Optimizing delivery to meet demand for integrative medicine services in an academic hospital setting: A pilot study.

CONTEXT: A rapidly growing body of evidence shows the positive benefits of integrative medicine (IM) services for patients in hospital-based settings. IM therapies, such as acupuncture, massage, meditation and relaxation, and animal-assisted therapy, reduce symptom burden of pain, anxiety, and stress and increase sense of well-being and satisfaction in hospitalized patients. Current challenges facing hospitals are to move beyond proof-of-concept studies and to provide hospital-based IM therapies. OBJECTIVE: The aim of our quality improvement project was to develop, implement, and evaluate a feasible, scalable, hospital-based "best practice" model for increasing demand for IM services and optimizing their delivery. DESIGN: A multidisciplinary team convened to use quality improvement tools to outline a process for providing IM services. SETTING: A large academic medical center in the Midwestern United States. PARTICIPANTS: IM leadership staff, IM providers, nurses, hospital team members, support staff, and quality improvement staff. INTERVENTIONS: After determining baseline levels of demand and service delivery, we sought to (1) increase nursing staff awareness of available IM services; (2) improve communication between IM providers and nurses; and (3) reinforce communication at the level of nurse supervisors, patients, and family members. MAIN OUTCOME MEASURES: We recorded the numbers and types of IM services ordered at baseline and postimplementation and determined the new delivery rate of requested services. RESULTS: We noted an increase in the number of IM orders, percentage of delivered IM services, and percentage of patients who reported that IM services improved their hospital stay.

Perspectives on the use of aromatherapy from clinicians attending an integrative medicine continuing education event.

BACKGROUND: The use of essential oils is growing in the United States, but clinician attitudes, experience, and beliefs regarding their use have not previously been studied. METHODS: One hundred five of 106 clinician attendees (99.1%) of an integrative medicine continuing education conference were surveyed using an audience response system to obtain baseline information. Response frequencies of each item were reported. Nonparametric correlations were assessed comparing the statement "In the last 12 months, I have used essential oils for myself and/or my family" with the other agree/disagree statements using Spearman's rho. RESULTS: A majority of participants personally used integrative medicine approaches other than aromatherapy (92.6%) and recommended them clinically (96.8%). Most had personally used essential oils (61%) and wished to offer essential oil recommendations or therapies to their patients (74.0%). Only 21.9% felt confident in their ability to counsel patients on safe use. Personal use of essential oils was highly correlated with confidence in the ability to counsel patients on safe use (Spearman coefficient 0.376, P = 0.000). CONCLUSIONS: This study indicates that clinicians interested in integrative medicine desire to provide aromatherapy recommendations, but do not feel confident in their ability to do so.

Introducing Essential Oils into Pediatric and Other Practices at an Academic Medical Center.

Aromatherapy is an integrative intervention that uses essential oils to address symptom management, potentially as a first-line intervention or as a complement to other medical treatments. Aromatherapy is gaining widespread acceptance and increased scientific evidence of efficacy. Integrative and holistic nursing care uses integrative therapies such as aromatherapy and the principle of moving from a less invasive intervention to a more invasive intervention according to patient needs, symptoms, and preferences. Aromatherapy is often provided as a minimally invasive, independent, and integrative nursing intervention. This article describes the process used to introduce essential oils into practices at a large Midwestern academic medical center.

A decade of offering a Healing Enhancement Program at an academic medical center.

An increased focus has been given to improving the patient experience in health care. This focus has included placing value in a patient-centric, holistic approach to patient care. In the past decade, the Healing Enhancement Program was developed at 1 large medical center to address this focus through implementation of such integrative medicine services as massage, acupuncture, and music therapy to holistically address the pain, anxiety, and tension that hospitalized patients often experience. We describe the development and growth of this program over the past decade.

Development of a Hospital-based Massage Therapy Course at an Academic Medical Center.

