High Unemployment Rate in Patients with Hidradenitis Suppurativa despite High Educational Attainment

BACKGROUND

Hidradenitis suppurativa (HS) is associated with lower socioeconomic status (SES). The adverse influence of HS on education and employment may explain this. It remains unknown whether HS causes downward social trajectories, i.e., social drift, or whether those affected are born into a lower SES. We aimed to assess the influence of HS on education and employment and compare the highest educational attainment of participants with their parents.

METHODS

An anonymous online survey was distributed by patient-led organisations. Frequencies were compared with χ2 and disease interactions with one-way ANOVA.

RESULTS

Among 335 respondents from 10 countries, 94.9% completed secondary/high school, 71.3% completed further education, 41.8% completed an undergraduate degree, 20% completed postgraduate education, 10.7% completed a masters, and 2.1% completed a doctorate. Participant education was greater than parental education (p < 0.001). Despite this, 24.2% were unemployed and 15.2% were receiving illness benefit. Compared to national statistics, HS participants from Ireland (p = 0.003), the USA (p < 0.001), and the UK (p < 0.001) were more likely to be unemployed/receiving illness benefit despite higher educational attainment in Ireland (p = 0.006) and the USA (p = 0.003) with similar education in the UK (p = 0.153).

CONCLUSIONS

Social drift describes downward social trajectories due to the development of a disease. Participants in this study report greater education than their parents and the background population, but despite this, they are experiencing downward social trajectories with higher unemployment and receipt of illness benefit. Disease onset in HS tends to be at peak educational age. Education does not appear to be impaired by early disease with disease accumulation during employment years limiting opportunities.

Metformin has anti-inflammatory effects and induces immunometabolic reprogramming via multiple mechanisms in hidradenitis suppurativa

BACKGROUND

Targeting immunometabolism has shown promise in treating autoimmune and inflammatory conditions. Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease involving painful lesions in apocrine gland-bearing skin. Therapeutic options for HS are limited and often ineffective; thus, there is a pressing need for improved treatments. To date, metabolic dysregulation has not been investigated in HS. As HS is highly inflammatory, we hypothesized that energy metabolism is dysregulated in these patients. Metformin, an antidiabetic drug, which is known to impact on cellular metabolic and signalling pathways, has been shown to have anti-inflammatory effects in cancer and arthritis. While metformin is not licensed for use in HS, patients with HS taking metformin show improved clinical symptoms.

OBJECTIVE

To assess the effect and mechanism of action of metformin in HS.

METHODS

To assess the effect of metformin in vivo, we compared the immune and metabolic profiles of peripheral blood mononuclear cells (PBMCs) of patients with HS taking metformin vs. those not taking metformin. To examine the effect of metformin treatment ex vivo, we employed a skin explant model on skin biopsies from patients with HS not taking metformin, which we cultured with metformin overnight. We used enzyme-linked immunosorbent assays, multiplex cytokine assays and quantitative real-time polymerase chain reaction (RT-PCR) to measure inflammatory markers, and Seahorse flux technology and quantitative RT-PCR to assess glucose metabolism.

RESULTS

We showed that metabolic pathways are dysregulated in the PBMCs of patients with HS vs. healthy individuals. In metformin-treated patients, these metabolic pathways were restored and their PBMCs had reduced inflammatory markers following long-term metformin treatment. In the skin explant model, we found that overnight culture with metformin reduced inflammatory cytokines and chemokines and glycolytic genes in lesions and tracts of patients with HS. Using in vitro assays, we found that metformin may induce these changes via the NLR family pyrin domain containing 3 (NLRP3) inflammasome and the AMP-activated protein kinase (AMPK)-mammalian target of rapamycin (mTOR) pathway, which is linked to glycolysis and protein synthesis.

CONCLUSIONS

Our study provides insight into the mechanisms of action of metformin in HS. The anti-inflammatory effects of metformin support its use as a therapeutic agent in HS, while its effects on immunometabolism suggest that targeting metabolism is a promising therapeutic option in inflammatory diseases, including HS.

