Kumar, S., Juresic, E., Barton, M., & Shafiq, J. (2010). Management of skin toxicity during radiation therapy: a review of the evidence. Journal of Medical Imaging and Radiation Oncology, 54, 264–279.
To review the evidence for skin care management and conduct a survey to assess current practices in Australia and New Zealand.
Databases searched were MEDLINE, PubMed, CINAHL, Google Scholar, and Google search. Searches were also completed by hand for the time period of 1980 to 2008.
Search keywords were radiation dermatitis, skin reaction, management, skin care, skin toxicity, moist desquamation, dry desquamation, erythema, sorbolene aqueous cream, and aloe vera.
Inclusion and exclusion criteria were not specified.
Thirty-one references were retrieved. Literature was evaluated on the basis of sample size. Meta-analysis was performed on studies reporting at least grade II skin toxicity.
Patients were undergoing the active antitumor treatment phase of care.
Findings were reviewed for washing, topical aloe vera, topical sucralfate, Biafine cream, corticosteroids, hyaluronic acid, barrier film, dressings, and wheatgrass extract for prophylaxis. For management, interventions included were topical steroid cream, sucralfate, and dressings. Meta-analysis across studies using any topical prophylaxis showed that any intervention was associated with lower odds of development of skin toxicity (p = 0.02). There were no significant results for management interventions. There was consistent evidence in favor of gentle washing with mild soap during RT. There was some evidence in support of corticosteroids, bepanthan, topical hyaluronic acid, calendula, and barrier films. Aloe vera was associated with higher toxicity. Evidence did not support the use of sucralfate, Biafine, or dressing for prevention. Evidence regarding interventions for management of skin toxicity was conflicted, and none produced significant effects.
Findings support the use of washing. There was some evidence in support of using corticosteroids, bepanthan, barrier films, calendula, and topical hyaluronic acid. Findings suggest that use of any topical therapy for prophylaxis may be more effective than no intervention.
Washing during RT should not be restricted. There is some evidence in support of using calendula, hyaluronic acid, no-sting barrier film, bepanthan, and topical steroids. Evidence does not support the use of aloe vera.
Kulkarni, A.P., Chaukar, D.A., Patil, V.P., Metgudmath, R.B., Hawaldar, R.W., & Divatia, J.V. (2016). Does tranexamic acid reduce blood loss during head and neck cancer surgery? Indian Journal of Anaesthesia, 60, 19–24.
To evaluate the effect of the administration of tranexamic acid (TA) upon blood loss and the need for transfusions in patients undergoing head and neck surgery
Patients undergoing supramajor head and neck surgeries were randomized to receive TA (10 mg/kg) or placebo (normal saline). The patients were stratified a priori based upon their anticipated surgical procedure. The attending anesthesiologist, blinded to the drug, administered 100 ml of solution of normal saline with or without TA (10 mg/kg) during 20 minutes postinduction of anesthesia, and, if the surgery was prolonged, every three hours during the surgery. Blood loss was measured during surgery and postoperatively for the first 24 hours. A transfusion trigger was established.
PHASE OF CARE: Active antitumor treatment
Randomized, placebo-controlled, double-blind, prospective study
Gravimetry, blood collection in suction bottles, and visual inspection were used to calculate intraoperative blood loss; postoperative blood loss was calculated with a measure of the blood collected in suction bottles during 24 hours.
Differences in intraoperative blood loss between the groups was not significant (p = 0.22); however, the placebo group demonstrated a significantly greater amount of blood loss postoperatively than the TA group (p = 0.009). This difference, however, did not translate to a significant difference between groups in the number of transfusions (p = 0.51).
The administration of TA in patients undergoing head and neck cancer surgery did not decrease intraoperative blood loss or overall blood loss; although it did reduce postoperative bleeding, this did not translate to a reduction in the number of transfusions.
Nurses must assess perioperative blood loss because it places patients at risk for serious complications. An ongoing need to evaluate measures exists to decrease this risk.
Kuhn, A., Porto, F.A., Miraglia, P., & Brunetto, A.L. (2009). Low-level infrared laser therapy in chemotherapy-induced oral mucositis: A randomized placebo-controlled trial in children. Journal of Pediatric Hematology/Oncology, 31, 33–37.
