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BACKGROUND: The services of Healthcare and Social Assistance (HCSA) workers are needed by society around the clock. As a result, these workers are exposed to shift work and long work hours. The combination of demanding work schedules and other hazards in the HCSA work environment increases the health and safety risks to these workers, as well as to their patients/clients and the public. METHODS: This paper has three aims: (1) provide an overview of the burden of shift work, long hours, and related sleep and fatigue problems in this sector; (2) suggest research priorities that would improve these ; and (3) discuss potential positive impacts of addressing these research priorities for the health and safety of workers and the public. The authors used a modified Delphi approach to anonymously rank-order priorities for improving HCSA worker health and safety and public safety. Input was also obtained from attendees at the 2019 National Institute for Occupational Safety and Health (NIOSH) Work Hours, Sleep, and Fatigue Forum. RESULTS: The highest rated research priorities were developing better designs for work schedules, and improving the HCSA culture and leadership approaches to shift work and long work hours. Additional priorities are identified. CONCLUSION: Research in these priority areas has the potential to benefit HCSA workers as well as their patients/clients, employers, and society.

La sociedad necesita servicios de enfermería esenciales a toda hora y, por ende, los enfermeros suelen trabajar por turnos y jornadas laborales extensas. Estos horarios pueden impedir que los enfermeros tengan las siete horas o más a diario de sueño de buena calidad que los expertos recomiendan (Watson, et al., 2015). Los enfermeros que trabajan por turnos y jornadas laborales extensas están en riesgo de tener enfermedad cardiovascular, trastornos gastrointestinales y sicológicos, cáncer, diabetes tipo 2, lesiones, trastornos osteomusculares, mortalidad por cualquier causa, desenlace reproductivo adverso y dificultad para manejar enfermedades crónicas (Caruso, et al., 2017; Caruso & Waters, 2008; Gan, et al. 2015; Gu, et al., 2015; DHHS, 2018; IARC Monographs Vol 124 Group, 2019; NIOSH, et al., 2015; Ramin, et al., 2014; Torquati, et al., 2017). Además, los enfermeros cansados están en riesgo de cometer errores en la atención de los pacientes y de sufrir accidentes vehiculares debido al estado de somnolencia (Bae y Fabry, 2014; Ftouni, et al., 2013; Geiger-Brown, et al., 2012; Geiger-Brown y Trinkoff, 2010; Lee, et al., 2016; Trinkoff, et al., 2011). La presencia del trabajo por turnos y jornadas laborales extensas también está relacionada con problemas de retención e incluso con la expresión por parte de los enfermeros de la intención de dejar o abandonar el trabajo (Hayes, et al., 2012; Moloney, et al., 2018). Estas condiciones han contribuido también a la escasez de enfermeros en ciertas especialidades y lugares de ejercicio de la profesión (Marc, et al., 2018). La escasez es una gran preocupación dado que la población envejece y se proyecta un fuerte aumento de la necesidad de enfermeros (Auerbach, Buerhaus y Staiger, 2017). De este modo, se requieren de manera apremiante intervenciones para reducir la fatiga en la enfermería. La Academia Estadounidense de Enfermería (la Academia) respalda los esfuerzos por reducir la fatiga en los enfermeros mediante educación, políticas en el lugar de trabajo y sistemas de gestión, así como medidas de respuesta a la fatiga. La Academia recomienda que los servicios de atención médica y las entidades normativas establezcan políticas para abordar este peligro generalizado en el lugar de trabajo, y promover así la salud y seguridad de los enfermeros junto con la seguridad de los pacientes y el público.

Objective: Evidence is scant regarding symptom clusters and quality of life (QOL) over 1 year in women who receive adjuvant breast cancer chemotherapy (CTX). Our purpose was to identify the prevalence and severity of individual symptoms, symptom clusters, and QOL in women receiving adjuvant breast cancer CTX from baseline over 1 year. Methods: Symptoms were identified in a sample (n = 219) at three times: baseline (prior to the first adjuvant CTX treatment), 1 month after the last CTX (approximately 6 months after baseline), and 1 year after baseline. The Hospital Anxiety and Depression Scale and Symptom Experience Scale measured symptoms. The Medical Outcomes Study, Short-Form Survey, measured QOL. Exploratory factor analysis identified symptom clusters at each time and core symptoms in clusters over time. Results: The prevalence and severity of 10 symptoms decreased over time (P < 0.05). Fatigue, sleep disturbance, and pain were most prevalent; all were of mild severity. Two symptom clusters were identified at baseline and one met internal consistency reliability criteria at the later times. Core symptoms were identified. Both the physical and mental component scores of QOL improved over time (P < 0.01), but physical was below the general population norms 1 year after baseline. Conclusions: The symptom experience was dynamic, and symptom clusters changed over 1 year. Despite mild severity, core symptoms and clusters persisted over 1 year, and physical health was below the general population norms. Breast cancer survivors with persistent single and co-occurring symptoms need to be taught to manage the patterns of symptoms over time because they may not resolve by 1 year.

Fatigue is the most reported and most distressing symptom among patients with cancer. However, no questionnaire that measures fatigue and fatigue interference with life has been translated into Arabic.This study aimed to translate and validate the Arabic version of the Brief Fatigue Inventory (BFI-A).The BFI was translated into Arabic using the forward-backward translation technique. This cross-sectional study collected data from cancer patients through a self-administered questionnaire that included the BFI-A, Insomnia Severity Index (ISI), Zung Depression Scale (ZDS), MD Anderson Symptom Inventory total score (MDASI), and Medical Outcome Study Short Form 36 (SF-36) Vitality Subscale. Descriptive and inferential statistics were used including mean, standard deviation, internal consistency, and correlation coefficient using Pearson's correlation.A total of 79 patients were recruited in Amman, Jordan, in 2015. Mean of the total BFI-A was 4.01 (2.4), showing that 83.5% had nonsevere fatigue. Cronbach's α coefficient of the BFI-A was 0.93. The correlations between total BFI-A scores and BFI-A items were significant (P0.05) and ranged from 0.75 to 0.86. BFI-A showed a significant correlation (P0.05) with the following tools: ISI = 0.70, ZDS = 0.69, MDASI = 0.75, and SF-36 Vitality Subscale = -0.57.This study suggests that the BFI-A is a reliable and valid tool to assess fatigue among Arab cancer patients.دراسة للتحقق من النسخة العربية لمقياس التعب الوجيز (BFI–A).خالد سليمان، محمود الكلالدة، لؤي أبو شحرور، برنيس ييتس، آن بيرجر، تيتو مندوزا، ملكة ملك، أيمن بني سلامة، شارلز كليلاند، أحمد المنشاوي.يُعدّ التعب أكثر الأعراض التي يشكو منها مرضى السرطان وأكثرها تكديراً لهم. ومع ذلك، لم يُترجَم إلى اللغة العربية أي استبيان يقيس التعب ومدى إعاقته لحياة المريض.كانت هذه الدراسة تهدف إلى ترجمة "مقياس التعب الوجيز" (BFI-A) والتحقق من نسخته العربية.تُرجم المقياس إلى اللغة العربية بطريقة الترجمة المباشرة والعكسية. وجمعت هذه الدراسة المقطعية بيانات من مرضى السرطان من خلال استبيان ملأه المرضى بأنفسهم وتضمَّن "مقياس التعب الوجيز" (BFI-A)، و"مؤشر شدة الأرق" (ISI)، و"مقياس زونج للاكتئاب" (ZDS)، ومجموع درجات "قائمة أعراض" (MDASI)، و"المقياس الفرعي للحيوية في دراسة النتائج الطبية المختصرة المكونة من 36 بنداً" (SF-36). واستُخدمت إحصاءات وصفية واستنتاجية، منها المتوسط، والانحراف المعياري، والاتساق الداخلي، ومعامل الارتباط باستخدام ارتباط بيرسون.استعين اجمالا بتسعة وسبعين مريضا في مدينة عمان الاردنية عام 2015. وكان متوسط مجموع درجات « مقياس التعب الوجيز (BFI-A) هو 4.1)، مما يدل على ان 83.5٪ كانوا يعانون تعبا غير شديد. وكان معامل كرونباخ الفا لمقياس التعب الوجيز هو 0.93. وكانت علاقات الترابط بين مجموع درجات « مقياس التعب الوجيز » وبنود هذا المقياس علاقات وثيقة (0.05P)، وتراوحت من 0.75 الى 0.86. وتبين وجود ترابط وثيق (0.05P) بين « مقياس التعب الوجيز BFI-A)» والمقاييس التالية: مؤشر شدة الارق (0.70) (ISI)، ومقياس زونج للاكتئاب (0.69) (ZDS)، وقائمة الاعراض (0.75) (MDASI)، والمقياس الفرعي للحيوية في دراسة النتائج الطبية المختصره المكونه من 36 بندا (0.57-) (SF-36).تشير هذه الدراسة إلى أن (BFI-A) أداة موثوقة وصالحة لتقييم التعب لدى مرضى السرطان الناطقين بالعربية.Étude de validation de la version arabe du Brief Fatigue Inventory (BFI-A).La fatigue est le symptôme le plus fréquent et le plus éprouvant chez les patients atteints de cancer. Cependant, aucun questionnaire mesurant la fatigue et son interférence avec la vie quotidienne n’a été traduit en arabe.La présente étude visait à traduire et à valider la version arabe du Brief Fatigue Inventory (BFI-A).Le BFI a été traduit en arabe à l’aide de la technique de traduction/rétro-traduction. La présente étude transversale a permis de collecter des données de patients atteints de cancer en recourant à un auto-questionnaire comprenant le BFI-A, l’index de Sévérité de l’Insomnie (ISI), l’échelle d’auto-évaluation de la dépression de Zung (ZDS), l’inventaire des symptômes M.D. Anderson (MDASI) et la sous-échelle vitalité de la forme abrégée du questionnaire généraliste SF-36 (qualité de vie) du Medical Outcome Study. Des statistiques descriptives et inférentielles ont été utilisées, y compris la moyenne, l’écart type, la cohérence interne et le coefficient de corrélation de Pearson.79 patients au total ont été recrutés à Amman (Jordanie) en 2015. La moyenne totale du BFI-A était de 4,01 (2,4), indiquant que 83,5 % des patients présentaient un état de fatigue non sévère. Le coefficient alpha de Cronbach du BFI-A était de 0,93. Les corrélations entre les scores totaux et les rubriques du BFI-A étaient significatives (p0,05) et étaient comprises entre 0,75 et 0,86. Le BFI-A affichait une corrélation importante (p0,05) avec les instruments suivants : ISI = 0,70 ; ZDS = 0,69 ; MDASI = 0,75 et la sous-échelle vitalité du SF-36 (qualité de vie) = −0,57.La présente étude suggère que le BFI-A est un outil valable et fiable pour évaluer la fatigue chez les patients arabes atteints de cancer.

