To determine if the intrathecal analgesia technique is not inferior to continuous epidural (EP) infusions for postoperative pain in patients undergoing liver resections

Patients who had epidural analgesia had catheters inserted at the T9-10 or T10-11 levels. Ropivacaine and morphine were injected prior to anesthesia. In the intrathecal group, a dural puncture was done at the L3-4 or L 5-6 level, and morphine and saline were injected prior to anesthesia. In the EP group analgesia was continued with ropivacaine. In both groups, patients could receive 1 mg boluses of morphine from a patient-controlled IV pump. A value of 10 mm was used to determine noninferiority. Assessments were done at four, eight, 12, 24, 36, and 48 hours.

• N = 50
• AGE = Not provided
• MALES: Not provided        
• FEMALES: Not provided
• KEY DISEASE CHARACTERISTICS: Undergoing liver resection for cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Patients with elevated international normalized ratios or reduced platelet counts were excluded.

• SITE: Single site  
• SETTING TYPE: Inpatient  
• LOCATION: Italy

PHASE OF CARE: Active antitumor treatment

Prospective noninferiority trial

• Morphine consumption
• Visual Analog Scale (VAS) for pain (100 mm assumed but not specified)

The time to first morphine requirement was longer in the epidural group at all time points, and by 48 hours, morphine use in the intrathecal group was four times higher than in the epidural group (p < 0.001). Extubation time and recovery room time were significantly shorter in the epidural group (p < 0.05). The total amount of morphine required in the intrathecal group was higher (p < 0.01). No significant differences between the groups in postoperative pain scores were reported.

Although this study reported that a single dose of intrathecal preoperative analgesia was not inferior to epidural analgesia, other measures reflecting postoperative pain were in favor of epidural analgesia. A single preoperative dose of intrathecal morphine may be a viable alternative approach to manage acute pain.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Other limitations/explanation: No demographic information was reported.

The findings of this study suggested that a single intrathecal dose of morphine preoperatively can provide an alternative approach for the management of postoperative pain, which may be useful for patients in whom continuous epidural analgesia is not appropriate.

To assess the efficacy of Uncaria tomentosa (cat’s claw) on quality of life, fatigue, anxiety, depression, and sleep quality in patients with terminal cancer when used in conjunction with monitoring for changes in biochemical and inflammatory parameters

A 100 mg dose of dry extract of Uncaria tomentosa (U tomentosa) was administered orally three times daily for eight weeks.

• N = 51  
• MEDIAN AGE = 64 years (range = 33–85 years)
• MALES: 53%, FEMALES: 47%
• KEY DISEASE CHARACTERISTICS: Solid tumors with no additional therapeutic options; life expectancy greater than two months
• OTHER KEY SAMPLE CHARACTERISTICS: 74.5% white; 19.6% colon; 15.3% breast, 13.7% lung; Karnofsky Performance Status ≤ 80 (65%)

• SITE: Single-site 
• SETTING TYPE: Not specified
• LOCATION: Academic center, Sao Paulo, Brazil

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

• Single-center, open-label study
• Prospective, repeated measures

• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30)
• Functional Assessment of Chronic Illness Therapy–​Fatigue (FACIT-F)
• Chalder Fatigue Scale (CFQ)
• Hospital Anxiety and Depression Scale (HADS) 
• Pittsburgh Sleep Quality Index–Brazil (PSQI-BR)

Overall quality of life (p = 0.00411) and social functioning (p = 0.0341) improved. Fatigue as assessed by the CFQ improved (p = 0.0496). No improvement in sleep quality anxiety was determined. There was no change in liver function, kidney function, blood counts, or inflammatory blood parameters.

Managing symptoms in patients with no additional treatment options is important. U tomentosa improved overall quality of life and social functioning and reduced fatigue in patients with cancer who had no additional treatment options. U tomentosa did not affect sleep quality, anxiety, or depression, but it did not alter the inflammatory parameters studied.

• Small sample (< 100)
• Risk of bias (no control group)  
• Risk of bias (no blinding)
• Risk of bias (sample characteristics)
• Findings not generalizable

U tomentosa may be useful in reducing fatigue and improving overall quality of life in patients who have no other treatment options.

To determine whether the average decrease in fatigue from days 1 (baseline) to 21 and from days 21 to 49 was greater in patients who received guarana versus placebo, as measured by Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F) scores.

