Michèle Aubin

Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.

Assessing Pain in Dementia Patients with Comorbid Delirium and/or Depression

Pain in older adults with severe limitations in ability to communicate is often assessed with observational methods. However, many of the behaviors that are used to assess pain often overlap with behavioral manifestations of delirium and depression. Such overlap can make the assessment of pain in patients with comorbid delirium and/or depression especially challenging. In this study, we assessed pain using the Doloplus-II (one of the most established pain assessment methods for seniors with dementia) and examined the extent to which each of its items were also predictive of delirium, depression, and dementia severity. As expected, several Doloplus-II items were found to be related to dementia severity, depression, and/or delirium. Clinicians assessing pain in dementia patients with comorbid depression or delirium should place less emphasis on items that have reduced specificity in identifying pain problems. Instead, assessment should be informed by items with higher specificity as well as other sources of information (e.g., results of physical examinations and information from caregivers). Although in this investigation we used the Doloplus-II to assess pain, it is likely that our findings generalize to other observational pain assessment measures developed for patients with dementia.

Impact of an Educational Program on Pain Management in Patients With Cancer Living at Home

PURPOSE/OBJECTIVES To assess the effect of an educational homecare program on pain relief in patients with advanced cancer. DESIGN Quasi-experimental (pretest post-test, nonequivalent group). SETTING Four community-based primary care centers providing social and healthcare services in the Quebec City region of Canada. SAMPLE 80 homecare patients with advanced cancer who were free of cognitive impairment, who presented with pain or were taking analgesics to relieve pain, and who had a life expectancy of six weeks or longer. METHODS The educational intervention included information regarding pain assessment and monitoring using a daily pain diary and the provision of specific recommendations in case of loss of pain control. Pain intensity data were collected prior to the intervention, and reassessments were made two and four weeks later. Data on beliefs were collected at baseline and two weeks. All data were collected by personal interviews. MAIN RESEARCH VARIABLES Patients beliefs about the use of opioids; average and maximum pain intensities. FINDINGS Patients beliefs regarding the use of opioids were modified successfully following the educational intervention. Average pain was unaffected in the control group and was reduced significantly in patients who received the educational program. The reduction remained after controlling for patients initial beliefs. Maximum pain decreased significantly over time in both the experimental and control groups. CONCLUSIONS An educational intervention can be effective in improving the monitoring and relief of pain in patients with cancer living at home. IMPLICATIONS FOR NURSING Homecare nurses can be trained to effectively administer the educational program during their regular homecare visits.

Prediction of health professionals' intention to screen for decisional conflict in clinical practice.

Objective  To identify the determinants of the intention of physicians to screen for decisional conflict in clinical practice.

The systematic evaluation of instruments designed to assess pain in persons with limited ability to communicate

Chronic pain is often underdetected and undertreated in long-term care facilities. The use of self-report measures of pain (such as the visual analogue scale) is often problematic for older adults residing in long-term care because of the high prevalence of visual and auditory deficits and severe cognitive impairment. Observational measures of pain have been developed to address this concern. A systematic grid designed to assess the properties of existing observational measures of pain was used for seniors with dementia. The grid focused on the evaluation of content validity (12 items), construct validity (12 items), reliability (13 items) and clinical utility (10 items). Among the 24 instruments that were evaluated, several were deemed to be promising in the assessment of pain among older persons with severe dementia. Nonetheless, additional research is needed before their routine integration in the practices of long-term care settings.

Patient, primary care physician and specialist expectations of primary care physician involvement in cancer care.

