Safety, feasibility, and impact on the gut microbiome of kefir administration in critically ill adults.

BACKGROUND: Dysbiosis of the gut microbiome is frequent in the intensive care unit (ICU), potentially leading to a heightened risk of nosocomial infections. Enhancing the gut microbiome has been proposed as a strategic approach to mitigate potential adverse outcomes. While prior research on select probiotic supplements has not successfully shown to improve gut microbial diversity, fermented foods offer a promising alternative. In this open-label phase I safety and feasibility study, we examined the safety and feasibility of kefir as an initial step towards utilizing fermented foods to mitigate gut dysbiosis in critically ill patients. METHODS: We administered kefir in escalating doses (60 mL, followed by 120 mL after 12 h, then 240 mL daily) to 54 critically ill patients with an intact gastrointestinal tract. To evaluate kefir's safety, we monitored for gastrointestinal symptoms. Feasibility was determined by whether patients received a minimum of 75% of their assigned kefir doses. To assess changes in the gut microbiome composition following kefir administration, we collected two stool samples from 13 patients: one within 72 h of admission to the ICU and another at least 72 h after the first stool sample. RESULTS: After administering kefir, none of the 54 critically ill patients exhibited signs of kefir-related bacteremia. No side effects like bloating, vomiting, or aspiration were noted, except for diarrhea in two patients concurrently on laxatives. Out of the 393 kefir doses prescribed for all participants, 359 (91%) were successfully administered. We were able to collect an initial stool sample from 29 (54%) patients and a follow-up sample from 13 (24%) patients. Analysis of the 26 paired samples revealed no increase in gut microbial α-diversity between the two timepoints. However, there was a significant improvement in the Gut Microbiome Wellness Index (GMWI) by the second timepoint (P = 0.034, one-sided Wilcoxon signed-rank test); this finding supports our hypothesis that kefir administration can improve gut health in critically ill patients. Additionally, the known microbial species in kefir were found to exhibit varying levels of engraftment in patients' guts. CONCLUSIONS: Providing kefir to critically ill individuals is safe and feasible. Our findings warrant a larger evaluation of kefir's safety, tolerability, and impact on gut microbiome dysbiosis in patients admitted to the ICU. TRIAL REGISTRATION: NCT05416814; trial registered on June 13, 2022.

The Safety and Efficacy of Low-Dose Naltrexone in Patients with Fibromyalgia: A Systematic Review.

Fibromyalgia (FM) is a chronic pain sensitivity syndrome characterized by diffuse musculoskeletal pain and many other systemic manifestations. Low-dose naltrexone (LDN) has been increasingly used as an off-label treatment option in FM. However, current evidence on the safety and efficacy of LDN in patients with FM is not well known. To systematically assess the current evidence on the safety and efficacy of LDN use in the treatment of FM. A comprehensive bibliographic search was conducted on EBM Reviews - Cochrane Central Register of Controlled Trials, EBM Reviews - Cochrane Database of Systematic, Embase, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions and Scopus databases in September 2022. Inclusion criteria were articles that were published in English, focusing on clinical trials involving LDN for the treatment of FM. Two reviewers independently screened and extracted the data. A qualitative analysis was used due to the high methodological heterogeneity between studies. The electronic search produced 805 articles. After applying the inclusion criteria, 9 articles (one RCT, two case reports, two case series, and four pilot trials) were selected for evaluation. LDN intervention protocols, study designs, and follow-up periods were different among the included studies. Overall, LDN was found to be effective in the symptomatic management of FM, and of the 78% of included studies that evaluated for safety, no severe adverse events were reported. Proving the efficacy and safety of low-dose naltrexone is a future possibility based on current study data, but the level of scientific evidence is limited. Future well-designed trials with large sample sizes are required.

Dietary supplement use and recommendations for discontinuation in an integrative oncology clinic.

