Assessment of cognitive function in patients with metastatic cancer: Are we using the right tools?

OBJECTIVE: This study aimed at analyzing the validity and reliability of the continuous reaction time (CRT) test, the finger-tapping test (FTT), the Digit Span Test (DST), the Trail Making Test - part B (TMTB), and the Mini-Mental State Examination (MMSE) in patients with metastatic cancer. METHOD: Eighty adult patients and 81 healthy controls were assessed between July of 2010 and November of 2015. The neuropsychological tests were analyzed regarding construct/discriminant/criterion validity and reliability. RESULTS: In terms of construct validity, it was not possible to estimate a model for the MMSE because of a skewed response distribution. For discriminant validity, patients were slower on two measures of the CRT (p = 0.00483, p = 0.00030) and FTT dominant hand (p = 0.00306). Regarding sensitivity and specificity, only the DST and TMTB seemed to predict cognitive deficit; however, the ROC curve areas were ≤ 0.73. In terms of criterion validity, there were few significant correlations between the tests and the sociodemographic and clinical variables, and for the most part were very weak. Reliability was deemed to be adequate for the TMTB, DST, and FTT. SIGNIFICANCE OF RESULTS: The findings of the full validation analyses were not clear-cut. However, CRT test, DST, FTT, and TMTB demonstrated partial positive results, indicating that these tests have good potential for use in clinical settings and require further study.

La calidez en enfermería: formulación de constructo y variables relacionadas / The Warmth in Nursing: Construct Formulation and Related Variables / O calor humano em enfermagem: formulação do construto e variáveis relacionadas

La calidez es un fenómeno subjetivo fundamental en las relaciones personales. La calidez se contagia y, así, puede ser un factor favorecedor en el cuidado, mas no existe consenso en su definición ni dominios. Medir la calidez es significativo, pues es un predictor de satisfacción usuaria; sin embargo, no se encontraron modos de medirla, lo que motivó esta revisión. Objetivos: Identificar en la revisión teórica comportamientos que representen la calidez del enfermero y operar el constructo calidez en enfermería y variables relacionadas. Método: Revisión integrativa que abarcó la exploración y análisis de la evidencia sobre calidez, la cual corresponde a la primera etapa del proyecto de investigación titulado: Construcción y validación de una escala de medición de la calidez presente en los enfermeros, donde se pretende construir y validar una escala que permita medir este fenómeno. Se revisaron definiciones de calidez en diccionarios, textos y artículos de diversas bases de datos. Los descriptores utilizados fueron: calidez, calidez y enfermería, en español e inglés. Para definir el constructo y sus variables se complementó el modelo de tres fases de Luiz Pasquali con los procedimientos de Ethel Bauzer y Floyd Fowler. Resultados: Se formuló el constructo calidez en enfermería, se identificaron 2 dominios, 28 variables verbales, 9 no verbales y 93 comportamientos. Conclusiones: Los resultados de la fase teórica del modelo aplicado permitieron formular constructo, dominios y variables de calidez en enfermería. Estos aportes son de interés para la gestión del cuidado enfermero y enseñanza, pues se relacionan directamente con la satisfacción usuaria.

The warmth is a subjective phenomenon, fundamental in human relationships. The warmth is contagious, so may be a factor favoring care, but there is no consensus on its definition and domains. Since warmth is a predictor of user satisfaction, it is relevant to use an appropriate way to measure it; however, there have not been found ways to measure it, which motivated this revision. The three-stage procedure of Luiz Pasquali was used to do that, which considers Theoretical, Empirical and Analytical phases. This paper presents the results of the first theoretical phase: behaviors associated with warmth previously identified in the literature. Objectives: To identify behaviors that represent the warmth of the Nurse by reviewing specialized literature, and to operationalize the construct warmth and related variables. Method: Integrative literature review that included the exploration and analysis of the evidence on warmth, which corresponds to the first stage of the research project entitled: Construction and validation of a scale for measuring this warmth in Nursing, which aims to build and validate a scale to measure this phenomenon. This work corresponds to the Theoretical Phase of Pascuali's model. Definition of warmth was revised by using dictionaries and technical articles from various repositories. The descriptors used were "warmth" and "warmth and nursing" in Spanish and English. To define the construct and its variables, the Ethel Bauzer's procedures and Floyd Fowler's method were also considered to supplement the Pascuali's model. Results: Formulation of the construct Warmth in Nursing which includes, 2 domains, 28 verbal variables, 9 nonverbal variables and 93 behaviors. Conclusions: The results of the theoretical phase of the applied model, allowed to formulate the construct domains and variables of Warmth in Nursing. These contributions are of interest for the management of nursing care and teaching, as are directly related to user satisfaction.

