Publications by authors named "Suzanna Zick"

66 Publications

Relations among parent-reported physical activity and interoception in children.

Physiol Behav 2022 Oct 27;254:113895. Epub 2022 Jun 27.

University of Michigan, Ann Arbor, MI, United States. Electronic address:

Background: Interoception is the sense of one's internal body and emotional state; it plays a critical role in guiding self-regulatory behaviors. Physical activity (PA) can support interoceptive processes, but limited research has examined the association in children. This study explored the relations among parent-reported PA and several interoceptive domains in children aged 3 - 10 years old.

Methods: Baseline data were analyzed from a cluster-randomized controlled study examining a yoga intervention (N = 122). Parents completed a questionnaire that included the Caregiver Questionnaire for Interoceptive Awareness, Second Edition (CQIA-2) and two measures of PA, the PROMIS Parent-Proxy Short Form (PROMIS-PA) and the adapted Burdette Proxy Report (aBPR-PA). Psychometrics of the CQIA-2 subscales were assessed and then used in subsequent analyses to examine the association between PA and interoceptive sensibility.

Results: Seventy percent of the surveys were completed by mothers (30% by fathers), and their children (56% female, M = 5.81 ± 1.7 years) were predominately white. Across all children, PA had a significant positive relationship with interoceptive domains related to emotion and physical energy (p < 0.01). Children who met the PROMIS-PA "good" cutoff had a clearer sense of emotion and physical energy (F(2,115) = 4.30, p = 0.016, R = 0.070), compared to children who did not. Children's age predicted interoceptive sensibility of illness and toileting needs (F(1,116) = 14.16, p < 0.001, R = 0.109).

Conclusion: Children with higher PA levels were perceived to have better interoceptive sensibility of emotion and physical energy. Children's age was predictive of interoceptive domains representing the awareness of illness and toileting needs. Future work should consider incorporating direct measures of PA and child-reported interoceptive sensibility. A better understanding of their relationship will likely help guide the design of more effective interventions for health behavior development.
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http://dx.doi.org/10.1016/j.physbeh.2022.113895DOI Listing
October 2022

Cancer-Related Fatigue Outcome Measures in Integrative Oncology: Evidence for Practice and Research Recommendations.

Oncology (Williston Park) 2022 05;36(5):276-287

Cancer-related fatigue (CRF) is one of the most common symptoms across the cancer continuum and is often underreported and undertreated. Defined as a distressing, persistent, subjective sense of tiredness or exhaustion related to cancer or its treatment, CRF includes physical, emotional, cognitive, and spiritual dimensions. Patient-reported outcome (PRO) measures are the most widely used tool to screen for and assess fatigue and the associated negative impacts on quality of life. However, selecting subjective CRF measures can be complex. This has resulted in the availability of and inconsistent use of numerous PROs, limiting the ability to cross-compare outcomes clinically and within research. To address this, the PROs that are most widely reported in the literature are recommended to support the standardization of a core set of validated measures. The National Comprehensive Cancer Network single-item tool for clinical significance is recommended for quick use in clinical environments; the Brief Fatigue Inventory allows for fast, easy, helpful cutoffs on severity threshold for triage, and measures both severity and interference with daily functioning; while the MD Anderson Symptom Inventory allows for multisymptomatic assessment. In addition, a fundamental consideration for any PRO use is the administrative burden on the patient and clinician. In this review, we aim to summarize current, validated PROs specific to CRF to aid clinicians and researchers in patient care and in study design and implementation. We conclude with suggestions for future directions in CRF research that can increase the possibility for long-term impact on future guidelines of fatigue management.
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http://dx.doi.org/10.46883/2022.25920958DOI Listing
May 2022

Acupressure for Cancer-fatigue in Ovarian Cancer Survivor (AcuOva) Study: A community-based clinical trial study protocol examining the impact of self-acupressure on persistent cancer-related fatigue in ovarian cancer survivors.

Contemp Clin Trials 2021 08 10;107:106477. Epub 2021 Jun 10.

Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA. Electronic address:

Background Persistent cancer-related fatigue is one of the most common and burdensome symptoms experienced by ovarian cancer survivors. Despite the high burden of fatigue in ovarian cancer survivors, there are few available treatments. Previous research has shown self-acupressure to be a safe method for improving persistent fatigue, sleep, and quality of life among fatigued breast cancer survivors, yet there are no studies examining self-acupressure for fatigue in ovarian cancer survivors. Methods A three group parallel, randomized controlled trial will be conducted to evaluate the efficacy of self-acupressure taught and delivered via a patient-designed, custom-built mobile app ("MeTime") and accompanying hand-held device ("AcuWand") to help guide correct pressure application. A sample of 165 ovarian cancer survivors, who have completed primary cancer treatment will be recruited from tumor registries in Michigan and Los Angeles. Participants will be mailed a tablet preloaded with the app and a device, and all visits will be conducted remotely. Participants will be randomized to 6-weeks of daily self-acupressure via the app and device, or a sham app and device, or no care group. Self-report measures will be completed at baseline, 6-weeks (post-intervention), 3-, and 6-months. Primary outcome is the Brief Fatigue Inventory; secondary outcomes are sleep, quality of life, and symptoms commonly associated with persistent fatigue. Discussion An app based self-acupressure treatment may be an easily-accessible and inexpensive treatment to reduce fatigue in ovarian cancer survivors. The results of the study will provide information on the possible benefits of app-based self-acupressure for fatigue in ovarian cancer survivors. Trial registration: This study is registered at ClinicalTrials.gov Identifier: NCT03763838, date registered on December 4, 2018.
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http://dx.doi.org/10.1016/j.cct.2021.106477DOI Listing
August 2021

A Multi-Mineral Intervention to Modulate Colonic Mucosal Protein Profile: Results from a 90-Day Trial in Human Subjects.

Nutrients 2021 Mar 14;13(3). Epub 2021 Mar 14.

Department of Pathology, The University of Michigan Medical School, Ann Arbor, MI 48109, USA.

