Cochrane review summary for cancer nursing : influenza vaccination in children having chemotherapy for cancer

Background: Children having chemotherapy for cancer are prone to developing influenza infections. Influenza virus infection may lead to hospitalization/prolonged hospitalization, interruption of treatment, and other severe adverse outcomes such as death. Although clinical guidelines recommend children who are being treated for cancer be vaccinated against influenza, evidence supporting this recommendation is unclear.--------- Objectives: The objectives of this review were to (1) assess the efficacy of influenza vaccination in stimulating immunologic response in children with cancer receiving chemotherapy, compared with other control groups; (2) assess the efficacy of influenza vaccination in preventing influenza infection; and (3) establish any adverse effects associated with influenza vaccines in children with cancer.

The differential impact of holocaust trauma across three generations

In the current thesis, the reasons for the differential impact of Holocaust trauma on Holocaust survivors, and the differential intergenerational transmission of this trauma to survivors’ children and grandchildren were explored. A model specifically related to Holocaust trauma and its transmission was developed based on trauma, family systems and attachment theories as well as theoretical and anecdotal conjecture in the Holocaust literature. The Model of the Differential Impact of Holocaust Trauma across Three Generations was tested firstly by extensive meta-analyses of the literature pertaining to the psychological health of Holocaust survivors and their descendants and secondly via analysis of empirical study data. The meta-analyses reported in this thesis represent the first conducted with research pertaining to Holocaust survivors and grandchildren of Holocaust survivors. The meta-analysis of research conducted with children of survivors is the first to include both published and unpublished research. Meta-analytic techniques such as meta-regression and sub-set meta-analyses provided new information regarding the influence of a number of unmeasured demographic variables on the psychological health of Holocaust survivors and descendants. Based on the results of the meta-analyses it was concluded that Holocaust survivors and their children and grandchildren suffer from a statistically significantly higher level or greater severity of psychological symptoms than the general population. However it was also concluded that there is statistically significant variation in psychological health within the Holocaust survivor and descendant populations. Demographic variables which may explain a substantial amount of this variation have been largely under-assessed in the literature and so an empirical study was needed to clarify the role of demographics in determining survivor and descendant mental health. A total of 124 participants took part in the empirical study conducted for this thesis with 27 Holocaust survivors, 69 children of survivors and 28 grandchildren of survivors. A worldwide recruitment process was used to obtain these participants. Among the demographic variables assessed in the empirical study, aspects of the survivors’ Holocaust trauma (namely the exact nature of their Holocaust experiences, the extent of family bereavement and their country of origin) were found to be particularly potent predictors of not only their own psychological health but continue to be strongly influential in determining the psychological health of their descendants. Further highlighting the continuing influence of the Holocaust was the finding that number of Holocaust affected ancestors was the strongest demographic predictor of grandchild of survivor psychological health. Apart from demographic variables, the current thesis considered family environment dimensions which have been hypothesised to play a role in the transmission of the traumatic impact of the Holocaust from survivors to their descendants. Within the empirical study, parent-child attachment was found to be a key determinant in the transmission of Holocaust trauma from survivors to their children and insecure parent-child attachment continues to reverberate through the generations. In addition, survivors’ communication about the Holocaust and their Holocaust experiences to their children was found to be more influential than general communication within the family. Ten case studies (derived from the empirical study data set) are also provided; five Holocaust survivors, three children of survivors and two grandchildren of survivors. These cases add further to the picture of heterogeneity of the survivor and descendant populations in both experiences and adaptations. It is concluded that the legacy of the Holocaust continues to leave its mark on both its direct survivors and their descendants. Even two generations removed, the direct and indirect effects of the Holocaust have yet to be completely nullified. Research with Holocaust survivor families serves to highlight the differential impacts of state-based trauma and the ways in which its effects continue to be felt for generations. The revised and empirically tested Model of the Differential Impact of Holocaust Trauma across Three Generations presented at the conclusion of this thesis represents a further clarification of existing trauma theories as well as the first attempt at determining the relative importance of both cognitive, interpersonal/interfamilial interaction processes and demographic variables in post-trauma psychological health and transmission of traumatic impact.