Patients received baseline evaluations with questionnaires, then 50 mg of guarana or placebo twice daily, study questionnaires 21 days later, and a seven-day washout of the drug. Patients were then crossed over to the opposite group for 21 days of the drug, followed by questionnaire completion and toxicity assessment.

• The study included 60 women with breast cancer.
• Mean age was 50.2 years in the placebo-guarana group and 51.76 years in the guarana-placebo group.
• All patients had worsening fatigue on the Brief Fatigue Inventory (BFI) for eligibility and were entered prior to their second cycle of initial chemotherapy.
• Those with severe fatigue were excluded.
   

The study took place in two public and academic hospitals in São Paulo, Brazil.
 

Patients were undergoing the active treatment phase of care.

This was a double-blind, placebo-controlled, randomized, crossover trial.

• General demographic questionnaire    
• FACIT-F
• FACIT-Endocrine Symptoms (FACIT-ES)
• Hospital Anxiety and Depression Scale (HADS)
• Pittsburgh Sleep Quality Index (PSQI)
• Chalder Fatigue Scale

More patients showed improvement in FACIT-F in the guarana group at day 21 (p = 0.01) and day 49 (p = 0.02). Chalder Fatigue Scale scores decreased by 4.6 points on day 21 (p < 0.01), with no significance for day 49 compared to placebo. Sleep improvement was seen at day 49 (p = 0.05). Four patients discontinued guarana use because of tachycardia. Analysis was conducted between groups on specific days of the study, rather than analyzing the intervention condition and control condition as a whole between groups.

Guarana showed a superior effect to placebo in improving fatigue in patients with breast cancer undergoing treatment.

• The study had a small sample size, with less than 100 patients.
• Only one tumor type was used, and common comorbidities were excluded. 
• The statistical analysis was conducted to compare results between groups at days 21 and 49, rather than at a specific time point in the study and analyzing the findings between the experimental and control condition. This is not a meaningful comparison study.
   

Guarana may be an option to treat fatigue in this population, but additional research is needed to provide support for its clinical use. Patients should be cautioned on its use if they have angina, other cardiovascular disease, uncontrolled hypertension, or neurologic disorders.

To evaluate the effectiveness of treating epidermal growth factor receptor–inhibitor (EGFRI)-induced rash using a topical antibiotic or a combination of an antibiotic and benzoyl peroxide for grade 1 rash, or systemic treatment (oral antibiotics) for grade 2 or higher rash eruption.

On initiation of EGFRIs, all patients started sunscreen, a mild skin cleanser, and oatmeal cream daily. Patients with a grade 1 rash were treated with a topical antibiotic or an antibiotic and benzoyl peroxide. Patients with a grade 2 or higher rash eruption were treated with systemic treatment (oral antibiotics).

The study reported on a sample of 19 patients with lung and colorectal cancer who initiated therapy with EGFRI agents (erlotinib or cetuximab) and had skin alterations.

Portugal

This was a prospective, descriptive study.

• Clinical and photographic evaluation
• National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), version 3

• Eighteen of 19 patients developed a grade 2 rash.
• Of those 18 patients, 50% had a complete response to treatment with tetracyclines (mainly doxycycline).
• Only one patient had grade 3 rash, which did not respond to minocycline.
• None of the patients had to stop treatment with EGFRI therapy.

Tetracycline antibiotic treatment, in combination with benzoyl peroxide, was effective in completely resolving EGFRI-induced rash in 50% of the sample.

• This was a small, noncontrolled study.
• A combination of interventions was used; therefore, determining the effectiveness of the individual interventions is difficult.

To evaluate the effectiveness of treating epidermal growth factor receptor–inhibitor (EGFRI)-induced rash using a topical antibiotic or a combination of an antibiotic and benzoyl peroxide for grade 1 rash, or systemic treatment (oral antibiotics) for grade 2 or higher rash eruption.

On initiation of EGFRIs, all patients started sunscreen, a mild skin cleanser, and oatmeal cream daily. Patients with a grade 1 rash were treated with a topical antibiotic or an antibiotic and benzoyl peroxide. Patients with a grade 2 or higher rash eruption were treated with systemic treatment (oral antibiotics).

The study reported on a sample of 19 patients with lung and colorectal cancer who initiated therapy with EGFRI agents (erlotinib or cetuximab) and had skin alterations.

Portugal

This was a prospective, descriptive study.

• Clinical and photographic evaluation
• National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), version 3

• Eighteen of 19 patients developed a grade 2 rash.
• Of those 18 patients, 50% had a complete response to treatment with tetracyclines (mainly doxycycline).
• Only one patient had grade 3 rash, which did not respond to minocycline.
• None of the patients had to stop treatment with EGFRI therapy.

