Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting.

BACKGROUND: There have been recent advances in chemotherapy-induced nausea and vomiting using 5-HT(3) inhibitors and dexamethasone. However, many still experience these symptoms, and expert panels encourage additional methods to reduce these symptoms. OBJECTIVES: The objective was to assess the effectiveness of acupuncture-point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients. SEARCH STRATEGY: We searched MEDLINE, EMBASE, PsycLIT, MANTIS, Science Citation Index, CCTR (Cochrane Controlled Trials Registry), Cochrane Complementary Medicine Field Trials Register, Cochrane Pain, Palliative Care and Supportive Care Specialized Register, Cochrane Cancer Specialized Register, and conference abstracts. SELECTION CRITERIA: Randomized trials of acupuncture-point stimulation by any method (needles, electrical stimulation, magnets, or acupressure) and assessing chemotherapy-induced nausea or vomiting, or both. DATA COLLECTION AND ANALYSIS: Data were provided by investigators of the original trials and pooled using a fixed effect model. Relative risks were calculated on dichotomous data. Standardized mean differences were calculated for nausea severity. Weighted mean differences were calculated for number of emetic episodes. MAIN RESULTS: Eleven trials (N = 1247) were pooled. Overall, acupuncture-point stimulation of all methods combined reduced the incidence of acute vomiting (RR = 0.82; 95% confidence interval 0.69 to 0.99; P = 0.04), but not acute or delayed nausea severity compared to control. By modality, stimulation with needles reduced proportion of acute vomiting (RR = 0.74; 95% confidence interval 0.58 to 0.94; P = 0.01), but not acute nausea severity. Electroacupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% confidence interval 0.60 to 0.97; P = 0.02), but manual acupuncture did not; delayed symptoms for acupuncture were not reported. Acupressure reduced mean acute nausea severity (SMD = -0.19; 95% confidence interval -0.37 to -0.01; P = 0.04) but not acute vomiting or delayed symptoms. Noninvasive electrostimulation showed no benefit for any outcome. All trials used concomitant pharmacologic antiemetics, and all, except electroacupuncture trials, used state-of-the-art antiemetics. AUTHORS' CONCLUSIONS: This review complements data on post-operative nausea and vomiting suggesting a biologic effect of acupuncture-point stimulation. Electroacupuncture has demonstrated benefit for chemotherapy-induced acute vomiting, but studies combining electroacupuncture with state-of-the-art antiemetics and in patients with refractory symptoms are needed to determine clinical relevance. Self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control. Noninvasive electrostimulation appears unlikely to have a clinically relevant impact when patients are given state-of-the-art pharmacologic antiemetic therapy.

Use of herbs in women diagnosed with ovarian cancer.

Of 113 consecutive ovarian cancer patients identified in a gynecologic clinic in a major academic medical center in San Francisco, 41 patients were successfully contacted, were eligible, and participated in a telephone survey. We contacted women identified consecutively in the clinic database as having ovarian cancer and sent a letter introducing our research team and asking for help. Members of the research team then contacted the women to conduct the telephone interviews. Fifty-one percent (95% CI 35-67) of the women had taken herbs sometime since they were diagnosed with ovarian cancer. Most herb uses occurred concurrently with chemotherapy. Only 12% (95% CI 4-26) used an herbalist or other health practitioner for guidance in herb use. Only one woman took herbs instead of chemotherapy. A large number of women attending our practice in the San Francisco Bay area use herbs as complementary medicine during their cancer treatment.

Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis.

OBJECTIVE: To test the effectiveness of 3 mouthwashes used to treat chemotherapy-induced mucositis. The mouthwashes were as follows: salt and soda, chlorhexidine, and "magic" mouthwash (lidocaine, Benadryl, and Maalox). STUDY DESIGN: A randomized, double-blind clinical trial was implemented in 23 outpatient and office settings. Participants were monitored from the time they developed mucositis until cessation of the signs and symptoms of mucositis, or until they finished their 12-day supply of mouthwash. All participants followed a prescribed oral hygiene program and were randomly assigned a mouthwash. Nurses used the Oral Assessment Guide for initial assessment and taught patients how to assess their own mouths, then phoned the patients every other day to gather status reports. RESULTS: In 142 of 200 patients, there was a cessation of the signs and symptoms of mucositis within 12 days. No significant differences in time for the cessation of the signs and symptoms were observed among the 3 groups. CONCLUSIONS: Given the comparable effectiveness of the mouthwashes, the least costly was salt and soda mouthwash.