PURPOSE: This project evaluated the dietary supplement (DS) use of patients referred to an integrative oncology program and documented the frequency and reasons for recommending stopping DS. Many patients with cancer are taking dietary supplements and may not disclose such to their care teams. There is potential for harm in several ways: (1) interactions with their medications that may increase side effects, (2) interactions with their treatment that may lead to decreased efficacy, and 3) direct toxicity from the supplement. METHODS: Patient data (N = 100) were collected prospectively from an Integrative Oncology Clinic. The number and type of DS were documented. Using the Natural Medicines Database, we determined whether supplements interacted with the patient's other medications or cancer therapies. We calculated the percentage of patients in which a recommendation for discontinuation (DC) of DS was provided, along with the supporting reasons. RESULTS: We found that 91% of patients took DS, averaging 5.5 per patient (range 0-20). In 35% of patients, we recommended stopping some of their DS or other therapies, the reasons being: DC antioxidants, vitamin B12/iron while on chemo/RT (unless deficient or part of protocol) 32%; DC due to taking excess amounts (i.e., fat-soluble vitamins, calcium, iron) 13.5%; DC supplements with known toxicity (i.e., laetrile, Miracle mineral solution) 13.5%; DC due to interactions with other medications (i.e., anticoagulants) 13.5%; DC DS with potential to increase cancer growth (i.e., estrogenic potential in those with hormone-sensitive cancers, glutamine) 11%; DC due to potential for increased toxicity with chemotherapy (i.e., increased risk of bleeding, CIPN) 11%; DC probiotics, immune stimulants, and cannabis while on immunotherapy 5.4%. CONCLUSIONS: Patients with cancer referred to an integrative oncology clinic use large numbers of DS with the potential for adverse effects and/or decreasing efficacy of treatments. This study highlights the prevalence of DS usage in cancer patients referred to an integrative oncology clinic and demonstrates the need for counseling about safe supplement use.

Dietary Supplements for Pain Relief in Patients with Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Pain is the most frequently encountered symptom by patients with fibromyalgia (FM). Dietary supplements (DSs) in particular have a proven impact as a possible adjunctive therapy for symptom management in FM. However, there is currently no conclusive review outlining the evidence for DSs in pain management in FM. This study aims to assess currently available studies evaluating the use of DSs for pain relief in FM. Randomized controlled trials regarding the use of DSs on adult FM patients were included for evidence synthesis. Study results indicated that DSs significantly relieved pain in FM (SMD 1.23; 95% CI 0.02-2.43, P = 0.046) but did not improve quality of life (QoL) (SMD 0.73; 95% CI -0.07-1.53, P = 0.075) in the data. Adverse events of DSs varied from mild to severe, with the most common being gastrointestinal symptoms and androgenic side effects in 5.7% and 3.9% of patients, respectively. More well-designed RCTs are required in the future. The protocol for this review has been published on PROSPERO (CRD42020149941).

Effects of COVID-19 pandemic on mental health of children and adolescents: A systematic review of survey studies.

Objective: Mental health problems among children and adolescents are increasingly observed during the outbreak of COVID-19, leading to significant healthcare concerns. Survey studies provide unique opportunities for research during this pandemic, while there are no existing systematic reviews in this setting. The objective was to summarize existing survey studies addressing the effects of the current COVID-19 pandemic on the mental health of children and adolescents. Methods: For this systematic review, we performed an electronic search in multiple databases from December 2019 to December 2020. The quality appraisal of the included studies was performed with the Critical Appraisal Skills Programme Qualitative Checklist. Because of the high methodological heterogeneity between studies, a narrative synthesis of the qualitative data was used. Results: In total, 35 survey studies with 65,508 participants, ranging from 4 to 19 years of age, are included in this review. Anxiety (28%), depression (23%), loneliness (5%), stress (5%), fear (5%), tension (3%), anger (3%), fatigue (3%), confusion (3%), and worry (3%) were the most common mental health issues reported. Children and adolescents with psychiatric and/or developmental disorders, such as severe obesity, chronic lung disease, attention deficit hyperactivity disorder, cystic fibrosis, and obsessive-compulsive disorders, were especially vulnerable to the mental health effects of the COVID-19 pandemic. Age, gender, psychological quality, and negative coping strategies were identified as risk factors for the development of mental health problems. Social and family support, along with a positive coping style, was associated with better outcomes. Conclusion: The impact of the COVID-19 pandemic on mental health of children and adolescents is multifaceted and substantial. Survey studies regarding child and adolescent mental health amid COVID-19 indicated that anxiety, depression, loneliness, stress, and tension are the most observed symptoms. Positive coping strategies with family and social support may be important to achieving better outcomes. Due to limited available evidence, more well-designed studies in this area are urgently needed.

