Single Fraction versus Multiple Fraction Radiotherapy for Palliation of Painful Vertebral Bone Metastases: A Prospective Study

Context:

Metastatic bone disease is a commonly encountered problem in oncology practice. The most useful and cost effective treatment is radiotherapy (RT). Different fractionation schedule of RT can be used to treat such condition.

Aims:

Assessment of pain response in patients with vertebral bone metastasis after treating them with various radiation fractionations and to compare the toxicity profile in the treatment arms.

Settings and Design:

A prospective randomized study was designed to include total 64 patients from July 2010 to May 2011. Patients with histopathologically proven primary malignancy having symptomatic secondary deposits to vertebra were selected for the study. Patients were randomized to two arms receiving multiple fraction of RT with 30 Gy in 10 fractions and 8 Gy in single fraction RT, respectively.

Materials and Methods:

Patients with age >75 years, Karnofsky Performance Status (KPS) <40, features of cord compression were excluded from study. Initial pain response was assessed using Visual Analogue Scale (VAS) and compared using the same scale at weekly interval up to 1 month after treatment completion.

Results:

Arm A comprised of 33 patients while 31 patients were enrolled in Arm B. Baseline patient characteristics were comparable. Eleven patients were lost to follow-up. Initial pain scores were 7.23 ± 0.765 and 7.51 ± 0.55 in arm A and arm B, respectively. Pain scores reduced significantly in both the arms after 1 month (4.39 ± 1.82 in arm A; 5.25 ± 2.39 in arm B). Time of initiation of pain response was earlier in arm A (P = 0.0281), statistically significant. Mild G-I toxicity was noted in both the arms but differences in two arms were not statistically significant (P = 0.49), no interruption of treatment was required because of side effects.

Conclusions:

Different fractionation of radiation has same response and toxicity in treatment of vertebral bone metastasis. Single fraction RT may be safely used to treat these cases as this is more cost effective and less time consuming. Studies may be conducted to find out particular subgroup of patients to be benefitted more by either fractionation schedule; however, our study cannot comment on that issue.     

Effects of fentanyl on procedural pain and discomfort associated with central venous catheter insertion: A prospective,randomized, double-blind,placebo controlled trial

Context:

Central venous catheter (CVC) insertion induces pain and discomfort to a conscious patient despite application of a local anesthetic (LA) field block and this pain can be greatly lessened by using additional analgesics.

Aim:

The aim of this study is to evaluate the efficacy of fentanyl along with LA field infiltration in controlling pain and discomfort associated with CVC insertion.

Settings and Design:

A prospective, randomized, double-blind, placebo-controlled trial was conducted at tertiary referral center.

Materials and Methods:

Fifty-four patients scheduled for planned CVC were randomly assigned to receive either fentanyl (2 μg/kg) or 0.9% normal saline. Pain and discomfort using a verbal numeric rating pain scale at 5 times points during CVC insertion were assessed and analyzed.

Results:

The median interquartile range pain score is worst for placebo group after LAI (5 [3-6]) and in the immediate postprocedure period (5 [4-5]) which was significantly attenuated by addition of fentanyl (3.5 [2-5] and 3 [2-4]) (P = 0.009 and 0.001 respectively). Overall, fentanyl and placebo group were not statistically different with median discomfort score except at T10 (P = 0.047).

Conclusions:

Preprocedural bolus fentanyl infusion provides adequate analgesia and can be safely used for alleviating pain during CVC insertion in conscious patients.     

Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit

Context:

The role of hand hygiene in preventing health care associated infections (HCAIs) has been clearly established. However, compliance rates remain poor among health care personnel.

Aims:

a) To investigate the health care workers’ hand hygiene compliance rates in the intensive care unit (ICU), b) to assess reasons for non-compliance and c) to study the efficacy of a multimodal intervention strategy at improving compliance.

Settings:

A mixed medical–surgical ICU of a tertiary level hospital.

Design:

A before–after prospective, observational, intervention study.

Materials and Methods:

All health care personnel who came in contact with patients in the ICU were observed for their hand hygiene compliance before and after a multimodal intervention strategy (education, posters, verbal reminders and easy availability of products). A self-report questionnaire was also circulated to assess perceptions regarding compliance. Statistical analysis was done using χ² test or Fisher exact test (Epi info software).

