Conectar
To explore older inpatients and their caregivers' care experience and how this relates to the gerontology care practice.
Research interest in the conceptualization of safe care for older inpatients was growing, and these studies were predominantly reported from a single or healthcare perspective. There is a shortage of literature on how patients and their caregivers conceptualise safe care.
Constructivist grounded theory.
Stage 1 included semi-structured interviews with inpatients. Stage 2 included semi-structured interviews with caregivers and six field notes. Purposive and theoretical sampling were used to recruit 61 participants across six healthcare institutions. Data analysis included initial coding, focused coding, and theoretical coding using constant comparative, field notes and memo writing.
The substantive theory to emerge from the data was A balance of unsafe care incidents and interactive cooperative care. This core concept was informed by four categories: unsafe care incidents, interactive cooperative care, person-centred care, contextual conditions, and one care outcome. The relationships between these categories constituted a balance in which patient-centred care was the core, unsafe care incidents were the barriers, interactive cooperative care was the facilitator, and the result of the balance was the care outcome. The balance constituted a safe care ecosystem under the interaction of contextual conditions.
Interactive cooperative care is vital in enabling care stakeholders to reduce unsafe care incidents, which facilitates them in achieving safe care and further constructing a healthy care ecosystem.
This theory identifies barriers and facilitators encountered by care stakeholders to cope with everyday problems and guides them in developing personalised care plans to ensure patient safety.
To investigate the prevalence of anxiety and depression symptoms in intensive care unit (ICU) patients with cardiovascular disease (CVD) and to explore which elements are risk factors for the development of anxiety and depression symptoms.
A cross-sectional study.
A total of 1028 ICU patients with CVD were enrolled in this cross-sectional study. Logistic regression was used to assess risk factors and associations between anxiety and depression symptoms, and mediation analysis was used to explore the effect of risk factors on the association between anxiety and depression symptoms. Reporting of the study followed the STROBE checklist.
The results showed that among ICU patients with CVD, 38.1% had anxiety symptoms, 28.7% had depression symptoms and 19.3% had both anxiety and depression symptoms, and there was a significant association between anxiety and depression symptoms. We also identified female gender, hypertension, hyperlipidemia and cardiac function class IV as independent risk factors for anxiety and depression symptoms. Importantly, these factors also mediated the association between anxiety and depression symptoms, emphasising their role in the psychological well-being of this patient group.
ICU patients with CVD were prone to anxiety and depression symptoms. Female gender, hypertension, hyperlipidemia and cardiac function class IV were identified as independent risk factors that also served as mediators in the relationship between anxiety and depression symptoms. Especially, cardiac function class IV emerged as a critical factor in this association.
It is imperative for critical care professionals to recognize the elevated risk of depression and anxiety among ICU patients with severe CVD, especially those with cardiac function class IV, hypertension, hyperlipidemia and females. Proactive and supportive measures are essential for this vulnerable group during their ICU stay to safeguard their mental health and prevent negative outcomes.
No Patient or Public Contribution.
This study aims to investigate the epidemiological characteristics of COVID-19 infection among healthcare workers, including the severity, duration of infection, post-infection symptoms and related influencing factors.
A self-administered questionnaire was utilized to assess the post-infection status of primary healthcare workers in Jiangsu Province. The questionnaire collected information on demographic characteristics, lifestyle habits, post-infection clinical manifestations, work environment and recovery time of the respondents. Customized outcome events were selected as dependent variables and logistic regression models were employed to analyse the risk factors. Phi-coefficient was used to describe the relationship between post-infection symptoms.
The analysis revealed that several factors, such as female, older age, obesity, previous medical history, exposure to high-risk environments and stress, were associated with a higher likelihood of experiencing more severe outcomes. On the other hand, vaccination and regular exercise were found to contribute to an earlier resolution of the infection. Among the post-infection symptoms, cough, malaise and muscle aches were the most frequently reported. Overall, there was a weak association among symptoms persisting beyond 14 days, with only cough and malaise, malaise and dizziness and headache showing a stronger correlation.
The study findings indicate that the overall severity of the first wave of infection, following the complete lifting of restrictions in China, was low. The impact on primary healthcare workers was limited, and the post-infection symptoms exhibited similarity to those observed in other countries. It is important to highlight that these conclusions are specifically relevant to the population infected with the Omicron variant.
