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OBJECTIVES: To examine pain and spirituality, demographic/clinical factors associated with pain and spirituality, the contribution of spirituality to experiences pain over time, and how pain and spirituality relate to engagement with a caregiver-delivered intervention. SAMPLE & SETTING: Women with advanced breast cancer (n=256) enrolled in a home-based randomized controlled trial of foot reflexology. METHODS & VARIABLES: Secondary analyses were conducted with baseline and post-intervention data (including reflexology and control groups). Stepwise model building, linear mixed effects modeling and negative binomial regression were employed. Measures: Patient Reported Outcomes Measurement Information System-pain intensity; Long-Term Quality of Life- Spiritual/Philosophical subscale; demographic/clinical variables. RESULTS: Mean pain was 3.6/10 and spirituality was 3.2/4.0 at baseline. Participants who were younger (p

Sleep and fatigue-associated symptoms are prominent during chemotherapy. The purpose of this pilot study was to examine bright light effects on sleep disruption, fatigue, daytime sleepiness, depression, and quality of life (QOL) in women with stage I-III breast cancer undergoing chemotherapy. In this 2-group randomized controlled trial (NCT02658708), participants were randomized to receive either blue-green light of 12,000 lux (experimental) or dim red light of 5 lux (control). Light therapy was self-administered using a light visor cap at home. Both groups received 30-minute daily light therapy for 21 consecutive days following the 2(nd) cycle of chemotherapy. Sleep quality, fatigue, daytime sleepiness, depression, and QOL were self-reported, and nocturnal sleep was monitored by ambulatory polysomnography before the initiation of chemotherapy (baseline) and following the light intervention (post-test). Relative change was assessed at post-test controlling for pretest scores. At post-test, the experimental group self-reported significantly shorter sleep latency than controls (10 vs. 20 min, p=.045) consistent with polysomnography findings (14 vs. 63 min). Polysomnography also revealed longer total sleep time (467 vs. 315 min) and higher sleep efficiency (74% vs. 58%) in experimental vs. controls. Participants receiving bright light experienced a 30% relative decrease in depression, while there was a 24% increase in the controls. The experimental group reported substantially fewer increases in symptom intensity than controls (33% vs. 166%). These findings suggest that bright light likely improved sleep quality and depression and mitigated worsening intensity of symptoms during the first three cycles of chemotherapy. However, features of bright light, e.g., treatment duration, frequency, and timing in relation to chemotherapy treatment require further investigation.

Studies analyzing depressive symptoms across chronic disease populations are limited. Our descriptive comparison investigation included two studies on life-limiting conditions: Human Immunodeficiency Virus (HIV) and breast cancer. In both, depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale (CES-D). We found a mean depression score of 18.1 (± 11.8) overall ( N = 243). Over half (54%) reported clinically significant depressive symptoms (CES-D ≥ 16); 26% reported severe depressive symptoms (CES-D > 24). Disease and years of education were predictors of depressive symptoms. Persons living with breast cancer showed significantly worse depressive symptoms than persons living with HIV (p < 0.0001). After adjusting for disease, fewer years of education predicted worse depressive symptoms (p < 0.0001). This study demonstrated common determinants of depressive symptoms in both disease populations, suggesting that underlying conditions known to be predictors of depression could be assessed to identify those at higher risk for depression.

BACKGROUND Cancer patients often have other noncancer medical conditions. Presence of comorbidities negatively affects cancer survival. OBJECTIVE The aim of this study was to investigate comorbidity, risk factors for comorbidity, and how comorbidity was associated with symptoms and quality of life in patients being treated for breast cancer. METHODS One hundred and one breast cancer chemotherapy outpatients completed this study. Comorbid conditions, weight, height, and smoking status were identified by chart review. Symptoms and quality of life were self-reported using psychometrically sound instruments. Log-linear regression analyses with age as the covariate examined impact of ethnicity, body mass index (BMI), and smoking on comorbidities. RESULTS Approximately 84% of the participants had 1 or more comorbid conditions. Adjusting for age, number of comorbidities differed by BMI (P = .000); the obese group had significantly more comorbidities than the normal and overweight groups. The interaction between BMI and smoking was significant (P = .047). The obese participants who smoked had significantly more comorbidities compared with those who were obese but did not smoke (P = .001). More comorbid conditions were associated with greater pain (P < .05) and poorer sleep quality (P < .05). Comorbidity significantly correlated with symptoms and functional aspects of quality of life (P < .01 and P < .05, respectively). A greater number of comorbidities was associated with lower physical and role functioning and worse fatigue, dyspnea, appetite loss, and nausea and vomiting (all P < .05). CONCLUSIONS Comorbidity exerts negative impacts on symptoms and quality of life. Weight and smoking status are strong determinants of breast cancer comorbidity. IMPLICATIONS FOR PRACTICE Personalized care planning, weight management, and smoking cessation may lead to better cancer outcomes.

