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Background: In patients with lymphedema (LE), in addition to hand dominance, between-group comparisons of interlimb soft tissue differences need to account for differences in whole-body adiposity, measured directly by dual energy X-ray absorptiometry (DXA) or indirectly by body mass index. No study has evaluated the effects of hand dominance and whole-body adiposity on limb composition in patients with LE. This study's purpose was to compare soft tissue composition of affected and unaffected limbs of women with breast cancer, who did and did not have LE, controlling for dominance and percent body fat. Methods and Results: Whole-body DXA scans were acquired and included measures of percent body fat, upper limb total mass, upper limb fat mass, and upper limb fat-free mass. Participants were classified into one of three groups: women without LE; women with only subjective LE; and women with objective signs of LE at the time of assessment. Differences among the LE groups were evaluated using analysis of variance (ANOVA) and Chi-square analyses. Analysis of covariance (ANCOVA) was used to control for percent body fat and for the affected limb dominance. Compared to women without LE, women with objective signs of LE have greater total limb mass, fat mass, and fat-free mass in their affected limbs, independent of affected side dominance and percent body fat. In addition, the interlimb differences in total mass, fat mass, and fat-free mass were greater for the women with objective signs of LE, compared to the other two groups. Conclusions: DXA is useful in identifying soft tissue changes in patients with LE. Given that limb circumferences measure only changes in limb volume and that bioimpedance provides estimates of extracellular fluid, DXA has the advantage of being able to estimate the volumes of specific tissues in the limb.

Background: Lymphedema (LE) is a significant clinical problem for breast cancer survivors. While the water displacement test and circumferential assessment using a tape measure (TM) are common methods to assess differences in arm volumes, faster and more reliable methods are needed. Study purposes, in breast cancer survivors (n = 294), were to compare the average total arm volumes and interlimb volume ratios for women with and without a history of LE, using a TM and three-dimensional (3D), whole-body surface scanner (3D scan); compare the level of agreement between arm volumes and interlimb volume ratios obtained using the two devices; and evaluate the percent agreement between the two measures in classifying cases of LE using three accepted thresholds. Methods and Results: Measurements were done using a spring-loaded TM and Fit3D ProScanner. Paired t-tests and Bland-Altman analyses were used to achieve the study aims. For circumference and volume comparisons, compared with the 3D scan, values obtained using the TM were consistently smaller. In terms of level of agreement, the Bland-Altman analyses demonstrated large biases and wide limits of agreement for the calculated arm volumes and volume ratios. In terms of the classification of caseness, using the 200-mL interlimb volume difference criterion resulted in 81.6% overall agreement; using the >10% volume difference between the affected and unaffected arms resulted in 78.5% overall agreement; and using the volume ratio ≥1.04 criterion resulted in 62.5% overall agreement. For all three accepted threshold criteria, the percentage of cases was significantly different between the TM and 3D scan techniques. Conclusions: The 3D technology evaluated in this study has the potential to be used for self-initiated surveillance for LE. With improvements in landmark identification and software modifications, it is possible that accurate and reliable total arm volumes can be calculated and used for early detection.

Background Sagittal fractures of equine cheek teeth are commonly observed during oral examination. There are few reports on the apical and endodontic pathology associated with such fractures seen during computed tomographic (CT) examination. Objectives This study aimed to document the prevalence of CT changes indicative of apical disease in equine cheek teeth, which have suffered a sagittal fracture involving the clinical ± reserve crown. Study design This study is a retrospective case series. Methods CT examinations of equine heads with sagittal fractures of cheek teeth present were reviewed: 81 teeth from 49 horses were identified to have a sagittal cheek tooth fracture. The images were evaluated for apical pathology including gas (in the endodontic system and periapically), widened periodontal space, periapical sclerosis, apical clubbing, cementoma/hypercementosis, lamina dura loss, associated sinusitis and sinus mucosal swelling. An apical infection grading system was created to give each tooth a score. Hounsfield units were used to measure the density of the endodontic, apical and periapical regions. The fracture length ratio was recorded. Statistical analysis was performed using a generalised estimating equation to evaluate predictors of apical infection and associations between clinical signs and CT abnormalities. Results Eighty-seven sagittal fractures (56 buccal, 17 palatal/lingual and 14 midline) from 81 teeth were recorded (74 maxillary and 7 mandibular). Apical infection was diagnosed in 73% (37/51, P = .05) of buccal, 55% (6/11, P = .07) of palatal/lingual, 100% (13/13) of midline, 100% (6/6) of multiple fractures and 96% (23/24, P = .008) of fractures involving infundibula. There was no significant relationship between apical infection and the presence of clinical signs associated with dental pathology (P = .4). There was no significant association between fracture length ratio and apical infection (P = 1.0). Midline sagittal fractures were significantly associated with sinusitis when compared with all other maxillary fractures (odds ratio [OR] 5.92, 95% confidence interval [CI] 1.67-20.83, P = .006). Loss of the lamina dura was not significantly associated with apical infection (P = .5). Main limitations There is a maxillary cheek tooth bias in the data set and the subjective grading system. Conclusions A large proportion of fractured cheek teeth have evidence of apical infection on CT examination and therefore warrant treatment.

Background As genomic science moves beyond government-academic collaborations into routine healthcare operations, nursing’s holistic philosophy and evidence-based practice approach positions nurses as leaders to advance genomics and precision health care in routine patient care. Purpose To examine the status of and identify gaps for U.S. genomic nursing health care policy and precision health clinical practice implementation. Methods We conducted a scoping review and policy priorities analysis to clarify key genomic policy concepts and definitions, and to examine trends and utilization of health care quality benchmarking used in precision health. Findings Genomic nursing health care policy is an emerging area. Educating and training the nursing workforce to achieve full dissemination and integration of precision health into clinical practice remains an ongoing challenge. Use of health care quality measurement principles and federal benchmarking performance evaluation criteria for precision health implementation are not developed. Discussion Nine recommendations were formed with calls to action across nursing practice workforce and education, nursing research, and health care policy arenas. Conclusions To advance genomic nursing health care policy, it is imperative to develop genomic performance measurement tools for clinicians, purchasers, regulators and policymakers and to adequately prepare the nursing workforce.

Objectives Heart failure (HF) heavily burdens the global health system. Transitional care interventions attempt to streamline the hospital-to-home transition to ease the burden. This systematic review and meta-analysis aimed to evaluate the effectiveness of transitional care interventions on health care utilization after hospitalization for HF. Design Systematic review and meta-analysis including dose-response relationship. Setting and Participants Randomized controlled trials (RCTs) of transitional care interventions vs usual care in older patients discharged from the hospital with HF. Methods Electronic databases including MEDLINE, Embase, Cochrane Library, and CINAHL, were systematically searched from January 2009 to October 2019 to locate relevant systematic reviews or meta-analyses. The original RCTs included in the review articles were identified, and an additional search for recently published RCTs was performed from January 2014 to June 2020. This systematic review focused on health care utilization outcomes, including hospital readmissions for HF or any cause, emergency department (ED) visits, and length of hospital stay (LOS). Results Data were summarized from 38 RCTs covering 10,871 patients. Pooled evidence suggested a mean 11% [risk ratio (RR) 0.89, 95% confidence interval (CI) 0.82, 0.97] and 22% (RR 0.78, 95% CI 0.68, 0.89) risk reduction on all-cause and HF-specific readmissions, but no significant reduction (RR 0.94, 95% CI 0.83, 1.07) on ED visits. Findings were mixed for LOS. Subgroup analysis by different types of transitional care interventions indicated that multidisciplinary interventions currently have the best evidence for reducing readmissions up to 6 months post the index HF hospitalization. In addition, we observed an inverse linear dose-response relationship between intervention intensity (ie, frequency and duration of interventions) and complexity (ie, number of intervention components) and the risk of HF readmissions. Conclusions and Implications Transitional care interventions for hospitalized patients with HF reduced all-cause and HF-specific readmissions, but did not decrease ED visits. Multidisciplinary interventions are highly recommended if adequate resources are available.