Opportunity for significant reduction in risk of major adverse cardiac events with screening for cardiovascular disease risk factors in hidradenitis suppurativa

Patients with hidradenitis suppurativa (HS) have a high prevalence of cardiovascular disease risk factors and are at increased risk of major adverse cardiac events (MACE). Routine screening for risk factors is recommended but the benefit of this in risk reduction has not been evaluated. In this study of 117 patients attending hospital-based services for HS, there was a high burden of undiagnosed cardiovascular disease risk factors. Risk factor optimization significantly reduced 10-year risk of MACE.

Shorter time to initiation of biologic therapy in the setting of a hidradenitis suppurativa specialty clinic

Hidradenitis suppurativa (HS) is a chronic condition with a significant psychological and physical burden but a paucity of effective treatments. Early intervention with adalimumab improves disease outcomes. Two previous studies in Denmark and Northern Ireland have identified a time of 8.2 and 2.9 years, respectively, from first HS systemic/dermatology consultation to commencing a biologic. We aimed to evaluate the time from disease onset and from first specialty HS clinic review to the initiation of biologic therapy. We retrospectively reviewed 34 patients on biologic treatment for HS. The mean diagnostic delay was 12.4 years. The mean time from disease onset to biologic initiation was 14.8 years. Prior to a biologic, patients received a median of 3.3 treatments from the specialty HS clinic. The median time to biologic from first presentation at the specialty HS clinic was 1 year. This is shorter than the therapeutic delay reported in dermatology clinics in Denmark and Northern Ireland, providing evidence on the importance of specialized HS treatment. However, to make an impact with specialized HS care and earlier biologic initiation, diagnostic delay needs to be reduced.

Metformin Treatment of Hidradenitis Suppurativa: Effect on Metabolic Parameters, Inflammation, Cardiovascular Risk Biomarkers, and Immune Mediators

Hidradenitis suppurativa (HS) is a common cutaneous and systemic inflammatory disease with a significant impact on mental health and quality of life. It is associated with obesity, insulin resistance, metabolic syndrome, cardiovascular (CV) disease, and increased all-cause mortality. Metformin is used frequently in HS treatment and is effective for some patients. The mechanism of action of metformin in HS is unknown. A case-control study of 40 patients with HS (20 on metformin and 20 controls) was conducted to assess differences in metabolic markers, inflammation (C-reactive protein [CRP], serum adipokines, and CV risk biomarkers), and serum immune mediators. Body mass index (BMI), insulin resistance (77%), and metabolic syndrome (44%) were high overall, but not significantly different between the groups. This highlights the need for co-morbidity screening and management. A significant reduction in fasting insulin and a trend towards a reduction in insulin resistance were identified in the metformin group compared with pre-treatment levels. CV risk biomarkers were significantly favourable in the metformin group (lymphocytes, monocyte-lymphocyte ratio, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio). CRP was lower in the metformin group but was not statistically significant. Adipokines were dysregulated overall but were not different between the two groups. Serum IFN-γ, IL-8, TNF-α, and CXCL1 trended lower in the metformin group but did not reach significance. These results suggest that metformin improves CV risk biomarkers and insulin resistance in patients with HS. When the results of this study are considered alongside other studies in HS and related conditions, it is likely that metformin also has beneficial effects on metabolic markers and systemic inflammation in HS (CRP, serum adipokines, and immune mediators), warranting further research.

