Mucositis is an inflammatory process that can involve the mucosal epithelial cells from the mouth to the rectum. Historically, mucositis and stomatitis were used interchangeably, but momentum has increased toward more specific terminology since the 2000s. Stomatitis refers to inflammatory diseases of the mouth, including the mucosa, dentition, periapices, and periodontium, whereas mucositis refers more globally to an inflammatory process involving the mucous membranes of the oral cavity and the gastrointestinal tract. In addition, differentiation is needed regarding mucositis involving the oral cavity and the remainder of the gastrointestinal tract that require use of a scope-type device for close examination. As a result, oral cavity mucositis has been the focus of the majority of the studies reported to date. The mucous membranes beyond the oral cavity are more challenging to view, so the mouth has been presented as revealing potential changes in the gastrointestinal tract. However, because of the variation in morphology, function of different locations, and risks associated with procedures to validate that speculation, evidence is limited. The purpose of this article is to review evidence-based interventions for mucositis, particularly in the oral cavity, and provide clinicians with guidelines for nursing interventions.

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Background Cancer is treated using multiple modalities (e.g. surgery, radiotherapy and systemic therapies) and is frequently associated with adverse events that affect treatment delivery and quality of life. Regular adverse event reporting could improve care and safety through timely detection and management. Information technology provides a feasible monitoring model, but applied research is needed. This research programme developed and evaluated an electronic system, called eRAPID, for cancer patients to remotely self-report adverse events. Objectives The objectives were to address the following research questions: is it feasible to collect adverse event data from patients’ homes and in clinics during cancer treatment? Can eRAPID be implemented in different hospitals and treatment settings? Will oncology health-care professionals review eRAPID reports for decision-making? When added to usual care, will the eRAPID intervention (i.e. self-reporting with tailored advice) lead to clinical benefits (e.g. better adverse event control, improved patient safety and experiences)? Will eRAPID be cost-effective? Design Five mixed-methods work packages were conducted, incorporating co-design with patients and health-care professionals: work package 1 – development and implementation of the electronic platform across hospital centres; work package 2 – development of patient-reported adverse event items and advice (systematic and scoping reviews, patient interviews, Delphi exercise); work package 3 – mapping health-care professionals and care pathways; work package 4 – feasibility pilot studies to assess patient and clinician acceptability; and work package 5 – a single-centre randomised controlled trial of systemic treatment with a full health economic assessment. Setting The setting was three UK cancer centres (in Leeds, Manchester and Bristol). Participants The intervention was developed and evaluated with patients and clinicians. The systemic randomised controlled trial included 508 participants who were starting treatment for breast, colorectal or gynaecological cancer and 55 health-care professionals. The radiotherapy feasibility pilot recruited 167 patients undergoing treatment for pelvic cancers. The surgical feasibility pilot included 40 gastrointestinal cancer patients. Intervention eRAPID is an online system that allows patients to complete adverse event/symptom reports from home or hospital. The system provides immediate severity-graded advice based on clinical algorithms to guide self-management or hospital contact. Adverse event data are transferred to electronic patient records for review by clinical teams. Patients complete an online symptom report every week and whenever they experience symptoms. Main outcome measures In systemic treatment, the primary outcome was Functional Assessment of Cancer Therapy – General, Physical Well-Being score assessed at 6, 12 and 18 weeks (primary end point). Secondary outcomes included cost-effectiveness assessed through the comparison of health-care costs and quality-adjusted life-years. Patient self-efficacy was measured (using the Self-Efficacy for Managing Chronic Diseases 6-item Scale). The radiotherapy pilot studied feasibility (recruitment and attrition rates) and selection of outcome measures. The surgical pilot examined symptom report completeness, system actions, barriers to using eRAPID and technical performance. Results eRAPID was successfully developed and introduced across the treatments and centres. The systemic randomised controlled trial found no statistically significant effect of eRAPID on the primary end point at 18 weeks. There was a significant effect at 6 weeks (adjusted difference least square means 1.08, 95% confidence interval 0.12 to 2.05; p = 0.028) and 12 weeks (adjusted difference least square means 1.01, 95% confidence interval 0.05 to 1.98; p = 0.0395). No between-arm differences were found for admissions or calls/visits to acute oncology or chemotherapy delivery. Health economic analyses over 18 weeks indicated no statistically significant difference between the cost of the eRAPID information technology system and the cost of usual care (£12.28, 95% confidence interval –£1240.91 to £1167.69; p > 0.05). Mean differences were small, with eRAPID having a 55% probability of being cost-effective at the National Institute for Health and Care Excellence-recommended cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained. Patient self-efficacy was greater in the intervention arm (0.48, 95% confidence interval 0.13 to 0.83; p = 0.0073). Qualitative interviews indicated that many participants found eRAPID useful for support and guidance. Patient adherence to adverse-event symptom reporting was good (median compliance 72.2%). In the radiotherapy pilot, high levels of consent (73.2%) and low attrition rates (10%) were observed. Patient quality-of-life outcomes indicated a potential intervention benefit in chemoradiotherapy arms. In the surgical pilot, 40 out of 91 approached patients (44%) consented. Symptom report completion rates were high. Across the studies, clinician intervention engagement was varied. Both patient and staff feedback on the value of eRAPID was positive. Limitations The randomised controlled trial methodology led to small numbers of patients simultaneously using the intervention, thus reducing overall clinician exposure to and engagement with eRAPID. Furthermore, staff saw patients across both arms, introducing a contamination bias and potentially reducing the intervention effect. The health economic results were limited by numbers of missing data (e.g. for use of resources and EuroQol-5 Dimensions). Conclusions This research provides evidence that online symptom monitoring with inbuilt patient advice is acceptable to patients and clinical teams. Evidence of patient benefit was found, particularly during the early phases of treatment and in relation to self-efficacy. The findings will help improve the intervention and guide future trial designs. Future work Definitive trials in radiotherapy and surgical settings are suggested. Future research during systemic treatments could study self-report online interventions to replace elements of traditional follow-up care in the curative setting. Further research during modern targeted treatments (e.g. immunotherapy and small-molecule oral therapy) and in metastatic disease is recommended. Trial registration The systemic randomised controlled trial is registered as ISRCTN88520246. The radiotherapy trial is registered as ClinicalTrials.gov NCT02747264. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information.

