The purpose of this study was to describe health promotion behaviors and work productivity loss in informal caregivers of individuals with advanced stage cancer. Using a cross-sectional, correlational design, 70 caregivers completed measures of health behaviors, mood, social support, and burden. Absenteeism and presenteeism were evaluated in employed caregivers (n = 40). Caregivers reported low levels of physical activity. The mean percentage of work productivity loss due to caregiving was 22.9%. Greater work productivity loss was associated with greater number of caregiving hours, higher cancer stage, married status, and greater anxiety, depression, and burden related to financial problems, disrupted schedule, and health. Nurses should assess caregivers and provide health promotion interventions, which may ultimately reduce the economic impact of caregiving.

The purpose of this study was to describe nurses' knowledge, attitudes, and experiences regarding advance directives. A secondary purpose was to examine predictors of advance directive discussions between nurses and patients. Seven-hundred and nineteen respondents, randomly selected from a list of registered nurses in the state of Ohio, completed mailed questionnaires. Descriptive t test, chi-square, and logistic regression statistics were used in the data analyses. The respondents were knowledgeable and possessed positive attitudes about advance directives. Higher self-perceived confidence in advance directive discussion skills and the experience of caring for at least one patient with a current advance directive were found to be significant predictors of advance directive discussions. These findings suggest that experience with advance directives documents is critical for nurses' comfort and that developing interventions to further nurses' confidence in their discussion skills may increase advance directive discussions.

PURPOSE: Approximately 20% of caregivers (CGs) live > 1 hour away from the patient and are considered distance caregivers (DCGs) who often report higher distress and anxiety than local CGs. The purpose of this study was to test the effectiveness of an intervention aimed at reducing anxiety and distress in DCGs of patients with cancer. METHODS: This randomized controlled trial enrolled DCGs of patients with all cancer types who were being seen monthly by oncologists in outpatient clinics. There were three arms of the intervention delivered over a 4-month period: arm 1 (a) received 4 monthly videoconference-tailored coaching sessions with an advanced practice nurse or social worker focused on information and support, (b) participated in patient’s appointments with the oncologist via videoconference over the 4-month study period, and (c) had access to a website designed for DCGs. Arm 2 did not receive the coaching sessions but received the other two components, and arm 3 received access to the DCG website only. RESULTS: There were 302 DCGs who provided pre- and postintervention data. There were significant anxiety by group ( P = .028 and r = 0.16) and distress by group interactions ( P = .014 and r = 0.17). Arm 1 had the greatest percentage of DCGs who demonstrated improvement in anxiety (18.6%) and distress (25.2%). CONCLUSION: Coaching and use of videoconference technology (to join the DCG into the patient-oncologist office visit) were effective in reducing both anxiety and distress for DCGs. These components could be considered for local CGs who—with COVID-19—are unable to accompany the patient to oncologist visits.

Background Understanding the relationships between social and psychological determinants of health-related quality of life (HRQOL) is a critical step in developing effective screening tools and targeted interventions for psychosocial care. Objective The purpose of this study was to examine the relationships between dispositional optimism and HRQOL in newly-diagnosed adult cancer patients. Interventions/Methods A cross-sectional, predictive correlational design was used. The sample consisted of 163 patients with mixed diagnoses and stages who were within 180 days since diagnosis and had completed a battery of psychosocial measures upon enrollment into a psychosocial data registry during their first outpatient visit or treatment. Hierarchical multiple regression analyses were conducted to determine predictors of HRQOL. Results Optimism was significantly correlated with spiritual well-being, anxiety, depression, and HRQOL. Optimism was not a significant predictor of HRQOL at initial diagnosis and treatment when age, and scores for functional status, spiritual well-being, depression, and anxiety were entered into the regression equation. Conclusions Dispositional optimism is not a primary factor in HRQOL at initial diagnosis and treatment. Further exploration is needed to determine if optimism exerts a greater influence on HRQOL at another point along the cancer trajectory and if there is overlap between the constructs of optimism and spirituality. Implications for Practice Although systematic screening for dispositional optimism is not recommended, patients who display characteristics associated with low optimism require further assessment. Also, patients with poor functional status, young age, low levels of spirituality, and high levels of depression may be vulnerable for poor HRQOL.