In Canada, many health authorities recommend that primary care physicians (PCP) stay involved throughout their patients’ cancer journey to increase continuity of care. Few studies have focused on patient and physician expectations regarding PCP involvement in cancer care. To compare lung cancer patient, PCP and specialist expectations regarding PCP involvement in coordination of care, emotional support, information transmission and symptom relief at the different phases of cancer. Canadian survey of lung cancer patients, PCPs and cancer specialists A total of 395 patients completed questionnaires on their expectations regarding their PCP participation in several aspects of care, at different phases of their cancer. Also, 45 specialists and 232 community-based PCP involved in these patients’ care responded to a mail survey on the same aspects of cancer care. Most specialists did not expect participation of the PCP in coordination of care in the diagnosis and treatment phases (65% and 78% respectively), in contrast with patients (83% and 85%) and PCPs (80% and 59%) (p < 0.0001). At these same phases, the best agreement among the 3 groups was around PCP role in emotional support: 84% and more of all groups had this expectation. PCP participation in symptom relief was another shared expectation, but more unanimously at the treatment phase (p = 0.85). In the advanced phase, most specialists expect a major role of PCP in all aspects of care (from 81% to 97%). Patients and PCP agree with them mainly for emotional support and information transmission. Lung cancer patient, PCP and specialist expectations regarding PCP role differ with the phase of cancer and the specific aspect of cancer care. There is a need to reach a better agreement among them and to better define PCP role, in order to achieve more collaborative and integrated cancer care.BackgroundIn Canada, many health authorities recommend that primary care physicians (PCP) stay involved throughout their patients’ cancer journey to increase continuity of care. Few studies have focused on patient and physician expectations regarding PCP involvement in cancer care.ObjectiveTo compare lung cancer patient, PCP and specialist expectations regarding PCP involvement in coordination of care, emotional support, information transmission and symptom relief at the different phases of cancer.DesignCanadian survey of lung cancer patients, PCPs and cancer specialistsParticipantsA total of 395 patients completed questionnaires on their expectations regarding their PCP participation in several aspects of care, at different phases of their cancer. Also, 45 specialists and 232 community-based PCP involved in these patients’ care responded to a mail survey on the same aspects of cancer care.ResultsMost specialists did not expect participation of the PCP in coordination of care in the diagnosis and treatment phases (65% and 78% respectively), in contrast with patients (83% and 85%) and PCPs (80% and 59%) (p < 0.0001). At these same phases, the best agreement among the 3 groups was around PCP role in emotional support: 84% and more of all groups had this expectation. PCP participation in symptom relief was another shared expectation, but more unanimously at the treatment phase (p = 0.85). In the advanced phase, most specialists expect a major role of PCP in all aspects of care (from 81% to 97%). Patients and PCP agree with them mainly for emotional support and information transmission.ConclusionLung cancer patient, PCP and specialist expectations regarding PCP role differ with the phase of cancer and the specific aspect of cancer care. There is a need to reach a better agreement among them and to better define PCP role, in order to achieve more collaborative and integrated cancer care.

Family Physician Involvement in Cancer Care Follow-up: The Experience of a Cohort of Patients With Lung Cancer

PURPOSE There has been little research describing the involvement of family physicians in the follow-up of patients with cancer, especially during the primary treatment phase. We undertook a prospective longitudinal study of patients with lung cancer to assess their family physician’s involvement in their follow-up at the different phases of cancer. METHODS In 5 hospitals in the province of Quebec, Canada, patients with a recent diagnosis of lung cancer were surveyed every 3 to 6 months, whether they had metastasis or not, for a maximum of 18 months, to assess aspects of their family physician’s involvement in cancer care. RESULTS Of the 395 participating patients, 92% had a regular family physician but only 60% had been referred to a specialist by him/her or a colleague for the diagnosis of their lung cancer. A majority of patients identified the oncology team or oncologists as mainly responsible for their cancer care throughout their cancer journey, except at the advanced phase, where a majority attributed this role to their family physician. At baseline, only 16% of patients perceived a shared care pattern between their family physician and oncologists, but this proportion increased with cancer progression. Most patients would have liked their family physician to be more involved in all aspects of cancer care. CONCLUSIONS Although patients perceive that the oncology team is the main party responsible for the follow-up of their lung cancer, they also wish their family physicians to be involved. Better communication and collaboration between family physicians and the oncology team are needed to facilitate shared care in cancer follow-up.