Rumination, post-traumatic growth, and distress : structural equation modelling with cancer survivors

Objective Theoretical models of post-traumatic growth (PTG) have been derived in the general trauma literature to describe the post-trauma experience that facilitates the perception of positive life changes. To develop a statistical model identifying factors that are associated with PTG, structural equation modelling (SEM) was used in the current study to assess the relationships between perception of diagnosis severity, rumination, social support, distress, and PTG. Method A statistical model of PTG was tested in a sample of participants diagnosed with a variety of cancers (N=313). Results An initial principal components analysis of the measure used to assess rumination revealed three components: intrusive rumination, deliberate rumination of benefits, and life purpose rumination. SEM results indicated that the model fit the data well and that 30% of the variance in PTG was explained by the variables. Trauma severity was directly related to distress, but not to PTG. Deliberately ruminating on benefits and social support were directly related to PTG. Life purpose rumination and intrusive rumination were associated with distress. Conclusions The model showed that in addition to having unique correlating factors, distress was not related to PTG, thereby providing support for the notion that these are discrete constructs in the post-diagnosis experience. The statistical model provides support that post-diagnosis experience is simultaneously shaped by positive and negative life changes and that one or the other outcome may be prevalent or may occur concurrently. As such, an implication for practice is the need for supportive care that is holistic in nature.

Teachers’ knowledge of anxiety and identification of excessive anxiety in children

This study examined primary school teachers’ knowledge of anxiety and excessive anxiety symptoms in children. Three hundred and fifteen primary school teachers completed a questionnaire exploring their definitions of anxiety and the indications they associated with excessive anxiety in primary school children. Results showed that teachers had an understanding of what anxiety was in general but did not consistently distinguish normal anxiety from excessive anxiety, often defining all anxiety as a negative experience. Teachers were able to identify symptoms of excessive anxiety in children by recognizing anxiety-specific and general problem indications. The results provided preliminary evidence that teachers’ knowledge of anxiety and anxiety disorders does not appear to be a barrier in preventing children’s referrals for mental health treatment. Implications for practice and directions for future research are discussed.

Defining the parental burden of acute cough in children

Despite the prevalence of acute cough in children (<2 weeks duration), the burden to parents and families is largely unknown. The objectives of this study were to determine the parental burden of children’s acute cough, and to evaluate psychological and other infl uences on the reported burden of acute cough in children. Methods Parents of children with a current acute cough (<2 weeks) at enrolment completed 4 questionnaires (state trait anxiety inventory (STAI); short form health survey (SF-8); depression, anxiety and stress 21-item scale (DASS21); and our preliminary 48-item parent acute cough specifi c quality of life (PAC-QOL48) questionnaire). In PAC-QOL48, lower scores refl ect worse QOL. Results Median age of the 104 children enrolled was 2.63 (IQR 1.42, 4.79) years, 54 were boys. Median length of cough at enrolment was 3 (IQR 2, 5) days. Median total PAC-QOL48 score of parents enrolled at presentation to the emergency department (n = 70) was signifi cantly worse than of parents enrolled through the community (n = 24) (p < 0.01). More than half (n = 55) had sought medical assistance more than once for the current acute coughing illness. PAC-QOL48 score was signifi cantly negatively correlated to verbal category descriptive and visual analogue scale cough scores (Spearman r = −0.26, p = 0.05 and r = −0.46, p = 0.01 respectively) and DASS21 total score (r = −0.36, p = 0.01), but not to child’s age. Conclusions Consistent with data on chronic cough, stress was the predominant factor of parental burden. This study highlights the ongoing need for clinicians to be cognizant of parental worries and concerns when their children are coughing, and for further research into safe and effective therapies for acute cough in children.

Antibiotics for bronchiectasis exacerbations in children: rationale and study protocol for a randomised placebo-controlled trial

