This study describes a five-year expansion project to build a nine-story employee garage, a new post-anesthesia care unit, a new cardiothoracic intensive care unit, and expansion of existing operating room space to include eight new operating rooms. The construction plan included demolition of five circa 1910 mostly unused buildings.

One infection control practitioner (ICP) attended a University of Minnesota Health Care Facility Construction Management Indoor Air Quality Workshop.

An infection control education program for contractors was developed that all construction workers were required to complete the training prior to working on the construction project and annually thereafter.
The infection control training takes 30 minutes. The lesson plan is organized by sections that include precautions to take before, during, and after construction work. There also is an audiovisual program about Aspergillus and its transmission and the susceptibility of immunosuppressed patients.

An infection control team including the general contractor, project manager, ICP, and operating room nurse planner make rounds weekly or daily on all projects to monitor for compliance and answer questions. In addition, other precautions were implemented since patients could not be relocated away from the area of greatest activity.

• All windows adjacent to the demolition site were sealed with plastic.
• Prevailing wind direction was monitored, and extra pre-filters were added to all air intakes.
• Any dust generated during demolitions was wetted down.
• Air curtains were added to doorways directly facing the construction.
• Immunosuppressed patients were notified to wear N95 protection when entering the hospital.

Members of the design and construction department are engineers and architects and have attended classes on construction and infection control.

• The University Hospital is a tertiary care hospital in Cincinnati, Ohio. It has a level 1 trauma center, seven intensive care units, including a level 3 perinatal research center and neonatal intensive care unit and an adult burn unit.  
• There is an average daily census of 400.
• Parts of the original hospital were built in 1910, 1927, and 1969.  
• At any one time there are 4–6 major renovation projects.

During the first four years of demolition and renovation, the University Hospital had no nosocomial Aspergillus infections.

In the fifth year, of construction, two patients who had possible hospital-acquired infections were identified. An industrial hygienist was brought in to evaluate intervention and make recommendations, but nothing of concern was found.

Particle sampling remained the same from pre-construction to post-construction.

Both possible nosocomial Aspergillus infections occurred after a building that was connected to the hospital and shared air space began a large renovation project without using infection control prevention.

Hospitals must be aware not only of what is happening inside their own facilities, but also what is happening outside. ICPs must establish collegiality with contractors, architects, maintenance, and engineering personnel to produce an effective, comprehensive infection-prevention atmosphere during construction and renovation.

• Small study of one hospital initiative
• Case study

Evaluate and compare effectiveness of topical vitamin E and pycnogenol (pine bark extract) in treatment of chemotherapy-induced oral mucositis.

Children were randomly assigned to the use of vitamin E, pycnogenol, or sterile water rinses. All were also to follow a uniform oral care protocol, including brushing with a soft tooth brush and chlorhexidine mouth rinse 3 times/day. All study interventions were applied topically three times a day using a dropper. Medications were stored in a refrigerator before usage. The medication was kept in the patient’s mouth for 30 seconds and then swallowed. Patients were blinded to the treatment group. Patients were followed for seven days.

The study was comprised of 72 patients, with a mean age of 9.25 and a range of 6-15 years.

MALES 79%, FEMALES 21%

KEY DISEASE CHARACTERISTICS: All had hematological cancers, including ALL, AML, and NHL, and all were in induction or intensification phases of treatment.

SITE: Single site

SETTING TYPE: Multiple settings

LOCATION: India

PHASE OF CARE: Active antitumor treatment

APPLICATIONS: Pediatrics

 Single, blind, randomized placebo controlled

• WHO oral mucositis grading scale
• Oral Mucositis Assessment Scales (OMAS)
• Children’s International Mucositis Evaluation Scale
   

Mucositis grades in those receiving either vitamin E or pine bark extract were significantly lower than those on placebo (p </= 0.006). OMAS scores declined significantly and consistently across days 1-7, while these scores remained the same in the placebo group. There was significant improvement in pain scores in both intervention groups from day 4 onward, compared to placebo. There were no significant differences in study outcomes between those treated with vitamin E or pine bark.

Topical vitamin E and pine bark extract (pycnogenol) were of benefit in reducing severity of mucositis and pain associated with mucositis in these patients.

