To compare the efficacy of silver clear nylon dressing to standard skin care for the prevention and treatment of radiodermatitis in patients with anal canal and rectal cancer receiving chemoradiation therapy (XRT).

Patients were randomized to receive the silver dressing beginning on day 1 of radiation treatment or standard of care if radiation-induced dermatitis developed. Standard care involved using sulfadiazine cream at the time of development of grade 1 dermatitis. Patients wore the dressing 24 hours/day, seven days/week, except during XRT delivery. This was continued until two weeks after completion of XRT. The primary study outcome was skin toxicity at the last day of XRT. Skin toxicity was rated by multiple observers from digital photographs of the perineal skin area.

• The sample was comprised of 38 patients (50% male, 50% female).    
• Mean age was 63.8 years.
• Of the patients, 70% had disease of the anal canal and the rest had rectal cancer.
• Of the patients, 75% had 54 Gy or more of XRT. All received concurrent chemotherapy with 5 FU. Those with anal canal disease also received mitomycin C.

• Single site 
• Outpatient 
• Canada

Patients were undergoing the active antitumor treatment phase of care.

Skin scoring system grade 0–4:  grading by all 10 observers was calculated as the average score x10.

All patients completed XRT without major toxicity. There were four treatment breaks in the standard care arm and three in the silver dressing arm. On the last day of treatment, the mean dermatitis score was 2.53 for the standard arm and 1.67 for the silver dressing arm. When adjusted for age, there was no significant difference between groups in terms of severity of radiodermatitis.

There were no clear differences between study groups that indicated a substantial benefit for use of silver dressings.

• The study had a small sample size.
• The study had a risk of bias due to no blinding.
• Measurement/methods were not described.
• Measurement validity/reliability was questionable.*
• The intervention was expensive, impractical, or required training.*

*Dressings were provided free of charge; however, they are generally expensive. Measurement methods were unclear; the authors stated calculation of dermatitis severity using all 10 observer scores but then reported analysis only of average findings in each group. Findings showed no significant difference or meaningful size of effect; however, the authors concluded that the dressing was beneficial, which showed bias in the reporting.

The study did not provide strong support for the efficacy of silver nylon dressing to prevent radiation-induced dermatitis with radiation to the perineal area and skin.

DATABASES USED: Detailed review of evidence undertaken using a MEDLINE search from 1985–1996. Additional references were retrieved from a survey of references in each article and from unpublished and in-press research from key researchers in the area.

INCLUSION CRITERIA: English language; sample size of 20 or more participants; lymphedema related to breast cancer treatment; if other patients were included, at least 20 participants needed to be patients with breast cancer, and data for these patients were reported separately

EXCLUSION CRITERIA: Animal studies and non-English articles were excluded. Articles were excluded if their data were already published, if they were lymphedema-physiology based, if they discussed measurement techniques only, or if they were review articles.

• FINAL NUMBER STUDIES INCLUDED = 41 
• KEY SAMPLE CHARACTERISTICS: Treatments evaluated risk factor identification, lymphedema prevalence data, and treatment. No review of infection prevention or treatment is discussed in this document.

• Complex physical therapy (also known as complete decongestive therapy) includes four components used together:
• Skin care 
• Manual lymphatic drainage (MLD)
• Compression bandages
• Exercise.

In this review, all studies reported significant improvement. There was no comparison or control group.

• Compression techniques: Elastic sleeves (limitations in study quality)

Not Recommended for Practice

• Drug therapy
• Oral benzopyrones (e.g.,coumarin): Small RCTs; drugs pose significant liver toxicity

• Avoiding injury and heavy lifting, keeping weight under control, and avoiding injection, vaccination, and BP in affected arm seems prudent. 
• Air flight, injury, and trauma often are identified as precipitating factors but are not well studied. Further research and inquiry are necessary. 
• Caution against unsubstantiated recommendations citing a small study of women with lymphedema who needed hand surgery and successfully underwent surgery without any worsening of pre-existing lymphedema or onset of new swelling or infection.
• Provide patient education regarding risk factors and life-style.