This study helps to grasp the impacts of the first wave of COVID-19 infections on healthcare workers in China after the national lockdown was lifted.
Primary healthcare workers in Jiangsu Province, including doctors, nurses, pharmacists and other personnel from primary healthcare units such as community health service centres and health centres.
Patients often consider bone marrow aspiration and biopsy to be one of the most painful medical procedures. The effectiveness of non-pharmacological interventions to reduce pain during bone marrow aspiration and biopsy remains unclear.
To synthesize existing evidence regarding the effectiveness of non-pharmacological interventions in mitigating procedural pain among patients undergoing bone marrow aspiration and biopsy.
A systematic review and meta-analysis of randomized controlled trials.
Six electronic databases, including PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Library and Web of Science were searched from inception to July 15, 2023. The risk of bias was assessed using the Cochrane Risk of Bias Tool Version 2.0. Meta-analysis was conducted using STATA 16. The certainty of the evidence was assessed by the GRADE approach.
This meta-analysis included 18 studies derived from 17 articles involving a total of 1017 participants. The pooled results revealed statistically significant pain reduction effects using distraction (SMD: −.845, 95% CI: −1.344 to −.346, p < .001), powered bone marrow biopsy system (SMD: −.266, 95% CI: −.529 to −.003, p = .048), and acupoint stimulation (SMD: −1.016, 95% CI: −1.995 to −.037, p = .042) among patients undergoing bone marrow aspiration and biopsy. However, the pooled results on hypnosis (SMD: −1.228, 95% CI: −4.091 to 1.515, p = .368) showed no significant impact on pain reduction. Additionally, the pooled results for distraction did not demonstrate a significant effect on operative anxiety (MD: −2.942, 95% CI: −7.650 to 1.767, p = .221).
Distraction, powered bone marrow biopsy system and acupoint stimulation are effective in reducing pain among patients undergoing bone marrow aspiration and biopsy.
Not applicable.
This meta-analysis highlights the effectiveness of distraction, powered bone marrow biopsy system and acupoint stimulation for reducing pain in patients undergoing bone marrow biopsy. Healthcare professionals should consider integrating these interventions into pain management practices for these patients.
(PROSPERO): CRD42023422854.
Acceptance and commitment therapy (ACT) is a psychotherapy technique, which promotes psychological flexibility and enables patients to change behaviors based on value-directed goals. However, the beneficial effects of ACT on glycemic control, self-care behaviors, acceptance of diabetes, self-efficacy, and psychological burden are still unclear among patients with type 2 diabetes mellitus (T2DM).
This study aimed to systematically synthesize scientific evidence to determine the effectiveness of ACT among patients with T2DM on glycemic control, self-care behaviors, acceptance of diabetes, self-efficacy, and psychological burden and identify the optimal characteristics of effective interventions.
Nine electronic databases were searched to identify eligible studies of randomized controlled trials from inception to June 2023. Two reviewers independently assessed the study eligibility, extracted the data, and performed the quality appraisal using the Cochrane Risk of Bias 2 Tool. The meta-analysis was conducted using Review Manager 5.3. The certainty of the evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation system.
Ten studies involving 712 participants were included. ACT demonstrated significant improvements on patients' glycemic control (mean difference [MD]: 0.95%; p < .001), self-care behaviors (MD: 1.86; p = .03), diabetes acceptance (MD: 7.80; p < .001), self-efficacy (standardized mean difference [SMD]: 1.04; p < .001), anxiety (SMD: −1.15; p = .006), and depression (SMD: −1.10; p = .04). However, favorable but nonsignificant improvements were found in diabetes distress. Subgroup analyses demonstrated that ACT offered more than five sessions using individualized format, with theoretical underpinnings and professional input from multidisciplinary therapists are recommended to yield better results on glycemic control and self-care behaviors.
Acceptance and commitment therapy could generate beneficial effectiveness on glycemic control, self-care behaviors, acceptance of diabetes, self-efficacy, anxiety, and depression among patients with T2DM. Large-scale trials with rigorous design and representative samples are warranted to strengthen the current evidence.
Physical frailty (PF) is highly prevalent and associated with undesirable outcomes in stroke survivors aged 65 years or older. However, the long-term trajectories of PF are understudied in those older stroke survivors.