Background Despite bronchiectasis being increasingly recognised as an important cause of chronic respiratory morbidity in both indigenous and non-indigenous settings globally, high quality evidence to inform management is scarce. It is assumed that antibiotics are efficacious for all bronchiectasis exacerbations, but not all practitioners agree. Inadequately treated exacerbations may risk lung function deterioration. Our study tests the hypothesis that both oral azithromycin and amoxicillin-clavulanic acid are superior to placebo at improving resolution rates of respiratory exacerbations by day 14 in children with bronchiectasis unrelated to cystic fibrosis. Methods We are conducting a bronchiectasis exacerbation study (BEST), which is a multicentre, randomised, double-blind, double-dummy, placebo-controlled, parallel group trial, in five centres (Brisbane, Perth, Darwin, Melbourne, Auckland). In the component of BEST presented here, 189 children fulfilling inclusion criteria are randomised (allocation-concealed) to receive amoxicillin-clavulanic acid (22.5 mg/kg twice daily) with placebo-azithromycin; azithromycin (5 mg/kg daily) with placebo-amoxicillin-clavulanic acid; or placebo-azithromycin with placebo-amoxicillin-clavulanic acid for 14 days. Clinical data and a paediatric cough-specific quality of life score are obtained at baseline, at the start and resolution of exacerbations, and at day 14. In most children, blood and deep nasal swabs are also collected at the same time points. The primary outcome is the proportion of children whose exacerbations have resolved at day 14. The main secondary outcome is the paediatric cough-specific quality of life score. Other outcomes are time to next exacerbation; requirement for hospitalisation; duration of exacerbation; and spirometry data. Descriptive viral and bacteriological data from nasal samples and blood markers will also be reported. Discussion Effective, evidence-based management of exacerbations in people with bronchiectasis is clinically important. Yet, there are few randomised controlled trials (RCTs) in the neglected area of non-cystic fibrosis bronchiectasis. Indeed, no published RCTs addressing the treatment of bronchiectasis exacerbations in children exist. Our multicentre, double-blind RCT is designed to determine if azithromycin and amoxicillin-clavulanic acid, compared with placebo, improve symptom resolution on day 14 in children with acute respiratory exacerbations. Our planned assessment of the predictors of antibiotic response, the role of antibiotic-resistant respiratory pathogens, and whether early treatment with antibiotics affects duration and time to the next exacerbation, are also all novel.

Bronchiectasis exacerbation study on azithromycin and amoxycillin-clavulanate for respiratory exacerbations in children (BEST-2) : study protocol for a randomized controlled trial

Background Bronchiectasis unrelated to cystic fibrosis (CF) is being increasingly recognized in children and adults globally, both in resource-poor and in affluent countries. However, high-quality evidence to inform management is scarce. Oral amoxycillin-clavulanate is often the first antibiotic chosen for non-severe respiratory exacerbations, because of the antibiotic-susceptibility patterns detected in the respiratory pathogens commonly associated with bronchiectasis. Azithromycin has a prolonged half-life, and with its unique anti-bacterial, immunomodulatory, and anti-inflammatory properties, presents an attractive alternative. Our proposed study will test the hypothesis that oral azithromycin is non-inferior (within a 20% margin) to amoxycillin-clavulanate at achieving resolution of non-severe respiratory exacerbations by day 21 of treatment in children with non-CF bronchiectasis. Methods This will be a multicenter, randomized, double-blind, double-dummy, placebo-controlled, parallel group trial involving six Australian and New Zealand centers. In total, 170 eligible children will be stratified by site and bronchiectasis etiology, and randomized (allocation concealed) to receive: 1) azithromycin (5 mg/kg daily) with placebo amoxycillin-clavulanate or 2) amoxycillin-clavulanate (22.5 mg/kg twice daily) with placebo azithromycin for 21 days as treatment for non-severe respiratory exacerbations. Clinical data and a parent-proxy cough-specific quality of life (PC-QOL) score will be obtained at baseline, at the start and resolution of exacerbations, and on day 21. In most children, blood and deep-nasal swabs will also be collected at the same time points. The primary outcome is the proportion of children whose exacerbations have resolved at day 21. The main secondary outcome is the PC-QOL score. Other outcomes are: time to next exacerbation; requirement for hospitalization; duration of exacerbation, and spirometry data. Descriptive viral and bacteriological data from nasal samples and blood inflammatory markers will be reported where available. Discussion Currently, there are no published randomized controlled trials (RCT) to underpin effective, evidence-based management of acute respiratory exacerbations in children with non-CF bronchiectasis. To help address this information gap, we are conducting two RCTs. The first (bronchiectasis exacerbation study; BEST-1) evaluates the efficacy of azithromycin and amoxycillin-clavulanate compared with placebo, and the second RCT (BEST-2), described here, is designed to determine if azithromycin is non-inferior to amoxycillin-clavulanate in achieving symptom resolution by day 21 of treatment in children with acute respiratory exacerbations. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR) number ACTRN12612000010897. http://www.anzctr.org.au/trial_view.aspx?id=347879

The development of chronic cough in children following presentation to a tertiary paediatric emergency department with acute respiratory illness : study protocol for a prospective cohort study