BACKGROUND: Massage therapy is offered increasingly in US medical facilities. Although the United States has many massage schools, their education differs, along with licensure and standards. As massage therapy in hospitals expands and proves its value, massage therapists need increased training and skills in working with patients who have various complex medical concerns, to provide safe and effective treatment. These services for hospitalized patients can impact patient experience substantially and provide additional treatment options for pain and anxiety, among other symptoms. The present article summarizes the initial development and description of a hospital-based massage therapy course at a Midwest medical center. METHODS: A hospital-based massage therapy course was developed on the basis of clinical experience and knowledge from massage therapists working in the complex medical environment. This massage therapy course had three components in its educational experience: online learning, classroom study, and a 25-hr shadowing experience. The in-classroom study portion included an entire day in the simulation center. RESULTS: The hospital-based massage therapy course addressed the educational needs of therapists transitioning to work with interdisciplinary medical teams and with patients who have complicated medical conditions. Feedback from students in the course indicated key learning opportunities and additional content that are needed to address the knowledge and skills necessary when providing massage therapy in a complex medical environment. CONCLUSIONS: The complexity of care in medical settings is increasing while the length of hospital stay is decreasing. For this reason, massage provided in the hospital requires more specialized training to work in these environments. This course provides an example initial step in how to address some of the educational needs of therapists who are transitioning to working in the complex medical environment.

A decade of building massage therapy services at an academic medical center as part of a healing enhancement program.

The use of complementary and integrative medicine therapies is steadily becoming an integral part of health care. Massage therapy is increasingly offered to hospitalized patients for various conditions to assist with the management of common symptoms such as pain, anxiety, and tension. This article summarizes a decade of building the massage therapy service at a large tertiary care medical center, from the early pilot studies and research to the current program offerings, and the hopes and dreams for the future.

Feasibility and effect of chair massage offered to nurses during work hours on stress-related symptoms: a pilot study.

This study assessed feasibility and effect of weekly, 15-min chair massages during work for 38 nurses. Mean Perceived Stress Scale-14 (PSS-14), Smith Anxiety Scale (SAS), linear analog self-assessment scale (LASA), and symptom visual analog scale (SX-VAS) scores were tracked at baseline, 5 weeks, and 10 weeks. Of 400 available massage appointments, 329 were used. At 10 weeks, mean PSS-14 score decreased from 17.85 to 14.92 (P = .002); mean SAS score, from 49.45 to 40.95 (P < .001). Mean LASA score increased from 42.39 to 44.84 (P = .006); mean SX-VAS score, from 65.03 to 74.47 (P < .001). Massages for nurses during work hours reduced stress-related symptoms.

A randomized trial of the efficacy of hand disinfection for prevention of rhinovirus infection.

BACKGROUND: Hand disinfection is frequently recommended for prevention of rhinovirus (RV) infection and RV-associated common colds. The effectiveness of this intervention has not been established in a natural setting. The purpose of this study was to determine the effect of hand disinfection on RV infection and RV-associated common cold illness in a natural setting. METHODS: A controlled clinical trial was done in young adult volunteers during 9 weeks of the fall 2009 RV season. Volunteers were randomized to either an antiviral hand treatment containing 2% citric acid and 2% malic acid in 62% ethanol (n = 116) or to a no-treatment control group (n = 96). The hand treatment was applied every 3 hours while the subjects were awake. All volunteers kept a daily diary of symptoms and had a nasal lavage for polymerase chain reaction once each week and 2 additional lavages around the time of each common cold illness. The primary endpoint was the number of RV-associated illnesses. The incidence of RV infection and of common cold illnesses were evaluated as secondary endpoints. RESULTS: The hand treatment did not significantly reduce RV infection or RV-related common cold illnesses. The total number of common cold illnesses was significantly reduced in the intent-to-treat analysis, but this effect was not seen in the per protocol analysis. CONCLUSIONS: In this study, hand disinfection did not reduce RV infection or RV-related common cold illnesses. CLINICAL TRIALS REGISTRATION: NCT00993759.

Effect of massage on pain management for thoracic surgery patients.