The overall goal of this study was to determine whether Aquamin, a calcium-, magnesium-, trace element-rich, red algae-derived natural product, would alter the expression of proteins involved in growth-regulation and differentiation in colon. Thirty healthy human subjects (at risk for colorectal cancer) were enrolled in a three-arm, 90-day interventional trial. Aquamin was compared to calcium alone and placebo. Before and after the interventional period, colonic biopsies were obtained. Biopsies were evaluated by immunohistology for expression of Ki67 (proliferation marker) and for CK20 and p21 (differentiation markers). Tandem mass tag-mass spectrometry-based detection was used to assess levels of multiple proteins. As compared to placebo or calcium, Aquamin reduced the level of Ki67 expression and slightly increased CK20 expression. Increased p21 expression was observed with both calcium and Aquamin. In proteomic screen, Aquamin treatment resulted in many more proteins being upregulated (including pro-apoptotic, cytokeratins, cell-cell adhesion molecules, and components of the basement membrane) or downregulated (proliferation and nucleic acid metabolism) than placebo. Calcium alone also altered the expression of many of the same proteins but not to the same extent as Aquamin. We conclude that daily Aquamin ingestion alters protein expression profile in the colon that could be beneficial to colonic health.
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http://dx.doi.org/10.3390/nu13030939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002192PMC
March 2021

Integrative Oncology Education: An Emerging Competency for Oncology Providers.

Curr Oncol 2021 02 10;28(1):853-862. Epub 2021 Feb 10.

Department of Family Medicine, University of Michigan, Ann Arbor, MI 48109, USA.

A growing number of cancer patients use complementary and alternative therapies during and after conventional cancer treatment. Patients are often reluctant to discuss these therapies with their oncologist, and oncologists may have limited knowledge and confidence on how to advise patients on the appropriate use. Integrative oncology is a patient-centered, evidence-informed field that utilizes mind-body practices, lifestyle modifications and/or natural products interwoven with conventional cancer treatment. It prioritizes safety and best available evidence to offer appropriate interventions alongside conventional care. There are few opportunities for oncologists to learn about integrative oncology. In this commentary, we highlight the Integrative Oncology Scholars (IOS) program as a means to increase competency in this growing field. We provide an overview of several integrative oncology modalities that are taught through this program, including lifestyle modifications, physical activity, and mind-body interventions. We conclude that as more evidence is generated in this field, it will be essential that oncology healthcare providers are aware of the prevalent use of these modalities by their patients and cancer centers include Integrative Oncology trained physicians and other healthcare professionals in their team to discuss and recommend evidence-based integrative oncology therapies alongside conventional cancer treatments to their patients.
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http://dx.doi.org/10.3390/curroncol28010084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985783PMC
February 2021

Feasibility study of a modified yoga program for chronic pain among elderly adults in assisted and independent living.

Explore (NY) 2022 Jan-Feb;18(1):104-107. Epub 2020 Nov 23.

Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, United States.

Context: Yoga improves quality of life in elders ≥65 years, but studies among elders with chronic pain are limited.

Objective: Conduct a feasibility study of gentle yoga among elders in assisted and independent living.

Design: Single arm pre/post clinical trial.

Subjects: Adults (≥65 years of age) with self-identified chronic pain (≥3 on a 10-point scale, lasting for ≥3 months) and no current yoga practice.

Intervention: Ten weekly 60-min gentle yoga classes tailored to elderly adults.

Outcome Measures: At baseline, weeks 5, 10 (end of intervention), and 20 (follow-up), we collected data on feasibility (adherence, retention, safety), pain, anxiety, depression, fatigue, sleep disturbance, and physical function.

Results: Twenty-six participants enrolled (88% women, 77% white, 58% in assisted living) with average age of 86.6 ± 4.4 (Mean, STD). Twenty participants completed the intervention, with 90% adhering (completing ≥6 classes). Nine participants (45% of completers) experienced adverse events, which were non-serious and related to transient musculoskeletal pain. No adverse events resulted in study withdrawal. Participants reported being somewhat likely to recommend yoga to a friend, and quite a bit likely to do yoga again. At the end of the intervention, four of twenty participants reported practicing yoga outside of class. Anxiety significantly decreased from 5.80 (SE=0.90) to 4.44 (SE=0.74) (p = 0.014), but there were no changes in other measures.

Conclusions: Our pilot 10-week yoga study was generally safe for and suitable to assisted and independent living elderly adults. Future studies are needed to examine other effects of yoga in assisted/independent living adults with chronic pain.
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http://dx.doi.org/10.1016/j.explore.2020.11.010DOI Listing
March 2022

Returning to a Patient-Centered Approach in the Management of Hypothyroidism.

Ann Fam Med 2020 09;18(5):388-389

University of Michigan Medical School, Ann Arbor, Michigan.

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http://dx.doi.org/10.1370/afm.2602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489959PMC
September 2020

Association of chronic spinal pain with diet quality.

Pain Rep 2020 Sep-Oct;5(5):e837. Epub 2020 Aug 11.

Departments of Environmental Health Sciences and Nutritional Sciences, Center for Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA.

Introduction: Chronic spinal pain is disabling and has high personal and societal costs. Risk factors include behavioral factors; however, little is known about the role of diet quality and its association with spinal pain. Higher diet quality and consumption of macronutrients that drive higher diet quality were hypothesized to be associated with lower odds of having spinal pain.

Methods: An analysis of a population-based data set (NHANES cycle 2009-2010) was conducted. Diet quality was calculated using the Healthy Eating Index 2015 (score 0-100). To examine odds of pain related to dietary intake, generalized linear regressions were used adjusting for relevant covariates.

Results: Of 4123 participants (mean age 43.5 ± 0.44 [SD], 2167 [52.6%] female), 800 (19.4%) reported chronic spinal pain. People with chronic spinal pain consumed similar amounts of calories to those with no spinal pain (2137 ± 44.5 vs 2159.9 ± 27.7), but had significantly poorer diet quality compared to people without spinal pain (51.97 ± 0.65 vs 54.31 ± 0.39, = 0.007). From multivariate analyses, individuals with diet quality in the highest tertile on Healthy Eating Index-2015 were 24% less likely to report chronic spinal pain relative to those in the lowest tertile. Higher fruit, whole grain, and dairy intake were associated with 20% to 26% lower likelihood (all for trend <0.028) of chronic spinal pain. Added sugars were associated with 49% increased odds of chronic spinal pain ( for trend = 0.002).

Conclusion: Although causality cannot be assumed, this study supports continued investigation into the role of nutritional quality as a factor that may impact pain.
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http://dx.doi.org/10.1097/PR9.0000000000000837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431251PMC
August 2020

Education Competencies for Integrative Oncology-Results of a Systematic Review and an International and Interprofessional Consensus Procedure.

J Cancer Educ 2022 Jun;37(3):499-507

Institute for Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353, Berlin, Germany.