To evaluate the efficacy of low level laser therapy (LLLT) for the treatment of chemotherapy-induced oral mucositis (OM) in pediatric patients undergoing chemotherapy or stem cell transplant
Children and adolescents with cancer receiving chemotherapy or hematopoietic stem cell transplantation (HSCT) who developed grade II OM were included. OM was scored daily by the same investigator. In the experimental group, the treatment was applied to each OM lesion for five consecutive days. The control group received sham treatments to each OM lesion for five consecutive days also.
This was a single site, inpatient study conducted in the Pediatric Oncology Unit of the Hospital de Clinicas de Porto Alegre at Federal University of Rio Grande do Sul, Brazil.
The study was a randomized, placebo-controlled trial.
No differences were found in grades of mucositis as a function of the LLLT protocol. Mucositis was diagnosed 5.0 to 7.5 days postchemotherapy. On the seventh day after the diagnosis of mucositis, 1 out of 9 patients in the laser group and 9 out of 12 patients in the sham group had grade II or greater OM (p = 0.029). The mean OM duration in the laser group as compared to the sham group was 3.1 days less (p = 0.004).
LLLT can significantly reduce the duration of chemotherapy-induced OM in children.
Laser therapy is effective in treatment of mucositis, but it is very high tech and requires special equipment and highly trained personnel.
Kuderer, N.M. (2011). Meta-analysis of randomized controlled trials of granulocyte colony-stimulating factor prophylaxis in adult cancer patients receiving chemotherapy. Cancer Treatment and Research, 157, 127–143.
The primary purpose of this study was to determine the percentage of patients experiencing febrile neutropenia. A secondary goal was to examine infection-related mortality, all early mortality during chemotherapy, bone pain or musculoskeletal pain, and relative dose intensity.
Medline, EMBASE, Cancerlit, Cochrane, Database of Systematic Reviews,and Cochrane Central Register of Controlled Trials database were reviewed.
Key words include G-CSF, granulocyte–colony-stimulating factor, colony-stimulating factors (CSFs), recombinant G-CSF, lenograstim, filgrastim, pegfilgrastim, and pegylated filgrastim, randomized controlled trials
Inclusion criteria was primary and secondary G-CSF prophylaxis
Studies were excluded if they encompassed those with granulocyte macrophage–colony-stimulating factor (GM-CSF), RCTs in children, leukemia or multiple myeloma, bone marrow or peripheral blood stem cell transplantation, and studies of established neutropenia or febrile neutropenia.
12,128 potentially relevant papers were reviewed.
Cochran’s Q statistic and inconsistency index of Higgins,fixed-effects model, and random effects models.
The Jadad scale was used to evaluate study quality.
17 randomized, controlled trials (RCTs) were included.
The total sample size was 3,493 patients
The sample across all studies ranged from 31–928
Key characteristics included filgrastim in 10 trials (59%), lenograstim in six trials (35%), and pegfilgrastim in one trial (6%). Eleven trials (65%) involved patients with solid tumors and six (35%) were in patients with lymphoma, including four (24%) limited to older adult patients, eight studies using placebo control, and three that permitted secondary G-CSF in control patients (two prohibited its use and the remaining studies did not specify). Five RCTs prohibited the use of prophylactic antibiotics and three used antibiotic prophylaxis. The remaining did not specify.
Active treatment
Reductions in infection-related and early mortality with G-CSF were seen in patients with solid tumors but not among those with lymphoma.
This analysis and review confirms that primary prophylaxis with G-CSF significantly reduces the risk of febrile neutropenia while sustaining and enhancing chemotherapy dose delivery in patients receiving conventional chemotherapy across a broad range of baseline risk in eligible trials. The most important and previously unreported observation that emerged from this overview is the observed reduction in infection-related (RR = 0.552, p = 0.018) and all-cause (RR = 0.599, p = 0.002) early mortality in patients randomized to receive primary prophylaxis with G-CSF. There were no differences based on whether or not patients also received prophylactic antibiotics or between those receiving G-CSF as primary or secondary prophylaxis.
Kuderer, N.M., Dale, D.C., Crawford, J., & Lyman, G.H. (2007). Impact of primary prophylaxis with granulocyte colony-stimulating factor on febrile neutropenia and mortality in adult cancer patients receiving chemotherapy: A systematic review. Journal of Clinical Oncology, 25, 3158–3167.
