Push or pull? : The relationship between quality of care and use of complementary and alternative medicine among patients with lung cancer in Sweden

Little is known about relationships between quality of care (QoC) and use of complementary and alternative medicine (CAM) among patients with lung cancer (LC). Purpose: This study examines CAM-use among patients with LC in Sweden, associations between QoC and CAM-use among these patients, and reported aspects of LC-care perceived as particularly positive and negative by patients, as well as suggestions for improving QoC. Methods: Survey data from 94 patient members of the Swedish LC patient organization about CAM-use and QoC as measured by the instrument “Quality from the patient’s perspective” were analyzed. Results: Fifty (53%) LC-patients used CAM, with 40 of the CAM-users reporting that CAM helped them. The most common CAMs used were dietary supplements and natural remedies, followed by prayer. Significantly more patients reported using prayer and meditation for cure than was the case for other types of CAM used. Less than half the CAM-users reported having spoken with staff from the biomedical health care system about their CAM-use. Patients provided numerous suggestions for improving LC-care in a variety of areas, aiming at a more effective and cohesive care trajectory. No differences in QoC were found between CAM-users and non-CAM-users, but differences in CAM-use i.e. type of CAM, reasons for using CAM, and CAM-provider consulted could be associated with different experiences of care. Conclusions: It is important to recognize that CAM-users are not a homogeneous group but might seek different types of CAMs and CAM-providers in different situations depending on experiences of care.

Risk of recurrent stroke and death after first stroke in long-distance ski race participants

Background: Physical activity is of benefit for primary prevention of cardiovascular diseases, but it appears to increase the risk for atrial fibrillation. We aimed to study a cohort of patients following a first stroke in individuals with previous high physical activity, compare them to the general population with respect to recurrent stroke and death, and relate these to atrial fibrillation. Methods and results: From the participants of the Vasaloppet, the world's largest ski-race, and matched individuals from the general population (n=708 604), we identified 5964 patients hospitalized with a first-time stroke between 1994 and 2010. Individuals with severe diseases were excluded. One half percent of skiers and 1% of nonskiers were hospitalized due to stroke. The incidence rate was 8.3 per 100 person-years among skiers and 11.1 among nonskiers. The hazard ratio (HR) for recurrent stroke or death between the 2 groups was 0.76 (95% CI 0.67 to 0.86). The result was consistent in subgroups. The HR for death was 0.66 (95% CI 0.56 to 0.78) and for recurrent stroke 0.82 (95% CI 0.70 to 0.96). After adjustment for smoking and socioeconomic factors, the HR for death was consistent at 0.70 (95% CI 0.56 to 0.87) while the HR for recurrent stroke was not statistically significant. Outcomes for skiers with atrial fibrillation tended to show a lower risk than for nonskiers. Conclusions: This large cohort study supports the hypothesis that patients with a stroke and with prior regular physical activity have a lower risk of death, while their risk for recurrent stroke is similar to that of nonskiers. The skiers had a higher incidence of atrial fibrillation, but still no increased risk of recurring stroke.

The influence of sex, age, and race experience on pacing profiles during the 90 km Vasaloppet ski race

The purpose of this study was to investigate pacing-profile differences during the 90 km Vasaloppet ski race related to the categories of sex, age, and race experience. Skiing times from eight sections (S1 to S8) were analyzed. For each of the three categories, 400 pairs of skiers were matched to have a finish time within 60 seconds, the same start group, and an assignment to the same group for the other two categories. Paired-samples Student’s t-tests were used to investigate sectional pacing-profile differences between the subgroups. Results showed that males skied faster in S2 (P=0.0042), S3 (P=0.0049), S4 (P=0.010), and S1–S4 (P<0.001), whereas females skied faster in S6 (P<0.001), S7 (P<0.001), S8 (P=0.0088), and S5–S8 (P<0.001). For the age category, old subjects (40 to 59 years) skied faster than young subjects (19 to 39 years) in S3 (P=0.0029), and for the other sections, there were no differences. Experienced subjects (≥4 Vasaloppet ski race completions) skied faster in S1 (P<0.001) and S1–S4 (P=0.0054); inexperienced skiers (<4 Vasaloppet ski race completions) had a shorter mean skiing time in S5–S8 (P=0.0063). In conclusion, females had a more even pacing profile than that of males with the same finish time, start group, age, and race experience. No clear age-related pacing-profile difference was identified for the matched subgroups. Moreover, experienced skiers skied faster in the first half whereas inexperienced skiers had higher skiing speeds during the second half of the race.