Integrative oncology is a burgeoning field and typically provided by a multiprofessional team. To ensure cancer patients receive effective, appropriate, and safe care, health professionals providing integrative cancer care should have a certain set of competencies. The aim of this project was to define core competencies for different health professions involved in integrative oncology. The project consisted of two phases. A systematic literature review on published competencies was performed, and the results informed an international and interprofessional consensus procedure. The second phase consisted of three rounds of consensus procedure and included 28 experts representing 7 different professions (medical doctors, psychologists, nurses, naturopathic doctors, traditional Chinese medicine practitioners, yoga practitioners, patient navigators) as well as patient advocates, public health experts, and members of the Society for Integrative Oncology. A total of 40 integrative medicine competencies were identified in the literature review. These were further complemented by 18 core oncology competencies. The final round of the consensus procedure yielded 37 core competencies in the following categories: knowledge (n = 11), skills (n = 17), and abilities (n = 9). There was an agreement that these competencies are relevant for all participating professions. The integrative oncology core competencies combine both fundamental oncology knowledge and integrative medicine competencies that are necessary to provide effective and safe integrative oncology care for cancer patients. They can be used as a starting point for developing profession-specific learning objectives and to establish integrative oncology education and training programs to meet the needs of cancer patients and health professionals.
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http://dx.doi.org/10.1007/s13187-020-01829-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876161PMC
June 2022

Access and Cost-Related Nonadherence to Prescription Medications Among Lupus Patients and Controls: The Michigan Lupus Epidemiology and Surveillance Program.

Arthritis Care Res (Hoboken) 2021 11 24;73(11):1561-1567. Epub 2021 Sep 24.

University of Michigan, Ann Arbor.

Objective: Medication access and adherence are important determinants of health outcomes. We investigated factors associated with access and cost-related nonadherence to prescriptions in a population-based cohort of systemic lupus erythematosus (SLE) patients and controls.

Methods: Detailed sociodemographic and prescription data were collected by structured interview in 2014-2015 from participants in the Michigan Lupus Epidemiology and Surveillance (MILES) cohort. We compared access between cases and frequency-matched controls and examined associated factors in separate multivariable logistic regression models.

Results: A total of 654 participants (462 SLE patients, 192 controls) completed the baseline visit; 584 (89%) were female, 285 (44%) were Black, and the mean age was 53 years. SLE patients and controls reported similar frequencies of being unable to access prescribed medications (12.1% versus 9.4%, respectively; P was not significant). SLE patients were twice as likely as controls to report cost-related prescription nonadherence in the preceding 12 months to save money (21.7% versus 10.4%; P = 0.001) but were also more likely to ask their doctor for lower cost alternatives (23.8% versus 15.6%; P = 0.02). Disparities were found in association with income, race, and health insurance status, but the main findings persisted after adjusting for these and other variables in multivariable models.

Conclusion: SLE patients were more likely than controls from the general population to report cost-related prescription nonadherence, including skipping doses, taking less medicine, and delaying filling prescriptions; yet, <1 in 4 patients asked providers for lower cost medications. Consideration of medication costs in patient decision-making could provide a meaningful avenue for improving access and adherence to medications.
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http://dx.doi.org/10.1002/acr.24397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9219566PMC
November 2021

A Calcium-Rich Multimineral Intervention to Modulate Colonic Microbial Communities and Metabolomic Profiles in Humans: Results from a 90-Day Trial.

Cancer Prev Res (Phila) 2020 01 26;13(1):101-116. Epub 2019 Nov 26.

Department of Pathology, The University of Michigan Medical School, Ann Arbor, Michigan.

Aquamin is a calcium-, magnesium-, and multiple trace element-rich natural product with colon polyp prevention efficacy based on preclinical studies. The goal of this study was to determine the effects of Aquamin on colonic microbial community and attendant metabolomic profile. Thirty healthy human participants were enrolled in a 90-day trial in which Aquamin (delivering 800 mg of calcium per day) was compared with calcium alone or placebo. Before and after the intervention, colonic biopsies and stool specimens were obtained. All 30 participants completed the study without serious adverse event or change in liver and renal function markers. Compared with pretreatment values, intervention with Aquamin led to a reduction in total bacterial DNA ( = 0.0001) and a shift in the microbial community measured by thetaYC (θ; = 0.0087). Treatment with calcium also produced a decline in total bacteria, but smaller than seen with Aquamin, whereas no reduction was observed with placebo in the colon. In parallel with microbial changes, a reduction in total bile acid levels ( = 0.0375) and a slight increase in the level of the short-chain fatty acid (SCFA) acetate in stool specimens ( < 0.0001) from Aquamin-treated participants were noted. No change in bile acids or SCFAs was observed with calcium or placebo. We conclude that Aquamin is safe and tolerable in healthy human participants and may produce beneficial alterations in the colonic microbial community and the attendant metabolomic profile. Because the number of participants was small, the findings should be considered preliminary.
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http://dx.doi.org/10.1158/1940-6207.CAPR-19-0325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528938PMC
January 2020

Integrative Therapies for Cancer-Related Fatigue.

Cancer J 2019 Sep/Oct;25(5):349-356

Department of Family Medicine, University of Michigan Health System.

Cancer-related fatigue (CRF) is a common symptom for which cancer patients often use integrative and integrative therapies; however, evidence supporting these therapies is limited. The aim of this review is to provide evidence-based recommendations for integrative interventions during and after cancer treatment for CRF. These recommendations are based on a systematic literature review from 1990 through 2019. Cognitive behavior therapy plus hypnosis and American ginseng can be considered during active treatment, and acupressure, mindfulness-based cognitive therapy, and qigong/tai chi easy can be considered during posttreatment. Coenzyme Q10 and L-carnitine are not recommended during active-treatment. All other integrative therapies for CRF had insufficient evidence to make a recommendation. While there is increasing evidence for integrative therapies for CRF, because of lack of rigorous trials and replication, no therapies could be definitively recommended. Further rigorously designed integrative therapy research is needed and should consider implementation and dissemination.
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http://dx.doi.org/10.1097/PPO.0000000000000396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388739PMC
August 2020

Prescription Opioid Use in Patients With and Without Systemic Lupus Erythematosus - Michigan Lupus Epidemiology and Surveillance Program, 2014-2015.

MMWR Morb Mortal Wkly Rep 2019 Sep 27;68(38):819-824. Epub 2019 Sep 27.

