injury falls per 1,000 patient days, percent of surveyed patients with hospital-acquired pressure injuries (HAPI), catheter-associated urinary tract infections, ventilator-associated pneumonia, and central line-associated bloodstream infections (CLABSI) per 1,000 central line days. RESULTS: The odds for total falls, injury falls, HAPI, and CLABSI in the medical-surgical units were higher with lower NHPPD ratios, OR = 4.67, p = .000; OR = 4.33, p = .001; OR = 3.77, p = .004 and OR = 2.61, p = .006, respectively. For the CCUs, lower rates of NHPPD increased the odds for total falls, OR = 6.25, p = .0007, HAPIs OR = 3.91, p = .001 and CLABSI, OR = 4.78, p = .000. Skill mix was associated with total falls, OR = 2.40, p = .005 and HAPIs OR = 2.07, p = .03 in the medical-surgical units but had no effect in any NSOs in the CCUs. LINKING EVIDENCE TO ACTION: Higher rates of nurses per patient were effective in improving some NSOs but not others. Skill mix had no effect on any of the six NSOs in the CCUs. As such, the results remain inconclusive as the benefits of the higher nurse to patient ratios in this low-income country warranting further multisite studies in different settings and countries.

The satisfaction of families in the care of their loved ones in CCUs in Lebanon.

BACKGROUND: The needs of family members vary among cultures and hospitals. Often, these needs remain unmet increasing their stress and anxiety and decreasing their satisfaction with care, which may negatively impact the quality of patient care. AIMS: To assess the satisfaction of families with the care of their loved ones in critical care units (CCUs) in a large university medical centre in Lebanon and to assess the predictors of satisfaction. METHODS: A cross-sectional descriptive design was conducted using the Critical Care Family Satisfaction Survey (CCFSS). The participants were 123 adult relatives or significant others of patients cared for in both adult and paediatric intensive care units for at least 3 days. RESULTS: The CCFSS showed acceptable internal reliability and construct validity in a Lebanese population. In general, families were satisfied with the care their loved ones received in the CCUs, and the least satisfaction was in the area of 'comfort' and the highest was in 'assurance'. Younger family members with more education were less satisfied with care and Christian families expressed less satisfaction with informational needs compared with Muslim families. Families of children in the paediatric CCU expressed least satisfaction with care. Gender, residency, relationship to patient, unit, prior experience in a CCU and diagnosis had no effect on satisfaction scores. CONCLUSIONS: Assessment of family satisfaction in different cultures is important as each culture has specific needs that are essential to decipher. IMPLICATIONS FOR PRACTICE: Patient satisfaction leads to improved quality of care; thus, it behoves nurses to meet the needs of families from different cultures to help them cope and increase their satisfaction, which leads to improve patient outcomes.

Distraction Using the BUZZY for Children During an IV Insertion.

UNLABELLED: Needle pricks are rated by children as their most feared medical event resulting in acute pain, anxiety and distress, which negatively affects both the child and his/her parents. OBJECTIVES: To investigate the effects of external cold and vibration via the "BUZZY" on pain ratings of children, their parents and nurses during peripheral IV insertion, to measure the time to a successful IV insertion and to assess the factors that are associated with pain perception of children. METHODS: In this randomized control trial (RCT), children between the ages of 4 to 12years were assigned to either an intervention or a control group. The intervention group (n=25) had the "BUZZY" applied during IV insertion while the control group (n=23) did not have the "BUZZY". Children were asked to rate their pain along with their parents and nurses on the Wong-Baker FACES Pain Rating Scale. Time to successful IV insertion and background characteristic of children were assessed and compared. RESULTS: Pain scores were significantly lower in the "BUZZY" group for children and the nurses. Time to a successful IV insertion did not differ between groups. Gender, age, previous hospitalization, diagnoses and analgesics were all factors associated with the children's pain scores. However, a multiple regression analysis found that only the "BUZZY" remained a significant predictor of pain scores in children. CLINICAL IMPLICATIONS: The "BUZZY" may be an easily accessed, inexpensive ($39.95 each at $0.09 per 3 minute stick), and effective technique to control or reduce pain in young children undergoing IV insertion.

NeoSeal to Prevent Nasal Injury in Preterm Infants Receiving Oxygen Therapy.

