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Objectives: To propose an integrated framework for survivorship care and palliative care, explore application of this framework in cancer patients, and identify research opportunities to expand the evidence base for practice. Data Sources: Peer-reviewed literature, online documents from the National Quality Forum and National Consensus Project for Quality Palliative Care, and reports from the Centers for Disease Control and the Institute of Medicine. Conclusion: The interface between palliative care domains and survivorship care results in prioritizing needs and coordination of care along the cancer trajectory. Implications for Nursing Practice: Principles of the proposed model may be incorporated into survivorship care plans and assist with multidisciplinary care of these complex patients. [ABSTRACT FROM AUTHOR]

Goals: The aims of this secondary data analysis were to (a) categorize patterns in the development, duration, intensity, and resolution of sore mouth (which can be considered a proxy for oral mucositis) severity and distress over two cycles of chemotherapy in cancer outpatients and (b) examine the relationship of demographic (age, gender, marital status, and educational level) and disease characteristics (type of cancer and type of chemotherapy) to specific patterns of sore mouth (SM).Materials and Methods: Visual graphical analysis (VGA) was applied to identify individual patterns of SM severity and distress in 51 outpatients receiving chemotherapy who provided daily reports of sore mouth using a computerized interactive voice response system. The majority were female (n = 41, 8%) with a mean age of 53 (SD = 8.35). Most had breast cancer (68%), and one third received chemotherapy with adriamycin and cyclophosphamide (AC). VGA is a technique in which graphs of individual patients' symptoms are coded for specific individual or group profiles.Main Results: Seven distinct patterns were identified based on variability in onset, duration, and intensity (degree of severity or distress). Chemotherapy agents were significantly associated with patterns of SM. The AC regimen was significantly associated with late onset; however, the intensity did not last long. In contrast, patients receiving R-CHOP were significantly more likely to experience duration intensity (SM after day 15 and a score equal to or greater than a 5 on a 1-10 scale).Conclusions: VGA revealed symptom patterns often hidden in traditional analysis. Understanding individual variability is important to the design and implementation of future intervention research and clinical care. [ABSTRACT FROM AUTHOR]

BACKGROUND:: Research to address clinical symptoms and the way they change over time in an individual is of paramount importance to healthcare researchers who are interested in improving the quality of life for ill patients. However, typical statistical methods that rely on means can obscure individual trajectories of change. Visual graphical analysis (VGA) is a technique that can provide researchers with an alternative method of quantitative statistical analysis that is more sensitive to individual change and variation. OBJECTIVES:: To (a) describe the use of VGA as a method to evaluate longitudinal data, (b) discuss challenges to using this method, and (c) offer recommendations for future research in which the method could be implemented. APPROACH:: This methodological article uses data collected from a primary study to present the method of VGA. Daily self-reported sore mouth severity scores from patients receiving outpatient chemotherapy were used in this VGA. The steps of VGA include (a) determining inclusion criteria, (b) managing missing data, (c) creating visual graphs, (d) identifying specific patterns, and (e) performing validation and verification. DISCUSSION:: Because symptoms occur differently for each patient, this method allows researchers to see symptom trajectories on an individual basis. Creation and analysis of longitudinal graphs could be used also to inspect other symptoms or clinical problems such as headaches, fatigue, constipation, nausea and vomiting, and psychological difficulties. The value of VGA is that it allows a researcher to study the patterns of an individual's experience, as opposed to averaging all individuals' responses over time. Although graphical analysis is exploratory in nature, it may lead to enhanced longitudinal recognition of symptoms that might not be identified otherwise by quantitative data analysis using summary statistics. [ABSTRACT FROM AUTHOR]

PURPOSE: The purpose of this article is as follows: 1) to describe the characteristics and scope of mucosal tissue injury associated with cancer treatment; 2) to discuss recent advances in related basic and clinical science; and 3) to articulate research needs and opportunities to be addressed through collaborative interdisciplinary research. OVERVIEW: Mucosal tissue injury is both a direct and indirect consequence of cancer therapy, with manifestations that include damage and a number of other potentially serious sequelae. Current research in mucosal tissue injury is focused on the biology, immunology, and genetics of mucosal injury; clinical problems; assessment and management; and processes and outcomes of care. CLINICAL IMPLICATIONS: Results from these various areas of research enhance the understanding of the mechanisms of mucosal tissue injury, provide direction for the development of policy and for clinical practice, and help to define research needs and opportunities. Future research on the complex process of mucosal tissue injury will be interdisciplinary and will cross the boundaries among basic, translational, and clinical science. [ABSTRACT FROM AUTHOR]

Background: Cervical and uterine cancers are common in women. Diagnosis and treatment of these cancers can lead to significant issues with body image, sexuality, and sexual functioning. A comprehensive review can improve understanding of these 3 concepts, in turn enhancing identification and management., Objectives: To (1) present the qualitative, descriptive, and correlational research literature surrounding body image, sexuality, and sexual functioning in women with uterine and cervical cancer; (2) identify gaps in the literature; and (3) explore the implications of the findings for future research., Methods: A comprehensive search of the literature was undertaken by searching PubMed, CINAHL, and PsycINFO using predetermined subject headings, keywords, and exploded topics. After a comprehensive evaluation using specific criteria, 121 articles were reviewed., Results: Qualitative studies provided information about women's issues with body image, sexuality, and sexual functioning, whereas quantitative studies focused primarily on sexual functioning. The literature lacks correlational studies examining body image and sexuality. Significant issues regarding communication and quality of life were noted, and few studies were based on clear conceptual models., Conclusion: The state of the science gleaned from this review reveals that while much is known about sexual functioning, little is known about body image and sexuality., Implications for Practice: Further work is warranted to develop conceptual models and research on body image, sexuality, and sexual functioning as a foundation for interventions to improve quality of life., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Disturbances in body image can have an impact on sexual health and are prevalent in women of reproductive age. Although body image is important, the definition of this concept is inconsistent across the disciplines of nursing, medicine, and psychology. Use of a consistent definition in clinical practice and research could lead to a more comprehensive understanding of disturbances in body image, thereby advancing research-based knowledge and clinical practice. The purpose of this concept development was to advance the concept of body image as it relates to sexual health among women of reproductive age from the perspectives of 3 disciplines with a strong focus on body image: nursing, medicine, and psychology., Methods: Strategies for concept development as described by Rodgers provided the basis for this work. The process includes a search, review, and synthesis of the literature surrounding the concept of interest., Results: Seventy-one articles, mostly qualitative and quantitative descriptive, were included and used to develop the concept. Body image related to sexual health in women of reproductive age is a multifaceted concept that is composed of an emotional and behavioral response to one's perceived appearance, sexuality, and degree of femininity. An individual's body image is influenced by sociocultural identities, race, ethnicity, and health status. It has both physical and psychological impact on health outcomes., Discussion: This interprofessional and comprehensive definition of body image should enhance understanding, assessment, and management of body image disturbances, thus bridging disciplines and enhancing interprofessional research and practice., (© 2021 by the American College of Nurse-Midwives.)