Family caregiving skill: development of the concept.

Families increasingly are expected to provide complex care at home to ill relatives. Such care requires a level of caregiving knowledge and skill unprecedented among lay persons, yet family caregiving skill has never been formally developed as a concept in nursing. The purpose of the study reported here was to develop the concept of family caregiving skill systematically through qualitative analysis of interviews with patients (n = 30) receiving chemotherapy for cancer and their primary family caregivers (n = 29). Open coding and constant comparison constituted the analytic methods. Sixty-three indicators of caregiving skill were identified for nine core caregiving processes. Family caregiving skill was defined as the ability to engage effectively and smoothly in these nine processes. Properties of family caregiving skill also were identified. Conceptualizing skill as a variable and identifying indicators of varying levels of skill provides a basis for measurement and will allow clinicians to more precisely assess family caregiving skill.

Gender differences for the predictors of depression in young adults with genital herpes.

Genital herpes is a chronic, stigmatizing, sexually transmitted disease (STD), which is increasing despite efforts to control its spread. Depression is commonly reported among people diagnosed with genital herpes and differences in depression by gender have been reported. Therefore, the purpose of this study was to identify gender differences in the predictors of depression in young adults with genital herpes by secondary analyses of baseline data from a randomized clinical trial (RCT). For the RCT, young adults (193 females, 59 males) with genital herpes were recruited from newspaper advertisements. Participants completed questionnaires measuring illness burden, attitudes toward herpes, stress symptoms, mood states, depression, self-concealment, self-disclosure, substance use, and demographics. Univariate analyses and multiple regression techniques were used to identify variables predictive of depression in this sample. In women, increased anger, decreased vigor, increased confusion, a negative attitude toward herpes, self-concealment, and stress symptoms from genital herpes predicted more depression (R2 = 0.63). In men, increased depression was predicted by increased anger, a negative attitude toward herpes, and a decreased willingness to share personal information with a stranger (R2 = 0.51). Findings suggest that future psychoeducational interventions should address anger as a predictor of depression in this population. Gender-specific interventions need to be developed in order to assist young adults who are living with genital herpes.

Acupressure for nausea: results of a pilot study.

PURPOSE/OBJECTIVES: To compare differences in nausea experience and intensity in women undergoing chemotherapy for breast cancer between those receiving usual care plus acupressure training and treatment and those receiving only usual care. DESIGN: Single-cycle, randomized clinical trial. SETTING: Outpatient oncology clinic in a major teaching medical center and a private outpatient oncology practice. SAMPLE: Seventeen women participated in the study. The typical participant was 49.5 years old (SD = 6.0), Caucasian (59%), not married/partnered (76%), on disability (53%), born a U.S. citizen (76%), and heterosexual (88%); lived alone (59%); had at least graduated from high school (100%); and had an annual personal income of $50,000 or greater (65%). METHODS: The intervention included finger acupressure bilaterally at P6 and ST36, acupressure points located on the forearm and by the knee. Baseline and poststudy questionnaires plus a daily log were used to collect data. MAIN RESEARCH VARIABLES: Nausea experience measured by the Rhodes inventory of Nausea, Vomiting, and Retching and nausea intensity. FINDINGS: Significant differences existed between the two groups in regard to nausea experience (p < 0.01) and nausea intensity (p < 0.04) during the first 10 days of the chemotherapy cycle, with the acupressure group reporting less intensity and experience of nausea. CONCLUSIONS: Finger acupressure may decrease nausea among women undergoing chemotherapy for breast cancer. IMPLICATIONS FOR NURSING PRACTICE: This study must be replicated prior to advising patients about the efficacy of acupressure for the treatment of nausea.

Factors influencing oral mucositis in patients receiving chemotherapy.