Treatment of hidradenitis suppurativa with brodalumab in biologic treatment failures - experiences from a specialty clinic

Hidradenitis suppurativa is characterised by increased interleukin-17A/C/F. Two open-label trials of brodalumab, an IL-17 receptor antagonist, have been completed with 8/10 patients receiving brodalumab fortnightly and 10/10 patients receiving brodalumab weekly achieving HiSCR75. All patients were biologic "experienced" but were not reported to have failed biologic treatment. We report outcomes for 8 patients treated with brodalumab 210mg fortnightly for HS who had failed at least one biologic to provide real world evidence. 4/8 patients remain on brodalumab with the mean treatment duration 11.3 months. All patients who remain on brodalumab subjectively report continued treatment efficacy. The mean DLQI reduced from 20.6 to 16.8 at week 16. All patients required concurrent antibiotics due to flares. Brodalumab may be effective in patients who have previously failed multiple biologics but efficacy in our real world study falls short of the two open-label trials. This may reflect severe treatment-resistant disease. In the absence of further licensed treatments for HS, brodalumab may be a good option following adalimumab failure.

Association of Biologic Treatment in Hidradenitis Suppurativa With Reduced Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio

This cohort study assesses whether an association exists between biologic treatment for hidradenitis suppurativa and neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and monocyte-lymphocyte ratio.

Alcohol and Psoriasis for the Dermatologist: Know, Screen, Intervene

Psoriasis patients are at increased risk of harmful alcohol use and alcohol dependency with many deleterious effects. Increasing alcohol use is associated with worsening psoriasis severity, is a risk factor for poor response to systemic treatments and may impact on comorbidities such as psoriatic arthritis, cardiovascular disease, cancer and liver disease. Harmful alcohol use and alcohol dependency can be defined by the updated ICD-11 coding system and screening can be completed using many tools including the Cut down, Annoyed, Guilty, Eye-Opener (CAGE), Alcohol Use Disorders Identification Test (AUDIT) and Michigan Alcohol Screening Test (MAST) questionnaires. Dermatologists may be able to complete brief interventions encouraging alcohol reduction in psoriasis patients. Psoriasis patients may respond to messages of gain with reduced psoriasis severity and loss with reduced cardiovascular risk. It is important for dermatologists to discuss alcohol with all psoriasis patients, to be aware of the impact of alcohol in psoriasis and to familiarise themselves with screening tools, brief intervention and local services available to patients who require specialist input for harmful alcohol use or alcohol dependency.

The prevalence of hidradenitis suppurativa outside the hospital setting: the impact of the undiagnosed

Linked Article: Prens et al. Br J Dermatol 2022; 186:814–822.

'Not relevant' responses in the era of COVID-19: are we underestimating Dermatology Life Quality Index values?

Since March 2020, the UK and Ireland have entered a series of lockdowns in the wake of the coronavirus pandemic with restrictions resulting in the closure of nonessential retail, hospitality and sports with employees encouraged to work from home. In this retrospective study we have demonstrated a significant decrease in DLQI values, increase in the number of ‘not relevant’ responses (NRRs) in the DLQI and change between DLQI and the modified DLQI‐R during the pandemic. Given the restrictions imposed on our patients, it is important for clinicians to identify the number of NRRs in the DLQI and acknowledge the potential effect on treatment decisions and data collection for disease registries and clinical trials during the pandemic.

Real world use of biologic drug levels and anti-drug antibodies in patients with psoriasis - does therapeutic drug monitoring have a place in routine clinical practice?

Background: Psoriasis is a chronic disorder with increasing new treatments targeting the T-helper cell (Th)-1/Th17 axis. There remains a subset of patients who experience a primary or secondary failure to biologic treatments.Methods: We present ten patients with psoriasis who failed biologic therapy with measurement of serum drug levels and anti-drug antibody levels (ADAs) with review of the current literature. Our objective was to identify demographic factors, disease status, drug level and ADAs which might correlate with primary and secondary failure.Results: There are a number of factors affecting drug levels in patients with psoriasis on biologics including the presence of ADAs, patient adherence to treatment regimes, pharmacogenetics and the pharmacokinetic properties of the drug following subcutaneous injection. Our results demonstrate that biologic failure is related to low serum drug levels subtherapeutic in 80% of our cohort. Primary failure may correlate with the presence of ADAs but not with serum drug levels. All patients were ANA negative and there remains considerable debate on the utility of routine ANA testing.Conclusions: The role of therapeutic drug monitoring in dermatology remains uncertain and requires further study. We aim to promote debate in the dermatology community as to the utility of therapeutic drug monitoring in routine practice.

