Kay Savik

Therapeutic Massage and Healing Touch Improve Symptoms in Cancer

Complementary therapies are increasingly used to reduce side effects of cancer treatment, without evidence for their effectiveness. In a randomized, prospective, 2-period, crossover intervention study, the authors tested the effects of therapeutic massage (MT) and healing touch (HT), in comparison to presence alone or standard care, in inducing relaxation and reducing symptoms in 230 subjects. MT and HT lowered blood pressure, respiratory rate (RR), and heart rate (HR). MT lowered anxiety and HT lowered fatigue, and both lowered totalmooddisturbance. Pain ratings were lower after MT and HT, with 4-week nonsteroidal antiinflammatory drug use less during MT. There were no effects on nausea. Presence reduced RR and HR but did not differ from standard care on any measure of pain, nausea, mood states, anxiety, or fatigue. MTand HT are more effective than presence alone or standard care in reducing pain, mood disturbance, and fatigue in patients receiving cancer chemotherapy.

Risk factors for the development of bronchiolitis obliterans syndrome after lung transplantation

OBJECTIVE This study identifies specific clinical and immunologic factors in lung transplant recipients that influence the subsequent development of chronic allograft dysfunction. METHODS The study group consisted of 132 consecutive patients who received lung allografts (76 single, 25 bilateral single, and 31 heart-lung) and survived at least 90 days. One hundred twenty-one patients were used in the analysis that modeled time to development of histologic obliterative bronchiolitis or bronchiolitis obliterans syndrome. RESULTS Variables noted to have an effect on the time to development of bronchiolitis obliterans syndrome included cytomegalovirus pneumonitis (RR = 3.2, p = 0.001), late acute rejection (RR = 1.3, p = 0.02), human leukocyte antigen mismatches at the A loci (RR = 1.8, p = 0.02), total human leukocyte antigen mismatches (RR = 1.4, p = 0.04), and absence of donor antigen-specific hyporeactivity (52% vs 100% survival free from bronchiolitis obliterans syndrome at 2 years; p = 0.005). Cytomegalovirus pneumonitis had a significant effect on time to obliterative bronchiolitis (RR = 3.6, p = 0.0005), as did donor antigen-specific hyporeactivity (52% vs 100% survival free from obliterative bronchiolitis at 2 years; p = 0.01). In multivariate analysis, cytomegalovirus pneumonitis (RR = 3.2, p = 0.02), human leukocyte antigen mismatches at the A loci (RR = 2.4, p = 0.006), and late acute rejection (RR = 1.3, p = 0.02) were identified as predictors of bronchiolitis obliterans syndrome. Cytomegalovirus pneumonitis was associated with time to development of histologic obliterative bronchiolitis (RR = 2.3, p = 0.02). CONCLUSIONS Several risk factors were associated with the development of chronic allograft dysfunction, which, in turn, had a significant impact on long-term survival. Early identification of lung allograft recipients with risk factors for the development of bronchiolitis obliterans syndrome may allow modification in immunosuppression and antiviral therapy to potentially decrease the prevalence of this disorder.

Somali and Oromo Refugees: Correlates of Torture and Trauma History

OBJECTIVES This cross-sectional, community-based, epidemiological study characterized Somali and Ethiopian (Oromo) refugees in Minnesota to determine torture prevalence and associated problems. METHODS A comprehensive questionnaire was developed, then administered by trained ethnic interviewers to a nonprobability sample of 1134. Measures assessed torture techniques; traumatic events; and social, physical, and psychological problems, including posttraumatic stress symptoms. RESULTS Torture prevalence ranged from 25% to 69% by ethnicity and gender, higher than usually reported. Unexpectedly, women were tortured as often as men. Torture survivors had more health problems, including posttraumatic stress. CONCLUSIONS This study highlights the need to recognize torture in African refugees, especially women, identify indicators of posttraumatic stress in torture survivors, and provide additional resources to care for tortured refugees.