• Small sample (<100)
• Risk of bias (no blinding)
• Unintended interventions or applicable interventions not described that would influence results.*
• Other limitations/*explanation. Short study duration. Baseline mucositis scores not described, and it is not known if there were differences between study groups at baseline. ANOVA was used, but it is not clear what the potential time effect was, as mucositis declined in all subjects. Patients were blinded, but evaluators were not. There is no information provided regarding compliance with the oral care regimen, though it is stated that compliance was evaluated, it is not clear how. There is no information provided about use of analgesics.

Topical vitamin E and pine bark extract may have some promise for the management of oral mucositis. Further research on these interventions is warranted.

To evaluate the frequency and evolution of oral mucositis (OM) among stem cell transplant recipients subjected to therapeutic laser versus mucositis formula

Patients (n = 22) were randomly assigned to control or low level laser therapy (LLLT) daily. The treatment phase for both groups began with the initial clinical manifestations of mucositis with follow up until day +15 after transplant. Two types of laser were used on alternate days, one indicated for tissue repair and the other for analgesia.

• The study reported on 22 patients with a mean age of 27.5–32.7 years.
• The sample was 23% female and 77% male.
• Patients had hematologic malignancies and were receiving the myeloablative conditioning regimen and allogeneic stem cell transplant.
• All patients were given preventive treatment consisting of soft-bristled toothbushes and saline rinses four times daily followed by benzidamine solution, which was replaced with a 0.12% chlorhexidine gluconate solution toward the end of the study.
• The control group received the standard of care with the mucositis formula (antiinflammatory [benzidamine], antifungal [nistatin], and anesthetic [neututocain] with distilled water).

This was a single-site conducted in the bone marrow transplant unit (BMTU) of the University Hospital School of Medicine of Ribeirao Preto (UHSMRP) at the University of São Paulo in Brazil.

The study was a randomized controlled trial.

• The World Health Organization (WHO) Oral Toxicity Scale and Oral Mucositis Assessment Scale (OMAS) were used.
• Patients in the laser group completed questionnaires about laser therapy.

The laser treatment group had lower frequency of oral mucositis (p = 0.02) and a lower mean grade of mucositis (p < 0.01).

The inclusion of LLLT was effective in lowering the frequency and treating oral mucositis in patients being treated with high dose myeloablative chemotherapy in preparation for stem cell transplant.

• The sample size was small with fewer than 30 patients.
• The control group did not receive sham treatment, so the study was not blinded.
• Authors did not describe the areas that were treated with lasers.

Laser therapy is effective in the treatment of mucositis, but it is very high tech and requires special equipment and highly trained personnel.

Mesna was given to patients undergoing allogeneic bone marrow transplantation and administered high-dose chemotherapy. Doses were administered at 400 mg/m² at hours 0, 1, 3, 5, 8, 11, 14, 17, and 20. Fluid also was administered at 3,000 mL/m².

• N = 11 patients
• KEY DISEASE CHARACTERISTICS: Four patients had leukemia; others had nonmalignant disorders.

• Prospective, experimental, nonrandomized, convenience sample

• Clinical signs and symptoms
• Daily urinalysis
• Observed drop in hemoglobin level
• Patients evaluated for 60 days

Three patients developed transient but asymptomatic hemorrhagic cystitis. One patient developed late onset but moderate hemorrhagic cystitis.

• Very small sample size
• Only four patients with cancer
• Mesna hours different than published guidelines
• Patients with leukemia not separated in the analysis

To evaluate the effects of transcranial magnetic stimulation on neuropathic pain

Patients with neuropathic pain by standardized assessment were randomized to receive either transcranial magnetic stimulation or sham stimulation. After the identification of optimal scalp location, electrodes were used to apply 20 Hz in pulses every day for 10 consecutive days. Procedures for the actual and sham procedures were the same. Study measurements were done before and after the first, fifth, and tenth sessions, and at 15 days and one month later.

• N = 30
• MEAN AGE = 47.5 years
• MALES: Not provided        
• FEMALES: Not provided
• KEY DISEASE CHARACTERISTICS: Postmastectomy neuropathic pain; soft tissue sarcoma; giant cell glioma

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Egypt

Randomized, sham-controlled trial

• Visual Analog Scale (VAS) for pain

An analysis showed pain reductions in both groups over time, but there were significantly greater pain reductions in the actual stimulation group compared to the sham procedure (p = 0.0001). T tests between groups at each time point showed that there was no real effect of the actual stimulation procedure after the first session. At this point, pain declined and remained stable over time. These effects remained at 15 days but did not remain at one month.