PURPOSE: Oral mucositis is a painful complication of chemotherapy and can greatly affect patients' morbidity and mortality. Findings from two previous studies suggested a decrease in the prevalence of chemotherapy-induced mucositis in patients with solid tumors. The purposes of this study were to follow a large cohort of outpatients to determine the prevalence of mucositis and to identify whether certain clinical factors were significant in the development of mucositis. DESCRIPTION OF STUDY: In this prospective study, a convenience sample of 199 outpatients was followed for three cycles or until mucositis developed. The clinical factors monitored included the following: pretreatment dental examination/repair; initial standard chemotherapy dosage; prophylactic use of colony-stimulating factors; and use of preventive mouthwashes or other prophylactic measures. RESULTS: Oral mucositis developed in 50 patients (25.1%). Prechemotherapy dental examination/repair and initial standard chemotherapy dosage were equivalent among both groups. Of the 48 patients in whom mucositis developed, 10 (20.8%) received prophylactic colony-stimulating factors. Of 134 patients in whom mucositis did not develop, 46 (34.3%) received prophylactic colony-stimulating factors. This difference was statistically nonsignificant. CLINICAL IMPLICATIONS: Differences in the clinical factors investigated could not explain the lower prevalence of oral mucositis among the current patient cohort. The reason for the diminishing prevalence of this side effect remains unclear, and additional parameters, particularly detailed oral hygiene practices, should be evaluated. In the meantime, oncology clinicians should consider the teaching of patients and urging them to use good oral hygiene practices as necessary and potentially preventive measures against chemotherapy-induced mucositis.

Risk factors for chemotherapy-induced oral mucositis: dental appliances, oral hygiene, previous oral lesions, and history of smoking.

Oral mucositis is one of the dose-limiting toxicities of several chemotherapy (CTX) agents. There are suggested risk factors that could influence the development of mucositis. The presence of dental appliances, history of oral lesions, or smoking have the potential to irritate the oral mucosa and produce breaks in the integrity of the mucosa. The purposes of this study were to determine if there were differences in the incidence, severity, and time to onset of CTX-induced mucositis in oncology outpatients who wore dental appliances, had a history of oral lesions, had varying oral hygiene/care practices, and had a history of smoking and those who did not. Patients who were initiated a course of CTX that included stomatotoxic agents were followed for three complete cycles of CTX. They were instructed on how to examine their mouths for mucositis, to contact, and then visit their outpatient settings if it occurred. Clinicians corroborated the presence of mucositis, and the Eiler's Oral Assessment Guide was used by clinicians to determine the severity. Of 332 outpatients, almost half (46%) wore some type of dental appliance, 32% had a history of oral lesions, 10% were currently smoking, and 63% had a history of smoking. Oral hygiene/care practices varied: 81% brushed their teeth two or more times a day, 29% flossed at least daily, 11% had visited their dentist within 2 months of beginning CTX, and 10% had their teeth professionally cleaned within two months of beginning CTX. There was a 31% (n = 104) incidence of CTX-induced mucositis. No significant differences were found in the incidence between patients who wore dental appliances, had a history of oral lesions, had a history of smoking, and practiced different hygiene/care and patients who did not. Of 104 patients who developed mucositis, the average severity rating was 13.05 +/- 2.88 (+/-SD) (a normal mouth is rated at 8) and the average time to onset was 22.3 +/- 21.46 days. There were no significant differences found in severity or time to onset of mucositis between patients who wore dental appliances, had a history of oral lesions, had a history of smoking, and practiced different dental hygiene/care and patients who did not. Although not significant, there were interesting differences in the time to onset across the suggested risk factors (e.g., patients who had visited a dentist or who had their teeth professionally cleaned within 2 months before beginning before CTX developed mucositis 7.4 and 10.6 days sooner, respectively, than patients who did not). These findings suggest that risk factors for the development of CTX-induced mucositis are not as simple and direct as clinicians may believe.

Effects of psycho-educational interventions on sexual health risks and psycho-social adaptation in young adults with genital herpes.

The purpose of this study was to test the outcomes of group psycho-educational intervention (PEI) led by nurses on sexual health risks (knowledge, behaviour, disease burden) and psycho-social adaptation (depression, mood states, self-efficacy) in young adults with the chronic disease, genital herpes. Two hundred and fifty-two young adults with symptomatic genital herpes participated in a randomized controlled trial (RCT). The intervention was participation in a three-session group PEI facilitated by a nurse in the community. Participants completed questionnaires measuring sexual health risks (herpes knowledge, sexual risk behaviour, disease burden of patterns of recurrences of outbreaks of the disease), and psycho-social adaptation (depression using the Beck Depression Inventory [BDI], mood states using the Profile of Mood States [POMS], and feelings of self-efficacy for protection from sexually transmitted diseases [PSTD]) at induction into the study, and at 3 and 6 months. Participants were mainly employed, Caucasian, single women in their twenties (X = 27.1 years, SD = 4.3), with some college education; 23% of the sample were men. After controlling for baseline knowledge about genital herpes, the experimental group had significantly more knowledge than the control group at 3 and 6 months' post-intervention. They also reported using condoms and spermicides to prevent the spread of genital herpes more often than did the control group. The implications for nurses in the community include the following: (a) PEI is an intervention that can be used by nurses in the community with a high-risk population; (b) group intervention is a viable treatment for people with a highly stigmatized, chronic sexually transmitted disease (STD); and (c) further testing of the use of PEI by nurses in the community with other high-risk populations is needed.