To evaluate primary granulocyte colony-stimulating factor (G-CSF) prophylaxis versus a placebo or untreated control group
DATABASES USED: Electronic databases through December 2006: MEDLINE, EMBASE, CANCERLIT, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effect, and Conference Proceedings (American Society of Clinical Oncology and American Society of Hematology). In addition, references from included articles and relevant published reports were hand searched, and references from leaders in the field were solicited. The literature search had no language restrictions.
INCLUSION CRITERIA:
EXCLUSION CRITERIA:
FINAL NUMBER STUDIES INCLUDED = 17 RCTs of primary prophylactic G-CSF
TOTAL PATIENTS INCLUDED IN REVIEW = 3,493 patients
KEY SAMPLE CHARACTERISTICS:
The occurrence of FN was reported as an outcome in 15 trials with 3,182 patients.
Infection-related mortality was reported as an outcome in 12 trials including 1,454 control patients and 1,463 patients receiving G-CSF.
Early mortality was reported in 13 trials with 3,122 patients.
Relative dose intensity (RDI) was reported as an outcome in 10 trials. The average RDI among control patients in these studies ranged from 71.0%–95.0%, with a mean RDI of 86.7% (median RDI: 88.5%).
Bone or musculoskeletal pain during the course of chemotherapy was reported as an outcome in 14 trials including 3,029 patients.
Kucuktulu, E., Guner, A., Kahraman, I., Topbas, M., & Kucuktulu, U. (2013). The protective effects of glutamine on radiation-induced diarrhea. Supportive Care in Cancer, 21(4), 1071–1075.
To investigate the protective effects of glutamine on radiation-induced diarrhea
Patients were divided into two groups. One group received 15 g oral glutamine each day beginning one week prior to radiotherapy and continuing until one week after radiation therapy completion. The other group was given an oral glucose solution.
The study was conducted at a single outpatient site in Turkey.
Patients were undergoing the active treatment phase of care.
This was a two-group prospective trial.
No between-group differences were found in overall incidence of diarrhea. None of the patients in the glutamine group developed grade 3–4 diarrhea, compared to 69% of those in the placebo group (p = 0.0000). More patients in the placebo group required loperamide and parenteral supportive therapy.
Findings suggest that oral glutamine may be helpful in the prevention and management of severe radiation-induced diarrhea.
Findings suggest that oral glutamine may help in the prevention of severe radiation-induced diarrhea. However, study design issues limit the quality of this study. Use of glutamine warrants further investigation in large, well-designed randomized studies.
Kuchinski, A. M., Reading, M., & Lash, A. A. (2009). Treatment-related fatigue and exercise in patients with cancer: a systematic review. Medsurg Nursing, 18, 174–180.
To determine if patients receiving treatment for cancer experienced less treatment-related fatigue if they participated in a regular committed exercise regimen, compared to those who did not exercise regularly.
Databases searched were CINAHL, MEDLINE, Ovid, and ProQuest between January 2000 and October 2006.
Search keywords were fatigue, cancer, and exercise.
Studies were included in the review if
Two unpublished doctoral dissertations were also included.
Initially, 400 articles addressing the topics of fatigue, cancer, and exercise were found. When the inclusion criteria were applied, 10 studies were included. Levels of evidence presented were established using the Priority Symptom Management (PRISM) system developed by the Oncology Nursing Society. No meta-analysis was performed due to differing definitions and methods of measurement of fatigue across studies. All studies demonstrated strong levels of evidence of PRISM level I or II. Brief summaries of study design, exercise regimen, outcomes, limitations, level of evidence, and study recommendations were provided. Studies were identified within two major categories: home-based exercise interventions and out-of-home exercise interventions.
The majority of studies (eight of 10) used home-based exercise interventions.
Eight of the studies had findings that supported exercise during treatment to reduce fatigue. In the two studies that did not show differences in fatigue, one had a very small sample size and one showed poor patient adherence to the exercise regimen.
Exercise was generally well tolerated by participants, and there were no adverse events associated with exercise.
Components of the regimens that were found to be beneficial were
Theoretical foundations of studies were reviewed. These included
The evidence suggested that an individualized exercise program should be included in the treatment of patients receiving chemotherapy and/or radiation therapy. Studies have not shown any adverse effects, such as increased fatigue or falls, as a result of exercise. Studies retrieved were limited to four types of cancer: multiple myeloma, breast, lung, and prostate. Studies reviewed encompassed both early and late stages of disease.
