Scanning the Global Literature.

CHEMOTHERAPY CAN IMPAIR QUALITY OF LIFE AT THE END OF LIFE

The association of chemotherapy and quality of life near death was investigated in a longitudinal, multi-institutional cohort study.[1] Three hundred twelve patients with end-stage solid cancer (progressive, previously treated, metastatic) and a life expectancy of 6 months or less were asked to provide sociodemographics, health status, and performance status (ECOG). Postmortem, the caregiver most knowledgeable about each patient was interviewed about the patient's quality of life before death. Chemotherapy use was determined from reviewing charts.

At baseline, patients receiving chemotherapy had been younger, more likely treated in an academic medical center, more often had pancreatic and breast cancer, and had better performance than patients not receiving chemotherapy (multiple logistic regression). Patients with an initially good performance status (ECOG 1) who had received chemotherapy were found to have a significantly lower quality of life toward the end of life than patients with an initially good performance status who had not received chemotherapy (OR 0.35, 95% CI, 0.17-0.75). The quality of life of patients with an initially poorer performance (ECOG 2 and 3) did not differ with regard to chemotherapy. Chemotherapy was not associated with better survival.

Commentary by Gunver Kienle, Dr med

The trend of patients receiving aggressive chemotherapy in terminal stages of cancer increases far beyond recommendations and evidence.[2] Patients with good performance status are the ones most likely to receive and to be referred for palliative chemotherapy. However, astonishingly, particularly in these patients, chemotherapy seems to impair quality of life. This is reminiscent of the randomized controlled trial by Temel et al wherein patients with newly diagnosed non–small cell lung cancer received either early palliative care along with standard oncological care or standard oncological care alone.[3] Here, patients who received early palliative care not only had significantly less aggressive chemotherapy, they also had significantly better quality of life and lived significantly longer. For many patients' friends and family members, chemotherapy may be equated with hope and fighting cancer, and this perception may lead to great pressure for inappropriate or even harmful treatments. Placing patients in a supportive integrative, holistic cancer care environment that addresses not only the cancer but also vitality, emotional, mental, and spiritual issues and focuses on the unmet needs of cancer patients may reduce the pressure that could result in decisions that may do more harm than good.

THE EFFECT OF WHOLE-BODY MASSAGE ON THE PROCESS AND PHYSIOLOGICAL OUTCOME OF TRAUMA INTENSIVE CARE UNIT PATIENTS: A DOUBLE-BLIND RANDOMIZED CLINICAL TRIAL

Hospital patients treated for traumatic injuries in intensive care units may experience emotional stress and anxiety that can negatively affect hemodynamic stability, resulting in increased blood pressure (BP), increased heart and respiration rates, and behaviors such as restlessness and agitation. This study examined the effects of a single session of massage therapy on a convenience sample of patients in a trauma intensive care unit (ICU) at an Iranian academic medical center. Patients hospitalized more than 7 days, with Glasgow Coma Scale (GCS) score of 7 to 12, intracranial pressure below 20 mmHg, hemodynamic stability, and without infectious disease, hepatitis, skin condition, a history of psychiatric disorder, or contraindication for changes of body position were eligible. Of those, 108 patients were randomly assigned to standard care alone or to standard care plus massage therapy, resulting in an equal number (54) of participants per group. Exclusion criteria were recent loss of consciousness or cardiac event. The 45-minute massage treatment encompassing the back, neck and shoulders, arms and hands, legs and feet, chest and abdomen was provided by family members who had undergone training. Outcomes measured included systolic and diastolic BP, temperature, heart and respiratory rates, GCS score, and arterial blood gases. All data were recorded by a nurse before the intervention, at 1 hour, and at 3 hours after the intervention. Six participants became ineligible following enrollment and were excluded from data analysis.

Results showed statistically significant changes in systolic BP and GCS score at 1 and 3 hours post-intervention and in diastolic BP and heart and respiratory rates at 1 hour post-intervention. In arterial blood gases, statistically significant differences were observed in blood pH, oxygen saturation (a measure of hemoglobin transport of oxygen), and partial pressure of oxygen (a measure of oxygen dissolved in the blood). No significant differences were observed in bicarbonate or partial pressure of carbon dioxide.

Commentary by Martha Menard, PhD, LMT

Massage appeared to be a safe intervention with temporary benefits for ICU patients in this study. The use of family members to provide massage in the ICU is a potentially cost-effective method to make massage therapy more available to hospitalized patients, and one that could also reduce the sense of helplessness caregivers may experience. Future studies should however, describe in more detail the content and duration of the training given to the family members who provide massage interventions as well as a more thorough description of the massage intervention itself. Other research has shown conflicting evidence regarding the effects of massage therapy on vital signs in healthy volunteers and across different disease conditions, possibly due to variations in massage protocols used across studies. A strength of this study was the use of arterial blood gases as an outcome measure, which has seldom been included in previous studies.