Aerobic power and lean mass are indicators of competitive sprint performance among elite female cross-country skiers

The purpose of this study was to establish the optimal allometric models to predict International Ski Federation’s ski-ranking points for sprint competitions (FISsprint) among elite female cross-country skiers based on maximal oxygen uptake (V̇O2max) and lean mass (LM). Ten elite female cross-country skiers (age: 24.5±2.8 years [mean ± SD]) completed a treadmill roller-skiing test to determine V̇O2max (ie, aerobic power) using the diagonal stride technique, whereas LM (ie, a surrogate indicator of anaerobic capacity) was determined by dual-emission X-ray anthropometry. The subjects’ FISsprint were used as competitive performance measures. Power function modeling was used to predict the skiers’ FISsprint based on V̇O2max, LM, and body mass. The subjects’ test and performance data were as follows: V̇O2max, 4.0±0.3 L min-1; LM, 48.9±4.4 kg; body mass, 64.0±5.2 kg; and FISsprint, 116.4±59.6 points. The following power function models were established for the prediction of FISsprint: 3.91×105 ∙ VO -6.002maxand 6.95×1010 ∙ LM-5.25; these models explained 66% (P=0.0043) and 52% (P=0.019), respectively, of the variance in the FISsprint. Body mass failed to contribute to both models; hence, the models are based on V̇O2max and LM expressed absolutely. The results demonstrate that the physiological variables that reflect aerobic power and anaerobic capacity are important indicators of competitive sprint performance among elite female skiers. To accurately indicate performance capability among elite female skiers, the presented power function models should be used. Skiers whose V̇O2max differs by 1% will differ in their FISsprint by 5.8%, whereas the corresponding 1% difference in LM is related to an FISsprint difference of 5.1%, where both differences are in favor of the skier with higher V̇O2max or LM. It is recommended that coaches use the absolute expression of these variables to monitor skiers’ performance-related training adaptations linked to changes in aerobic power and anaerobic capacity.

Emergency department triage scales and their components : a systematic review of the scientific evidence

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED? 2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted. We found ED triage scales to be supported, at best, by limited and often insufficient evidence. The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

Acupuncture with manual and electrical stimulation for labour pain : a longitudinal randomised controlled trial

Background: Acupuncture is commonly used to reduce pain during labour despite contradictory results. The aim of this study is to evaluate the effectiveness of acupuncture with manual stimulation and acupuncture with combined manual and electrical stimulation (electro-acupuncture) compared with standard care in reducing labour pain. Our hypothesis was that both acupuncture stimulation techniques were more effective than standard care, and that electro-acupuncture was most effective.  Methods: A longitudinal randomised controlled trial. The recruitment of participants took place at the admission to the labour ward between November 2008 and October 2011 at two Swedish hospitals. 303 nulliparous women with normal pregnancies were randomised to: 40 minutes of manual acupuncture (MA), electro-acupuncture (EA), or standard care without acupuncture (SC). Primary outcome: labour pain, assessed by Visual Analogue Scale (VAS). Secondary outcomes: relaxation, use of obstetric pain relief during labour and post-partum assessments of labour pain. The sample size calculation was based on the primary outcome and a difference of 15 mm on VAS was regarded as clinically relevant, this gave 101 in each group, including a total of 303 women.  Results: Mean estimated pain scores on VAS (SC: 69.0, MA: 66.4 and EA: 68.5), adjusted for: treatment, age, education, and time from baseline, with no interactions did not differ between the groups (SC vs MA: mean difference 2.6, 95% confidence interval [CI] -1.7-6.9 and SC vs EA: mean difference 0.6 [95% CI] -3.6-4.8). Fewer number of women in the EA group used epidural analgesia (46%) than women in the MA group (61%) and SC group (70%) (EA vs SC: odds ratio [OR] 0.35; [95% CI] 0.19-0.67).  Conclusions: Acupuncture does not reduce women's experience of labour pain, neither with manual stimulation nor with combined manual and electrical stimulation. However, fewer women in the EA group used epidural analgesia thus indicating that the effect of acupuncture with electrical stimulation may be underestimated. These findings were obtained in a context with free access to other forms of pain relief.

Acupuncture with manual and electrical stimulation for labour pain : a two month follow up of recollection of pain and birth experience.

BACKGROUND: In a previous randomised controlled trial we showed that acupuncture with a combination of manual- and electrical stimulation (EA) did not affect the level of pain, as compared with acupuncture with manual stimulation (MA) and standard care (SC), but reduced the need for other forms of pain relief, including epidural analgesia. To dismiss an under-treatment of pain in the trial, we did a long-term follow up on the recollection of labour pain and the birth experience comparing acupuncture with manual stimulation, acupuncture with combined electrical and manual stimulation with standard care. Our hypothesis was that despite the lower frequency of use of other pain relief, women who had received EA would make similar retrospective assessments of labour pain and the birth experience 2 months after birth as women who received standard care (SC) or acupuncture with manual stimulation (MA). METHODS: Secondary analyses of data collected for a randomised controlled trial conducted at two delivery wards in Sweden. A total of 303 nulliparous women with normal pregnancies were randomised to: 40 min of MA or EA, or SC without acupuncture. Questionnaires were administered the day after partus and 2 months later. RESULTS: Two months postpartum, the mean recalled pain on the visual analogue scale (SC: 70.1, MA: 69.3 and EA: 68.7) did not differ between the groups (SC vs MA: adjusted mean difference 0.8, 95 % confidence interval [CI] -6.3 to 7.9 and SC vs EA: mean difference 1.3 CI 95 % -5.5 to 8.1). Positive birth experience (SC: 54.3 %, MA: 64.6 % and EA: 61.0 %) did not differ between the groups (SC vs MA: adjusted Odds Ratio [OR] 1.8, CI 95 % 0.9 to 3.7 and SC vs EA: OR 1.4 CI 95 % 0.7 to 2.6). CONCLUSIONS: Despite the lower use of other pain relief, women who received acupuncture with the combination of manual and electrical stimulation during labour made the same retrospective assessments of labour pain and birth experience 2 months postpartum as those who received acupuncture with manual stimulation or standard care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01197950.