Tetracyclines were effective in completely resolving grade 2 EGFRI-induced rash in 50% of the sample.

• This was a small, noncontrolled study.
• No statistical analysis of the difference in prevalence rates was reported.

To conduct a systematic review to identify which nursing interventions are used to reduce fatigue caused by cancer treatment and to identify the level of evidence for those interventions.

Databases searched were PubMed and CINAHL (1995–February 2005).

Search keywords were cancer, cancer treatment, chemotherapy, distraction, education, exercise, fatigue, nursing intervention, radiotherapy, and sleep promotion.

Studies were included in the review if 

• The intervention was performed by nurses
• The study was conducted by nurses
• The intervention was performed with adults
• The intervention was performed during cancer treatment.

An initial search was performed to find systematic reviews. No reviews of studies meeting the inclusion criteria were found. A second search to locate intervention studies yielded 192 studies in CINAHL and 78 in PubMed. Screening for inclusion criteria resulted in the identification of 18 studies that were then included in the review. Ten studies reported the effects of exercise, five reported education and counseling, two reported distraction and relaxation, and one reported sleep promotion.

The sample was comprised of 904 patients across 18 studies.

Exercise Studies

• Sample sizes varied from 22 to 119 patients.
• Kind of exercise varied from a seated video exercise program to an aerobic program at home or in a supervised clinic.
• Intensity of exercise varied.
• Patient adherence to exercise programs was a problem, and not all studies accounted for this factor.
• Only five studies divided patients into exercisers and nonexercisers based on usual activity. 
• Five studies demonstrated significant effects in the intervention group.
• One qualitative study was found in which fatigue changed from a negative to a positive experience with exercise, and patients experienced increased physical activity and increased level of energy.

Education and Counseling

• Three studies were randomized, controlled trials (RCTs), one used a pre-/posttest design, and one was longitudinal.
• Information was provided on tape, by telephone, or in person.
• Information was given in 3 to 10 sessions and included information about other symptoms in addition to fatigue in four out of the five studies.
• In two studies, fatigue increased with the intervention, and in three studies, a decrease was found in the experimental group.
• Talking to someone was an important aspect, a trend associated with group interaction was found, and one study found a significant effect over time.

Distraction and Relaxation

• One RCT used relaxation breathing every day for six weeks in patients who received stem cell transplantation. The intervention group experienced significantly less fatigue.
• One crossover design study used virtual reality during intravenous chemotherapy treatment. There was a significant effect, but the posttest was performed immediately after treatment.

Sleep Promotion

• One study used a pre-/posttest design using an individualized sleep promotion plan. No significant effects were found.

Sleep promotion was identified as a promising intervention despite the single study results because other studies have shown a relationship between fatigue and sleep disorders. More research is warranted in this area. Lack of effect seen with education and counseling studies may be due to small sample sizes, lack of equivalent control groups, and lack of sensitivity in fatigue measurement. It is also possible that education alone is not enough to change patient behavior. Exercise is shown to be effective, but nothing is known about the long-term effects of exercise after treatment and whether exercise can prevent the beginning of fatigue. Adherence to exercise programs is an area that requires attention. No data were available regarding the level of activity prior to cancer treatment, which might influence the findings in this area.

• None of the studies used a theoretical framework, likely explained by the fact that no satisfactory theory has been formulated to explain fatigue in this population. Some studies did not even use a definition of fatigue.
• Fatigue was measured differently, and three different measures were used.
• In two-thirds of the studies, the sample was breast cancer patients receiving chemotherapy, limiting the external validity of the findings.
• Half of the studies had very small sample sizes of less than 30 patients.
• Study of distraction and relaxation was limited by the timing of fatigue measurement.
• No long-term effects or ongoing intervention was studied.

There are several promising interventions that can be provided by nurses. It is likely that a combination of interventions may be most helpful for patients. More research is specifically needed on the effects of interventions that enhance the quality of sleep, education, and counseling related to fatigue management and prevention.

To evaluate whether expressive writing (EW) was an effective stress management intervention for patients with breast cancer.

Women were assigned to write about their cancer experience (EW group; n = 24) or neutral topics (neutral writing [NW] group; n = 25). Women were asked to write for 20 minutes a day for a total of four writing sessions that were completed over a seven-day period. Patients were reassessed approximately three days before and two weeks after surgery.