A qualitative study exploring the views, attitudes and beliefs of patients and health professionals towards exercise intervention for people who are surgically treated for lung cancer

Surgical removal remains the best curative option for patients diagnosed with early-stage lung cancer. However, it is also associated with significant morbidity and reduced quality of life. Interventions to improve patient outcomes are required. This study aimed to explore the views, attitudes and beliefs of key stakeholders on exercise intervention for people who are surgically treated for lung cancer to inform the development of future interventions. Focus groups and individual interviews were carried out at two Scottish sites. The study was guided by the Health Action Process Approach behaviour change model. A total of 23 (12 patients and 11 health professionals) participated in the study. The data analysis resulted in three main themes: attitudes and beliefs, external factors and intervention design. The results highlighted certain key elements that should be included in an exercise intervention, such as the need for supervised sessions, an element of individualisation and the perceived social benefits of exercising with others. This study emphasises the importance of including key stakeholders in the development of complex interventions such as exercise and provides important information for the development of future exercise intervention trials for people who are surgically treated for lung cancer.

The symptom phenotype of oncology outpatients remains relatively stable from prior to through 1 week following chemotherapy

Some oncology outpatients experience a higher number of and more severe symptoms during chemotherapy (CTX). However, little is known about whether this high risk phenotype persists over time. Latent transition analysis (LTA) was used to examine the probability that patients remained in the same symptom class when assessed prior to the administration of and following their next dose of CTX. For the patients whose class membership remained consistent, differences in demographic and clinical characteristics, and quality of life (QOL) were evaluated. The Memorial Symptom Assessment Scale (MSAS) was used to evaluate symptom burden. LTA was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of the MSAS symptoms. Of the 906 patients evaluated, 83.9% were classified in the same symptom occurrence class at both assessments. Of these 760 patients, 25.0% were classified as Low-Low, 44.1% as Moderate-Moderate and 30.9% as High-High. Compared to the Low-Low class, the other two classes were younger, more likely to be women and to report child care responsibilities, and had a lower functional status and a higher comorbidity scores. The two higher classes reported lower QOL scores. The use of LTA could assist clinicians to identify higher risk patients and initiate more aggressive interventions.

Children's understanding of cancer and views on health-related behaviour: a 'draw and write' study

BACKGROUND

Few studies have explored young children's understanding of cancer and health-related behaviours yet this is essential to develop health promotion initiatives that build on young children's current knowledge levels and awareness.

METHOD

An exploratory descriptive design using the 'draw and write' technique was used to investigate children's views of cancer and health behaviours. The sample included 195 children aged eight to 11 years from five schools in deprived, affluent and rural locations in Scotland.

RESULTS

When asked about cancer children demonstrated a good level of awareness by responding with text and drawings about the what they understood cancer to be; types of cancer; causes of cancer; what happens to people who have cancer; their personal experience of cancer and the emotions they associated with cancer. Older children, and children attending affluent schools, have more defined ideas about the causes of cancer and awareness of broader issues such as the risk of passive smoking or the potential impact on the family. Factors such as alcohol and illegal drugs were only reported by children attending schools in deprived locations. Children demonstrated considerable knowledge about healthy and unhealthy lifestyle behaviours; however, it is not clear whether this knowledge translates into their behaviours or the choices offered within their home environment.

CONCLUSIONS

Children view cancer in a negative way from an early age, even without personal experience. There is a need to demystify cancer in terms of its causes, how to recognize it, how it is treated and to publicize improved survival rates. There is a need for targeted and developmentally appropriate approaches to be taken to health education in schools, with an awareness of the influence of the media on children's information. Strategies should take into consideration the socio-economic and cultural contexts of children's lives which influence their choices and behaviours.

