Stacey A. Page

A randomized controlled trial of a brief psychoeducational support group for partners of early stage breast cancer patients.

Partners of breast cancer patients are relied upon for support at a time when their own coping abilities are taxed by the challenge of cancer, yet few studies have investigated psychosocial interventions that include or target the patients ‘significant other’. Of the 118 consecutive patients approached, 36 patients and their partners participated in a randomized controlled trial of a brief psychoeducational group program for partners only. Psychometric instruments (including the Profile of Mood States (POMS), the Index of Marital Satisfaction (IMS) and DUKE‐UNC Functional Social Support Scale (FSSS)) were administered pre‐test, post‐test and at 3 months follow‐up. The Mental Adjustment to Cancer Scale (MAC) was also completed by patients. Three months after the intervention, partners had less mood disturbance than did controls. Patients whose partners received the intervention reported less mood disturbance, greater confidant support (CS) and greater marital satisfaction. Copyright

Chiropractic Care and Public Health: Answering Difficult Questions About Safety, Care Through the Lifespan, and Community Action

The purpose of this collaborative summary is to document current chiropractic involvement in the public health movement, reflect on social ecological levels of influence as a profession, and summarize the relationship of chiropractic to the current public health topics of: safety, health issues through the lifespan, and effective participation in community health issues. The questions that are addressed include: Is spinal manipulative therapy for neck and low-back pain a public health problem? What is the role of chiropractic care in prevention or reduction of musculoskeletal injuries in children? What ways can doctors of chiropractic stay updated on evidence-based information about vaccines and immunization throughout the lifespan? Can smoking cessation be a prevention strategy for back pain? Does chiropractic have relevance within the VA Health Care System for chronic pain and comorbid disorders? How can chiropractic use cognitive behavioral therapy to address chronic low back pain as a public health problem? What opportunities exist for doctors of chiropractic to more effectively serve the aging population? What is the role of ethics and the contribution of the chiropractic profession to public health? What public health roles can chiropractic interns perform for underserved communities in a collaborative environment? Can the chiropractic profession contribute to community health? What opportunities do doctors of chiropractic have to be involved in health care reform in the areas of prevention and public health? What role do citizen-doctors of chiropractic have in organizing community action on health-related matters? How can our future chiropractic graduates become socially responsible agents of change?

Components of an Anticancer Diet: Dietary Recommendations, Restrictions and Supplements of the Bill Henderson Protocol

The use of complementary and alternative medicines including dietary supplements, herbals and special diets to prevent or treat disease continues to be popular. The following paper provides a description of an alternative dietary approach to the self-management and treatment of cancer, the Bill Henderson Protocol (BHP). This diet encourages daily intake of raw foods, a combination of cottage cheese and flaxseed oil and a number of supplements. Some foods and food groups are restricted (e.g., gluten, meat, dairy). Early background theory that contributed to the protocol’s development is presented as is a summary of relevant evidence concerning the anti-cancer fighting properties of the individual components. Supplement intake is considered in relation to daily recommended intakes. Challenges and risks to protocol adherence are discussed. As with many complementary and alternative interventions, clear evidence of this dietary protocol’s safety and efficacy is lacking. Consumers of this protocol may require guidance on the ability of this protocol to meet their individual nutritional needs.

Oral cannabinoids for spasticity in multiple sclerosis: will attitude continue to limit use?