Background: Health information technology (IT) interventions to decrease readmissions for cirrhosis may be limited by patient-associated factors., Objective: The aim of this study was to determine perspectives regarding adoption versus refusal of health IT interventions among patient-caregiver dyads., Methods: Inpatients with cirrhosis and their caregivers were approached to participate in a randomized health IT intervention trial requiring daily contact with research teams via the Patient Buddy app. This app focuses on ascites, medications, and hepatic encephalopathy over 30 days. Regression analyses for characteristics associated with acceptance were performed. For those who declined, a semistructured interview was performed with themes focused on caregivers, protocol, transport/logistics, technology demands, and privacy., Results: A total of 349 patient-caregiver dyads were approached (191 from Virginia Commonwealth University, 56 from Richmond Veterans Affairs Medical Center, and 102 from Mayo Clinic), 87 of which (25%) agreed to participate. On regression, dyads agreeing included a male patient (odds ratio [OR] 2.08, P=.01), gastrointestinal bleeding (OR 2.3, P=.006), or hepatic encephalopathy admission (OR 2.0, P=.01), whereas opioid use (OR 0.46, P=.03) and alcohol-related etiology (OR 0.54, P=.02) were associated with refusal. Race, study site, and other admission reasons did not contribute to refusing participation. Among the 262 dyads who declined randomization, caregiver reluctance (43%), perceived burden (31%), technology-related issues (14%), transportation/logistics (10%), and others (4%), but not privacy, were highlighted as major concerns., Conclusions: Patients with cirrhosis admitted with hepatic encephalopathy and gastrointestinal bleeding without opioid use or alcohol-related etiologies were more likely to participate in a health IT intervention focused on preventing readmissions. Caregiver and study burden but not privacy were major reasons to decline participation. Reducing perceived patient-caregiver burden and improving communication may improve participation., Trial Registration: ClinicalTrials.gov NCT03564626; https://www.clinicaltrials.gov/ct2/show/NCT03564626., (©Chathur Acharya, Tejasav S Sehrawat, Deborah B McGuire, Jawaid Shaw, Andrew Fagan, Sara McGeorge, Amy Olofson, Melanie B White, Edith Gavis, Patrick S Kamath, Lori Bergstrom, Jasmohan Singh Bajaj. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 09.04.2021.)