Optimal V. O2max-to-mass ratio for predicting 15 km performance among elite male cross-country skiers

The aim of this study was 1) to validate the 0.5 body-mass exponent for maximal oxygen uptake (V. O2max) as the optimal predictor of performance in a 15 km classical-technique skiing competition among elite male cross-country skiers and 2) to evaluate the influence of distance covered on the body-mass exponent for V. O2max among elite male skiers. Twenty-four elite male skiers (age: 21.4±3.3 years [mean ± standard deviation]) completed an incremental treadmill roller-skiing test to determine their V. O2max. Performance data were collected from a 15 km classicaltechnique cross-country skiing competition performed on a 5 km course. Power-function modeling (ie, an allometric scaling approach) was used to establish the optimal body-mass exponent for V . O2max to predict the skiing performance. The optimal power-function models were found to be race speed = 8.83⋅(V . O2max m-0.53) 0.66 and lap speed = 5.89⋅(V . O2max m-(0.49+0.018lap)) 0.43e0.010age, which explained 69% and 81% of the variance in skiing speed, respectively. All the variables contributed to the models. Based on the validation results, it may be recommended that V. O2max divided by the square root of body mass (mL⋅min−1 ⋅kg−0.5) should be used when elite male skiers’ performance capability in 15 km classical-technique races is evaluated. Moreover, the body-mass exponent for V . O2max was demonstrated to be influenced by the distance covered, indicating that heavier skiers have a more pronounced positive pacing profile (ie, race speed gradually decreasing throughout the race) compared to that of lighter skiers.

Manual and electroacupuncture for labour pain : study design of a longitudinal randomized controlled trial

Introduction. Results from previous studies on acupuncture for labour pain are contradictory and lack important information on methodology. However, studies indicate that acupuncture has a positive effect on women's experiences of labour pain. The aim of the present study was to evaluate the efficacy of two different acupuncture stimulations, manual or electrical stimulation, compared with standard care in the relief of labour pain as the primary outcome. This paper will present in-depth information on the design of the study, following the CONSORT and STRICTA recommendations. Methods. The study was designed as a randomized controlled trial based on western medical theories. Nulliparous women with normal pregnancies admitted to the delivery ward after a spontaneous onset of labour were randomly allocated into one of three groups: manual acupuncture, electroacupuncture, or standard care. Sample size calculation gave 101 women in each group, including a total of 303 women. A Visual Analogue Scale was used for assessing pain every 30 minutes for five hours and thereafter every hour until birth. Questionnaires were distributed before treatment, directly after the birth, and at one day and two months postpartum. Blood samples were collected before and after the first treatment. This trial is registered at ClinicalTrials.gov: NCT01197950.

Struggling with daily life and enduring pain : a qualitative study of women's experiences with pelvic girdle pain during pregnancy

Background. Few studies have investigated the experiences of living with pelvic girdle pain (PGP) and its impact on pregnant women’s lives. To address this gap in knowledge, this study investigates the experiences of women living with PGP during pregnancy. Methods. A purposive sample, of nine pregnant women with diagnosed PGP, were interviewed about their experiences. Interviews were recorded, transcribed to text and analysed using a Grounded Theory approach. Results. The core category that evolved from the analysis of experiences of living with PGP in pregnancy was “struggling with daily life and enduring pain”. Three properties addressing the actions caused by PGP were identified: i) grasping the incomprehensible; ii) balancing support and dependence and iii) managing the losses. These experiences expressed by the informants constitute a basis for the consequences of PGP: iv) enduring pain; v) being a burden; vi) calculating the risks and the experiences of the informants as vii) abdicating as a mother. Finally, the informants’ experiences of the consequences regarding the current pregnancy and any potential future pregnancies is presented in viii) paying the price and reconsidering the future. A conceptual model of the actions and consequences experienced by the pregnant informants living with PGP is presented. Conclusions. PGP during pregnancy greatly affects the informant’s experiences of her pregnancy, her roles in relationships, and her social context. For informants with young children, PGP negatively affects the role of being a mother, a situation that further strains the experience. As the constant pain disturbs most aspects of the lives of the informants, improvements in the treatment of PGP is of importance as to increase the quality of life. This pregnancy-related condition is prevalent and must be considered a major public health concern during pregnancy.