PURPOSE Malignant fungating wounds (MFWs) afflict up to 14% of patients with advanced cancer. The bacterial community structures of MFW may influence the development and severity of wound symptoms. The purpose of this systematic review was to evaluate existing evidence regarding the relationship between microbiome and symptoms of MFWs. METHODS A systematic review of the published literature from January 1995 to January 2020 was conducted. An established quality assessment tool was used to assess the quality of the included studies. SEARCH STRATEGY We searched 4 major electronic databases and retrieved 724 articles; 7 met inclusion criteria. FINDINGS/CONCLUSIONS Seven studies were included; the overall quality of the included 7 studies was ranked as adequate. Findings from the studies provided an incomplete characterization of the microbiome and metabolome of MFW; none included modern genomic technologies. Twenty different species of aerobes and 14 species of anaerobes were identified, with inconsistent identification of biofilms and multi-drug-resistant bacteria. Symptom occurrence increased with the number of bacteria species (P = .0003) and the presence of at least 1 anaerobe (P = .0006) in malignant wound beds. Cancer wound-derived odor was associated with dimethyl trisulfide and 4 fatty acid volatiles. Periwound and moisture-associated skin damage were associated with higher putrescine levels in exudates. IMPLICATIONS Understanding the role of microbiota of MFW in developing or amplifying the severity of wound symptoms is the first step toward development of more precise and effective topical interventions.

Context The prevalence of chronic pain in cancer survivors is double that of the general U.S. population. Opioids have been the foundation of cancer pain management for decades; however, there is a paucity of literature on long-term opioid therapy (LTOT) in cancer survivors. An understanding of factors related to LTOT use in cancer survivors is needed to address chronic pain and balance opioid harms in the expanding population of cancer survivors. Objectives To analyze the research of LTOT utilization and factors associated with persistent opioid use in cancer survivors. Methods A five-stage integrative review process was adapted from Whittemore and Knafl. Data sources searched included Web of Science, PubMed, Embase, Cochrane, and Google Scholar. Quantitative research studies from 2010 to present related to cancer survivors managed on LTOT were included. Editorials, reviews, or abstracts were excluded. Results After reviewing 315 articles, 21 articles were included. We found that there were several definitions of LTOT in the reviewed studies, but the duration of opioid use (i.e., more than three months after completion of curative treatment) was the most common. The reviewed literature describes a relationship between LTOT and important biopsychosocial factors (cancer type, socioeconomic factors, and comorbidities). Conclusion The studies in this review shed light on the factors associated with LTOT in cancer survivors. LTOT was common in certain populations of cancer survivors and those with a collection of patient-specific characteristics. This review suggests that there is a critical need for specialized research on chronic cancer pain and opioid safety in cancer survivors.

Purpose of the Study More than 50% of breast cancer survivors without a diagnosis of lymphedema suffer daily from numerous and co-occurring lymphedema symptoms. This study aimed to identify lymphedema symptom patterns and the association of such patterns with phenotypic characteristics and biomarkers using latent class analysis (LCA). A prospective, descriptive, and repeated-measure design was used to enroll 140 women and collect data. Recent Findings LCA identified three distinct lymphedema symptom classes at 8 weeks and 12 months post-surgery: low, moderate, and severe symptom classes and associated phenotypic characteristics. Participants were more likely to be in the severe symptom classes at 12 months post-surgery if they had lower education level, cording, an axillary syndrome at 8 weeks post-surgery, neoadjuvant chemotherapy, and radiation. Summary Pre-surgery level of IL1-a, IL-6, IL-8, and VEGF was associated with the severe symptom class at 8 weeks post-surgery, suggesting that such biomarkers may be used to predict risk for lymphedema symptoms.

Precision health refers to personalized healthcare based on a person’s unique genetic, genomic, or omic composition within the context of lifestyle, social, economic, cultural and environmental influences to help individuals achieve well-being and optimal health. Precision health utilizes big data sets that combine omics (i.e. genomic sequence, protein, metabolite, and microbiome information) with clinical information and health outcomes to optimize disease diagnosis, treatment and prevention specific to each patient. Successful implementation of precision health requires interprofessional collaboration, community outreach efforts, and coordination of care, a mission that nurses are well-positioned to lead. Despite the surge of interest and attention to precision health, most nurses are not well-versed in precision health or its implications for the nursing profession. Based on a critical analysis of literature and expert opinions, this paper provides an overview of precision health and the importance of engaging the nursing profession for its implementation. Other topics reviewed in this paper include big data and omics, information science, integration of family health history in precision health, and nursing omics research in symptom science. The paper concludes with recommendations for nurse leaders in research, education, clinical practice, nursing administration and policy settings for which to develop strategic plans to implement precision health. Keywords: Nurses, Genomics, Omics, Precision medicine, Precision health

BACKGROUND Early intervention with self-management strategies can potentially reduce the risk of progression of breast cancer-related lymphedema (BCRL). OBJECTIVE To determine if The-Optimal-Lymph-Flow (TOLF) program focused on self-management strategies applied to patients with a subclinical or mild stage of BCRL can improve lymphedema-related behaviors, symptom experience, and limb circumference changes. METHODS A total of 41 women with subclinical or mild lymphedema were enrolled in TOLF program. Lymphedema-related behaviors and lymphedema-related symptom experiences were measured by the Breast Cancer and Lymphedema Symptom Experience Index, and limb circumference changes were measured by sequential circumferential limb measurements at baseline and 1, 3, 6, and 12 months after the intervention. Generalized estimating equations were used to estimate the effects of the intervention on outcomes. RESULTS Generalized estimating equations revealed that lymphedema-related behaviors and the number and severity of lymphedema-related symptoms were significantly improved at 4 postintervention test points compared with baseline (all P < .001). Reduced lymphedema-related symptom distress in functional, social, emotional, and psychological and self-perception (all P < .01) also resulted. The majority (77.5%) of patients maintained their preintervention lymphedema status; 17.5% of them reversed from mild lymphedema to subclinical lymphedema; 5.0% of them had lymphedema status progression. CONCLUSION Positive outcomes in terms of lymphedema-related behaviors, relieving lymphedema-related symptom experience, and halting the progression of lymphedema status were documented following TOLF. IMPLICATIONS FOR PRACTICE Nurses could educate patients to incorporate the self-management strategies of TOLF program into daily life to help patients prevent or reverse subclinical or mild stage of BCRL.

Purpose The purpose of this study was to describe the experiences of older adult Haitian immigrants in managing type 2 diabetes mellitus (T2DM). Methods A descriptive qualitative approach using semistructured interviews was conducted with 20 older adult Haitian immigrants with T2DM. Interviews were transcribed verbatim and categorized using NVivo. An iterative descriptive data analysis method was used to examine the data, compare codes, challenge interpretations, and develop themes inductively. Results Older adult Haitian immigrants reported that T2DM affected every aspect of their lives. Financial hardship and social isolation were described as the major barriers to T2DM management, which forced them to choose between basic needs and health care, and at times, they had to forgo medications or avoid seeking medical care. They recognized that creating and maintaining good community support was the key to self-management of T2DM. Conclusions Financial hardship and social isolation have a tremendous impact on the ability of older Haitian immigrants to manage T2DM effectively. It is challenging to modify these barriers through individual efforts, and clinical, research, and public efforts may be necessary to address these concerns.