• Age: Three out of four studies reviewed suggested that older patients are more likely to develop lymphedema.
• Wound complications and increased wound drainage
• Obesity 
• Prior infection
• Axillary surgery
• Radiotherapy
• Recurrent disease

• Strategies for early detection needed 
• Lymphedema research needed

To determine the efficacy of 8 mg oral ondansetron plus 8 mg oral dexamethasone as prechemotherapy antiemetic regimen for patients receiving moderately emetogenic chemotherapy (MEC)

Patients who received treatment with MEC were given a standard oral regimen of 8 mg ondansetron and 8 mg dexamethasone. Patients were instructed to take these medications one hour prior to their scheduled treatments. Nursing staff assessed compliance prior to chemotherapy treatment. Nursing staff assessed each patient on day one after chemotherapy treatment.

• The study consisted of 81 participants.
• Mean age was 54 years with a range of 32–80 years.
• The sample was 65% female and 35% male.
• All participants were patients with cancer receiving moderately emetogenic chemotherapy (MEC).
• Cancer diagnoses were breast (48%), lung (25%), colorectal (23%), and gynecologic (4%).
• The sample was composed of 53% patients receiving adjuvant chemotherapy and 47% patients being treated with palliative intention.
• The most frequent chemotherapy regimens were anthracycline (48%) and carboplatin-based (28%).

The study was conducted at a single, outpatient site in Australia.

Study participants were in active treatment, receiving palliative care.

This was a retrospective, descriptive audit.

Common Terminology Criteria for Adverse Events (CTAE v3.0) was used to measure severity of acute nausea and vomiting.

• The 8 mg of oral ondansetron plus 8 mg oral dexamethasone regimen achieved control of acute emesis in 75% of all patients and control of acute nausea in 44% of the patients.
• Patients treated with anthracycline-based chemotherapy had a significantly higher incidence of both acute emesis (90% versus 59%; p = 0.001) and nausea (67% versus 21%; p < 0.001) when compared with those who received nonanthracycline-based chemotherapy.

The use of 8 mg oral ondansetron and 8 mg oral dexamethasone as antiemetics for MEC offers comparable efficacy to other regimens for control of acute emesis; however, this regimen does not adequately control acute nausea, particularly in anthracycline-based regimens.

• Retrospective data audit did not have available data on use of rescue medications in the first 24 hours following chemotherapy.
• Data was descriptive only.

Although 8 mg oral ondansetron and 8 mg oral dexamethasone provided adequate rates of relief of acute CINV in nonanthracycline-based chemotherapy regimens, they alone are not adequate for anthracycline-based regimens.

To test the effectiveness of major depression treatment using add-on therapy methylphenidate to mirtazapine compared with the addition of placebo to mirtazapine in terminally ill patients with cancer (prognosis of living less than three months)

• N = 88   
• AGE RANGE = 44.39–70.82 years, no significant difference between groups
• MALES: 10 males (23%) in one group and 20 males (46%) in one group, FEMALES: Not reported
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: The study excluded patients who were already being treated with antidepressants and who had existing psychiatric comorbidities. Cancer diseases were not significantly different between groups, and the study included patients with breast, upper gastrointestinal, colorectal, renal, pancreatic, bone, urinary tract, prostate, uterine-cervical-ovarian (grouped), and other cancers.
• OTHER KEY SAMPLE CHARACTERISTICS: Breast cancer occurrence was the only significant difference between groups.

• SITE: Single site   
• SETTING TYPE: Multiple settings    
• LOCATION: University of Malaya Medical Centre in Kuala Lumpur, Malaysia

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

Four-week, randomized, double-blind, placebo-controlled trial

• Montgomery-Åsberg Depression Rating Scale (MADRS): 10-item measure of appearance of depression symptoms. One item is by self-report, and nine items are rated by clinicians.
• Clinical Global Impression-Severity (CGI-S): single-item measure of clinicians' impression of illness severity

Symptom relief by day 3 was noted among patients with the add-on therapy. Scores on the depression scale and severity of illness were improved by day 3 and day 14, respectively.