See page 1517 Spasticity is a distressing and disabling symptom that many people with multiple sclerosis face daily because there is inadequate treatment. As one part of an upper motor-neuron syndrome, spasticity manifests as muscle stiffness, spasms, and pain. It also contributes to limited mobility and impaired sleep. The hypothesis that cannabis derivatives (eg, -9-tetrahydrocannabinol [ -THC], cannabidiol) relieve spasticity and other symptoms of multiple sclerosis has received increasing attention in recent years. Identification and characterisation of cannabinoid receptors (eg, CB1, CB2), recognition of endogenous cannabinoid ligands, and evidence that activation of the CB1 receptor in the brain leads to inhibitory influences on neurotransmitter release supports this hypothesis. The benefit of cannabinoids in animal models of spasticity and the results of small clinical trials have led to investigation of cannabinoids as symptomatic therapy in multiple sclerosis. The potential role of cannabinoids as neuroprotective agents is also intriguing. Although off-label use of a large variety of approved drugs is probably done every day by physicians for every condition, use of cannabinoids has remained limited. Concern about treatment risk, lack of a safe, accessible, and reliable cannabis supply, unclear dosing of smoked cannabis, and lack of social and legal acceptance of cannabinoids as legitimate treatment contribute to this limited use. The study by John Zajicek and colleagues in this issue of The Lancet is the first large multicentre randomised placebo-controlled trial of cannabinoid therapy in multiple sclerosis and is thus an important step forward. Although this trial failed to detect a significant treatment effect of any cannabinoid on the primary outcome, spasticity as measured by the Ashworth scale, use of -THC decreased timed walk (median 12%, 95% CI 6% to 21%) compared with 4% for placebo and cannabis extract ( 2% to 7%, and 0% to 10%, respectively). Subjective improvement of spasticity-related symptoms (spasticity, pain, sleep, spasms) occurred more frequently with cannabinoids than with placebo, whereas there was no treatment effect on symptoms less specifically related to spasticity (irritability, depression, tiredness, tremor, energy). In previous studies subjective reports of improvement in various symptoms of multiple sclerosis were almost universal, whereas comparison with a placebo group in Zajicek’s study suggests a fairly specific effect on spasticity. Although failing to achieve an effect on the primary outcome suggests Kajicek and colleagues’ trial is negative, the Ashworth scale does not correlate with function or with other measures of spasticity. Lack of benefit on the Ashworth scale might also be partly related to inclusion of non-ambulatory patients. Inclusion of patients with such a highly variable degree of spasticity could have meant that the investigators assessed patients who had greater variability than in other studies that used this scale. Descending inhibitory influences generated by cannabinoids could also fail to affect spasticity in people with severe spinal-cord pathology, because transmission through the spinal cord is impaired. These patients would have been non-ambulatory and hence could not have diminished the apparent effect of treatment on timed walk but might have done so for other measures assessed, including the Ashworth scale. Future studies should consider the potential confounding effect of including such patients with severe spinal-cord disease and should not rely totally on the Ashworth scale. Another possible contribution to the limited treatment effect could have been the route of administration. Oral administration of cannabinoids is unpredictable and leads to lower bioavailability than smoked cannabis. Although smoking cannabis is therapeutically unacceptable because of additional risks associated with smoking, alternative methods have met with some success and need to be further assessed. In Zajicek and colleagues’ study, most of the reported serious adverse events were expected in this population and minor adverse events were consistent with known side-effects of cannabis. As noted by Zajicek and colleagues, their findings must be interpreted in light of the fact that most of participants (and physicians) correctly identified whether or not they were taking active medication, which illustrates the difficulty of blinding during trials of cannabinoids. What does this study mean to clinicians and to people with multiple sclerosis? We now have as much evidence to support the use of these oral cannabinoids for spasticity in ambulatory people with multiple sclerosis as we do for many standard therapies for spasticity, including baclofen. However, because we do not know how these cannabinoids compare with other antispasticity treatments, they should generally only be considered when other therapy has failed. Caution should also be advised about driving while using cannabinoids. Perhaps, as in Zajicek’s study, driving should not be permitted. Finally, we still have no data to compare the risks and benefits of smoked cannabis. Hopefully Zajicek and colleagues’ study will stimulate further research to develop and evaluate safe and effective formulations of cannabis, and will inform debate over the social and legal restrictions that limit its use. In the meantime, when other treatment inadequately controls spasticity, oral cannabinoids should be considered where law permits their possession and use.

The biobank for the molecular classification of kidney disease: research translation and precision medicine in nephrology

BackgroundAdvances in technology and the ability to interrogate disease pathogenesis using systems biology approaches are exploding. As exemplified by the substantial progress in the personalized diagnosis and treatment of cancer, the application of systems biology to enable precision medicine in other disciplines such as Nephrology is well underway. Infrastructure that permits the integration of clinical data, patient biospecimens and advanced technologies is required for institutions to contribute to, and benefit from research in molecular disease classification and to devise specific and patient-oriented treatments.Methods and resultsWe describe the establishment of the Biobank for the Molecular Classification of Kidney Disease (BMCKD) at the University of Calgary, Alberta, Canada. The BMCKD consists of a fully equipped wet laboratory, an information technology infrastructure, and a formal operational, ethical and legal framework for banking human biospecimens and storing clinical data. The BMCKD first consolidated a large retrospective cohort of kidney biopsy specimens to create a population-based renal pathology database and tissue inventory of glomerular and other kidney diseases. The BMCKD will continue to prospectively bank all kidney biopsies performed in Southern Alberta. The BMCKD is equipped to perform molecular, clinical and epidemiologic studies in renal pathology. The BMCKD also developed formal biobanking procedures for human specimens such as blood, urine and nucleic acids collected for basic and clinical research studies or for advanced diagnostic technologies in clinical care. The BMCKD is guided by standard operating procedures, an ethics framework and legal agreements with stakeholders that include researchers, data custodians and patients. The design and structure of the BMCKD permits its inclusion in a wide variety of research and clinical activities.ConclusionThe BMCKD is a core multidisciplinary facility that will bridge basic and clinical research and integrate precision medicine into renal pathology and nephrology.