Well-designed, rigorously implemented instrumentation studies are essential to develop valid, reliable pain assessment tools in non-communicative (non-self-reporting) palliative care patients. When conducting a pain instrumentation study, a research team identified methodologic challenges surrounding informed consent, eligibility criteria, acute pain operational definitions, patient recruitment, missing data, and study-related training during a run-in phase at the beginning of the project and during the conduct of the study. The team dealt with these challenges through identifying root causes, implementing remedial measures, and collecting data to demonstrate improvement or resolution. Effective strategies included obtaining Institutional Review Board (IRB) approval for a waiver of informed consent, modifying eligibility criteria, ensuring that operational definitions and study procedures were consistent with clinical practice, decreasing time from screening to data collection to improve recruitment, increasing study nurse staffing by re-budgeting grant funds, focusing time and resources on high accruing clinical units, revising processes to minimize missing data, and developing detailed training for users of the instrument. With these multi-pronged solutions, the team exceeded the patient accrual target by 25% within the funding period and reduced missing data. While pain instrumentation studies in non-communicative patients have similar challenges to other palliative care studies, some of the solutions may be unique and several are applicable to other palliative care studies, particularly instrumentation research. The team's experience may also be useful for funders and IRBs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: A valid and reliable instrument is needed to assess acute pain in critically ill patients unable to self-report and who may be transitioning between critical care and other settings., Aim: To examine the reliability, validity, and clinical utility of the Multidimensional Objective Pain Assessment Tool (MOPAT) when used over time by critical care nurses to assess acute pain in non-communicative critically ill patients., Methods: Twenty-seven patients had pain assessed at two time points (T1 and T2) surrounding a painful event for up to 3 days. Twenty-one ICU nurses participated in pain assessments and completed the Clinical Utility Questionnaire., Results: Internal consistency reliability coefficient alphas for the MOPAT were .68 at T1 and .72 at T2. Inter-rater agreement during painful procedures or turning was 68% for the behavioral dimension and 80% for the physiologic dimension. Validity was evidenced by decreases (p < .001) in the MOPAT total and behavioral and physiologic dimension scores when comparing T1 and T2. Nurses found the tool clinically useful., Conclusion: The MOPAT can be used in the critical care setting as a helpful tool to assess pain in non-communicative patients. The MOPAT is unique in that the instrument can be used over time and across settings., (Copyright © 2017 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Palliative care patients who have pain are often unable to self-report their pain, placing them at increased risk for underrecognized and undertreated pain. Use of appropriate pain assessment tools significantly enhances the likelihood of effective pain management and improved pain-related outcomes. This paper reviews selected tools and provides palliative care clinicians with a practical approach to selecting a pain assessment tool for noncommunicative adult patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Context: Pancreatic cancer presents a wide spectrum of significant symptomatology. The high symptom burden, coupled with a rapidly fatal diagnosis, limits preparation or time for adjustment for both patients and their family caregivers. From the initial diagnosis and throughout the illness experience, the physical and emotional demands of caregiving can predispose caregivers themselves to illness and a greater risk of mortality. Understanding the negative and positive aspects of caregiving for patients with advanced pancreatic cancer will inform interventions that promote positive caregiver outcomes and support caregivers in their role., Objectives: To provide feasibility data for a larger, mixed methods, longitudinal study focused on the experience of family caregivers of patients with advanced pancreatic cancer and preliminary qualitative data to substantiate the significance of studying this caregiver population., Methods: This was a mixed methods study guided by the Stress Process Model. Eight family caregivers of patients with advanced pancreatic cancer from oncology practices of a university-affiliated medical center were surveyed., Results: The pilot results supported the ability to recruit and retain participants and informed recruitment and data collection procedures. The qualitative results provided preliminary insights into caregiver experiences during the diagnosis and treatment phases. Key findings that substantiated the significance of studying these caregivers included the caregiving context of the history of sentinel symptoms, the crisis of diagnosis, the violation of assumptions about life and health, recognition of the circle of association, and contextual factors, as well as primary and secondary stressors, coping strategies, resources, discoveries, gains and growth, associated changes/transitions, and unmet caregiver needs., Conclusion: Findings indicated caregivers' willingness to participate in research, highlighted the negative and positive aspects of the caregiver experience, and reinforced the significance of the future study and the need to develop interventions to support family caregivers in their roles., (Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Mucositis is a highly significant, and sometimes dose-limiting, toxicity of cancer therapy. The goal of this systematic review was to update the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO) Clinical Practice Guidelines for mucositis., Methods: A literature search was conducted to identify eligible published articles, based on predefined inclusion/exclusion criteria. Each article was independently reviewed by 2 reviewers. Studies were rated according to the presence of major and minor flaws as per previously published criteria. The body of evidence for each intervention, in each treatment setting, was assigned a level of evidence, based on previously published criteria. Guidelines were developed based on the level of evidence, with 3 possible guideline determinations: recommendation, suggestion, or no guideline possible., Results: The literature search identified 8279 papers, 1032 of which were retrieved for detailed evaluation based on titles and abstracts. Of these, 570 qualified for final inclusion in the systematic reviews. Sixteen new guidelines were developed for or against the use of various interventions in specific treatment settings. In total, the MASCC/ISOO Mucositis Guidelines now include 32 guidelines: 22 for oral mucositis and 10 for gastrointestinal mucositis. This article describes these updated guidelines., Conclusions: The updated MASCC/ISOO Clinical Practice Guidelines for mucositis will help clinicians provide evidence-based management of mucositis secondary to cancer therapy., (© 2014 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.)

Purpose: The purpose of this project was to evaluate research in basic oral care interventions to update evidence-based practice guidelines for preventing and treating oral mucositis (OM) in cancer patients undergoing radio- or chemotherapy., Methods: A systematic review of available literature was conducted by the Basic Oral Care Section of the Mucositis Study Group of MASCC/ISOO. Seven interventions--oral care protocols, dental care, normal saline, sodium bicarbonate, mixed medication mouthwash, chlorhexidine, and calcium phosphate--were evaluated using the Hadorn (J Clin Epidemiol 49:749-754, 1996) criteria to determine level of evidence, followed by a guideline determination of one of the following: recommendation, suggestion, or no guideline possible, using Somerfield's (Classic Pap Cur Comments 4:881-886, 2000) schema., Results: Fifty-two published papers were examined by treatment population (radiotherapy, chemotherapy, and hematopoietic stem cell transplant) and by whether the intervention aimed to prevent or treat OM. The resulting practice suggestions included using oral care protocols for preventing OM across all treatment modalities and age groups and not using chlorhexidine mouthwash for preventing OM in adults with head and neck cancer undergoing radiotherapy. Considering inadequate and/or conflicting evidence, no guidelines for prevention or treatment of OM were possible for the interventions of dental care, normal saline, sodium bicarbonate, mixed medication mouthwash, chlorhexidine in patients receiving chemotherapy or hematopoietic stem cell transplant, or calcium phosphate., Conclusions: The evidence for basic oral care interventions supports the use of oral care protocols in patient populations receiving radiation and/or chemotherapy and does not support chlorhexidine for prevention of mucositis in head and neck cancer patients receiving radiotherapy. Additional well-designed research is needed for other interventions to improve the amount and quality of evidence guiding future clinical care.

Objective: To describe a quality improvement project involving education and referral criteria to influence oncology provider referrals to a palliative care service., Methods: A single group post-test only quasi-experimental design was used to evaluate palliative care service (PCS) referrals following an intervention consisting of a didactic presentation, education outreach visits (EOV) to key providers, and referral criteria. Data on patient demographics, cancer types, consult volume, reasons for referral, pre-consult length of stay, overall hospital stay, and discharge disposition were collected pre-intervention, then post-intervention for 7.5 months and compared., Setting and Sample: Attending oncologists, nurse practitioner, and house staff from the solid tumor division at a 700-bed urban teaching hospital participated in the project. Two geriatricians, a palliative care nurse practitioner, and rotating geriatric fellows staffed the PCS., Results: The percentage of oncology referrals to PCS increased significantly following the intervention (χ(2) = 6.108, p = .013). 24.9% (390) patients were referred in the 4.6 years pre-intervention and 31.5% (106) patients were referred during 7.5 months post-intervention. The proportion of consults for pain management was significantly greater post-intervention (χ(2) = 5.378, p = .02), compared to pre-intervention, when most referrals were related to end-of-life issues. Lung, pancreatic, and colon were the most common cancer types at both periods, and there were no significant differences in patient demographics, pre-referral length of hospitalization or overall hospital days. There was a trend toward more patients being discharged alive following the intervention., Conclusion: A quality improvement project supported the use of education and referral criteria to influence both the frequency and reasons for palliative care referral by oncology providers.