Common limitations found among the studies reviewed included
Use of common definitions and methods of measurement of outcome variables is needed to further advance this area of study. Evidence supports the inclusion of scheduled exercise in the care plan of patients undergoing cancer treatment. It was noted that approximately 50% of healthy Americans have been shown to have difficulty initiating and maintaining an exercise program for more than three months. This suggests that individuals with cancer are likely to need professional support to begin and maintain an exercise program. Nurses’ awareness of the role of exercise can enable better education that benefits patients.
Kubo, K., Miyazaki, Y., Murayama, T., Shimazaki, R., Usui, N., Urabe, A., . . . Tamura, K. (2016). A randomized, double-blind trial of pegfilgrastim versus filgrastim for the management of neutropenia during CHASE(R) chemotherapy for malignant lymphoma. British Journal of Haematology, 174, 563–570.
To compare the safety and efficacy of pegfilgrastim and filgrastim in patients being treated with intensive chemotherapy for malignant lymphoma
Patient receiving CHASE(R) chemotherapy were randomized to receive either a single dose of pegfilgrastim or daily doses of filgrastim starting on day 4 after the completion of therapy. The primary endpoint was the duration of severe neutropenia.
The primary endpoint was the duration of severe neutropenia. Secondary endpoints were the duration of neutropenia and the incidence of febrile neutropenia.
The mean duration of severe neutropenia in patients receiving pegfilgrastim was 4.5 days (SD = 1.2) and 4.7 days (SD = 1.3) in the filgrastim group (p < 0.001). This demonstrated that noninferiority of pegfilgrastim compared to filgrastim. The neutrophil count peaked on the day after the start of the study drug administration for pegfilgrastim and on day 5 for filgrastim. The peak of the nadir was between days 8 and 10 for both groups and then returned to ≥ 1.0 x 10^9/L by day 16 in all patients. The mean duration of neutropenia was 5.2 (SD = 1.3) days for pegfilgrastim and 5.1 (SD = 1.3) days for filgrastim. The mean neutrophil count at nadir was 0.013 (SD = 0.026) x 10^9/L in the pegfilgrastim group and 0.017 (SD = 0.055) x 10^9/L in the filgrastim group. The incidence of febrile neutropenia was 56.6% in the pegfilgrastim group and 55.6% in the filgrastim group.
In respect to both primary and secondary endpoints, noninferiority was proven. While not an endpoint of the study, the adverse effects were very similar as well.
Education about neutropenia, the duration of neutropenia, and the risk of febrile neutropenia as well as the importance of a granulocyte–colony-stimulating factor (G-CSF), whether filgrastim or pegfilgrastim, is important. In addition, nurses should provide education on the side effects of both medications.
Kubo, M., Onishi, H., Kuroki, S., Okido, M., Shimada, K., Yokohata, K., . . . Katano, M. (2012). Short-term and low-dose prednisolone administration reduces aromatase inhibitor–induced arthralgia in patients with breast cancer. Anticancer Research, 32, 2331–2336.
To determine whether short-term and low-dose prednisolone reduces aromatase inhibitor (AI)–induced arthralgias in patients with breast cancer
Prednisolone 5 mg was administered to women once daily in the morning for one week.
Patients were undergoing active antitumor treatment.
The study was a prospective intervention clinical trial.
Joint symptoms improved in 67% of patients immediately after prednisolone, 63% continued to report relief at one month, and 52% at two months. Thirty percent of patients reported an improvement in daily life at one week and one month and 26% at two months.
Results suggest that a low dose of 5 mg of prednisolone given for one week at the initiation of AI therapy can relieve arthralgias in some patients.
While this study suggests that AI-related pain can be reduced in patients with breast cancer using prednisolone, randomized controlled trials are needed that reflect longer follow-up and adverse event monitoring. Insufficient evidence exists to recommend practice implementation.
Krüger, W.H., Bohlius, J., Cornely, O.A., Einsele, H., Hebart, H., Massenkeil, G., . . . Wolf, H.H. (2005). Antimicrobial prophylaxis in allogeneic bone marrow transplantation. Guidelines of the infectious diseases working party (AGIHO) of the German Society of Haematology and Oncology. Annals of Oncology, 16, 1381–1390.
To provide a guideline for the use of antimicrobial prophylaxis for patients in an allogeneic bone marrow transplantation setting.