Background Acute respiratory illness, a leading cause of cough in children, accounts for a substantial proportion of childhood morbidity and mortality worldwide. In some children acute cough progresses to chronic cough (> 4 weeks duration), impacting on morbidity and decreasing quality of life. Despite the importance of chronic cough as a cause of substantial childhood morbidity and associated economic, family and social costs, data on the prevalence, predictors, aetiology and natural history of the symptom are scarce. This study aims to comprehensively describe the epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children presenting to a tertiary paediatric emergency department. Methods/design A prospective cohort study of children aged <15 years attending the Royal Children's Hospital Emergency Department, Brisbane, for a respiratory illness that includes parent reported cough (wet or dry) as a symptom. The primary objective is to determine the prevalence and predictors of chronic cough (>= 4 weeks duration) post presentation with acute respiratory illness. Demographic, epidemiological, risk factor, microbiological and clinical data are completed at enrolment. Subjects complete daily cough dairies and weekly follow-up contacts for 28(+/-3) days to ascertain cough persistence. Children who continue to cough for 28 days post enrolment are referred to a paediatric respiratory physician for review. Primary analysis will be the proportion of children with persistent cough at day 28(+/-3). Multivariate analyses will be performed to evaluate variables independently associated with chronic cough at day 28(+/-3). Discussion Our protocol will be the first to comprehensively describe the natural history, epidemiology, aetiology and outcomes of cough during and after acute respiratory illness in children. The results will contribute to studies leading to the development of evidence-based clinical guidelines to improve the early detection and management of chronic cough in children during and after acute respiratory illness.

Does a 10-valent pneumococcal-Haemophilus influenzae protein D conjugate vaccine prevent respiratory exacerbations in children with recurrent protracted bacterial bronchitis, chronic suppurative lung disease and bronchiectasis : protocol for a randomised controlled trial

Background Recurrent protracted bacterial bronchitis (PBB), chronic suppurative lung disease (CSLD) and bronchiectasis are characterised by a chronic wet cough and are important causes of childhood respiratory morbidity globally. Haemophilus influenzae and Streptococcus pneumoniae are the most commonly associated pathogens. As respiratory exacerbations impair quality of life and may be associated with disease progression, we will determine if the novel 10-valent pneumococcal-Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) reduces exacerbations in these children. Methods A multi-centre, parallel group, double-blind, randomised controlled trial in tertiary paediatric centres from three Australian cities is planned. Two hundred six children aged 18 months to 14 years with recurrent PBB, CSLD or bronchiectasis will be randomised to receive either two doses of PHiD-CV or control meningococcal (ACYW(135)) conjugate vaccine 2 months apart and followed for 12 months after the second vaccine dose. Randomisation will be stratified by site, age (<6 years and >= 6 years) and aetiology (recurrent PBB or CSLD/bronchiectasis). Clinical histories, respiratory status (including spirometry in children aged >= 6 years), nasopharyngeal and saliva swabs, and serum will be collected at baseline and at 2, 3, 8 and 14 months post-enrolment. Local and systemic reactions will be recorded on daily diaries for 7 and 30 days, respectively, following each vaccine dose and serious adverse events monitored throughout the trial. Fortnightly, parental contact will help record respiratory exacerbations. The primary outcome is the incidence of respiratory exacerbations in the 12 months following the second vaccine dose. Secondary outcomes include: nasopharyngeal carriage of H. influenzae and S. pneumoniae vaccine and vaccine-related serotypes; systemic and mucosal immune responses to H. influenzae proteins and S. pneumoniae vaccine and vaccine-related serotypes; impact upon lung function in children aged >= 6 years; and vaccine safety. Discussion As H. influenzae is the most common bacterial pathogen associated with these chronic respiratory diseases in children, a novel pneumococcal conjugate vaccine that also impacts upon H. influenzae and helps prevent respiratory exacerbations would assist clinical management with potential short- and long-term health benefits. Our study will be the first to assess vaccine efficacy targeting H. influenzae in children with recurrent PBB, CSLD and bronchiectasis.

Cough formation in viral infections in children

Using a multidisciplinary approach, Human Respiratory Viral Infections is set at the level between the definitive reference work and an essential clinical manual. Exploring recent advances in human respiratory viral research, the text builds on the basic sciences of epidemiology, virology, molecular biology, and immunology to cover clinical diagnosis, mechanism of pathogenesis, manifestations of disease, impact, treatment, and management strategies.