Use of Complementary and Integrative Medicine Among Patients With Glioblastoma Multiforme Seen at a Tertiary Care Center.

Background: Glioblastoma multiforme (GBM) is among the most aggressive and lethal tumors, with a median survival of 12-15 months. Many patients use complementary and integrative medicine (CIM) therapies to supplement their cancer treatment. Objective: To determine the prevalence of CIM use and identify the most frequently used types of CIM in a cohort of patients with GBM seen at a tertiary care medical center in the United States. Methods: An anonymous survey was mailed through the US Postal Service from August 1, 2019, through February 21, 2020, to patients with GBM. Results: A total of 346 surveys were mailed, and 146 responses (42%) were received. The median age of respondents was 61 years (range, 52-68 years), and 85 (58%) were male. Most patients had undergone surgery (90%), chemotherapy (96%), and radiotherapy (95%). The median time from diagnosis of GBM to survey participation was 18 months (range, 12-31 months). Most respondents (81%) used some form of CIM, most frequently meditation (22%), relaxation and other stress management techniques (19%), chiropractic therapy (16%), and acupuncture (12%). Compared with men, women more commonly meditated (32% vs 16%; P = .046) and practiced yoga (20% vs 6%; P = .04). We observed age-based differences, with younger patients more commonly meditating, practicing relaxation and stress management techniques, and receiving chiropractic therapy (P < .05 for all). Conclusions: Providers should encourage patients with GBM to discuss their interest in CIM therapies and guide them to evidence-based treatments that may help improve their quality of life.

Impact of Massage Therapy on the Quality of Life of Hospice Patients and Their Caregivers: A Pilot Study.

Evidence for massage therapy (MT) in hospice patients remains limited. We conducted a prospective pilot study on MTs impact on quality of life of hospice patients and caregivers. Patient-caregiver dyads were enrolled if patients scored ≥5 on pain, depression, anxiety, or well-being using the revised Edmonton Symptom Assessment System Revised (ESAS-r). The patient received MT weekly for up to 3 massages with assessments completed at baseline, after each massage, and 1 week after the final massage for patients and at baseline and 1 week after final massage for caregivers. A satisfaction survey was completed at study completion. A pro-rated area under the curve (AUC) was utilized to assess the primary endpoints of change in ESAS-r for patient ratings of pain, depression and anxiety as well as the Linear Analogue Self-Assessment (LASA). Median difference scores (end of study value)-(baseline value) for each participant and caregiver were calculated. Of 27 patients and caregivers enrolled, 25 patients received MT. Fifteen patients completed all 3 MT sessions and were given the final symptom assessment and satisfaction survey and their caregivers completed final assessments. The proportion of patients considered success (AUC > baseline) in the primary endpoints were the following: pain 40.9%, depression 40.9%, anxiety 54.5%, LASA 54.5%. Median difference scores were largely zero indicating no significant temporal change in symptoms. Patients were highly satisfied with MT. This pilot study indicated that MT was a feasible and well-received intervention in our population of patients with inadequately controlled symptoms.

Cutaneous myiasis with eosinophilic pleural effusion: A case report.