PURPOSE: To determine if a foam septum protector prevents nasal injury in preterm infants receiving nasal heated humidified oxygen. DESIGN: A retrospective before and after comparative design was used. SAMPLE: Medical records of 101 preterm infants receiving either nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV) were reviewed; 50 were in the control group and 51 were in the intervention group that had the NeoSeal septum protector applied. The groups were not different in terms of gender, birth weight, gestational age, days intubated, or on days on NCPAP/NIPPV. Skin condition of nares was scored daily using the Neonatal Skin Risk Assessment Scale (NSRAS). RESULTS: Infants who had the NeoSeal applied had significantly less nasal injuries, OR = 4.08; 95% confidence interval (CI), 1.22-9.59; p = .01. The best predictors of nasal injury were gestational age and whether the NeoSeal was applied or not.

Does administrative support negate the consequences of nurse abuse?

AIM: To assess the relationship between disruptive/abusive situations and the 'intention to leave' nursing. BACKGROUND: While every nurse deserves to feel safe in his or her working environment, nurse abuse remains a common occurrence worldwide. Only when hospitals are safe, is retention enhanced and patient care improved. METHOD: A cross-sectional survey was conducted with 1053 nurses. RESULTS: Almost 70% of nurses experienced stressful disruptive/abusive situations that were mainly caused by patients/families. The majority felt skilled in dealing with these situations, yet around 40% considered leaving nursing because of disruption/abuse. Stress from disruption/abuse, the skill in dealing with abuse and the administrations' support were the best predictors for the 'intention to leave'. CONCLUSIONS: It may not be the amount of abuse per se that affects the nurses' intention to leave, but rather how the abuse is perceived, the skill in dealing with it and the support received from administration. IMPLICATIONS FOR NURSING MANAGEMENT: The support received from nursing administration may negate the effect of stress and the 'intention to leave' because of disruptive/abusive situations. This should behove nurse managers and administrators to have a system in place to provide support for nurses, which in turn could improve job satisfaction and retention.

Substance abuse In Middle Eastern adolescents living in two different countries: spiritual, cultural, family and personal factors.

It is estimated that the percentage of students using illicit substances by sixth grade has tripled over the last decade not only in developed countries but in developing countries as well probably due to the transition to a more Western society. Although much has been done to understand the mechanisms underlying substance abuse, few studies have been conducted with minority ethnic and religious groups such as Middle Eastern Youth. The primary goal of this study was to determine whether there are differences in factors contributing to substance abuse in adolescents from Lebanon versus the U.S.A. and to decipher the role of spirituality, religion, and culture among other factors that may influence substance abuse. A correlational cross-sectional design was used with adolescents living in two different countries: Los Angeles, California and Beirut, Lebanon. Muslim adolescents had significantly less rates of alcohol and substance use than Christians in both Lebanon and Los Angeles. More years lived in the U.S.A. increases the likelihood of abuse for both Muslims and Christians. Attachment to God and family was negatively associated with substance abuse. These results among others facilitate a better understanding of the influence of culture, religion, family and personal factors on substance abuse. Culturally sensitive interventions could benefit from the findings of this pilot study.

Implementing a Rapid Response Team: A Quality Improvement Project in a Low- to Middle-Income Country.

BACKGROUND: The benefits of rapid response teams (RRTs) have been controversial with few studies conducted in low- to middle-income countries. OBJECTIVE: The aim of this study was to investigate the effectiveness of implementing an RRT on 4 patient outcomes. METHODS: We conducted a quality improvement pre-and-post design using the Plan-Do-Study-Act model in a tertiary hospital in a low- to middle-income country. We collected data before and after implementing the RRT in 4 phases and over 4 years. RESULTS: Survival to discharge after cardiac arrest was 25.0% per 1000 discharges in 2016 and increased to 50% in 2019, a 50% increase. The rate of activations per 1000 discharges was 20.45% for the code team in 2016 and 33.6% for the RRT team in 2019. Thirty-one patients who arrested were transferred to a critical care unit before implementing the RRT, and 33% of such patients were transferred after. The time it took the code team to arrive at the bedside was 3.1 minutes in 2016 and decreased to 1.7 minutes for the RRT team to arrive in 2019, a 46% decrease. DISCUSSION AND CLINICAL IMPLICATIONS: Implementing an RTT led by nurses in a low- to middle-income country increased the survival rate of patients who had a cardiac arrest by 50%. The role of nurses in improving patient outcomes and saving lives is substantial and empowers nurses to call for assistance to save patient lives who show early signs of a cardiac arrest. Hospital administrators should continue to use strategies to improve nurses' timely response to the clinical deterioration of patients and to continue to collect data to assess the effect of the RRT over time.