Diabetes Distress (DD) can be experienced differently by family members living with T1D. We examined concordance and discordance between youth and parent report of DD and the relationship with youth glycemic control, diabetes-specific family conflict and parent involvement in diabetes tasks in a sample of youth starting real-time continuous glucose monitoring (CGM). Youth (N=120, 51% male) with T1D ages 8-17 years and their parents (84% mothers) completed surveys assessing DD, family conflict and parent involvement. Previously validated cut-points of >41 (PAID-Peds, youth) and >56 (PAID-PR, parents) identified clinically significant DD. Youth/parent dyads were classified as concordant when both youth and parents scored below (Youth Low/Parent Low) or above (Youth High/Parent High) the cut-points. Youth/parent dyads were classified as discordant when youth scored below and parent scored above (Youth Low/Parent High) or youth scored above and parent scored below (Youth High/Parent Low) the cut-points. Youth had a mean±SD age of 12.7±2.7 years, T1D duration 6.1±3.6 years and A1c 8.0±0.8%; 84% were pump treated. About ¼ of youth (26%) and parents (23%) reported clinically significant DD with 62% of dyads concordant for low DD, 10% concordant for high DD and 28% discordant for DD. Concordant groups did not differ significantly from discordant groups. In the 2 discordant groups, A1c and youth-reported family conflict differed significantly; A1c: 7.5±0.9% vs. 8.3±0.7% (p=.043) and family conflict: 5.6±5.1 vs. 22.9±22.0 (p=.036) in the Youth Low/Parent High and Youth High/Parent Low groups, respectively. Parent involvement did not differ across the groups. DD can be perceived differently by youth with T1D and their parents. When youth perceive high DD and parents do not, youth appear at risk for adverse outcomes, highlighting the importance of youth perceptions. Disclosure K. Wentzell: None. M. R. Fu: None. L. K. Volkening: None. L. M. Laffel: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Dexcom, Inc., Dompe, Insulogic LLC, Janssen Pharmaceuticals, Inc., Laxmi Therapeutic Devices, LifeScan, Lilly Diabetes, Medtronic, Provention Bio, Inc. Funding National Institutes of Health (R01DK089349, K12DK094721, P30DK036836)

Background: Awareness of disease status has been identified as a factor in the treatment decision-making process. Women with recurrent ovarian cancer are facing the challenge of making treatment decisions throughout the disease trajectory. It is not understood how women with ovarian cancer perceive their disease and subsequently make treatment decisions. Purpose: The purpose of this phenomenological study was to understand the lived experience of women with recurrent ovarian cancer, how they understood their disease and made their treatment decisions. Methods: A qualitative design with a descriptive phenomenological method was used to conduct 2 in-depth interviews with 12 women (n = 24 interviews). Each interview was ∼60 minutes and was digitally recorded and professionally transcribed. Data collection focused on patients' understanding of their disease and how patients participated in treatment decisions. A modified version of Colaizzi's method of phenomenological reduction guided data analysis. Results: Three themes emerged to describe the phenomenon of being aware of disease status: (1) perceiving recurrent ovarian cancer as a chronic illness, (2) perceived inability to make treatment decisions, and (3) enduring emotional distress. Conclusions and Implications: This study revealed how 12 women conceptualized recurrent ovarian cancer as a chronic disease and their perceived inability to make treatment decisions because of lack of information and professional qualifications, resulting in enduring emotional distress. Future research should replicate the study to confirm the persistence of the themes for racially, ethnically, and religiously diverse patient samples and to improve understanding of awareness of disease status and decision-making processes of patients.

Background Lymphedema is a progressive and chronic illness. Early detection and treatment often lead to better clinical outcomes and improvement of patients' quality of life. Lymphedema symptoms can assist in detecting lymphedema. However, the use of patient-reported symptom evaluation is still limited in clinical practice. To address this gap in clinical practice, a metropolitan cancer center implemented an electronic patient evaluation of lymphedema symptoms (EPE-LE) to enable patients' real-time symptom report during patients' routine clinical visit while waiting to see their doctors in a waiting room. The purpose of this clinical project was to evaluate the usefulness of EPE-LE during patients' routine clinical visit. Methods A cross-sectional design was used. Participants were outpatient post-surgical breast cancer patients and clinicians who were involved in the EPE-LE implementation at a metropolitan cancer center of US. Data were collected during the three-month EPE-LE implementation, including patients' report of lymphedema symptoms, patient and clinician satisfaction, and referral to lymphedema specialists. Descriptive statistics were used for data analysis. Results During the three-month implementation, a total of 334 patients utilized the EPE-LE to report their lymphedema symptoms and 24 referrals to lymphedema specialists. Nearly all of the patients found that the EPE-LE was easy to use (91%) and that they were satisfied with the EPE-LE for reporting lymphedema symptoms (89%). The majority (70%) of patients reported that the EPE-LE helped them to learn about symptoms related to lymphedema and encouraged them to monitor their symptoms. All clinicians (100%) agreed that the use of the EPE-LE improved their lymphedema symptom assessment in post-surgical breast cancer patients; 75% reported that the EPE-LE increased their communication with patients related to lymphedema symptoms, 75% agreed they would recommend the EPE-LE for use at other cancer centers, and 75% reported that the information retrieved from the EPE-LE was helpful in evaluation of lymphedema. Conclusions The use of EPE-LE enhanced patients' real-time report of lymphedema symptoms, improved patient education on lymphedema symptoms, and helped clinicians for evaluation of lymphedema. The use of EPE-LE is an example how to implement evidence-based research into clinical practice that provides benefits for both patients and clinicians.

Background The-Optimal-Lymph-Flow (TOLF) is a patient-centered, web- and mobile-based mHealth system that delivers safe, easy, and feasible digital therapy of lymphatic exercises and limb mobility exercises. Objective The purpose of this randomized clinical trial (RCT) was to evaluate the effectiveness of the web- and mobile-based TOLF system for managing chronic pain and symptoms related to lymphedema. The primary outcome includes pain reduction, and the secondary outcomes focus on symptom relief, limb volume difference measured by infrared perometer, BMI, and quality of life (QOL) related to pain. We hypothesized that participants in the intervention group would have improved pain and symptom experiences, limb volume difference, BMI, and QOL. Methods A parallel RCT with a control–experimental, pre- and posttest, and repeated-measures design were used. A total of 120 patients were recruited face-to-face at the point of care during clinical visits. Patients were randomized according to pain in a 1:1 ratio into either the arm precaution (AP) control group to improve limb mobility and arm protection or The-Optimal-Lymph flow (TOLF) intervention group to promote lymph flow and limb mobility. Trial outcomes were evaluated at baseline and at week 12 after the intervention. Descriptive statistics, Fisher exact tests, Wilcoxon rank-sum tests, t test, and generalized linear mixed effects models were performed for data analysis. Results At the study endpoint of 12 weeks, significantly fewer patients in the TOLF intervention group compared with the AP control group reported chronic pain (45% [27/60] vs 70% [42/60]; odds ratio [OR] 0.39, 95% CI 0.17-0.90; P=.02). Patients who received the TOLF intervention were significantly more likely to achieve a complete reduction in pain (50% [23/46] vs 22% [11/51]; OR 3.56, 95% CI 1.39-9.76; P=.005) and soreness (43% [21/49] vs 22% [11/51]; OR 2.60, 95% CI 1.03-6.81; P=.03). Significantly lower median severity scores were found in the TOLF group for chronic pain (MedTOLF=0, IQR 0-1 vs MedAP=1, IQR 0-2; P=.02) and general bodily pain (MedTOLF=1, IQR=0-1.5 vs MedAP=1, IQR 1-3; P=.04). Compared with the AP control group, significantly fewer patients in the TOLF group reported arm/hand swelling (P=.04), heaviness (P=.03), redness (P=.03), and limited movement in shoulder (P=.02) and arm (P=.03). No significant differences between the TOLF and AP groups were found in complete reduction of aching (P=.12) and tenderness (P=.65), mean numbers of lymphedema symptom reported (P=.11), ≥5% limb volume differences (P=.48), and BMI (P=.12). Conclusions The TOLF intervention had significant benefits for breast cancer survivors to manage chronic pain, soreness, general bodily pain, arm/hand swelling, heaviness, and impaired limb mobility. The intervention resulted in a 13% reduction (from 40% [24/60] to 27% [16/60]) in proportions of patients who took pain medications compared with the AP control group, which had a 5% increase (from 40% [24/60] to 45% [27/60]). A 12% reduction (from 27% [16/60] to 15% [9/60]) in proportions of patients with ≥5% limb volume differences was found in the TOLF intervention, while a 5% increase in the AP control group (from 40% [24/60] to 45% [27/60]) was found. In conclusion, the TOLF intervention can be a better choice for breast cancer survivors to reduce chronic pain and limb volume. Trial Registration Clinicaltrials.gov NCT02462226; https://clinicaltrials.gov/ct2/show/NCT02462226 International Registered Report Identifier (IRRID) RR2-10.2196/resprot.5104