• Small sample (< 100)
• Measurement validity/reliability questionable
• Subject withdrawals ≥ 10%
• Discontinuation rate above 26% because of death and 11% because of adverse events

Early patient screening for depression among patients in palliative care is highlighted. Improved depression scores were noted by day 3 and improved the severity of illness by day 14. Consider add-on therapy with a fixed dose of mirtazapine and adding methylphenidate as described for patients with cancer with major depressive disorders in palliative care. Whether or not the rapid antidepressant effect of methylphenidate outweighs the potential for significant adverse effects needs to be individually determined for each patient.

To evaluate the effect of music in children with cancer who undergo lumbar puncture (LP)

Children were randomized to use either earphones with music (intervention group ) or earphones without music (control group) using iPods. The researcher and physician were blinded to participant group assignment. Immediately prior to the LP procedure, heart rate, blood pressure, oxygen saturation, and respiratory rate were obtained, and pain and anxiety scores were recorded. Directly after the procedure was finished, anxiety was remeasured. Self-reported pain was obtained before, during, and after LP. Physiologic parameters were recorded throughout the procedure. No local anesthetics or other analgesics were administered, which was usual care. Ten children in each group were chosen to be interviewed as well immediately after the LP procedure.

• The study reported on a sample of 40 pediatric patients.
• Patient age ranged from 7 to 12 years.
• The sample was 37.5% female and 32.5% male.
• All children had leukemia and were to have a lumbar puncture procedure.

• Single site
• Outpatient setting
• Hanoi, Vietnam

• Patients were undergoing the active treatment phase of care.
• The study has clinical applicability for pediatrics.

A double-blind, randomized controlled trial design was used.

• Pain Numeric Rating Scale (NRS): Pain intensity self-reported from 0 (no pain) to 10 (worst pain)
• Spielberger State-Trait Anxiety Inventory (STAI)–short form
• Physiologic measures of heart rate, blood pressure, etc.
• Brief semi-structured interview

Pain scores during LP were significantly lower for the music group (p < 0.001), 2.35 compared to 5.65 in controls. Pain scores after the procedure were also lower for the music group (p < 0.003). Anxiety scores after 10 minutes of music before LP were lower for children in the music group (p < 0.001). Anxiety after LP was also lower in the music group (p < 0.001) compared to controls; however, pre- and post-differences in anxiety in both intervention and control groups were minimal. Heart rate and respiratory rate were significantly different between the two groups, with lowered heart (p = 0.012) and respiratory rate (p = 0.009) during the procedure. In interviews, most of the children in the music group indicated that listening to their favorite music helped them feel calm and took their minds off the procedure.

Use of music as a distraction may be helpful to reduce pain and anxiety in children undergoing lumbar puncture.

• The study had a small sample, with less than 100 participants.
• The STAI was developed for and generally used in adults, and has not been validated in children.
• The children themselves could not be blinded to the intervention, and because the children in the control group were entered into the study with the knowledge that they might be given the intervention, but were then assigned to control, they may have felt they were missing something. This could have influenced findings.
• Potential risks with reuse of earphones for providing the music may be present.
• Post-anxiety between groups was reported, but no pre-post change in anxiety was reported. The music group also had lower anxiety at baseline, so it is not clear whether any post difference was due to the intervention.

This study does not provide convincing support for effectiveness of listening to music to reduce anxiety, but it appeared to reduce pain during the procedure. Music provision is a potentially low-risk and low-cost intervention that may be helpful to reduce pain and anxiety in children who are undergoing uncomfortable procedures. Further study of the use of music in combination with other forms of distractions and methods to combat pain are indicated. It is not clear if providing music via use of iPod and earphones is the best approach, as children in this study did indicate that the earphones were somewhat uncomfortable, and use of earphones for multiple patients could be a potential source for transmission of infection.

To evaluate possible differences between the severity and duration of oral mucositis (OM) and other clinical end points previously found to be associated with OM in patients who received palifermin compared to those who did not

A retrospective chart review of 99 consecutive patients who received an allogeneic hematopoietic stem cell transplantation (AHSCT) with palifermin from December 2006 to December 2009 was conducted, and 30 patients who received AHSCT from January to December 2005 served as control group (this group was treated before palifermin became standard of practice). Palifermin was administered for three consecutive days with the third dose 24 hours before the initiation of fractionated total body irradiation and three additional doses after the completion of the conditioning regimen (days 0–2). All patients received a comprehensive oral care regimen, and oral assessments were conducted every three days by a certified respiratory therapist.

