Advancing supportive oncology care via collaboration between psycho-oncology and integrative medicine.

PURPOSE: As survival after cancer diagnosis increases, patients are increasingly turning toward integrative therapies (e.g., yoga, acupuncture, massage) to manage acute and chronic concerns related to cancer treatment and survivorship. As such, integrative medicine programs devoted to combining conventional Western cancer care with complementary treatments such as yoga, acupuncture, botanicals, and homeopathy are increasingly common in cancer communities around the world. However, few integrative medicine programs have included psycho-oncology providers in order to systematically evaluate and treat psychological and behavioral health factors affecting adjustment to cancer. METHODS: A pilot program was initiated at a large academic medical center to explore benefits of a collaborative clinic visit conducted with psycho-oncology and integrative medicine within an existing supportive oncology clinic. Collaborative medical and psychological interventions were provided to enhance patient quality of life and reduce symptom burden. RESULTS: Forty-nine patients were seen via the dyadic consultation model. Sixty-eight percent of patients rated their emotional distress at or above clinical cutoffs, indicating unmet supportive care needs. The majority of patients seen were White, non-Hispanic, and female. CONCLUSIONS: Many cancer patients and survivors report persistent emotional distress and chronic physical problems associated with their diagnosis and treatment. The types of patients seen in this pilot program raise concern about ongoing inequalities in access to integrative medicine and psycho-oncology services, which may contribute to downstream health disparities and poorer clinical outcomes. Future directions will explore billing practices, financial sustainability, and methods to increase access to this type of program for demographically diverse individuals across cancer populations.

Utilization and Perception of Integrative Medicine Among Plastic Surgery Patients.

BACKGROUND: Integrative medicine (IM) is currently used by 40% of Americans. Our objective is to examine the prevalence and perception of IM utilization in patients being evaluated for elective plastic surgery. METHODS: In July 2014, 402 consecutive patients presenting to plastic surgery clinics at the University of Florida, Veterans Affairs (VA), and Private Practices in Gainesville, Florida were requested to complete a survey regarding utilization of and attitudes towards IM. RESULTS: The survey completion rate was 75.5% (n = 331). The respondents' mean age was 48.5 years, and they were primarily white (75%), married (48%), and educated with at least a college degree (58%). The respondents were distributed between the university (74%), VA (15%), and private practice (11%). There was an equal mix of reconstructive (52%) and cosmetic (48%) visits. Overall IM utilization was 80.0%. Integrative medicine use correlated with having a college degree (P = 0.0002) and being middle age (40-64 years, P < 0.005). A higher utilization rate of IM in the private sector (87.0%) compared with the university (76.1%) and VA (71.0%) was not statistically significant (P = 0.17). Similarly, higher IM utilization in cosmetic patients compared with reconstructive patients (81% vs 74%) was not statistically significant (P = 0.56). The majority of patients stated a strong belief in self-healing techniques (71%, P < 0.005), and they desired (61%) that their physician should be familiar with these techniques (P < 0.005). CONCLUSIONS: The IM utilization is highly prevalent among plastic surgery patients regardless of reason for visit (cosmetic versus reconstruction) or practice setting (private versus academic versus VA). Increasing awareness of IM usage and potential impact on outcomes is especially important for academic and VA plastic surgeons. Moreover, an opportunity exists to study how certain aspects of IM can positively impact plastic surgery care.

Multilevel Determinants of Long COVID and Potential for Telehealth Intervention.

Background: Post-coronavirus disease 2019 (COVID-19) syndrome, or long COVID, has a variety of symptoms, but little is known about the condition. This study evaluated the association between individual factors, social determinants of health, and the likelihood of long COVID by assessing internet usage as an indicator of viable access to telehealth. Methods: Data from the 2022 National Health Interview Survey identified adults who (1) reported a previous COVID-19-positive test and/or diagnosis and (2) experienced long COVID. A 2-stage selection model predicted COVID-19 infection in the first stage and long COVID in the second stage. To test the potential use of telehealth, binary dependent variable regression evaluated internet usage among respondents with long COVID. Results: About 40% (N=10,318) of respondents had tested positive/been diagnosed with COVID-19, but less than 20% of them (N=1797) had long COVID. Although older respondents were less likely to have COVID (odds ratio [OR]=0.48; 95% confidence interval [CI]=0.44, 0.53), they were more likely to experience long COVID (OR=1.63; CI=1.37, 1.93). Relative to White individuals, Black individuals were less likely to have COVID (OR=0.78; CI=0.69, 0.89) but significantly more likely (OR=1.21; CI=1.09, 1.64) to experience long COVID. Long COVID was also more likely among low-income earners (first income-to-poverty ratio quartile OR=1.40, CI=1.14, 1.72; second income-to-poverty ratio OR=1.37, CI=1.14, 1.64) and those without a college degree (OR=1.42; CI=1.01, 1.66). There were no statistically significant differences in internet access between racial, geographic, or income groups. Conclusion: Long COVID is significantly more likely among Black individuals and low-income households than among their counterparts, but with few recourses available, telehealth service delivery could be a feasible intervention mechanism.