O calor humano é um fenômeno subjetivo fundamental nos relacionamentos. O calor humano é contagioso, por isso pode ser um fator relevante no cuidado, mas não há consenso sobre sua definição ou domínios. Medir o calor humano é relevante porque é um preditor de satisfação do usuário, no entanto, não encontraram maneiras de medir, o que motivou essa revisão. Foi usado o modelo de três fases do autor brasileiro Luiz Pasquali: teórica, empírica e analítica. Este trabalho mostra os resultados da primeira fase teórica: a literatura identifica comportamentos que são associados com o calor humano. Objetivos: Identificar numa fase de revisão teórica, os comportamentos que representam o calor humano do enfermeiro. Operacionalizar a definição do construto calor humano em enfermagem, bem como identificar as variáveis. Método: Revisão integrativa que abrange a exploração e análise das evidências em calidez (calor humano), o que corresponde à primeira fase do projeto de pesquisa intitulado: Construção e validação de uma escala para medir esse calor em Enfermagem, que tem como objetivo construir e validar uma escala para medir este fenómeno. Este trabalho corresponde ao resultado da fase teórico do modelo. Os descritores utilizados foram calidez, calidez dos enfermeiros e sua correspondente em inglês e espanhol. Para a definição de calor humano e construção de variáveis que a representam, o modelo de três fases de Luiz Pasquali, foi complementado por procedimentos de Ethel Bauzer e Floyd Fowler. Resultados: Foi formulado o construto Calor humano do Enfermeiro, dois domínios, 28 variáveis verbais e 9 não-verbais. 93 comportamentos totais identificados com a calidez dos enfermeiros. Conclusões: Os resultados da fase teórica do modelo aplicado permitiram formular os domínios construir e variáveis do calidez em enfermagem. Estas contribuições são de interesse para a gestão da assistência de enfermagem e ensino, como estão diretamente relacionados à satisfação do usuári

Self-efficacy and fear avoidance beliefs in chronic low back pain patients: coexistence and associated factors.

A cross sectional study was conducted with the objective to assess the coexistence of self-efficacy and fear avoidance beliefs and establish the associated factors. Data collection was performed (215 individuals with lower back pain at three health services and two industries). The following instruments were used: Tampa Scale for Kinesiophobia, Beck's Depression Inventory, Piper's Fatigue Scale, Oswestry Disability Index, and the Chronic Pain Self-Efficacy Scale. Wilks' lambda test was performed, followed by MANOVA model to assess the effect of self-efficacy beliefs and fear avoidance on independent variables. Most subjects were women (65.1%), 45 years of age or younger (50.7%), with a family income between $450 and $1,350 per month (49.3%). Depression was present in 21.4%, fatigue in 29.3%, and disability in 68%. The average (standard deviation) of self-efficacy was 180.8 (60.4), and fear avoidance was 42.0 (11.5). A significant negative correlation was observed between the total score of both beliefs. The Wilks' lambda test showed that gender, income, depression, disability, and fatigue were significant and were included in the model. In the Manova analysis, low self-efficacy was associated with lower income, fatigue, depression, and level of disability (p < .001). High fear avoidance was associated to the male gender, lower income, depression, and level of disability (p < .001). The analysis of the confidence areas showed that a reduced self-efficacy and increased fear avoidance are related to an increased level of disability (p < .001). Specific intervention strategies must be implemented change these beliefs.

Non-analgesic effects of opioids: the cognitive effects of opioids in chronic pain of malignant and non-malignant origin. An update.