• N = 129  
• AGE RANGE = 18–59.2 years
• MALES: 51%, FEMALES: 49%
• KEY DISEASE CHARACTERISTICS: Hematologic malignancies (acute lymphoblastic leukemia and acute myeloid leukemia)
• OTHER KEY SAMPLE CHARACTERISTICS: Conditioned with fractionated total body irradiation and etoposide

• SITE: Single site    
• SETTING TYPE: Not specified    
• LOCATION: Cancer center

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care  

• Retrospective chart review

• National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) v2.0
• OM grades 1 and 2 were categorized as mild, and grades 3 and 4 were categorized as severe.

OM developed in 95% of patients in the palifermin group and all 30 patients in the control group. Severe OM developed in 34% of the palifermin group and 80% of the control group (p < 0.0001) with the median duration of OM 13 days with palifermin and 18 days with the control. The median duration of sever OM was not found to be different between groups. The median duration patient-controlled analgesia use was shorter in the palifermin group as was the use of opioids. No significant difference in the duration of total parenteral nutrition use was found.

Palifermin reduced the incidence of severe OM and the overall duration of OM in this study. This supported the use of palifermin.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (sample characteristics)

This study supported palifermin use in this population. However, additional studies providing evidence on quality of life and patient-reported outcomes are needed.

To evaluate whether adding methylphenidate to mirtazapine in the treatment of depression in terminally ill patients with cancer will cause an earlier antidepressant response compared to patients receiving mirtazapine and a placebo

Patients initially were interviewed by a psychiatrist to confirm the diagnosis of major depressive symptoms using the Mini-International Neuropsychiatric Inventory. Patients were randomized and double-blinded (1:1) to receive either methylphenidate (MPH) or a placebo with mirtazapine (MTZ). Patients taking MTZ received a fixed dosage while MPH was first dosed at 5 mg BID then increased, if needed, after day 3. Outcomes were assessed at baseline and at six subsequent follow-up visits during the double-blind treatment on days 3, 6, 9, 14, 21, and 28. Assessments included the Montgomery-Asberg Depression Rating Scale and the Clinical Global Impression–Severity scale.

• N = 88  
• MEAN AGE = 59.52 years (group 1), 55.89 years (group 2 [placebo])
• MALES: 78%, FEMALES: 22%
• KEY DISEASE CHARACTERISTICS: Patients diagnosed with a major depressive disorder in the terminal disease stage of any type of cancer 
• OTHER KEY SAMPLE CHARACTERISTICS: Receiving palliative care with a life expectancy less than three months; oncology or surgery departments or palliative care units; Malay, Chinese, Indian, and other ethnicities were included; 84% were inpatient in both groups

• SITE: Single-site    
• SETTING TYPE: Multiple settings    
• LOCATION: University Malaya Medical Centre, Kuala Lumpur, Malaysia

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care 

Randomized, double-blinded, placebo-controlled study

• Montgomery-Asberg Depression Rating Scale (MADRS): A clinician-rated scale for the assessment of depression that includes 10 items (nine are patient-reported and one is based on observation). 
• Clinical Global Impression–Severity Scale (CGI-S): A single-item, clinician-rated scale that reflects the global severity of illness at time of assessment.

Although this was a small-scale study and the dropout rate was high, this study has implications for a small subset of patients. The addition of MPH to the standard treatment of depression may improve the response rates of terminally ill patients with cancer, beginning as early as three days after starting treatment. MPH must be used with caution due to side effects.

• Small sample (< 100)
• Risk of bias (sample characteristics)
• Findings not generalizable
• Subject withdrawals ≥ 10%
• Other limitations/explanation: The percentage of males was higher in the placebo group. There was a high dropout rate, mostly because of death, but side effects and personal reasons also were mentioned. Well-designed, larger studies need to be done. A study using MPH alone would be useful. Some of the symptoms could be related to the disease rather than depression.