Results:

Hand hygiene compliance among medical personnel working in the ICU was 26% and the most common reason cited for non-compliance was lack of time (37%). The overall compliance improved significantly following the intervention to 57.36% (P<0.000). All health care worker groups showed significant improvements: staff nurses (21.48–61.59%, P<0.0000), nursing students (9.86–33.33%, P<0.0000), resident trainees (21.62–60.71%, P<0.0000), visiting consultants (22–57.14%, P=0.0001), physiotherapists (70–75.95%, P=0.413) and paramedical staff (10.71–55.45%, P< 0.0000).

Conclusions:

Hand hygiene compliance among health care workers in the ICU is poor; however, intervention strategies, such as the one used, can be useful in improving the compliance rates significantly.     

Effects of an integrated Yoga Program on Self-reported Depression Scores in Breast Cancer Patients Undergoing Conventional Treatment: A Randomized Controlled Trial

Aim:

To compare the effects of yoga program with supportive therapy on self-reported symptoms of depression in breast cancer patients undergoing conventional treatment.

Patients and Methods:

Ninety-eight breast cancer patients with stage II and III disease from a cancer center were randomly assigned to receive yoga (n = 45) and supportive therapy (n = 53) over a 24-week period during which they underwent surgery followed by adjuvant radiotherapy (RT) or chemotherapy (CT) or both. The study stoppage criteria was progressive disease rendering the patient bedridden or any physical musculoskeletal injury resulting from intervention or less than 60% attendance to yoga intervention. Subjects underwent yoga intervention for 60 min daily with control group undergoing supportive therapy during their hospital visits. Beck''s Depression Inventory (BDI) and symptom checklist were assessed at baseline, after surgery, before, during, and after RT and six cycles of CT. We used analysis of covariance (intent-to-treat) to study the effects of intervention on depression scores and Pearson correlation analyses to evaluate the bivariate relationships.

Results:

A total of 69 participants contributed data to the current analysis (yoga, n = 33, and controls, n = 36). There was 29% attrition in this study. The results suggest an overall decrease in self-reported depression with time in both the groups. There was a significant decrease in depression scores in the yoga group as compared to controls following surgery, RT, and CT (P < 0.01). There was a positive correlation (P < 0.001) between depression scores with symptom severity and distress during surgery, RT, and CT.

Conclusion:

The results suggest possible antidepressant effects with yoga intervention in breast cancer patients undergoing conventional treatment.     

Evaluation of obstetric admissions to intensive care unit of a tertiary referral center in coastal India

Background and Aim:

To evaluate the occurrence, indications, course, interventions, and outcome of obstetric patients admitted to the intensive care unit (ICU).

Design:

Retrospective study.

Setting:

ICU of a Medical College Hospital.

Materials and Methods:

The data collected were age, parity, obstetric status, primary diagnosis, interventions, and outcome of obstetric patients admitted to the ICU from Jan 2005 to June 2011.

Results:

Total deliveries were 16,804 in 6.5 years. Obstetric admissions to the ICU were (n = 65) which constitutes 0.39% of deliveries. Majority of the admissions were in the postpartum period (n = 46, 70.8%). The two common indications for admission were obstetric hemorrhage (n = 18, 27.7%) and pregnancy related hypertension with its complications (n = 17, 26.2%). The most common intervention was artificial ventilation (n = 41, 63%). The mortality among obstetric admissions in the ICU was (33.8% (22/65)). The patients appropriate for High Dependency Unit (HDU) care was (32.3% (21/65)). The statistical analysis was done by fractional percentage and Chi-square test.

Conclusions:

Hemorrhage and pregnancy-related hypertension with its complications are the two common indications for ICU admissions. The need for a HDU should be considered.     

Mechanism-based Classification and Physical Therapy Management of Persons with Cancer Pain: A Prospective Case Series

Context:

Mechanism-based classification (MBC) was established with current evidence and physical therapy (PT) management methods for both cancer and for noncancer pain.