Opioids constitute the basis for pharmacological treatment of moderate to severe pain in cancer pain and non-cancer pain patients. Their action is mediated by the activation of opioid receptors, which integrates the pain modulation system with other effects in the central nervous system including cognition resulting in complex interactions between pain, opioids and cognition. The literature on this complexity is sparse and information regarding the cognitive effects of opioids in chronic pain patients is substantially lacking. Two previous systematic reviews on cancer pain and non-cancer pain patients only using controlled studies were updated. Fourteen controlled studies on the cognitive effects of opioids in chronic non-cancer pain patients and eleven controlled studies in cancer pain patients were included and analyzed. Opioid treatment involved slightly opposite outcomes in the two patient groups: no effects or worsening of cognitive function in cancer pain patients and no effect or improvements in the chronic non-cancer pain patients, however, due to methodological limitations and a huge variety of designs definite conclusions are difficult to draw from the studies. In studies of higher quality of evidence opioid induced deficits in cognitive functioning were associated with dose increase and the use of supplemental doses of opioids in cancer patients. Future perspectives should comprise the conduction of high quality randomized controlled trials (RCTs) involving relevant control groups and validated neuropsychological assessments tools before and after opioid treatment in order to further explore the complex interaction between pain, opioids and cognition.

A systematic review of topical treatments to control the odor of malignant fungating wounds.

CONTEXT: Malignant fungating wounds (MFW) result from cutaneous infiltration by carcinogenic cells. Fetid odor, profuse exudate, pain, and infection are common symptoms that add to the physical and psychological suffering of patients with MFW. The topical treatment of MFW remains controversial. OBJECTIVES: To collect evidence about topical treatments to control the odor of MFW. METHODS: Fourteen sources of data were used, without restriction in terms of language, period, or study design. The patient, intervention, comparison, and outcome strategy for the development of research questions yielded 334 descriptors related to oncology, MFW, topical treatments, medications, and symptoms of these lesions. Data from the abstracts of these articles were extracted by two independent researchers and decisions were reached by consensus among them. Through an analysis of these abstracts, studies that broached the topic of MFW odor were selected. These studies were analyzed in their entirety and were classified according to quality, levels of evidence, and grade of recommendation. RESULTS: Of 11,111 studies identified, 325 (2.93%) made reference to the control of some symptoms of MFW by means of topical interventions: 12.4% related to odor, 16.8% to exudate, 17.8% to bleeding, 31.0% to pain, and 22.0% to MFW-related infection. Within the 59 studies that analyzed odor control, seven were clinical trials (35%), five were case series (25%), and eight (40%) were case studies. Eleven topical treatments were identified. Topical metronidazole and Mesalt dressing yielded 2b level of evidence or B grade of recommendation. Activated carbon dressing and curcumin ointment yielded 2c level of evidence or B grade of recommendation. C and D grades of recommendation were observed for seven topical treatments: topical arsenic trioxide, essential oils, green tea extract, hydropolymer dressings, antiseptic solutions, hydrogels, and debridement enzymes. The variety of interventions and of the methodological quality of the studies did not allow for meta-analysis. CONCLUSION: Of the 59 studies of odor, 20 fulfilled all the criteria for inclusion. Few studies of high quality were found, and the principal methodological flaws were the design of the studies, the sample size, and the absence of scales to measure odor. Grade B evidence for the treatment of MFW was found with topical metronidazole, Mesalt dressing, activated carbon dressing, and curcumin ointment.

Nurses' perception of power regarding their clinical role.

This article reports on a study on nurses' perception of power regarding their clinical role before and after implementation of a nursing diagnosis classification. Sixty clinical nurses (average age=37.2+/-7.0 years) from a Brazilian teaching hospital answered the Power as Knowing Participation in Change Tool (PKPCT) before and after the implementation of a diagnosis classification. PKPCT has four domains and provides total and partial scores. Reliability coefficients ranged from 0.88 to 0.98. Total scores were not statistically different between assessments (p=0.21), although scores in the 'Involvement in Creating Change' domain were higher in the second assessment (p=0.04). Further studies providing sound evidence regarding the impact of nursing classification systems on nurses' power perception are needed to guide decisions on teaching and clinical practice.

Cognitive impairment in cancer pain patients receiving opioids: a pilot study.

This study aimed to compare cognitive function of cancer pain patients being given opioids during their cancer treatment (n = 14) with that of patients receiving treatment without opioids (n = 12). Correlations between cognitive function, pain intensity, and opioid dose were analyzed. Patients were assessed 3 times in a 1-month period, using the Trail-Making Test, Mini-Mental State Examination, Digit Span, and Brief Cognitive Screening Battery. Opioid use was not associated with clear cognitive impairment. Patients being treated without opioids did perform better in the Digit Span Test reverse-order test (P = .029) and the clock drawing test (P = .023), but the differences arose in just 1 assessment in each case. Pain intensity correlated negatively with scores in the Mini-Mental State Examination (P = .001) and some Brief Cognitive Screening Battery tests (incidental recall, immediate recall, and late recall; P

The PICO strategy for the research question construction and evidence search.