The PRO-SELF Mouth Aware program: an effective approach for reducing chemotherapy-induced mucositis.

Many oncology patients receive chemotherapy drugs that have the potential to induce oral mucositis. If mucositis is not prevented, patients will have to manage the problems associated with mucositis: pain, local infection, and decreased ability to take fluids or food. At the time of this writing, clinical approaches for mucositis management are variable and generally ineffective. The mouth care program, PRO-SELF: Mouth Aware (PSMA), presented in this article, was found to be a significant component of a self-care program that may have reduced the incidence of chemotherapy-induced mucositis. The PSMA program has three dimensions: (a) didactic information, (b) development of self-care exercises (skills), and (c) supportive interactions with a nurse in the setting where the patients are receiving their treatment. This program focuses on decreasing the direct (i.e., incidence and severity of mucositis) and indirect morbidities of oral mucositis (i.e., number of local infections, level of discomfort/pain, and disruption in fluid and/or food intake). It provides the critical dimensions (i.e., specific information, self-care exercises, and nurse support) to promote the prevention of mucositis. The PSMA program is designed to provide patients with a definitive self-care repertoire to manage chemotherapy-induced mucositis in the home without the direct supervision of a health care provider.

Differences in fatigue by treatment methods in women with breast cancer.

PURPOSE/OBJECTIVES: To investigate the differences between various cancer therapies (radiation, hormonal, chemotherapy, and their combinations) and the specific dimensions of fatigue (affective meaning, behavioral/severity, cognitive/mood, and sensory). DESIGN: Descriptive, cross-sectional, mailed survey design. SAMPLE AND SETTING: Data were collected from women who were breast cancer survivors and members of a nonprofit educational organization in the North-east. Criteria for this study included no self-reported disease recurrence, and treatment was within 18 months prior to the mailed survey (N = 322). The typical participant was middle-aged (mean = 52.2; SD = 10.3), Caucasian (93%), postmenopausal (55%), and diagnosed with cancer 2.42 (SD = 2.6) years prior to the study. METHODS: Secondary data analysis from a study using the Piper Fatigue Scale. VARIABLES: Level of fatigue. FINDINGS: Significant differences were found by treatment in total fatigue scores (p < 0.03) and cognitive/mood scores (p < 0.05). Women who received combination therapy had the highest fatigue scores (mean = 4.8; SD = 2.0); those who received only radiation therapy had the lowest fatigue scores (mean = 2.7; SD = 2.0). CONCLUSIONS: Fatigue in breast cancer survivors varies by type of cancer therapy. Future studies are needed to investigate the relationships between fatigue and hormonal therapy, and they need to be designed to examine changes over time. IMPLICATIONS FOR NURSING PRACTICE: Study findings advance knowledge about fatigue in women with breast cancer and aid nurses in providing anticipatory guidance for women undergoing different treatment regimens.

The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer.

PURPOSE/OBJECTIVES: To confirm the multidimensionality of the Piper Fatigue Scale (PFS) and to reduce the total number of PFS items without compromising reliability and validity estimates. DESIGN: Methodologic, part of a larger, cross-sectional, mailed survey design study. SETTING: Urban and suburban area in the northeast United States. SAMPLE: As part of the larger study, 2,250 surveys were distributed to women survivors of breast cancer who were on a mailing list for the educational organization Living Beyond Breast Cancer, 715 surveys (32%) were returned. Of these, 382 women met this methodologic study's criteria for having completed each of the 40 items on the PFS. The average respondent was 50 years old, postmenopausal, and treated with combination cancer therapy. METHODS: Principal axes factor analysis with oblique rotation. MAIN RESEARCH VARIABLES: Fatigue factors/subscales. FINDINGS: Five factors/subscales were identified initially. Because the fifth factor contained only two items (ability to bathe/wash and ability to dress), these items and the associated factor/subscale were dropped from the final solution. An additional nine items, not loading on any factor (> 0.40), also were dropped. The remaining items and factors/subscales were reviewed to ensure that the criteria were met: a pattern of inter-item correlations between 0.30-0.70; a minimum number of five or more items/subscale; standardized alpha for the subscales and total scale of at least 0.89; and absence of gender-specific items. CONCLUSIONS: The revised version of the PFS consists of 22 items and four subscales: behavioral/severity (6 items), affective meaning (5 items), sensory (5 items) and cognitive/mood (6 items). Standardized alpha for the entire scale (n = 22 items) is 0.97, indicating that some redundancy still may exist among the items. Additional revisions await further testing. IMPLICATIONS FOR NURSING PRACTICE: As fatigue is acknowledged to be the most frequent symptom experienced by patients with cancer, accurate measurement and assessment is essential to advance not only the science of fatigue but, most importantly, to evaluate the efficacy of intervention strategies on patient and family outcomes.