2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours

Chemotherapy-induced neutropenia is a major risk factor for infection-related morbidity and mortality and also a significant dose-limiting toxicity in cancer treatment. Patients developing severe (grade 3/4) or febrile neutropenia (FN) during chemotherapy frequently receive dose reductions and/or delays to their chemotherapy. This may impact the success of treatment, particularly when treatment intent is either curative or to prolong survival. In Europe, prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs), such as filgrastim (including approved biosimilars), lenograstim or pegfilgrastim is available to reduce the risk of chemotherapy-induced neutropenia. However, the use of G-CSF prophylactic treatment varies widely in clinical practice, both in the timing of therapy and in the patients to whom it is offered. The need for generally applicable, European-focused guidelines led to the formation of a European Guidelines Working Party by the European Organisation for Research and Treatment of Cancer (EORTC) and the publication in 2006 of guidelines for the use of G-CSF in adult cancer patients at risk of chemotherapy-induced FN. A new systematic literature review has been undertaken to ensure that recommendations are current and provide guidance on clinical practice in Europe. We recommend that patient-related adverse risk factors, such as elderly age (≥65 years) and neutrophil count be evaluated in the overall assessment of FN risk before administering each cycle of chemotherapy. It is important that after a previous episode of FN, patients receive prophylactic administration of G-CSF in subsequent cycles. We provide an expanded list of common chemotherapy regimens considered to have a high (≥20%) or intermediate (10-20%) risk of FN. Prophylactic G-CSF continues to be recommended in patients receiving a chemotherapy regimen with high risk of FN. When using a chemotherapy regimen associated with FN in 10-20% of patients, particular attention should be given to patient-related risk factors that may increase the overall risk of FN. In situations where dose-dense or dose-intense chemotherapy strategies have survival benefits, prophylactic G-CSF support is recommended. Similarly, if reductions in chemotherapy dose intensity or density are known to be associated with a poor prognosis, primary G-CSF prophylaxis may be used to maintain chemotherapy. Clinical evidence shows that filgrastim, lenograstim and pegfilgrastim have clinical efficacy and we recommend the use of any of these agents to prevent FN and FN-related complications where indicated. Filgrastim biosimilars are also approved for use in Europe. While other forms of G-CSF, including biosimilars, are administered by a course of daily injections, pegfilgrastim allows once-per-cycle administration. Choice of formulation remains a matter for individual clinical judgement. Evidence from multiple low level studies derived from audit data and clinical practice suggests that some patients receive suboptimal daily G-CSFs; the use of pegfilgrastim may avoid this problem.

Working in collaboration with young people and health professionals. A staged approach to the implementation of a randomised controlled trial

ASyMS© is an Advanced Symptom Management System utilising mobile phone technology to monitor chemotherapy-related symptoms and promote self-care. It was first developed with an adult cancer population and is now being evaluated with young people through an iterative development process. ASyMS© involves patients recording and sending symptom reports to the hospital and receiving tailored self-care advice. Health professionals are alerted when severe symptoms are reported. Three phases of the ASyMS©-YG (young people) study are complete. Phase 1 involved young people identifying the symptoms to be assessed. Phase 2 involved young people testing the symptom report system, and ascertaining young people’s, parents’ and professionals’ perceptions of ASyMS©-YG. This paper reports on Phase 3, in which the system was developed further in preparation for a randomised controlled trial (RCT). Health professionals devised an alert system based on risk modelling side-effect severity, and young people and professionals developed self-care advice. A pilot study was conducted to test the alert system and study design in readiness for a definitive RCT. The contribution young people and professionals have made to this project is invaluable in evaluating the practical effectiveness of ASyMS©-YG and ensuring the intervention is acceptable and works in everyday practice.