BACKGROUND: Cutaneous myiasis is frequently observed; however, eosinophilic pleural effusion induced by this condition is rare. CASE SUMMARY: We report the case of a 65-year-old female Tibetan patient from Qinghai Province, who presented to West China Hospital of Sichuan University around mid-November 2011 with a chief complaint of recurrent cough, occasional hemoptysis, and right chest pain. There was no past medical and surgical history of note, except for occasional dietary habit of eating raw meat. Clinical examination revealed a left lung collapse and diminished breathing sounds in her left lung, with moist rales heard in both lungs. Chest X-rays demonstrated a left hydropneumothorax and a right lung infection. Chest computed tomography revealed a left hydropneumothorax with partial compressive atelectasis and patchy consolidation on the right lung. Laboratory data revealed peripheral blood eosinophilia of 37.2%, with a white blood cell count of 10.4 × 109/L. Serum immunoglobulin E levels were elevated (1650 unit/mL). Serum parasite antibodies were negative except for cysticercosis immunoglobulin G. Bone marrow aspirates were hypercellular, with a marked increase in the number of mature eosinophils and eosinophilic myelocytes. An ultrasound-guided left-sided thoracentesis produced a yellow-cloudy exudative fluid. Failure to respond to antibiotic treatment during hospitalization for her symptoms and persistent blood eosinophilia led the team to start oral albendazole (400 mg/d) for presumed parasitic infestation for three consecutive days after the ninth day of hospitalization. Intermittent migratory stabbing pain and swelling sensation on both her upper arms and shoulders were reported; tender nodules and worm-like live organisms were observed in the responding sites 1 wk later. After the removal of the live organisms, they were subsequently identified as first stage hypodermal larvae by the Sichuan Institute of Parasites. The patient's symptoms were relieved soon afterwards. Telephonic follow-up 1 mo later indicated that the blood eosinophilia and pleural effusion were resolved. CONCLUSION: Eosinophilic pleural fluid can be present in a wide array of disorders. Myiasis should be an important consideration for the differential diagnosis when eosinophilic pleural effusion with blood eosinophilia is observed.

Viral Respiratory Infections: An Ounce of Prevention Is Worth a Pound of Cure.

The sudden outbreak and global spread of COVID-19 demanded a tremendous amount of attention for viral respiratory infections (VRIs) in modern times. Evidence accumulated over the past few decades increasingly suggests the importance of recognizing the background and context of lifestyle factors in the prevention of VRIs recurrence. The focus of attention has specifically been on how to optimize respiratory barrier function and immune function during the period of the pandemic outbreak. This viewpoint discusses the impact of a healthy lifestyle on VRIs and demonstrates a practical approach to preventing the occurrence of VRIs based on contemporary evidence.

Acupuncture for palliative cancer pain management: systematic review.

BACKGROUND: Pain is one of the most common and problematic symptoms encountered by patients with cancer. Due to the multifactorial aetiology, pain management of these patients frequently requires multidisciplinary interventions including conventional support and specialty palliative care. Acupuncture has been identified as a possible adjunctive therapy for symptom management in cancer pain, and there is currently no systematic review focused solely on the evidence of acupuncture on cancer pain in palliative care. OBJECTIVE: To critically analyse currently available publications regarding the use of acupuncture for pain management among patients with cancer in palliative care settings. METHODS: Multiple academic databases were searched from inception to 29 October 2020. Randomised controlled trials involving acupuncture in palliative care for treatment of cancer-related pain were synthesised. Data were extracted by two independent reviewers, and methodological quality of each included study was assessed using the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence. RESULTS: Five studies (n=189) were included in this systematic review. Results indicated a favourable effect of acupuncture on pain relief in palliative care for patients with cancer. According to OCEBM 2011 Levels of Evidence, they were level 2 in one case (20%), level 3 in two cases (40%) and level 4 in the remaining (40%). Low-level evidence adversely affects the reliability of findings. CONCLUSIONS: Acupuncture may be an effective and safe treatment associated with pain reduction in the palliative care of patients with cancer. Further high-quality, adequately powered studies are needed in the future.

The Impact of a 20-Minute Animal-Assisted Activity Session on the Physiological and Emotional States in Patients With Fibromyalgia.

OBJECTIVE: To study the direct physiological and emotional impact of an animal-assisted activity (AAA) session (a form of complementary and integrative medicine) in patients with fibromyalgia (FM). PATIENTS AND METHODS: The study population consisted of 221 participants with FM who were attending Mayo Clinic's Fibromyalgia Treatment Program between August 5, 2017, and September 1, 2018. This was a randomized controlled trial. Participants were randomly assigned to either the treatment group (a 20-minute session with a certified therapy dog and handler) or the control group (a 20-minute session with a handler only). To gain a better understanding of the direct physiological and emotional effects of AAA in patients with FM, we used multiple noninvasive physiologic-emotional biomarkers, including salivary cortisol and oxytocin concentrations, tympanic membrane temperatures, and various cardiac parameters, in addition to standardized pain and mood-based questionnaires. RESULTS: Results show a decrease in heart rate, an increase in heart rate variability, an increase in well-being survey scores, an increase in salivary oxytocin, and subsequent tympanic membrane temperature changes, suggesting that participants in the treatment group were in a more positive emotional-physiologic state as a result of the AAA session compared with the control group. CONCLUSION: Our results suggest that a 20-minute therapy dog visit in an outpatient setting can significantly and positively impact the physical and mental health of patients with FM.