COST-EFFECTIVENESS OF TAI CHI FOR FALL PREVENTION IN PARKINSON'S DISEASE[1]

Clinical research supports that tai chi, along with other conventional forms of exercise, offer multiple potential benefits for people with Parkinson's disease (PD), including improved balance and reductions in the rate of falls. However, little research has evaluated the relative cost-effectiveness of tai chi vs other exercise-based programs for preventing falls. This study represents a secondary analysis of a 3-arm randomized controlled trial of exercise for PD.[2] The original trial consisted of a 6-month active intervention period (with 60-minute classes conducted 2 times weekly) and a 3-month post-intervention follow-up and compared tai chi and resistance training to a stretching control. The study included individuals who were diagnosed with mild to moderate PD. This new study presents findings based on a cost-effectiveness analysis of the tai chi program compared with stretching and resistance training programs on the primary outcome of falls prevented; it also evaluated relative impacts on quality-adjusted life years (QALY) gained as a secondary outcome.

Over the 9-month study period, 526 falls were documented on the basis of participant monthly self-reports. Participants in tai chi had the lowest average number of falls (87 vs 172 vs 267, compared with resistance and stretching, respectively; P=.01) and the lowest fall incidence rate (per 100 person-months, P=.005). Tai chi also had the lowest average per-person use costs ($1238) compared with stretching ($1721) and resistance training ($1368), respectively. Not surprisingly, economic analyses supported that when compared with stretching, tai chi cost an average of $175 less for each additional fall prevented and produced a substantial improvement in QALY gained at a lower cost. Because of the inferiority of the resistance training program in cost (ie, more costly) and effectiveness (less effective), it was removed from analyses. The authors conclude that tai chi represents a cost-effective strategy for optimizing spending to prevent falls and maximize health gains in people with Parkinson's disease. They also appropriately caution that while these results are promising, they warrant further validation.

Commentary by Peter M. Wayne, PhD

Building on a landmark study published in The New England Journal of Medicine,[2] this study extends findings on the clinical benefits of tai chi for balance and fall prevention to the pragmatic domain of cost-effectiveness. This study represents one of only a handful of cost-effectiveness analyses of mind-body exercise for secondary rehabilitation or management of chronic or degenerative conditions. In combination with ongoing basic research informing mechanisms underlying the therapeutic effects of mind-body interventions, pragmatic cost-effectiveness research as exemplified in this study is essential to inform the translation and integration of such practices into healthcare and to inform the policies that will guide this integration.

A CLUSTER OF ELEVATED BLOOD LEAD LEVELS AMONG US AYURVEDA USERS

Breeher et al conducted this public health investigation after identifying an index case of a person with elevated blood lead levels (BLLs) associated with Ayurvedic medicine use. The individual lived in a small community in Iowa where Ayurvedic medicine use was common. Ayurvedic medicines were typically obtained either while traveling in India or through direct importation from an Indian clinic. The investigators placed advertisements in local newspapers to recruit potentially affected individuals. One hundred fifteen participants responded and subsequently underwent blood testing for lead and other heavy metals using atomic absorption spectroscopy through the University of Iowa State Hygienic Laboratory. Forty percent (n=46) of the individuals had BLLs ≥10.0 μg/dL. Thirty percent had BLLs ≥25.0 μg/dL. In addition, individuals were asked to submit their Ayurvedic medicines for analysis. Of 182 Ayurvedic supplements submitted for testing, 27.5% had lead levels exceeding California and US Food and Drug Administration maximum permitted limits. BLLs were also found to be associated with intake of those Ayurvedic medicines containing lead. Individuals with BLLs ≥10.0 μg/dL were estimated to consume a mean 0.03 g lead/day compared to only 0.001 g/day for participants with BLLs ≥10.0 μg/dL (P<.0001).

Commentary by Robert Saper, MD, MPH

Rasashastra is a class of Ayurvedic medicines that contain compounds called bhasmas. Bhasmas are made from minerals, metals, and/or gems through elaborate ancient preparation protocols. Metals such as lead, mercury, arsenic, gold, iron, and zinc are commonly and intentionally used. Ayurvedic experts claim that any toxic properties of metals such as lead are removed in the preparation process if it is done appropriately and that bhasmas are safe and therapeutic. Bhasmas can be formulated to be taken alone or in combination with herbs.

This investigation is consistent with previous investigations of Ayurvedic medicines that found that approximately one-fifth of Ayurvedic medicines contain potentially elevated levels of lead. Prior to this investigation, more than 100 case reports of lead toxicity associated with Ayurvedic medicine use have been reported since the 1970s in North America, Europe, Asia, Africa, and Oceania. This cluster of 46 patients is the largest group of patients with elevated BLLs associated with Ayurvedic medicine reported to date.

Lead is a well-established toxin to multiple organ systems. Consequences of lead toxicity are many and include developmental delay, intellectual and cognitive impairment, seizures, anemia, renal insufficiency, hypertension, constipation, and abdominal pain. Mean lead levels in the US general population are approximately 2 μg/dL. Deleterious impacts of even relatively modestly elevated BLLs in the 5 to 10 μg/dL range are well documented. Given the preponderance of evidence of harm from lead, the intentional use of lead compounds in traditional medicine preparations, no matter how they are prepared, is unacceptable and should be stopped.