The supportive care needs of carers of people affected by cancer stationed in British Forces Germany

Carers are central to the effective support of people affected by cancer. Little is known however about the specific support needs of carers of military personnel. This study aimed to determine the supportive care needs of unpaid carers within British Forces (including military/civilian personnel, their families and dependent adults) currently stationed in Germany. Qualitative semi-structured interviews were conducted with seven carers (six men and one woman) in three British army garrisons across Germany, to identify core aspects of the experience of caregiving in this environment. Analysis of interviews with carers was based on qualitative thematic and content analysis. Three key themes were identified: (1) impact on carers of their partners being diagnosed with cancer; (2) provision of support; and (3) challenges to accessing and obtaining support. Central issues pivot around the context of working and living in the armed forces and a lack of supportive care infrastructure. While drawing on a small sample size, this study nonetheless identifies that carers of people with cancer within the armed forces, who are stationed in Germany require a specialised and contextually specific set of services to address their supportive care needs.

Association of beta-glucan endogenous production with increased stress tolerance of intestinal lactobacilli

The exopolysaccharide beta-glucan has been reported to be associated with many health-promoting and prebiotic properties. The membrane-associated glycosyltransferase enzyme (encoded by the gtf gene), responsible for microbial beta-glucan production, catalyzes the conversion of sugar nucleotides into beta-glucan. In this study, the gtf gene from Pediococcus parvulus 2.6 was heterologously expressed in Lactobacillus paracasei NFBC 338. When grown in the presence of glucose (7%, wt/vol), the recombinant strain (pNZ44-GTF(+)) displayed a "ropy" phenotype, while scanning electron microscopy (SEM) revealed strands of polysaccharide-linking neighboring cells. Beta-glucan biosynthesis was confirmed by agglutination tests carried out with Streptococcus pneumoniae type 37-specific antibodies, which specifically detect glucan-producing cells. Further analysis showed a approximately 2-fold increase in viscosity in broth media for the beta-glucan-producing strain over 24 h compared to the control strain, which did not show any significant increase in viscosity. In addition, we analyzed the ability of beta-glucan-producing Lactobacillus paracasei NFBC 338 to survive both technological and gastrointestinal stresses. Heat stress assays revealed that production of the polysaccharide was associated with significantly increased protection during heat stress (60-fold), acid stress (20-fold), and simulated gastric juice stress (15-fold). Bile stress assays revealed a more modest but significant 5.5-fold increase in survival for the beta-glucan-producing strain compared to that of the control strain. These results suggest that production of a beta-glucan exopolysaccharide by strains destined for use as probiotics may afford them greater performance/protection during cultivation, processing, and ingestion. As such, expression of the gtf gene may prove to be a straightforward approach to improve strains that might otherwise prove sensitive in such applications.

Patients' perceptions and experiences of using a mobile phone-based advanced symptom management system (ASyMS) to monitor and manage chemotherapy related toxicity

Chemotherapy forms a core component of treatment for the majority patients with cancer. Recent changes in cancer services mean patients frequently receive such treatment as outpatients and are often required to manage side effects at home without direct support from oncology health professionals. Information technology continues to develop to support patients in the community; this study evaluated the impact of a mobile phone-based advanced symptom management system (ASyMS) on chemotherapy related toxicity in patients with lung, breast or colorectal cancer. One hundred and twelve patients were randomized from seven clinical sites across the UK; 56 patients used the mobile phone to record their symptoms, sending their reports directly to the nurses at their clinical site; 56 control group patients received standard care. Health professionals were alerted about any severe or life-threatening symptoms through the development of a chemotherapy symptom risk model. Patients' perceptions of ASyMS were evaluated pre and post participation. Patients reported many benefits of using ASyMS including improved communication with health professionals, improvements in the management of their symptoms, and feeling reassured their symptoms were being monitored while at home. ASyMS has the potential to positively impact on the management of symptoms in patients receiving chemotherapy treatment.