Predictors of coping in parents of children with an intellectual disability: comparison between Lebanese mothers and fathers.

This cross-sectional study was designed to assess the predictors of coping behaviors of 147 Lebanese parents (101 mothers and 46 fathers) with a child with intellectual disability. It assessed the contribution of child's and parent's characteristics, informal social support, and stress on the coping behaviors of fathers and mothers. Multiple regression analysis confirmed that the father's education, informal social support, and stress were the best predictors of coping. The child's age, severity of illness, and parental health did not significantly contribute to predicting coping behaviors. Contrary to expectations in a Middle Eastern culture, both fathers and mothers reported similar levels of stress, perceived informal social support, and coping. Although informal social support cannot be forced on parents, health professionals can mobilize resources that are culturally sensitive, such as home visitation by nurses or support from other parents. This may especially be beneficial in developing countries with limited resources.

Determinants of premature infant pain responses to heel sticks.

The exposure of premature infants to stressors, such as pain intended to ensure their survival, may instead alter their brain development and contribute to several learning and behavioral difficulties observed in later childhood. The objective of this descriptive, cross-sectional study was to compare the pain responses of 72 preterm infants to a heel stick procedure taking into consideration a variety of factors, including the use of opioids and sedatives. The pain scores assessed on the Preterm Infant Pain Profile (PIPP) scale were highest for the lowest gestational age (GA) group. Multiple linear regression analysis with the four predictor variables noted to be correlated with the PIPP scores (GA, type of needle, severity of illness, and behavioral state) indicated a significant overall relationship (F [5/66] = 5.62, p < 0.01) and accounted for 44% of the variance. All but severity of illness did not add significantly to the variance. Gender, postnatal age, amount, opioids, and sedatives used were not correlated to the PIPP scores. It was concluded that sick premature infants and those who have been exposed to a variety of painful procedures may not manifest behavioral or physiological signs of pain, but may be the most to benefit from precise pain assessment and prudent management.

The psychometric properties of the Ages and Stages Questionnaires-3 in Arabic: Cross-sectional observational study.

BACKGROUND: Screening for developmental delay is recommended for pediatricians, yet validated screening tools in Arabic are scarce. AIMS: Assess the reliability, validity, sensitivity and specificity of the Arabic ASQ-3 in detecting developmental delays in children aged 4-33 months. STUDY DESIGN: Cross-sectional observational study. SUBJECTS: A sample of 491 children from all Lebanese governorates from five age groups (4, 10, 18, 27 and 33 months). OUTCOME MEASURES: Internal consistency using Cronbach's alpha (Cα), convergent construct validity using Pearson Correlation Coefficient (CC) comparing ASQ-3 in Arabic (A-ASQ-3) to Bayley scale for infant development (BSID-III) scores were computed. A subset sample (n = 35) underwent assessment with BSID-III for convergent validity, and sensitivity and specificity. A-ASQ-3 scores were compared to the US mean cutoff scores. RESULTS: Subjects' mean age was 17.75 ±â€¯10.6 months. Cα was 0.85; Pearson CC showed positive moderate correlation between A-ASQ-3 gross and fine motor scores and BSID-III composite motor scores (r = 0.42, p = 0.002; r = 0.39, p = 0.004, respectively); and positive moderate correlation between A-ASQ-3 problem solving and BSID-III cognitive scores (r = 0.43, p = 0.001). A-ASQ-3 had 100% sensitivity and 50% specificity for cognitive scores; 60% sensitivity and 70% specificity for motor scores. CONCLUSION: A-ASQ-3 has adequate reliability and validity for the tested age groups. It is plausible that this would hold true for the rest of the questionnaires. Further testing is needed to make the five clusters more aligned with the US sample scores and to improve the sensitivity and specificity.

Pragmatic Trial to Evaluate the Effect of a Promotora Telephone Intervention on the Duration of Breastfeeding.

OBJECTIVE: To evaluate the effectiveness of a telephone intervention delivered by promotoras (lay health care workers) to increase the duration of exclusive breastfeeding (EBF) in Hispanic women at 12 weeks postpartum. Secondary objectives were to assess breastfeeding duration (BFD) and to evaluate background variables that may be associated with EBF and BFD. DESIGN: Pragmatic trial. SETTING: Two obstetric clinics affiliated with a community medical center in Southern California. PARTICIPANTS: We recruited 61 participants from the two clinics. Participants were 18 to 45 years old and planned to breastfeed their infants. Women who showed interest in the study were sequentially divided into an intervention (n = 31) or a control group (n = 30). METHODS: The intervention consisted of telephone support for breastfeeding provided by certified and trained promotoras. RESULTS: Fourteen out of 31 (45%) participants in the intervention group continued to practice EBF compared with 4 out of 30 (13%) in the control group (odds ratio = 3.39, p = .04). Breastfeeding duration in days was significantly longer for the participants in the intervention group (F =1/59 = 29.88, p < .01). The positive predictors of EBF at 12 weeks after birth were prior breastfeeding experience, perceived breastfeeding support, promotora telephone support, and higher scores on the acculturation scale. Positive predictors of BFD were breastfeeding support, promotora telephone support, and higher scores on breastfeeding self-efficacy. A negative predictor was lower household income. CONCLUSION: Our results indicate that a telephone support intervention delivered by promotoras may increase the rates of EBF by threefold at 12 weeks after birth.

Breast Cancer Risk Factors: a Cross- Cultural Comparison between the West and the East

Background: The incidence of breast cancer in Lebanon is higher than any other Middle ­Eastern country, is diagnosed at a younger age than women in Western countries, and is more aggressive and fatal. Therefore addressing risk factors in this population is of paramount importance. Methods: A descriptive cross-sectional, comparative design evaluated the risk factors for breast cancer in a convenient sample of 105 Lebanese-American women with 250 Lebanese. Odds Ratio, Chi square t-tests or ANOVA were used to compare the two groups' risk factors and knowledge of screening tools. Associations found to be statistically significant were included in three multiple logistic regression models to estimate the odds of each variable for performing a mammography, a clinical breast exam (CBE) and a breast self-exam (BSE). Results: There were more Muslims in the Lebanese-American sample who perceived having a better income, and had a better understanding of the effectiveness of the mammogram, the CBE and the BSE. The Lebanese group reached menopause at an older age, t = 2.66, p = 0.05, smoked more, OR = 1.42, p = 0.001 and were five times more likely to live close to a main road or highway, OR = 5.75, p = 0.001 than the Lebanese-American group. The Lebanese- Americana group breast fed longer χ2= 11.68, p = .008, used contraceptives more, OR = 1.74, p = 0.027, exercised more, OR = 1.61, p < 0.001, and consumed more vegetables and fruits than their Lebanese counterparts, OR= 1.22, p = 0.002, and OR = 1.27 p = 0.001, respectively. For ever having a mammogram, the duration of breastfeeding (>6 months), effectiveness of the mammogram, and exercise were significant predictors. While for ever having a CBE, smoking, eating fruits, and exercise were significant. No variables were related to performing a BSE. Conclusion: The Lebanese women had higher risk factors for developing breast cancer, and had less knowledge of the benefits of breast cancer screening tools, calling for the importance of promoting healthy life styles and education.

Is the Effect of Postpartum Depression on Mother-Infant Bonding Universal?

PURPOSE: Although the negative consequences of maternal depression on infants has been documented in several Western societies, similar studies have not been conducted in Middle-Eastern countries where cultural norms and traditions may differ. The main objective of this study was to determine the risk factors for postpartum depression (PPD) and its relationship to mother -infant bonding in a Lebanese population. METHODS: One hundred and fifty participants were administered the Edinburgh Postpartum Depression Scale (EPDS), and the social support scale at 2-3 days postpartum. At 10-12 weeks mother-infant bonding using the Postpartum Bonding Questionnaire (PBQ) and depression using the Beck Inventory (BDI-II) were assessed during a telephone interview. RESULTS: The prevalence of depression was 19% with an average score of 10.9 ±â€¯6.02 on the EPDS. At 10-12 weeks 2.7% of the whole sample was depressed with an average score of 18.60 ±â€¯16.87 on the BDI-II. Risk factors of PPD on the EPDS were; history of alcohol use, complications during pregnancy, not a good marital relationship, baby admitted to an intensive care unit, history of depression and low social support. Risk factors for impaired bonding were age, history of depression, BDI-II scores above 20 and low social support. The multiple regression analysis found that impaired bonding was associated with older age, history of depression and low social support, which explained 39% of the variance, F = 7.12, p = 0.02. CONCLUSION: The prevalence of PPD was higher than previously reported at day 2-3 post-delivery, but lower at 10-12 weeks postpartum. Impaired mother- infant bonding was associated older mothers, history of depression, low social support and BDI-II scores above 20 which should alert practitioner to assessing these factors in post-partum mothers.