Objective: To examine glycemic variability within 1 month and 1 year following surgery among adult patients, with and without Type 2 Diabetes (T2D), treated for stage II-III colon cancer. Method: A retrospective analysis of electronic health record data was conducted. Glycemic variability (i.e., standard deviation [SD] and coefficient of variation [CV] of > 2 blood glucose measures) was assessed within 1 month and within 1 year following colon surgery. Chi-square (χ2), Fisher’s exact, and Mann-Whitney U tests were used for the analyses. Results: Among the sample of 165 patients with stage II–III colon cancer, those with T2D had higher glycemic variability compared to patients without T2D ( p < .001), with values within 1 month following surgery (SD = 44.69 mg/dL, CV = 27.4%) vs (SD = 20.55 mg/dL, CV = 17.53%); and within 1 year following surgery (SD = 45.04 mg/dL, CV = 29.04%) vs (SD = 21.36 mg/dL, CV = 18.6%). Associations were found between lower body mass index and higher glycemic variability (i.e., SD [r = −.413, p < .05] and CV [r = −.481, p < .01]) within 1 month following surgery in patients with T2D. Higher preoperative glucose was associated with higher glycemic variability (i.e., SD r = .448, p < .01) within 1 year in patients with T2D. Demographic and clinical characteristics were weakly associated with glycemic variability in patients without T2D. Conclusions: Patients with stage II–III colon cancer with T2D experienced higher glycemic variability within 1 month and within 1 year following surgery compared to those without T2D. Associations between glycemic variability and demographic and clinical characteristics differed by T2D status. Further research in prospective studies is warranted.

Psychoneurological symptom clusters are co-occurring and interrelated physiological symptoms that may include cancer-related fatigue, pain, depressive symptoms, cognitive disturbances, and sleep disturbances. These symptoms are hypothesized to share a common systemic proinflammatory etiology. Thus, an investigation of systemic immune biomarkers is an important approach to test this hypothesis. Here, we investigated the associations between extracellular vesicle (EV)-associated and soluble cytokines with immune markers and symptom clusters in men with non-metastatic prostate cancer. This observational study included 40 men with non-metastatic prostate cancer at the start (T1) of external beam radiation therapy (EBRT) and 3 months post treatment (T2), as well as 20 men with non-metastatic prostate cancer on active surveillance (AS) seen at one time point. Collected questionnaires assessed patient-reported fatigue, sleep disturbances, depressive symptoms, and cognitive fatigue. In total, 45 soluble and EV-associated biomarkers in plasma were determined by multiplex assays. Principal component analysis (PCA) was used to identify psychoneurological symptom clusters for each study group and their time points. Bivariate correlation analysis was run for each identified PCA cluster with the concentrations of EV-associated and soluble cytokines and immune markers. Both EV-associated and soluble forms of RANTES significantly correlated with the symptom cluster for EBRT at T1, whereas, at T2, soluble IFNα2, IL-9, and IL-17 correlated with the corresponding symptom cluster. For the AS group, soluble survivin correlated with psychoneurological symptoms. Linking specific inflammatory cytokines with psychoneurological symptom clusters in men receiving prostate cancer treatment can enhance understanding of the underlying mechanisms of this phenomenon and aid in developing targeted interventions.

Nurses are on the frontline of palliative care, and in some countries, are the only contact for patients and families facing life-threatening illness. The Oman Cancer Association in the Sultanate of Oman, in collaboration with the Middle Eastern Cancer Consortium and the Oncology Nursing Society, led a palliative care initiative over the past decade to better integrate palliative care into the health care system. Components of this initiative include integrating palliative care into the health care curricula and providing palliative care education to over 400 nurses and other health care professionals within Oman. The four-part education series includes the following courses: (1) Foundations of Palliative Care, (2) Advanced Concepts in Palliative Care, (3) Palliative Care Leadership, and (4) Palliative Care Research. Additional participants from 17 different countries in the Middle East and northern Africa also attended the training. Twenty of the trainees who were considered palliative care leaders in their countries then participated in a Train the Trainer course. This group trained the last cohort of health care professionals in Oman and then took learned concepts and strategies back to their respective countries in order to provide country-wide education and build palliative care capacity in the region. Outcomes include the development of palliative care units, quality improvement projects that improved care, and advocacy projects to increase opioid availability within some countries. The collaborative continues its work and connections through social medial, email, and virtual collaboration. Other countries can use this model to permeate palliative care within their regions.

Objective Neuroimaging studies of hematologic cancer patients report altered activity in dorsal attention and central executive networks. To determine the consequences of these altered brain networks, we evaluated neurophysiological correlates of attention and working memory in hematologic cancer patients prior to initiating treatment. Methods Hematologic cancer patients (19–80 years) were excluded for premorbid cognitive impairment, prior non-hematologic cancer diagnosis, and prior chemotherapy. Attention was manipulated by presenting an irrelevant spatial cue prior to visual search displays. Working memory was manipulated by presenting irrelevant distractors within memory displays. Electroencephalogram was recorded during task performance. Results Patients (n = 28) and controls (n = 15) were balanced on age, gender, and education. Spatial cues evoked larger N2pc amplitudes, a correlate of spatial attention, in patients than controls (p 0.7). Memory distractors evoked larger contralateral delay activity amplitudes, a correlate of working memory load, in patients (p = .028; Cohen’s d = 1.1) but not controls (p = .64). Conclusions Prior to initiating treatment, hematologic cancer patients demonstrated poor control over spatial attention and working memory, consistent with altered dorsal attention and central executive network activity. Significance Hematologic cancer patients may be at a higher risk for selecting, processing, and storing distracting information that would compete with more immediate goal-related behaviors.

