Yoojin Lee

A Randomized Trial of Tai Chi for Fibromyalgia

BACKGROUND Previous research has suggested that tai chi offers a therapeutic benefit in patients with fibromyalgia. METHODS We conducted a single-blind, randomized trial of classic Yang-style tai chi as compared with a control intervention consisting of wellness education and stretching for the treatment of fibromyalgia (defined by American College of Rheumatology 1990 criteria). Sessions lasted 60 minutes each and took place twice a week for 12 weeks for each of the study groups. The primary end point was a change in the Fibromyalgia Impact Questionnaire (FIQ) score (ranging from 0 to 100, with higher scores indicating more severe symptoms) at the end of 12 weeks. Secondary end points included summary scores on the physical and mental components of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). All assessments were repeated at 24 weeks to test the durability of the response. RESULTS Of the 66 randomly assigned patients, the 33 in the tai chi group had clinically important improvements in the FIQ total score and quality of life. Mean (+/-SD) baseline and 12-week FIQ scores for the tai chi group were 62.9+/-15.5 and 35.1+/-18.8, respectively, versus 68.0+/-11 and 58.6+/-17.6, respectively, for the control group (change from baseline in the tai chi group vs. change from baseline in the control group, -18.4 points; P<0.001). The corresponding SF-36 physical-component scores were 28.5+/-8.4 and 37.0+/-10.5 for the tai chi group versus 28.0+/-7.8 and 29.4+/-7.4 for the control group (between-group difference, 7.1 points; P=0.001), and the mental-component scores were 42.6+/-12.2 and 50.3+/-10.2 for the tai chi group versus 37.8+/-10.5 and 39.4+/-11.9 for the control group (between-group difference, 6.1 points; P=0.03). Improvements were maintained at 24 weeks (between-group difference in the FIQ score, -18.3 points; P<0.001). No adverse events were observed. CONCLUSIONS Tai chi may be a useful treatment for fibromyalgia and merits long-term study in larger study populations. (Funded by the National Center for Complementary and Alternative Medicine and others; ClinicalTrials.gov number, NCT00515008.)

Effect of Daily Hemodialysis on Depressive Symptoms and Postdialysis Recovery Time: Interim Report From the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study

BACKGROUND Clinical depression and postdialysis fatigue are important concerns for patients with kidney failure and can have a negative impact on quality of life and survival. STUDY DESIGN The FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study is an ongoing prospective cohort study investigating the clinical and economic benefits of daily (6 times per week) hemodialysis (HD). In this interim report, as part of an a priori planned analysis, we examine the long-term impact of daily HD on depressive symptoms, measured using the Beck Depression Inventory (BDI) survey, and postdialysis recovery time, measured using a previously validated questionnaire. SETTING & PARTICIPANTS Adult patients initiating daily HD with a planned 12-month follow-up. OUTCOMES & MEASUREMENTS The BDI survey and postdialysis recovery time question were administered at baseline, and changes were assessed at months 4 and 12. RESULTS 239 participants were enrolled (intention-to-treat cohort) and 128 completed the study (per-protocol cohort). Mean age was 52 years, 64% were men, 55% had an arteriovenous fistula, and 90% transitioned from in-center HD therapy. In the per-protocol cohort, there was a significant decrease in mean BDI score over 12 months (11.2 [95% CI, 9.6-12.9] vs 7.8 [95% CI, 6.5-9.1]; P<0.001). For robustness, the intention-to-treat analysis was performed, yielding similar results. The percentage of patients with depressive symptoms (BDI score>10) significantly decreased during 12 months (41% vs 27%; P=0.03). Similarly, in the per-protocol cohort, there was a significant decrease in postdialysis recovery time over 12 months (476 [95% CI, 359-594] vs 63 minutes [95% CI, 32-95]; P<0.001). The intention-to-treat analysis yielded similar results. The percentage of patients experiencing prolonged postdialysis recovery time (>or=60 minutes) also significantly decreased (81% vs 35%; P=0.001). LIMITATIONS Observational study with lack of control arm. CONCLUSIONS Daily HD is associated with long-term improvement in depressive symptoms and postdialysis recovery time.

At-home short daily hemodialysis improves the long-term health-related quality of life

Patients with chronic kidney disease treated by in-center conventional hemodialysis (3 times per week) have significant impairments in health-related quality of life measures, which have been associated with increased morbidity and mortality. FREEDOM is an ongoing prospective cohort study measuring the potential benefits of at-home short daily (6 times per week) hemodialysis. In this interim report we examine the long-term effect of short daily hemodialysis on health-related quality of life, as measured by the SF-36 health survey. This was administered at baseline, 4 and 12 months after initiation of short daily hemodialysis to 291 participants (total cohort), of which 154 completed the 12-month follow-up (as-treated cohort). At the time of analysis, the mean age was 53 years, 66% were men, 58% had an AV fistula, 90% transitioned from in-center hemodialysis, and 45% had diabetes mellitus. In the total cohort analysis, both the physical- and mental-component summary scores improved over the 12-month period, as did all 8 individual domains of the SF-36. The as-treated cohort analysis showed similar improvements with the exception of the role-emotional domain. Significantly, in the as-treated cohort, the percentage of patients achieving a physical-component summary score at least equivalent to the general population more than doubled. Hence, at-home short daily hemodialysis is associated with long-term improvements in various physical and mental health-related quality of life measures.