Integrative Medicine in Long COVID.

Physiatry and Integrative Medicine practice approaches the care of patients holistically to achieve recovery and optimal function. The current lack of knowledge on proven treatments for long COVID has resulted in a surge in both demand and use of complementary and integrative health (CIH) treatments. This overview summarizes CIH therapies using the framework of the United States National Center for Complementary and Integrative Health, divided into nutritional, psychological, physical, and combinations of these categories. Representative therapies selected based on the availability of published and ongoing research for post-COVID conditions are described.

Assessing Psychological Resilience and Distress Among Graduate Health Profession Students During the COVID-19 Pandemic.

Background: Resilience, a person's ability to adapt to adverse events, is associated with positive outcomes, especially in the field of healthcare. Research into the effects of the COVID-19 pandemic may help to understand and combat the long-term mental health burden for trainees in health care. Objective: This cross-sectional study aimed to assess the impact of the pandemic on health profession students' educational experiences, determine the association between their self-reported resilience and psychological distress and assess group differences between students from different graduate health profession programs in an academic medical center. Methods: Graduate health profession students completed a 44-question online survey and the 10-item Connor Davidson Resilience Scale (CD-RISC-10) during the COVID-19 pandemic period between January-March 2021. We used descriptive statistics, independent samples t test, Related-samples Wilcoxon signed rank test, Pearson correlations test and Analysis of variance (ANOVA) to analyze the data. Results: Majority of respondents reported that COVID-19 had a negative impact on their education and caused a reduction in educational opportunities (76.6% and 73% respectively). Majority also reported feeling burned out, lonely/isolated, or frustrated by COVID-19 restrictions (70.0%, 67.4%, and 61.8% respectively). Students reported increased use of both avoidant and adaptive coping strategies during the pandemic. Higher resilience scores were associated with higher self-reported stress, fewer burnout symptoms, and better overall well-being. Conclusion: The COVID-19 pandemic significantly affected students in graduate health profession programs. Instructional quality, educational opportunities, institutional trust, peer socialization, and personal health and wellbeing were perceived to be negatively impacted. Students may require additional support and resources from their training programs to mitigate these concerns. Future studies should evaluate the long-term impact of the COVID-19 pandemic among pandemic-era graduate health profession students.

Intermittent Fasting: Potential Utility in the Treatment of Chronic Pain across the Clinical Spectrum.

Dietary behavior can have a consequential and wide-ranging influence on human health. Intermittent fasting, which involves intermittent restriction in energy intake, has been shown to have beneficial cellular, physiological, and system-wide effects in animal and human studies. Despite the potential utility in preventing, slowing, and reversing disease processes, the clinical application of intermittent fasting remains limited. The health benefits associated with the simple implementation of a 12 to 16 h fast suggest a promising role in the treatment of chronic pain. A literature review was completed to characterize the physiologic benefits of intermittent fasting and to relate the evidence to the mechanisms underlying chronic pain. Research on different fasting regimens is outlined and an overview of research demonstrating the benefits of intermittent fasting across diverse health conditions is provided. Data on the physiologic effects of intermittent fasting are summarized. The physiology of different pain states is reviewed and the possible implications for intermittent fasting in the treatment of chronic pain through non-invasive management, prehabilitation, and rehabilitation following injury and invasive procedures are presented. Evidence indicates the potential utility of intermittent fasting in the comprehensive management of chronic pain and warrants further investigation.

Acupuncture, Shingles, and Allergen Immunotherapy.