Formal caregivers in nursing homes provide care to vulnerable older adults with chronic conditions. Caregiver burden affects formal caregivers. The purpose of this integrative review was to explore formal caregiver burden among nursing staff in nursing homes. Specific aims were to gain an understanding of the attributes, definitions, measures, and primary outcomes. A systematic search of CINAHL, PubMed, PsycINFO, and Embase was completed. The sample included 19 articles, which were published in English between January 1980 and April 2020. Attributes varied; however, perceived stress was frequently identified, consistent with the formal caregiver burden definition. Psychometric measures employed in the studies indicated heterogeneity. Primary outcomes included differences in burden, resident behavior, occupational and personal factors, and resident care. Research is needed to gain an understanding of this recently defined concept. Formal caregiver burden in nursing homes has emerged as a priority for research during the pandemic with new challenges and guidelines.

Introduction: Introduction Sleep disturbances are common in adolescents with neurodevelopmental disorders (NDDs). Inclusion of vulnerable populations such as adolescents with NDDs into sleep intervention efforts is essential as they are at high-risk for poor physical/mental health outcomes. The objective of this study is to pilot a sequential, multiple assignment, randomized trial (SMART) design to compare the impact of a sequence of sleep interventions, based on treatment response, to optimize sleep health in adolescents with NDDs. Methods: Methods Recruitment began June 2019 using convenience sampling. The SMART pilot feasibility study includes 1-week of baseline sleep data, and two 4-week periods of a sleep intervention (9-week total study enrollment). Interventions include exogenous melatonin, The Bedtime Bank, and their combination. Exogenous melatonin (liquid, immediate release, 3mg) is administered 30 minutes before bedtime. The Bedtime Bank, a behavioral sleep intervention, is based upon contingency contracting that relies on a credit- or debt-based system to hold adolescents accountable for maintaining a consistent bedtime. At baseline participants completed demographics, PROMIS pediatric sleep questionnaires, the Cleveland Adolescent Sleepiness Questionnaire (CASQ), salivary & urinary endogenous melatonin measurement, and one week of actigraphy. Upon enrollment, participants were randomly assigned to either melatonin or The Bedtime Bank. Participants who respond (nightly increase in total sleep time (TST) ≥18 minutes) remain on the assigned intervention; if non-responsive participants are re-randomized to a different sleep intervention or combination. Results: Results At baseline, participants (n=29, aged 10–18 years) had an average TST of 7 hours 11 minutes. PROMIS Sleep Disturbance (M=64.3, SE=2.5), PROMIS Sleep-Related Impairment scores (M=58.9, SE=2.2), and CASQ scores (M=40.0, SD= 10.5) were higher than reported normative values. Salivary DLMO & urinary 6-sulfatoyxmelatonin analysis is ongoing. For participants who completed the full 9-week trial, nearly 30% (n=7/24) were responsive (increased baseline TST ≥18 minutes) to one of the 4-week interventions. Conclusion: Conclusion Baseline data of the enrolled participants demonstrates poor indicators of TST, sleep disturbance, and sleep related impairment. Preliminary results of this SMART indicate some adolescents are responsive to sleep interventions aimed to improve their TST. Support (if any) Support: This clinical trial is funded by the National Institute of Nursing Research, National Institutes of Health (1K01NR017465-01A1).

We describe a mixed qualitative and quantitative research study in a military facility regarding the role of nature in well-being. Study intervention included two 20-minute walks. One walk was in an intentionally designed woodland environment (Green Road) and the other was on a busy campus road in a medical treatment facility (Urban Road). Twelve volunteers from a military facility participated in both walks in a cross-over experimental design. The two walking sessions were randomly ordered and preceded by pre-walk instructions appropriate to each road’s characteristics and incorporated focused attention and present moment orientation. A semi-structured post-walk interview, the primary outcome, was conducted after the conclusion of each walk. Qualitative data analyses consisted of sentiments and themes by using NVivo 12 software. The Green Road was unanimously rated as positive (100%). Responses to Urban Road were evenly distributed among positive (33.3%), negative (33.3%), and neutral/mixed (33.3%) sentiments. The Green Road yielded predominantly positive themes such as enjoyment of nature, relaxation, and feelings of privacy and safety. Urban Road produced significantly more negative themes such as concerns for safety, dislike of noise and other noxious experiences. Quantitative assessment of distress and mindfulness with Distress Thermometer (DT) and Mindful Attention Awareness Scale-state version (MAAS) demonstrated that a walk on the Green Road significantly decreased distress and increased mindfulness compared to a walk on the Urban Road. We also observed that pre-walk instructions could direct attention to both obvious and subtle elements of experience and enhance awareness. Results support the notion that an intentional nature-based environment may produce significantly more positive experiences and result in health-promoting benefits in a military health-care setting compared to an urban environment. Future studies with clinical populations could advance our understanding of the healing value of nature-based interventions. The impact of intentional green environments may be enhanced by well-designed instructions for both recreational and therapeutic use.

Introduction Promoting cessation services like quitlines is important to reduce tobacco-related morbidity and mortality. A critical need exists to improve clinical staff's awareness of tobacco quitlines and reduce barriers in recommending and referring tobacco-using patients. The purpose was to obtain information on the use of the Nebraska Tobacco Quitline (NTQ) by Federally Qualified Health Center (FQHC) clinical staff at FQHC settings with tobacco-using patients. Specific aims were: 1) identify FQHC clinical staff and setting characteristics that influence current tobacco cessation assessment and interventions, and 2) identify barriers and facilitators that influence future use of NTQ by FQHC clinical staff and settings. Methods This study recruited participants from seven FQHC settings. All FQHC provider and non-provider clinical staff were recruited to complete a Clinical Staff Survey. The Medical Director, Associate Medical Director, or Nurse Manager at each FQHC was asked to provide setting information through the Setting Survey. Descriptive statistics were used to report percentages and qualitative data were analyzed using pattern coding. Results The main findings include insufficient awareness and insufficient perceived effectiveness of NTQ, non-providers reporting a limited role in tobacco cessation efforts beyond assessment of tobacco use, and the lack of supportive setting processes for intervention use. Conclusions Targeted efforts are needed to increase awareness and perceived effectiveness of NTQ, for role expansion for non-providers, and to add Electronic Health Record (EHR) prompts and e-referral capability to increase cessation interventions including NTQ referrals. Future research is suggested to better understand patient-specific barriers in using NTQ.

BackgroundFatigue is a consistently reported, severe symptom among patients with gliomas throughout the disease trajectory. Genomic pathways associated with fatigue in glioma patients have yet to be identified.MethodsClinical factors (performance status, tumor details, age, gender) were collected by chart review on glioma patients with fatigue (“I have lack of energy” on Functional Assessment of Cancer Therapy-Brain), as well as available genotyping data. Candidate genes in clock and inflammatory pathways were identified from a literature review, of which 50 single nucleotide polymorphisms (SNPs) in 7 genes were available. Clinical factors and SNPs identified by univariate analyses were included in a multivariate model for moderate-severe fatigue.ResultsThe study included 176 patients (median age = 47 years, 67% males). Moderate-severe fatigue was reported by 43%. Results from multivariate analysis revealed poor performance status and 2 SNPs were associated with fatigue severity. Moderate-severe fatigue was more common in patients with poor performance status (OR = 3.52, P < .01). For each additional copy of the minor allele in rs934945 (PER2) the odds of fatigue decreased (OR = 0.51, P < .05). For each additional copy of the minor allele in rs922270 (ARTNL2) the odds of fatigue increased (OR = 2.38, P < .01). Both of these genes are important in the circadian clock pathway, which has been implicated in diurnal preference, and duration and quality of sleep. No genes in the inflammatory pathway were associated with fatigue in the current study.ConclusionsIdentifying patients at highest risk for fatigue during treatment allows for improved clinical monitoring and enrichment of patient selection for clinical trials.