Impact of Short Daily Hemodialysis on Restless Legs Symptoms and Sleep Disturbances

BACKGROUND AND OBJECTIVES Restless legs syndrome (RLS) and sleep disturbances are common among in-center hemodialysis patients and are associated with increased morbidity/mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The FREEDOM study is an ongoing prospective cohort study investigating the benefits of home short daily hemodialysis (SDHD) (6 times/week). In this interim report, we examine the long-term effect of SDHD on the prevalence and severity of RLS, as measured by the International Restless Legs Syndrome (IRLS) Study Group rating scale, and sleep disturbances, as measured by the Medical Outcomes Study sleep survey. RESULTS 235 participants were included in this report (intention-to-treat cohort), of which 127 completed the 12-month follow-up (per-protocol cohort). Mean age was 52 years, 55% had an arteriovenous fistula, and 40% suffered from RLS. In the per-protocol analysis, among patients with RLS, the mean IRLS score improved significantly at month 12, after adjustment for use of RLS-related medications (18 versus 11). Among patients with moderate-to-severe RLS (IRLS score ≥15), there was an even greater improvement in the IRLS score (23 versus 13). The intention-to-treat analysis yielded similar results. Over 12 months, there was decline in the percentage of patients reporting RLS (35% versus 26%) and those reporting moderate-to-severe RLS (59% versus 43%). There was a similar and sustained 12-month improvement in several scales of the sleep survey, after adjustment for presence of RLS and use of anxiolytics and hypnotics. CONCLUSIONS Home SDHD is associated with long-term improvement in the prevalence and severity of RLS and sleep disturbances.

Comparison of hilar clamping and non-hilar clamping partial nephrectomy for tumours involving a solitary kidney.

Study Type – Therapy (case series)

Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents

IMPORTANCE It is important to understand the relationship between sleep medication use and injurious falls in nursing home residents. OBJECTIVE To conduct a case-crossover study to estimate the association between nonbenzodiazepine hypnotic drug use (zolpidem tartrate, eszopiclone, or zaleplon) and the risk for hip fracture among a nationwide sample of long-stay nursing home residents, overall and stratified by individual and facility-level characteristics. DESIGN AND SETTING Case-crossover study performed in an academic research setting. PARTICIPANTS The study participants included 15,528 long-stay US nursing home residents 50 years or older with a hip fracture documented in Medicare Part A and Part D fee-for-service claims between July 1, 2007, and December 31, 2008. MAIN OUTCOME MEASURES Odds ratios (ORs) of hip fracture were estimated using conditional logistic regression models by comparing the exposure to nonbenzodiazepine hypnotic drugs during the 0 to 29 days before the hip fracture (hazard period) with the exposure during the 60 to 89 and 120 to 149 days before the hip fracture (control periods). Analyses were stratified by individual and facility-level characteristics. RESULTS Among the study participants, 1715 (11.0%) were dispensed a nonbenzodiazepine hypnotic drug before the hip fracture, with 927 exposure-discordant pairs included in the analyses. The mean (SD) age of participants was 81.0 (9.7) years, and 77.6% were female. The risk for hip fracture was elevated among users of a nonbenzodiazepine hypnotic drug (OR, 1.66; 95% CI, 1.45-1.90). The association between nonbenzodiazepine hypnotic drug use and hip fracture was somes greater in new users (OR, 2.20; 95% CI, 1.76-2.74) and in residents with mild vs moderate to severe impairment in cognition (OR, 1.86 vs 1.43; P = .06), with moderate vs total or severe functional impairment (OR, 1.71 vs 1.16; P = .11), with limited vs full assistance required with transfers (OR, 2.02 vs 1.43; P = .02), or in a facility with fewer Medicaid beds (OR, 1.90 vs 1.46; P = .05). CONCLUSIONS AND RELEVANCE The risk for hip fracture is elevated among nursing home residents using a nonbenzodiazepine hypnotic drug. New users and residents having mild to moderate cognitive impairment or requiring limited assistance with transfers may be most vulnerable to the use of these drugs. Caution should be exercised when prescribing sleep medications to nursing home residents.

Irritable bowel syndrome: emerging paradigm in pathophysiology.

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders, characterized by abdominal pain, bloating, and changes in bowel habits. These symptoms cannot be explained by structural abnormalities and there is no specific laboratory test or biomarker for IBS. Therefore, IBS is classified as a functional disorder with diagnosis dependent on the history taking about manifested symptoms and careful physical examination. Although a great deal of research has been carried out in this area, the pathophysiology of IBS is complex and not completely understood. Multiple factors are thought to contribute to the symptoms in IBS patients; altered gastrointestinal motility, visceral hypersensitivity, and the brain-gut interaction are important classical concepts in IBS pathophysiology. New areas of research in this arena include inflammation, postinfectious low-grade inflammation, genetic and immunologic factors, an altered microbiota, dietary factors, and enteroendocrine cells. These emerging studies have not shown consistent results, provoking controversy in the IBS field. However, certain lines of evidence suggest that these mechanisms are important at least a subset of IBS patients, confirming that IBS symptoms cannot be explained by a single etiological mechanism. Therefore, it is important to keep in mind that IBS requires a more holistic approach to determining effective treatment and understanding the underlying mechanisms.