Background: The Varicella-zoster virus (VZV) remains dormant in the dorsal root ganglia and can become reactive later in a person's life. Factors such as stress, trauma, chronic disease, systemic illness, immune disorders, and age-related decline in host immunologic responses can potentially incite reactivation. Activation of VZV resulting in shingles following acupuncture has been reported in the literature previously, and some mechanisms have been proposed for this observation. Case: A patient with a history of total thyroidectomy for thyroid cancer presented with chronic neck pain. She was clinically and biochemically in a euthyroid state and on thyroid replacement therapy. She had a history of chickenpox, at age 13, and seasonal allergies. After her first acupuncture session, she received an allergy shot for her seasonal allergies. A day after the procedure, she developed a vesicular rash and was subsequently diagnosed with acute Herpes zoster. Subsequent acupuncture was withheld following this event. She received acyclovir and applied topical Aloe vera to the cutaneous lesions, and developed mild scarring, but did not experience postherpetic neuralgia. Conclusions: Acupuncture is a minor trauma that can predispose a patient to reactivation of VZV and shingles in the setting of immune activation with allergen immunotherapy.

Functional medicine: Focusing on imbalances in core metabolic processes.

This medical field surveys details of assimilation, defense and repair, energy, biotransformation and elimination, transport, communication, and structural integrity, and addresses 5 lifestyle factors.

Improving burnout and well-being among medicine residents: Impact of a grassroots intervention compared to a formal program curriculum.

BACKGROUND: With growing resident burnout, Accreditation Council for Graduate Medical Education issued new requirements for program interventions to optimize resident well-being. Little evidence exists on how to best teach resiliency to residents. This study assesses the impact of both a grassroots intervention and formal resiliency curriculum on resident burnout and well-being. MATERIALS AND METHODS: From November 2016 to August 2017, residents in a large Internal Medicine Residency Program participated in grassroots wellness interventions from the resident-led Gator Council in Gainesville, FL USA. From August 2017 to June 2018, residents participated in a formal program-driven resiliency curriculum. Wellness interventions included monthly morning reports, bimonthly workshops, and biannual noon conferences. Pre- and postintervention Maslach Burnout Inventory (MBI) and Physician Well-Being Index (PWBI) assessed the effect of both interventions on resident burnout and well-being. Statistical analyses used Student's t-test, Fisher's exact tests, and linear regression model. RESULTS: One hundred and twenty-two residents participated in grassroots interventions. One hundred and seventeen (87 residents, 35 students) participated in formal curriculum. Mean MBI scores for all three sections did not differ between pre -and postgrassroots intervention (emotional exhaustion [EE] P = 0.46; depersonalization [DP] P = 0.43; personal accomplishment [PA] P = 0.73]) or between pre- and postcurriculum (EE P = 0.20; DP P = 0.40; PA P = 0.51). Students scored higher burnout levels compared to residents in EE (P = 0.001) and PA (P = 0.02). Pre- versus postcurriculum PWBI scores did not differ among residents (P = 0.20), while PWBI scores improved among students (P = 0.01). CONCLUSIONS: This study found no improvement in resident burnout or well-being from a bottom-up and top-down approach. Our results imply the need for an early wellness curriculum to improve student well-being given their higher level of burnout. System-wide efforts are vital to combat physician burnout.

Models of Care for Postacute COVID-19 Clinics: Experiences and a Practical Framework for Outpatient Physiatry Settings.

ABSTRACT: After surviving infection with the SARS-CoV-2 virus, individuals may have persistent symptoms and prolonged impairments that may last for weeks to months. The frequency and heterogeneity of persistent post-COVID conditions have created challenges in care. Specialty clinics are being established in response to an increasing need to care for patients with postacute sequelae of SARS-CoV-2 or long COVID syndrome. Although many post-COVID conditions can be bettered through a comprehensive rehabilitation plan, various clinical settings may benefit from differing models of coordinated care. We present five models of care in varying degrees of development and compare processes and adaptations to address the unique needs of each center and their unique patient populations. Forging a path to recovery will necessitate a multidisciplinary team with physiatry involvement to meet the distinctive needs of patients with postacute sequelae of SARS-CoV-2. Furthermore, it is imperative that there be equitable access to this care and commitment from healthcare institutions to provide resources for these programs.

Promoting Resilience in Medicine: The Effects of a Mind-Body Medicine Elective to Improve Medical Student Well-being.