Background: Oxidative stress is associated with poor perinatal outcomes. Little is known regarding the longitudinal levels of oxidative stress in the perinatal period or the correlation between maternal and neonatal oxidative stress levels. Objective: Describe and compare oxidative stress, specifically superoxide, superoxide dismutase, catalase, and glutathione levels, over the perinatal period. Study Design: Longitudinal descriptive design using a convenience sample of medically high- and low-risk pregnant women ( n = 140) from a maternal–fetal medicine and general obstetrics practice, respectively. Blood was obtained from women at 12–20 and 24–28 weeks’ gestation and during labor, from the umbilical cord at birth, and from neonates at 24–72 hr after birth. Levels of superoxide were measured using electron paramagnetic resonance (EPR) spectroscopy; antioxidants (superoxide dismutase, catalase, and glutathione) were measured using commercial assay kits. Relationships between oxidative stress levels at different time points were examined using nonparametric methods. Pregnancy outcome was collected. Results: Demographic variables, outcome variables, and oxidative stress levels in maternal blood, cord blood, and infants differed between medically high- and low-risk women. Descriptive patterns for oxidative stress measures varied over time and between risk groups. Significant correlations between time points were noted, suggesting intraindividual consistency may exist throughout the perinatal period. However, these correlations were not consistent across each medical risk group. Conclusion: EPR spectroscopy is a feasible method for the perinatal population. Results provide new information on perinatal circulating superoxide levels and warrant further investigation into potential relationships between prenatal and neonatal physiologic dysregulation of oxidative stress.

Introduction: Women diagnosed with breast cancer (BC) are at increased risk of sleep deficiency. Approximately 30–60% of these women report poor sleep during and following surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. The purpose of this study was to examine the relationship between genetic variation in circadian rhythm genes and self-reported sleep quality in women with BC.Methods: This cross-sectional study recruited women with a first diagnosis of breast cancer at five sites in Nebraska and South Dakota. Sixty women were included in the study. Twenty-six circadian genes were selected for exome sequencing using the Nextera Rapid Capture Expanded Exome kit. 414 variants had a minor allele frequency of ≥5% and were included in the exploratory analysis. The association between Pittsburgh Sleep Quality Index (PSQI) score and genetic variants was determined by two-sample t-test or ANOVA.Results: Twenty-five variants were associated with the PSQI score at p < 0.10, of which 19 were significant at p

Background: Many chronic conditions, including heart disease, cancer, and rheumatoid arthritis, are associated with underlying chronic inflammatory processes. Literature reviews have analyzed a variety of integrative therapies and their relationships with chronic inflammation. This systematic review is unique in reporting solely on yoga’s relationship with inflammation. Its purpose was to synthesize current literature examining the impact of yoga interventions on inflammatory biomarkers in adults with chronic inflammatory–related disorders. Method: Searches of several electronic databases were conducted. Inclusion criteria were (a) English language, (b) sample age >18 years old, (c) yoga interventions involving postures with or without yoga breathing and/or meditation, and (d) measured inflammatory biomarkers. Results: The final review included 15 primary studies. Of these, seven were rated as excellent and eight as average or fair. There was considerable variability in yoga types, components, frequency, session length, intervention duration, and intensity. The most common biomarkers measured were interleukin-6 ( n = 11), C-reactive protein ( n = 10), and tumor necrosis factor ( n = 8). Most studies reported positive effects on inflammatory biomarkers ( n = 11) from baseline to post yoga intervention. Analysis of the dose showed higher total dose (>1,000 min) resulted in greater improvements in inflammation. Conclusion: This review suggests that yoga can be a viable intervention to reduce inflammation across a multitude of chronic conditions. Future studies with detailed descriptions of yoga interventions, measurement of new and well-established inflammatory biomarkers, and larger sample sizes are warranted to advance the science and corroborate results.

The purpose of this integrative review was to explore formal caregiver burden in nursing homes among direct care nursing staff. The aim was to gain an understanding of the state of the science of formal caregiver burden, it’s measurement, and its effect on resident care. Based on PRISMA guidelines, a systematic search of CINAHL, PubMed, PsycINFO and Embase databases was conducted using terms from the definition of formal caregiver burden, three conceptual models, and the thesaurus feature of each database for years ranging from 1979-2019. Inclusion criteria consisted of peer-reviewed articles in English that focused on the key terms of formal caregiver burden among direct care nursing staff only in nursing home facilities. Out of 925 citations, 20 articles met criteria; 15 quantitative and 5 qualitative studies. Sample sizes ranged from 11-1283, number of facilities from 1-55, and bed size from 31-203. Psychometric measures used in the studies reported lower validity and reliability, a variety of conceptual definitions interchangeably, and primarily studied nursing assistants (n=19). Five studies included nurses as formal caregivers, and one studied only nurses. Variables used to identify burden were racial disparities (n=2), trauma experience (n=1), depression (n=4), distress (n=3), mental health (n=1), stress (n=2), health complaints (n=1), and alienation (n=1). Two studies evaluated the effect on resident care, one finding significant results of in-service training contributing to positive attitudes of formal caregivers toward confused residents. Current limitations in the understanding of formal caregiver burden limit the advancement of research.

Background: The role of oxidative stress remains unclear in the multifactorial pathophysiologic mechanism of lung disease in preterm infants. Aims: The aim of this study was to examine the associations among chronic lung disease (CLD), oxidative stress, and oxygen requirements in preterm infants. Design: Prospective, longitudinal, and correlational design. Subjects: Preterm infants born at Measurements: The diagnosis of CLD was obtained from the medical record. Oxidative stress was measured using 8-hydroxydeoxyguanosine (8-OHdG) in the cord blood at birth and urine on Days 1 and 7. Oxygen requirements were measured using fraction of inspired oxygen (FIO2) recorded in the first hour after birth/admission and the average FIO2 during the first 12 hr and 7 days after birth. Descriptive statistics are presented. Comparison analyses were performed using Kruskal–Wallis and Fisher’s exact tests. Results: Infants with CLD ( n = 12) had lower gestational age ( p = .04) and weight ( p = .04) at birth, more days on the ventilator ( p = .004), and longer neonatal intensive care unit stay ( p = .04) compared to infants without CLD ( n = 19). CLD was associated with lower oxidative stress levels ( p = .03) and higher oxygen requirements during the first 12 hr ( p = .025) and on Day 7 ( p = .001). Lower oxidative stress levels on Day 7 were associated with higher oxygen requirements in the first 12 hr ( p = .01) and on Day 7 ( p = .03). Conclusion: Our results linking CLD and higher oxygen requirements with low oxidative stress contradict previous reports. Findings identify a gap in knowledge for postresuscitation oxygen therapy in preterm infants and expose the role of oxidative stress from inflammation and intermittent hypoxia in the etiology of CLD.