Psychosocial assessment, which includes depression, is extremely important to the nursing profession. For those who care for terminally ill patients with cancer, having options to improve quality of life for a patient suffering from depression can have significant clinical implications. Using MPH may be one option to consider when seeking quick results in treating a major depressive disorder in terminally ill patients. MPH must be used with caution due to potential side effects, and the need for further research in this population is indicated.

The objective of the study is to synthesize information regarding the effect of nebulized furosemide in managing dyspnea.

• Databases searched were MEDLINE, EMBASE, CINAHL, and the Internet (1988–2006), and a manual search of article references was done.
• Search keywords were dyspnea, breathlessness, inhaled, nebulized, and furosemide.
• Studies were included if they reported on findings of experimental or clinical trial of nebulized furosemide for management of dyspnea in adults.
• No exclusion criteria were specified.

• The initial search provided 112 citations. 
• The report states that a critical review of evidence was done. 
• No specific process or review/quality criteria are described.

The final sample included 42 articles, including 39 randomized controlled trials; 2 studies in cancer, 35 in asthma, 8 studies in health volunteers, and 1 in chronic obstructive pulmonary disease.

• Some evidence suggests that nebulized furosemide could be an option in the management of dyspnea, but sufficiently powered experimental studies are lacking to have a strong conclusion in this area.
• Data in reports regarding possible diuretic effects of nebulized furosemide are lacking.
   

• Strong evidence is lacking to draw conclusions regarding effectiveness of nebulized furosemide for dyspnea management, and reporting of any diurectic effects of this approach also is lacking.
• Research in this area has a number of methodologic limitations that preclude drawing any firm conclusions.
• As some evidence exists of symptom relief produced by nebulized furosemide, further evaluation may be warranted, with appropriate placebo-controlled research.

Dyspnea was only measured in five studies reviewed.

This review demonstrates a lack of strong evidence in the area of nebulized furosemide for dyspnea and little evidence was found in the management of dyspnea in patients with cancer.

The study involved searches of the MEDLINE, Healthplan, PsychLIT, and Allied and Complementary Medicine databases. The articles included were published prior to December 1998.

The study consisted of a critical review of psychological therapies used by patients with cancer. Authors identified 627 relevant articles reporting 329 intervention trials. Authors identified 11 papers discussing 15 trials of fair quality and exploring interventions aimed at reducing depression.

Despite increased use of RCT designs, the methodological quality was generally suboptimal.

No intervention can be recommended for depression reduction, but interventions involving group therapy, education, structured counseling, cognitive-behavioral therapy (CBT), communication-skills training, and self-esteem building warrant further exploration before recommendations can be made.

• FINAL NUMBER STUDIES INCLUDED = 10 for qualitative review (nine in meta-analysis)
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,131
• SAMPLE RANGE ACROSS STUDIES: 21–389 patients
• KEY SAMPLE CHARACTERISTICS: All patients had prostate cancer.  

PHASE OF CARE: Multiple phases of care

The meta-analysis across all studies with all types of interventions showed a positive effect of intervention (p = 0.002). In four studies using exercise, there was no significant effect. Across three studies of psychosocial interventions, including psychotherapy and peer support, the was an overall significant effect (point estimate –0.961, p = 0.003). In two studies of educational interventions, there was no statistically significant effect.

The findings of this study suggest that psychosocial interventions can be effective in reducing depressive symptoms among patients with prostate cancer.

The majority of studies included were of low quality. The authors stated that in multiple-arm studies, outcomes were only used in certain selected study arms. For each subanalysis, there were few individual studies. There were some discrepancies in the report regarding the number of studies included. Samples were mixed in terms of inclusion of patients who did or did not have clinically relevant depressive symptoms. Most studies were brief, and the long-term benefits of the interventions were not clear.

Although this analysis provides relatively limited evidence regarding the effectiveness of individual types of interventions, its findings do suggest that some intervention is more effective than doing nothing. Nurses need to identify patients with symptoms of depression and those at risk for depression and take action.