Differences in outcomes among patients experiencing different types of cancer-related pain.

PURPOSE/OBJECTIVES: To determine differences in pain characteristics, mood states, and quality of life (QOL) in outpatients with different types of cancer-related pain (i.e., somatic, visceral, or neuropathic) compared to outpatients who were pain-free. DESIGN: Descriptive, comparative. SETTING: Sixteen outpatient facilities that are part of the Oncology Nursing Research Network. SAMPLE: A convenience sample of 129 outpatients who experienced cancer-related pain and 169 pain-free patients, all of whom were actively being treated for cancer. METHODS: All patients completed a demographic questionnaire, the Multidimensional Quality of Life Scale-Cancer, and the Profile of Mood States, Patients with pain completed a Cancer Pain Questionnaire and the McGill Pain Questionnaire. Patients' medical records were reviewed. MAIN RESEARCH VARIABLES: Types of cancer-related pain (i.e., somatic visceral, or neuropathic), pain intensity, pain duration, quality of pain, QOL, and mood states. FINDINGS: No differences were found in any pain characteristics or any pain indices from the word descriptors of the McGill Pain Questionnaire. Patients with somatic and visceral pain had significantly higher fatigue scores than pain-free patients. In addition, patients with somatic and visceral pain had significantly lower physical well-being, nutrition, and total QOL scores and more symptom distress than pain-free patients. CONCLUSIONS: The type of cancer-related pain appears to influence the mood states and QOL of outpatients with cancer. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses need fo determine the type of pain the patient is experiencing and the impact of the pain on the patient's mood and QOL.

Gender differences in the dimensions of quality of life.

PURPOSE/OBJECTIVES: To explore gender differences and similarities in the dimensions of quality of life (QOL). DESIGN: Secondary analysis of the Multidimensional Quality of Life Scale--Cancer Version (MQOLS--CA) data from two different research studies. SETTINGS: Multiple outpatient oncology sites. SAMPLE: The typical female participant (n = 254) was 58 years old (SD +/- 11.3) with 14 years of education, married/partnered (64%), Caucasian (88%), and diagnosed with breast (47%) or colorectal (16%) cancer. The typical male participant (n = 222) was 60 years old (SD +/- 14) with 14.3 years of education, married/partnered (69%), Caucasian (85%), and diagnosed with colorectal (31%) or prostate (13%) cancer. METHODS: Factor analytic procedures and reliability testing. MAIN RESEARCH VARIABLES: QOL as measured by the MQOLS-CA, gender. FINDINGS: For women, two factors emerged from the analysis procedures-psychosocial well-being (7 items) and physical competence (6 items). For the men, two different factors emerged--vitality (8 items) and personal resources (4 items). None of the cancer-specific items from the MQOLS-CA loaded on any of the factors for either gender. CONCLUSIONS: Measurement of QOL requires gender-specific questions to accurately address the dimensions of the concept of QOL in females and males. IMPLICATIONS FOR NURSING PRACTICE: Additional research is warranted to replicate these findings. Gender-specific interventions could then be developed and tested to maximize the QOL of all patients.

Differences in patients' and family caregivers' perceptions of the pain experience influence patient and caregiver outcomes.