Introduction: Geriatric assessment can predict the risk of toxicities of chemotherapy in older adults. Genetic risk categories correlate with survival following intensive chemotherapy in AML. Integrating geriatric assessment for patient profiling and genetic profiling of leukemic cells represents an innovative precision medicine approach to personalize therapy selection in older adults with AML. We report results of a pre-planned interim analysis of a pragmatic phase II trial using such strategy that has an overarching goal to reduce early mortality (NCT03226418). Methods: Patients ≥60 years with a new diagnosis of AML underwent geriatric assessment prior to initiation of treatment. Geriatric assessment of physical function, cognitive function and comorbidity burden were used to determine fitness for intensive chemotherapy (Table 1). Additional assessment included Karnofsky Performance Scale (KPS), Patient Health Questionnaire-9 (PHQ-9), and Mini Nutritional Assessment-Short Form (MNA). Genetic profiling for therapy selection relied on karyotyping and followed the 2017 European LeukemiaNet criteria. While available mutation test results were incorporated to risk stratify, the study did not require to wait for the results prior to therapy initiation given an anticipated turnaround time of 1-2 weeks for mutation test results. Therapy selection followed the algorithm demonstrated in Figure 1. Patients with good or intermediate-risk AML received intensive chemotherapy such as 7+3 +/- gemtuzumab or midostaurin if determined to be fit. Patients with high-risk AML received low-intensity chemotherapy such as a hypomethylating agent with or without novel drugs, or CPX 351 if they were fit and met the FDA-approved indications. Patients with organ dysfunction (e.g. creatinine ≥2 mg/dl) and those requiring chemotherapy for other malignancy received low-intensity chemotherapy. Chemotherapy at diagnosis or follow up could be administered in community oncology settings. Patients were followed for assessment of quality of life, functional and oncologic outcomes. Results: Between July 2017-June 2019, a total of 31 patients (including 1 MDS patient considered screen failure) were enrolled. The pre-planned interim analysis results are based on the first 27 AML patients. Baseline characteristics included a median age of 70 years (range 60-84 years), 56% female, 96% white, and a median KPS of 80% (range 60-100%). As presented in Table 1, over half of the patients had ≥3 comorbidities, impairment in objective physical function (short physical performance battery) and Montreal Cognitive Assessment. Additionally, 67% had poor nutritional status (MNA score of ≤11) and 26% had abnormal depression screen (PHQ-9 score of ≥10). Risk categories included adverse (64%), intermediate (16%), and good-risk AML (20%). Patients had one or more of the following mutations: FLT3 ITD (11%), NPM1 (22%), biallelic CEBPA (4%), IDH1 (15%), IDH2 (8%), RUNX1 (15%), ASXL1 (22%), and TP53 (19%). Three patients received intensive chemotherapy; CPX 351 (n=2) or 7+3+ gemtuzumab (n=1). Other patients received decitabine or azacitidine alone (n=16), azacitidine and venetoclax (n=5) or decitabine and midostaurin (n=3). The median time from diagnosis to therapy initiation was 7 days (0-20 days) whereas the median time from enrollment to therapy initiation was 2 days (range 0-9). Mortality at 30 days from diagnosis was 3.7% (95% confidence interval, CI 0.7-18.3%) and at 90 days was 29.6% (95% CI 15.9-48.5%). Mortality compared favorably to an unmatched historical cohort of patients ≥60 years treated at our center between 2011-2016, where 30-day mortality was 30% (95% CI 22-40%) and 90-day was 41% (95% CI 32-52%) (Future Oncol. 2019;15:1989-95). Conclusions: Our model to personalize AML therapy selection represents an innovative approach to precision medicine that incorporates both geriatric assessment for patient profiling and genetic profiling of leukemia cells. Geriatric assessment demonstrated high frequency of impairment in objective physical and cognitive function. Patients were able to start therapy within a median of 2 days following enrollment. Pragmatic aspects of the trial included broad eligibility criteria and co-management of patients with community oncologists. Our pre-planned interim analysis data appear promising with lower rates of early mortality compared to unmatched historical controls. Disclosures Bhatt: Pfizer: Consultancy; CSL Behring: Consultancy; Agios: Consultancy; Abbvie: Consultancy; Partner therapeutics: Consultancy; Incyte: Consultancy, Research Funding; Tolero Pharmaceuticals: Research Funding; National Marrow Donor Program: Consultancy. Al-Kadhimi:Celldex Biotech: Other: Stocks; Seattle Genetics: Other: Stocks. Armitage:Oncology Analytics: Consultancy; Partner Therapeutics: Consultancy; Samus Therapeutics: Consultancy; Ascentage: Consultancy; Tesaro bio: Membership on an entity's Board of Directors or advisory committees; Union Pacific: Consultancy. Holstein:GSK: Consultancy; Genentech: Membership on an entity's Board of Directors or advisory committees; Sorrento: Consultancy; Celgene: Consultancy; Takeda: Membership on an entity's Board of Directors or advisory committees; Adaptive Biotechnologies: Membership on an entity's Board of Directors or advisory committees. Gundabolu:Samus Therapeutics: Research Funding; Jazz pharmaceuticals: Consultancy; Pfizer: Consultancy; Novartis: Consultancy. OffLabel Disclosure: Single agent azacitidine and decitabine as well as decitabine in combination with midostaurin are not approved by the US FDA for acute myeloid leukemia.

Among patients who survive over two years post-allo-HSCT, cGVHD and subsequent cancers represent a significant source of morbidity and mortality. Long-term treatment with immunosuppressive agents and cGVHD-related immune dysregulation may promote the development of subsequent cancers. The burden of subsequent cancers has not yet been described in patients with the most severe manifestations of cGVHD, who likely represent a high-risk population. 439 patients were enrolled on the prospective NIH Chronic GVHD Natural History Study from 2004 to 2019, underwent one-week evaluation by subspecialists, and were scored in accordance with 2005 NIH criteria. Follow-up data were collected by annual survey in which patients self-reported cancer diagnoses and provided consent for confirmatory medical records. Cumulative incidence was estimated for non-melanoma skin cancer (NMSC) competing with death, relapse, or cancer other than NMSC and for cancer other than NMSC competing with death or relapse using the method of Gooley. Potential predictors of subsequent cancers including demographics, transplant characteristics, and cGVHD-related factors were assessed using Gray's test in univariable analysis and Cox proportional hazards models in multivariable analysis. Patients must have been free of post-transplant relapse, NMSC (for NMSC analyses only), and cancer other than NMSC at evaluation to be included in analysis. 22 NMSC and 19 cancers other than NMSC were observed among 205 eligible patients, with cumulative incidences at 60 months of 11.2% (95% CI: 6.9-16.7) and 7.3% (95% CI 4.1-11.8), respectively. The most common cancers other than NMSC were oral squamous cell carcinoma and melanoma (n=6 each). Factors associated with NMSC in univariable analysis were older age at transplant, older age at evaluation, having received sirolimus for cGVHD, having received extracorporeal photopheresis or psoralen-ultraviolet therapy for cGVHD as well as higher CRP, higher NK cell count, and greater BMI at evaluation. Only older age at transplant (HR=2.12; 95% CI: 1.35-3.31) and higher CRP (HR=9.61; 95% CI: 1.29-71.73) remained associated in the multivariable model. Factors associated with subsequent cancers other than NMSC in univariable analysis were T-cell depletion, lymphoid malignant indication for transplant, and increasing severity of oral cGVHD by NIH score. Only lymphoid malignant indication for transplant (HR=2.58; 95% CI: 1.31-5.07) remained significant in multivariable analysis. The association of CRP with NMSC may represent an effect of cGVHD-related inflammation, with CRP previously associated with cGVHD severity. Interestingly, sirolimus was associated with increased risk of NMSC despite its purported antineoplastic effects. One study has previously reported increased risk of NMSC in allo-HSCT recipients treated with sirolimus, however, numerous studies have reported that sirolimus reduces risk of NMSC in solid organ recipients. In this study population, sirolimus was often prescribed later in patients already with refractory cGVHD and adjustment for measures of disease severity attenuated this association in multivariable modeling. The association of lymphoid indication with cancers other than NMSC may be attributable to age as patients with lymphoid malignancies were older at transplant than those with other indications. Additionally, differences in pre-transplant therapies for lymphoid vs. other indications may also contribute to this observation. Post-transplant patients with cGVHD are at high risk of developing subsequent cancers, with higher incidence of NMSC than other cancers. This study identifies potential risk groups for subsequent cancers, highlights patients who may benefit from increased surveillance, and reiterates the need for effective cGVHD therapy to mitigate risks associated with long-term immunosuppression and immune dysfunction. Disclosures Cowen: UpToDate: Other: Royalties; Elsevier: Other: Royalties.