Massage Compared with Massage Plus Acupuncture for Breast Cancer Patients Undergoing Reconstructive Surgery.

Objectives: Integrative therapies have been incorporated increasingly into health and wellness in the United States in recent decades. Their potential benefits are under evaluation in various situations, including pain and symptom relief for cancer patients and survivors. This pilot study evaluated whether combining two integrative complementary approaches augments a patient's benefit by reducing postoperative stress, pain, anxiety, muscle tension, and fatigue compared with one integrative complementary approach alone. Design: Patients undergoing autologous tissue breast reconstruction were randomly assigned to one of two postoperative complementary alternative therapies for three consecutive days. All participants were observed for up to 3 months. Subjects: Forty-two participants were recruited from January 29, 2016 to July 11, 2018. Interventions: Twenty-one participants were randomly assigned to massage alone and 21 to massage and acupuncture. Outcome measures: Stress, anxiety, relaxation, nausea, fatigue, pain, and mood (score 0-10) were measured at enrollment before surgery and postoperative days 1, 2, and 3 before and after the intervention. Patient satisfaction was evaluated. Results: Stress decreased from baseline for both Massage-Only Group and Massage+Acupuncture Group after each treatment intervention. Change in stress score from baseline decreased significantly more in the Massage-Only Group at pretreatment and posttreatment (p = 0.03 and p = 0.04). After adjustment for baseline values, change in fatigue, anxiety, relaxation, nausea, pain, and mood scores did not differ between groups. When patients were asked whether they would recommend the study, 100% (19/19) of Massage-Only Group and 94% (17/18) of Massage+Acupuncture Group responded yes (p = 0.49). Conclusion: No additive beneficial effects were observed with addition of acupuncture to massage for pain, anxiety, relaxation, nausea, fatigue, and mood. Combined massage and acupuncture was not as effective in reducing stress as massage alone, although both groups had significant stress reduction. These findings indicate a need for larger studies to explore these therapies further.

Impact of herbs and dietary supplements in patients with fibromyalgia: A protocol for a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Fibromyalgia (FM) is a common chronic pain condition that seriously affects the quality of patient lives. Its etiology, pathogenesis, and treatment still remain uncertain. Dietary supplements have been widely trialed for symptom relief for FM. The review aims to synthesize the previous literature publications to assess the impact of herbs and dietary supplements on FM patients. METHODS: We will conduct a literature search in the following databases PubMed, MEDLINE, EMBASE, Cochrane Library, Scopus, and Global Health from database inception to December 2019. Clinical studies published in the English language that used human participants and address the efficacy, safety, and acceptability of herbs and dietary supplements on individuals with FM will be included. The risk of bias and quality assessment of each trial will be evaluated. If trials are enough, a meta-analysis will be conducted using software RevMan5.3, Cochrane Collaboration. RESULT: Our review will be the first attempt to facilitate evidence-based management using herbs and dietary supplements to treat patients with FM. CONCLUSION: The findings may provide a framework for future research and clinic practice in FM management. PROSPERO REGISTRATION NUMBER: CRD42020149941.

Physiological State of Therapy Dogs during Animal-Assisted Activities in an Outpatient Setting.

