Effect of traditional yoga, mindfulness-based cognitive therapy, and cognitive behavioral therapy, on health related quality of life: a randomized controlled trial on patients on sick leave because of burnout.

BACKGROUND: To explore if health related quality of life(HRQoL) increased after traditional yoga(TY), mindfulness based cognitive therapy(MBCT), or cognitive behavioral therapy(CBT), in patients on sick leave because of burnout. METHODS: Randomized controlled trial, blinded, in ninety-four primary health care patients, block randomized to TY, MBCT or CBT (active control) between September 2007 and November 2009. Patients were living in the Stockholm metropolitan area, Sweden, were aged 18-65 years and were on 50%-100% sick leave. A group treatment for 20 weeks, three hours per week, with homework four hours per week. HRQoL was measured by the SWED-QUAL questionnaire, comprising 67 items grouped into 13 subscales, each with a separate index, and scores from 0 (worse) to 100 (best). SWED-QUAL covers aspects of physical and emotional well-being, cognitive function, sleep, general health and social and sexual functioning. Statistics: Wilcoxon's rank sum and Wilcoxon's sign rank tests, Bonett-Price for medians and confidence intervals, and Cohen's D. RESULTS: Twenty-six patients in the TY (21 women), and 27 patients in both the MBCT (24 women) and in the CBT (25 women), were analyzed. Ten subscales in TY and seven subscales in MBCT and CBT showed improvements, p < 0.05, in several of the main domains affected in burnout, e.g. emotional well-being, physical well-being, cognitive function and sleep. The median improvement ranged from 0 to 27 points in TY, from 4 to 25 points in CBT and from 0 to 25 points in MBCT. The effect size was mainly medium or large. Comparison of treatments showed no statistical differences, but better effect (small) of both TY and MBCT compared to CBT. When comparing the effect of TY and MBCT, both showed a better effect (small) in two subscales each. CONCLUSIONS: A 20 week group treatment with TY, CBT or MBCT had equal effects on HRQoL, and particularly on main domains affected in burnout. This indicates that TY, MBCT and CBT can be used as both treatment and prevention, to improve HRQoL in patients on sick leave because of burnout, reducing the risk of future morbidity. TRIAL REGISTRATION: July 22, 2012, retrospectively registered. ClinicalTrails.gov NCT01168661 . FUNDING: Stockholm County Council, grant 2003-5.

Measuring patients' health and suffering - the first stages of instrument development.

BACKGROUND: Patients have reported unanticipated and transformative health changes in existential character after integrative healthcare rehabilitation. Although there are several instruments measuring patients' experiences of health, identified instruments do not sufficiently capture patients' experiences of health and suffering after integrative health care. From a caring science perspective, health and suffering are understood as an integral part of human life. The objective of this study was to develop a first version of an instrument to measure patients' experiences of health and suffering, focusing on existential signs. METHODS: This Swedish study used a methodological design with three iterative phases for instrument development. Firstly, an item pool was developed based on qualitative patient interviews (n = 64). Subsequently, the relevance of the items was explored in two rounds of cognitive patient interviews (n = 5 and n = 3). Finally, expert consultations (n = 5) were used to further refine the instrument. The construct of the instrument, its dimensions and domains emerged through the iterative development process. RESULTS: The first phase development of the instrument resulted in two inter-related overarching dimensions: existential signs of 'Health' and 'Suffering', characterised by five domains: 'Life passion and energy', 'Personal freedom', 'Relationships', 'Presence in life' and 'Meaning'. Instrument items were formulated using contemporary language and word pairs to reflect a movement and relation between health and suffering. The cognitive interviews and expert opinions helped refine items and domains. CONCLUSIONS: The dimensions, domains and items of the instrument 'Existential signs of health and suffering' are well represented in caring science theories. Further clinical implementation and evaluation of the instrument, including psychometric properties, will allow for greater diversity in terms of context generalisability and patient characteristics. The instrument is anticipated to be of value for evaluations in research, development of healthcare practice and theory development in caring science.

Caring touch as a bodily anchor for patients after sustaining a motor vehicle accident with minor or no physical injuries - a mixed methods study.