Informal caregivers are a key component of end-of-life/palliative care and are increasingly recognized as recipients of care. Numerous factors affect the care they give and they have significant care needs themselves. The purpose of this survey was to identify key research questions, priorities, and next steps for research on caregivers and palliative care. A literature search of publications between 2006 and 2011 was conducted, yielding 109 studies that were evaluated on type, quality, topic, and other factors. An interdisciplinary group of healthcare professionals examined results and recommended research priorities. Existing research is primarily descriptive in nature, with few interventions to guide practice. Future research priorities include factors influencing caregivers and roles, information and support needs, caregiver health, end-of-life issues, healthcare disparities, and delivery and costs of care. Conclusions include that expanding the science will contribute to improving caregiver performance and health., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: This repeated measures, prospective study was designed to explore and describe symptom dimensions, depressive symptoms, and uncertainty in newly diagnosed oropharyngeal and laryngeal cancer patients during and 1 month following treatment., Materials and Methods: A non-probability sample of 21 oropharyngeal and laryngeal cancer patients receiving definitive radiation completed the Memorial Symptom Assessment Scale, Beck Depression Inventory, and Mishel's Uncertainty in Illness Scale at treatment initiation, and at 5, 9, and 12 weeks., Results: A common pattern of 11 symptoms, which changed as treatment progressed, was problematic for patients. Physical symptoms increased by 50% at week 5 and 9. Depression was experienced by 24% of patients. Uncertainty was found to be high at all time points and unexpectedly remained unchanged over time (p = 0.73). Positive correlations (p < 0.05) were found among number of symptoms, symptom distress, and depressive symptoms. Uncertainty was correlated (p < 0.05) statistically only to symptom distress., Conclusion: This study is the first to identify uncertainty in illness among oropharyngeal and laryngeal cancer patients and found it to be higher than for other cancer populations. Findings provide insights into the uncertainty of living through treatment and provide information for patient care. The consistent pattern of high levels of uncertainty during and 1 month after treatment suggests that the uncertainty related to acute illness could extend into chronic uncertainty which may interfere with a cancer survivor's adaption to daily living after treatment. Further research is needed to investigate other variables that influence uncertainty during treatment as well as 1 to 6 months after treatment for head and neck cancer.

Purpose/objectives: To describe coping among patients with laryngeal and oropharyngeal cancer during definitive radiation with or without chemotherapy., Research Approach: Qualitative content analysis conducted within a larger study., Setting: Two radiation oncology outpatient clinics in Baltimore, MD., Participants: 21 patients with oropharyngeal or laryngeal cancer., Methodologic Approach: Interviews with open-ended questions were conducted during treatment. Questions covered topics such as coping during treatment, treatment-related issues, and resources., Main Research Variables: Coping, treatment, and coping resources., Findings: Patients' self-assessments suggested they were coping or that coping was rough or upsetting. Issues that required coping varied over four time points. Physical side effects were problematic during and one month after treatment completion. Patients used coping to manage the uncertainties of physical and psychological aspects of their experience. Family and friend support was a common coping strategy used by patients, with the intensity of side effects corresponding with the support provided across time points., Conclusions: Findings confirm previous research, but also provide new information about ways in which patients with head and neck cancer cope with their illness experience. Emergent themes provide insight into patients' feelings, issues, and assistance received with coping., Interpretation: Patients with head and neck cancer need education on the amount and severity of side effects and should be appraised of potential difficulties with scheduling, driving, and other logistic issues. Patients also should be informed of helpful types of support and coping strategies. Additional research is needed to expand the findings related to patients' coping with treatment and to explore the experiences of family and friends who provide social support.

Evidence-based guidelines in clinical oncology practice are now prominent, with emphasis on clinical, health outcome and economic perspectives. Given the complexity of cancer management, a multidisciplinary approach is essential. Evidence-based guidelines to address supportive cancer care have merged expert opinion, systematic evaluation of clinical and research data, and meta-analyses of clinical trials. Production of supportive care guidelines by the interdisciplinary team is dependent on sufficient high-quality research studies. Once published, it is essential they be customized at institutional and national levels. Implementation in clinical practice is perhaps the greatest challenge. Optimal management occurs through integration of country-specific issues, including care access, healthcare resources, information technology, and national coordination of healthcare practices. The purpose of this article is to: (1) provide an overview of interdisciplinary cancer management using evidence-based guidelines; (2) delineate the theory and practice of guideline dissemination, utilization and outcome assessment; and (3) recommend future research strategies to maximize guidelines use in clinical practice., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Aim: This paper reports findings of a study to examine the independent contribution of chest pain, fatigue and dyspnoea to health-related quality of life in people with chronic stable angina., Background: People with chronic stable angina experience poorer quality of life in multiple areas including physical and emotional health. Emerging evidence suggests the presence of concomitant symptoms yet there are no systematic studies examining the impact of symptom clusters on quality of life in people with chronic angina., Method: Outpatients (n = 134), recruited over a 16-month period in 2000 and 2001, with confirmed coronary heart disease and chronic angina completed reliable and valid questionnaires measuring chest pain frequency, fatigue, dyspnoea and quality of life. The data have contemporary relevance because despite changes in treatment of coronary heart disease, chronic angina remains prevalent worldwide. Hierarchical multiple linear regression was used to examine the symptom cluster of chest pain frequency, fatigue and dyspnoea in predicting quality of life., Results: The sample was predominantly white (74·6%), men (59·7%) with a mean age of 63·4 (sd 12·12) years. Controlling for age, gender, social status and co-morbidities, the symptom cluster of chest pain frequency, dyspnoea and fatigue accounted for a statistically significant increase in unadjusted R² (F of Δ, P < 0·05) for the models predicting physical limitation (R² Δ 24·1%), disease perception (R² Δ 24·6%), Short Form-36 Physical Component Score (R² Δ 24·3%) and Mental Component Score (R² Δ 07·0%)., Conclusion: Symptom assessment and management of people with chronic stable angina should involve multiple symptoms. Greater fatigue predicted poorer quality of life in multiple areas. As a possible indicator of depression, it warrants further assessment and follow-up., (© 2011 Blackwell Publishing Ltd.)