Introduction: Whether adults aged ≥60 years with AML benefit from multiagent (or intensive) chemotherapy is a matter of controversy. Prior studies have demonstrated conflicting results. We performed analysis of a large National Cancer Data Base (NCDB) to determine the value of multiagent vs. single agent chemotherapy. Methods: NCDB captures approximately 70% of all cancer diagnoses in US, and undergoes rigorous quality monitoring. We utilized NCDB to identify patients aged 60-79 years, who were newly diagnosed with AML (other than APL) between the years 2004-2014. Logistic regression model was used to determine factors associated with the use of multiagent chemotherapy. Kaplan-Meier curves were generated and compared using the log rank test. Logistic regression model and Cox Proportional Hazard model were used for one-month mortality and OS analyses, respectively. In a separate analysis, patients who received single agent (n=6743) vs. multiagent chemotherapy (n=6743) were matched based on the variables age, Charlson comorbidity score, and AML subtypes (good-risk AML, therapy-related AML/AML with myelodysplasia related changes, and other intermediate/high-risk AML). A Cox Proportional Hazard model was used for OS analysis of the matched cohort. Results: Of a total of 25,621 patients, 70% received multiagent chemotherapy. The receipt of multiagent chemotherapy declined with increasing age, Charlson comorbidity score, AML subtypes other than good-risk, female, non-academic center, shorter distance traveled to receive care, lower rate of high school graduation, and more recent year of diagnosis. Patients treated with multiagent chemotherapy had higher likelihood of receiving hematopoietic cell transplant (HCT) (9% vs. 1%); lower one-month mortality (11% vs. 19%); and greater 1-year OS (43% vs. 28%) (Figure 1). The use of multiagent chemotherapy had particularly higher 1-year OS in patients aged 60-64 and 65-69 years, in good-risk AML, patients with Charlson comorbidity score of 0-1 and those who did not receive upfront HCT consolidation (Table 1). One-month mortality (odds ratio 1.64, 95% confidence interval, CI 1.51-1.78) and OS (hazard ratio, HR 1.32, 95% CI 1.28-1.36) remained more favorable for multiagent chemotherapy group in multivariable analyses. Other factors that affected OS included age, comorbidity, AML subtypes, median household income, insurance, use of HCT, academic status of facility, distance traveled to receive care, sex and year of diagnosis. In a matched analysis of 13,486 patients, the use of single agent vs. multiagent chemotherapy resulted in a higher risk of mortality (HR 1.28, 95% CI 1.23-1.32). Conclusions: In one of the largest real-world studies, we demonstrate an association between factors such as age, comorbidity and AML subtypes and the use of multiagent chemotherapy. After adjusting for covariates, the use of multiagent chemotherapy among older adults was associated with higher receipt of HCT, and improved one-month mortality and OS. Improved OS was confirmed in a matched analysis. Certain groups such as patients younger than 70 years, good-risk AML and those with low Charlson comorbidity score had the greater OS benefit with the use of multiagent chemotherapy. Further studies to determine the role of multiagent or intensive chemotherapy are particularly important with approvals of several new drugs in the recent years and integration of many novel drugs in both low-intensity and intensive chemotherapy regimens. Disclosures Bhatt: Tolero Pharmaceuticals: Research Funding; Incyte: Consultancy, Research Funding; Partner therapeutics: Consultancy; Abbvie: Consultancy; Agios: Consultancy; CSL Behring: Consultancy; National Marrow Donor Program: Consultancy; Pfizer: Consultancy. Holstein:Celgene: Consultancy; Adaptive Biotechnologies: Membership on an entity's Board of Directors or advisory committees; GSK: Consultancy; Genentech: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; Sorrento: Consultancy. Al-Kadhimi:Celldex Biotech: Other: Stocks; Seattle Genetics: Other: Stocks. Armitage:Union Pacific: Consultancy; Tesaro bio: Membership on an entity's Board of Directors or advisory committees; Ascentage: Consultancy; Samus Therapeutics: Consultancy; Oncology Analytics: Consultancy; Partner Therapeutics: Consultancy. Gundabolu:Pfizer: Consultancy; Novartis: Consultancy; Jazz pharmaceuticals: Consultancy; Samus Therapeutics: Research Funding.

SIGNIFICANCE: Poor sleep quality is a common and persistent problem reported by women with breast cancer (BC). Empirical evidence identifies many risk factors for self-reported sleep deficiency but inconsistencies limit translation to practice. PURPOSE: To increase understanding of risk factors predicting self-reported poor sleep quality in women with BC who completed the Breast Cancer Collaborative Registry (BCCR) questionnaire. METHODS: This cross-sectional study recruited women with a first diagnosis of BC (n=1302) at five sites in Nebraska and South Dakota. Women completed the BCCR that includes numerous variables as well as the Pittsburgh Sleep Quality Index (PSQI) and SF-36v2 (n=1260). Descriptive statistics and non-parametric correlations were used to determine associations and create predictive models of sleep quality with BCCR variables and SF36v2 subscales. RESULTS: Most women were white (93.7%) and married (71.5%); mean age was 60.1 (21–90) years. Poor sleep was self-reported by 53% of women. Seven variables were highly associated with sleep quality (p≤0.001). The first model found younger age, lower physical activity, and higher fatigue were the strongest combined and independent variables predicting poor sleep quality (F=23.0 (p

In 2005, the National Institutes of Health (NIH) chronic graft-versus-host disease (cGVHD) consensus project provided diagnosis and staging criteria, based mostly on clinical experience and expert opinion. These criteria were revised in 2014, aiming to provide enhanced specificity and clarity. However, the impact of 2014 changes to the original NIH cGVHD severity scoring criteria has not been reported. In this study, 284 patients, prospectively enrolled on the National Cancer Institute's cross-sectional cGVHD natural history study, were scored using the 2005 NIH cGVHD criteria and then rescored according to the 2014 modifications. In comparing the two criteria, 2014 cGVHD global severity scoring resulted in a tendency toward being categorized as milder scores (75 vs. 72% of severe score per 2014, p = 0.0009), with a statistically significant shift in NIH liver and lung scores toward milder categories (p

Usporedba NIH kriterija za kronični GVHD 2005 i 2014 godina.

Answer questions and earn CME/CNE Evidence regarding cancer-related fatigue (fatigue) has accumulated sufficiently such that recommendations for screening, evaluation, and/or management have been released recently by 4 leading cancer organizations. These evidence-based fatigue recommendations are available for clinicians, and some have patient versions; but barriers at the patient, clinician, and system levels hinder dissemination and implementation into practice. The underlying biologic mechanisms for this debilitating symptom have not been elucidated completely, hindering the development of mechanistically driven interventions. However, significant progress has been made toward methods for screening and comprehensively evaluating fatigue and other common symptoms using reliable and valid self-report measures. Limited data exist to support the use of any pharmacologic agent; however, several nonpharmacologic interventions have been shown to be effective in reducing fatigue in adults. Never before have evidence-based recommendations for fatigue management been disseminated by 4 premier cancer organizations (the National Comprehensive Cancer, the Oncology Nursing Society, the Canadian Partnership Against Cancer/Canadian Association of Psychosocial Oncology, and the American Society of Clinical Oncology). Clinicians may ask: Are we ready for implementation into practice? The reply: A variety of approaches to screening, evaluation, and management are ready for implementation. To reduce fatigue severity and distress and its impact on functioning, intensified collaborations and close partnerships between clinicians and researchers are needed, with an emphasis on system-wide efforts to disseminate and implement these evidence-based recommendations.

Home sleep apnea testing (HSAT) has increased due to improvements in technology, accessibility, and changes in third party reimbursement requirements. Research studies using HSAT have not consistently reported procedures and methodological challenges. This paper had two objectives: (1) summarize the literature on use of HSAT in research of adults and (2) identify methodological strategies to use in research and practice to standardize HSAT procedures and information. Search strategy included studies of participants undergoing sleep testing for OSA using HSAT. MEDLINE via PubMed, CINAHL, and Embase with the following search terms: “polysomnography,” “home,” “level III,” “obstructive sleep apnea,” and “out of center testing.” Research articles that met inclusion criteria (n = 34) inconsistently reported methods and methodological challenges in terms of: (a) participant sampling; (b) instrumentation issues; (c) clinical variables; (d) data processing; and (e) patient acceptability. Ten methodological strategies were identified for adoption when using HSAT in research and practice. Future studies need to address the methodological challenges summarized in this paper as well as identify and report consistent HSAT procedures and information.

