C.M.J. Potting

Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients

PurposeThe aim of this project was to develop clinical practice guidelines on the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and management of oral mucositis (OM) in cancer patients.MethodsA systematic review of the available literature was conducted. The body of evidence for the use of each agent, in each setting, was assigned a level of evidence. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, or no guideline possible.ResultsA recommendation was developed in favor of patient-controlled analgesia with morphine in hematopoietic stem cell transplant (HSCT) patients. Suggestions were developed in favor of transdermal fentanyl in standard dose chemotherapy and HSCT patients and morphine mouth rinse and doxepin rinse in head and neck radiation therapy (H&N RT) patients. Recommendations were developed against the use of topical antimicrobial agents for the prevention of mucositis. These included recommendations against the use of iseganan for mucositis prevention in HSCT and H&N RT and against the use of antimicrobial lozenges (polymyxin–tobramycin–amphotericin B lozenges/paste and bacitracin–clotrimazole–gentamicin lozenges) for mucositis prevention in H&N RT. Recommendations were developed against the use of the mucosal coating agent sucralfate for the prevention or treatment of chemotherapy-induced or radiation-induced OM. No guidelines were possible for any other agent due to insufficient and/or conflicting evidence.ConclusionAdditional well-designed research is needed on prevention and management approaches for OM.

Physical Exercise for Patients Undergoing Hematopoietic Stem Cell Transplantation: Systematic Review and Meta-Analyses of Randomized Controlled Trials

Background The treatment-related burden for patients undergoing hematopoietic stem cell transplantation (HSCT) may be relieved by physical exercises. Purpose The purpose of this study was to summarize and analyze the evidence provided by randomized controlled trials (RCTs) on physical exercise interventions among patients with cancer undergoing HSCT. Data Sources PubMed, CINAHL, EMBASE, the Cochrane Library, and PEDro were searched for relevant RCTs up to October 1, 2011. Study Selection Two reviewers screened articles on inclusion criteria and indentified relevant RCTs. Data Extraction Two authors assessed the selected articles for risk of bias. Data extraction was performed by 1 reviewer. Meta-analyses were undertaken to estimate the outcomes quality of life (QOL), psychological well-being and distress, and fatigue. Data Synthesis Eleven studies were included, with study populations consisting of recipients undergoing either an allogeneic or autologous HSCT (n=734). Four studies had low risk of bias. The exercise interventions were performed before, during, and after hospitalization for the HSCT. Different exercise programs on endurance, resistance and/or activities of daily living training, progressive relaxation, and stretching were used. Meta-analyses showed that exercise during hospitalization led to a higher QOL (weighted mean difference=8.72, 95% confidence interval=3.13, 14.31) and less fatigue (standardized mean difference=0.53, 95% confidence interval=0.16, 0.91) in patients with an allogeneic HSCT at the moment of discharge from the hospital. No marked effects were found for psychological well-being and distress. Individual study results suggested significant positive effects on QOL, fatigue, psychological well-being and distress, and physical functioning. Limitations Prevalent shortcomings in the included studies were the heterogeneity among studies and the lack of blinding of participants, personnel, and outcome assessment. Conclusions The results suggest that recipients of HSCT may benefit from physical exercise.

Management of related donor care: a European survey.

Donating BM or peripheral stem cells is a challenging process that requires a considerable commitment on the part of the donating individual, especially when there is a relationship between donor and recipient. In order to develop a better understanding of related donor management, the research subcommittee of the European Group for Blood and Marrow Transplantation-Nurses Group (EBMT-NG) designed a questionnaire to survey European transplant centres. This questionnaire investigated several key areas, including guidelines, patient information, donor consent and follow-up services. It was distributed to a sample of delegates (N=150) at the 2005 meeting of the EBMT-NG. Guidelines for the information given to patients were primarily from local (33, 52%), and a combination of local and national (13, 21%) sources. Transplant information was predominantly given to related donors by the recipients transplant team (36, 57%). A total of 33 (52%) centres indicated that donors were also consented by transplant doctors, whereas 16 (25%) identified that consent was obtained by doctors who were not connected with the transplant team. At present, there is a lack of recognized standardized guidelines for the management of related donors. The development of such guidelines would assist in maintaining patient autonomy, confidentiality and access to accurate and objective information.