Transcranial stimulation resulted in significant reductions in neuropathic pain. Because the main change occurred after the first session, it was not clear if repeated sessions were beneficial.

• Small sample (< 100)
• Unintended interventions or applicable interventions not described that would influence results
• Other limitations/explanation: No information was provided regarding analgesic use.

The findings of this study suggested that transcranial stimulation can reduce neuropathic pain in patients with cancer. This is a noninvasive technique that may provide an important alternative for pain control. Additional research is needed to determine most effective dosing, timing, and efficacy in comparison to other interventions.

To assess effectiveness of an ambulatory rehabilitation program for women with breast cancer

A sample of patients referred to a rehabilitation center was selected based on criteria of diagnosis of breast cancer, considered to be disease free. Patients were then randomly assigned to an intervention group or a control group that continued with usual activity in the community. The rehabilitation program was conducted three to five days per week for up to eight weeks and was aimed at improving activity and participation in activities. Interventions included physiotherapy, lymphedema care, occupational therapy, and clinical psychology for counseling and support. Study assessments were done at baseline and at four months after program completion.

• The study reported on a sample of 79 female patients with breast cancer.
• Median patient age was 57 years (range = 33–80).
• About half of the patients had undergone mastectomy, while 66% in the intervention group and 55% in the control group had undergone lumpectomy. More patients in the intervention group had received chemotherapy, and slightly more than 70% in both groups had received radiotherapy.
• More than half (62%) of patients were married or partnered; 63% in the intervention group versus 38% in the control group had tertiary level education.
• At baseline, depression scores were higher in the intervention group.
• Duration of disease was 2.3 years in the intervention group and 4.0 years among controls, ranging from < 1 to 24 years.

• Single site
• Outpatient setting
• Australia

Patients were undergoing multiple phases of care.

A randomized, single-blind, controlled trial design was used.

• Depression Anxiety Distress Scale
• Perceived Impact of Problems Profile
• Cancer Rehabilitation Evaluation System Short Form
• Functional Independent Measure (FIM)

Out of 42 patients, 31 completed the rehabilitation program. Over the study period, more patients in the treatment group showed a decrease in depression scores compared with the control group (p = 0.02). Intervention group patients also showed significant differences in impact profile scores (p = 0.05). There were no differences between groups in anxiety or FIM scores.

Findings suggest that comprehensive multidisciplinary rehabilitation may improve depression among women with breast cancer.

• The study had a small sample size, with less than 100 participants.
• The study had baseline sample/group differences of import that could have influenced results.
• Risk of bias existed due to no blinding, no appropriate attentional control condition, and sample characteristics.
• Subject withdrawals were ≥ 10%.
• Of the intervention group patients, 26% did not complete the rehabilitation program, leading to the question of practicality and acceptability of this approach for patients.
• Intervention group patients were more depressed at baseline; other studies have shown that interventions for depression tend to work better for individuals who actually have clinically relevant depression. It is not known if there could have been a floor effect in measurement used.
• Intervention group patients were more educated. 
• More control group patients had symptoms such as phantom breast sensations and phantom breast pain, which might have influenced findings.
• Given differences in the prevalence of some demographic factors, it is surprising that differences were not significant. 
• There was a very broad range of time since diagnosis, suggesting very broad differences in the sample that were not taken into account.

Some patients may benefit from a multidisciplinary rehabilitation program after breast cancer treatment. This study provides some evidence in support of this approach, but has several limitations. Further research is needed to determine the benefit versus cost of such programs.

To evaluate the effectiveness of a multidisciplinary rehabilitation program for individuals after treatment for primary brain tumors

Patients were assigned to treatment or wait-list control comparison groups according to an assessment of their needs by the clinical provider. The rehabilitation treatment team was blinded to study group assignment. The intervention included individualized 30-minute therapy sessions with social, psychological, occupational, and physical therapy in half-hour sessions two to three times a week for as many as eight weeks. The individualized intervention incorporated elements of education, health promotion, intensive mobilization, and task reacquisition programs as determined appropriate by the rehabilitation team. Study assessments were done at baseline and at three and six months. Functional independence measures were the primary outcomes of the study.