Evidence based practice is the use of the best scientific evidence to support the clinical decision making. The identification of the best evidence requires the construction of an appropriate research question and review of the literature. This article describes the use of the PICO strategy for the construction of the research question and bibliographical search.

Therapeutical intervention, relaxation, mental images, and spirituality (RIME) for spiritual pain in terminal patients. A training program.

Therapeutic intervention involving the technique of Relaxation, Mental Images, and Spirituality (RIME) can foster the redefinition of spiritual pain in terminal patients. A training course was developed to instruct health care professionals in its use, and the results were followed up by evaluating reactions of professionals to its use in intervention with patients. Six subjects (a nurse, a doctor, three psychologists, and an alternative therapist), all skilled in palliative care, were invited to take part in the experience. They worked with 11 terminal patients in public hospitals of the cities of Campinas, Piracicaba, and São Paulo, located in Brazil. The theoretical basis for the study involves action research and phenomenology, and the results were analyzed using both qualitative and quantitative methods. The analysis of the experience of the professionals revealed 5 categories and 15 subcategories. The analysis of the nature of spiritual pain revealed 6 categories and 11 subcategories. The administration of RIME revealed statistically significant differences (p < 0.0001), i.e., patients reported a greater level of well-being at the end than at the beginning of sessions, which suggests that RIME led to the redefinition of spiritual pain for these terminal patients. The training program proposed has shown itself to be effective in preparing health care professionals for the use of RIME intervention.

[Evidence-based practice applied to diagnostic reasoning]. / Prática baseada em evidências, aplicada ao raciocínio diagnóstico.

Nurses apply knowledge, perceptual and cognitive skills to analyze patient data and propose nursing interventions. The interventions' outcomes depend on their appropriateness which, in turn, depends on the accuracy of nurses' interpretations. The purpose of this paper is to discuss the use of evidenced-based practice (EBP) for nursing diagnostic reasoning, by means of a written case study. The principles of EBP in diagnostic reasoning are: validity of a diagnostic test; ability of a test to discriminate those who do or do not display a specific response; ability of a test to estimate the magnitude of a response; and the appropriateness of a diagnostic test within the clinical context. Gaps in nursing knowledge jeopardize the application of EBP principles in clinical nursing assessment and diagnosis. The authors present a framework to demonstrate the application of EBP to diagnostic reasoning.

Pain in chronic leg ulcers.

OBJECTIVES: Describe the characteristics of pain in patients with chronic leg ulcers, correlate these descriptions with the characteristics of the ulcers and with patients' sociodemographic data, and determine the measures used for pain management. DESIGN: Descriptive and cross-sectional study with quantitative approach. SETTING AND SUBJECTS: The convenience sample was composed of 90 patients with chronic leg ulcers drawn from 4 outpatient departments in Sao Paulo and Curitiba. INSTRUMENTS: Intensity and quality of patients' pain were determined using a 0-10 numeric pain intensity rating scale and a short version of the McGill Pain Questionnaire. METHODS: After gaining ethics committee approval, patients were selected during their ambulatory visits and interviewed by researchers. Data obtained were analyzed using the Kolmogorov-Smirnov Normality test, Mann-Whitney test, Chi-Square test, and Spearman's Correlation coefficient. RESULTS: Seventy-three (81.11%) patients had venous ulcers. The mean pain intensity reported was 3.10 (SD = 3.15), the mean intensity of the "worst pain of the week" was 7.56 (SD = 2.96), and the mean intensity of the "best pain of the week" was 2.05 (SD = 2.37). The McGill Questionnaire showed that sensitive descriptors were most frequently used to describe the pain. Statistically significant correlations (P < .05) were observed. The most intense pain was reported in subjects from the lowest income bracket studied and female gender and was correlated with alterations in sleep, movement, walking, and mood. Nonsteroidal antiinflammatory drugs were most commonly used (70%) for pain management. CONCLUSIONS: This study indicates the need for more attention and understanding on the part of healthcare workers regarding leg ulcer pain and its characteristics and the need for specific and effective procedures designed to contribute to the improvement in quality of life of these individuals.