Aims:

This study aims to describe the efficacy of MBC-based PT in persons with primary complaints of cancer pain.

Settings and Design:

A prospective case series of patients who attended the physiotherapy department of a multispecialty university-affiliated teaching hospital.

Material and Methods:

A total of 24 adults (18 female, 6 male) aged 47.5 ± 10.6 years, with primary diagnosis of heterogeneous group of cancer, chief complaints of chronic disabling pain were included in the study on their consent for participation The patients were evaluated and classified on the basis of five predominant mechanisms for pain. Physical therapy interventions were recommended based on mechanisms identified and home program was prescribed with a patient log to ensure compliance. Treatments were given in five consecutive weekly sessions for five weeks each of 30 min duration.

Statistical Analysis Used:

Pre–post comparisons for pain severity (PS) and pain interference (PI) subscales of Brief pain inventory-Cancer pain (BPI-CP) and, European organization for research and treatment in cancer-quality of life questionnaire (EORTC-QLQ-C30) were done using Wilcoxon signed-rank test at 95% confidence interval using SPSS for Windows version 16.0 (SPSS Inc, Chicago, IL).

Results:

There were statistically significant (P < 0.05) reduction in pain severity, pain interference and total BPI-CP scores, and the EORTC-QLQ-C30.

Conclusion:

MBC-PT was effective for improving BPI-CP and EORTC-QLQ-C30 scores in people with cancer pain.     

Evaluation of Knowledge Among Interns in a Medical College Regarding Palliative Care in People Living with HIV/AIDS and the Impact of a Structured Intervention

Background:

The evolving nature of palliative care and its renewed role in people living with HIV/AIDS (PLWHA) in the post-HAART (highly active anti-retroviral therapy) era warrants an evaluation of the present curriculum in medical under graduates.

Objectives:

The objectives are(1) to measure the existing knowledge regarding palliative care and its application to PLWHA among medical interns and (2) to measure the impact of a structured intervention on knowledge dimensions.

Design and Setting:

Interventional repeated measures study.

Materials and Methods:

A convenience sample of 106 interns in the medical college completed a pre-test assessment and a post-test assessment following a structured intervention for evaluation and comparison of knowledge over three dimensions which were (1) knowledge of palliative care and its application in PLWHA, (2) medical symptoms in PLWHA requiring palliative care and (3) psychosocial needs in PLWHA requiring palliative care.

Results:

The mean scores on knowledge showed a consistent increase after the structured intervention and Student’s t-test was significant across three dimensions of knowledge of palliative care and its application (t=9.12, P value <0.001), medical symptoms in PLWHA requiring palliative care (t=12.72, P value <0.001) and psychosocial needs in PLWHA (t=11.14, P value <0.001).

Conclusion:

In spite of the unique challenges presented by the varying course of illness in PLWHA and the variety of needs on the medical, psychosocial and family dimensions, a structured approach and an integrated course curriculum involving principles of both primary and palliative care principles will improve the efficiency of the undergraduate medical education program and enable delivery of effective palliative care interventions and improve quality of life in PLWHA.     

Psychiatric Morbidity,Pain Perception,and Functional Status of Chronic Pain Patients in Palliative Care

Context:

Psychological factors, such as that exist when we experience pain, can profoundly alter the strength of pain perception.

Aim:

The study aims to estimate the prevalence of psychiatric disorders, and its association with perception of pain and functional status in chronic patients in palliative care.

Materials and Methods:

The sample was selected via simple randomisation and post consent were assessed using (1) a semi- structured questionnaire to elicit socio-demographic information and medical data (2) Brief Pain Inventory (3) ICD-10 Symptom Checklist (4) ICD-10-Diagnostic Criteria for Research (DCR) (5) Montgomery Asberg Depression Rating Scale (MADRS) (6) Covi Anxiety Rating Scale (7) Karnofsky Performance Status Scale. Data was analysed using independent sample t test and chi square test.

Results:

The psychiatric morbidity was 67% with depression and adjustment disorders being the major diagnosis. There was a significant association between psychiatric morbidity pain variables (P = 0.000). Psychiatric morbidity significantly impaired activity, mood, working, walk, sleep, relationship, and enjoyment. There was no association between aetiology of pain, type of cancer, treatment for primary condition and treatment for pain and psychiatric morbidity. The functional status of cancer patients was also poorer in patients with psychiatric morbidity (P = 0.008).

