A validation study of the WHO analgesic ladder: a two-step vs three-step strategy

Goals of work The aims of the present study were to verify whether an innovative therapeutic strategy for the treatment of mild-moderate chronic cancer pain, passing directly from step I to step III of the WHO analgesic ladder, is more effective than the traditional three-step strategy and to evaluate the tolerability and therapeutic index in both strategies.Methods Patients aged 18 years or older with multiple viscera or bone metastases or with locally advanced disease were randomized. Pain intensity was assessed using a 0–10 numerical rating scale based on four questions selected from the validated Italian version of the Brief Pain Inventory. Treatment-specific variables and other symptoms were recorded at baseline up to a maximum follow-up of 90 days per patient.Results Fifty-four patients were randomized onto the study, and pain intensity was assessed over a period of 2,649 days. The innovative treatment presented a statistically significant advantage over the traditional strategy in terms of the percentage of days with worst pain 5 (22.8 vs 28.6%, p<0.001) and 7 (8.6 vs 11.2%, p=0.023). Grades 3 and 4 anorexia and constipation were more frequently reported in the innovative strategy arm, although prophylactic laxative therapy was used less in this setting.Conclusions Our preliminary data would seem to suggest that a direct move to the third step of the WHO analgesic ladder is feasible and could reduce some pain scores but also requires careful management of side effects.     

Evidence‐based practice for pain management for cancer patients in an acute care setting

The purpose of this study is to implement an evidence utilization project using an audit and feedback approach to improve cancer pain management. A three‐phased audit and feedback approach was used. A 46‐bed oncology nursing unit in the university's cancer centre was selected as a research site. Nursing records extracted from 137 patients (65 for the baseline assessment and 72 for the follow‐up audit) were used to examine nurse compliance with four audit criteria derived from best practice guidelines related to the assessment and management of pain. We observed a significant improvement in compliance from baseline to follow‐up for the following criteria: documenting the side effects of opioids (2–83%), use of a formalized pain assessment tool (22–75%), and providing education for pain assessment and management to patients and caregivers (0–47%). The audit and feedback method was applicable to the implementation of clinical practice guidelines for cancer pain management. Leadership from both administrative personnel and staff nurses working together contributes to the spread of an evidence‐based practice culture in clinical settings. As it was conducted in a single oncology nursing unit and was implemented over a short period of time, the results should be carefully interpreted.     

Principles of economic evaluation for interventions of chronic musculoskeletal pain

Economic evaluation is attracting increasing attention to inform policy makers, insurers and other payers of the value of existing and new treatment modalities. Hence, it is desirable to assess not only the medical but also the economic consequences the new treatments produce. The available literature on economic evaluation revealed an urgent need for sound economic evaluation studies in the field of chronic musculoskeletal pain. Due to the generally weak methodology, the intended purpose of economic evaluation to help set funding priorities has often been bypassed. Although in general therapists have no direct responsibility for allocating scarce resources in the field of musculoskeletal pain, they are confronted with the results of these decisions in their everyday work. A clear understanding of the main principles of economic evaluation studies might therefore be advantageous. This paper addresses important methodological issues in economic evaluation research, such as the techniques for economic evaluation studies and the analytic perspective. In addition, the paper pays attention to the inclusion of costs and outcomes in economic evaluation research, sensitivity analysis, discounting, incremental analysis and ratios, and collecting of data.Further emphasis is placed on the transparent reporting of methods and study results. A clear reporting may help therapists and other researchers interpret the results of published studies and apply them to their own studies, and it may help decision makers generalize results from one setting to another.     

螺旋断层放疗系统治疗肿瘤的快速卫生技术评估

目的快速评估螺旋断层放射治疗系统(helical tomotherapy,HT)治疗肿瘤的有效性、安全性和适用性,为政府卫生政策制定者提供当前可得的最佳决策证据。方法计算机检索PubMed、EMbase、The Cochrane Library、CNKI、WanFang Data、VIP和CBM,同时检索相关专业网站。由2位评价者根据纳入与排除标准独立筛选文献、提取资料和评价质量后,行描述性分析。结果 1最终纳入150个研究,其中卫生技术评估(HTA)4个、临床对照试验(CCT)18个和观察性研究127个。2 4个HTA全文发表于2006~2009年,证据数量较少,质量较低;纳入的145个原始研究结果显示,HT主要用于14类肿瘤的治疗,治疗肿瘤总体毒性较低,生存率较高。虽纳入研究质量均低,但前列腺癌、头颈部癌、鼻咽癌、宫颈癌、肺癌和肝癌研究证据较多,累计样本量较大,其疗效和安全性结果可靠。3 Clinicaltrials.gov上已注册56个HT相关临床试验,多为欧美国家注册,其中9个研究已完成,但尚未公布研究结果。结论当前证据显示HT安全性高,临床疗效较好,但上述结论仍需开展更多高质量长随访研究加以验证。该设备不仅购置、维护和使用费用较高,对操作者的技术、培训和资质要求也高。建议政府根据我国的肿瘤流行病学特征、卫生资源配置、疾病负担和医疗卫生服务水平等因素综合评估后,减少购置数量,合理配置,高效使用;同时立项资助高质量长周期随访研究,生产本土化证据,不断指导和完善科学决策。     