There is renewed interest in identifying breast cancer patients' participation in decision-making about adjuvant chemotherapy. There is a gap in the literature regarding the impact of these decisions on quality of life (QOL) and quality of care (QOC). Our aims were to determine similarities and differences in how patients diagnosed with breast cancer preferred to make decisions with providers about cancer treatment, to examine the patient's recall of her role when the decision was made about chemotherapy and to determine how preferred and actual roles, as well as congruence between them, relate to QOL and perceived QOC.Greater Plains Collaborative clinical data research network of PCORnet conducted the 'Share Thoughts on Breast Cancer' survey among women 12-18 months post-diagnosis at eight sites in seven Midwestern United States. Patients recalled their preferred and actual treatment decision-making roles and three new shared decision-making (SDM) variables were created. Patients completed QOL and QOC measurements. Correlations and t-tests were used.Of 1235 returned surveys, 873 (full sample) and 329 (subsample who received chemotherapy) were used. About one-half of women in both the full (50.7%) and subsample (49.8%,) preferred SDM with providers about treatment decisions, but only 41.2% (full) and 42.6% (subsample) reported experiencing SDM. Significant differences were found between preferred versus actual roles in the full (p .001) and subsample (p .004). In the full sample, there were no relationships between five decision-making variables with QOL, but there was an association with QOC. The subsample's decision-making variables related to several QOL scales and QOC items, with a more patient-centered decision than originally preferred related to higher physical and social/family well-being, overall QOL and QOC.Patients benefit from providers' efforts to identify patient preferences, encourage an active role in SDM, and tailor decision making to their desired choice.

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions.

This study enumerated CD45(hi)/CD34(+) and CD45(hi)/CD133(+) human hematopoietic stem cells (HSCs) and progenitor granulocyte-macrophage colony forming cells (GM-CFCs) in blood and trochanteric and femoral bone marrow in 233 individuals. Stem cell frequencies were determined with multiparameter flow cytometry and using an internal control to determine the intrinsic variance of the assays. Progenitor cell frequency was determined using a standard colony assay technique. The frequency of outliers from undetermined methodological causes was highest for blood, but less than 5% for all values. The frequency of CD45(hi)/CD133(+) cells correlated highly with the frequency of CD45(hi)/CD34(+) cells in trochanteric and femoral bone marrow. The frequency of these HSC populations in trochanteric and femoral bone marrow rose significantly with age. In contrast, there was no significant trend of either of these cell populations with age in the blood. Trochanteric marrow progenitor GM-CFCs showed no significant trends with age, but femoral marrow GM-CFCs trended downward with age, potentially because of the reported conversion of red marrow at this site to fat with age. Hematopoietic stem and progenitor cells exhibited changes in frequencies with age that differed between blood and bone marrow. We previously reported that side population (SP) multipotential HSC, which includes the precursors of CD45(hi)/CD133(+) and CD45(hi)/CD34(+), decline with age. Potentially the increases in stem cell frequencies in the intermediate compartment between SP and GM progenitor cells observed in this study represent a compensatory increase for the loss of more potent members of the HSC hierarchy.

Chronic graft-versus-host disease (cGVHD) reduces relapse risk in patients with hematological malignancies treated with allogeneic hematopoietic stem cell transplant (allo-HSCT). Nevertheless, relapse remains a major barrier to treatment success. Better understanding of factors determining relapse risk in the cGVHD patient population may lead to development of improved strategies for malignancy control. We hypothesized that cGVHD-related factors would contribute to decreased risk of relapse in addition to other well-known transplant related factors. Patients (N=275) were enrolled on the NCI cross-sectional cGVHD natural history study (NCT00092235) and described using NIH criteria for disease severity and organ scoring. Subjects were subsequently followed for malignancy relapse and survival. Potential predictors of relapse were assessed for their association with risk of relapse using Gray's test. Cox proportional hazards modeling was performed to estimate the joint effect of factors on risk of relapse. Seventeen patients experienced relapse at a median follow-up of 85 months. 48-month cumulative incidence of relapse was 5.7% (95% CI 3.3-8.9%). Median progression-free survival was 156 months. Factors associated with increased risk of relapse in multivariable analysis included aggressive malignancy as an indication for transplant (HR 3.93, 95% CI 1.27-9.10), shorter time from transplant to cGVHD evaluation (HR 0.24, 95% CI 0.06-0.88), and higher number of prior lines of systemic immunosuppressive therapy for cGVHD (HR 0.34, 95% CI 0.12-0.98). Interestingly, conditioning intensity, T-cell depletion, HLA-match, female donor to male recipient, blood vs. marrow stem cell source, or malignancy remission status at transplant were not predictive of relapse in univariate or multivariate analyses. These data suggest an important inverse relationship between cGVHD severity and likelihood of relapse post-transplant. Most classical relapse predictors seem to be abrogated by these effects.

Context Patients with breast cancer receiving chemotherapy (CTX) experience multiple concurrent symptoms, but little is known about how symptoms change during and after treatment. Knowledge of the identity and trajectory of symptom clusters (SCs) would enhance measurement and management. Objectives We aimed to identify SCs and their change over time from baseline to completion of breast cancer CTX. Methods SCs were identified and assessed for change in 219 women from Nebraska at four times: baseline, during cycles #3 and #4 of CTX, and one month after finishing CTX. Ten symptoms were measured: two using the Hospital Anxiety and Depression Scale and eight using the Symptom Experience Scale. Exploratory factor analysis was conducted at each time point, then changes in SCs were evaluated at different times. Results Two SCs were identified before and after initiating CTX: gastrointestinal and treatment-related. The number and type of symptoms in each cluster differed over time. Clusters were dynamic during CTX with changes in the number and type of symptoms. Only one treatment-related SC, which consisted of fatigue, pain, and sleep disturbance, was identified after CTX completion. Conclusion SCs during CTX appear to be dynamic, changing over time from before until after CTX completion. Repeated assessments of SCs reveal symptoms that are present and when patients are most burdened and in need of additional support.

Background: Knowledge of sleep aid use is limited despite the high prevalence of insomnia among women before, during, and following breast cancer adjuvant chemotherapy treatments (CTX). This study's purpose was to (1) determine the frequency and characteristics of participants taking sleep aid(s); (2) identify the frequency and percentage of sleep aid use by category (prescription sedative/hypnotics, prescription anti-depressants, prescription analgesics, prescription anti-emetics, over-the-counter (OTC) analgesics, OTC cold/flu/sinus, OTC sleep, alcohol, and herbal supplements); and (3) compare sleep aid use by category in the experimental and control groups within a randomized-controlled clinical trial (RCT). Methods: Longitudinal, descriptive, secondary RCT data analysis of women (n=219) receiving out-patient CTX, and at 30, 60, and 90 days following the last CTX and 1 year following CTX1. Participants recorded daily sleep aid use on a Sleep Diary. Analyses included descriptives, chi-square, and RM-ANOVA. Results: Approximately 20% of participants took at least one sleep aid before CTX1; usage decreased over time (12–18%); a second sleep aid was used infrequently. Prescription sedative/hypnotics (46%) and OTC analgesics (24%) were used most frequently. OTC sleep aids were most commonly used as a second aid. Prescription sedative/hypnotics [F(7,211)=4.26, p=0.00] and OTC analgesics [F(7,211)=2.38, p=0.023] use decreased significantly over time. Conclusions: Results reflect the natural course of CTX, recovery, and healing. Comprehensive screening for sleep–wake disturbances and sleep aid use may lead to a better understanding of the risks and benefits of pharmacologic and non-pharmacologic interventions, and ultimately lead to selection of the safest and most effective treatment. Copyright © 2010 John Wiley & Sons, Ltd.