Respiratory viruses and chronic rejection in lung transplant recipients

UNLABELLED BACKGROUND; Chronic rejection manifested as obliterative bronchiolitis (OB) and bronchiolitis obliterans syndrome (BOS) continue to be major causes of morbidity and mortality after lung transplantation. Community respiratory virus (CRV) infection, including respiratory syncytial virus, parainfluenza virus, and influenza virus, can infect and also cause morbidity in lung transplant recipients. Because CRV and OB/BOS affect the small airways, we sought to determine whether CRV infections predisposed patients to OB/BOS. METHODS To determine whether CRV predisposed to OB/BOS, a proportional hazards regression analysis of time to OB/BOS was performed with CRV as a time-dependent covariate. To determine the influence of OB/BOS on the subsequent development of CRV infection, we reversed the outcome and time-dependent covariate. To illustrate the effect of CRV on OB/BOS and the effect of OB/BOS on CRV, landmark plots were generated at specific time points. Time to development of OB/BOS was then compared using the Kaplan-Meier method. RESULTS In our institution, we documented 40 infections caused by CRV in 33 lung transplant recipients during an 11-year period. Community respiratory virus infections occurred predominantly during seasonal community outbreaks, except for parainfluenza infections, which occurred throughout the year. The diagnosis of OB/BOS occurred throughout the year and was not associated with seasonal outbreaks of CRV. Community respiratory virus infection involving both upper and lower respiratory tracts did not predispose to OB or BOS (relative risk [RR], 1.1; 95% confidence interval [CI], 0.52-2.3; p = 0.81). However, patients with documented CRV infection of the lower respiratory tract were predisposed to high-grade BOS development (RR, 2.3; 95% CI, 1.1-4.9; p = 0.04). In addition, a patient with pre-existing OB or BOS was predisposed to developing both upper and lower respiratory tract infection with CRV (RR, 4.2; 95% CI, 1.9-9.4; p < 0.001). CONCLUSIONS Patients with CRV infection of the lower respiratory tract were predisposed to high-grade BOS development, and patients with OB and BOS were predisposed to CRV infections.

Supplementation with dietary fiber improves fecal incontinence.

BackgroundHuman studies have shown that dietary fiber affects stool composition and consistency. Because fecal incontinence has been shown to be exacerbated by liquid stools or diarrhea, management strategies that make stool consistency less loose or liquid may be useful. ObjectiveTo compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined. MethodsThirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment. ResultsIn the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by non-significant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods. ConclusionsSupplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.

Impact of transplantation on quality of life in patients with diabetes and renal dysfunction.

Background. Simultaneous pancreas/kidney transplant (SPK) is an effective therapy that enables people with insulin-dependent diabetes mellitus (IDDM) and renal failure to maintain a more normal lifestyle, without the burdens of dialysis and insulin therapy. However, SPK has been viewed as a higher cost and higher risk procedure than kidney transplant, and it is unclear if SPK offers better health and quality of life (QOL) outcomes than insulin therapy plus kidney transplant alone (KTA). The purpose of this study is to determine which procedure affords better health and QOL outcomes. Methods. This is a prospective observational study with assessments at pretransplant and 1 and 3 years posttransplant. Patients with IDDM and renal dysfunction who received either SPK or KTA from August 1990 to September 1993 at a university transplant center were enrolled. A convenience sample of patients with IDDM and complications not seeking transplants were enrolled during the same time interval. The main outcome measures were the SF-36 Short Form Health Survey and a Satisfaction with Diabetes Therapy Scale. Results. Most health status and QOL measures improved from baseline values within each transplant group. After adjustment for diabetes severity and other baseline variables, year 3 follow-up scores of the SPK cohort were better than those of the KTA cohort for several SF-36 scales: physical functioning (P =0.038); bodily pain (P =0.047), general health (P =0.014), and the physical component summary (P =0.003). SPK recipients also reported greater satisfaction with diabetes therapy (P =0.014) and perceived more benefits to secondary complications. The KTA patients, however, had higher adjusted scores for the role-emotional subscale (P =.037) and the mental component summary (P =.037). By year 3, the SPK cohort is at the 30th and 51st percentiles of the general adult US population in self-reported physical and mental health; the KTA cohort is at the 10th and 73rd percentiles. Conclusions. At follow-up, both SPK and KTA patients report better health and quality of life but SPK patients report greater improvements than KTA patients in physical health and in areas that are diabetes specific. Although the improved physical outcomes of SPK patients are consistent with perceived benefits to secondary complications, the mental health differences cannot be explained by the study data and warrant further study.

Effects of Patient-Directed Music Intervention on Anxiety and Sedative Exposure in Critically Ill Patients Receiving Mechanical Ventilatory Support: A Randomized Clinical Trial