BACKGROUND: Poor mental health is common among medical students. In response, some medical schools have implemented wellness interventions. The University of Florida College of Medicine recently introduced a mind-body medicine elective, Promoting Resilience in Medicine (PRIMe), based on the Georgetown University School of Medicine course. PRIMe teaches meditation techniques including mindfulness, biofeedback, art, and journaling in a faculty-facilitated small group setting. METHODS: First- and second-year medical students (N = 24) who participated in the 11-week elective (3 cohorts over 2 years) completed anonymous surveys regarding their experiences. Measures included the Freiberg Mindfulness Inventory (FMI), Perceived Stress Scale-10 item (PSS-10), and a series of multiple-choice and free-response questions developed for this study. The study was approved by the University of Florida Institutional Review Board. RESULTS: Among students with available pre- and posttest scores, the average PSS-10 score at pretest was 14.4 (SD = 6.17, range = 3-26) and at posttest was 14.2 (SD = 4.17, range = 8-22), suggesting no change in perceived stress. However, average scores on the FMI improved from 34.4 (SD = 6.10, range = 24-47) at pretest to 41.8 (SD = 4.81, range = 33-49) at posttest. The overwhelming majority of participants (95.8%) described the course as "definitely" worth it. The greatest improvements were noted in mindfulness, relationships with peers, and having a safe place in medical school to receive support. Learning mindfulness/meditation skills and increasing social support were noted as the primary factors impacting student well-being. CONCLUSION: A mind-body medicine elective course may be a practical method to improve medical student well-being and improve ability to care for patients. Future studies should include follow-up testing to determine if benefits are sustained over time. In addition, more work is needed to understand the cost-benefit of providing instruction in mind-body medicine techniques to all medical students.

Hormonal Regulation In Pcos Using Acupuncture And Herbal Supplements: A Case Report And Review Of The Literature.

Polycystic ovarian syndrome (PCOS) is a common cause of menstrual irregularity and hyperandrogenism in women of reproductive age. Conventional treatment is centered around the use of oral contraceptive pills (OCPs) to regulate menstrual cycles, protect against endometrial hyperplasia, and manage clinically evident androgen excess. Many women prefer to avoid OCPs due to concerns about risks and adverse effects, or simply because they desire a non-pharmacologic approach. We present the case of a young woman with a strong preference for a natural approach to her care who presented with PCOS manifesting in menstrual irregularity, acne, and hirsutism. In this case, acupuncture as well as the botanicals Vitex agnus-castus and diindolylmethane were used over a 10-month period. The patient regained menstrual cyclicity, and clinical and biochemical hyperandrogenism normalized. This report underscores the need for an integrative approach to the management of multifactorial disorders such as PCOS and highlights the basic science and clinical data supporting the use of acupuncture, Vitex agnus-castus, and diindolylmethane in patients with this condition.

Medical Cannabis for the Primary Care Physician.

Medical cannabis use is common in the United States and increasingly more socially acceptable. As more patients seek out and acquire medical cannabis, primary care physicians will be faced with a growing number of patients seeking information on the indications, efficacy, and safety of medical cannabis. We present a case of a patient with several chronic health conditions who asks her primary care provider whether she should try medical cannabis. We provide a review of the pharmacology of medical cannabis, the state of evidence regarding the efficacy of medical cannabis, variations in the types of medical cannabis, and safety monitoring considerations for the primary care physician.

Nurturing the Seeds of Change: Strengthening the Lifestyle Medicine Movement With the Donald A. Pegg Student Leadership Award.

Student-led Lifestyle Medicine Interest Groups (LMIGs) empower the next generation of healthcare professionals to tackle the pandemic of lifestyle-related chronic diseases and provide important pathways to increasing the visibility of Lifestyle Medicine (LM) in health professions schools. Each year, the Donald A. Pegg Student Leadership Award offers four allied health students a seed grant to start or support LMIGs at their schools as well as financial assistance to attend the annual American College of Lifestyle Medicine (ACLM) conference. The 2017 student winners were Paresh Jaini, Albert Barrera, Alyssa Greenwell, and Alicja Baska. With the support of the Pegg Award, the awardees and their faculty advisors have made great strides in LM at their institutions in the areas of research, community outreach, student education, and global networking. Their LMIG activities have included students presenting research at national conferences, initiating a chapter of the national organization Walk with a Doc, hosting educational lectures on LM principles, sponsoring plant-based cooking sessions, facilitating stress management workshops, and hosting a national-level LM congress in Europe. Through the ACLM, the Pegg Award generates an atmosphere of growth for LMIGs, fostering the expansion, vision, and integration of LM into the education of health professions students worldwide.