Background: Accurate assessment in hospice patients who cannot communicate their pain is almost impossible, increasing their risk for unrecognized and inadequately managed pain., Objective: The purpose of this article is to describe a series of small-scale projects aimed at developing and refining an instrument to assess acute pain in noncommunicative hospice patients., Methods: Project 1 was a clinical project in which focus groups with hospice nurses yielded an adaptation of an existing pain assessment measure that was named the Multidimensional Objective Pain Assessment Tool (MOPAT) and had behavioral and physiological subscales. Projects 2 and 3 tested the MOPAT in 30 cognitively impaired/nonresponsive hospice inpatients and 28 alert and oriented hospice inpatients, with study nurses and hospice nurses rating pain with the MOPAT before and after a pain-relieving intervention and rating its clinical usefulness. Projects 3 and 4 analyzed the reliability, validity, and clinical utility of the MOPAT., Results: Overall internal consistency reliability of the MOPAT was demonstrated with Cronbach's α coefficients of 0.79 before and 0.84 after the pain-relieving intervention. The behavioral and physiological subscale scores changed significantly (p < .035) after pain medication, demonstrating sensitivity to changes in pain. Principal components factor analysis revealed two factors matching the subscales and accounting for 66% of the variance. Nearly all the hospice nurses found the MOPAT helpful, easy to use and understand, and conducive to use in daily practice., Conclusion: The MOPAT has preliminary evidence of reliability, validity, and clinical utility. Full-scale psychometric testing in hospice and acute care hospital patients is currently underway.

Purpose/objectives: To present a comprehensive summary of the existing research literature related to prevalence and correlates of depression in adult patients with head and neck cancer to establish a knowledge base for future research., Data Sources: Quantitative studies in English measuring depression or mood in adults with head and neck cancer published from 1986-2008., Data Synthesis: A substantial body of knowledge exists regarding prevalence, correlates, and predictors of depression in patients with head and neck cancer. Prevalence rates of depression are high at diagnosis, during treatment, and in the first six months following treatment, and mild to moderate depression may continue for three to six years after diagnosis. Certain patient demographic characteristics (e.g., marital status, education), symptoms, and specific time points in the illness trajectory (e.g., time of treatment) are correlated with depression. Specific patient variables at diagnosis, such as depression, can predict depression at later time points., Conclusions: Additional research should assess symptoms using consistent depression instruments or clinical interviews based on specific criteria in patients with head and neck cancer. Specifically, multisite studies should be conducted to increase sample sizes. Research related to symptom clusters and the effect of clusters on patients is needed. Longitudinal studies that examine depression and patient characteristics, symptoms, type of treatments, and the correlates of depression across the trajectory of illness are important. Replication of existing research using multiple patient and clinical characteristics to explore predictors of depression may reveal profiles for patients most at risk., Implications for Nursing: This comprehensive summary of existing research literature related to the prevalence and correlates of depression among adult patients with head and neck cancer provides evidence-based information that can be used by oncology nurses in their practice.

Purpose/objectives: To introduce the use of a statistical technique known as multilevel growth-curve analysis and illustrate how the method can be advantageous in comparison with traditional repeated measures for the study of trajectories of signs and symptoms in individual patients over time., Data Sources: Data were derived from use of the technique in a randomized clinical trial of a psychoeducational intervention to reduce severity of oral mucositis and oral pain., Data Synthesis: The development of new biologic models that seek to explain clustering of signs and symptoms or the appearance and resolution of signs and symptoms motivates the need to use more sophisticated statistical techniques to test such models., Conclusions: The application of multilevel growth model to an existing data set demonstrates that the model can be effective in the study of individual differences in trajectories of change in signs and symptoms., Implications for Nursing: This method for the study of changes in patients' signs and symptoms over time can be of particular interest to nursing, both from a clinical point of view and as a way to test theoretical models that have been proposed to capture patient experiences with signs and symptoms.

Background: African Americans (AAs) have low rates of colorectal cancer (CRC) screening. To the authors' knowledge, factors that influence their participation, especially individuals with a family history of CRC ("family history"), are not well understood., Methods: A secondary analysis of the 2002 Maryland Cancer Survey data examined predictors of risk-appropriate, timely CRC screening ("screening") in AAs with a family history and in individuals without a family history. Predictors that were evaluated included age, sex, family history, mammogram or prostate-specific antigen (PSA) screening, body mass index, activity, fruit/vegetable consumption, alcohol, smoking, perceived risk of cancer, education, employment, insurance, access to a healthcare provider, and healthcare provider recommendation of fecal occult blood test (FOBT) and/or sigmoidoscopy/colonoscopy., Results: In individuals without a family history of CRC (N = 492), recommendation for FOBT (odds ratio [OR] of 11.90; 95% confidence interval [95% CI], 6.84-20.71) and sigmoidoscopy/colonscopy (OR of 7.06; 95% CI, 4.11-12.14), moderate/vigorous activity (OR of 1.74; 95% CI, 1.06-2.28), and PSA screening history (OR of 2.68; 95% CI, 1.01-7.81) were found to be predictive of screening. In individuals with a family history (N = 88), recommendation for sigmoidoscopy/colonscopy (OR of 24.3; 95%, CI 5.30-111.34) and vigorous activity (OR of 5.21; 95% CI, 1.09-24.88) were found to be predictive of screening. However, family history did not predict screening when the analysis was controlled for age, education, and insurance. AAs who had a family history were less likely to screen compared with their white counterparts (N = 293) and compared with AAs who were at average risk for CRC (P < .05)., Conclusions: Regardless of family history, healthcare provider recommendation and activity level were important predictors of screening. Lower screening rates were observed in AAs who had a family history compared with individuals who did not. The authors believe that, for AAs who have a family history, further examination of barriers and facilitators to CRC screening within the cultural context is warranted.