This was classified as a guideline of evidence-based medicine criteria. The author used a table to rate available evidence-based articles about antimicrobial prophylaxis in allogeneic bone marrow transplant recipients.
Evidence was rated using this table.
Category, Grade Definition
Strength of Recommendation
A Good evidence to support a recommendation for use (strongly recommended)
B Moderate evidence to support a recommendation for use (generally recommended)
C Poor evidence to support a recommendation (optional)
D Moderate evidence to support a recommendation against use (generally not recommended)
E Good evidence to support a recommendation against use (never recommended)
Quality of Evidence
I Evidence from at least one well-executed randomized, controlled trial
II Evidence from at least one well-designed clinical trial without randomization; cohort or
case-controlled analytic studies (preferable from more than one center); multiple time-series
studies; or dramatic results from uncontrolled experiments
III Evidence from opinions of respected authorities based on clinical experience, descriptive
studies, or reports of expert committees.
Bacterial
Al: Fluoroquinolones should be used for antibacterial prophylaxis.
BII: Pneumococcus prophylaxis should be used for any patient with active chronic graft-versus-host disease and for the remainder of the patient's life following splenectomy.
BIII: Patients already receiving Pneumocystis carinii pneumonia (PCP)-prophylaxis with trimethoprim/sulfamethoxazole (TMP-SMZ) should have additional prophylaxis based on the epidemiology for the area and patterns of resistance.
DI: Anti-infectious prophylaxis with intravenous immunoglobulins should be used.
Cytomegalovirus
Preventing Exposure
AIII: All patients being considered for allogeneic stem cell transplant should have anti-cytomegalovirus (CMV) IgG-antibody testing. This is recommended to establish the risk for reactivation (de novo infection).
BIII: CMV-negative transplant candidates and patients should not share drinking cups or eating utensils that have been used by others. If a patient who is CMV-negative is in a monogamous relationship, his/her partner is advised to be CMV-serotested. If his/her partner is positive or the patient is not in a monogamous relationship, condom use during sexual contact is recommended.
Al: Transplant recipients who are CMV-seronegative should receive blood products from donors who have also tested negative. When blood banks lack CMV-negative donors, only leukocyte-depleted red cells and thrombocytes should be issued to this group.
DI: CMV prophylaxis should use preparations of human immunoglobulin for CMV-negative matched related donors.
Preventing Disease and Reactivation
BIII: For a CMV-positive recipient, most transplant physicians recommend a CMV-positive donor.
Al: Any patient at risk for CMV disease should be screened for pp65 antigenemia or nucleic acid using real-time polymerase chain reaction (PCR) at least weekly after transplant from days 10 to 100.
Al: Patients should begin pre-emptive therapy following one positive pp65 or two consecutive PCR results. Pre-emptive therapy is advised for two weeks, followed by another two weeks of maintenance therapy.
AI: In a pre-emptive setting, if the patient has resistance to ganciclovir, switching to foscarnet is recommended.
AI: The recommendation for herpes simplex virus (HSV) reactivation in IgG-positive patients is acyclovir. Acyclovir therapy should begin between the start of conditioning therapy and day 1 after the transplant and should continue until day 30 after stem cell transplantation.
Al: The recommendation of drugs for prophylaxis or therapy of CMV are ganciclovir and foscarnet. (Cidofovir has a BII recommendation.)
EI: High-dose acyclovir and valacyclovir should be used to prevent CMV.
El: Human immunoglobulins should be used for prophylaxis or therapy of CMV.
Herpes Simplex Virus
Preventing Exposure
AIII: Serum tests for anti-HSV serostatus are mandatory.
Preventing Reactivation
AI: Acyclovir should be used for standard reactivation prophylaxis, beginning between the start of conditioning therapy and day 1 posttransplant and continuing to day 30 following stem cell transplant.
CI: Evidence is lacking for the use of acyclovir prophylaxis increased to 100 days or more.
BIII: If repeated reactivation is present after 30 days of prophylaxis, continued therapy is recommended.
EIII: Acyclovir is not recommended for continued HSV prophylaxis at times when gancyclovir or foscarnet is used for CMV therapy or prophylaxis because gancyclovir and foscarnet are effective against HSV in vitro.
CIII: The effectiveness of valacyclovir and famciclovir in preventing HSV reactivation lacks the support of trials, but they are presumed effective.