Conclusion:

There is a high prevalence of psychiatric illness in chronic pain patients of any aetiology. Psychiatric morbidity is associated with increased pain perception, impairment in activity and poor functional status.     

Attitudes Toward Euthanasia Among Doctors in a Tertiary Care Hospital in South India: A Cross Sectional study

Context:

Advances in expertise and equipment have enabled the medical profession to exercise more control over the processes of life and death, creating a number of moral and ethical dilemmas. People may live for extended periods with chronic painful or debilitating conditions that may be incurable.

Aim:

This study attempts to study the attitudes of doctors toward euthanasia and the possible factors responsible for these attitudes.

Settings and Design:

A cross-sectional survey of 213 doctors working at a tertiary care hospital was conducted to determine their attitudes toward euthanasia.

Materials and Methods:

A self-administered questionnaire was used to assess attitudes and personal perceptions about euthanasia.

Statistical Analysis Used:

The Chi square test was used to assess factors influencing attitudes toward euthanasia.

Results:

A majority of the respondents (69.3%) supported the concept of euthanasia. Relief from unbearable pain and suffering was the most commonly (80.3%) cited reason for being willing to consider the option of euthanasia. Majority of those who were against euthanasia (66.2%) felt that the freedom to perform euthanasia could easily be misused. Disapproval of euthanasia was associated with religious affiliation (P<0.001) and speciality (P<0.001).

Conclusions:

A majority of the doctors in this study supported euthanasia for the relief of unbearable pain and suffering. Religion and speciality appear to be significant in determining attitudes toward euthanasia.     

Propofol versus flunitrazepam for inducing and maintaining sleep in postoperative ICU patients

Context:

Sleep deprivation is a common problem on intensive care units (ICUs) influencing not only cognition, but also cellular functions. An appropriate sleep-wake cycle should therefore be maintained to improve patients’ outcome. Multiple disruptive factors on ICUs necessitate the administration of sedating and sleep-promoting drugs for patients who are not analgo-sedated.

Aims:

The objective of the present study was to evaluate sleep quantity and sleep quality in ICU patients receiving either propofol or flunitrazepam.

Settings and Design:

Monocentric, randomized, double-blinded trial.

Materials and Methods:

A total of 66 ICU patients were enrolled in the study (flunitrazepam n = 32, propofol n = 34). Propofol was injected continuously (2 mg/kg/h), flunitrazepam as a bolus dose (0.015 mg/kg). Differences between groups were evaluated using a standardized sleep diary and the bispectral index (BIS).

Statistical Analysis Used:

Group comparisons were performed by Mann-Whitney U-Test. P < 0.05 was considered to be statistically significant.

Results:

Sleep quality and the frequency of awakenings were significantly better in the propofol group (Pg). In the same group lower BIS values were recorded (median BIS propofol 74.05, flunitrazepam 78.7 [P = 0.016]). BIS values had to be classified predominantly to slow-wave sleep under propofol and light sleep after administration of flunitrazepam. Sleep quality improved in the Pg with decreasing frequency of awakenings and in the flunitrazepam group with increasing sleep duration.

Conclusions:

Continuous low-dose injection of propofol for promoting and maintaining night sleep in ICU patients who are not analgo-sedated was superior to flunitrazepam regarding sleep quality and sleep structure.     

A comparative study of complications and long term outcomes of Surgical Tracheostomy and two techniques of Percutaneous Tracheostomy

Context:

The operative technique for surgical tracheostomy has remained unchanged, but different techniques for percutaneous tracheostomy have evolved due to interest in minimally invasive procedures for the critically ill patient.

Aims:

To compare the periprocedural complications and long term outcomes of bedside surgical tracheostomy (ST) with two percutaneous tracheostomy (PCT) techniques, namely serial guide wire dilating forceps (GWDF) and PercuTwist (PT).

Settings and Design:

This prospective observational study was carried out in ICU of a tertiary referral centre over three year period on adult intubated patients needing elective tracheostomy.