Prioritization of future research topics for children's hospice care by its key stakeholders: a Delphi study

The Delphi process, widely used in health research to seek consensus on key issues amongst large stakeholder groups, was adopted to allow families, hospice staff/volunteers and linked professionals to identify and prioritize future research priorities for children's hospice care. In the qualitative Round 1, interviews with families (n = 5), linked professionals (n = 18) and focus groups with hospice staff and volunteers (n = 44) led to the generation of 56 research topics categorised within 14 broad themes. To give a larger number of stakeholders (n = 621) (including families n = 293; hospice staff/volunteers n = 216 and professionals n = 112) the opportunity to rate the importance of each research topic and seek group consensus on the future research priorities for children's hospice care, subsequent Rounds 2 and 3 involved the use of postal questionnaires. Response rates to questionnaires were 44% in Round 2 (274/621) and 83% in Round 3 (204/247). Participants prioritized research topics relating to 1) hospice and respite care needs of young people (aged 16 +), 2) pain and symptom management and 3) bereavement and end-of-life care. There was wide acknowledgement by those took part in the process of the difficulty in rating the topics, and emphasis on the fact that all of the topics raised during the project are of high importance and merit further research. The current salient issues perceived by key stakeholders as being the research priorities for children's hospice care were identified. Addressing these priority topics for research would further contribute to the development of a much needed evidence base in children's hospice and palliative care research and optimise the delivery of children's hospice services that are underpinned by valid and robust research.

Exploring the experiences and perspectives of families using a children's hospice and professionals providing hospice care to identify future research priorities for children's hospice care

The main objective of this study is to generate a list of priority topics for children's hospice care research in Scotland from the perspective of its key stakeholders. The method consists of qualitative semi-structured interviews with families using hospice services (n = 5), four focus groups with hospice staff and volunteers (n = 44) and telephone interviews with professionals associated with the hospice (n = 18). Fourteen broad themes emerged following thematic content and interpretive analysis of the interview data. Some of the research themes were specific to certain stakeholder groups, whereas other themes were identified unanimously across all the stakeholder groups as being priority areas for future research. Increasing awareness of and improving access to children's hospice care, hospice and respite care needs of young people, community/home care and issues related to supporting the wider family arose, independently, in all three stakeholder groups as being priority topics for future research. In conclusion, a greater evidence base is required in the field of children's palliative care and the topics researched should be identified and led by those most closely involved in the hospices. Engaging families and care providers in the process of identifying research priorities resulted in the development of an extensive research agenda, which will contribute to quality hospice care for children and families.

Evaluation of a mobile phone-based, advanced symptom management system (ASyMS) in the management of chemotherapy-related toxicity

OBJECTIVES

To evaluate the impact of a mobile phone-based, remote monitoring, advanced symptom management system (ASyMS) on the incidence, severity and distress of six chemotherapy-related symptoms (nausea, vomiting, fatigue, mucositis, hand-foot syndrome and diarrhoea) in patients with lung, breast or colorectal cancer.

DESIGN

A two group (intervention and control) by five time points (baseline, pre-cycle 2, pre-cycle 3, pre-cycle 4 and pre-cycle 5) randomised controlled trial.

SETTING

Seven clinical sites in the UK; five specialist cancer centres and two local district hospitals.

PARTICIPANTS

One hundred and twelve people with breast, lung or colorectal cancer receiving outpatient chemotherapy.

INTERVENTIONS

A mobile phone-based, remote monitoring, advanced symptom management system (ASyMS).

MAIN OUTCOME MEASURES

Chemotherapy-related morbidity of six common chemotherapy-related symptoms (nausea, vomiting, fatigue, mucositis, hand-foot syndrome and diarrhoea).

RESULTS

There were significantly higher reports of fatigue in the control group compared to the intervention group (odds ratio = 2.29, 95%CI = 1.04 to 5.05, P = 0.040) and reports of hand-foot syndrome were on average lower in the control group (odds ratio control/intervention = 0.39, 95%CI = 0.17 to 0.92, P = 0.031).