Background: Patients with head and neck cancer (HNC) experience painful, debilitating symptoms and functional limitations that can interrupt cancer treatment, and decrease their health-related quality of life (HRQoL). The Electronic Patient Visit Assessment (ePVA) for head and neck is a web-based mHealth patient-reported measure that asks questions about 21 categories of symptoms and functional limitations common to HNC. This article presents the development and usefulness of the ePVA as a clinical support tool for real-time interventions for patient-reported symptoms and functional limitations in HNC. Methods: Between January 2018 and August 2019, 75 participants were enrolled in a clinical usefulness study of the ePVA. Upon signing informed consent, participants completed the ePVA and the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ) general (C30) questionnaire v3.0 (scores range from 0 to 100 with 100 representing best HRQoL). Clinical usefulness of the ePVA was defined as demonstration of reliability, convergent validity with HRQoL, and acceptability of the ePVA (i.e., >70% of eligible participants complete the ePVA at two or more visits and >70% of ePVA reports are read by providers). Formal focus group discussions with the interdisciplinary teamthat cared for patients with HNC guided the development of the ePVA as a clinical support tool. Qualitative and quantitative methods were used throughout the study. Descriptive statistics consisting of means and frequencies, Pearson correlation coefficient, and Student���s t-tests were calculated using SAS 9.4 and STATA. Results: The participants were primarily male (71%), White (76%), diagnosed with oropharyngeal or oralcavity cancers (53%), and undergoing treatment for HNC (69%). Data analyses supported the reliability (alpha =0.85), convergent validity with HRQoL scores, and acceptability of the ePVA. Participants with the highest number of symptoms and functional limitations reported significantly worse HRQoL (sumof symptoms: r=���0.50, P

Background: The-Optimal-Lymph-Flow (TOLF) intervention aims to promote lymph flow through therapeutic lymphatic exercises to relieve lymphatic pain, swelling, lymphedema symptoms, and to decrease lymph fluid levels among breast cancer survivors. To enhance the efficacy of the TOLF intervention, an innovative, intelligent, Kinect-enhanced lymphatic exercise intervention (Kinect-TOLF) was developed to teach patients to perform the lymphatic exercises correctly. Objectives: This feasibility trial aimed to determine the feasibility, usability, and effects of the Kinect-TOLF on lymphatic pain, swelling, lymphedema symptoms, and lymph fluid levels. Methods: A single-arm feasibility trial with a pre- and post-test design was employed to recruit 30 breast cancer survivors with persistent lymphatic pain or swelling. Patients received a single training session to learn how to perform the lymphatic exercises using the Kinect-TOLF program. Descriptive statistics, Wilcoxon signed-rank tests, t-test, Spearman’s rank correlation coefficients, linear regressions, and Cohen’s d were performed for data analysis. Qualitative data were assessed for common themes. Results: The Kinect-TOLF was effective in training patients to perform the lymphatic exercises correctly with high user satisfaction. Significant reductions were found in scores of lymphatic pain ( MedΔ = −1.00, CI = [−1.5, −0.1], P = .004), arm/hand swelling ( MedΔ = −1.00, CI = [−1.5, −0.5], P = .004), total swelling ( MedΔ = −1.5, CI = [−2.0, −1.0], P = .003), number of lymphedema symptoms ( MΔ = −3.8, CI = [−5.5, −2.1], P Δ = −5.3, CI = [−9.5, −1.1], P = .016). A significant reduction in lymph fluid levels was found in mean L-Dex scores ( MΔ = −2.68, CI = [−4.67, −0.69], P = .010). Greater decrease in mean L-Dex scores were found in patients with abnormal lymph fluid levels (L-Dex ≥ 7.1) ( MΔ = −5.19, CI = [−1.75, −8.63], P = .008). Patients’ qualitative feedback supported the results of the study. Conclusions: The Kinect-TOLF is safe, feasible, and effective in reducing lymphatic pain, swelling, lymphedema symptoms, and in decreasing lymph fluid levels. Future research should focus on a randomized clinical trial to confirm the unique or synergistic efficacy of the Kinect-TOLF in comparison with current lymphedema treatment and other forms of exercises or movement therapy. This study was registered in ClinicalTrials.gov with US ClinicalTrials.gov Identifier: NCT03999177.

Background: Breast cancer-related lymphedema (BCRL) limits the movements of patients' limbs, which leads to a diminished ability to achieve essential activities of daily living (ADLs). The purpose of this study was to examine the associations between limb volume changes from the baseline before breast cancer surgery and self-reported difficulty in performing ADLs at 12 months following cancer surgery. We hypothesized that a positive association existed between limb volume changes from the baseline and self-reported difficulty in performing ADLs at 12 months following breast cancer surgery. Methods and Results: The data of the present study were part of a larger study with 140 breast cancer patients recruited before breast cancer surgery and followed up during their first year of treatment. Patients with more than 10% limb volume increase reported more frequent distress in performing 13 ADL items, compared with patients whose limb volume increased by 5%-10%. Regression analysis showed a significant increase in the odds ratio of reporting difficulty in ADLs compared with the group with less than 5% limb volume increase. Conclusion: Overall, patients with a greater limb volume increase underwent more difficulty performing ADLs. Patients reported more difficulty in performing ADLs even with 5%-10% limb volume increase. Currently, there is no standardized guideline to diagnose BCRL, although previous evidence suggests a limb volume increase greater than 10% as a criterion for BCRL. The findings from the present study suggest a more precise and clinically meaningful criteria for diagnosing BCRL to accommodate those with 5%-10% increase in limb volume.

This study explored the association between oral microbes and head and neck cancer (HNC) as well as symptoms related to patients with HNC before surgical treatment. Fifty-six patients with HNC and 64 matched healthy controls were recruited from West China hospital in Southwest China. The demographic, clinical, and symptom data were collected. Salivary samples were collected to determine the microbial characteristics using 16S rRNA gene sequencing. Patients with HNC presented increased Capnocytophaga abundances. The oral microbial markers as Capnocytophaga (area under the curve=0.81) achieved a high classification power between the HNC patients and healthy controls. Moreover, using Capnocytophaga in conjunction with symptom of voice/speech difficulty achieved an overall predicting accuracy of 92.5% comparing with using Capnocytophaga alone (79.2% accuracy) in distinguishing the HNC patients from healthy controls. Salivary microbial profiles and HNC symptoms may be potential biomarkers for HNC screening.

Purpose Lymphedema is a chronic condition that may result from cancer-related surgery. The incidence of lymphedema varies greatly; however, patients remain at risk for life and may experience decreased quality of life and functional capacity. Providing recommendations for an evidence-based guideline for care of cancer treatment-related lymphedema will help to improve outcomes for patients with this chronic condition. Methodologic approach A panel of healthcare professionals with patient representation convened to develop a national clinical practice guideline on prospective surveillance, risk reduction, and conservative treatment of lymphedema. Systematic reviews of the literature were conducted and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology approach was used to assess the evidence. Findings The panel made multiple recommendations for patients who are at risk for or experiencing lymphedema. Implications for nursing Early diagnosis and treatment of lymphedema may mitigate symptoms. This evidence-based guideline supports patients, clinicians, and other healthcare professionals in clinical decision making. Supplementary material can be found at https //onf.ons.org/supplementary-material-ons-guidelines-cancer-treatment-related-lymphedema.

Background Fear of cancer recurrence (FCR) is the most prevalent need among breast cancer survivors. Age is the most consistent predictor of higher FCR, with prevalence rates as high as 70% among young adults. Although the association between age and higher FCR is well established, a more comprehensive understanding of the factors contributing to higher FCR among young adult breast cancer survivors is needed. Objective The purpose of this integrative review was to explore the factors associated with higher FCR among young adult breast cancer survivors (≤ 45 years old). Methods A literature search was conducted using PubMed, CINAHL, PsycINFO, and EMBASE databases with specific Medical Subject Headings terms delimited to FCR, diagnosis, sex, and age range. The initial search yielded 378 studies, 13 of which met the eligibility criteria. Results Themes include motherhood status, health behaviors and decision making (eg, surveillance behaviors and surgical decision making), psychological morbidity, and social support. Cognitive behavioral factors include cognitive processing, metacognition, illness intrusiveness, and self-efficacy. Conclusion Fear of cancer recurrence among young adult breast cancer survivors is a unique construct requiring further exploration and tailored interventions to improve the health-related quality of life for this population. Implications for practice Oncology nurses should screen all cancer survivors for FCR, with particular attention to the unique needs of young adults. Future research should address the role of age-appropriate support and increased levels of FCR during surveillance periods.

Introduction: Malignant fungating wounds (MFWs), non-healing wounds caused by aggressive proliferation of malignant tumors, afflict 5%-14.5% of patients with advanced cancer. We conducted an integrative review to evaluate the level of evidence of peer-reviewed literature published from 2000 to 2019 on symptoms of MFWs, and the impact of the symptoms on functional performance among patients with advanced cancer. Methods: Four electronic databases were searched and 1506 articles were retrieved. A total of 1056 abstracts were screened for relevance and a full review of the 26 articles was performed. A total of 12 articles met inclusion criteria. An established quality assessment tool was used to rate the quality of the included studies. Results: The overall quality of the included 12 studies was adequate. This integrative review of the literature provided strong evidence that patients with MFWs suffered multiple symptoms, including pain, odor, exudate, bleeding, pruritus, perceived wound status, perceived bulk effect and lymphedema. Quantitative research was not able to capture the occurrence and characteristics of all the identified symptoms. There was a lack of quantitative research on the impact of MFWs and symptoms on patients' functional performance. Yet, qualitative studies provided vivid description of how the symptoms negatively affected patients' functional performance. Future research should develop a clinical tool that enables the comprehensive assessment of symptoms of MFWs. Well-designed quantitative research is needed to delineate the impact of symptoms of MFWs on patients' functional performance to ensure quality palliative care.

Purpose Early detection and intervention of lymphedema is essential for improving the quality of life of breast cancer survivors. Previous studies have shown that patients have symptoms such as arm tightness and arm heaviness before experiencing obvious limb swelling. Thus, this study aimed to develop a symptom-warning model for the early detection of breast cancer-related lymphedema. Methods A cross-sectional study was conducted at a tertiary hospital in Beijing between April 2017 and December 2018. A total of 24 lymphedema-associated symptoms were identified as candidate predictors. Circumferential measurements were used to diagnose lymphedema. The data were randomly split into training and validation sets with a 7:3 ratio to derive and evaluate six machine learning models. Both the discrimination and calibration of each model were assessed on the validation set. Results A total of 533 patients were included in the study. The logistic regression model showed the best performance for early detection of lymphedema, with AUC = 0.889 (0.840–0.938), sensitivity = 0.771, specificity = 0.883, accuracy = 0.825, and Brier scores = 0.141. Calibration was also acceptable. It has been deployed as an open-access web application, allowing users to estimate the probability of lymphedema individually in real time. The application can be found at https://apredictiontoolforlymphedema.shinyapps.io/dynnomapp/ . Conclusion The symptom-warning model developed by logistic regression performed well in the early detection of lymphedema. Integrating this model into an open-access web application is beneficial to patients and healthcare providers to monitor lymphedema status in real-time.

Malignant fungating wounds present in 5–14% of advanced cancer patients in the United States and are a result of cancerous cells infiltrating and proliferating in the skin. Presentation of malignant fungating wounds often occurs in the last 6 months of life and therefore become symbols of impending death for patients and their families. Due to the incurable and severe nature of these wounds, patients require palliative care until death to minimize pain and suffering. Symptoms associated with these chronic wounds include malodor, pain, bleeding, necrosis, large amounts of exudate, increased microbial growth, and more. Limited research using culture-based techniques has been conducted on malignant fungating wounds and therefore no optimal approach to treating these wounds has been established. Despite limited data, associations between the cutaneous microbiome of these wounds and severity of symptoms have been made. The presence of at least one strain of obligate anaerobic bacteria is linked with severe odor and exudate. A concentration of over 105/g bacteria is linked with increased pain and exudate. Bacterial metabolites such as DMTS and putrescine are linked with components of malignant fungating wound odor and degradation of periwound skin. The few but significant associations made between the malignant fungating wound microbiome and severity of symptoms indicate that further study on this topic using 16S rRNA gene sequencing may reveal potential therapeutic targets within the microbiome to significantly improve current methods of treatment used in the palliative care approach.

This study aimed to evaluate patterns of symptoms, physical function and quality of life (QoL) among patients with head and neck cancer (HNC) prior to, 3-9 days post-surgery, and one month post-surgery.A prospective, repeated-measures design with consecutively-identified sampling was used to recruit HNC patients undergoing surgical treatment. Data collected included demographic and clinical characteristics, symptoms by M.D. Anderson Symptom Inventory-Head and Neck Module-Chinese version (MDASI-HN-C), physical function and QoL by Function Subscales of European Cancer Research Treatment Organization Quality of Life Core Scale (EORTC QLQ C30).105 HNC patients suffered multiple symptoms prior to and after surgery. Pain, difficulty with voice/speech, disturbed sleep and problems with mucus (30.48%~91.43%) were the most prevalent symptoms prior to and post-surgery. Numbers of symptoms as well as specific symptoms, such as fatigue, dry mouth, problems with mucus, pain and disturbed sleep, were significantly associated with poor physical function (p 0.05). Tracheostomy, feeding tube and age were also linked with poor physical function and poor QoL (p 0.05).Findings of our study underscore the importance of managing symptoms in HNC patients to ensure patients' physical function and QoL prior to and after surgical treatment. Further research should focus on developing targeted interventions for symptoms that are linked to HNC patients' poor physical function and QoL.

This pilot, double-blind, randomized, placebo-controlled study is aimed at evaluating the effectiveness of low-level laser therapy (LLLT) as a complementary treatment to complete decongestive therapy (CDT) treating lymphedema among breast cancer patients for 12 months post-intervention. Study population was breast cancer patients who were diagnosed and referred to lymphedema clinic for CDT. Participants (n = 22) were randomized and assigned into either an active laser intervention group or an inactive laser placebo-control group. Active LLLT was administered to participants twice a week at the beginning of each CDT session. Outcome measures included lymphedema symptoms, symptom distress, and limb volume by an infrared perometer. Participants in the active and placebo laser groups were comparable in demographic and clinical predictors of lymphedema. In comparison with the placebo group (83.3%), significantly fewer participants in the active laser group (55.6%) reported more than one lymphedema symptom (p = 0.012) at 12 months post-intervention. Significantly, more patients in the active laser group (44.4%) reported less than two impaired limb mobility symptoms in comparison with the placebo group (33.3%) at 12 months post-intervention (p = 0.017). The active laser group had statistically significant improvements in symptom distress of sadness (p = 0.005) from 73 to 11% and self-perception (p = 0.030) from 36 to 0% over time from baseline to 12-months post-intervention. There was no significant reduction in limb volume. Findings of the trial demonstrated significant benefits of complementary LLLT for relieving symptoms and improvement of emotional distress in breast cancer patients with lymphedema.

Palliative wound, ostomy, and continence care is a nascent area of palliative care nursing, with little research and few evidence-based guidelines to guide practice. The majority of patients at end of life will suffer from a wound, ostomy, or continence malady, requiring specialist-level consultation with a wound, ostomy, and continence nurse (WOC nurse). Palliative wound, ostomy, and continence care emphasizes an interprofessional, patient-centered approach to alleviate suffering and promote well-being and quality of life through the preservation or restoration of functional performance. A combination of evidence-based wound, ostomy, and continence nursing interventions and advanced symptom management science is the hallmark of this nursing specialty.