To identify PF trajectories and relative predictors associated with the PF trajectories in older stroke survivors.
This is a secondary analysis of a population-based cohort study in the United States.
Six hundred and sixty-three older stroke survivors from the National Health and Ageing Trends Study from 2015 to 2021 were included. PF was operationally assessed based on the Fried Frailty Phenotype. Trajectories were identified by group-based trajectory modelling. The associations between sociodemographic characteristics, clinical factors, symptoms, cognitive factors and PF trajectories were examined using the design-based logistic regression method.
Most older stroke survivors were 75 and older (63.32%), female (53.99%), white (80.54%) and partnered (50.64%). Two PF trajectory groups were identified (Group 1: low risk, robust; 49.47%; Group 2: high risk, deteriorating; 50.53%). Individuals were at a higher risk to be assigned to Group 2 if they were 75–84 years (adjusted odds ratio [aOR]: 2.16, 95% CI: 1.23–3.80) or 85+ years (aOR: 2.77, 95% CI: 1.52–5.04), had fair self-reported health (aOR: 2.78, 95% CI: 1.53–5.07) or poor self-reported health (aOR: 3.37, 95% CI: 1.51–7.52), had comorbidities (aOR: 8.44, 95% CI: 1.31–54.42), had breathing problems (aOR: 2.18, 95% CI: 1.18–4.02) and had balance problems (aOR: 1.70, 95% CI: 1.06–2.73).
PF trajectories in older stroke survivors were heterogeneous and were associated with age, self-rated health status, comorbidities, breathing problems and balance problems.
Early, routine, dynamic screening for stroke-related physical frailty (PF) and relative predictors might be beneficial for identifying the most vulnerable individuals. Our findings might help develop strategies to manage PF progression.
The reporting followed the STROBE guideline.
To investigate the factors that facilitate or hinder nurses in providing patient education.
A mixed-method systematic review.
Six databases (Cochrane Library, PubMed, EMBASE, Web of Science, MEDLINE and ERIC) were systematically searched for relevant publications.
The study was conducted following the JBI for mixed-method systematic reviews, and the reporting followed the PRISMA guideline. Two researchers independently performed literature screening, literature evaluation, data extraction and synthesis. PROSPERO registration number: CRD42023427451.
Twenty-six eligible articles were included, including 15 quantitative articles, 10 qualitative articles and 2 mixed-methods articles. The resultant synthesis of key findings led to the identification of these barriers and facilitators, categorised into five distinct levels: nurse-related factors, organisational factors, patient-related factors, the nurse–patient relationship and interdisciplinary collaboration.
The findings highlight the factors that facilitate or hinder nurses in providing patient education, suggesting that multifaceted interventions can enhance the practice of patient education in nursing and support the development of appropriate patient education guidelines or public policies.
This review delineates the facilitators and barriers influencing nurses' provision of patient education, offering an initial framework for nursing managers to craft interventions aimed at enhancing the quality of patient education provided by nurses, consequently elevating the overall quality of nursing.
To explore the association between nurse managers' paternalistic leadership and nurses' perceived workplace bullying (WPB), as well as to examine the mediating role of organizational climate in this association.
There is a lack of empirical evidence regarding the relationship between nurse managers' paternalistic leadership, organizational climate and nurses' perceived WPB. Clarifying this relationship is crucial to understand how paternalistic leadership influences WPB and for nursing managers to seek organizational-level solutions to prevent it.
A cross-sectional survey was performed from 4 January to 10 February 2022, in six tertiary hospitals in mainland China. Demographic information, Paternalistic Leadership Scale, Organizational Climate Scale and Negative Acts Questionnaire-Revised were used in the survey. Descriptive statistics, Spearman correlation analyses and a structural equation model were used for data analysis.
A total of 5093 valid questionnaires were collected. Moral leadership and authoritarian leadership have both direct and indirect effects on WPB through the mediating effect of organizational climate. The former is negatively related to WPB and the latter is positively related to WPB. Benevolent leadership was only negatively associated with WPB via the mediating effect of organizational climate.
The three components of paternalistic leadership have different effects on WPB through the mediating effect of organizational climate. Nurse managers are recommended to strengthen moral leadership, balance benevolent leadership, reduce authoritarian leadership and strive to create a positive organizational climate in their efforts to mitigate WPB among nurses.