Rheumatic diseases are a leading cause of chronic, noncancer pain. Systemic lupus erythematosus (SLE) is a chronic autoimmune rheumatic disease characterized by periodic flares that can result in irreversible target organ damage, including end-stage renal disease. Both intermittent and chronic musculoskeletal pain, as well as fibromyalgia (considered a centralized pain disorder due to dysregulation of pain processing in the central nervous system), are common in SLE. Opioids are generally not indicated for long-term management of musculoskeletal pain or centralized pain (fibromyalgia) because of lack of efficacy, safety issues ranging from adverse medical effects to overdose, and risk for addiction (1,2). In this study of 462 patients with SLE from the population-based Michigan Lupus Epidemiology and Surveillance (MILES) Cohort and 192 frequency-matched persons without SLE, nearly one third (31%) of SLE patients were using prescription opioids during the study period (2014-2015), compared with 8% of persons without SLE (p<0.001). Among the SLE patients using opioids, 97 (68%) were using them for >1 year, and 31 (22%) were concomitantly on two or more opioid medications. Among SLE patients, those using the emergency department (ED) were approximately twice as likely to use prescription opioids (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.3-3.6; p = 0.004). In SLE, the combined contributions of underlying disease and adverse effects of immunosuppressive and glucocorticoid therapies already put patients at higher risk for some known adverse effects attributed to long-term opioid use. Addressing the widespread and long-term use of opioid therapy in SLE will require strategies aimed at preventing opioid initiation, tapering and discontinuation of opioids among patients who are not achieving treatment goals of reduced pain and increased function, and consideration of nonopioid pain management strategies.
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http://dx.doi.org/10.15585/mmwr.mm6838a2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6762189PMC
September 2019

Self-Administered Acupressure for Chronic Low Back Pain: A Randomized Controlled Pilot Trial.

Pain Med 2019 12;20(12):2588-2597

Department of Family Medicine.

Objective Chronic low back pain (CLBP) is associated with fatigue, pain, poor sleep, and disability. Acupressure is a low-risk treatment option used to manage symptoms in other groups, but its efficacy, particularly on fatigue and sleep, is unknown in CLBP. This study examined preliminary effects of two types of self-administered acupressure (relaxing and stimulating) on fatigue, pain, sleep, and reported disability. Methods A randomized pilot trial was conducted (N = 67) in which participants were randomized into six weeks of relaxing acupressure, stimulating acupressure, or usual care. Fatigue was measured by the Brief Fatigue Inventory, pain was measured by the Brief Pain Inventory, sleep was measured by the Pittsburgh Sleep Quality Index, and reported disability was measured by the Roland Morris Scale. Results Baseline characteristics were similar across groups. An intent-to-treat analysis using general linear models showed positive improvement in pain in acupressure groups compared with usual care. Pain was reduced by 35-36% in the acupressure groups. Improvement in fatigue was also found in stimulating acupressure compared with usual care. Adverse events were minimal and related to application of too much pressure. Discussion Although this was a small study, acupressure demonstrated promising preliminary support of efficacy for pain and fatigue reduction in this population.
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http://dx.doi.org/10.1093/pm/pnz138DOI Listing
December 2019

Dietary Omega Polyunsaturated Fatty Acid Intake and Patient-Reported Outcomes in Systemic Lupus Erythematosus: The Michigan Lupus Epidemiology and Surveillance Program.

Arthritis Care Res (Hoboken) 2020 07;72(7):874-881

University of Michigan, Ann Arbor.

Objective: To examine associations between dietary intake of omega-3 (n-3; generally antiinflammatory) and omega-6 (n-6; generally proinflammatory) fatty acids and patient-reported outcomes in systemic lupus erythematosus (SLE).

Methods: This study was based on the population-based Michigan Lupus Epidemiology and Surveillance cohort. Estimates of n-3 and n-6 intake were derived from Diet History Questionnaire II items (past year with portion size version). Patient-reported outcomes included self-reported lupus activity (Systemic Lupus Activity Questionnaire [SLAQ]). Multivariable regression, adjusted for age, sex, race, and body mass index, was used to assess associations between absolute intake of n-3 and n-6, as well as the n-6:n-3 ratio, and patient-reported outcomes.

Results: Among 456 SLE cases, 425 (93.2%) were female, 207 (45.4%) were African American, and the mean ± SD age was 52.9 ± 12.3 years. Controlling for potential confounders, the average SLAQ score was significantly higher by 0.3 points (95% confidence interval [95% CI] 0.1, 0.6; P = 0.013) with each unit increase of the n-6:n-3 ratio. Both lupus activity and Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance scores were lower with each 1-gram/1,000 kcal increase of n-3 fatty acids (SLAQ regression coefficient β = -0.8 [95% CI -1.6, 0.0]; P = 0.055; PROMIS sleep β = -1.1 [95% CI -2.0, -0.2]; P = 0.017). Higher n-3 intakes were nonsignificantly associated with lower levels of depressive symptoms and comorbid fibromyalgia, and with higher quality of life, whereas results for the n6:n3 ratio trended in the opposite direction.

Conclusion: This population-based study suggests that higher dietary intake of n-3 fatty acids and lower n-6:n-3 ratios are favorably associated with patient-reported outcomes in SLE, particularly self-reported lupus activity and sleep quality.
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http://dx.doi.org/10.1002/acr.23925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842394PMC
July 2020

Facilitators and Barriers to Supplemental Nutrition Assistance Program Incentive Use: Findings From a Clinic Intervention for Low-Income Patients.

Am J Prev Med 2019 04 21;56(4):571-579. Epub 2019 Feb 21.

Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.

Introduction: Healthy food incentives matching Supplemental Nutrition Assistance Program (SNAP) benefits spent on fruits and vegetables subsidize increased produce consumption among low-income individuals at risk for food insecurity and diet-related disease. Yet many eligible participants do not use these incentives, in part because of limited awareness. This study examined the acceptability and impact of a primary care-based informational intervention on facilitators and barriers to use of the statewide SNAP incentive program Double Up Food Bucks.

Methods: Focus groups (n=5) were conducted April-June 2015 among a purposive sample (n=26) of SNAP-enrolled adults from a Michigan health clinic serving low-income patients. All had participated in a waiting room-based informational intervention about Double Up Food Bucks; none had used Double Up Food Bucks before the intervention. Groups were stratified by Double Up Food Bucks use/non-use during the 6-month intervention period. Results were analyzed in 2016-2017 through an iterative content analysis process.

Results: Participants reported the waiting room intervention was acceptable and a key facilitator of first-time Double Up Food Bucks use. Motivators for Double Up Food Bucks use included (1) eating more healthfully, (2) stretching SNAP benefits, (3) higher-quality produce at markets, and (4) unique market environments. Remaining barriers included (1) lack of transportation, (2) limited market locations/hours, and (3) persistent confusion among a small number of participants regarding incentive use.