Background: Annually, over 65,000 persons are diagnosed with head and neck cancer in the United States. During treatment, up to 50% of patients become severely symptomatic with pain, fatigue, mouth sores, and inability to eat. Long term complications are lymphedema, fibrosis, dysphagia, and musculoskeletal impairment. Patients��� ability to perform daily activities and to interact socially may be impaired, resulting in poor quality of life. A pragmatic, clinically useful assessment is needed to ensure early detection and intervention for patients to report symptoms and functional limitations over time. We developed the Electronic Patient Visit Assessment (ePVA) that enables patients to report 42 symptoms related to head and neck cancer and 17 limitations of functional status. This manuscript reports (I) the development of the ePVA, (II) the content validity of the ePVA, and (III) the usability and reliability of the ePVA. Methods: Usability was evaluated using the ���Think Aloud��� technique to guide the iterative process to refine the ePVA based on participants��� evaluations. After signing the informed consent, 30 participants with head and neck cancer completed the ePVA using digital tablet devices while thinking aloud about ease of use. All patient conversations were recorded and professionally transcribed. Reliability of the ePVA symptom and functional limitation measures was estimated using the Kuder-Richardson test. Convergent validity of the ePVA was evaluated using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 global QoL/health scale. Transcribed qualitative data were analyzed using directed content analysis approach. Quantitative analyses consisted of descriptive statistics and correlation analyses. Results: Among participants, 90% strongly agreed or agreed that the ePVA system was easy to use and 80% were very satisfied. Only minor usability problems were reported due to formatting and software ���bugs���. Reporting of usability problems decreased in frequency over the study period and no usability problems were reported by the last 3 participants who completed the ePVA. Based on participants��� suggestions during the iterative process, refinement of the ePVA included increased touch sensitivity of the touch screen technology and customized error messages to improve ease of use. The ePVA also recorded patient reported symptoms (mouth symptoms: 93%, fibrosis: 60%, fatigue: 60%). The ePVA demonstrated acceptable reliability (alpha =0.82���0.85) and convergent validity (ePVA total number of reported symptoms and function limitations was negatively correlated with EORTC QLQ-C30 global QOL/health scale: r=���0.55038, P

Background Transitional care interventions that bridge the care gap from hospital to home have proven to be effective in lessening the burden of healthcare systems by reducing hospital readmissions. Yet, the effects of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress remains unclear. Objectives To evaluate the effectiveness and dose-response of transitional care interventions on patient-centered health outcomes of mortality, quality of life, and emotional distress among individuals with heart failure and to identify the trial-level characteristics potentially affecting the overall effectiveness. Design Systematic review with random-effects meta-analysis, meta-regression, and dose-response analysis of randomized controlled trials comparing transitional care interventions with usual care in adult people hospitalized with heart failure. Data sources Electronic databases including MEDLINE, Embase, Cochrane Library, and CINAHL were systematically searched from January 1, 2000 to June 31, 2020. Review methods Authors independently reviewed the retrieved articles based on inclusion and exclusion criteria, extracted data, and assessed risk of bias using the Cochrane risk-of-bias tool version 2.0. We pooled data from each study using random-effects meta-analysis and performed meta-regression to explore the impact of pre-specified trial-level factors. Dose-response meta-analysis was conducted to examine the relationship between the intensity (i.e., frequency and duration of interventions) and complexity (i.e., number of intervention components) of transitional care interventions and the treatment effects. Results Data were synthesized from 42 trials covering a total of 10,784 people with heart failure. Comparing to usual care, transitional care interventions achieved pooled evidence of a mean 18% risk reduction on mortality (0.82, 95% CI 0.71 to 0.95, P = 0.009) and better improvement in quality of life (-4.37, 95% CI -7.20 to -1.54, P = 0.002). There were insufficient data to determine with certainty the effects on anxiety and depression. Meta-regression showed greater efficacy in trials that delivered the intervention by a multidisciplinary team. Dose-response analyses demonstrated that mortality and quality of life were improved with increased intensity and complexity of the transitional care interventions. Conclusions Transitional care interventions were effective in reducing mortality and improving quality of life for adult people with heart failure. The effects on emotional distress were inconclusive due to insufficient data, highlighting the need for further research. Registration number CRD42019132732

Accuracy of body weight perception is an individual's perception of their body weight in comparison with actual body weight and is associated with weight-related behaviors. Chinese Americans have increased risk for obesity but no studies have examined accuracy of body weight perception.This study was a descriptive and cross-sectional study, which was conducted in a community health center in New York. Study subjects were all Chinese-American adults. Demographic information, accuracy of perception of body weight, anthropometric measures (weight, height, body mass index [BMI], waist circumference [WC], hip circumference [HC], weight to height ratio, weight to hip ratio), fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1C) and obesity-related diseases (hypertension, diabetes, heart disease, and stroke) were assessed.A total of 162 Chinese Americans were recruited. 52 subjects (32%) did not perceive body weight correctly: 32 subjects had underestimation and 20 subjects had overestimation of body weight. Significant differences were found among subjects in the three groups of different accuracy of body weight perception in terms of gender (p=0.003), age (p=0.003), education years (p=0.047), WC (p0.001), HC (p≤0.001), weight/height ratio (p=0.001), and BMI (p0.001). Accuracy of perception of body weight significantly predicted WC (p0.001), HC (p0.001), weight to height ratio (p=0.001), BMI (p0.001) and weight (0.001) even after controlling for all demographic factors.The study identified that around one-third of Chinese Americans did not perceive their body weight correctly. Intervention studies for obesity management in Chinese Americans should address gender difference, target on older subjects, and focus on educating the normal values and significances of WC, HC and HbA1C among Chinese Americans.

Symptom assessment is crucial for patient care through the entire disease trajectory. Patients often experience multiple symptoms concurrently. The symptom experience index is reliable and valid as an instrument developed in the USA for assessing multiple symptoms and distress. The aim of the study was to translate and evaluate the Chinese version of the instrument in healthy adults and oncology patients. This is a psychometric study with a cross-sectional design. To ensure the semantic equivalence and content validity, an integrative translation method was employed to translate the English version into Chinese language. The participants were recruited during 2014 from a large university, two university-affiliated hospitals and a community in Changchun, China. The Chinese version demonstrated high internal consistency, test-retest reliability and content validity. Construct validity was supported by factor analysis and significant differences of symptom experience scores between healthy and oncology groups. Participants' acceptance of the Chinese version and its ability to collect adequate data among Chinese population provided evidence for using this version among Chinese population. This study provided initial evidence to support the psychometric properties of the Chinese version. The Chinese version demonstrated adequate reliability and validity to assess multiple symptom experience by Chinese populations.

Purpose The-Optimal-Lymph-Flow health IT system (TOLF) is a patient-centered, web-and-mobile-based educational and behavioral health IT system focusing on safe, innovative, and pragmatic self-care strategies for lymphedema symptom management. The purpose of this study was to evaluate usability, feasibility, and acceptability of TOLF among the end-user of breast cancer survivors. Methods Two types of usability testing were completed with 30 breast cancer survivors: heuristic evaluation and end-user testing. Each participant was asked to think aloud while completing a set of specified tasks designed to explicate and freely explore the system features. A heuristic evaluation checklist, the Perceived Ease of Use and Usefulness Questionnaire, and The Post Study System Usability Questionnaire were used to evaluate usability of the system. Open-ended questions were used to gather qualitative data. Quantitative data were analyzed using descriptive statistics and qualitative data were summarized thematically. Results Breast cancer survivors were very satisfied with the system: 90% (n=27) rated the system having no usability problems; 10% (n=3) noted minor cosmetic problems: spelling errors or text font size. The majority of participants 96.6% (n=29) strongly agreed that the system was easy to use and effective in helping to learn about lymphedema, symptoms and self-care strategies. Themes from the qualitative data included empowerment, high quality information, loving avatar simulation videos, easy accessibility, and user-friendliness. Conclusions This usability study provided evidence on breast cancer survivor's acceptance and highly positive evaluation of TOLF's usability as well as feasibility of using technologically-driven delivery model to enhance self-care strategies for lymphedema symptom management.

To translate the Breast Cancer and Lymphedema Symptom Experience Index (BCLE-SEI) into Chinese language and evaluate its psychometric properties among breast cancer survivors with and without lymphedema in China.The BCLE-SEI was translated from English to Chinese language using an integrative translation method. The Chinese version was then evaluated for its psychometric properties using a comparison-group and test-retest method. Purposive sampling was used to recruit 219 breast cancer survivors with and without lymphedema in Beijing, China. Cronbach's alpha and test-retest reliability were conducted to assess the reliability; discriminant validity, criterion-related validity and exploratory factor analysis were examined to assess the validity of the instrument.No semantic modifications to items were needed in terms of comparability of language and similarity of interpretability. Feedback on the pretest of the Chinese version by 15 Chinese breast cancer patients resulted in one item modification. The Chinese version of the instrument demonstrated excellent reliability (Cronbach's alpha = 0.930-0.967) and test-retest reliability (r = 0.572-0.705, p 0.001, n = 34). A significant difference was observed between the lymphedema group and non-lymphedema group (z = -7.127, p 0.001). The criterion-related validity was supported by negative correlation with the Short-Form Health Survey (physical component summary, r = -0.612; mental component summary, r = -0.540). Factor analysis for symptom occurrence revealed 5 factors, which explained 66.1% of the total sample variance; 5 factors were also identified in symptom distress, which explained 70.6% of the total sample variance.The Chinese BCLE-SEI is a reliable and valid instrument to evaluate breast cancer-related lymphedema symptom experience for Chinese breast cancer survivors.