This study enhanced our comprehension of the relationship between different leadership styles and WPB. Greater emphasis should be placed on moral leadership in the promotion of nursing managers and nursing leadership training programs. Additionally, nursing managers should focus on establishing a positive organizational climate that helps to reduce WPB.
No patient or public contribution. This study did not involve patients, service users, caregivers or members of the public.
Caregivers of children with chronic diseases suffer from great parenting pressure, which directly affects the treatment and rehabilitation of children, reduces the quality of life of caregivers and damages family functioning. Existing reviews have not systematically summarized and evaluated interventions for parenting stress in caregivers of children with chronic diseases.
Embase, PubMed, Web of Science, OVID, CNKI, CBM, Wan Fang and Cochrane Library were searched for eligible reviews in November 2021 and October 2022.
Two reviewers independently screened titles and abstracts, reviewed full texts of articles for eligibility, and appraised the quality of reviews using JBI. The quality of the evidence was assessed using GRADE. Findings are reported in accordance with PRISMA checklist. Narrative summaries grouped findings by intervention types.
Out of 2632 records, we included 21 systematic reviews for a synthesis. Interventions for parenting stress in children with chronic diseases were divided into seven categories. Cognitive behavioural interventions, psychosocial interventions, child behavioural and/or developmental parent interventions and synthesized interventions have shown high-level evidence in reducing parenting stress for caregivers of children with chronic diseases. Furthermore, outcome measures and intervention protocols were highly heterogeneous across interventions.
This umbrella review suggest that reducing the parenting stress of caregivers of children with chronic diseases can directly target caregivers' parenting stress through cognitive behavioural interventions/psychosocial interventions and/or provide guidance to parents on the behavioural and developmental problems of children with chronic diseases. A more standardized approach to outcome measures is essential to assess efficacy and compare interventions across studies.
The findings provide information and evidence for reducing parenting stress among caregivers of children with chronic diseases to guide the development of comprehensive intervention strategies.
Patient or public contribution does not apply to this study.
This study aims to propose a self-management clusters classification method to determine the self-management ability of elderly patients with mild cognitive impairment (MCI) associated with diabetes mellitus (DM).
MCI associated with DM is a common chronic disease in old adults. Self-management affects the disease progression of patients to a large extent. However, the comorbidity and patients' self-management ability are heterogeneous.
A cross-sectional study based on cluster analysis is designed in this paper.
The study included 235 participants. The diabetes self-management scale is used to evaluate the self-management ability of patients. SPSS 21.0 was used to analyse the data, including descriptive statistics, agglomerative hierarchical clustering with Ward's method before k-means clustering, k-means clustering analysis, analysis of variance and chi-square test.
Three clusters of self-management styles were classified as follows: Disease neglect type, life oriented type and medical dependence type. Among all participants, the percentages of the three clusters above are 9.78%, 32.77% and 57.45%, respectively. The difference between the six dimensions of each cluster is statistically significant.
This study classified three groups of self-management styles, and each group has its own self-management characteristics. The characteristics of the three clusters may help to provide personalized self-management strategies and delay the disease progression of MCI associated with DM patients.
Typological methods can be used to discover the characteristics of patient clusters and provide personalized care to improve the efficiency of patient self-management to delay the progress of the disease.
In our study, we invited patients and members of the public to participate in the research survey and conducted data collection.
The aims of this study were to (i) compare the prevalence of multidimensional frailty in middle-aged and older people with stroke and to (ii) explore the relationship between multidimensional frailty and quality of life (QoL) in this patient population.
In recent years, stroke patients have become increasingly younger. As an important risk factor for stroke patients, frailty has gradually drawn research attention because of its multidimensional nature.
This study used a cross-sectional design.
The study included 234 stroke patients aged 45 and older. Multidimensional frailty was defined as a holistic condition in which a person experiences losses in one or more domains of human functioning (physical, psychological and social) based on the Tilburg Frailty Indicator, and QoL was based on the short version of the Stroke-Specific Quality of Life Scale. Hierarchical regression was used to analyse the correlation factors of QoL. STROBE checklist guides the reporting of the manuscript.