Context— No tools exist to measure patients' self-efficacy for and adherence to the complex home-care regimen after having a left ventricular device (LVAD) implanted. Objective— To develop 2 new instruments, the LVAD Patient Self-Efficacy Scale (LPSES) and the LVAD Patient Home Management Adherence Scale (LPHMAS), and evaluate their psychometric properties. Methods— This multistage instrumentation study recruited 102 patients (77.5% men and 22.5% women) aged 20 to 82 years, predominantly from the Midwest (34.3%) and the Northeast (26.5%) regions of the United States. Main indications for LVAD were bridge-to-transplant (69.6%) and destination therapy (21.6%), with mean implant duration of 19.9 (SD, 15.5) months. Study participants completed the following instruments: LPSES, LPHMAS, General Self-Efficacy Scale (GSES), Medical Outcomes Study General Adherence (MOSGA), and Self-Care Heart Failure Index (SCHFI) confidence and maintenance subscales. Item analyses, psychometric properties including factorial and convergent validities, and internal consistency reliability were tested. Results— Factor analyses showed that the variances for the 20-item LPSES and 9-item LPHMAS were 60.2% and 53.6%, respectively. Convergent validity of the newly developed instruments was supported by the following correlations: LPSES and GSES ( r = 0.34); LPSES and SCHFI-confidence ( r = 0.60); LPHMAS and MOSGA ( r = 0.33); LPHMAS and SCHFI-maintenance ( r = 0.40). Internal consistency reliability coefficients were 0.94 (LPSES) and 0.84 (LPHMAS). Based on these data, the LPSES and LPHMAS are valid and reliable measures of self-efficacy and adherence specific for LVAD patients. Confirmatory testing is needed to further support the validity of these instruments for use in research and clinical practice.

There is no empirical study about the context and influence of self-management (SM) factors on quality of life (QOL) among adults with left ventricular assist device (LVADs). The purpose of this study was to close this knowledge gap by: (1) differentiating select SM factors (e.g., cognition) and overall QOL based on LVAD implant durations; (2) examining the relationships among SM factors and QOL variables; and (3) identifying which SM factors predict QOL.An observational study was employed including 87 LVAD patients, ages 20 to 80 years, with mean implant durations of 18.5 ± 15.1 months. Patients completed 1 demographic questionnaire and 6 measures of SM factors (cognition-general and executive function, LVAD self-efficacy, care dependency and adherence) and QOL. Data were analyzed with descriptive and inferential statistical procedures.There was no significant difference in SM factors and overall QOL by LVAD implant durations. SM factors, including cognitive function, LVAD self-efficacy, and adherence, correlated positively with QOL (r = 0.35 to 0.48, p0.05), but LVAD care dependency correlated negatively with QOL (r = -0.21, p0.05). The general and executive function of cognition and LVAD adherence were significant predictors of QOL.The data inferred that higher level of cognitive function is associated with higher self-efficacy, adherence and greater QOL, whereas lower care dependency is associated with greater QOL. Higher cognitive function and adherence to the LVAD care regimen predicted better QOL outcome. Further research is needed to elucidate the mechanism by which SM factors influence QOL in adults with long-term LVADs.