A review of quality assessment of the methodology used in guidelines and systematic reviews on oral mucositis

AIMS AND OBJECTIVES The objective of this study was to identify and to assess the quality of evidence-based guidelines and systematic reviews we used in the case of oral mucositis, to apply general quality criteria for the prevention and treatment of oral mucositis in patients receiving chemotherapy, radiotherapy or both. DESIGN Systematic review. METHODS Literature searches were carried out in several electronic databases and websites. Publications were included if they concerned oral mucositis involving adults treated for cancer and had been published after 1 January 2000. As far as systematic reviews were concerned, the article had to report a search strategy, if the search was minimally conducted in the database PubMed or Medline and the articles included in the review were subjected to some kind of methodological assessment. The Appraisal of Guidelines for Research and Education (AGREE) instrument was used to assess the quality of the guidelines and the Overview Quality Assessment Questionnaire (OQAQ) was used for the quality of systematic reviews. RESULTS Thirty-one articles met the inclusion criteria of which 11 were guidelines and 20 were systematic reviews. Nine of the 11 guidelines did not explicitly describe how they identified, selected and summarised the available evidence. Reviews suffered from lack of clarity, for instance, in performing a thorough literature search. The quality varied among the different guidelines and reviews. CONCLUSION Most guidelines and systematic reviews had serious methodological flaws. RELEVANCE TO CLINICAL PRACTICE There is a need to improve the methodological quality of guidelines and systematic reviews for the prevention and treatment of oral mucositis if they are to be used in clinical practice.

How prompt is prompt in daily practice? Earlier initiation of empirical antibacterial therapy for the febrile neutropenic patient

With fever being the most common manifestation of early sepsis, clinical practice guidelines emphasise the prompt institution of broad-spectrum antibacterial therapy at its onset. An audit was performed on the haematology ward to determine whether there was any delay in starting antibiotic treatment during neutropenia in clinical patients and to define the main reasons for this. Strategies were developed, implemented and evaluated on short- and long-term implications on the delay in the start of antibacterial therapy. The procedures specified in the protocol for starting empirical antibacterial therapy were audited to assess whether the target for starting therapy within 30 min of fever was achieved. Initial results indicated that two major changes to the protocol were necessary to achieve a reduction in the delay between detection of fever and starting antibacterial therapy. This modified protocol was evaluated 4 months after implementation by means of a consecutive audit. After 3 years, a third audit was performed to determine the long-term implications of the improved protocol. In the initial audit, the mean time interval between the onset of fever and the administration of antibacterial therapy was 75 min. With the modified protocol, the mean time to starting therapy was shortened to 32 min (P < 0.05). Changing the protocol for starting antibacterial therapy allowed nurses to administer the first dose of antibiotic significantly earlier.

Providing oral care in haematological oncology patients: Nurses’ knowledge and skills

In the international literature, the most commonly recommended intervention for managing oral mucositis is good oral care, assuming that nurses have sufficient knowledge and skills to perform oral care correctly. The aim of the present study was to investigate if knowledge and skills about oral care improve when education in oral care is provided to nurses in charge of patients who are at risk of oral mucositis. This intervention study consists of a baseline test on the knowledge and skills of nurses of the haematology wards of two different hospitals. Oral care education sessions were given in one hospital and follow-up tests were performed in both hospitals. Nursing records were examined and observations of nurses performing oral care were made at baseline as well as at follow-up. The results show significant differences in the scores for knowledge and skills before and after the education, whereas there was no difference in scores at the two points in time for the comparison hospital, where no education had taken place. The records test showed no differences at baseline or follow-up for the two groups. Observations showed that nurses who followed the education session implemented the oral care protocol considerably better than those who did not attended. Education in oral care has a positive influence on the knowledge and skills of nurses who care for patient at risk of oral mucositis, but not on the quality of oral care documentation.

Physical exercise prior to hematopoietic stem cell transplantation: A feasibility study

ABSTRACT Purpose: This study explores the feasibility and preliminary effectiveness of an exercise program in people scheduled for hematopoietic stem cell transplantation (HSCT). Methods: In this controlled clinical trial, we compare pre-transplantation exercise to no exercise in the waiting period for an allogeneic of autologous HSCT. The supervised individually tailored exercise program (4–6 weeks) consisted of aerobic endurance, muscle strength, and relaxation exercises, administered twice a week in the period prior to HSCT. Feasibility was determined based on inclusion rate, attrition rate, adherence to intervention, safety, and satisfaction (0–10). Preliminary effectiveness was determined primarily by self-perceived physical functioning, quality of life (QOL), and fatigue. Secondary outcomes were global perceived effect (GPE), blood counts, hospital stay, and physical fitness. Results: Forty-six patients were eligible, of whom 29 (69%) participated: 14 in the intervention group and 15 in the control group. The adherence rate to training was 69%. No adverse events or injuries occurred. Satisfaction of training conditions was high (mean 9.2 ± 1.3). Positive (follow-up) trends in favor of the intervention group were found for self-perceived physical functioning, QOL, fatigue, GPE, blood counts, and hospital stay. Conclusion: Exercise prior to HSCT is safe and feasible, and positive trends suggest favorable preliminary effectiveness. Adherence to the exercise program needs to be optimized in a future trial.

Erratum to: Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients [Support Care Cancer, DOI 10.1007/s00520-013-1871-y]

Deborah P. Saunders & Joel B. Epstein & Sharon Elad & Justin Allemano & Paolo Bossi & Marianne D. van de Wetering & Nikhil G. Rao & Carin Potting & Karis K. Cheng & Annette Freidank & Michael T. Brennan & Joanne Bowen & Kristopher Dennis & Rajesh V. Lalla & For The Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO)