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Patients with haematological diseases are entitled to supportive care. Considering organisational and technological development, support in the form of caring communication provided through the web is today a possible alternative. The aim of this thesis was to examine the usefulness and importance of a web-based counselling service to patients with haematological diseases. The basis for the thesis was a development project funded by the Swedish Cancer Society, which provided an opportunity to offer patients communication with a nurse through a web-based counselling service. Four studies were performed from a patient perspective. Study I had a cross-sectional design, measuring occurrence of anxiety and depression, and these variables’ associations to mastery, social support, and insomnia among patients with haematological diseases. Study II was a qualitative content analysis focusing on conditions for provision and use of the web-based counselling service. Study III used a qualitative hermeneutical approach to focus on patients’ experiences of using the counselling service. Study IV was a qualitative deductive analysis examining how communication within the web-based counselling service can be caring in accordance to caring theory. The results revealed that females of 30-49 years of age are vulnerable to experiencing anxiety. Low sense of mastery and support are associated with anxiety and/or depression. Being able to self-identify the need for support as well as appreciate the written medium are necessary conditions for the web-based counselling service to be used. The counselling service must also be part of a comprehensive range of supportive activities and web-based services to be useful. The main importance of the communication is that the patient’s influence on the communication is strengthened, and that the constant access to individual medical and caring assessment can imply a sense of safety. When patients share their innermost concerns and search for support, nursing compassion and competence can substantiate in explicit written responses. A conclusion is that there is a caring potential in communication within a web-based counselling service. To make this form of communication possible, nurses should take possession of and ensure that this medium for communication is offered to patients. Nurses should also increase their knowledge of caring communication in writing and how this possibly can impact patients.

Patients with haematological diseases are entitled to supportive care. Considering organisational and technological development, support in the form of caring communication provided through the web is today a possible alternative. The aim of this thesis was to examine the usefulness and importance of a web-based counselling service to patients with haematological diseases. The basis for the thesis was a development project funded by the Swedish Cancer Society, which provided an opportunity to offer patients communication with a nurse through a web-based counselling service. Four studies were performed from a patient perspective. Study I had a cross-sectional design, measuring occurrence of anxiety and depression, and these variables’ associations to mastery, social support, and insomnia among patients with haematological diseases. Study II was a qualitative content analysis focusing on conditions for provision and use of the web-based counselling service. Study III used a qualitative hermeneutical approach to focus on patients’ experiences of using the counselling service. Study IV was a qualitative deductive analysis examining how communication within the web-based counselling service can be caring in accordance to caring theory. The results revealed that females of 30-49 years of age are vulnerable to experiencing anxiety. Low sense of mastery and support are associated with anxiety and/or depression. Being able to self-identify the need for support as well as appreciate the written medium are necessary conditions for the web-based counselling service to be used. The counselling service must also be part of a comprehensive range of supportive activities and web-based services to be useful. The main importance of the communication is that the patient’s influence on the communication is strengthened, and that the constant access to individual medical and caring assessment can imply a sense of safety. When patients share their innermost concerns and search for support, nursing compassion and competence can substantiate in explicit written responses. A conclusion is that there is a caring potential in communication within a web-based counselling service. To make this form of communication possible, nurses should take possession of and ensure that this medium for communication is offered to patients. Nurses should also increase their knowledge of caring communication in writing and how this possibly can impact patients.

Unmet psychosocial needs indicate a desire for additional support in cancer patients, having a direct clinical utility in directing the provision of supportive care. There is evidence in wider cancer groups that unmet needs relate to psychological wellbeing but this relationship has yet to be fully explored and factors that may explain or moderate this relationship yet to be examined. There has been little investigation of type or prevalence of unmet need in haematological cancer patients, however, haematological cancers are noteworthy for their high levels of associated distress. Understanding causality of distress is key to the effective implementation of supportive care services. This thesis aimed to highlight the unmet needs most relevant to haematological cancer patients and to explore their impact upon psychological wellbeing. This thesis comprises four interconnected research studies: a systematic review exploring existing knowledge of unmet needs; a qualitative exploration of patient experiences of unmet needs and their impact; a quantitative questionnaire study of unmet need and psychological wellbeing in newly diagnosed haematological cancer patients, placing a special emphasis on the difference between active treatment and watch and wait regimes; and, a second quantitative questionnaire study that explores unmet need, psychological wellbeing, and psychological flexibility as a potential moderator in their relationship in a sample of haematological cancer survivors. This thesis demonstrates a relationship between unmet need and psychological wellbeing in haematological cancer patients. Fear of recurrence, concerns about loved ones, being able to do the things you used to, and a need for information were all found to be of relevance. The qualitative study highlighted that patients feel that, as haematology patients, they are distinct from other cancer patients which impacts upon the perceived acceptability of support services and specific barriers to the accessing of support services are presented. Significant correlations between unmet need and key psychological outcomes such as anxiety, depression and quality of life were observed in both quantitative studies. In addition, the concept of psychological flexibility was found to moderate the relationship between unmet need and psychological wellbeing in haematological cancer survivors. This work has clear implications for both future research and clinical practice. Unmet needs assessment has the potential to be used as a screening tool for overall psychological wellbeing, a way to stratify and understand the specific causes of distress and poor quality of life for this patient group. In the UK, on-going support for cancer patients diminishes at the end of treatment, these findings suggest that further support is needed in order to meet the psychological needs of cancer survivors. Further research is needed to further explore the role of psychological flexibility in cancer-related distress: interventions that target psychological flexibility have the potential to improve both unmet need and distress.

Bakgrund: Att genomgå behandlingar vid hematologisk cancer innebär en stor omställning i det dagliga livet. Symtom och biverkningar har en stor påverkan på kropp och själ. Hematologisk cancer innefattar olika typer av cancer: leukemi, lymfom och myelom. Den behandling som ges vid hematologisk cancer innefattar stamcellstransplantation, strålning och cellgifter. Syfte: Syftet med denna studie var att beskriva patienters upplevelser av behandlingar vid hematologisk cancer. Metod: Datamaterialet analyserades med kvalitativ innehållsanalys. Data insamlades genom sex bloggar. Resultat: Ur analysen av datamaterialet framträdde tre kategorier; den nya vardagen, en känslomässig berg- och dalbana samt ständigt rätta sig efter kroppens begränsningar med sju underkategorier. Konklusion: Denna studies resultat har bidragit med information som med fördel kan användas för att få en ökad förståelse av personer med hematologisk cancer. Denna kunskap kan hjälpa sjuksköterskor att ge en god, patientcentrerad vård och därmed öka patientens välbefinnande. / Background: To go through treatment against haematological cancer means a big change in the daily life. Symptoms and side effects makes a big impact on both body and soul. Haematological cancer includes, in this study, three different types of cancer: leukemia, lymphoma and myeloma. The treatments given for haematological cancer involves stem cell transplant, radiation therapy and chemo therapy. Purpose: The purpose with this study was to describe patients’ experiences during treatments for haematological cancer. Method: The data was analyzed through a qualitative analysis of the context. Data were collected from six blogs. Result: Three categories emerged from the analysis; the new situation of the patients everyday life, the emotional rollercoaster and continuously comply with the body's limitations, with seven sub-categories. Conclusion: The result of this study has contributed with further knowledge about persons living with haematological cancer. This knowledge can help nurses give these patients a good, patient-centered care and raise their well-being.

Rugby has become a popular team sport worldwide with players training harder and competing more frequently, placing a great physiological demand on their bodies. To retain this performance level, players need to recover sufficiently between training and competitions. Two popular recovery techniques used are cold water immersion (CWI) and contrast water therapy (CWT). Despite numerous publications a lack still exists with regard to these specific recovery methods on physical and haematological parameters. Against this background, the main objectives of this study were firstly, to determine the effects of CWI compared to those of passive recovery (PAR) over a 48-hour period on physical and haematological parameters after an intense anaerobic exercise session in a cohort of male university-level rugby players. Secondly, to determine the effects of CWT compared to those of PAR over a 48-hour period on physical and haematological parameters after an intense anaerobic exercise session in a cohort of male university-level rugby players. Twenty-three rugby players of the North-West University participated in the study. The players were randomly assigned to either a control (n = 11; age: 20.1±0.3 y) or experimental (n = 12; age: 19.9±0.3 y) group. Participants reported to the laboratory where base line measurements were taken on certain physical (vertical jump test (VJT) height, VJT peak speed, VJT peak power and grip strength) and haematological (base excess (BEx), blood lactate (BLa-), calcium (Ca+), bicarbonate (HCO3), haemoglobin, haematocrit, pH level, partial oxygen level (PO2), partial carbon dioxide (PCO2), plasma glucose, potassium (K+), saturated oxygen (SO2), sodium (Na+) and total carbon dioxide (TCO2)) components. Thereafter participants were accompanied to the field to complete an intense anaerobic exercise session, followed by a recovery period of either CWI vs. PAR (week 1) or CWT vs. PAR (week 2). The recovery session comprised of either sitting passively in a still area (PAR), or immersion of CWI (8–10°C), or alternating immersions of five cycles between cold (1 min; 8–10°C) and warm water (3min; 40-42°C), totalling 20 minutes. Exactly three minutes, 24 and 48 hours after the recovery intervention all the measurements were re-taken to assess acute and longer-term effects of recovery. Descriptive statistics were followed by a linear mixed model analysis with an autoregressive 1 heterogeneous (AR1-Heterogeneous) structure, and between-group differences were examined using a one-way analysis of variance (ANOVA). Significance was set at p ≤0.05. Effect sizes were calculated to determine practical significance per recovery intervention as well as within groups. CWI indicated better recovery than PAR, with three out of the nine variables (BLa-, Na+ and haemoglobin) returning at 0 h post-recovery, and five (PO2, plasma glucose, VJT height, VJT peak power, VJT peak speed) only at 24 h post-CWI. In contrast, the PAR-group did not demonstrate recovery in any of the variables at 0 h post-PAR. However, an improvement was seen in VJT height across all time points. Four (BLa-, haemoglobin, VJT peak power and VJT peak speed) out of a possible nine variables recovered at 24 h with an additional two (PO2 and grip strength) variables showing recuperation at 48 h. A significant decrease (p ≤0.05) was seen in VJT height, PO2 and Na+ from post-anaerobic to immediately following either CWI or PAR (except for VJT height). Significant increases (p ≤0.05) were observed in VJT height, plasma glucose, and Na+ from 0 h post-recovery to 48 h post-recovery for both CWI and PAR. PO2 also significantly increased (p ≤0.05) from 0 h to 24 and 48 h post-CWI and for the PAR-group at 48 h. CWI tended to have a faster recovery rate than PAR over a 24-h period. The CWT vs. PAR showed the same trend, at 0-hours, six variables (BLa-, haemoglobin, VJT-height, VJT peak-power, VJT peak-speed and grip strength) was restored to base line, whereas plasma glucose recovered at 24-hours post-CWT. In addition, players’ jump and grip strength performance improved from base line. The PAR-group demonstrated recovery at 0 hours in four variables (BLa-, VJT height, VJT peak-speed and grip strength), and two variables (Na+ and haemoglobin) at 24-hours and plasma glucose at 48 hours. A significant decrease (p ≤0.05) was seen in haemoglobin and BLa- from post-anaerobic to either 24 or 48 hours for both groups. A significant increase in plasma glucose and PO2 from 0 to 24 hours was observed in both groups. No significant intergroup change in physical components was noticed. However, intergroup results indicated CWT to be superior to PAR with statistical significance observed in BLa- and grip strength (p ≤0.05) at various time points. The conclusion drawn from the above-mentioned results is that a recovery session comprising either 20-minutes of CWI or CWT may lead to significantly better physical components and restoration of haematological components in university-level rugby players compared to that of passive recovery. However, a detrimental effect was noticed in some components over the recovery period. / MA (Sport Science), North-West University, Potchefstroom Campus, 2015

Rugby has become a popular team sport worldwide with players training harder and competing more frequently, placing a great physiological demand on their bodies. To retain this performance level, players need to recover sufficiently between training and competitions. Two popular recovery techniques used are cold water immersion (CWI) and contrast water therapy (CWT). Despite numerous publications a lack still exists with regard to these specific recovery methods on physical and haematological parameters. Against this background, the main objectives of this study were firstly, to determine the effects of CWI compared to those of passive recovery (PAR) over a 48-hour period on physical and haematological parameters after an intense anaerobic exercise session in a cohort of male university-level rugby players. Secondly, to determine the effects of CWT compared to those of PAR over a 48-hour period on physical and haematological parameters after an intense anaerobic exercise session in a cohort of male university-level rugby players. Twenty-three rugby players of the North-West University participated in the study. The players were randomly assigned to either a control (n = 11; age: 20.1±0.3 y) or experimental (n = 12; age: 19.9±0.3 y) group. Participants reported to the laboratory where base line measurements were taken on certain physical (vertical jump test (VJT) height, VJT peak speed, VJT peak power and grip strength) and haematological (base excess (BEx), blood lactate (BLa-), calcium (Ca+), bicarbonate (HCO3), haemoglobin, haematocrit, pH level, partial oxygen level (PO2), partial carbon dioxide (PCO2), plasma glucose, potassium (K+), saturated oxygen (SO2), sodium (Na+) and total carbon dioxide (TCO2)) components. Thereafter participants were accompanied to the field to complete an intense anaerobic exercise session, followed by a recovery period of either CWI vs. PAR (week 1) or CWT vs. PAR (week 2). The recovery session comprised of either sitting passively in a still area (PAR), or immersion of CWI (8–10°C), or alternating immersions of five cycles between cold (1 min; 8–10°C) and warm water (3min; 40-42°C), totalling 20 minutes. Exactly three minutes, 24 and 48 hours after the recovery intervention all the measurements were re-taken to assess acute and longer-term effects of recovery. Descriptive statistics were followed by a linear mixed model analysis with an autoregressive 1 heterogeneous (AR1-Heterogeneous) structure, and between-group differences were examined using a one-way analysis of variance (ANOVA). Significance was set at p ≤0.05. Effect sizes were calculated to determine practical significance per recovery intervention as well as within groups. CWI indicated better recovery than PAR, with three out of the nine variables (BLa-, Na+ and haemoglobin) returning at 0 h post-recovery, and five (PO2, plasma glucose, VJT height, VJT peak power, VJT peak speed) only at 24 h post-CWI. In contrast, the PAR-group did not demonstrate recovery in any of the variables at 0 h post-PAR. However, an improvement was seen in VJT height across all time points. Four (BLa-, haemoglobin, VJT peak power and VJT peak speed) out of a possible nine variables recovered at 24 h with an additional two (PO2 and grip strength) variables showing recuperation at 48 h. A significant decrease (p ≤0.05) was seen in VJT height, PO2 and Na+ from post-anaerobic to immediately following either CWI or PAR (except for VJT height). Significant increases (p ≤0.05) were observed in VJT height, plasma glucose, and Na+ from 0 h post-recovery to 48 h post-recovery for both CWI and PAR. PO2 also significantly increased (p ≤0.05) from 0 h to 24 and 48 h post-CWI and for the PAR-group at 48 h. CWI tended to have a faster recovery rate than PAR over a 24-h period. The CWT vs. PAR showed the same trend, at 0-hours, six variables (BLa-, haemoglobin, VJT-height, VJT peak-power, VJT peak-speed and grip strength) was restored to base line, whereas plasma glucose recovered at 24-hours post-CWT. In addition, players’ jump and grip strength performance improved from base line. The PAR-group demonstrated recovery at 0 hours in four variables (BLa-, VJT height, VJT peak-speed and grip strength), and two variables (Na+ and haemoglobin) at 24-hours and plasma glucose at 48 hours. A significant decrease (p ≤0.05) was seen in haemoglobin and BLa- from post-anaerobic to either 24 or 48 hours for both groups. A significant increase in plasma glucose and PO2 from 0 to 24 hours was observed in both groups. No significant intergroup change in physical components was noticed. However, intergroup results indicated CWT to be superior to PAR with statistical significance observed in BLa- and grip strength (p ≤0.05) at various time points. The conclusion drawn from the above-mentioned results is that a recovery session comprising either 20-minutes of CWI or CWT may lead to significantly better physical components and restoration of haematological components in university-level rugby players compared to that of passive recovery. However, a detrimental effect was noticed in some components over the recovery period. / MA (Sport Science), North-West University, Potchefstroom Campus, 2015

Haematological malignancies and their treatment lead to prolonged periods of severe thrombocytopenia (platelet count ≤ 50 x 10⁹/l). Despite the use of prophylactic platelet transfusions, haemorrhage remains an important complication during this thrombocytopenic period. Within a 30 day period up to 70% of patients have clinically significant haemorrhage (World Health Organization (WHO) grade 2 or above bleeding) and up to 10% have severe or life-threatening haemorrhage (WHO grade 3 or 4 bleeding). Hence our current management of these patients to prevent haemorrhage is sub-optimal. The aim of this thesis was to identify clinical and laboratory factors that may predict the risk of haemorrhage in patients with haematological malignancies and severe thrombocytopenia. This was achieved via several different study designs and assessed the effect of clinical and laboratory factors on any or clinically significant haemorrhage and their effect on intracranial haemorrhage. This thesis has demonstrated that there is no consensus on how bleeding is assessed and graded in this patient group. Also it showed that the absolute immature platelet number may be a better alternative to the total platelet count to guide administration of platelet transfusions. Female sex, a previous history of a fungal infection, a high C-reactive protein, a high white cell count, a low platelet count, anaemia, impaired renal function, and recent clinically significant haemorrhage were all found to be independent risk factors for haemorrhage. Patients who were in complete remission from their haematological malignancy had a much lower risk of bleeding.

Derzeit ist es gängige Praxis, die Chemotherapie entsprechend der Körperoberfläche des Patienten zu dosieren. Diese Praxis ist jedoch nicht ideal, da es Patienten gibt, die starke Nebenwirkungen haben und andere, die kaum Nebenwirkungen aufweisen. Damit intelligentere Dosierungsschemata entwickelt werden können und prophylaktische Maßnahmen zum Verhindern von Therapienebenwirkungen besser geplant werden können, ist die Kenntnis der Faktoren erforderlich, welche die Nebenwirkungen verursachen. Die hämatologischen Nebenwirkungen der Chemotherapie sind dabei am stärksten ausgeprägt und führen oft zu Dosiserosionen, Zeitverschiebungen zwischen den Chemotherapiezyklen oder sogar zu einem Abbruch der Therapie. Das hat wiederum negative Auswirkungen auf den Therapieerfolg. In dieser Arbeit wurden daher Prognosemodelle für chemotherapieinduzierte hämatologische Nebenwirkungen aufgebaut. Die Daten von 1399 Patienten mit aggressivem Non-Hodgkin-Lymphom und einem breiten Altersspektrum von 18-75 Jahren aus der NHL-B1/B2-Studie (Pfreundschuh et al. 2004a und b) gingen in die Analyse ein. Es wurden für die jüngeren (<= 60 Jahre) und die älteren Patienten (> 60 Jahre) multivariate Proportionale Odds Regressionsmodelle für die drei hämatopoetischen Linien der Leukozytopenie, Thrombozytopenie und Anämie gerechnet und an zwei unabhängigen Datensätzen, auch unter Rituximab-haltigen Chemotherapieschemata, validiert. Die hier entwickelten Modelle konnten ein breites Heterogenitätsspektrum für die hämatologischen Nebenwirkungen erklären. Bemerkenswert ist, dass einige der Faktoren für hämatologische Nebenwirkungen gleichzeitig auch Faktoren des Internationalen Prognostischen Index für das Therapieergebnis sind. Die im ersten Chemotherapiezyklus beobachtete Nebenwirkung war der stärkste prognostische Faktor. Mit einigen der Modelle konnte die kumulative Nebenwirkung über die Chemotherapiezyklen hinweg gezeigt werden. Die Demonstration des Zusammenhangs zwischen den für Leukozytopenie ermittelten Risikogruppen und den klinisch relevanten Größen Infektion, Antibiotikagabe, Hospitalisierungstage und therapieassoziierte Todesfälle ist ein sehr wichtiges Ergebnis der Arbeit. Es wurde eine Internetseite (www.toxcalculator.com) entwickelt, welche den Ärzten die Möglichkeit bietet, die bei dem Patienten vorliegenden Prognosefaktoren einzugeben und dann die Modellvorhersagen für die zu erwartenden hämatologischen Nebenwirkungen zu erhalten. Die Ergebnisse der Arbeit wurden in der hochrangigen Zeitschrift ‚Annals of Oncology‘ publiziert (Ziepert et al. 2008).

Introduction Neutropenia is a life-threatening and dose-limiting toxicity of palliative lung cancer chemotherapy. Whilst some neutropenias are inevitable, evidence suggests that patients with a previous neutropenic event are 50% more likely to have a further neutropenic event. The aim of this research is to evaluate the variables associated with the risk of secondary neutropenic events and the role of chemotherapy dose reductions. Methods A retrospective analysis was carried out on 361 biochemical neutropenic events in palliative lung cancer patients across 5 sites in South Yorkshire and Bassetlaw. Predictors for a secondary neutropenic event were investigated in univariate and multivariate logistic regression analysis. The predictive model was validated through discrimination statistics, described by Receiver Operating Characteristic Area Under Curve (ROC-AUC). Results The incident rate for secondary neutropenic events was 32.7%. Patients with a successful intervention received a higher mean Relative Dose Intensity (RDI) of 75.65% compared to 65.05%, across the 2 chemotherapy cycles. The univariate analysis found that the biochemical type of neutropenia (depth and length of suppression) (p=0.003), dose reduction of drug 1 (p=0.042), average dose reduction (p=0.019), and cumulative dose reduction (p=0.018) were significant at reducing the risk of secondary neutropenia. Granulocyte-Colony Stimulating Factor did not offer a protective effect. The final logistic regression model evaluated 357 events and included all variables due to significant interrelationship. The model had a ROC-AUC of 0.76 (0.71-0.81) (p= 0.0021), explaining 27% of the variance. Conclusion Appropriate dose reductions play a vital role in preventing secondary neutropenic events and delivering optimal RDIs. The results of this study can aid in identifying high-risk patients.