BACKGROUND: Patients who sustain a motor vehicle accident may experience long-term distress, even if they are uninjured or only slightly injured. There is a risk of neglecting patients with minor or no physical injuries, which might impact future health problems. The aim of this study was to explore patients' subjective experiences and perspectives on pain and other factors of importance after an early nursing intervention consisting of "caring touch" (tactile massage and healing touch) for patients subjected to a motor vehicle accident with minor or no physical injuries. METHODS: A mixed method approach was used. The qualitative outcomes were themes derived from individual interviews. The quantitative outcomes were measured by visual analogue scale for pain (VAS, 0-100), sense of coherence (SOC), post-traumatic stress (IES-R) and health status (EQ-5D index and EQ-5D self-rated health). Forty-one patients of in total 124 eligible patients accepted the invitation to participate in the study. Twenty-seven patients completed follow-up after 6 months whereby they had received up to eight treatments with either tactile massage or healing touch. RESULTS: Patients reported that caring touch may assist in trauma recovery by functioning as a physical "anchor" on the patient's way of suffering, facilitating the transition of patients from feeling as though their body is "turned off" to becoming "awake". By caring touch the patients enjoyed a compassionate care and experience moments of pain alleviation. The VAS pain ratings significantly decreased both immediately after the caring touch treatment sessions and over the follow-up period. The median scores for VAS (p < 0.001) and IES-R (p 0.002) had decreased 6 months after the accident whereas the EQ-5D index had increased (p < 0.001). There were no statistically significant differences of the SOC or EQ-5D self-rated health scores over time. CONCLUSIONS: In the care of patients suffering from a MVA with minor or no physical injuries, a caring touch intervention is associated with patients' report of decreased pain and improved wellbeing up to 6 months after the accident. TRIAL REGISTRATION: ClinicalTrials.gov Id: NCT02610205 . Date 25 November 2015.

Usage and cost of first-line drugs for patients referred to inpatient anthroposophic integrative care or inpatient conventional care for stress-related mental disorders--a register based study.

BACKGROUND: Stress-related mental disorders (SRMD) are common and costly. Rehabilitation strategies, including pharmacotherapy, may be complicated to evaluate. Previous research has indicated increased quality of life and self-rated health for SRMD patients that receive a combination of conventional and complementary therapies, i.e. integrative care. The aim of this retrospective registry study was to explore and contrast the prescription of first-line drugs for SRMD patients referred to hospital inpatient anthroposophic integrative care (AIC) or inpatient conventional care (CC). METHODS: SRMD patients that had received AIC or CC were identified through high-quality inpatient registry data from Stockholm County Council and matched by available background characteristics including diagnosis (ICD-10: F43), age, gender and socio-economics. General disease load was estimated by analysis of ICD-10 chapter data. The Swedish Prescribed Drug Register was then used to investigate purchased defined daily doses (DDD) and cost of drugs from 90-days before/after, and 180-days before/after, the first visits (index) to AIC and CC respectively. First-line drug categories were Anatomical Therapeutic Chemical classification codes N05A (antipsychotics), N05B (anxiolytics), N05C (hypnotics and sedatives) and N06A (antidepressants). RESULTS: There were no statistically significant differences between the AIC (n = 161) and the CC (n = 1571) cohorts in terms of background characteristics and the overall disease loads were similar between the groups the preceding year. At baseline, the prescription of first-line anxiolytics and antidepressants were not statistically different between groups whereas the prescription of antipsychotics and hypnotics/sedatives were lower for the AIC cohort. The overall change in drug prescriptions and costs during the investigated periods, both for the 90-days before/after and for the 180-days before/after the index visit, showed a general decrease within the AIC cohort with significantly less prescribed anxiolytics and hypnotics/sedatives. During the same time periods there was a general increase in prescriptions and costs of first-line drugs within the CC cohort. The overall disease loads were generally stable within both cohorts over time, except that the CC cohort had increased visits registered with an ICD-10 F-chapter diagnosis the year after index. CONCLUSIONS: The results suggests that there may be different drug utilization patterns for SRMD patients referred to AIC or CC. Different management strategies between AIC and CC providers, different SRMD disease severities and different preferences of patients referred to AIC and CC are hypothetical differentiating factors that may influence drug outcomes over time. Additional studies including prospective and randomized clinical trials are warranted to determine if there is a causal link between inpatient AIC and reduced drug utilization.