Although sudden fatigue/exhaustion is a symptom expression that oncology clinicians frequently hear from their patients, empirical information about this phenomenon is limited. This study investigated the occurrence and characteristics of sudden fatigue in patients treated for breast cancer. This cross-sectional descriptive study enrolled 114 breast cancer chemotherapy outpatients from a cancer clinic and an urban teaching hospital in the Midwestern United States. Subjects were screened for sudden fatigue and completed an investigator-developed Sudden Onset of Fatigue Questionnaire on the day of their chemotherapy treatment. Descriptive statistics were used to examine prevalence and clinical characteristics. Approximately half (46 %) of the patients (age 31–67, 62 % Black, and 70 % unemployed) experienced sudden fatigue. The majority (81 %) reported more than one (median = 3) episode per day; 67 % of episodes lasted 60 min or less. The sudden fatigue was most likely (77 %) to occur between 10 a.m. and 5 p.m., while individuals were active (94 %). When it occurred, individuals stopped activities and sought immediate rest. It was described as abrupt exhaustion/weakness often (66 %) accompanied by other symptoms. Fatigue intensity before, during, and after a specific episode were 5, 9, and 5, respectively, on 0–10 (highest) scale. To better characterize sudden fatigue, a new descriptor, sudden exhaustion syndrome, which encompasses observed abrupt onset, transitory exhaustion/paralysis, and multiple symptoms, is proposed. Individuals may experience multiple occurrences of sudden exhaustion across a day, especially during activities. The syndrome needs to be recognized by oncology professionals. Patients should be educated about the syndrome to enhance sense of control and prevent harm.

The strong and potentially reciprocal relationship between cancer-related fatigue (CRF) and disrupted sleep-wake patterns suggests a possible shared physiologic pathway. A growing body of evidence supports this and shows that abnormalities in the 24-hour rhythm of stress-related hormones may be related to chronic fatigue and sleep disturbances. Aberrations in the hypothalamic-pituitary-adrenal (HPA) axis, the primary neuroendocrine interface responding to stress, induce important biologic and behavioral consequences. HPA aberrations have long been associated with chronic fatigue syndrome. Many overlapping symptoms exist between chronic fatigue syndrome and CRF, including sleep disruption. Therefore, in the absence of knowledge about CRF mechanisms, emerging biologic models from chronic fatigue syndrome may assist in understanding the cause of CRF. Cancer-associated stressors also may alter the circadian functions of HPA-associated neuroendocrine activities, which result in the symptoms of fatigue and disrupted sleep-wake patterns in patients with cancer. Exploring promising physiologic models furthers the knowledge about CRF and disrupted sleep and may foster hypothesis-based studies of mechanisms that underlie apparent overlapping symptoms, providing the basis for new management to improve sleep and lessen fatigue.

Prevention of pressure ulcers is fundamental to safe care of nursing home residents yet the role of hydration in pressure ulcer prevention has not been systematically examined. This randomized clinical trial was undertaken to determine whether administration of supplemental fluid to nursing home residents at risk for pressure ulcers would enhance collagen deposition, increase estimated total body water, augment subcutaneous tissue oxygenation, and was safe. After a baseline period, 64 subjects were randomized to receive the fluid volume prescribed or additional fluid (prescribed plus 10 mL/kg) for 5 days. Participants' potential to heal as measured with hydroxyproline was low at baseline and did not increase significantly during treatment when additional fluid was systematically provided. Fluid intake increased significantly during treatment. Estimates of total body water and subcutaneous oxygen did not increase, indicating hydration was not improved. Supplemental fluid did not result in overhydration as measured by clinical parameters. Further work is needed to examine the relationship between fluid intake and hydration in nursing home residents as well as the role of hydration in pressure ulcer prevention.

E90 Cancer-related fatigue (crF) is a significant and highly prevalent clinical problem. it is long lasting and characterized by a significant temporal variability. The symptom often is not continually present but comes and goes in a somewhat roller coaster fashion (Berger, 1998). crF affects all aspects of patients’ lives and decreases quality of life. Although fatigue is one of the most impairing cancer-related Patterns of Fatigue and Effect of Exercise in Patients Receiving Chemotherapy for Breast Cancer

Summary Fatigue is highly prevalent among persons with cancer and has great impact on their lives. The cancer-related fatigue (CRF) experience is subjective and multidimensional; understanding it from the individual's perspective is essential. This qualitative study explored the meaning of CRF from the individual's perspective. A phenomenological approach, embodiment, served as the philosophical framework. The study was conducted in a freestanding outpatient cancer clinic in a major metropolitan area. Ten cancer patients who were undergoing chemotherapy received audio-tape recorded semi-structured individual interviews and six completed a 2-week daily diary keeping activity. Data analysis proceeded through reduction methodology to seek commonalities in meanings, situations, and embodied experiences. The analysis resulted in the following thematic categories: different fatigue, physical sensations, "I cannot…", emotional sensations, gaining sense of control, fatigue as holistic experience. Participants described fatigue of an unexpected kind and degree that was much more than just being tired. Their inability to anticipate the scope of CRF and lack of awareness of strategies to combat CRF distressed some participants. Various individual strategies, based on personal experience, were developed to regain a sense of control. Health care providers can be instrumental in enabling cancer patients to recognize and manage CRF.