Wearable electronic devices for chronic pain intensity assessment: A systematic review

Wearable electronic devices are a convenient solution to pain intensity assessment as they can provide continuous monitoring for more precise medication adjustments. However, there is little evidence regarding the use of wearable electronic devices for chronic pain intensity assessment. Our primary objective was to examine the physiologic parameters used by wearable electronic devices for chronic pain intensity assessment. We initially inquired PubMed, CINAHL, and Embase for studies evaluating the use of wearable electronic devices for chronic pain intensity assessment. We updated our inquiry by searching on PubMed, Embase, Scopus, and Google Scholar. English peer-reviewed studies were included, with no exclusions based on time frame or publication status. Of 348 articles that were identified on the first inquiry, 8 fulfilled the eligibility criteria. Of 179 articles that were identified on the last inquiry, only 1 fulfilled the eligibility criteria. We found articles evaluating wristbands, smartwatches, and belts. Parameters evaluated were psychomotor and sleep patterns, space and time mobility, heart rate variability, and skeletal muscle electrical activity. Most of the studies found significant positive associations between physiological parameters measured by wearable electronic devices and self-reporting pain scales. Wearable electronic devices reliably reflect physiologic or biometric parameters, providing a physiological correlation for pain. Early stage investigation suggests that the degree of pain intensity can be discerned, which ideally will reduce the bias inherent to existing numeric/verbal scales. Further research on the use of these devices is vital.     

Assessment of peri-operative quality of life in patients undergoing surgery for gastrointestinal cancer

The purpose of this study was to assess the pre- and postoperative quality of life (QOL) of patients with gastrointestinal cancer and to investigate the relationship between QOL and various psychological and clinical factors. Eighty-five patients who underwent surgery for gastrointestinal cancer and 26 control patients undergoing surgery for digestive diseases other than cancer were interviewed. Two tests were administered to assess QOL and psychological status respectively: the Japanese-language version of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the Japanese-language version of the Hospital Anxiety and Depression Scale (HADS). Each test was administered before surgery, before discharge, and 6 months after discharge. Gastrointestinal tumors were localized to the stomach, colon, or rectum in 88% of cases and classified as advanced stage or early stage according to staging protocols. Changes in EORTC QLQ-C30 subscale scores over time were compared among advanced stage, early stage, and control patients. All groups showed significant changes in subscale scores of QOL; the scores of the advanced-stage group indicated worse QOL than the early-stage and control groups in a lot of areas. The physical function (PF2) QOL subscore was influenced by diagnosis, postoperative complications, medical equipment at discharge, and the length of admission and negatively correlated with depression and anxiety. These results suggest that QOL in gastrointestinal cancer patients is variable over time and is influenced by various clinical factors. Therefore, consideration of these clinical factors is paramount to the optimal care of gastrointestinal cancer patients.     

Nursing prioritization of the patient need for care: A tacit knowledge embedded in the clinical decision-making literature

Every day in clinical settings, nurses practise in complex and dynamic situations. Nurses work to achieve emergent order in these situations through nursing prioritization of the patient need for care. As direct research on nursing prioritization had not been reported, a study, using critical realism as method, was designed to discern the profession's embedded understanding from within the clinical decision-making literature. The research synthesizes a tacit knowledge on nursing prioritization of the patient need for care from key international literature (from 1966 to 2003). Nursing prioritization was discerned in both education and practice literatures; interrelationships between these and theoretical approaches were also identified. Nursing prioritization of the patient need for care was revealed both as a non-sequential decision-making process throughout unfolding patient situations and as an advanced skill of nursing practice. Increasing confidence with this skill is the hallmark of developing expertise.     

73例生存期3年以上急性白血病患者生活质量及影响因素分析

目的：探讨生存期3年以上急性白血病患者生活质量及其影响因素。方法：采用一般状况调查问卷、癌症患者生活质量测定量表（European Organization for Research and Treatment of Cancer, EORTC QLQ-C30）中文版、体能状况评估表（ECOG）对73例生存期3年以上急性白血病患者进行问卷调查。结果：生存期3年以上急性白血病患者生活质量总分为（82.2±20.7）分,其中躯体功能得分最高,社会功能得分最低。在症状维度中,恶心呕吐症状最轻微,经济困难情况最严重。影响急性白血病患者生活质量总健康状况的因素为：体能状况、是否恢复工作。结论：生存期3年以上急性白血病患者生活质量得到改善,癌症相关症状得到控制。可根据患者体能状况及恢复工作情况给与康复指导,提高其生活质量。     

Minimal Clinically Important Difference of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF) for Fatigue Worsening in Asian Breast Cancer Patients

Context

The minimal clinically important difference (MCID) of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF), a questionnaire that measures cancer-related fatigue, has not been established in patients with cancer.