Using Kinect sensors to monitor and provide feedback to patients performing intervention or rehabilitation exercises is an upcoming trend in healthcare. However, the joint positions measured by the Kinect sensor are often unreliable, especially for joints that are occluded by other parts of the body. Also, users’ motion sequences differ significantly even when doing the same exercise and are not temporally aligned, making the evaluation of the correctness of their movement challenging. This paper aims to develop a Kinect-based intervention system, which can guide the users to perform the exercises more effectively. To circumvent the unreliability of the Kinect measurements, we developed a denoising algorithm using a Gaussian Process regression model. We simultaneously capture the joint positions using both a Kinect sensor and a motion capture (MOCAP) system during a training stage and train a Gaussian process regression model to map the noisy Kinect measurements to the more accurate MOCAP measurements. For the sequences alignment issue, we develop a gradient-weighted dynamic time warping approach that can automatically recognize the endpoints of different subsequences from the original user’s motion sequence, and furthermore temporally align the subsequences from multiple actors. During a live exercise session, the system applies the same alignment algorithm to a live-captured Kinect sequence to divide it into subsequences, and furthermore compare each subsequence with its corresponding reference subsequence, and generates feedback to the user based on the comparison results. Our results show that the denoised Kinect measurements by the proposed denoising algorithm are more accurate than several benchmark methods and the proposed temporal alignment approach can precisely detect the end of each subsequence in an exercise with very small amount of delay. These methods have been integrated into a prototype system for guiding patients with risks for breast-cancer related lymphedema to perform a set of lymphatic exercises. The system can provide relevant feedback to the patient performing an exercise in real time., This paper presents the development and validation of a kinect-based in-home exercise system for lymphatic health and lymphedema intervention.

Using Kinect sensors to monitor and provide feedback to patients performing intervention or rehabilitation exercises is an upcoming trend in healthcare. However, the users’ motion sequences differ significantly even when doing the same exercise and are not temporally aligned, making the evaluation of the correctness of their movement challenging. We have developed a method to divide the long motion sequence for each exercise into multiple subsequences, each corresponding to the transition of one key pose to another. We also developed a subsequence-based dynamic time warping algorithm that can automatically detect the endpoint of each subsequence with minimum delay, while simultaneously aligning the detected subsequence to the reference subsequence for the exercise. These methods have been integrated into a prototype system for guiding patients at risks for breast-cancer related lymphedema to perform a set of lymphatic exercises in order to promote lymphatic health and reduce the risk of lymphedema. The system can provide relevant feedback to the patient performing an exercise in real time.

Purpose: Pap smear screening programs have been ineffective in reducing cervical cancer mortality in most Latin American and Caribbean countries, in part due to low screening rates. The purpose of this review was to analyze recent studies to identify demographic, social, and cultural factors influencing women’s participation in Pap screening programs in Latin America and the Caribbean. Design/Method: For this integrative review, cervical cancer screening in Latin America and the Caribbean was searched using PubMed, CINAHL, EMBASE, and PsycINFO databases. Findings/Results: Demographic barriers to screening were socioeconomic status, education, race/ethnicity, and geography. Social barriers included lack of uniformity in screening guidelines, lack of knowledge regarding cervical cancer, and lack of preventive culture. Cultural barriers were fear/embarrassment and gender roles. Conclusions: There are multilevel barriers to Pap smear utilization among women in Latin America and the Caribbean. Implications for Practice: Findings highlight a need for health system engagement, promotion of preventive care, and community-generated educational programs and solutions.

Background: Although the benefits of aerobic exercise and strength training for patients with type 2 diabetes have been studied extensively, research on physical activity among Chinese American immigrants diagnosed with prediabetes or type 2 diabetes has been limited.We sought to learn more about this population's knowledge of physical activity, the types and intensity levels performed, and the barriers to such activity.A concurrent mixed-methods design was used. The short version of the International Physical Activity Questionnaire-Chinese was used to quantitatively measure participants' levels of exercise intensity. Semistructured face-to-face interviews were conducted to obtain qualitative information regarding participants' knowledge about physical activity, the types performed, and the barriers to such activity.A total of 100 Chinese American immigrants were recruited for the study from January to July 2012 in New York City. On average, participants had lived with a diagnosis of prediabetes or type 2 diabetes for 3.3 years and had lived in the United States for 21.5 years. Energy expenditure was measured in metabolic equivalent of task (MET) units; intensity was measured in cumulative MET-minutes per week. The mean total intensity score was 2,744 MET-minutes per week. This was achieved mainly through walking. The mean intensity score for walking was 1,454 MET-minutes per week; the mean duration was 79 minutes per day. Vigorous physical activity was least common. The mean intensity score for vigorous physical activity was 399 MET-minutes per week, and the mean duration was 17 minutes per week. Regarding types of physical activity, the most common were housekeeping, walking up stairs, and taking walking or stretching breaks every hour during the workday. Based on the interviews, three themes emerged regarding barriers to moderate or vigorous physical activity: insufficient education about physical activity, health concerns about physical activity, and work-related barriers to physical activity.The majority of Chinese American immigrants with prediabetes or type 2 diabetes do not engage in sufficient physical activity, performing at a rate significantly below that of the general U.S.Increases in the intensity and duration of physical activity should be promoted as part of diabetes management for Chinese American immigrants.

Purpose This study aimed to examine factors associated with reported infection and symptoms among individuals with extremity lymphedema. Design A cross-sectional study was used. Methods Data were collected from a survey supported by the National Lymphedema Network from March 2006 through January 2010. A total of 1837 participants reported having extremity lymphedema. Logistic regression analyses were used. Findings Factors associated with reported infection among individuals with extremity lymphedema included male gender, decreased annual household income, decreased self-care, self-report of heaviness, and lower extremity as opposed to upper extremity. Factors associated with symptoms included infection, decreased self-care, lower knowledge level of self-care, decreased annual household income, and presence of secondary lower extremity lymphedema. Conclusions/Clinical Relevance Select factors of income, self-care status, and site of lymphedema were associated with increased occurrence of infection and symptoms among individuals with extremity lymphedema. Longitudinal studies are needed to identify risk factors contributing to infections and symptoms in individuals with lymphedema.

Obesity is one of the risk factors for developing lymphedema following breast cancer treatment. We prospectively enrolled 140 women and followed the participants for 12 months after surgery to investigate patterns of obesity and lymph fluid level in the first year of cancer treatment. Electrical bioimpedance devices were used to measure weight, BMI, and percent of body fat as well as lymph fluid level. General instructions were given to the participants on maintaining pre-surgery weight. Among the 140 participants, 136 completed the study with 2.9% attrition. More than 60% of the participants were obese (30.8%) or overweight (32.4%), while only two participants were underweight and about 35% had normal weight. This pattern of obesity and overweight was consistent at 4–8 weeks and 12 months post-surgery. At 12 months post-surgery, the majority of the women (72.1%) maintained pre-surgery weight and 15.4% had &gt, 5% weight loss, 12.5% of the women increase &gt, 5% of their weight. Significantly more patients in the obesity group had lymphedema defined by L-Dex ratio &gt, 7.1 than those in the normal/underweight and overweight group at pre-surgery and 4–8 weeks post-surgery. There was a trend of more patients in the obesity group had L-Dex ratio &gt, 7.1 at 12 months post-surgery. Obesity and overweight remain among women at the time of cancer diagnosis and the patterns of obesity and overweight continue during the first year of treatment. General instructions on having nutrition-balanced and portion-appropriate diet and physical activities daily or weekly can be effective to maintain pre-surgery weight.