Background: Unexplained prolonged fatigue (UPF) is one of the most common complaints in primary care. UPF is difficult to manage because of its nonspecific nature and unknown mechanism. UPF frequently frustrates health care professionals and has negative impacts on the physician-patient relationship. Although it is nonfatal, fatigue-associated functional impairments and economic consequences are substantial, negatively impacting patients' quality of life.Objectives: To evaluate current knowledge development of UPF and to help focus the direction of future investigations.Methods: A literature review was undertaken with the MEDLINE databases chosen as the primary electronic resources to retrieve the literature.Results: Current understanding of UPF is limited. Lack of consistent scientific language is a major problem. There is no consensus about the case definition of UPF even for the most widely studied chronic fatigue syndrome (CFS). Various sets of classification have been developed, each with sim...

Background Cancer has a great impact on the well-being of affected persons and their caregivers long into survivorship. Objective This article reviews the state of science on the survivorship experience of cancer survivors and caregivers, with a focus on symptom burden and quality of life (QOL) after treatment termination. Methods The primary databases utilized included PubMed and CINAHL. Search results were limited to human participants, English language, and publications from 2008 to 2013. The articles retrieved included studies of prostate, breast, colorectal, and gynecologic cancers during adulthood. Results As many as a third of cancer survivors experienced symptoms after treatment cessation equivalent to those experienced during treatment. Fatigue, depression or mood disturbance, sleep disruption, pain, and cognitive limitation were commonly reported by survivors across various malignancies; depression, anxiety, and sleep disturbance affected some caregivers. The studies indicated residual symptoms that extend into survivorship have a great impact on QOL and are associated with disability and healthcare utilization. Younger age, lower socioeconomic status, and increased comorbidities are associated with poorer QOL and higher symptom distress in cancer survivors. Younger age and lower income are associated with greater distress and poorer QOL in caregivers. Conclusions Survivors and caregivers struggle with symptom burden and diminished QOL long into survivorship. Longitudinal studies are needed to investigate the persistence and severity of symptom burden over time as well as long-term and late effects of these symptoms. Implications for practice Interventions designed to help alleviate symptom burden in those most affected are needed.

Purpose/objectives To describe current nursing practices in the United States regarding care and safety of patients taking oral chemotherapy. Design This three-phase study consisted of development, validation, and implementation of a national online survey. Setting Survey of oncology nurses in outpatient settings. Sample 577 oncology nurses. Methods Surveys were emailed to 5,000 members of the Oncology Nursing Society. The survey included 17 forced-choice items and one free-text item. Descriptive statistics and content analysis were obtained. Main research variables Patient care practices, nursing resources, and barriers to medication adherence. Findings Fifty-one percent of the respondents worked in practices that had developed specific policies, procedures, and resources for patients on oral chemotherapy. Barriers to treatment adherence included cost (81%) and adverse effects (72%). Practices with specific policies differed in clinical and statistical significance from practices without policies on almost every survey item. Free-text responses revealed that many practices have erratic procedures and inadequate interdisciplinary communication. Conclusions Systematic reliable policies and procedures for patient education, documentation, and interdisciplinary communication are urgently needed. Implications for nursing Nurses should provide education and repeated teaching to improve patient safety, adherence to the medication, and self-monitoring for adverse effects.

Pressure ulcers are areas of tissue damage caused by unrelieved pressure that results in ischemia. About 70% of pressure ulcers occur in adults who are older than 65 years of age; the most common sites are the sacrum and heels. The rate at which new ulcers develop in acute care settings varies from 0.4% to 38%, with a mean incidence of about 7%. Recovery in patients who have pressure ulcers is delayed, as demonstrated by an increased length of hospitalization and increased health care costs. This article addresses recovery in older adults who are at risk for the development of a pressure ulcer.