• N = 106 (85 completed the six-month assessment)
• MEAN AGE = 51.4 years (range = 21–77 years)
• MALES: 43%, FEMALES: 57%
• KEY DISEASE CHARACTERISTICS: Primary brain tumors with a median time since diagnosis of 2.1 years; all received initial treatment involving surgery, chemotherapy, and/or radiation therapy; 53% of subjects in both groups had World Health Organization grade III or IV tumors and similar rates of steroid use; intervention group reported more symptoms at baseline (i.e., ataxia, cognitive impairment, seizures, paresis, visual impairment, dysphasia, dysarthria, sensory-perceptual deficits, bowel or bladder dysfunction) than the wait-list control group; proportion of patients with ataxia, dysarthria, and visual impairment was significantly larger in the intervention group
• OTHER KEY SAMPLE CHARACTERISTICS: More than 80% of participants in both groups were living with a partner, and the majority had at least a secondary level education.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Australia

• PHASE OF CARE: Transition phase after active treatment

Prospective trial

• Visual Analog Scale (VAS) for pain
• Cancer Rehabilitation Evaluation System Short Form (CARES-SF)
• Depression Anxiety Stress Scale (DASS)
• Functional Independence Measures (FIM) for motor skills and cognition
• Perceived Impact of Problem Profile (PIPP)

At three months, FIM Motor (self-care, sphincter, location, and mobility subscales) and FIM Cognition (communication and psychosocial subscales) scores were significantly improved in the treatment group compared to the control group. At six months, the FIM Motor (sphincter subscale) and FIM Cognition (communication, psychosocial, and cognition subscales) scores were significantly improved in the treatment group compared to the control group. There were no significant differences between groups in DASS measures of anxiety or depression from baseline to three or six months. There also were no differences observed between groups in PIPP results from baseline to three or six months, which measured the impact of functional areas also on the FIM. The greatest improvements seen were at the three-month follow-up date.

The findings of this study demonstrated that multicomponent rehabilitation can improve measures of self-care and some specific areas of motor and cognitive function.

• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)
• Selective outcomes reporting
• Key sample group differences that could influence results
• Measurement validity/reliability questionable 
• Findings not generalizable
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: Functional independence was higher at baseline in the wait-list control group by study design, because those with more obvious needs were given the intervention immediately. Therefore, the scoring of function by the control group may have been subject to a ceiling effect in the study measure. Results regarding motor and cognitive function were based on single subscales of the FIM assessment measure with no confirmatory data from a more objective measurement. It is not clear how many patients may have been receiving chemotherapy or radiation therapy during the timeframe of this study, which also could have affected outcome measurements. The fact that findings on perception of impact did not align with FIM results calls into question the overall reliability of findings. The findings are specific to patients with brain tumors and are not necessarily generalizable to other groups.

The findings of this study showed some functional benefits of multicomponent rehabilitation for patients with primary brain tumors. This study was limited by its design and the clinical nature of rehabilitation aimed to provide individualized interventions on the basis of needs assessed by care providers. This suggests that patients may benefit in the areas of self-care. The degree to which these benefits are maintained over time is not clear from this study.

To compare the efficacy and safety of sublingual metopimazine to ondansetron orally disintegrating tablet (ODT) in patients receiving highly emetogenic chemotherapy (HEC) for the prevention of delayed (not acute) chemotherapy-induced nausea and vomiting (CINV)

Participants were randomized to one of two treatment arms. In group 1, patients received 7.5 mg sublingual metopimazine every eight hours on days 2–6, and, in group 2, patients received ODT ondansetron on days 2–6.

• The study consisted of 210 participants.
• The sublingual metopimazine group had 103 patients, and the ODT ondansetron group had 97 patients.

• Patients recorded symptoms in daily diaries.
• The Functional Living Index–Emesis (FLIE) was used.

No significant differences were found between the two groups in control of delayed CINV, quality of life (QOL), or safety; however, control of delayed CINV was inferior compared to other studies.

• This study evaluated an “old” regimen that has since been considered suboptimal care per current consensus guidelines because of availability of newer, superior agents.
• Corticosteroids were not allowed in the study.
• The overall dose of metopimazine was low (ineffective).

To compare granisetron plus dexamethasone to granisetron alone in the prevention of acute emesis

Patients were randomly assigned to receive either granisetron alone or in combination with dexamethasone. One group received a single IV dose of 3 mg granisetron and the other group received 3 mg IV granisetron and 8 mg IV dexamethasone 30 minutes prior to chemotherapy. Patients were evaluated for 24 hours. Efficacy was determined according to a scale established by investigators.