Materials and Methods:

Patients with anticipated difficult neck anatomy were assigned for ST based on discretion of intensivist. Patients included for PCT were randomly assigned to the GWDT and PT technique. 90 patients underwent either bedside ST (n = 30), PCT by GWDF technique (n = 30) or PCT with PercuTwist (n = 30) and were followed up with fibreoptic bronchoscopy monthly for 06 months.

Statistical Analysis Used:

Data was analyzed by applying chi square tests for categorical variables.

Results:

Periprocedural complications during PCT included major bleeding (>100ml) in two patients in GWDF group which required conversion to ST. Periprocedural bleeding was also the main complication in ST. Increased incidence of granulation tissue and tracheal narrowing in long term was seen in both ST and PCT groups. All of the P values analysed for the intra operative, post operative complications or long term outcomes were >0.05.

Conclusions:

There was no statistically significant difference in incidence of complications of ST and two techniques of PCT. Proper case selection makes PCT as safe as ST.     

Attitudes and Beliefs About Chronic Pain Among Nurses–Biomedical or Behavioral? A Cross-sectional Survey

Context:

Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in chronic pain. Several reasons have been identified including inadequacies in nursing education, absence of curriculum content related to pain management, and attitudes and beliefs related to chronic pain.

Aims:

The objective of this paper was to assess the chronic pain-related attitudes and beliefs among nursing professionals in order to evaluate the biomedical and behavioral dimensions of their perceptions on pain.

Settings and Design:

Cross-sectional survey of 363 nurses in a multispecialty hospital.

Materials and Methods:

The study utilized a self-report questionnaire – pain attitudes and beliefs scale (PABS) – which had 31 items (statements about pain) for each of which the person had to indicate the level at which he or she agreed or disagreed with each statement. Factor 1 score indicated a biomedical dimension while factor 2 score indicated a behavioral dimension to pain.

Statistical Analysis Used:

Comparisons across individual and professional variables for both dimensions were done using one-way ANOVA and correlations were done using the Karl–Pearson co-efficient using SPSS version 11.5 for Windows.

Results:

The overall factor 1 score was 52.95 ± 10.23 and factor 2 score was 20.93 ± 4.72 (P = 0.00). The female nurses had a higher behavioral dimension score (21.1 ± 4.81) than their male counterparts (19.55 ± 3.67) which was significant at P < 0.05 level.

Conclusions:

Nurses had a greater orientation toward the biomedical dimension of chronic pain than the behavioral dimension. This difference was more pronounced in female nurses and those nurses who reported very “good” general health had higher behavioral dimension scores than those who had good general health. The study findings have important curricular implications for nurses and practical implications in palliative care.     

A randomized controlled trial to compare the efficacy of bisphosphonates in the management of painful bone metastasis

Introduction:

The prospective interventional single-institution randomized control study was carried out to compare the pain relieving efficacy among different bisphosphonates at the cost of incidence of skeletal-related events (SRE).

Materials and Methods:

During June 2008 and May 2011, 256 patients with painful bone metastasis in solid tumors with a pain score of at least 5 were randomized into three arms: zoledronic acid (4 mg, i.v.), ibandronate (6 mg, i.v.) and pamidronate (90 mg, i.v.). Radiation was given to all patients, either 800 cGy single fraction or 20 Gy in five fractions. The ANOVA test was used for analysis. The Pearson test was used to correlate pain scores with proportions of responders as statistical estimation of pain relief.

Results:

With a mean baseline pain score of 6.5 ± 1.2, there was no difference in pain scores among the three treatment arms, assessed at 3 months and at the end of the study. However, the pain scores at 6 months were statistically reduced in zoledronic acid-receiving patients (1.5 ± 0.4) unlike the scores in patients receiving ibandronate (3.1 ± 0.5) and pamidronate (2.3 ± 0.4), with a P-value of 0.024. The response was statistically significant at 6 months (0.039) and at the end of the study (0.023), in favor of zoledronic acid. Pearson''s correlation demonstrated a statistically significant positive correlation between pain scores and response rates. There were no statistical differences in the narcotic scores among the treatment arms during the study period. The overall duration of pain relief was not different in any of treatment arms. The time of detection of hypercalcemia was no different; however, the incidence of hypercalcemia was significantly less in the zoledronic acid arm (28.3%) against 44.6% and 50% in ibandronate and pamidronate arms, respectively, with a P-value of 0.041.