Distance caregivers (DCGs) are a growing phenomenon in the United States Family members are struggling to provide care to loved ones with chronic illnesses such as cancer, from a distance. Unlike local caregiving research, distance caregiving research is limited and inconsistent definitions of distance make it difficult to compare studies. To date, DCGs have not been afforded the opportunities for educational and emotional support that local caregivers have received from the health care teams. Because they are not usually present at medical appointments, DCGs do not receive first-hand information from the health care team about the patient's condition, disease progression, and/or treatment options. These caregivers report feeling left out of important family discussions. They experience anxiety related to the uncertainty of the family members' well-being and guilt related to not being available to help local caregivers more. The challenges of distance caregiving are especially evident when the distance caregiver has a parent with advanced cancer. Family-centered care, attending to the needs of the whole family regardless of their geographic location is critical for quality cancer care. In this manuscript, the sparse literature on distance caregiving is reviewed. Recommendations for future research and for the development of creative technologically advanced interventions for this underserved caregiving population are suggested.

• Background Numerous methods are used to measure and assess nutritional status of chronically critically ill patients.• Objectives To discuss the multiple methods used to assess nutritional status in chronically critically ill patients, describe the nutritional status of chronically critically ill patients, and assess the relationship between nutritional indicators and outcomes of mechanical ventilation.• Methods A descriptive, longitudinal design was used to collect weekly data on 360 adult patients who required more than 72 hours of mechanical ventilation and had a hospital stay of 7 days or more. Data on body mass index and biochemical markers of nutritional status were collected. Patients’ nutritional intake compared with physicians’ orders, dieticians’ recommendations, and indirect calorimetry and physicians’ orders compared with dieticians’ recommendations were used to assess nutritional status. Relationships between nutritional indicators and variables of mechanical ventilation were determined.• ResultsInconsistencies among nurses’ implementation, physicians’ orders, and dieticians’ recommendations resulted in wide variations in patients’ calculated nutritional adequacy. Patients received a mean of 83% of the energy intake ordered by their physicians (SD 33%, range 0%–200%). Patients who required partial or total ventilator support upon discharge had a lower body mass index at admission than did patients with spontaneous respirations (Mann-Whitney U = 8441, P = .001).• Conclusions In this sample, the variability in weaning progression and outcomes most likely reflects illness severity and complexity rather than nutritional status or nutritional therapies. Further studies are needed to determine the best methods to define nutritional adequacy and to evaluate nutritional status.

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A nine-month-old female infant presented with a two-day history of vomiting, diarrhea and decreased urine output, along with a three-month history of lethargy and reduced tone. Her early development had been normal, but regression of skills had begun three months before presentation, with a loss of gross motor skills progressing to a loss of head control. The child had been exclusively breastfed until solids were slowly introduced over the last month. Her family was of South-East Asian ethnic origin, and her mother was a strict life-long vegan who took prenatal vitamins during pregnancy.On examination, the baby was sleepy and pale. Her weight was 6.65 kg (< 3rd percentile), height was 69 cm (25th percentile) and head circumference was 41 cm (< 3rd percentile). The liver edge was 3 cm below the costal margin. The splenic tip was palpable. Her axial and peripheral muscle tone was decreased, with frog-like posture of both legs. No antigravity power was exhibited. Reflexes were 3+ in her lower extremities and 2+ in her upper extremities. She was able to fix visually but did not follow.Laboratory investigations showed a hemo- /L. The blood smear showed pancytopenia with severe leukoerythroblastic change, dysplastic red blood cells and rare hypersegmented neutrophils; it appeared severely megaloblastic overall (Figure 1). The albumin level was 18 (range 34-42) g/L. Vitamin B 12 level was less than 37 (range 133-695) pmol/L (lower reporting limit), and the folate level was 14 (range 7-36) nmol/L. A bone marrow biopsy showed morphological changes consistent with megaloblastic anemia. Magnetic resonance imaging (MRI) of the patient's brain showed generalized atrophy. Metabolic and biochemical investigations, including acylcarnitine profile, plasma amino acid and urine organic acids, showed abnormalities consistent with dietary protein deficiency.Because the infant had been mostly breastfed with limited solid intake, we examined the mother. Her complete blood count was normal, but her vitamin B 12 level was low at 63 (adult reference range 133-695, deficient < 107) pmol/L. Review of the mother's prenatal blood work indicated a normal hemoglobin level, with a normal mean corpuscular volume.The infant's anemia was managed initially with a slow transfusion of packed red blood cells. Intramuscular injections of vitamin B 12 (1000 µg) were given daily for seven days, then weekly for the next month, along with oral iron supplementation. Nasogastric feeding with formula was initiated because of poor suck, and breastfeeding was maintained for comfort. The mother was started on oral B 12 supplementation.Five months later, the infant was consuming solid baby food and infant formula, and her growth parameters had improved. Her muscle tone and neurologic status had also improved. The complete blood count and B 12 levels were normal. • Infant B 12 sufficiency is related to maternal levels via neonatal stores at birth and the amount in breast milk. Cases Vitamin• Vitamin B 12 deficiency in infants, although rare, is important to recogn...