BACKGROUND: Integrative therapies such as massage have gained support as interventions that improve the overall patient experience during hospitalization. Thoracic surgery patients undergo long procedures and commonly have postoperative back, neck, and shoulder pain. PURPOSE: Given the promising effects of massage therapy for alleviation of pain, we studied the effectiveness and feasibility of massage therapy delivered in the postoperative thoracic surgery setting. METHODS: Patients who received massage in the postoperative setting had pain scores evaluated pre and post massage on a rating scale of 0 to 10 (0 = no pain, 10 = worst possible pain). RESULTS: In total, 160 patients completed the pilot study and received massage therapy that was individualized. Patients receiving massage therapy had significantly decreased pain scores after massage (p ≤ .001), and patients' comments were very favorable. Patients and staff were highly satisfied with having massage therapy available, and no major barriers to implementing massage therapy were identified. CONCLUSIONS: Massage therapy may be an important additional pain management component of the healing experience for patients after thoracic surgery.

Effectiveness of hand sanitizers with and without organic acids for removal of rhinovirus from hands.

These studies evaluated the effectiveness of ethanol hand sanitizers with or without organic acids to remove detectable rhinovirus from the hands and prevent experimental rhinovirus infection. Ethanol hand sanitizers were significantly more effective than hand washing with soap and water. The addition of organic acids to the ethanol provided residual virucidal activity that persisted for at least 4 h. Whether these treatments will reduce rhinovirus infection in the natural setting remains to be determined.

Alternative hand contamination technique to compare the activities of antimicrobial and nonantimicrobial soaps under different test conditions.

Antimicrobial hand soaps provide a greater bacterial reduction than nonantimicrobial soaps. However, the link between greater bacterial reduction and a reduction of disease has not been definitively demonstrated. Confounding factors, such as compliance, soap volume, and wash time, may all influence the outcomes of studies. The aim of this work was to examine the effects of wash time and soap volume on the relative activities and the subsequent transfer of bacteria to inanimate objects for antimicrobial and nonantimicrobial soaps. Increasing the wash time from 15 to 30 seconds increased reduction of Shigella flexneri from 2.90 to 3.33 log(10) counts (P = 0.086) for the antimicrobial soap, while nonantimicrobial soap achieved reductions of 1.72 and 1.67 log(10) counts (P > 0.6). Increasing soap volume increased bacterial reductions for both the antimicrobial and the nonantimicrobial soaps. When the soap volume was normalized based on weight (approximately 3 g), nonantimicrobial soap reduced Serratia marcescens by 1.08 log(10) counts, compared to the 3.83-log(10) reduction caused by the antimicrobial soap (P < 0.001). The transfer of Escherichia coli to plastic balls following a 15-second hand wash with antimicrobial soap resulted in a bacterial recovery of 2.49 log(10) counts, compared to the 4.22-log(10) (P < 0.001) bacterial recovery on balls handled by hands washed with nonantimicrobial soap. This indicates that nonantimicrobial soap was less active and that the effectiveness of antimicrobial soaps can be improved with longer wash time and greater soap volume. The transfer of bacteria to objects was significantly reduced due to greater reduction in bacteria following the use of antimicrobial soap.

Effect of hand wash agents on controlling the transmission of pathogenic bacteria from hands to food.

The goals of this study were to evaluate the effectiveness of two hand wash regimens in reducing transient bacteria on the skin following a single hand wash and the subsequent transfer of the bacteria to a ready-to-eat food item, freshly cut cantaloupe melon. The number of bacteria recovered from hands and the quantity transferred to the melon were significantly less following the use of an antibacterial soap compared with plain soap. The antimicrobial soap achieved > 3-log reductions versus Escherichia coli and 3.31- and 2.83-log reductions versus Shigella flexneri. The plain soap failed to achieve a 2-log reduction against either organism. The bacteria recovered from the melon handled by hands treated with antimicrobial hand soap averaged 2 log. Melon handled following hand washing with plain soap had > 3 log bacteria in the experiments. Based on previously published feeding studies, an infection rate in the range of approximately 15 to 25% would be expected after ingesting melon containing 2 log CFU compared with ingesting greater than the 3 log transferred from hands washed with plain soap, which would result in a higher infection attack rate of 50 to 80%. The data thus demonstrate there is a greater potential to reduce the transmission and acquisition of disease through the use of an antimicrobial hand wash than through the use of plain soap.

The scavenger mRNA decapping enzyme DcpS is a member of the HIT family of pyrophosphatases.