Conclusion:

The use of bisphosphonates for 6 months or more results in a statistical significant improvement in bone pain, more so with zoledronic acid. Hypercalcemia, an SRE, was significantly less in the zoledronic acid arm.     

Distress Screening Using Distress Thermometer in Head and Neck Cancer Patients Undergoing Radiotherapy and Evaluation of Causal Factors Predicting Occurrence of Distress

Introduction:

Distress is commonly seen in head and neck cancer patients undergoing radiotherapy. Causal factors of distress are multifactorial; which encompasses physical, psychological, spiritual, and existential factors with complex interrelationship among the factors.

Materials and Methods:

Thirty patients undergoing head and neck radiotherapy were included in the study. Patients were screened for pain scores, distress scores, physical and psychological symptoms, and spiritual and emotional distress.

Results:

Significant increasing trend seen for pain score, distress score, and total number of symptoms during 2^nd week, 4^th week, and on completion of radiotherapy treatment (all P''s < 0.001) compared to pretreatment. Those who had chemotherapy (CT) along with radiation had significantly greater pain score (t = 5.54, P = 0.03) and distress score (t = 3.9, P = 0.05) at 2 weeks into radiotherapy compared to those who did not receive CT. There was significantly higher grade of skin toxicity in those with spiritual distress (Somers’ d = 0.36, P = 0.02) and higher grade of mucositis in those with existential distress (d = 0.34, P = 0.02) at 4 weeks into radiotherapy.

Conclusion:

Positive correlation between distress score and pain score and occurrence of physical symptoms. Increasing trend seen for pain score, distress score, and total number of symptoms during 2^nd week, 4^th week, and completion of radiotherapy treatment compared to pretreatment. Increase in distress score in those with existential and spiritual distress.     

Alcohol-based hand rub and ventilator-associated pneumonia after elective neurosurgery: An interventional study

Background:

Interventional studies on the effect of alcohol-based hand rub on ventilator-associated pneumonia (VAP) among neurosurgical patients are scarce.

Aim:

To observe the effect of alcohol-based hand rub on tracheobronchial colonization and VAP after elective neurosurgical procedures.

Materials and Methods:

An interventional study using a “before–after” design in a tertiary care center in Kerala. Two 9-month study periods were compared; between these periods, an infection control protocol incorporating an alcohol-based hand rub was implemented for a period of 3 months and continued thereafter. Consecutive patients who required mechanical ventilation after neurosurgery between January and September 2006 and 2007, respectively, were included. Outcome measures included VAP rate, tracheobronchial colonization rate, profile of microorganisms and patient survival.

Results:

A total of 352 patients were on mechanical ventilator for a varying period of 1–125 days. The patients in the control and intervention groups were similar with regard to sex, age and type of neurosurgery. Tracheobronchial colonization was seen in 86 (48.6%) of 177 in the control group and 73 (41.7%) of 175 among the intervention group (P = 0.195). The VAP rates in the control and intervention groups were 14.03 and 6.48 per 1000 ventilator days (P = 0.08). The predominant organisms causing VAP and tracheobronchial colonization were Klebsiella and Pseudomonas aeruginosa, respectively, in both groups. Patient survival rates were 87.6% (control) and 92% (intervention).

Conclusion:

Clinical results indicated a better outcome, showing a reduction in tracheobronchial colonization rate and VAP rate, although this was not statistically significant.     

Lumbopelvic joint manipulation and quadriceps activation of people with patellofemoral pain syndrome

Context:

Quadriceps weakness and inhibition are impairments associated with patellofemoral pain syndrome (PFPS). Lumbopelvic joint manipulation has been shown to improve quadriceps force output and inhibition, but the duration of the effect is unknown.

Objective:

To determine whether quadriceps strength and activation are increased and maintained for 1 hour after high-grade or low-grade joint mobilization or manipulation applied at the lumbopelvic region in people with PFPS.