The purposes of this study were to determine if there were differences in pain intensity scores, pain duration scores, mood states, and quality of life of oncology outpatients whose pain intensity scores were congruent with their family caregivers compared to patients whose pain intensity scores were non-congruent and to determine if there were differences in mood states, health status, and caregiver strain between family caregivers whose pain intensity scores were congruent with their family members and those family caregivers whose pain intensity scores were non-congruent. A total of 78 patient-caregiver dyads participated in the study. Patients completed a Demographic Questionnaire, a Cancer Pain Questionnaire, the Profile of Mood States, and the Multidimensional Quality of Life Scale-Cancer 2. Family caregivers completed a demographic questionnaire, the Profile of Mood States, the Caregiver Strain Index, and the Medical Outcome Study Short-Form Health Survey. Both patients and family caregivers rated the patient's pain intensity using a visual analogue scale (VAS). Patients in the non-congruent dyads (i.e. difference of >10 on the VAS score) had significantly more mood disturbance and a poorer quality of life than patients in the congruent dyads. Family caregivers in the non-congruent dyads had significantly higher caregiver strain score than caregivers in the congruent dyads. These findings suggest that differences in the perception of the pain experience between patients and their family caregivers is associated with deleterious outcomes for the patient and their family caregivers.

Patients' perspectives of fatigue while undergoing chemotherapy.

PURPOSE/OBJECTIVES: To explore the experience of fatigue from the perspective of patients undergoing chemotherapy. DESIGN: Qualitative research and secondary analysis of data from a larger study. SETTING: Participants were recruited from 18 sites, including large outpatient chemotherapy clinics and private medical oncologists' offices. SAMPLE: 127 adult patients who were beginning their first protocol of chemotherapy. METHODS: Data were collected through individual and open-ended interviews and a qualitative, thematic analysis of the participants' responses using grounded theory techniques. MAIN RESEARCH VARIABLE: The experience of fatigue as perceived by patients undergoing chemotherapy. FINDINGS: The analysis resulted in eight major thematic categories: (a) experiencing fatigue, (b) effects on well-being, (c) attribution of origin, (d) awareness and expectations, (e) emotional reactions, (f) activity, (g) the "biggest" concern, and (h) strategies and plans. CONCLUSIONS: This study demonstrates the variation, extent, duration, and temporality of fatigue among patients receiving chemotherapy and the dynamic, changing aspects of the experience. IMPLICATIONS FOR NURSING PRACTICE: Fatigue must be considered within the context of patients' daily lives and environments, disease processes, and treatment modalities. Nurses must listen carefully to patients' own descriptions of being tired. Further research examining patients' perspectives of and experiences related to fatigue is necessary to increase the theoretical understanding of fatigue and to improve therapeutic nursing interventions.

Health-related fitness and quality of life in organ transplant recipients.

BACKGROUND: The purpose of this study was to describe the levels of health-related fitness and quality of life in a group of organ transplant recipients who participated in the 1996 U.S. Transplant Games. METHODS: A total of 128 transplant recipients were selected on a first reply basis for testing. Subjects with the following organ types were tested: kidney (n=76), liver (n=16), heart (n=19), lung (n=6), pancreas/kidney (n=7), and bone marrow (n=4). Cardiorespiratory fitness (peak oxygen uptake) was measured using symptom-limited treadmill exercise tests with expired gas analysis. The percentage of body fat was measured using skinfold measurements, and the Medical Outcomes Short Form questionnaire (SF-36) was used to evaluate health-related quality of life. RESULTS: Participants achieved near age-predicted cardiorespiratory fitness (94.7+/-32.5% of age-predicted levels). Scores on the SF-36 were near normal. The active subjects (76% of total sample) had significantly higher levels of peak VO2 and quality of life and a lower percentage of body fat compared with inactive subjects (P<0.01). CONCLUSIONS: Although this is a highly select group which is not representative of the general transplant population, the data suggest that near-normal levels of physical functioning and quality of life are possible after transplantation and that those who participate in regular physical activity may achieve even higher levels.

Clinical nurse specialists in California: who claims the title?

State nursing practice acts granting legal authority to advanced practice nurses vary widely, with many states not recognizing clinical nurse specialists (CNSs). This survey identified characteristics of registered nurses claiming the CNS title in California. A literature-based survey tool was designed, piloted, and distributed to 209,846 nurses in California, with instructions to return the survey if the recipient self-identified as a CNS. Among the 1061 respondents, 65% were prepared with a Master's in Nursing. Most CNSs practiced in hospitals, and patients were the most frequently listed clients. CNSs overwhelmingly identified their primary role as clinical expert. Major barriers to practice included lack of public recognition and legal recognition in nursing practice acts. Significant differences were found in most characteristics between graduate-prepared and nongraduate-prepared CNSs. Variability in practice and educational preparation is not only potentially confusing to other healthcare providers and the public, but it may not serve the best interests of CNS clients.