Many breast cancer survivors have coexistent chronic diseases or comorbidities at the time of their cancer diagnosis. The purpose of the study was to evaluate the association of comorbidities on breast cancer survivors’ quality of life. A prospective design was used to recruit 140 women before cancer surgery, 134 women completed the study. Comorbidities were assessed using self-report and verified by medical record review and the Charlson Comorbidity Index (CCI) before and 12-month after cancer surgery. Quality of life was evaluated using Short-Form Health Survey (SF-36 v2). Descriptive statistics, chi-square tests, t-tests, Fisher’s exact test, and correlations were performed for data analysis. A total of 28 comorbidities were identified. Among the 134 patients, 73.8% had at least one of the comorbidities, 54.7% had 2–4, and only 7.4% had 5–8. Comorbidities did not change at 12 months after surgery. Numbers of comorbidities by patients’ self-report and weighted categorization of comorbidities by CCI had a similar negative correlation with overall quality of life scores as well as domains of general health, physical functioning, bodily pain, and vitality. Comorbidities, specifically hypertension, arthritis, and diabetes, were associated with poorer quality of life in multiple domains among breast cancer survivors. Future research should consider the combined influence of comorbidity and cancer on patients’ quality of life.

Objective Up to 40% of breast cancer survivors develop lymphedema, a chronic and sometimes disabling condition that manifests as abnormal swelling of the effected arm or hand or upper chest areas. Although the effects of lymphedema on quality of life have been well established, less well documented are the sexual experiences of breast cancer survivors with lymphedema. This study is the first to compare the sexual experiences of women with (n = 243) and without breast cancer-related lymphedema (n = 109). Methods A mixed-method design was used to explore both quantitatively and qualitatively the impact of lymphedema on participants' sexual experiences. Results Participants with breast cancer-related lymphedema reported struggles with compression garments and sexual intimacy, negative feelings involving the breast and arm, and feelings of decreased sexual desire. Conclusions Recommendations for healthcare professionals, social workers, and marriage and family therapists are offered with the aim of assisting women with breast cancer-related lymphedema and their sexual partners. Copyright © 2015 John Wiley & Sons, Ltd.

Using Kinect sensors to monitor and provide feedback to patients performing intervention or rehabilitation exercises is an upcoming trend in healthcare. However, the joint positions measured by the Kinect sensor are often unreliable, especially for joints that are occluded by other parts of the body. Motion capture (MOCAP) systems using multiple cameras from different view angles can accurately track marker positions on the patient. But such systems are costly and inconvenient to patients. In this work, we simultaneously capture the joint positions using both a Kinect sensor and a MOCAP system during a training stage and train a Gaussian Process regression model to map the noisy Kinect measurements to the more accurate MOCAP measurements. To deal with the inherent variations in limb lengths and body postures among different people, we further propose a joint standardization method, which translates the raw joint positions of different people into a standard coordinate, where the distance between each pair of adjacent joints is kept at a reference distance. Our experiments show that the denoised Kinect measurements by the proposed method are more accurate than several benchmark methods.

Objective: to estimate the prevalence and to identify possible factors associated with the occurrence of lymphedema in women undergoing treatment for breast cancer. Methods: a prevalence study with 125 women. An interview and a consultation of the medical record were carried out using a questionnaire. Univariate and multivariate analysis were performed through logistic regression. Results: a prevalence rate of 34.4% was found. Obesity, sentinel lymph node biopsy, radiotherapy, and the presence of some treatment complications were statistically significant for the occurrence of lymphedema. Conclusion: the prevalence of lymphedema in this study was high. The variables positively related to lymphedema, considered as associated factors, were: obesity, sentinel lymph node biopsy, radiotherapy and some treatment related complications (adhesion, retraction, paraesthesia, seroma, fibrosis, infection and dehiscence). Objetivo: estimar a prevalência e identificar possíveis fatores associados à ocorrência do linfedema em mulheres submetidas a tratamento para câncer de mama. Métodos: estudo de prevalência, com 125 mulheres. Foi realizada entrevista e consulta ao prontuário utilizando-se de questionário. Realizou-se análise univariada e multivariada por meio da regressão logística. Resultados: encontrou-se uma taxa de prevalência de 34,4%. A obesidade, a biópsia de linfonodo sentinela, a radioterapia e a presença de alguma complicação do tratamento mostraram-se estatisticamente significativos para a ocorrência do linfedema. Conclusão: a prevalência de linfedema neste estudo foi alta. As variáveis positivamente relacionadas ao linfedema, consideradas como fatores associados, foram: obesidade, biópsia de linfonodo sentinela, radioterapia e ter alguma complicação relacionada ao tratamento (aderência, retração, parestesia, seroma, fibrose, infecção e deiscência).

Cancer-related lymphedema is a progressive and chronic syndrome of abnormal swelling and multiple symptoms resulting from cancer treatment. Even with modern medical advances, lymphedema remains a major health problem affecting thousands of cancer survivors. To provide healthcare professionals with evidence-based clinical practice guidelines for lymphedema treatment and management, a systematic review was conducted to evaluate 75 selected articles from 2009-2014 by the Oncology Nursing Society Putting Evidence Into Practice lymphedema team. Findings of the systematic review support complete decongestive therapy, compression bandages, and compression garments with highest evidence for best clinical practice. Weight management, full-body exercise, information provision, prevention, and early intervention protocols are likely to be effective for clinical practice. Historic recommendations for activity restriction and avoidance of aerobic and resistive exercises that limit cancer survivors' daily lives have been challenged with more evidence. Cancer survivors may not need to restrict activities such as resistive or aerobic exercises and weightlifting with gradual exercise progression. Future research should focus on providing high-level evidence using randomized clinical trials with larger samples and studying lymphedema beyond breast cancer.

Advances in cancer treatments continue to reduce the incidence of lymphedema. Yet, many breast cancer survivors still face long-term postoperative challenges as a result of developing lymphedema. The purpose of this study was to preliminarily evaluate The Optimal Lymph Flow program, a patient-centered education and behavioral program focusing on self-care strategies to enhance lymphedema risk reduction by promoting lymph flow and optimize body mass index (BMI). A prospective, longitudinal, quasi-experimental design with repeated-measures was used. The study outcomes included lymph volume changes by infrared perometer, and BMI by a bioimpedance device at pre-surgery baseline, 2–4 weeks after surgery, 6-month and 12-month follow-up. A total of 140 patients were recruited and participated in The Optimal Lymph Flow program; 134 patients completed the study with 4 % attrition rate. Fifty-eight percent of patients had axillary node dissection and 42 % had sentinel lymph node biopsy (SLNB). The majority (97 %) of patients maintained and improved their preoperative limb volume (LV) and BMI at the study endpoint of 12 months following cancer surgery. Cumulatively, two patients with SLNB and two patients with axillary lymph node dissection had measurable lymphedema (>10 % LV change). At the 12-month follow-up, among the four patients with measurable lymphedema, two patients’ LV returned to preoperative level without compression therapy but by maintaining The Optimal Lymph Flow exercises to promote daily lymph flow. This educational and behavioral program is effective in enhancing lymphedema risk reduction. The study provided initial evidence for emerging change in lymphedema care from treatment-focus to proactive risk reduction.

Patients with head and neck cancer can experience pain that impacts quality of life. Therefore, we developed a patient-reported Electronic Patient Visit Assessment (ePVA) for early detection and intervention for pain. Patients use interactive touch screen technology to indicate presence and location of pain and functional limitations (eg. limited mobility of mouth, neck, shoulders). To test clinical usefulness of the ePVA, after informed consent, 72 participants with head and neck cancer completed the ePVA one time before, during, or after treatment at an academic cancer center in northeastern United States between August 2017 and August 2018. After completing the ePVA, participants answered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). Quality of Life (QoL) scores were calculated using EORTC QLQ-C30 QoL subscale, ranging between 0 - 100, higher scores indicating better quality of life. Data were analyzed using means, frequencies, and t-test statistics. The mean age of the study population was 62. Majority of participants were male (64%), had stage III or IV cancer (69%), and were of the white race (68%). Majority of participants reported presence of pain (54%, 39 of 72), which significantly affected their QoL (Pain: mean QoL = 68.1; No pain: mean QoL= 83.3, p