Conclusions: Low-income patients who received an informational intervention about Double Up Food Bucks reported numerous benefits from participation. Yet barriers remained for a subset of patients. Improving geographic accessibility and ease of SNAP incentive redemption may further improve dietary quality and food security among vulnerable populations.
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http://dx.doi.org/10.1016/j.amepre.2018.11.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6757336PMC
April 2019

Impact of Self-Acupressure on Co-Occurring Symptoms in Cancer Survivors.

JNCI Cancer Spectr 2018 Nov 16;2(4):pky064. Epub 2019 Jan 16.

Department of Anesthesiology, University of Michigan, Ann Arbor, MI.

Background: Cancer survivors with fatigue often experience depressive symptoms, anxiety, and pain. Previously, we reported that self-acupressure improved fatigue; however, its impact on other co-occurring symptoms and their involvement in treatment action has not been explored.

Methods: Changes in depressive symptoms, anxiety, and pain were examined prior to and following two formulas of self-acupressure and usual care using linear mixed models in 288 women from a previously reported clinical trial. Participants were categorized by random assignment into one of three groups: 1) relaxing acupressure, 2) stimulating acupressure, or 3) usual care. Moderators investigated were body mass index, age, depressive symptoms, anxiety, sleep and pain, and mediators were change in these symptoms.

Results: Following treatment, depressive symptoms improved statistically significantly for the relaxing acupressure group (41.5%) compared with stimulating acupressure (25%) and usual care (7.7%). Both acupressure groups were associated with greater improvements in anxiety than usual care, but only relaxing acupressure was associated with greater reductions in pain severity, and only stimulating acupressure was associated with greater reductions in pain interference. There were no statistically significant moderators of sleep quality, anxiety, or depressive symptoms. Fatigue statistically significantly moderated pain, and age statistically significantly modified fatigue. Changes in depressive symptoms and sleep quality statistically significantly mediated the relationship between relaxing acupressure and usual care on fatigue; however, the effect was small.

Conclusions: Acupressure was associated with greater improvements than usual care in anxiety, pain, and symptoms of depression in breast cancer survivors with troublesome fatigue. These findings warrant further evaluation in suitably controlled randomized trials.
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http://dx.doi.org/10.1093/jncics/pky064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334818PMC
November 2018

Pros and Cons of Dietary Strategies Popular Among Cancer Patients.

Oncology (Williston Park) 2018 11;32(11):542-7

As many as 48% of cancer patients pursue popular diets, including the alkaline, Paleolithic, ketogenic, vegan, and macrobiotic diets, with the hope that they will improve survival and prevent recurrence. These diets have positive aspects consistent with the dietary guidelines proposed by the American Cancer Society (ACS) and the American Institute for Cancer Research (AICR). All of the diets emphasize eating vegetables, all but the ketogenic diet encourage eating fruit, and all but the vegan diet limit refined grains and alcohol. Both the macrobiotic and the alkaline diets meet the majority of the ACS and AICR guidelines. Negative aspects of these diets include pseudo-scientific rationales for their anti-cancer properties, limited evidence that they improve cancer outcomes, the possibility for nutrient insufficiencies, and elimination of food groups proven beneficial for cancer prevention and general health. Moreover, with nutritional counseling, nutrient insufficiencies and misalignment with cancer clinical guidelines can often be addressed. Clinicians should consider strategies to encourage evidence-based dietary changes that encourage positive features of popular cancer diets, while minimizing negative aspects.
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November 2018

Integrative Oncology Scholars Program: A Model for Integrative Oncology Education.

J Altern Complement Med 2018 Sep/Oct;24(9-10):1018-1022

1 Department of Family Medicine, University of Michigan , Ann Arbor, Michigan.

Objectives: Oncology providers are often confronted by patients who use complementary or alternative therapies, but have limited knowledge or confidence on how to advise patients on appropriate use. Despite this, there are few opportunities for oncology providers to learn about complementary or alternative therapies, while at the same time there is a high demand for integrative oncology (IO) training. To address a gap in IO educational opportunities, and particularly for nonphysicians, we created the Integrative Oncology Scholars (IOS) Program. The program's goal is to train 100 IO leaders and facilitate partnerships between them and complementary practitioners.

Design: Four iterations of a year-long National Cancer Institute-funded educational program that combines in-person team-based learning and eLearning to teach the evidence, application, and philosophy supporting IO.

Settings: In-person sessions take place at the University of Michigan, and eLearning is implemented using a Canvas website (Instructure, Inc., Salt Lake City, UT).

Subjects: Nurses, social workers, physician assistants, psychologists, physicians, pharmacists, and physical/occupational therapists with active oncology practices. Educational intervention: Four cohorts of 25 oncology providers per year will learn the evidence base for complementary and alternative approaches to a wide number of oncology topics, including symptom control, dietary supplements commonly used by cancer patients, diet, and the utility of specific integrative approaches for common oncology side-effects such as fatigue.

Outcome Measures: A mixed methods approach will be used to evaluate overall IOS Program progress and individual scholar's impact on IO research, education, and clinical endeavors.

Results: The first cohort of 25 IOS has been recruited and their education will begin in Summer 2018. Scholars come from 13 states and represent 23 different healthcare systems.

Conclusions: The IOS Program has the potential to increase the number of trained IO providers, educators, and researchers in the United States.
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http://dx.doi.org/10.1089/acm.2018.0184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157348PMC
October 2018

Diets for Health: Goals and Guidelines.

Am Fam Physician 2018 06;97(11):721-728

University of Michigan School of Public Health, Ann Arbor, MI, USA.

Diet is the single most significant risk factor for disability and premature death. Patients and physicians often have difficulty staying abreast of diet trends, many of which focus primarily on weight loss rather than nutrition and health. Recommending an eating style can help patients make positive change. Dietary patterns that support health include the Mediterranean diet, the Dietary Approaches to Stop Hypertension diet, the 2015 Dietary Guidelines for Americans, and the Healthy Eating Plate. These approaches have benefits that include prevention of cardiovascular disease, cancer, type 2 diabetes mellitus, and obesity. These dietary patterns are supported by strong evidence that promotes a primary focus on unprocessed foods, fruits and vegetables, plant-based fats and proteins, legumes, whole grains, and nuts. Added sugars should be limited to less than 5% to 10% of daily caloric intake. Vegetables (not including potatoes) and fruits should make up one-half of each meal. Carbohydrate sources should primarily include beans/legumes, whole grains, fruits, and vegetables. An emphasis on monounsaturated fats, such as olive oil, avocados, and nuts, and omega-3 fatty acids, such as flax, cold-water fish, and nuts, helps prevent cardiovascular disease, type 2 diabetes, and cognitive decline. A focus on foods rather than macronutrients can assist patients in understanding a healthy diet. Addressing barriers to following a healthy diet and utilizing the entire health care team can assist patients in following these guidelines.
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June 2018

Does Reverse Triiodothyronine Testing Have Clinical Utility? An Analysis of Practice Variation Based on Order Data from a National Reference Laboratory.