CONCLUSION

The study demonstrates that ASyMS can support the management of symptoms in patients with lung, breast and colorectal cancer receiving chemotherapy.

Guidelines on the standards for the training of specialised health professionals dealing with breast cancer

According to EUSOMA position paper 'The requirements of a specialist breast unit', each breast unit should have a core team made up of health professionals who have undergone specialist training in breast cancer. In this paper, on behalf of EUSOMA, authors have identified the standards of training in breast cancer, to harmonise and foster breast care training in Europe. The aim of this paper is to contribute to the increase in the level of care in a breast unit, as the input of qualified health professionals increases the quality of breast cancer patient care.

A Systematic Review of Worldwide Cancer Nursing Research

The aim of this study was to assess the cancer nursing research papers published in the past decade; identify their characteristics in terms of country of origin, participants, settings, diagnostic foci, and methodologic choices; and evaluate their quality. A systematic review was carried out of all published papers in the Cumulative Index of Nursing and Allied Health Literature between the years 1994 and 2003, using the keywords "cancer," "nursing," and "research." A total of 619 papers met inclusion criteria and were evaluated by 5 researchers. Almost half the papers were derived from the United States (49.1%), followed by the UK, Sweden, Canada, and Australia. In more than half of the published papers (52.2%), health professionals (mostly nurses) were the studies' participants. Also, much of the published research used patients with mixed diagnosis, or patients with breast or hematologic cancers. Two-thirds of the studies were quantitative, whereas most studies were descriptive in nature. The quality of both quantitative and qualitative studies was low, with only a small percentage meeting the highest quality criteria. Studies reporting funding and those published in journals with an impact factor showed a higher quality score than those not reporting funding or not published in journals with an impact factor. Cancer nursing research is still in a developmental stage, although it has made a considerable contribution to the evidence base of the discipline. A number of issues need to be tackled before we improve our output, such as organizational or workforce issues, infrastructure support, funding, and methodologic challenges.

EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphomas and solid tumours

Chemotherapy-induced neutropenia is not only a major risk factor for infection-related morbidity and mortality, but is also a significant dose-limiting toxicity in cancer treatment. Patients developing severe (grade 3/4) or febrile neutropenia (FN) during chemotherapy frequently receive dose reductions and/or delays to their chemotherapy. This may impact on the success of treatment, particularly when treatment intent is either curative or to prolong survival. The incidence of severe or FN can be reduced by prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs), such as filgrastim, lenograstim or pegfilgrastim. However, the use of G-CSF prophylactic treatment varies widely in clinical practice, both in the timing of therapy and in the patients to whom it is offered. While several academic groups have produced evidence-based clinical practice guidelines in an effort to standardise and optimise the management of FN, there remains a need for generally applicable, European-focused guidelines. To this end, we undertook a systematic literature review and formulated recommendations for the use of G-CSF in adult cancer patients at risk of chemotherapy-induced FN. We recommend that patient-related adverse risk factors such as elderly age (>or=65 years), be evaluated in the overall assessment of FN risk prior to administering each cycle of chemotherapy. In addition, when using a chemotherapy regimen associated with FN in >20% patients, prophylactic G-CSF is recommended. When using a chemotherapy regimen associated with FN in 10-20% patients, particular attention should be given to patient-related risk factors that may increase the overall risk of FN. In situations where dose-dense or dose-intense chemotherapy strategies have survival benefits, prophylactic G-CSF support is recommended. Similarly, if reductions in chemotherapy dose intensity or density are known to be associated with a poor prognosis, primary G-CSF prophylaxis may be used to maintain chemotherapy. Finally, studies have shown that filgrastim, lenograstim and pegfilgrastim have clinical efficacy and we recommend the use of any of these agents to prevent FN and FN-related complications, where indicated.