Therapy dogs are increasingly being incorporated into numerous clinical settings. However, there are only a handful of studies that have focused on the impact of animal-assisted activity or therapy sessions on the wellbeing of the therapy dogs. Furthermore, these studies show mixed results. The goal of this study was to provide an in-depth picture of the effects of these interactions on the dogs involved by considering multiple physiological measures known to be associated with emotional state (continuous heart rate, heart rate variability, pre- and post-session tympanic membrane temperatures, and salivary cortisol and oxytocin concentrations). Nineteen Mayo Clinic Caring Canine therapy dogs completed five 20-minute animal-assisted activity (AAA) visits each in an outpatient clinical setting (Mayo Clinic Fibromyalgia and Chronic Fatigue Clinic). From a physiological perspective, the dogs showed a neutral to positive response to the AAA sessions. Heart rate (HR) was significantly lower at the end of the session compared with the beginning of the session (F = 17.26, df1 = 1, df2 = 29.7, p = 0.0003). The right tympanic membrane temperature was lower post-session (F = 8.87, df1 = 1, df2 = 107, p = 0.003). All other emotional indicators remained stable between pre- and post-session. These results suggest that the dogs involved were not negatively affected by their participation in the AAA. Moreover, there was some evidence suggesting the dogs may have been in a more relaxed state at the end of the session (lower HR and lower right tympanic membrane temperature) compared to the beginning of the session.

Wellness Coaching: An Intervention to Increase Healthy Behavior in Breast Cancer Survivors.

BACKGROUND: Regular physical activity after breast cancer diagnosis improves survival rates and quality of life (QOL). However, breast cancer survivors rarely meet guidelines for recommended levels of physical activity. Wellness coaching interventions (WCIs) have improved exercise and health behaviors in other patient populations. OBJECTIVES: This study assessed the feasibility and effectiveness of WCIs for increasing physical activity in breast cancer survivors; secondary measures included changes in dietary habits, weight, and QOL. METHODS: 20 obese or overweight breast cancer survivors who recently completed active breast cancer treatment were recruited into a single-arm, 12-week WCI pilot feasibility study. The intervention was comprised of one in-person wellness coaching visit followed by four telephone calls over 12 weeks and 12 weekly emails containing wellness recommendations. FINDINGS: Significant improvements from pre- to postintervention were seen in physical activity level, dietary habits, and in some aspects of QOL. Forty percent of participants achieved the 3% postintervention weight-loss goal, but this was not sustained at 30 weeks.

Real-world experiences with acupuncture among breast cancer survivors: a cross-sectional survey study.

PURPOSE: The purpose of this study was to evaluate acupuncture use among breast cancer survivors, including perceived symptom improvements and referral patterns. METHODS: Breast cancer survivors who had used acupuncture for cancer- or treatment-related symptoms were identified using an ongoing prospective Mayo Clinic Breast Disease Registry (MCBDR). Additionally, Mayo Clinic electronic health records (MCEHR) were queried to identify eligible participants. All received a mailed consent form and survey including acupuncture-related questions about acupuncture referrals, delivery, and costs. Respondents were also asked to recall symptom severity before and after acupuncture treatment and time to benefit on Likert scales. RESULTS: Acupuncture use was reported among 415 participants (12.3%) of the MCBDR. Among MCBDR and MCEHR eligible participants, 241 women returned surveys. A total of 193 (82.1%) participants reported a symptomatic benefit from acupuncture, and 57 (24.1% of participants) reported a "substantial benefit" or "totally resolved my symptoms" (corresponding to 4 and 5 on the 5-point Likert scale). The mean symptom severity decreased by at least 1 point of the 5-point scale for each symptom; the percentage of patients who reported an improvement in symptoms ranged from 56% (lymphedema) to 79% (headache). The majority of patients reported time to benefit as "immediate" (34%) or "after a few treatments" (40.4%). Over half of the participants self-referred for treatment; 24.1% were referred by their oncologist. Acupuncture delivery was more frequent in private offices (61.0%) than in hospital or medical settings (42.3%). Twelve participants (5.1%) reported negative side effects, such as discomfort. CONCLUSIONS: Acupuncture is commonly utilized by patients for a variety of breast cancer-related symptoms. However, patients frequently self-refer for acupuncture treatments, and most acupuncture care is completed at private offices, rather than medical clinic or hospital settings.

The Modified WHO Analgesic Ladder: Is It Appropriate for Chronic Non-Cancer Pain?