Thyroid 2018 07 13;28(7):842-848. Epub 2018 Jun 13.

5 Department of Pathology, University of Utah Health Sciences Center , Salt Lake City, Utah.

Background: Clinical laboratories are under pressure to increase value by improving test utilization. The clinical utility of reverse triiodothyronine (rT3) is controversial. A study was conducted to identify order patterns that might suggest inappropriate utilization of rT3.

Methods: All orders for thyroid tests placed over a period of one year at a national reference laboratory were reviewed. Order patterns by client (hospital) and by provider were analyzed. A Pareto analysis was conducted to determine the percentage of orders placed as a function of the percentage of providers. A systematic review of the indexed literature and an informal review of the web were conducted to identify indications for rT3 testing.

Results: There were 402,386 orders for 447,664 thyroid tests, including 91,767 orders for rT3. These orders were placed by 60,733 providers located at 1139 different organizations. Only 20% of providers who ordered thyroid tests placed an order for rT3. Of those who placed an order for rT3, 95% placed two orders or fewer for rT3. One hundred providers (0.1% of the 60,733 providers who placed orders for thyroid tests) accounted for 29.5% of the orders for rT3. Of the 100 providers, 60 with the highest order volumes for rT3 were classified as practitioners of functional medicine. A systematic review of Medline found little evidence to support the high volumes of orders for rT3. A survey of Web sites for functional medicine suggests that rT3 is useful for the diagnosis of rT3 dominance and can be used to direct triiodothyronine replacement therapy.

Conclusions: There is wide practice variation in rT3 testing. A high proportion of tests are ordered by a relatively small proportion of providers. There is little evidence to support high volumes of rT3 testing placed by some practitioners.
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http://dx.doi.org/10.1089/thy.2017.0645DOI Listing
July 2018

"Doubling Up" on Produce at Detroit Farmers Markets: Patterns and Correlates of Use of a Healthy Food Incentive.

Am J Prev Med 2018 02 12;54(2):181-189. Epub 2017 Dec 12.

Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan.

Introduction: Federal food assistance programs such as the Supplemental Nutrition Assistance Program (SNAP) help address food insecurity, yet many participants still struggle to afford nutritionally adequate foods. The U.S. Department of Agriculture has committed $100 million to the expansion and evaluation of SNAP healthy food incentives, which match SNAP funds spent on produce. However, little is known about who uses SNAP incentives or how often they are used. This study examines patterns and correlates of use of the SNAP incentive Double Up Food Bucks at all eight participating Detroit farmers markets during 2012-2013.

Methods: SNAP/Double Up Food Bucks transactions from handwritten farmers market logs (n=21,541) were linked with state administrative SNAP enrollment data. Frequency of incentive use and characteristics of Double Up Food Bucks users relative to the overall Detroit SNAP-enrolled population were examined, as were market-level characteristics associated with program use. Negative binomial regression was used to estimate predictors of repeat transactions (analyses conducted 2015-2017).

Results: Although demographic characteristics of Double Up Food Bucks users reflected those of the overall Detroit SNAP-enrolled population, Double Up Food Bucks users were poorer and disproportionately female. One third of Double Up Food Bucks users had more than one transaction during the 2-year period. Repeat transactions were directly correlated with identifying as white (incidence rate ratio=2.34, 95% CI=2.11, 2.59, p<0.001), and inversely correlated with driving distance from market of first transaction (incidence rate ratio=0.98 per mile, 95% CI=0.98, 0.99, p<0.001). Rates of repeat transactions also varied significantly by market.

Conclusions: Addressing barriers to initial use and return visits can help maximize the impact and reach of SNAP incentives among Americans at highest risk of diet-related disease.
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http://dx.doi.org/10.1016/j.amepre.2017.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5783733PMC
February 2018

Brain Connectivity Patterns Dissociate Action of Specific Acupressure Treatments in Fatigued Breast Cancer Survivors.

Front Neurol 2017 23;8:298. Epub 2017 Jun 23.

Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.

Persistent fatigue is a pernicious symptom in many cancer survivors. Existing treatments are limited or ineffective and often lack any underlying biologic rationale. Acupressure is emerging as a promising new intervention for persistent cancer-related fatigue; however, the underlying mechanisms of action are unknown. Our previous investigations suggested that fatigued breast cancer survivors have alterations in brain neurochemistry within the posterior insula and disturbed functional connectivity to the default mode network (DMN), as compared to non-fatigued breast cancer survivors. Here, we investigated if insula and DMN connectivity were modulated by self-administered acupressure by randomizing breast cancer survivors ( = 19) to two distinct treatments: relaxing acupressure or stimulating acupressure. All participants underwent proton magnetic resonance spectroscopy of the posterior insula and functional connectivity magnetic resonance imaging at baseline and immediately following 6 weeks of acupressure self-treatment. As compared to baseline measures, relaxing acupressure decreased posterior insula to dorsolateral prefrontal cortex connectivity, whereas stimulating acupressure enhanced this connectivity ( < 0.05 corrected). For relaxing but not stimulating acupressure, reduced connectivity was associated with sleep improvement. In addition, connectivity of the DMN to the superior colliculus was increased with relaxing acupressure and decreased with stimulating acupressure, whereas DMN connectivity to the bilateral pulvinar was increased with stimulating and decreased with relaxing acupressure ( < 0.05 corrected). These data suggest that self-administered acupressure at different acupoints has specificity in relation to their mechanisms of action in fatigued breast cancer survivors.
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http://dx.doi.org/10.3389/fneur.2017.00298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481304PMC
June 2017

Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment.

CA Cancer J Clin 2017 05 24;67(3):194-232. Epub 2017 Apr 24.

Professor, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.