Cancer-related fatigue (CRF) is a significant clinical symptom. Effective assessment of CRF attributes from the patients' perspective is essential. This study tested the psychometric properties of the Wu Cancer Fatigue Scale (WCFS). A total of 172 outpatients with breast cancer, who were at various stages and on various chemotherapy regimens, and were undergoing treatment at one of three cancer clinics in a Midwest metropolitan area, participated in this study. The participants were instructed to complete four instruments in the following order: the 16-item WCFS, Schwartz Cancer Fatigue Scale (SCFS), Geriatric Depression Scale (GDS), and Cancer-Related Fatigue Distress Scale (CRFDS). Structural equation modeling (LISREL 8.54) supported the one-factor measurement model with nine items remaining. Nonsignificant Satorra-Bentler Scaled Chi-square (27)=32.52, P=0.21, standardized root mean square residual=0.032, nonnormal fit index=0.97, comparative fit index=0.98, and incremental fit index=0.98 indicated a good model fit. Convergent validity with the SCFS was 0.78, concurrent validity with the GDS was 0.60, and predictive validity with the CRFDS was 0.73. Internal consistency reliability was α=0.91 for the nine-item scale. The revised WCFS is a reliable and valid instrument that aims to measure the subjective characteristics of CRF from the patients' perspective. It may prove useful in both clinical and research settings.

Hyperbaric oxygen therapy, a treatment alternative for chronic wounds, has been used for several decades yet little is known about factors that influence physicians to incorporate this therapy into practice. To assess wound care physician knowledge of, attitudes toward, and adoption of hyperbaric oxygen therapy and to identify factors associated with physician adoption of this therapy, a 23-item questionnaire, based on Rogers' diffusion of innovation model, was developed by the authors and distributed to 653 American Academy of Wound Management Board-certified physicians. Of the 246 (43%) physicians in the study population who responded to the study survey, 167 (68%) reported they had used or referred patients for hyperbaric oxygen therapy during the past 12 months. More than half of the respondents reported a relatively high level of familiarity with and a positive attitude toward the effects of hyperbaric oxygen therapy on wound healing. Physician adoption of hyperbaric oxygen therapy was significantly associated with a community of100,000 residents (adjusted odds ratio = 2.29, 95% confidence interval = 1.05 to 5.04); patient request for hyperbaric oxygen therapy (adjusted odds ratio = 5.38, 95% confidence interval = 2.50 to 11.56); positive attitude toward (adjusted odds ratio = 3.38, 95% confidence interval = 1.49 to 7.66) and high level of familiarity with hyperbaric oxygen therapy (adjusted odds ratio = 5.33, 95% confidence interval = 1.72 to 6.49); and practice location in either Florida or Texas (adjusted odds ratio = 3.44, 95% confidence interval = 1.24 to 9.54). Although the majority of the respondents reported adoption of hyperbaric oxygen therapy, most adopters are concentrated only in a few geographic areas. Despite the limitations of this study, especially the potential effects of sampling and response bias, the results help explain factors that have facilitated and hindered the adoption of this technology into practice.

BACKGROUND Cancer-related fatigue (CRF) is a highly prevalent, subjective experience of patients with and survivors of cancer. Effective assessment of the attributes of CRF from the patient's perspective is essential. The current study developed a measure of CRF from the patient's perspective and determined its psychometric properties for patients with cancer undergoing chemotherapy. METHODS Chemotherapy outpatients in a free-standing metropolitan area cancer clinic participated in the current multiphase study. In the instrument development phase, 42 items were generated from a qualitative study with 10 semistructured individual interviews and 6 daily fatigue diaries. These items were revised based on content evaluation by 20 cancer patient content experts. In the instrument analysis phase, the 30 content-validated items were pilot tested by 30 patients with breast carcinoma using cognitive interview techniques. The psychometric properties of the resulting 16-item, 5-point CRF rating scale were tested with 82 patients with breast carcinoma. RESULTS Principal axis factoring gave a one-factor solution accounting for 59% variance. Coefficient alpha reliability was 0.95 for the final 15-item scale. Convergent validity with the Schwartz Cancer Fatigue Scale was 0.84, concurrent validity with the Geriatric Depression Scale was 0.61, and predictive validity with the Cancer-Related Fatigue Distress Scale was 0.83. CONCLUSIONS This newly developed instrument to assess the subjective fatigue symptoms of patients with cancer demonstrated effective use of diary and interview methods in instrument development and both cognitive interviewing and traditional psychometric techniques in instrument analysis. The instrument has promising psychometric properties, but confirmatory testing is needed. Cancer 2004. © 2004 American Cancer Society.