BACKGROUND: This study’s purpose was twofold: (1) to establish adherence rates to a behavioral therapy (BT) sleep intervention and (2) to identify psychological and physical symptom predictors of adherence to the intervention in women undergoing breast cancer chemotherapy. METHODS: A randomized controlled trial began 48 h before the first of four chemotherapy treatments. Women with stages I–IIIA breast cancer (n=113) received a BT sleep intervention composed of stimulus control, modified sleep restriction (MSR), relaxation therapy (RT), and sleep hygiene counseling components. A BT plan was developed by a research nurse and each participant, reinforced on day 8, and repeated for chemotherapy cycles 2, 3, and 4. Adherence to the BT plan was measured daily; total adherence score was computed at each chemotherapy cycle by combining adherence estimates of all BT plan components. Psychological and physical symptoms over the past 7 days were measured 2 days prior to and 7 days after each chemotherapy treatment. RESULTS: Total adherence rates to the BT plan were 51–52% at all four treatments but adherence varied by component. Sleep disturbance, pain, and anxiety significantly decreased whereas depression significantly increased across chemotherapy. Structural equation modeling revealed a good model fit with decreasing sleep disturbances (0.409) and increasing depression (−0.711) contributing to lower total adherence rates. Increasing depression predicted lower MSR adherence (−0.203) and decreasing sleep disturbances predicted lower RT adherence (1.220). CONCLUSIONS: Sleep disturbance and depression significantly impacted adherence rates during chemotherapy. Results warrant attention when promoting adherence to BT sleep interventions during chemotherapy treatment.

Hematological deficiencies increase with aging leading to anemias, reduced hematopoietic stress responses and myelodysplasias. This study tested the hypothesis that side population hematopoietic stem cells (SP-HSC) would decrease with aging, correlating with IGF-1 and IL-6 levels and increases in bone marrow fat. Marrow was obtained from the femoral head and trochanteric region of the femur at surgery for total hip replacement (N = 100). Whole trabecular marrow samples were ground in a sterile mortar and pestle and cellularity and fat content determined. Marrow and blood mononuclear cells were stained with Hoechst dye and the SP-HSC profiles acquired. Marrow stromal cells (MSC) were enumerated flow cytometrically employing the Stro-1 antibody, and clonally in the colony forming unit fibroblast (CFU-F) assay. Plasma levels of IGF-1 (ng/ml) and IL-6 (pg/ml) were measured by ELISA. SP-HSC in blood and bone marrow decreased with age but the quality of the surviving stem cells increased. MSC decreased non-significantly. IGF-1 levels (mean = 30.7, SEM = 2) decreased and IL-6 levels (mean = 4.4, SEM = 1) increased with age as did marrow fat (mean = 1.2 mm fat/g, SEM = 0.04). There were no significant correlations between cytokine levels or fat and SP-HSC numbers. Stem cells appear to be progressively lost with aging and only the highest quality stem cells survive.

Dr. Carmen Escalante, Professor and Chair of General Internal Medicine, Ambulatory Treatment, and Emergency Care at The University of Texas MD Anderson Cancer Center, presents the lecture, “Cancer-related Fatigue.” Cancer-related fatigue is one of the most common symptoms experienced by cancer patients and cancer survivors. Dr. Escalante’s lecture provides a multidisciplinary perspective on cancer-related fatigue and focuses on the prevalence, characteristics, hypothesized pathophysiology, and common causes of this condition. Patient assessment and customized strategies for management, including non-pharmacologic and pharmacologic interventions, are presented. Resumen

Evidence-based practice can be hard to implement in the "real world" of clinical care. A set of reference cards with outcome-specific intervention options can make that practice possible. The Oncology Nursing Society Putting Evidence Into Practice (ONS PEP) resources cover 16 topics to improve care for patients with cancer and their families. A survey evaluated awareness of the tools and the need for further research on their adoption. The survey also elicited target topics for future ONS PEP resources. Awareness of the resources varies among different nursing roles. Increased awareness among clinicians can guide and support improved patient care.

Cancer-related fatigue is defined as a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. It is one of the most common side effects in patients with cancer. Fatigue has been shown to be a consequence of active treatment, but it may also persist into posttreatment periods. Furthermore, difficulties in end-of-life care can be compounded by fatigue. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer-Related Fatigue provide guidance on screening for fatigue and recommendations for interventions based on the stage of treatment. Interventions may include education and counseling, general strategies for the management of fatigue, and specific nonpharmacologic and pharmacologic interventions. Fatigue is a frequently underreported complication in patients with cancer and, when reported, is responsible for reduced quality of life. Therefore, routine screening to identify fatigue is an important component in improving the quality of life for patients living with cancer.

This secondary analysis describes sleep and health-related factors in healthy overweight and obese mid-life and older rural women enrolled in the" Women Weigh-In for Wellness" randomized clinical trial. The aim of the trial was to promote healthy behaviors and weight-loss. We analyzed demographic, anthropometric, and biomarker variables, self-reported measurements of sleep disturbance and pain interference, and objective 24-h sleep/wake patterns at baseline, 6 months, and the change over time. Although self-reported sleep disturbance reflected normal sleep, pain interference was slightly higher than normal. There were associations between higher self-reported sleep disturbance, pain interference and several other variables. Women who achieved 5 % or more weight loss exhibited positive associations between sleep, pain, and health-related factors. Weight loss and lower pain predicted lower self-reported sleep disturbance. Our results suggest that overweight and obese rural women who adopt healthy behaviors and achieve weight loss also may experience improved sleep and other health benefits. Clinical trial # NCT01307644.

Symptom management is a vital aspect of the practice of oncology nursing. The Oncology Nursing Society has identified outcomes sensitive to nursing intervention, known as nursing-sensitive patient outcomes. This article presents information about sleep-wake disturbances that occur in patients with cancer and makes recommendations for evidence-based interventions to improve sleep for patients. Sleep-wake disturbances occur in 30%-75% of people with cancer and have a negative impact on other symptoms and quality of life. Despite the frequency and severity of sleep-wake disturbances, limited research has tested interventions to improve sleep-wake outcomes. Although no interventions currently receive the highest recommendations for implementation into practice, several nonpharmacologic interventions show initial positive findings in promoting high-quality sleep and daytime functioning. Oncology nurses can screen for sleep-wake disturbances and suggest tailored interventions. Four categories of promising interventions are cognitive-behavioral therapy, complementary therapies, psychoeducation and information, and exercise. Clinicians can use the Putting Evidence Into Practice (PEP) card and PEP resources at www.ons.org/outcomes to improve sleep-wake outcomes.

The number of distance education courses offered by nurse anesthesia programs has increased substantially. Emerging distance learning trends must be researched to ensure high-quality education for student registered nurse anesthetists. However, research to examine distance learning has been hampered by a lack of theoretical models. This article introduces the Community of Inquiry model for use in nurse anesthesia education. This model has been used for more than a decade to guide and research distance learning in higher education. A major strength of this model learning. However, it lacks applicability to the development of higher order thinking for student registered nurse anesthetists. Thus, a new derived Community of Inquiry model was designed to improve these students' higher order thinking in distance learning. The derived model integrates Bloom's revised taxonomy into the original Community of Inquiry model and provides a means to design, evaluate, and research higher order thinking in nurse anesthesia distance education courses.

Methods: The present study examined the association between fatigue, pain, overall quality of life, and perceived health status with employment at 1-year post-transplant. Participants (N1⁄4404) completed a lifestyle survey 1-year post-SCT. Participants provided current employment status and whether change was attributable to their health status. Results: Participants were predominatelymarried/partnered (81.7%), Caucasian/Non-Hispanic (81.6%), males (52%) between ages 19-76 (mean: 56 years) and majority underwent autologous transplants (70.1%). Prior to illness diagnosis, 60.8% were employed Full-Time, which decreased at the time of transplant (35.5%) and at 1-year post-SCT (31.0%). Employment status was correlated with all variables of interest (p