The regulatory effect of histamine on the immune response: Characterization of the cells involved☆

Abstract Any immunological response is the end result of the equilibrium between many positive and negative regulatory factors. It has been recently demonstrated that histamine receptor-bearing T lymphocytes could play a role in this regulation. This work aims to study the effects of different cell populations after incubation with histamine on the proliferative response of normal lymphocytes. The histamine-incubated peripheral blood lymphocytes (PBL) lower the proliferative response of normal cells toward mitogens (phytohemagglutinin, concanavalin A) and antigens (mixed lymphocyte culture). In order to precise the cell subpopulations involved in this suppression, PBL have been depleted of adherent cells and B and T lymphocytes have been purified by a standard rosette technique. The enriched B cells do not suppress the normal response but the suppressor activity of T cells, as well as adherent cell-depleted PBL, are significantly reduced compared to the one of PBL. The initial suppressor activity is restored by addition of 1% adherent cells (and not 5 or 10%) to adherent cell-depleted lymphocytes and 10% adherent cells (not 1 or 5%) to T-enriched population. These observations suggest a role for adherent cells in this regulation.

Implementation of screening for distress with professional cancer navigators

RésuméLe dépistage de la détresse est proposé comme une première étape pour optimiser la réponse aux besoins des patients atteints de cancer. Ce changement de pratique peut contribuer à une meilleure coordination des soins, une fonction clé des intervenants pivots en oncologie.ObjectifDécrire les perceptions d’acteurs clés face à l’implantation du dépistage de la détresse par des intervenants pivots en oncologie au Québec et en Nouvelle-Écosse.Matériel et méthodesÉtude descriptive pré/post implantation. Des entrevues ont été réalisées avec des intervenants pivots en oncologie (infirmières pivot en oncologie du Québec et cancer patient navigators de la Nouvelle-Écosse), des membres d’équipe d’oncologie psychosociale et spirituelle du Québec et des gestionnaires des deux provinces, avant et après le processus d’implantation.RésultatsDes avantages et des défis similaires ont été soulignés dans les deux sites par les différents groupes d’acteurs participants. Le dépistage de la détresse a été perçu comme un changement de pratique important, améliorant le fonctionnement de l’équipe d’oncologie et les soins centrés sur le patient. Des recommandations pour faciliter le processus d’implantation sont suggérées.ConclusionCette étude soutient la pertinence d’impliquer les intervenants pivots en oncologie dans le processus d’implantation du dépistage de la détresse.AbstractScreening for Distress is suggested as a first step to optimize response to cancer patients’ needs. This change of practice may positively impact coordination of care, a key function of professional cancer navigators.AimTo describe the perceptions of implementing Screening for Distress with professional cancer navigators from the perspective of key actors in Quebec and Nova Scotia.ProcedureA descriptive pre- and post-implementation study was performed. Interviews were conducted with professional navigators (pivot nurses in oncology from Quebec and cancer patient navigators from Nova Scotia), psychosocial and spiritual oncology staff from Quebec, and health administrators from both provinces, prior to and following the implementation process.ResultsDifferent actors described similar advantages and challenges within both sites. Screening for Distress was perceived as an important change of practice, improving oncology team functioning and patient-centered care. Recommendations to facilitate the implementation process were suggested.ConclusionThis study supports the relevance of involving professional navigators in the implementation process of Screening for Distress.

[Validity 'and Utilities' clinic of a grid observation (PACSLAC-F) to evaluate the pain in seniors with dementia's living in the Long-Term Care ].

This study presents the validation of the French Canadian version (PACLSAC-F) of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). Unlike the published validation of the English version of the PACSLAC, which was validated retrospectively, the French version was validated prospectively. The PACSLAC-F was completed by nurses working in long-term care facilities after observing 86 seniors, with severe cognitive impairment, in calm, painful or distressing but non-painful situations. The test-retest and inter-observer reliability, the internal consistency, and the discriminent validity were found to be satisfactory. To evaluate the convergent validity with the DOLOPLUS-2 and the clinical relevance of the PACSLAC, it was also completed by nurses during their work shift, with 26 additional patients, for three days per week during a period of four weeks. These results encourage us to test the PACSLAC in a comprehensive program of pain management targeting this population.