A total of 128 (54.7%) participants had multidimensional frailty, 48 (44.5%) were middle aged and 80 (63.5%) were older adults. The overall QoL mean score of the participants was 47.86 ± 9.04. Multidimensional frailty was negatively correlated with QoL. Hierarchical regression analysis showed that multidimensional frailty could independently explain 14.6% of the variation in QoL in stroke patients.
Multidimensional frailty was prevalent in middle-aged and older people with stroke, and it was a significant factor associated with QoL in stroke patients.
This study emphasises the importance of the early identification of multidimensional frailty. And targeted interventions should be studied to prevent the occurrence of multidimensional frailty and thereby improve the QoL of patients.
There are no patient or public contributions to this study.
People who are insecurely housed and use drugs are disproportionately affected by drug poisonings. Nurses are uniquely positioned to utilize harm reduction strategies to address the needs of the whole person. Needle debris encompasses drug paraphernalia discarded in public spaces. Studying needle debris provides a strategic opportunity to identify where drugs are being used and target public health strategies accordingly.
Our aim in this article is to illustrate how spatial video geonarratives (SVG) combined GPS technology interviews, and videos of locations with needle debris, can elicit valuable data for nursing research.
Using SVG required knowledge of how to collect data wearing cameras and practice sessions were necessary. A Miufly camera worn at waist height on a belt provided the stability to walk while interviewing stakeholders. We wore the cameras and conducted go-along interviews with outreach workers, while filming the built environment. Upon completion of data collection, both the interview and GPS information were analysed using Wordmapper software.
This methodology resulted in data presented uniquely in both a visual map and narrative. These data were richer than if a single modality had been used. These data highlighted specific contextual factors that were related to the location of needle debris, which created opportunities for nursing interventions to support people experiencing vulnerability.
Providing a favourable practice environment has been regarded as an essential to improve the job outcomes of newly graduated nurses (NGNs). However, little is known about how and when NGNs can best utilize their practice environment to produce optimal job outcomes.
The aim of this study, which is based on the Conservation of Resources Theory and the Social Cognitive Model of Career Self-Management, is to investigate whether NGNs who have a higher level of personal growth initiative are more likely to benefit from their practice environment and achieve better job outcomes by increasing their occupational self-efficacy.
A cross-sectional study.
From 1 September 2022, to 30 September 2022, 279 NGNs from five Chinese state-owned hospitals were recruited for this study. The participants completed measures of practice environment, personal growth initiative, occupational self-efficacy, job stress, job satisfaction, turnover intention and quality of care. A descriptive analysis and a moderated mediation model were computed. Reporting adhered to the STROBE statement.
The influence of the practice environment on job outcomes was significantly mediated by occupational self-efficacy, with personal growth initiative acting as a moderator of this mediation effect.
NGNs who exhibited a higher degree of personal growth initiative were more likely to derive benefits from their practice environment and attain positive job outcomes by enhancing their occupational self-efficacy. To boost NGNs' occupational self-efficacy and achieve optimal job outcomes, hospital administrators may not only provide a supportive practice environment for them but also conduct interventions that promote their personal growth initiative.
This study was designed to examine the psychosocial factors associated with NGNs' job outcomes. The study was not conducted using suggestions from the patient groups or the public.
Our findings indicate that favourable practise contexts may not always benefit the nursing job outcome if NGNs do not exhibit a high level of personal growth initiative and produce increased occupational self-efficacy. Therefore, hospital administrators should consider implementing an intervention to improve the personal growth initiative of NGNs so that they can take full advantage of the practice environment and gain resources at work to create optimal job outcomes.
(i) To estimate the national incidence of unplanned removal of peripherally inserted central catheters (PICCs) in China. (ii) To explore the associated risk factors to provide evidence for the prevention.
A multi-centre prospective cohort study.
A representative sample of 3222 Chinese adult patients with successful PICC insertion was recruited for the PICC Safety Management Research (PATH) using a two-stage cluster sampling method from December 2020 to June 2022. Sixty hospitals from seven Chinese provinces representing all geographical regions were selected. Demographic information and PICC characteristics were collected using a standard online case report form. Risk factors for the unplanned removal of PICCs were assessed using a cause-specific hazard model and verified using a sub-distribution hazard model. STROBE guidelines were followed in reporting this study.