Varicella-Zoster Virus
AIII: All patients being considered for stem cell transplant should avoid contact with those suspected of active varicella-zoster virus (VZV) infection or reactivation.
BIII: Those living with or in close contact with a transplant patient should be vaccinated before transplant.
AIII: To prevent nosocomial spread, transplant patients with overt VZV disease are to be isolated until all lesions are crusted.
CIII: Long-term acyclovir prophylaxis is not effective for prevention.
Epstein-Barr Virus
AIII: Seronegative transplant candidates and patients with Epstein-Barr virus (EBV) should not share drinking cups or eating utensils that have been used by others. If a patient negative for EBV is in a monogamous relationship, his/her partner is advised to be EBV-serotested. If his/her partner is positive or the patient is not in a monogamous relationship, condom use during sexual contact is recommended.
Community Respiratory Virus
AIII: Exposure prophylaxis is critical in avoiding respiratory syncytial virus, influenza, parainfluenza, and adenovirus.
BII: Those living with or working on units with transplant patients should be vaccinated for influenza.
BIII: Patients should receive a two-week course of amantadine or rimantadine for chemoprophylaxis if vaccination occurred during an influenza outbreak.
Yeasts
CIII: Foods at risk for allowing fungi to colonize in the gastrointestinal (GI) tract should be restricted.
AIII: Hand washing and disinfecting by personnel should be performed to prevent GI-colonizing fungi from reaching patients at risk.
Al: It is recommended to take fluconazole 400 mg/day IV or orally to prevent yeast infections in allogeneic stem cell recipients while they are neutropenic.
BI: One study found itraconazole superior to fluconazole but noted that GI side effects can limit oral use.
EII: Itraconazole is not recommended for yeast prophylaxis because of interactions with metabolism of busulfan.
EI: Itraconazole is not recommended for yeast prophylaxis because of interactions with metabolism of cyclophosphamide.
Molds
AII: Stem cell transplant candidates and patients must avoid construction, renovation, or other areas with dust exposure.
AII: Use of air conditioning with high-efficiency particulate absorption filtration or laminar air flow in transplant units reduces mold spore presence in the air and mortality related to fungal invasion.
BIII: Transplant patients should wear appropriate fitting masks when traveling through or to areas off the transplant unit.
BII: No drug demonstrates effectiveness for the primary prophylaxis of aspergillosis following bone marrow transplant.
DII: Itraconazole capsules are limited based on low bioavailability.
AI: For patients with acute leukemia, itraconazole solution reduced the incidence of invasive aspergillosis if plasma levels were greater than 500 ng/mL.
AIII: Secondary prophylaxis with a drug having systemic effectiveness was recommended despite a lack of trial evidence.
Pneumocystis jiroveci (formerly Pneumocystis carinii)
BIII: Stem cell recipients are not to have contact with patients with known PCP.
AII: TMP-SMZ prophylaxis should be used for all allogeneic transplant patients beginning at engraftment until the completion of immunosuppressive therapy or when chronic graft-versus-host disease is resolved.
AII: Dapsone or aerosolized pentacarinate should be used when TMP-SMZ is contraindicated or when the patient does not tolerate it. Higher breakthrough rates are noted with these alternate drugs.
Toxoplasmosis
AIII: Allograft recipient candidates should be tested for Toxoplasma gondii antibodies to identify risk for reactivation. Education should include ways to avoid exposure.
CIII: Toxoplasma prophylaxis at the time of acute graft-versus-host disease or secondary prophylaxis following history of toxoplasmosis should be performed.
Food
BIII: Foods with a risk of fungi, bacteria, or other contamination should be eliminated during and following stem cell transplant, and safer alternatives should be used (e.g., pasteurized cheese instead of unpasteurized cheese).
Vaccination After Stem Cell Transplant
AIII: Immunity against specific pathogens should be analyzed one year after allogeneic transplant with reimmunization with inactivated vaccine or toxoids.
The article also states that stem cell transplant recipients are not to receive live-attenuated virus vaccination during the two years after transplant. No rating was provided for this “strictly contraindicated” recommendation.
Specific recommendations with strong evidence, AI and EI, should be included in nursing practice guidelines with recommendations for and against practice, respectively. Other recommendations should not be included until higher evidence from trials can be demonstrated or included in the “Evidence Not Established” category.