High prevalence but limited evidence in complementary and alternative medicine: guidelines for future research.

The use of complementary and alternative Medicine (CAM) has increased over the past two decades in Europe. Nonetheless, research investigating the evidence to support its use remains limited. The CAMbrella project funded by the European Commission aimed to develop a strategic research agenda starting by systematically evaluating the state of CAM in the EU. CAMbrella involved 9 work packages covering issues such as the definition of CAM; its legal status, provision and use in the EU; and a synthesis of international research perspectives. Based on the work package reports, we developed a strategic and methodologically robust research roadmap based on expert workshops, a systematic Delphi-based process and a final consensus conference. The CAMbrella project suggests six core areas for research to examine the potential contribution of CAM to the health care challenges faced by the EU. These areas include evaluating the prevalence of CAM use in Europe; the EU cititzens' needs and attitudes regarding CAM; the safety of CAM; the comparative effectiveness of CAM; the effects of meaning and context on CAM outcomes; and different models for integrating CAM into existing health care systems. CAM research should use methods generally accepted in the evaluation of health services, including comparative effectiveness studies and mixed-methods designs. A research strategy is urgently needed, ideally led by a European CAM coordinating research office dedicated to fostering systematic communication between EU governments, the public, charitable and industry funders, researchers and other stakeholders. A European Centre for CAM should also be established to monitor and further a coordinated research strategy with sufficient funds to commission and promote high quality, independent research focusing on the public's health needs and pan-European collaboration. There is a disparity between highly prevalent use of CAM in Europe and solid knowledge about it. A strategic approach on CAM research should be established to investigate the identified gaps of knowledge and to address upcoming health care challenges.

Symptoms of antenatal common mental disorders, preterm birth and low birthweight: a prospective cohort study in a semi-rural district of Vietnam.

OBJECTIVES: To examine the association of low birthweight (LBW) and prematurity with clinically significant symptoms of antenatal common mental disorders (ACMDs) during the third trimester of pregnancy in a semi-rural area in Vietnam. METHODS: Prospective community-based cohort study. Severity of ACMD symptoms was assessed with the Edinburgh Depression Scale, low birthweight was defined as below 2500 g, and gestational age was estimated according to last menstrual period. Reproductive and socio-demographic risk factors were measured as potential confounders of the association between ACMD and the outcomes. We conducted bivariate analyses of association between ACMD and the perinatal outcomes, employing chi-square tests, crude odds ratios and 95% confidence intervals. Multiple logistic regression analysis was used to adjust for confounding. FINDINGS: We found a prevalence of clinically significant symptoms of ACMDs of 37.4%, which were significantly associated with preterm birth (adjusted OR 1.98, CI95% = 1.14-3.43) and low birthweight (adjusted OR 2.24, CI95%  = 1.02-4.95). Among the examined risk factors for the outcome measures, only maternal age was found to be statistically significant for low birthweight and preterm birth. CONCLUSIONS: This study confirms that clinically significant symptom levels of ACMD in Vietnam are associated with preterm birth and low birthweight. These findings highlight the importance of cost-effective public health interventions for ACMD in Vietnam and further exploration of its physiological link with preterm birth and low birthweight.

Science, practice and mythology: a definition and examination of the implications of scientism in medicine.

Scientism is a philosophy which purports to define what the world 'really is'. It adopts what the philosopher Thomas Nagel called 'an epistemological criterion of reality', defining what is real as that which can be discovered by certain quite specific methods of investigation. As a consequence all features of experience not revealed by those methods are deemed 'subjective' in a way that suggests they are either not real, or lie beyond the scope of meaningful rational inquiry. This devalues capacities that (we argue) are in fact essential components of good reasoning and virtuous practice. Ultimately, the implications of scientism for statements of value undermine value-judgements essential for science itself to have a sound basis. Scientism has implications, therefore, for ontology, epistemology and also for which claims we can assert as objective truths about the world. Adopting scientism as a world view will have consequences for reasoning and decision-making in clinical and other contexts. We analyse the implications of this approach and conclude that we need to reject scientism if we are to avoid stifling virtuous practice and to develop richer conceptions of human reasoning.