Considerable progress in research and clinical application has been made since the original guidelines for managing mucositis in cancer patients were published in 2004, and the first active drug for the prevention and treatment of this condition has been approved by the United States Food and Drug Administration and other regulatory agencies in Europe and Australia. These changes necessitate an updated review of the literature and guidelines. Panel members reviewed the biomedical literature on mucositis published in English between January 2002 and May 2005 and reached a consensus based on the criteria of the American Society of Clinical Oncology. Changes in the guidelines included recommendations for the use of palifermin for oral mucositis associated with stem cell transplantation, amifostine for radiation proctitis, and cryotherapy for mucositis associated with high-dose melphalan. Recommendations against specific practices were introduced: Systemic glutamine was not recommended for the prevention of gastrointestinal mucositis, and sucralfate and antimicrobial lozenges were not recommended for radiation-induced oral mucositis. Furthermore, new guidelines suggested that granulocyte-macrophage-colony stimulating factor mouthwashes not be used for oral mucositis prevention in the transplantation population. Advances in mucositis treatment and research have been complemented by an increased rate of publication on mucosal injury in cancer. However, additional and sustained efforts will be required to gain a fuller understanding of the pathobiology, impact on overall patient status, optimal therapeutic strategies, and improved educational programs for health professionals, patients, and caregivers. These efforts are likely to have significant clinical and economic impact on the treatment of cancer patients. Cancer 2007;109:820-31. (c) 2007 American Cancer Society.

Background: The Basic Oral Care Group is one of eight subcommittees functioning within the Mucositis Study Group Guidelines Panel of the Multinational Association of Supportive Care in Cancer and International Society for Oral Oncology (MASCC/ISOO). The Basic Oral Care Group, comprised of the four authors of this paper, represented the disciplines of nursing (DBM, JJ), dentistry (MEPC), and pediatric dentistry (PW). This group reviewed research and clinical literature to update the original 2004 Mucositis Management Guidelines in the areas of basic oral care, bland rinses, protocols and education, and good clinical practices such as pain management, oral assessment, oral care, and dental care., Materials and Methods: Over 100 articles published between 2000 and 2005 were identified, and 32 of these were useful for the analysis. Each article was rated by at least two authors using a structured rating form and systematic determination of levels of evidence, based on the American Society of Clinical Oncology criteria. Discussion at the 2005 MASCC/ISOO Geneva pre-conference meeting of the Guidelines Panel resulted in the development of consensus on the interpretation of the literature., Results: Based on the literature and on Panel discussions, a revision of the original guidelines for protocols and education was produced by the group, and they developed a set of recommendations related to good clinical practices., Conclusions: Although research remains scanty for components of basic oral care, bland rinses, protocols, and education, the original 2004 guidelines with the help of newer literature from 2000 to 2005 and expert consensus among the Guidelines Panel enabled the development of useful clinical practice guidelines for managing oral mucositis in patients receiving cancer treatment with radiation and/or chemotherapy.

Background: The Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) Mucositis and Patient and Professional Education Study Groups are collaborating to improve the promulgation of the updated mucositis management guidelines. The initial step in the collaboration was to survey cancer care health professionals to determine their awareness of the original 2004 guidelines and their opinions on the usefulness of patient educational materials based on the guidelines., Materials and Methods: The authors surveyed four samples (three US and one European) of cancer health care professionals attending three cancer-related professional conferences between May and July 2005 using a ten-item questionnaire in both paper-and-pencil and web-based formats. Data were compiled and analyzed using descriptive statistics., Results: All respondents were generally aware of the importance of mucositis as a treatment-limiting toxicity with life-threatening complications and endorsed regular oral assessment and dental care practices. Only about one third of the US respondents were aware of the 2004 guidelines in contrast to 80% of the European respondents. A majority of respondents across all four surveys (66-93%) felt strongly that educational materials based on the guidelines were needed and that they would use them, while a smaller number (7-29%) indicated they might use them if a patient had a problem with mucositis., Conclusions: Awareness of the guidelines remains limited in the US, and use of the guidelines worldwide is minimal. The Mucositis and Patient and Professional Education Study Groups have developed a set of strategies to enhance dissemination, awareness, and use of the updated guidelines and to promote patient education based on the guidelines. Future work will focus on implementation and evaluation of the guidelines in clinical practice.

Goals: Little is known about Israeli elders' cancer pain experience. The purpose of this study was to explore the cancer pain experience, including pain intensity, pain management index, pain interference, symptom severity, and knowledge and attitudes toward pain and pain control., Patients and Methods: Descriptive cross-sectional methods were used to obtain data with four instruments. The patients were 39 Israelis 65 years and older who were receiving outpatient treatment for cancer in a major hospital center in Israel., Results: Results showed that over half (56.7%) reported severe worst pain and had negative pain management indexes (56.4%). In addition, knowledge and attitudes toward pain and pain control were poor (54.55%). There were no significant relationships between pain intensity and other variables. However, pain interference demonstrated a significant positive relationship with symptom severity. Post hoc analysis revealed that Ashkenazi Jewish and more educated patients reported significantly less pain interference than Sephardic Jewish patients., Conclusion: Larger samples representative of the cultural differences in Israel are needed to more definitively identify elements of the cancer pain experience in Israeli elders that can be addressed to improve pain management.