Parental perspectives on consent for participation in large-scale, non-biological data repositories

BackgroundData sharing presents several challenges to the informed consent process. Unique challenges emerge when sharing pediatric or pregnancy-related data. Here, parent preferences for sharing non-biological data are examined.MethodsGroups (n = 4 groups, 18 participants) and individual interviews (n = 19 participants) were conducted with participants from two provincial, longitudinal pregnancy cohorts (AOB and APrON). Qualitative content analysis was applied to transcripts of semi-structured interviews.ResultsParticipants were supportive of a broad, one-time consent model or a tiered consent model. These preferences were grounded in the perceived obligations for reciprocity and accuracy. Parents want reciprocity among participants, repositories and researchers regarding respect and trust. Furthermore, parents’ worry about the interrelationships between the validity of the consent processes and secondary data use.ConclusionsThough parent participants agree that their research data should be made available for secondary use, they believe their consent is still required. Given their understanding that obtaining and informed consent can be challenging in the case of secondary use, parents agreed that a broad, one-time consent model was acceptable, reducing the logistical burden while maintaining respect for their contribution. This broad model also maintained participant trust in the research and secondary use of their data. The broad, one-time model also reflected parents’ perspectives surrounding child involvement in the consent process. The majority of parents felt decision made during childhood were the parents responsibility and should remain in parental purview until the child reaches the age of majority.

The Perspectives and Practices of Alberta Chiropractors Regarding the Sale of Health Care Products in Chiropractic Offices

OBJECTIVE The purpose of this study is to describe the practices and perspectives of doctors of chiropractic in Alberta, Canada, regarding the sale of health products. This practice is considered in terms of ethical principles and professional practice standards. METHODS Chiropractic Web sites in Alberta were identified using the publically available Web site of the Alberta College and Association of Chiropractors. A random sample of chiropractors was drawn and mailed a brief 4-page survey and return envelope. There was a follow-up mail out to nonrespondents 3 weeks later. Practitioners provided responses regarding their personal and professional characteristics and their perspectives and practices regarding health product sales. RESULTS A total of 265 responses were received (response rate, 51.2%). Most practitioners endorsed health product sales by chiropractors (95%), and most were engaged in the practice (89%). Orthotics (77%) and pillows (69%) were sold most often, followed by nutritional supplements (68%), hot/cold packs (68%), and vitamins (52%). Some respondents identified areas of potential ethical concern, including product safety and efficacy, professional influence on consumer product purchase, and potential conflict of interest. Codes of ethics and conduct offer some guidance to practitioners, but their awareness of standards varied. CONCLUSIONS The chiropractic profession within Alberta condones product sales, and most of its membership engages in the practice. Individual members differ in their perspectives on this practice and in their awareness of the national code of ethics and conduct.

An Audit of Health Products Advertised for Sale on Chiropractic Web Sites in Canada and Consideration of These Practices in the Context of Canadian Chiropractic Codes of Ethics and Conduct

OBJECTIVE This study describes the extent to which chiropractors with Web sites practicing in Canada advertise health products for sale and considers this practice in the context of chiropractic codes of ethics and conduct. METHODS Chiropractic Web sites in Canada were identified using a public online business directory (Canada 411). The Web sites were searched, and an inventory of the health products for sale was taken. The influences of type of practice and province of practice on the sale of health product were assessed. Textual comments about health product marketing were summarized. National and provincial codes of ethics were reviewed, and the content on health product advertising was summarized. RESULTS Two hundred eighty-seven Web sites were reviewed. Just more than half of the Web sites contained information on health products for sale (n = 158, 54%). Orthotics were advertised most often (n = 136 practices, 47%), followed by vitamins/nutritional supplements (n = 53, 18%), pillows and supports (n = 40, 14%), and exercise/rehabilitation products (n = 20, 7%). Chiropractors in solo or group chiropractic practices were less likely to advertise health products than those in multidisciplinary practice (P < .001), whereas chiropractors in BC were less likely to advertise nutritional supplements (P < .01). Provincial codes of ethics and conduct varied in their guidelines regarding health product sales. CONCLUSIONS Variations in codes of ethics and in the proportions of practitioners advertising health products for sales across the country suggest that opinions may be divided on the acceptability of health product sales. Such practices raise questions and considerations for the chiropractic profession.

Causes of Death Among an Urban Homeless Population Considered by the Medical Examiner

Those who are homeless face illness and death, however, live in places not conducive to provision of end-of-life care. Limited information exists on causes of death among this group of people. To characterize causes of death, data were requested from the Office of the Chief Medical Examiner for Alberta Justice, Canada, for people determined to be homeless in the period 2007–2009. One hundred and thirty-two deaths were reported. Most deaths that could be classified were attributed to drug and alcohol use/abuse and to natural causes. For many, end-of-life circumstances may have been improved through provision of palliative care delivered in a hospice setting.

Meaning and challenges in the practice of multiple therapeutic massage modalities: a combined methods study.

BackgroundTherapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice.MethodsCombined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada.ResultsOf the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision.ConclusionsThe training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patients treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.