Skilled Nursing Facility Participation in Medicare’s Bundled Payments for Care Improvement Initiative: A Retrospective Study

Objective

To investigate differences in facility characteristics, patient characteristics, and outcomes between skilled nursing facilities (SNFs) that participated in Medicare’s voluntary Bundled Payments for Care Improvement (BPCI) initiative and nonparticipants, prior to BPCI.

A Pilot Study to Validate the Priority Nursing Interventions Classification Interventions and Nursing Outcomes Classification Outcomes for the Nursing Diagnosis "Excess Fluid Volume" in Cardiac Patients

PURPOSE.  To validate the content of the priority Nursing Interventions Classification (NIC) interventions and Nursing Outcomes Classification (NOC)-suggested outcomes for cardiac patients with the nursing diagnosis excess fluid volume in the Brazilian context.
METHODS.  The content of the interventions and outcomes was scored by seven expert nurses using a Likert scale, using the Fehring model.
FINDINGS.  From the 83 activities of the priority NIC interventions, nine had scores lower than 0.5 (nonuseful) and 50 had scores higher than 0.8 (major); from the 53 indicators of the suggested NOC outcomes, eight scored lower than 0.5 and 26 had scores higher than 0.8.
CONCLUSIONS.  The majority of the NIC interventions and NOC outcomes were considered useful by the Brazilian Cardiology expert nurses.
IMPLICATIONS FOR PRACTICE.  Clinical studies are an important strategy for validation of the usefulness of North American Nursing Diagnosis Association, NIC, and NOC language in clinical protocols. Additional studies are necessary to confirm the findings of this pilot study.     

Help seeking by health professionals for addiction: A mixed studies review

BackgroundWhen health professionals practice with active and untreated addiction, it is a complex occupational and professional issue impacting numerous stakeholders. Health professionals are responsive to evidence-based addiction interventions and their return-to-work has been demonstrated to be achievable, sustainable and safe. Facilitating help seeking in health professionals with addiction is a priority for reducing associated risks to their health and to patient safety.AimThe purpose of this study was to identify the process by which health professionals seek help for addiction, and factors that facilitate and deter help seeking, through a review of the qualitative and quantitative literature.MethodsBoth phases of this sequential mixed studies review followed the standard systematic review steps of: (1) identifying the review question, (2) defining eligibility criteria, (3) applying an extensive search strategy, (4) independent screening of titles and abstracts, (5) selecting relevant studies based on reviewing the full text, (6) appraising the quality of included studies, and (7) synthesizing the study findings. Our two searches of five databases from 1995 to 2015 resulted in the inclusion of eight qualitative and twenty-three quantitative studies. We first conducted a meta-synthesis of the qualitative literature to garner an understanding of the help seeking process for health professionals for addiction. We then conducted a narrative synthesis of the quantitative studies to generalize these findings through examining the data for convergent, complementary or divergent results.ResultsSynthesis of the included qualitative studies revealed that the professional and experiential context of healthcare compromised the health professional's readiness to seek help for addiction. Typically, a pivotal event initiated the help seeking process. The studies in the quantitative review identified that help seeking most often resulted from reports of adverse events to formal organizations such as their employer and regulatory bodies. This process does not adequately address the scope of health professionals requiring help for addiction. Informal sources such as colleagues and family, often aware of the addiction earlier, preferred referral to voluntary, confidential treatment programs.ConclusionsFacilitating the help seeking process for health professionals with addiction in as effective strategy to reduce the associated risks to the health professional, their families and colleagues, their employers and regulatory bodies, and to the general public. Our findings suggest that intervention is possible at multiple points in the help seeking process for health professionals with addiction. Confidential, compassionate and supportive alternatives offer potential for closing this gap.     

Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy

ObjectivesTo describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered “low-value”, and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations.MethodsWe analyzed 2002–2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression.ResultsFrom 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: ?3.1%; 95%CI ?4.7, ?1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: ?2.2%; 95%CI ?3.0, ?1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: ?0.6%; 95%CI ?2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI ?1.9, 2.0]; ?0.9% [95%CI ?3.1, 1.3]; and ?1.2% [95%CI ?5.3, 2.9], respectively).ConclusionsBefore and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.