Purpose/objectives: To evaluate the psychometric properties of two adapted scales, one for functional status and one for peripheral neuropathy secondary to neurotoxic chemotherapy., Design: Repeated measures methodologic design conducted within a Gynecologic Oncology Group (GOG) phase III clinical trial that randomly assigned patients with advanced epithelial ovarian cancer to cisplatin and cyclophosphamide or cisplatin and paclitaxel., Setting: 8 GOG institutions participating in the GOG clinical trial., Sample: 88 evaluable outpatients enrolled in the GOG clinical trial. Sample size at time 1 (T1) was 88 patients and at time 2 (T2) was 67 patients., Methods: All scales were administered at T1 (prior to initiation of chemotherapy) and T2 (after six cycles of chemotherapy but prior to second-look laparotomy). Internal consistency reliability, criterion validity, and construct validity were evaluated, and clinical application was explored., Main Research Variables: Self-reported peripheral neuropathy and functional status (comprised of physical function and role function subscales), the GOG performance status scale, and the GOG toxicity criteria., Findings: Reliability coefficients at T1 were physical function = 0.83, role function = 0.96, and peripheral neuropathy = 0.91; at T2, they were physical function = 0.83, role function = 0.92, and peripheral neuropathy = 0.89. At T1, physical function and role function correlated positively with performance status. Peripheral neuropathy correlated positively with GOG toxicity criteria used at T2. Principal component factor analysis suggested that the functional status scale had a two-factor structure with factors representing general and specific mobility and that the peripheral neuropathy scale also had a two-factor structure with factors representing foot and hand neuropathy., Conclusions: The physical function, role function, and peripheral neuropathy scales have internal consistency, reliability, criterion validity, and construct validity. However, revision of the scales should address modification of specific questions and consider increasing the Likert scale from a four-point to a five- or seven-point scale to enhance clinical sensitivity and application., Implications for Nursing: With minor modifications, these scales should be useful in assessing physical function, role function, and peripheral neuropathy in patients who receive agents that may cause peripheral neuropathy.

Objectives: To discuss implementation of evidence-based clinical practice guidelines for mucositis., Data Source: Published articles, book chapters, web sources, clinical experience, unpublished manuscripts., Conclusion: Nurses can implement evidence-based guidelines but must include an evaluation component to determine effect on clinical outcomes., Implications for Nursing Practice: Nurses have an integral role implementing and evaluating evidence-based practice guidelines for managing mucositis. When evidence is lacking and guidelines have gaps, nurses can play important roles in research to overcome these gaps.

Occurrence of cancer pain is highly variable and incompletely understood. Surveys are not population-based, are characterized by small heterogeneous samples, and provide sketchy data on etiology of pain, pain syndromes, and clinical or demographic factors. Moreover, the multiple dimensions of pain have not been thoroughly elucidated. Cancer-related pain is caused by the following: 1) direct tumor involvement, 2) diagnostic/therapeutic procedures, and 3) side effects or toxicities of treatment. Individuals may have more than one type of cancer-related pain simultaneously. Occurrence rates range from 14% to 100%, and between 33 and 50% of patients experience pain at some point in the cancer trajectory. Rates are higher (e.g., 70%-100%) in palliative care or pain management settings. Few researchers have focused solely on specific causes of pain in specific patient populations, and only a few included groups at higher risk for pain, such as the elderly or underserved. In general, researchers have not followed pain over time to determine its course, severity, effects on quality of life and functional status, and other related factors. Future researchers should aim to acquire specific information on occurrence of pain in a variety of cancer diagnoses, settings, and groups of people. Longitudinal designs, in-depth exploration of dimensions of pain, and delineation of specific issues in groups such as the elderly, children, and vulnerable populations are essential. Addressing these critical areas will improve our understanding of the occurrence and effects of pain and enhance our ability to provide appropriate interventions, thereby increasing patients' quality of life.

Oral complications of cancer therapy include mucositis, oral pain, poor oral intake, infection, bleeding, and difficulty communicating. Use of oral care standards can help manage these problems, but their systematic implementation is relatively rare. The purpose of this paper is to discuss barriers to implementing oral care standards, and to make suggestions for how such standards might be implemented in clinical settings. These purposes are accomplished through a review of relevant literature from various health-care disciplines, and discussion of one institution's implementation of an oral care standard for leukemia and bone marrow/stem cell transplant patients. Key principles underlying this successful institutional effort were recognition of the medical necessity of oral care, collaboration among health-care disciplines, and use of evidence-based practice wherever possible.

Chronic stable angina pectoris, the chest pain associated with reversible myocardial ischemia has detrimental effects on health-related quality of life, particularly in women. The limited research on gender differences in chronic stable angina suggests that angina may be experienced differently in women and that women report greater functional disability related to angina symptoms. No studies have examined gender differences in chronic stable angina from a multidimensional pain perspective or have included reliable and valid measures of pain that would facilitate comparing chronic angina patients with other chronic pain populations. The purpose of this descriptive study was to examine gender differences in characteristics of chronic stable angina using the short-form McGill pain questionnaire (SF-MPQ) and to explore relationships among these pain characteristics and perceived limitation in performing physical activities in patients with coronary artery disease (CAD) (physical limitation subscale of the Seattle angina questionnaire). One hundred and twenty-eight subjects (30.5% women) with stable CAD and angina pectoris documented by a cardiologist completed study questionnaires in an outpatient cardiology clinic. Results of the study suggest that men and women with chronic stable angina had more similarities than differences in chest pain characteristics. No significant gender differences were demonstrated in total sensory or affective intensity scores, the present pain intensity index, or the number of pain words chosen. However, women did report significantly greater pain intensity on the SF-MPQ visual analogue scale. Women were also significantly more likely to describe their chronic angina as 'hot-burning' and 'tender' and to have greater intensity of pain for these two descriptors. Despite the similarities in pain characteristics, women reported greater physical limitation related to anginal pain. The variables of social status and years diagnosed with CAD significantly interacted with gender in predicting physical limitation suggesting that gender-specific models of physical limitation in angina patients need to be explored. To our knowledge, this is one of the first studies that has assessed chronic anginal pain using a reliable and valid generic pain instrument. More research is needed to better understand the nature of gender differences in functional limitation secondary to anginal pain and the physiologic, cognitive-perceptual and psychosocial mechanisms that lead to angina-related functional disability.