Iodine loaded nanoparticles with commercial applicability increase survival in mice cancer models with low degree of side effects.

BACKGROUND: The recorded use of iodine in medicine, dates to 5000 BC. Molecular iodine (I2 ) has been claimed to exert an antineoplastic effect that triggers apoptotic and re-differentiation mechanisms in different types of cancer cells in animal studies. Hitherto, all experiments published have been carried out with I2 diluted in water preparations resulting in the administration of ionized iodide, either alone or in combination with low levels of I2 . To maximize the levels of I2 by avoiding water solutions we have managed to develop a colloidal nano particle (NP) loaded with I2 with a Z-average of 7-23 nm with remarkable stability, preferable osmolality and commercial applicability. AIMS: Here we report the results from formulation and pre-clinical studies with the rationale: a) to find a tolerable dose of the I2 NP system delivered intravenously or per-orally, and b) to determine if the tolerable doses are efficacious in murine models of cancer. METHODS AND RESULTS: A novel drug delivery system with I2 NP was formulated and murine cancer models with CT26, MDA-MB-231 and LL/2 cells were used to analyse the efficacy. Despite the formulation challenges we were successful in constructing stable NPs loaded with I2 which have convincing commercial applicability. We conclude that administration of the NP I2 drug delivery system: 1. Blunted tumour growth in a xenograft breast cancer model; 2. Had a significant effect on survival in the orthotopic, syngeneic lung metastasis model; 3. Showed reduced tumour burden in post-mortem evaluation and; 4. Was associated with low degree of side effects. CONCLUSIONS: Taken all together, our findings indicate that the NP I2 drug delivery system may serve as a novel effective cancer treatment with low degree of side effects. This is something which needs further exploration including confirmation in future clinical trials.

Integrative nursing in Europe - A competency profile for nursing students validated in a Delphi-study.

BACKGROUND: Integrative nursing is a framework for providing holistic care and includes complementary therapies and non-pharmacological interventions. There is no common European approach on how to educate healthcare professionals on complementary therapies and non-pharmacological interventions for symptom management. Nurses report a lack of formal education as the main barrier to applying integrative nursing. OBJECTIVES: The aim of this study is to develop and validate integrative nursing learning outcomes in a competency profile for bachelor nursing students. METHODS: A two-round Delphi study was conducted with experts on integrative nursing and/or nurse education from eight European countries. The expert panelists rated their level of agreement with learning outcomes in relation to "Knowledge, Skills, Responsibility and Autonomy" on a nine-point Likert scale (1 = strongly disagree/9 = strongly agree) and were invited to add comments in an open text field. The Rand manual's description of levels of appropriateness was used, and experts' suggestions were analyzed thematically and used for reformulating or adding learning outcomes. RESULTS: In the first round, 19 out of 23 experts participated, versus 18 in the second round. In all, thirty-five learning outcomes within the three areas Knowledge, Skills and Responsibility/Autonomy were rated. After two Delphi rounds, twenty-four included learning outcomes were classified as appropriate, with median levels of appropriateness between 7 and 9; none had been classified as inappropriate. The learning outcomes include general knowledge about selected complementary therapies and non-pharmacological interventions, safety, national rules and regulations, communication and ethical skills and competencies for self-care actions and for applying simple evidence-based complementary therapies and non-pharmacological interventions in nursing practice. CONCLUSIONS: The competency profile consist of validated competencies; the high degree of consensus from the expert panelists makes the learning outcomes relevant for structuring a teaching module for nursing students about integrative nursing.

Patients' experiences and perceptions of integrative care for back and neck pain.