BackgroundLeeds was one of the sites for the DH EPaCCS pilots 2009–11 (Ipsos-Mori 2011) and implementation across the city has been ongoing since 2011. Bespoke templates have been developed to collect patient information specified in the 1SB1580 standard from within existing clinical systems of the healthcare provider organisations to support the elicitation, recording and sharing of people's key preferences about their care.Whilst implementing EPaCCS in Leeds it became apparent that reports could assist clinicians in identifying which patients might be suitable for EPaCCS, help streamline palliative care/GSF meetings and support organisational reporting requirements. The team therefore developed the reports outlined below.AimsUse electronic coding of patient information to develop reports to: highlight those patients with a palliative code in their record for consideration by clinicians for EPaCCS streamline palliative care/Gold Standard Framework meetings by focusing on patients preferences enable GP practices and healthcare organisations to meet their reporting requirements and monitor care outcomes.ResultsEPaCCS reports have been developed within the SystmOne clinical IT system populated by GP's, specialist palliative care and community nurses. Since clinicians started using the EPaCCS reports there has been a significant increase in the numbers of patients identified as having palliative care needs and who have subsequently been included on EPaCCS. Clinicians report that GSF/palliative care meetings are more streamlined and effective. Practices are also able to evidence QOF requirements of a palliative care register and meeting; similarly other healthcare organisations can meet their reporting requirements using EPaCCS.ConclusionsThe introduction of reports into the Leeds Systmone EPaCCS has been beneficial to patients and clinicians in terms of more patients being identified and highlighting gaps in preferences being recorded. and clinicians are enabled to be more productive and proactive in their decision making and reporting requirements.

Background The DH End of Life Care (EoLC) Strategy (2008) identified EPaCCS as an enabler of greater co-ordination of patient care through supporting the elicitation, recording and sharing of people's key preferences about their care and enabling these preferences to be met across a wide variety of teams and organisations. A variety of approaches to the design of EPaCCS have been adopted across England (Ipsos-Mori 2011). In Leeds the emphasis has been on hosting EPaCCS within the current clinical IT systems that span the city, in response to the stakeholder priorities of accessibility in clinical practice and minimal duplication of record entry. Aim To design and implement an EPaCCS IT solution that maintained clinical intuitiveness across a multitude of clinical IT systems ie 'one click' from the organisational clinical record. Results Three clinical IT systems predominate. SystmOne is the platform for 66% of GP's, community nursing, OOH's and the two hospices, and EMIS is predominantly used by the remaining GPs. The acute Trust had a myriad of systems currently being amalgamated into a single Clinical Portal. Bespoke templates have been developed with clinicians and implemented to collect the patient information specified in the 1SB1580 standard within the existing clinical systems of the healthcare provider organisations. Interoperability between the IT systems to permit sharing of the EoLC plan is being pursued via the Leeds Care Record which will facilitate sharing of information between different clinical systems and is the first of its kind in the country. Conclusions The "one click away" approach to EPaCCS is a challenging one, and a lengthy process. However, the benefits of supporting clinicians to build a record of patient preferences and wishes for end of life care within their own clinical system are now being realised.