Non‐clamped partial nephrectomy: techniques and surgical outcomes

Study Type – Therapy (case series)
Level of Evidence 4

Pre-Operative Left Atrial Mechanical Function Predicts Risk of Atrial Fibrillation Following Cardiac Surgery

OBJECTIVES The purpose of this study was to examine whether left atrial (LA) mechanical function, as measured by LA total emptying fraction (TEF), is a predictor for the development of post-operative atrial fibrillation (POAF) following cardiac surgery. BACKGROUND POAF is an important and frequent complication of cardiac surgery. LA enlargement has been reported to be a risk factor for POAF, but the relationship between LA mechanical function and POAF is not well understood. We examined the relationship between pre-operative LA function and POAF in patients without a history of atrial fibrillation. METHODS A total of 101 subjects (mean age 64 ± 13 years) underwent pre-operative transthoracic echocardiograms and were followed for occurrence of POAF during the hospitalization for cardiac surgery. The left atrial maximum volume (LAVmax) and left atrial minimum volume (LAVmin) were measured and indexed to body surface area (LAVmaxI and LAVminI, respectively). LA TEF was calculated as: {[(LAVmax - LAVmin)/LAVmax] × 100%}. Univariate and multivariate analyses examined clinical and echocardiographic predictors of POAF. RESULTS POAF occurred in 41% of subjects. Mean LA TEF was 49 ± 15%, mean LAVmaxI was 38 ± 15 ml/m(2), and mean LAVminI was 20 ± 13 ml/m(2). Age, LA TEF, and LAVminI were independent predictors of POAF. LA TEF was lower in patients with POAF compared with those without POAF (43 ± 15% vs. 55 ± 13%, p < 0.001), and patients with a LA TEF <50% had a high risk of POAF (odds ratio: 7.94, 95% confidence interval: 3.23 to 19.54, p < 0.001). Compared with LAVmaxI >32 ml/m(2), LA TEF <50% had higher discriminatory power for POAF, which remained significantly higher when adjusted for age (p = 0.04). CONCLUSIONS LA TEF is an independent predictor of POAF and is a stronger predictor of POAF than LAVmaxI is. Impaired LA mechanical function may help to identify patients who are most likely to benefit from prophylaxis for POAF.

Provider-patient Adherence Dialogue in HIV Care: Results of a Multisite Study

Few studies have analyzed physician–patient adherence dialogue about ARV treatment in detail. We comprehensively describe physician–patient visits in HIV care, focusing on ARV-related dialogue, using a system that assigns each utterance both a topic code and a speech act code. Observational study using audio recordings of routine outpatient visits by people with HIV at specialty clinics. Providers were 34 physicians and 11 non-M.D. practitioners. Of 415 patients, 66% were male, 59% African–American. 78% reported currently taking ARVs. About 10% of utterances concerned ARV treatment. Among those using ARVs, 15% had any adherence problem solving dialogue. ARV problem solving talk included significantly more directives and control parameter utterances by providers than other topics. Providers were verbally dominant, asked five times as many questions as patients, and made 21 times as many directive utterances. Providers asked few open questions, and rarely checked patients’ understanding. Physicians respond to the challenges of caring for patients with HIV by adopting a somewhat physician-centered approach which is particularly evident in discussions about ARV adherence.ResumenPocos estudios han analizado en detalle el diálogo entre médicos y pacientes sobre la adherencia del paciente al tratamiento con antirretrovirales (ARVs). Se describe globalmente encuentros entre médicos y pacientes en el tratamiento del VIH, con enfoque en el diálogo sobre ARVs, usando un sistema que aplica a cada enunciado un código para el tema, y para el acto de del habla.Estudio observaciónal con uso de grabaciones de consultas externas rutinarias de personas con VIH en clínicas especializadas.Los proveedores fueron 34 médicos y 11 proveedores de otras clases. De 415 pacientes, 66% fueron hombres, 59% Africano-Americanos. 78% informaron tomar ARVs actualmente.Aproximadamente 10% de los enunciados se refirieron al tratamiento con ARVs. Entres los que usaron ARVs, 15% tuvieron algún diálogo sobre la resolución de problemas de adherencia al tratamiento. El diálogo sobre la resolución de problemas incluyó significativamente más actos directivos y enunciados en la clase de control, comparado a otros temas. Los proveedores dominaron la conversación, hicieron 5 veces más preguntas que los pacientes, y 21 veces más enunciados directivos. Los proveedores hicieron pocas preguntas abiertas, y raras veces chequearon el entendimiento del paciente.Los médicos responden al reto de atender a los pacientes con VIH adoptando un acercamiento que se centra en el médico, lo que se evidencia particularmente en la discusión sobre la adherencia al tratamiento con ARVs.