CONTEXT: Conventional guidelines in Sweden recommend primary care management for back and neck pain, yet these two conditions are the most common ones for which patients use complementary therapies. Despite the recent growth of integrative medicine (IM) in different clinical, academic, and societal contexts, few studies have defined and investigated comprehensive models of integrative care as compared to conventional management, especially using randomized clinical trials. OBJECTIVE: The study explores patients' experiences and perceptions when receiving conventional or integrative care in the management of back and neck pain. DESIGN: The research team conducted this study within a larger interventional study. In that study--a pragmatic randomized clinical pilot trial--the team developed a model for integrative medicine that combines complementary therapies that have an emerging evidence base and conventional treatments for patients with nonspecific back and neck pain. The research team implemented the model and compared the results for integrative care to results for conventional primary care. The current qualitative study included 11 focus-group discussions: conventional care (n= 5) and integrative care (n=6). SETTING: The research team implemented the interventional study in south suburban Stockholm, an area with higher unemployment, lower incomes, and receipt of more welfare support and sickness benefits compared to the average levels in Stockholm. PARTICIPANTS: The participants in the focus-group discussions were volunteers drawn from the larger randomized clinical trial. OUTCOME MEASURES: The research team transcribed all discussions from the focus groups verbatim and used latent content analysis to evaluate the data. RESULTS: Receiving diagnostic support and excluding pathology were strong reasons for participants to seek conventional care. Participants reported that they found conventional management to be reductionistic, with a focus on disease, and a lack of accessibility, time, and guidance. In contrast, participants reported that integrative care was holistic, whole-person management and facilitated increased treatment response, support, empowerment, and self-help strategies. Participants, however, perceived integrative care to be challenging because of additional treatment costs with complementary therapies and collaborative shortcomings between integrative and conventional practitioners generally. CONCLUSION: Integrative care represents a combination of valuable conventional medical diagnosis with empowering self-help strategies for some patients with nonspecific back and neck pain in Swedish primary care. Future studies should also investigate experiences and perceptions in the longer term from the perspective of patients, caregivers, and health systems.

Investigating the Long-Term Effect of an Interdisciplinary Multimodal Rehabilitation Program on Levels of Bioactive Lipids and Telomerase Activity in Blood from Patients with Chronic Pain.

Mechanism-based diagnosis and therapies for chronic pain are lacking. However, bio-psycho-social interventions such as interdisciplinary multimodal rehabilitation programs (IPRPs) have shown to be relatively effective treatments. In this context we aim to investigate the effects of IPRP on the changes in levels of bioactive lipids and telomerase activity in plasma, and if these changes are associated with changes in pain intensity and psychological distress. This exploratory study involves 18 patients with complex chronic pain participating in an IPRP. Self-reports of pain, psychological distress, physical activity, and blood samples were collected before the IPRP and at a six-month follow-up. Levels of arachidonoylethanolamide (AEA) and 2-arachidonoylglycerol (2-AG), palmitoylethanolamide (PEA), oleoylethanolamide (OEA), stearoylethanolamide (SEA), and telomerase activity were measured. Pain intensity was decreased, and SEA levels were increased at the six-month follow up. A significant correlation existed between changes in SEA levels and pain intensity. AEA levels, were inversely correlated with physical activity. Furthermore, 2-AG and telomerase activity was significantly correlated at the six-month follow-up. This study confirms that IPRP is relatively effective for reduction in chronic pain. Changes in SEA were correlated with changes in pain intensity, which might indicate that SEA changes reflect the pain reduction effects of IPRP.

Educational courses on non-pharmacologic complementary interventions for nurses across Europe: The INES mapping pilot study.

BACKGROUND: Pharmacological interventions still form the mainstay of the management of pain, anxiety, sleep problems and discomfort. In Europe, an estimated 100 million people use complementary non-pharmacological interventions (NPIs) for these conditions. In their pre-registration education, nurses do not generally learn about the various types of NPIs and how patients and health care professionals can include NPIs complementary to their standard care. Some nursing schools in Europe offer elective courses on NPIs, often relying on individual initiatives. Little is publicly available about the content of these programmes and how they relate to the current nursing curriculum for EU countries. OBJECTIVES: This pilot study aims to explore and map the field of nursing education with regard to complementary NPIs for nurses in Europe. DESIGN: A web-based open-access questionnaire administered through the online survey tool LimeSurvey® was designed by the authors. PARTICIPANTS: The questionnaire was sent to a purposive sample of 49 experts on nurse education and complementary NPIs from 16 European countries. All levels of education were eligible for inclusion. METHODS: The questionnaire consisted of 35 items regarding course content, teaching material, teaching methods and methods of assessment. In addition, respondents were invited to perform a strengths, weaknesses, opportunities and threats (SWOT) analysis in relation to their education programme. Qualitative data was analyzed using a directive content analysis approach. RESULTS: Between January and May 2020, thirty-one completed questionnaires from ten different countries were returned (response rate 63.3%). Massage, meditation, mindfulness and relaxation are the most taught interventions. Anxiety, stress, chronic pain, depression and sleep problems are the most common symptoms addressed. CONCLUSIONS: Currently, a consistent and European approach to education for nurses on complementary NPIs and integrative nursing is lacking. Although taught at regular nursing educational institutes, the courses discussed here are not yet embedded in mainstream education for nurses.