Answer questions and earn CME/CNE Patients with breast cancer commonly use complementary and integrative therapies as supportive care during cancer treatment and to manage treatment-related side effects. However, evidence supporting the use of such therapies in the oncology setting is limited. This report provides updated clinical practice guidelines from the Society for Integrative Oncology on the use of integrative therapies for specific clinical indications during and after breast cancer treatment, including anxiety/stress, depression/mood disorders, fatigue, quality of life/physical functioning, chemotherapy-induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance. Clinical practice guidelines are based on a systematic literature review from 1990 through 2015. Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction. Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders. Meditation and yoga are recommended to improve quality of life. Acupressure and acupuncture are recommended for reducing chemotherapy-induced nausea and vomiting. Acetyl-L-carnitine is not recommended to prevent chemotherapy-induced peripheral neuropathy due to a possibility of harm. No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment-related side effects. In summary, there is a growing body of evidence supporting the use of integrative therapies, especially mind-body therapies, as effective supportive care strategies during breast cancer treatment. Many integrative practices, however, remain understudied, with insufficient evidence to be definitively recommended or avoided. CA Cancer J Clin 2017;67:194-232. © 2017 American Cancer Society.
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http://dx.doi.org/10.3322/caac.21397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892208PMC
May 2017

Increasing Use of a Healthy Food Incentive: A Waiting Room Intervention Among Low-Income Patients.

Am J Prev Med 2017 Feb;52(2):154-162

Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; School of Public Health, University of Michigan, Ann Arbor, Michigan.

Introduction: Diet-related disease is disproportionately concentrated in low-income communities where fruit and vegetable consumption is far below guidelines. To address financial barriers, Double Up Food Bucks (DUFB)-a statewide healthy food incentive-matches Supplemental Nutrition Assistance Program (SNAP) funds spent at farmers markets. However, incentive use is limited. This study examined the impact of a brief waiting room-based intervention about DUFB on program utilization and produce consumption.

Study Design: Longitudinal, repeated measures, quasi-experimental trial.

Setting/participants: SNAP-enrolled adults at a health center in a low-income, racially and ethnically diverse area of Southeast Michigan.

Intervention: Participants received a brief explanation of DUFB, written program materials, a map highlighting market locations and hours, and an initial $10 market voucher. DUFB use and produce consumption were measured through four surveys over 5 months (August 2014-January 2015).

Main Outcome Measures: Outcome measures included DUFB use and fruit and vegetable consumption (analyses conducted in 2015-2016).

Results: A total of 302 eligible adults were identified, and 177 (59%) enrolled. One hundred twenty-seven (72%) completed all surveys. At baseline, 57% of participants reported shopping at a farmers market within the last year; 18% had previously used DUFB. By the end of the DUFB season, participants were significantly more likely to report DUFB use than at baseline (AOR=19.2, 95% CI=10.3, 35.5, p<0.001), with 69% of participants reporting use of DUFB at least once, and 34% reporting use of DUFB three or more times. Adjusted fruit and vegetable consumption increased from baseline by 0.65 servings/day (95% CI=0.37, 0.93, p<0.001) at 3 months, and remained 0.62 servings/day (95% CI=0.32, 0.92, p<0.001) higher than baseline 2 months post-DUFB season.

Conclusions: A brief clinic-based intervention was associated with a nearly fourfold increase in uptake of a SNAP incentive program, as well as clinically and statistically significant increases in produce consumption. Results suggested sustained behavior change even once the financial incentive was no longer available. Providing information about healthy food incentives is a low-cost, easily implemented intervention that may increase produce consumption among low-income patients.
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http://dx.doi.org/10.1016/j.amepre.2016.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444808PMC
February 2017

Fatigue reduction diet in breast cancer survivors: a pilot randomized clinical trial.

Breast Cancer Res Treat 2017 01 2;161(2):299-310. Epub 2016 Dec 2.

Department Family Medicine, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48105, USA.

Purpose: Fatigue is a prevalent and burdensome effect of breast cancer. Fatigue has been linked to chronic inflammation, and diets high in antioxidant nutrients have been associated with lesser prevalence and severity of fatigue. Studies are needed, however, to test if antioxidant-rich diets could improve fatigue.

Methods: Pilot, randomized, trial conducted between January 2014 and April 2015, to investigate if a 3-month diet rich in fruit, vegetables, whole grains, and omega-3 fatty acid-rich foods, named the fatigue reduction diet (FRD), improved fatigue and sleep compared to an attention control, named the general health curriculum (GHC). 30 stage 0 to III breast cancer survivors, who had completed cancer treatments, were randomized: 15 receiving the FRD and 15 the GHC. Primary outcome was change in fatigue, as measured by the brief fatigue Inventory, from baseline to 3 months analyzed using linear mixed models. Secondary analyses were changes in sleep quality, serum carotenoids, and fatty acids.

Results: From baseline to 3-month fatigue improved by 44 ± 39% in FRD compared to 8 ± 34% in GHC (p = 0.01); sleep quality improved by 2.5 ± 3.3 points in FRD, and diminished by 0.9 ± 2.3 in GHC (p = 0.03); serum total carotenoids (p < 0.01), β-cryptoxanthin (p = 0.02), lutein (p = 0.05), zeaxanthin (p = 0.01), lycopene (p = 0.05), omega-3 fatty acids (p < 0.01), and ratio of omega-3:omega-6 fatty acids (p = 0.02) were significantly increased, and percent saturated fatty acids were decreased (p = 0.04) in FRD; γ-tocopherol was significantly increased in GHC (p = 0.03), and there was a significant visit by group difference for α-carotene between the study groups (p = 0.05).

Conclusions: The FRD intervention improved fatigue and sleep in breast cancer survivors compared to the GHC. FRD diet could provide a non-toxic treatment strategy for persistent fatigue.
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http://dx.doi.org/10.1007/s10549-016-4070-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5480210PMC
January 2017

Connecting (T)issues: How Research in Fascia Biology Can Impact Integrative Oncology.

Cancer Res 2016 11 11;76(21):6159-6162. Epub 2016 Oct 11.

Department of Physical Medicine, New Jersey Medical School, Rutgers, the State University of New Jersey, New Brunswick, New Jersey.

Complementary and integrative treatments, such as massage, acupuncture, and yoga, are used by increasing numbers of cancer patients to manage symptoms and improve their quality of life. In addition, such treatments may have other important and currently overlooked benefits by reducing tissue stiffness and improving mobility. Recent advances in cancer biology are underscoring the importance of connective tissue in the local tumor environment. Inflammation and fibrosis are well-recognized contributors to cancer, and connective tissue stiffness is emerging as a driving factor in tumor growth. Physical-based therapies have been shown to reduce connective tissue inflammation and fibrosis and thus may have direct beneficial effects on cancer spreading and metastasis. Meanwhile, there is currently little knowledge on potential risks of applying mechanical forces in the vicinity of tumors. Thus, both basic and clinical research are needed to understand the full impact of integrative oncology on cancer biology as well as whole person health. Cancer Res; 76(21); 6159-62. ©2016 AACR.
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http://dx.doi.org/10.1158/0008-5472.CAN-16-0753DOI Listing
November 2016

Integrative Medicine in Head and Neck Cancer.