Angina pectoris causes substantial psychological and functional disability and adversely effects health-related quality of life, particularly in women. Studies of cardiac disease-specific quality of life in women with coronary artery disease and angina are limited because little reliability and validity data for these instruments exist for women. Therefore, the purpose of this study was to examine reliability and validity of the Seattle Angina Questionnaire (SAQ), a cardiac disease-related quality-of-life measure, in a sample of women with chronic stable angina. A secondary analysis was performed on SAQ data from 175 women with a confirmed diagnosis of CAD and angina pectoris. The majority of the women were older, white, living with their spouse, had a previous acute myocardial infarction, and had undergone revascularization. The Cronbach alpha was used to assess reliability of the SAQ's five subscales, and factor analysis was used to assess the SAQ's validity. Results suggest that the SAQ is a reliable and valid quality-of-life measure in women with CAD. The physical limitations subscale factored into two separate factors, suggesting that the subscale measures two domains of physical function: self-care and exercise tolerance/mobility. Future research is needed to determine whether examining different combinations of SAQ items might provide a more sensitive assessment of cardiac disease-specific quality of life in women.

Precise quantification of oral complications in cancer patients receiving bone marrow and stem cell transplantation is essential when testing new treatment strategies for mucositis. Using 133 adult transplant patients, the authors evaluated the 20 item oral mucositis index (OMI), adapted from the 34 item OMI, to facilitate use by nondental health professionals. The OMI-20 consists of nine items measuring erythema, nine measuring ulceration, one measuring atrophy, and one measuring edema; all are scored from 0 = none to 3 = severe and summed for a total possible score of 0-60. The two sets of nine items measuring erythema and ulceration can also be summed separately to produce subscale scores ranging from 0 to 27. Results demonstrated internal consistency, test-retest, and inter-rater reliability, and strong evidence of construct validity. Provided that clinical examiners have appropriate training and experience, the OMI-20 can be used as a reliable, valid, and quantifiable measure of mucositis in clinical research.

Oral mucositis (OM)-related outcomes constituting a meaningful clinical advance in bone marrow transplant patients were considered by an interdisciplinary panel. Meaningful outcomes are essential in product development for OM, a condition without effective prevention or treatment. The most important outcomes to measure, the feasibility of measuring these in a clinical trial, and clinically meaningful differences in these outcomes were determined by the panel. Most important are reduction in oral pain and use of opioid analgesics, improvement in oral intake and quality of life, and reduction of hospitalization duration. Reduction in the severity of OM measured by an objective evaluation of oral mucosa could provide insight regarding the biologic activity of an intervention. Further data are required to define the precise relationship between reduction in visible OM and improvement in outcome. Minimally, clinical trials for OM should assess oral pain, opioid use, oral intake, and include objective assessment of OM.

This study assessed the effectiveness of using focus groups to obtain information about the characteristics of pain and quality of life in adults with sickle cell disease and their families. Five focus group sessions were held. Four groups consisted of adults diagnosed with sickle cell disease and one was composed of family members. Although focus groups were useful for addressing the purposes of the study, several volunteers in the patient group were unable to attend due to the occurrence of pain episodes. Adults with sickle cell disease identified recurring disabling pain and its consequences as interfering with their physical, emotional, and social quality of life. Several reported a pain aura that signaled the initiation of a painful episode. Useful self-care techniques and coping strategies were also identified. Common emotional responses included anger, hostility, depression, disenfranchisement, death anxiety and fatalism. The belief by those with sickle cell disease that health professionals viewed them as drug dependent often fueled angry and hostile responses. Religion was a major source for coping. Family members' quality of life was affected and they felt the negative impact of sickle cell disease on family relationships. Family members also reported feelings of helplessness, guilt, and parental self-blame. Health care providers could use information gained through this study to positively influence the care of adults with sickle cell disease.

Objective: The purpose of this study was to pilot test a self-administered chest pain questionnaire, a revised version of the Chest Discomfort Diary (CDD-R), in a sample of patients with chronic angina selected from a population known to have low literacy., Design: The study design was descriptive and correlational., Sample: The study used a convenience sample of 27 subjects with documented history of coronary artery disease and angina. Characteristics of the sample included a mean age of 56.3 years (SD, 12.4 years), 88.9% African-American, and 56.3% male, and 59.3% had a history of acute myocardial infarction. Approximately 28% had achieved a 9th-grade education or less, and reading levels ranged from 4th grade to 12th grade. Subjects completed the CDD-R, a 36-item instrument reflecting multiple dimensions of anginal chest pain., Results: Descriptions of the location (left chest, 66.6%), character (pressure, 59.2%), and precipitants of chest pain (walking, 51.8%) were consistent with clinical descriptions of "typical angina." Other physical symptoms such as shortness of breath (88.8%) and fatigue (85.1%) were reported. Walking (55.5%) was the activity most frequently described as difficult to perform because of chest pain, with sublingual nitroglycerin (77.7%) the most frequently used and most effective chest pain relief strategy., Conclusion: The CDD-R adequately measured multiple characteristics of anginal chest pain. Further research is needed to establish construct validity of the CDD-R and to determine the feasibility of using the instrument to monitor changes over time in patients' chronic angina.