Tactile massage and hypnosis as a health promotion for nurses in emergency care--a qualitative study.

BACKGROUND: This study explores nursing personnel's experiences and perceptions of receiving tactile massage and hypnosis during a personnel health promotion project. Nursing in a short term emergency ward environment can be emotionally and physically exhausting due to the stressful work environment and the high dependency patient care. A health promotion project integrating tactile massage and hypnosis with conventional physical activities was therefore introduced for nursing personnel working in this setting at a large university hospital in Sweden. METHODS: Four semi-structured focus group discussions were conducted with volunteer nursing personnel participants after the health promotion project had been completed. There were 16 participants in the focus groups and there were 57 in the health promotion intervention. The discussions were transcribed verbatim and analysed with qualitative content analysis. RESULTS: The findings indicated that tactile massage and hypnosis may contribute to reduced levels of stress and pain and increase work ability for some nursing personnel. The sense of well-being obtained in relation to health promotion intervention with tactile massage and hypnosis seemed to have positive implications for both work and leisure. Self-awareness, contentment and self-control may be contributing factors related to engaging in tactile massage and hypnosis that might help nursing personnel understand their patients and colleagues and helped them deal with difficult situations that occurred during their working hours. CONCLUSION: The findings indicate that the integration of tactile massage and hypnosis in personnel health promotion may be valuable stress management options in addition to conventional physical activities.

Mental health priorities in Vietnam: a mixed-methods analysis.

BACKGROUND: The Mental Health Country Profile is a tool that was generated by the International Mental Health Policy and Services Project to inform policy makers, professionals and other key stakeholders about important issues which need to be considered in mental health policy development. The Mental Health Country Profile contains four domains, which include the mental health context, resources, provision and outcomes. We have aimed to generate a Mental Health Country Profile for Vietnam, in order to highlight the strengths and weaknesses of the Vietnamese mental health situation, in order to inform future reform efforts and decision-making. METHODS: This study used snowball sampling to identify informants for generating a Mental Health Country Profile for Vietnam, and the data gathering was done through semi-structured interviews and collection of relevant reports and documents. The material from the interviews and documents was analysed according to qualitative content analysis. RESULTS: Marked strengths of the Vietnam mental health system are the aims to move toward community management and detection of mental illness, and the active involvement of several multilateral organizations and NGOs. However, there are a number of shortages still found, including the lack of treatment interventions apart from medications, the high proportion of treatments to be paid out-of-pocket, prominence of large tertiary psychiatric hospitals, and a lack of preventative measures or mental health information to the public. CONCLUSIONS: At the end of this decade, mental health care in Vietnam is still characterised by unclear policy and poor critical mass especially within the governmental sector. This initial attempt to map the mental health situation of Vietnam suffers from a number of limitations and should be seen as a first step towards a comprehensive profile.

Legislative landscape for traditional health practitioners in Southern African development community countries: a scoping review.