INTRODUCTION: From 1986, the World Health Organization (WHO) analgesic ladder has been used as the simple and valuable pain-relieving guidance in the pharmaceutical pain management, however, with the development of medical history, notions about pain physiology and pain management have already updated. Is the analgesic ladder still appropriate for chronic non-cancer pain (CNCP) patients? This study aims to analyse the current usage of the analgesic ladder in patients with CNCP by evaluating previously published pertinent studies. METHODS: Literature published in English from January 1980 to April 2019 and cited on PubMed database was included. Analysis on the analgesic ladder, current status of CNCP management, and a new revised ladder model were developed based on relevant literature. RESULTS: The WHO analgesic ladder for cancer pain is not appropriate for current CNCP management. It is revised into a four-step ladder: the integrative therapies being adopted at each step for reducing or even stopping the use of opioid analgesics; interventional therapies being considered as step 3 before upgrading to strong opioids if non-opioids and weak opioids failed in CNCP management. DISCUSSION: A simple and valuable guideline in past years, the WHO analgesic ladder is inappropriate for the current use of CNCP control. A revised four-step analgesic ladder aligned with integrative medicine principles and minimally invasive interventions is recommended for control of CNCP.

Clinicians' Guide to Cannabidiol and Hemp Oils.

Cannabidiol (CBD) oils are low tetrahydrocannabinol products derived from Cannabis sativa that have become very popular over the past few years. Patients report relief for a variety of conditions, particularly pain, without the intoxicating adverse effects of medical marijuana. In June 2018, the first CBD-based drug, Epidiolex, was approved by the US Food and Drug Administration for treatment of rare, severe epilepsy, further putting the spotlight on CBD and hemp oils. There is a growing body of preclinical and clinical evidence to support use of CBD oils for many conditions, suggesting its potential role as another option for treating challenging chronic pain or opioid addiction. Care must be taken when directing patients toward CBD products because there is little regulation, and studies have found inaccurate labeling of CBD and tetrahydrocannabinol quantities. This article provides an overview of the scientific work on cannabinoids, CBD, and hemp oil and the distinction between marijuana, hemp, and the different components of CBD and hemp oil products. We summarize the current legal status of CBD and hemp oils in the United States and provide a guide to identifying higher-quality products so that clinicians can advise their patients on the safest and most evidence-based formulations. This review is based on a PubMed search using the terms CBD, cannabidiol, hemp oil, and medical marijuana. Articles were screened for relevance, and those with the most up-to-date information were selected for inclusion.

Use of Complementary and Integrative Therapies by Fibromyalgia Patients: A 14-Year Follow-up Study.

OBJECTIVE: To reevaluate the frequency and pattern of complementary and integrative medicine (CIM) use in patients with fibromyalgia (FM). PATIENTS AND METHODS: Consecutive patients with FM who were referred to the Mayo Clinic fibromyalgia treatment program from January 5 through July 27, 2017, were invited to complete a survey about their use of CIM therapies in the preceding 6 months. The survey asked about 3 primary CIM domains: treatments and techniques, vitamins and minerals, and herbs and other dietary supplements. For direct comparative purposes, we reused the survey instrument from our prior analogous study of CIM use, performed in 2003. RESULTS: Of the 310 patients who completed the survey, 304 (98.1%) reported using some form of CIM, similar to the percentage reported in our 2003 study (98%). The most frequently used CIM therapies in the current cohort were spiritual healing (54.0% [163 of 302]), massage therapy (50.0% [152 of 304]), chiropractic treatments (39.3% [118 of 300]), aromatherapy (39.0% [117 of 300]), exercise for a specific medical problem (38.6% [117 of 303]), melatonin (37.9% [77 of 203]), magnesium (36.3% [107 of 295]), green tea (36.1% [73 of 202]), and fish oil (34.5% [68 of 197]). We noted numerous substantial differences from the 2003 data in terms of the pattern of CIM use. CONCLUSION: The use of CIM therapies among patients with FM continues to be extremely common for adult patients of all ages. Given the continued high prevalence of CIM use, health care professionals must have awareness and knowledge of these various modalities and their potential incorporation into a multifaceted FM treatment regimen.