Design:

Randomized controlled clinical trial.

Setting:

University laboratory.

Patients or Other Participants:

Forty-eight people with PFPS (age = 24.6±8.9 years, height = 174.3 ± 11.2 cm, mass = 78.4 ± 16.8 kg) participated.

Intervention(s):

Participants were randomized to 1 of 3 groups: lumbopelvic joint manipulation (grade V), side-lying lumbar midrange flexion and extension passive range of motion (grade II) for 1 minute, or prone extension on the elbows for 3 minutes.

Main Outcome Measure(s):

Quadriceps force and activation were measured using the burst superimposition technique during a seated isometric knee extension task. A 2-way repeated-measures analysis of variance was performed to compare changes in quadriceps force and activation among groups over time (before intervention and at 0, 20, 40, and 60 minutes after intervention).

Results:

We found no differences in quadriceps force output (F_5,33,101,18 = 0.65, P = .67) or central activation ratio (F_4.84,92.03 = 0.38, P= .86) values among groups after intervention. When groups were pooled, we found differences across time for quadriceps force (F_2.66,_101.18 = 5.03, P = .004) and activation (F_2.42,92.03 = 3.85, P = .02). Quadriceps force was not different at 0 minutes after intervention (t₄₀ = 1.68, P = .10), but it decreased at 20 (t₄₀ = 2.16, P = .04), 40 (t₄₀ = 2.87, P = .01) and 60 (t₄₀ = 3.04, P = .004) minutes after intervention. All groups demonstrated decreased quadriceps activation at 0 minutes after intervention (t₄₀ = 4.17, P <.001), but subsequent measures were not different from preintervention levels (t₄₀ range, 1.53–1.83, P >.09).

Conclusions:

Interventions directed at the lumbopelvic region did not have immediate effects on quadriceps force output or activation. Muscle fatigue might have contributed to decreased force output and activation over 1 hour of testing.     

Comparison of clonidine and dexmedetomidine for short-term sedation of intensive care unit patients

Background and Objectives:

Patients on mechanical ventilation in intensive care unit (ICU) are often uncomfortable because of anxiety, pain, and endotracheal intubation; therefore, require sedation. Alpha-2 agonists are known to produce sedation. We compared clonidine and dexmedetomidine as sole agents for sedation.

Study Design:

Prospective, randomized, controlled open-label study.

Materials and Methods:

A total of 70 patients requiring a minimum of 12 h of mechanical ventilation with concomitant sedation, were randomly allocated into two groups. Group C (n = 35) received intravenous (IV) clonidine (1 μg/kg/h titrated up to 2 μg/kg/h to attain target sedation), and Group D (n = 35) received IV dexmedetomidine for sedation (loading 0.7 μg/kg and maintenance 0.2 μg/kg/h titrated up to 0.7 μg/kg/h to achieve target sedation). A Ramsay Sedation Score of 3-4 was considered as target sedation. Additional sedation with diazepam was given when required to achieve target sedation. The quality of sedation, hemodynamic changes and adverse effects were noted and compared between the two groups.

Results:

Target sedation was achieved in 86% observations in Group D and 62% in Group C (P = 0.04). Additional sedation was needed by more patients in Group C compared with Group D (14 and 8 in Groups C and D, respectively, P = 0.034), mainly due to concomitant hypotension on increasing the dose of clonidine. Hypotension was the most common side-effect in Group C, occurring in 11/35 patients of Group C and 3/35 patients of Group D (P = 0.02). Rebound hypertension was seen in four patients receiving clonidine, but none in receiving dexmedetomidine.

Conclusion:

Both clonidine and dexmedetomidine produced effective sedation; however, the hemodynamic stability provided by dexmedetomidine gives it an edge over clonidine for short-term sedation of ICU patients.     

Effect of multimodality chest physiotherapy in prevention of ventilator-associated pneumonia: A randomized clinical trial

Background:

Despite remarkable progress that has been achieved in the recent years in the diagnosis, prevention, and therapy for ventilator-associated pneumonia (VAP), this disease continues to create complication during the course of treatment in a significant proportion of patients while receiving mechanical ventilation.