Otolaryngol Head Neck Surg 2017 02 13;156(2):228-237. Epub 2016 Oct 13.

1 Head and Neck Translational Oncology Laboratory, Comprehensive Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan, USA.

Objective Complementary and alternative medicine, or integrative medicine, has become increasingly popular among patients with head and neck cancer. Despite its increasing prevalence, many patients feel uncomfortable discussing such therapies with their physicians, and many physicians are unaware and underequipped to evaluate or discuss their use with patients. The aim of this article is to use recent data to outline the decision making inherent to integrative medicine utilization among patients with head and neck cancer, to discuss the ethical implications inherent to balancing integrative and conventional approaches to treatment, and to highlight available resources to enhance head and neck cancer providers' understanding of integrative medicine. Data Sources Randomized controlled trials involving integrative medicine or complementary and alternative medicine treatment for cancer patients. Review Methods Trials were drawn from a systematic PubMed database search categorized into cancer prevention, treatment, and symptom management. Conclusions Integrative medicine is gaining popularity for the management of cancer and is most commonly used for symptom management. A number of randomized controlled trials provide data to support integrative therapies, yet physicians who treat head and neck cancer may be faced with ethical dilemmas and practical barriers surrounding incorporation of integrative medicine. Implications for Practice In the management of head and neck cancer, there is an increasing demand for awareness of, dialogue about, and research evaluating integrative medicine therapies. It is important for otolaryngologists to become aware of integrative therapy options, their risks and benefits, and resources for further information to effectively counsel their patients.
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http://dx.doi.org/10.1177/0194599816671885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5619701PMC
February 2017

Investigation of 2 Types of Self-administered Acupressure for Persistent Cancer-Related Fatigue in Breast Cancer Survivors: A Randomized Clinical Trial.

JAMA Oncol 2016 Nov;2(11):1470-1476

Department of Anesthesiology, University of Michigan, Ann Arbor.

Importance: Fatigue is a common and debilitating late-term effect of breast cancer that is associated with poor sleep and decreased quality of life, yet therapies remain limited. Acupressure has reduced fatigue in previous small studies, but rigorous clinical trials are needed.

Objectives: To investigate if 6 weeks of 2 types of self-administered acupressure improved fatigue, sleep, and quality of life vs usual care in breast cancer survivors and to determine if changes were sustained during a 4-week washout period.

Design, Setting, And Participants: Phase 3 randomized, single-blind, clinical trial conducted from March 1, 2011, through October 31, 2014. Women were recruited from the Michigan Tumor Registry.

Interventions: Randomization (1:1:1) to 6 weeks of daily self-administered relaxing acupressure, stimulating acupressure, or usual care.

Main Outcomes And Measures: The primary outcome was change in the Brief Fatigue Inventory score from baseline to weeks 6 and 10. Secondary analyses were sleep (Pittsburgh Sleep Quality Index) and quality of life (Long-Term Quality of Life Instrument).

Results: A total of 424 survivors of stages 0 to III breast cancer who had completed cancer treatments at least 12 months previously were screened, and 288 were randomized, with 270 receiving relaxing acupressure (n = 94), stimulating acupressure (n = 90), or usual care (n = 86). One woman withdrew owing to bruising at the acupoints. At week 6, the percentages of participants who achieved normal fatigue levels (Brief Fatigue Inventory score <4) were 66.2% (49 of 74) in relaxing acupressure, 60.9% (42 of 70) in stimulating acupressure, and 31.3% (26 of 84) in usual care. At week 10, a total of 56.3% (40 of 71) in relaxing acupressure, 60.9% (42 of 69) in stimulating acupressure, and 30.1% (25 of 83) in usual care continued to have normal fatigue. At neither time point were the 2 acupressure groups significantly different. Relaxing acupressure, but not stimulating acupressure, showed significant improvements in sleep quality compared with usual care at week 6, but not at week 10. Only relaxing acupressure significantly improved quality of life vs usual care at weeks 6 and 10.

Conclusions And Relevance: Both acupressure arms significantly reduced persistent fatigue compared with usual care, but only relaxing acupressure had significant effects on sleep quality and quality of life. Relaxing acupressure offers a possible low-cost option for managing symptoms.

Trial Registration: clinicaltrials.gov Identifier: NCT01281904.
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http://dx.doi.org/10.1001/jamaoncol.2016.1867DOI Listing
November 2016

Altered resting brain connectivity in persistent cancer related fatigue.

Neuroimage Clin 2015 7;8:305-13. Epub 2015 May 7.

Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48106, USA.

There is an estimated 3 million women in the US living as breast cancer survivors and persistent cancer related fatigue (PCRF) disrupts the lives of an estimated 30% of these women. PCRF is associated with decreased quality of life, decreased sleep quality, impaired cognition and depression. The mechanisms of cancer related fatigue are not well understood; however, preliminary findings indicate dysfunctional activity in the brain as a potential factor. Here we investigate the relationship between PCRF on intrinsic resting state connectivity in this population. Twenty-three age matched breast cancer survivors (15 fatigued and 8 non-fatigued) who completed all cancer-related treatments at least 12 weeks prior to the study, were recruited to undergo functional connectivity magnetic resonance imaging (fcMRI). Intrinsic resting state networks were examined with both seed based and independent component analysis methods. Comparisons of brain connectivity patterns between groups as well as correlations with self-reported fatigue symptoms were performed. Fatigued patients displayed greater left inferior parietal lobule to superior frontal gyrus connectivity as compared to non-fatigued patients (P < 0.05 FDR corrected). This enhanced connectivity was associated with increased physical fatigue (P = 0.04, r = 0.52) and poor sleep quality (P = 0.04, r = 0.52) in the fatigued group. In contrast greater connectivity in the non-fatigued group was found between the right precuneus to the periaqueductal gray as well as the left IPL to subgenual cortex (P < 0.05 FDR corrected). Mental fatigue scores were associated with greater default mode network (DMN) connectivity to the superior frontal gyrus (P = 0.05 FDR corrected) among fatigued subjects (r = 0.82) and less connectivity in the non-fatigued group (r = -0.88). These findings indicate that there is enhanced intrinsic DMN connectivity to the frontal gyrus in breast cancer survivors with persistent fatigue. As the DMN is a network involved in self-referential thinking we speculate that enhanced connectivity between the DMN and the frontal gyrus may be related to mental fatigue and poor sleep quality. In contrast, enhanced connectivity between the DMN and regions in the subgenual cingulate and brainstem may serve a protective function in the non-fatigued group.
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http://dx.doi.org/10.1016/j.nicl.2015.04.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4474178PMC
April 2016
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