The role of chemotherapy in the treatment of adult soft tissue sarcomas

Adult soft tissue sarcomas are relatively rare tumours which are curable with radical surgery. Approximately 50% of patients will develop inoperable disease or metastases for which chemotherapy may be inappropriate. Only two cytotoxic agents - doxorubicin and ifosfamide - have activity in > 20% of patients. For both these agents there is evidence of a dose-response relationship. There is currently no good evidence that combination chemotherapy confers a clinical benefit compared with single agents. Outside a clinical trial, standard first-line therapy should be with single agent doxorubicin at a dose intensity ≥ 70 mg2 every 3 weeks. Approximately 25% of patients may be expected to respond to this regimen. There is the suggestion that responses may occur to ifosfamide in patients who progress on doxorubicin. The role of chemotherapy in the adjuvant setting remains uncertain. Several trials have suggested a modest relapse-free and overall survival benefit for the use of post-operative chemotherapy and a recent overview of 14 randomised trials confirms a small though significant benefit. These benefits have to be weighed against the toxicity of chemotherapy. The importance of treating all patients with soft tissue sarcomas in clinical trials is stressed. There is an urgent need to define new active agents to treat this disease.

A randomised controlled trial of amniotic membrane in the treatment of a standardised burn injury in the merino lamb

Burn injury is associated with disabling scar formation which impacts on many aspects of the patient's life. Previously we have shown that the fetus heals a deep dermal burn in a scarless fashion. Amniotic membrane (AM) is the outermost fetal tisue and has beeen used as a dressing in thermal injuries, though there is little data to support this use. To assess the efficacy of AM in scar minimisation after deep dermal burn wound, we conducted a randomised controlled study in the 1-month lamb. Lambs were delivered by caesarian section and the amniotic membranes stored after which lambs were returned to their mothers post-operatively. At 1 month, a standardised deep dermal burn was created under general anaesthesia on both flanks of the lamb. One flank was covered with unmatched AM, the other with paraffin gauze. Animals were sequentially euthanased from Day 3-60 after injury and tissue analysed for histopathology and immunohistochemically for alpha-smooth muscle actin (alphaSMA) content. AM resulted in reduced scar tissue as assessed histopathologically and reduced alphaSMA content. This study provides the first laboratory evidence that AM may reduce scar formation after burn injury.

Comparison of three different dressings for partial thickness burns in children : study protocol for a randomised controlled trial

BACKGROUND: In the paediatric population, pain and distress associated with burn injuries during wound care procedures remain a constant challenge. Although silver dressings are the gold standard for burn care in Australasia, very few high-level trials have been conducted that compare silver dressings to determine which will provide the best level of care clinically. Therefore, for paediatric patients in particular, identifying silver dressings that are associated with lower levels of pain and rapid wound re-epithelialisation is imperative. This study will determine whether there is a difference in time to re-epithelialisation and pain and distress experienced during wound care procedures among Acticoat, Acticoat combined with Mepitel and Mepilex Ag dressings for acute, paediatric partial thickness burns. METHODS/DESIGN: Children aged 0 to 15 years with an acute partial thickness (superficial partial to deep partial thickness inclusive) burn injury and a burn total body surface area of ing groups: (1) Acticoat or (2) Acticoat combined with Mepitel or (3) Mepilex Ag. A minimum of 28 participants will be recruited for each treatment group. Primary measures of pain, distress and healing will be repeated at each dressing change until complete wound re-epithelialisation occurs or skin grafting is required. Additional data collected will include infection status at each dressing change, physical function, scar outcome and scar management requirements, cost effectiveness of each dressing and staff perspectives of the dressings. DISCUSSION: The results of this study will determine the effects of three commonly used silver and silicone burn dressing combinations on the rate of wound re-epithelialisation and pain experienced during dressing procedures in acute, paediatric partial thickness burn injuries. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000105741.

One tune, three dances : using a traumatic stress framework to understand trauma survivors as networked news sources

Newman and Nelson (2012) describe three ‘dances’ to explain the vacillating psychological states of trauma survivors: the dance of approach and avoidance; the dance of fragmentation and integration; and the dance of resilience and vulnerability. The first pair of seemingly opposite responses describes how survivors at times cope by ‘approaching’ the trauma, for example by gathering information about what happened; whilst at other times, the same person will cope by ‘avoiding’ the trauma by engaging in activities which distract them from the memory of the trauma or having to deal with the consequences of it. The ‘dance’ of fragmentation and integration describes the opposing individual or group experiences encountered after traumas or disasters. Individuals may experience fragmentation, or emotional disconnection, from the trauma as an adaptive means of survival. The ‘dance’ of resilience and vulnerability refers to an individual’s ability to ‘process’ trauma and return to a resilient state in which they re-learn to trust people and the world around them and ‘bounce back’ to a state of being resilient again. This paper will illustrate how an understanding of the three dances can be used to enable survivors of child sexual assault to engage with the media to tell their stories. I will give current examples from six months of journalism research, collaboration and writing of a series of news stories and features which broke an exclusive story simultaneously in The Australian and The Times in London during 2013.