Auricular acupuncture for spinal cord injury related neuropathic pain: a pilot controlled clinical trial.

OBJECTIVE: To obtain preliminary data on the effects of an auricular acupuncture protocol, Battlefield Acupuncture (BFA), on self-reported pain intensity in persons with chronic Spinal Cord Injury (SCI) and neuropathic pain. DESIGN: Pilot randomized delayed entry single center crossover clinical trial at an outpatient rehabilitation and integrative medicine hospital center. METHODS: Chronic (> one year post injury) ASIA impairment scale A through D individuals with SCI with injury level from C3 through T12 and below level neuropathic pain with at least five on the Numeric Rating Scale (NRS) were recruited. Twenty-four subjects were randomized to either an eight-week once weekly ten-needle BFA protocol (n = 13) or to a waiting list followed by the BFA protocol (n = 11). OUTCOME MEASURES: The primary outcome measure was change in the pain severity NRS. Secondary outcome was the Global Impression of Change. RESULTS: Demographically there were no significant differences between groups. Mean pain scores at baseline were higher in acupuncture than control subjects (7.75 ± 1.54 vs. 6.25 ± 1.04, P = 0.027). Although both groups reported significant reduction in pain during the trial period, the BFA group reported more pain reduction than the delayed entry group (average change in NRS at eight weeks -2.92 ± 2.11 vs. -1.13 ± 2.14, P = 0.065). There was a significant difference in groups when a group-by-time interaction in a mixed-effect repeated measures model (P = 0.014). CONCLUSION: This pilot study has provided proof of concept that BFA has clinically meaningful effect on the modulation of SCI neuropathic pain.

Healing Environments: Integrative Medicine and Palliative Care in Acute Care Settings.

Conventional medicine is excellent at saving lives; however, it has little to offer to address the physical, mental, and emotional distress associated with life-threatening or life-limiting disease. An integrative approach to palliative care in acute care settings can meet this need by creating healing environments that support patients, families, and health care professionals. Mindful use of language enhances the innate healing response, improves communication, and invites patients and families to participate in their care. Staff should be offered access to skills training to cultivate compassion and mindful practice to enhance both patient and self-care.

The consumer's perspective and the professional literature: what do persons with spinal cord injury want?

Different motives and purposes drive research. New knowledge advances any discipline, and use of the information obtained from careful scientific study as the basis for clinical practice promotes patient care. It is important to consider the preferences of persons with spinal cord injury (SCI) and use this as the framework in formulating research questions and clinical applications of discoveries made in the laboratory. A literature review of articles related to the interests and concerns of persons with SCI was conducted through the National Library of Medicine resource. Patient interest in finding a "cure" for SCI was not directly ascertained by any of the studies reviewed. Mobility remains the area of greatest interest, and decreased mobility has been rated as the most difficult consequence to deal with after the injury. This review indicates a congruence of the interests of both patients and researchers. However, the methodology most often used to ascertain the preferences of persons with SCI may need to be supplemented with different approaches. In addition, these preferences and the factors that influence them should be longitudinally assessed.

Prevention and treatment of heterotopic ossification after spinal cord injury.

BACKGROUND/OBJECTIVES: Heterotopic ossification (HO) is a frequent, irreversible complication after spinal cord injury (SCI). The objective of this article is to explain the etiology of HO; present new advances in prevention, diagnosis, and management of this complication; and provide a suggested algorithm for clinical management. ETIOLOGY: Although still hypothetical, trauma and overexpression of bone morphogenic protein(s) in traumatized soft tissue appear to play important roles as initiating factors of HO. PREVENTION: Preventive use of nonsteroidal antiinflammatory agents (NSAIDs) reduces the incidence of HO by a magnitude of 2 to 3. MANAGEMENT: Early determination of serum creatine phosphokinase may have a diagnostic value in predicting the onset and severity of HO, and an NSAID may be added to etidronate therapy in the initial inflammatory phase of HO formation until C-reactive protein levels return to normal range. Surgery is indicated in a subset of patients, and a regimen that includes radiation therapy may prevent postoperative recurrence. CONCLUSION: Significant progress has been made in the early prevention and management of HO. Further studies are needed to elucidate the etiology.