IMPORTANCE Alternatives to sedative medications, such as music, may alleviate the anxiety associated with ventilatory support. OBJECTIVE To test whether listening to self-initiated patient-directed music (PDM) can reduce anxiety and sedative exposure during ventilatory support in critically ill patients. DESIGN, SETTING, AND PATIENTS Randomized clinical trial that enrolled 373 patients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul, Minnesota, area receiving acute mechanical ventilatory support for respiratory failure between September 2006 and March 2011. Of the patients included in the study, 86% were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days. INTERVENTIONS Self-initiated PDM (n = 126) with preferred selections tailored by a music therapist whenever desired while receiving ventilatory support, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125). MAIN OUTCOMES AND MEASURES Daily assessments of anxiety (on 100-mm visual analog scale) and 2 aggregate measures of sedative exposure (intensity and frequency). RESULTS Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, -32.2 to -6.8) than patients in the usual care group (P = .003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by -0.18 (95% CI, -0.36 to -0.004) points/day (P = .05) and had reduced frequency by -0.21 (95% CI, -0.37 to -0.05) points/day (P = .01). The PDM group had reduced sedation frequency by -0.18 (95% CI, -0.36 to -0.004) points/day vs the NCH group (P = .04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity. CONCLUSIONS AND RELEVANCE Among ICU patients receiving acute ventilatory support for respiratory failure, PDM resulted in greater reduction in anxiety compared with usual care, but not compared with NCH. Concurrently, PDM resulted in greater reduction in sedation frequency compared with usual care or NCH, and greater reduction in sedation intensity compared with usual care, but not compared with NCH. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00440700.

Factors associated with very early weaning among primiparas intending to breastfeed.

Objectives: The major objective of this study was to identify predictor variables that accurately differentiated breastfeeding women who weaned during the first 4 weeks, those who weaned between 5 and 26 weeks, and those who weaned after 26 weeks. Predictors were demographic variables, Theory of Planned Behavior (TPB) variables, breastfeeding knowledge, and difficulties experienced during the first month. Methods: Primiparas who delivered healthy infants in an urban midwestern hospital provided initial data prior to discharge. Follow-up occurred at 1,3,6,9, and 12 months. Following appropriate bivariate analyses, polychotomous logistic regression was used to determine predictors of weaning group. Linear multiple regression was used to predict intended duration. Results: Most of the 84 women who weaned very early had intended to breastfeed considerably longer. According to the multivariate analysis, women who weaned earlier were younger, had completed fewer years of education, had a more positive bottle-feeding attitude and a less positive breastfeeding attitude, intended to breastfeed less time, had lower knowledge scores, had higher perceived insufficient milk scores, and planned to work outside the home. Variables postulated by the TPB to be direct predictors of intention explained 36% of the variance in intended duration. Conclusions: Women at risk for early weaning can be identified with reasonable accuracy using a TPB-based conceptual framework expanded to include breastfeeding specific variables. Casefinding using empirically derived screening methods and careful postpartum follow-up, along with professional intervention, should be used to avert unintended early weaning.

An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention.

Purpose To determine the cost and efficacy of 4 different regimens of incontinence-associated dermatitis (IAD) prevention in nursing home residents. Methods A multi-site open-label quasi-experimental study was conducted in 16 nursing homes stratified by location in 1 of 4 regions of the United States and randomly selected. In 3 of the 4 regimens, a moisture barrier ointment or cream of different compositions was applied after each episode of incontinence, and in 1 regimen, a polymer-based barrier film was applied 3 times per week. All regimens used a pH-balanced moisturizing cleanser. Time and motion measures were documented for the amount of skin care products used; the number, type, and time of caregivers performing IAD prevention care; and the number and type of supplies used. Rates of incontinence in each nursing home were determined during a 3-day surveillance period. Results A total of 1,918 nursing home residents were screened, and 51% (n = 981) qualified for prospective surveillance of incontinence dermatitis; the majority were female (80.1%) and elderly (96% ≥ 65 years old). A total of 78.6% (771/981) of the participants were incontinent of both urine and feces. Compared to the 3 regimens in which a barrier was applied after each episode of incontinence, the use of a regimen in which a barrier film was applied 3 times weekly had significantly lower costs for the barrier product, labor associated with barrier application, and total cost, which included products, labor, and supplies. There were also savings in total product (cleanser and barrier) and total labor costs. Conclusions The use of a defined skin care regimen that includes a cleanser and a moisture barrier is associated with a low rate of IAD in nursing home residents who are incontinent. Use of a polymer skin barrier film 3 times weekly is effective for preventing incontinence-associated skin breakdown and can provide significant cost savings.

Sampling in difficult to access refugee and immigrant communities

We evaluated sampling strategies and trust-building activities in a large multiphase epidemiologic study of torture prevalence in populations that were difficult to locate and enroll. Refugee groups under study were Somalis from Somalia and Oromos from Ethiopia who were living in Minneapolis and St. Paul, Minnesota, in 1999–2002. Without a complete sampling frame from which to randomly recruit participants, we employed purposive sampling methods. Through comparative and statistical analyses, we found no apparent differences between our sample and the underlying population and discovered no effects of recruiting methods on study outcomes, suggesting that the sample could be analyzed with confidence. Ethnographic trust and rapport-building activities among investigators, field staff, and immigrant communities made it possible to obtain the sample and gather sensitive data. Maintaining a culture of trust was crucial in recovering from damaging environmental events that threatened data collection.