We recently demonstrated that the major decapping activity in mammalian cells involves DcpS, a scavenger pyrophosphatase that hydrolyzes the residual cap structure following 3' to 5' decay of an mRNA. The association of DcpS with 3' to 5' exonuclease exosome components suggests that these two activities are linked and there is a coupled exonucleolytic decay-dependent decapping pathway. We purified DcpS from mammalian cells and identified the cDNA encoding a novel 40 kDa protein possessing DcpS activity. Consistent with purified DcpS, the recombinant protein specifically hydrolyzed methylated cap analog but did not hydrolyze unmethylated cap analog nor did it function on intact capped RNA. Sequence alignments of DcpS from different organisms revealed the presence of a conserved hexapeptide, containing a histidine triad (HIT) sequence with three histidines separated by hydrophobic residues. Mutagenesis analysis revealed that the central histidine within the DcpS HIT motif is critical for decapping activity and defines the HIT motif as a new mRNA decapping domain, making DcpS the first member of the HIT family of proteins with a defined biological function.

Identifying mRNAs bound by RNA-binding proteins using affinity purification and differential display.

Many methods are available and widely used to determine specific proteins that bind to a particular RNA of interest. However, approaches to identify unknown substrate RNAs to which an RNA-binding protein binds and potentially regulates are not as common. In this article we describe a technique termed isolation of specific nucleic acids associated with proteins (SNAAP) that allows the identification of mRNAs associated with a protein. Methods are detailed for expressing and purifying fusion proteins that are used to isolate substrate mRNPs employing differential display technology. Lastly, experiments are described to confirm that the RNAs identified are indeed bonafide substrates for an RNA-binding protein. As the number of known RNA-binding proteins increases, of which many are involved in genetic disorders, it is essential that methodologies exist to identify RNA-protein interactions to better understand the manifestation of disease.

Regulated alpha-globin mRNA decay is a cytoplasmic event proceeding through 3'-to-5' exosome-dependent decapping.

The alpha-globin mRNA contains a C-rich stability element (CRE) in its 3' untranslated region (3' UTR) which is critical for the stability of this long-lived mRNA. A protein complex, termed the alpha-complex, forms on the CRE and has been shown to contribute to stabilization of the mRNA by at least two mechanisms, first by interacting with the poly(A)-binding protein (PABP) to prevent deadenylation, and second by protecting the mRNA from attack by an erythroid endoribonuclease. In this report, we demonstrate that the alpha-globin 3' UTR can confer stability on a heterologous mRNA in cells, and this stability is dependent on the alpha-complex. Moreover, the stability was exclusively detected with cytoplasmic mRNA, suggesting that the regulation of alpha-globin mRNA stability is a cytoplasmic event. An additional mechanism by which the alpha-complex can confer stability on an RNA in vitro was also identified and shown to involve inhibition of 3' to 5' exonucleolytic degradation. Furthermore, using an in vitro mRNA decay system, we were able to follow the demise of the alpha-globin RNA and demonstrate that the decay was initiated by deadenylation followed by 3'-to-5' decay carried out by the exosome and ultimately hydrolysis of the residual cap structure.

Characterization and purification of a mammalian endoribonuclease specific for the alpha -globin mRNA.

The alpha-globin mRNA has previously been shown to be the target of an erythroid-enriched endoribonuclease (ErEN) activity which cleaves the mRNA within the 3'-untranslated region. We have currently undertaken a biochemical approach to purify this enzyme and have begun characterization of the enzyme to determine requirements for substrate recognition as well as optimal cleavage conditions. Through mutational analysis and truncations we show that a 26-nucleotide region of the alpha-globin 3'-untranslated region is an autonomous element that is both necessary and sufficient for cleavage by ErEN. Mutations throughout this region abolish cleavage activity by ErEN suggesting that the entire sequence is important for recognition and cleavage. ErEN is most active under biological salt concentrations and temperature and activity of the enzyme does not require cations. The size for ErEN was estimated by denaturing gel filtration analysis and is approximately 40 kDa. Interestingly, the exquisite specificity of ErEN cleavage became compromised with increased purity of the enzyme suggesting the involvement of other proteins in specificity of ErEN cleavage. Nondenaturing gel filtration of MEL extract demonstrated that ErEN is a component of an approximately 160 kDa complex implying that additional proteins may regulate ErEN activity and provide increased cleavage specificity.