• The sample was comprised of 49 women.
• Patients were older than 18 years; mean age was 56.89 years (standard deviation = 10.79 years).
• Women were recruited two or more months from neoadjuvant chemotherapy.
• Of the patients, 58% were white, 13% were black, 13% were Latina, and 16% were other; 52% were college graduates or had some graduate training; 44% had an annual income of greater than $50,000, 79% were married/cohabitating; and 49% had stage II and 54% had stage III.

• Cancer outpatient clinic
• MD Anderson Cancer Center, Texas

Patients were undergoing the active treatment phase of care.

The study was a randomized, controlled trial.

• Brief Symptom Inventory 18 (BSI 18)
• Perceived Stress Scale (PSS)
• Pittsburgh Sleep Quality Index (PSQI)
• Social Constraints Scale (SCS)
• Brief Pain Inventory (BPI)
• Impact of Events Scale (IES)
• Emotional Approach Coping Scale (EACS)
• Linguistic Inquiry and Word Count (LIWC)

The EW intervention did not significantly decrease women’s distress, perceived stress, sleep disturbance, or pain. There was some evidence that the EW group used more sleep medication at the presurgical assessment than the NW group. Social constraints moderated the effect of the intervention. Among women with high social constraints, the EW group reported lower average daily pain than the NW group. Among women with low social constraints, the EW group reported higher average daily pain than the NW group.

EW was not as broadly effective as a stress management intervention for women with breast cancer.

• The study had a small sample size and lacked statistical power.
• There was high attrition and inconsistent adherence.

These data do not support the use of EW as a presurgical mind-body complementary medicine program for this population.

The study included four weekly sessions of expressive writing associated with the first four cancer vaccines; patients were randomly assigned to neutral health issues writing or expressive writing of the group’s deepest thoughts and feelings.

Outcomes were psychological and behavioral adjustment, symptoms of distress, perceived stress, mood, and sleep.

• The sample was comprised of 42 patients (85% male) with newly diagnosed stage IV metastatic renal cell carcinoma who were four to six weeks postoperative.
• Mean age was 56.4 years.

• Outpatient
• Southwestern United States

Patients were undergoing the active treatment phase of care.

This was a pilot, randomized, controlled trial.

Pittsburgh Sleep Quality Index (PSQI)

Statistically significant improvements in the expressive writing group were found for four of the sleep disturbance measures on the PSQI (total score and subscales of Sleep Quality, Sleep Duration, and Daytime Dysfunction).

• The study had a small sample size.
• Generalizability was questionable because of the nature of the illness.
• Space is needed for the writing to occur, prior to the injection.

An expressive writing intervention involved four writing sessions. Patients were randomized to an expressive writing (EW) group in which they were instructed to write their deepest thoughts and feelings about their cancer or to a neutral writing (NW) group in which they were instructed to write about a different health behavior at each session. Writing instructions were developed from the Pennebaker and Beall model. Repeated measures at baseline, end of intervention, and 4, 6, 8, and 10 weeks later.

• N = 42 (EW = 21, NW = 21)
• AVERAGE AGE: 56.4 years
• MALES: 85%
• KEY DISEASE CHARACTERISTICS: Patients had newly diagnosed stage IV metastatic renal cell carcinoma and were participating in a phase II vaccine trial. Of the participants, 76% had metastases and 76% had no lung involvement.
• OTHER KEY SAMPLE CHARACTERISTICS: Patients were four to six weeks post-operation.

It is implied that the setting is outpatient, in which patients are participating in a phase II clinical trial using vaccine therapy.

• PHASE OF CARE: Active treatment

• Pilot study
• Randomized controlled trial  

• Profile of Mood States (POMS)

There was 86% and 81% adherence with each group. No differences in the POMS fatigue subscale were found; the POMS vigor subscale was significantly higher in the EW group.

• Sample size was small.
• Generalizability is questionable due to the nature of illness.
• Follow-up scores were averaged over multiple measures.
• Space for the writing to occur is required prior to the injection.

RESOURCE TYPE: Evidence-based guideline

Not provided

Nothing has been listed regarding the updated antiemetic guidelines and the used databases.

Nurses should know about pharmaceutical antiemetics advancement, assess patients' nausea and vomiting, and discuss the efficacy of the antiemetics with physicians if it is not within the recommended guidelines. Although some differences across guidelines exist, evidence and most guidelines support triplet therapy for HEC. It is unclear in these guidelines why multiday HEC recommendations do not include an NK₁.