• The study consisted of 125 participants, 63 in the granisetron only group (group 1) and 62 in the granisetron plus dexamethasone group (group 2).
• Median age was 64 years old in group 1, with a range of 40–72 years, and 63 years old in group 2, with a range of 20–70 years.
• The granisetron group was 33% female and the granisetron plus dexamethasone group was 40% female.
• Cancer diagnoses were GI, breast, and hematologic.
• The majority of patients (79% in group 1 and 77% in group 2) were receiving more than 60 mg/m² of cisplatin.

The study was conducted at a single setting in Iran.

All patients were in active treatment.

This was a randomized, single-blind, prospective study.

The number of emetic episodes was recorded. Complete response was defined as no emetic episodes.

The investigators developed a scale to record efficacy of the intervention with \"moderately effective\" defined as \"did not interfere with daily life,\" \"slightly effective\" as \"interfered with normal daily life,\" and \"not effective\" as \"bedridden due to nausea.\"

A higher percentage of patients (66.7%) in the group receiving both granisetron and dexamethasone had 0 emesis episodes, compared to fewer than half (42.8%) of patients who received granisetron alone (p < 0.0001).

The combination of granisetron plus dexamethasone was superior to granisetron alone for prevention of acute emesis.

• Minimal information was provided on the chemotherapeutic regimens used.
• The authors did not indicate if patients were chemotherapy naïve.
• Some data, such as age ranges and average reported, were different in the abstract than the body of the article, leading to questionable overall report.
• No valid, common measure of nausea and vomiting was used, and how this was recorded was not clear.

Findings indicate that dexamethasone should be included in antiemetic regimens, which is consistent with current care standards.

To test the feasibility and effectiveness of a computerized home-based cognitive intervention program

Subjects were randomly assigned to the intervention group or a wait-list control group. The intervention was a 12-week computerized training program (Lumos Labs) using the subjects' home computers. It included 48 sessions that were 20-30 minutes long, involving combinations of 13 exercises to improve executive function. Subjects were assigned five exercises to complete four times per week. Exercises were designed for practice and training in cognitive flexibility, working memory, processing speed, and verbal fluency.  Completion, duration and performance of exercises were recorded in the computer system, providing an adherence measure. Outcome measures were collected at baseline and within three days of intervention completion; wait-list controls had pre-post measures taken 12 weeks apart.

• N = 41    
• MEAN AGE = 55.5 years (SD = 0.5 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All subjects had stage I-IIIA  breast cancer, received surgical intervention and adjuvant chemotherapy, and completed treatment at least 18 months prior to study participation.
• OTHER KEY SAMPLE CHARACTERISTICS: Subjects had at least a high school education; 60%-70% also received radiation therapy and hormonal therapies.

• SITE: Single site    
• SETTING TYPE: Home  

PHASE OF CARE: Late effects and survivorship

Randomized controlled trial

• Wisconsin Card Sorting Test (WCST)
• Delis-Kaplan Executive Functions System, Letter Fluency Test
• Hopkins Verbal Learning Test Revised
• Wechsler Adult Intelligence Scale (digit span and symbol search subscales)
• Behavioral Rating Inventory of Executive Function (Global Executive Composite score)
• Clinical Assessment of Depression

There was 95% compliance with the training program. The intervention group had significant improvement as shown by Cohen’s d, the WCST (EF = 0.58, P = .008), the Letter Fluency Test (EF = 0.82, P = .003), and symbol search (EF = 0.87, P = .009). While there were no significant effects of age, education, radiation, or hormonal treatment, presence of depressive symptoms had a significant effect on self-reported global executive function.

This approach for training and home-based exercises is feasible, and compliance was high. The program was effective for improving some components of executive function. Further study with longitudinal measures is warranted to demonstrate maintained improvements in cognitive function after program completion or if continued program use is needed to maintain any improvements.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable
• Intervention expensive, impractical, or needs training
• The computerized training cost was covered by the research study; however, it is commercially available for individual cost, which may be an issue for some patients. The sample was a homogenous group of patients, potentially limiting generalizability to other patient groups.

The commercially available computerized “brain training” program studied here improved components of executive function after 12 weeks. This approach was associated with high patient compliance. Nurses can suggest that patients complaining of cognitive impairment consider trying this program.