Objective:

This study was designed to evaluate the effect of multimodality chest physiotherapy in intubated and mechanically ventilated patients undergoing treatment in the intensive care units (ICUs) for prevention of VAP.

Patients and Methods:

A total of 101 adult intubated and mechanically ventilated patients were included in this study. Manual hyperinflation (MH) and suctioning were administered to patients in the control group (n = 51), and positioning and chest wall vibrations in addition to MH plus suctioning (multimodality chest physiotherapy) were administered to patients in the study group (n = 50) till they were extubated. Both the groups were subjected to treatment twice a day. Standard care in the form of routine nursing care, pharmacological therapy, inhalation therapy, as advised by the concerned physician/surgeon was strictly implemented throughout the intervention period.

Results:

Data were analyzed using SPSS window version 9.0. The Clinical Pulmonary infection Score (CPIS) Score showed significant decrease at the end of extubation/successful outcome or discharge in both the groups (P = 0.00). In addition, significant decrease in mortality rate was noted in the study group (24%) as compared to the control group (49%) (P = 0.007).

Conclusions:

It was observed in this study that twice-daily multimodality chest physiotherapy was associated with a significant decrease in the CPIS Scores in the study group as compared to the control group suggesting a decrease in the occurrence of VAP. There was also a significant reduction in the mortality rates with the use of multimodality chest physiotherapy in mechanically ventilated patients.     

An online community improves adherence in an internet-mediated walking program. Part 1: results of a randomized controlled trial

Background

Approximately half of American adults do not meet recommended physical activity guidelines. Face-to-face lifestyle interventions improve health outcomes but are unlikely to yield population-level improvements because they can be difficult to disseminate, expensive to maintain, and inconvenient for the recipient. In contrast, Internet-based behavior change interventions can be disseminated widely at a lower cost. However, the impact of some Internet-mediated programs is limited by high attrition rates. Online communities that allow participants to communicate with each other by posting and reading messages may decrease participant attrition.

Objective

Our objective was to measure the impact of adding online community features to an Internet-mediated walking program on participant attrition and average daily step counts.

Methods

This randomized controlled trial included sedentary, ambulatory adults who used email regularly and had at least 1 of the following: overweight (body mass index [BMI] ≥ 25), type 2 diabetes, or coronary artery disease. All participants (n = 324) wore enhanced pedometers throughout the 16-week intervention and uploaded step-count data to the study server. Participants could log in to the study website to view graphs of their walking progress, individually-tailored motivational messages, and weekly calculated goals. Participants were randomized to 1 of 2 versions of a Web-based walking program. Those randomized to the “online community” arm could post and read messages with other participants while those randomized to the “no online community" arm could not read or post messages. The main outcome measures were participant attrition and average daily step counts over 16 weeks. Multiple regression analyses assessed the effect of the online community access controlling for age, sex, disease status, BMI, and baseline step counts.

Results

Both arms significantly increased their average daily steps between baseline and the end of the intervention period, but there were no significant differences in increase in step counts between arms using either intention-to-treat or completers analysis. In the intention-to-treat analysis, the average step count increase across both arms was 1888 ± 2400 steps. The percentage of completers was 13% higher in the online community arm than the no online community arm (online community arm, 79%, no online community arm, 66%, P = .02). In addition, online community arm participants remained engaged in the program longer than no online community arm participants (hazard ratio = 0.47, 95% CI = 0.25 - 0.90, P = .02). Participants with lower baseline social support posted more messages to the online community (P < .001) and viewed more posts (P < .001) than participants with higher baseline social support.

Conclusion

Adding online community features to an Internet-mediated walking program did not increase average daily step counts but did reduce participant attrition. Participants with low baseline social support used the online community features more than those with high baseline social support. Thus, online communities may be a promising approach to reducing attrition from online health behavior change interventions, particularly in populations with low social support.

Trial Registration

{"type":"clinical-trial","attrs":{"text":"NCT00729040","term_id":"NCT00729040"}}NCT00729040; http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00729040","term_id":"NCT00729040"}}NCT00729040 (Archived by WebCite at http://www.webcitation.org/5v1VH3n0A)