Three thousand one hundred and sixty-six patients were included in the final analysis with a mean age of 59 years and a total of 344,247 catheter days. The incidence of unplanned removal was 10.04%. Female, with thrombosis history, PICC insertion due to infusion failure, valved catheter and double-lumen catheter were risk factors, whereas longer insertion and exposure length were protective factors in the cause-specific hazard model. Higher BMI became an independent risk factor in the sub-distribution hazard model.
Unplanned removal of PICCs is a serious clinical challenge in China. Our findings call for prevention strategies targeting the identified risk factors.
Our study characterised the epidemiology of unplanned removal of PICCs among Chinese adult inpatients, highlighting the need for prevention among this population and providing a basis for the formulation of relevant prevention strategies.
Patients contributed through sharing their information required for the case report form. Healthcare professionals who provide direct care to the patient at each medical centre contributed by completing the online case report form.
As pharmacotherapy often leads to adverse reactions, mind–body exercise (MBE) treatments have become a more popular option for treating depression in people living with breast cancer (BC). However, the most effective type of MBE treatment for this population remains unclear.
The aim of this systematic review and network meta-analysis (NMA) was to compare the efficacy of the different MBE modes for depression in people with BC.
A systematic search for randomized controlled trials (RCTs) from inception to March 25, 2023, was conducted in the following database: EMBASE, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data, China Biology Medicine, OpenGrey, and ClinicalTrials.gov. A traditional meta-analysis was conducted using the random-effects model to directly assess the effectiveness of various MBE interventions. Stata 16.0 software was used for performing the NMA.
The NMA was performed in 32 eligible RCTs including 2361 participants. The efficacy of MBE treatments on depression was ranked as the following: Liuzijue (surface under the cumulative ranking curve [SUCRA] = 95.4%) > Tai chi (SUCRA = 76.9%) > yoga (SUCRA = 55.0%) > Baduanjin (SUCRA = 53.9%) > Pilates (SUCRA = 38.6%) > dance (SUCRA = 30.2%) > Qigong (SUCRA = 28.1%) > control (SUCRA = 21.9%).
Our research showed that Liuzijue and Tai chi might be the most significantly effective MBE intervention for mitigating depression among BC survivors. Healthcare professionals could consider recommending Liuzijue and Tai Chi as a complementary therapy for BC survivors who experience depression.
Background
Up to 45% of patients report cancer-related cognitive impairment (CRCI). A variety of characteristics are associated with the occurrence and/or severity of CRCI. However, an important gap in knowledge of risk factors for CRCI is the relative contribution of each factor. The multifactorial model of cancer-related cognitive impairment (MMCRCI) is a conceptual model of CRCI that can be used to evaluate the strength of relationships between various factors and CRCI.
Objectives
The purpose of this study was to use structural regression methods to evaluate the MMCRCI using data from a large sample of outpatients receiving chemotherapy (n = 1,343). Specifically, the relationships between self-reported CRCI and four MMCRCI concepts (i.e., social determinants of health, patient-specific factors, treatment factors, and co-occurring symptoms) were examined. The goals were to determine how well the four concepts predicted CRCI and determine the relative contribution of each concept to deficits in perceived cognitive function.
Methods
This study is part of a larger, longitudinal study that evaluated the symptom experience of oncology outpatients receiving chemotherapy. Adult patients were diagnosed with breast, gastrointestinal, gynecological, or lung cancer; had received chemotherapy within the preceding 4 weeks; were scheduled to receive at least two additional cycles of chemotherapy; were able to read, write, and understand English; and gave written informed consent. Self-reported CRCI was assessed using the attentional function index. Available study data were used to define the latent variables.
Results
On average, patients were 57 years of age, college educated, and with a mean Karnofsky Performance Status score of 80. Of the four concepts evaluated, whereas co-occurring symptoms explained the largest amount of variance in CRCI, treatment factors explained the smallest amount of variance. A simultaneous structural regression model that estimated the joint effect of the four exogenous latent variables on the CRCI latent variable was not significant.
Discussion
These findings suggest that testing individual components of the MMCRCI may provide useful information on the relationships among various risk factors, as well as refinements of the model. In terms of risk factors for CRCI, co-occurring symptoms may be more significant than treatment factors, patient-specific factors, and/or social determinants of health in patients receiving chemotherapy. 
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