BACKGROUND AND OBJECTIVES: Globally, contemporary legislation surrounding traditional health practitioners (THPs) is limited. This is also true for the member states of the Southern African Development Community (SADC). The main aim of this study is to map and review THP-related legislation among SADC countries. In order to limit the scope of the review, the emphasis is on defining THPs in terms of legal documents. METHODS: This scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews methods. Two independent reviewers reviewed applicable legal definitions of THPs by searching the Southern African Legal Information Institute (SAFLII) database in April 2018 for legislation and bills. To identify additional legislation applicable in countries not listed on SAFLII and/or further relevant SADC legislation, the search engines, Google and PubMed, were used in August 2018 and results were reviewed by two independent reviewers. Full texts of available policy and legal documents were screened to identify policies and legislation relating to the regulation of THPs. Legislation was deemed relevant if it was a draft of or promulgated legislation relating to THPs. RESULTS: Four of 14 Southern African countries have legislation relating to THPs. Three countries, namely South Africa, Namibia and Zimbabwe, have acknowledged the roles and importance of THPs in healthcare delivery by creating a council to register and formalise practices, although they have not operationalised nor registered and defined THPs. In contrast, Tanzania has established a definition couched in terms that acknowledge the context-specific and situational knowledge of THPs, while also outlining methods and the importance of local recognition. Tanzanian legislation; thus, provides a definition of THP that specifically operationalises THPs, whereas legislation in South Africa, Namibia and Zimbabwe allocates the power to a council to decide or recognise who a THP is; this council can prescribe procedures to be followed for the registration of a THP. CONCLUSIONS: This review highlights the differences and similarities between the various policies and legislation pertaining to THPs in SADC countries. Legislation regarding THPs is available in four of the 14 SADC countries. While South Africa, Tanzania, Namibia and Zimbabwe have legislation that provides guidance as to THP recognition, registration and practices, THPs continue to be loosely defined in most of these countries. Not having an exact definition for THPs may hamper the promotion and inclusion of THPs in national health systems, but it may also be something that is unavoidable given the tensions between lived practices and rigid legalistic frameworks.

What is an exceptional cancer trajectory?: Multiple stakeholder perspectives on cancer trajectories in relation to complementary and alternative medicine use.

BACKGROUND: Although links between exceptional cancer trajectories (ECTs) and complementary and alternative medicines (CAMs) have been suggested, most research on ECT uses predefined criteria for ECTs without necessarily including CAM use. Little knowledge can be found about subjective perspectives of ECTs in relation to CAM. OBJECTIVES: This Swedish study explores how patients, significant others, and CAM and biomedical health care (BHC) providers reason about ECT, including the role of CAM. METHODS: Using a case study approach, open interviews were conducted with multiple stakeholders about cancer trajectories reported as exceptional. RESULTS: In-depth analysis of 5 cases indicated that although all stakeholders agreed that the reported cases were positive, in no case was the same trajectory considered exceptional by all stakeholders. Different stakeholders shared neither conceptualizations of what constituted an ECT nor attributions for positive trajectories. Patients, significant others, and CAM providers emphasized unexpectedly long survival and well-being in ECTs, whereas BHC providers only referred to survival. CAM and BHC providers normalized reported trajectories, although the forms for this differed between provider groups. CONCLUDING DISCUSSION: Stakeholders' accounts are discussed relative to different health care domains, legitimization processes, and legal constraints, which have led to the lack of a public sphere for CAM use in cancer.

Exploring integrative medicine for back and neck pain - a pragmatic randomised clinical pilot trial.

BACKGROUND: A model for integrative medicine (IM) adapted to Swedish primary care was previously developed. The aim of this study was to explore the feasibility of a pragmatic randomised clinical trial to investigate the effectiveness of the IM model versus conventional primary care in the management of patients with non-specific back/neck pain. Specific objectives included the exploration of recruitment and retention rates, patient and care characteristics, clinical differences and effect sizes between groups, selected outcome measures and power calculations to inform the basis of a full-scale trial. METHODS: Eighty patients with back/neck pain of at least two weeks duration were randomised to the two types of care. Outcome measures were standardised health related quality of life (the eight domains of SF-36) complemented by a set of exploratory "IM tailored" outcomes targeting self-rated disability, stress and well-being (0-10 scales); days in pain (0-14); and the use of analgesics and health care over the last two weeks (yes/no). Data on clinical management were derived from medical records. Outcome changes from baseline to follow-up after 16 weeks were used to explore the differences between the groups. RESULTS: Seventy-five percent (80/107) of screened patients in general practice were eligible and feasible to enroll into the trial. Eighty-two percent (36/44) of the integrative and 75% (27/36) of the conventional care group completed follow-up after 16 weeks. Most patients had back/neck pain of at least three months duration. Conventional care typically comprised advice and prescription of analgesics, occasionally complemented with sick leave or a written referral to physiotherapy. IM care generally integrated seven treatment sessions from two different types of complementary therapies with conventional care over ten weeks. The study was underpowered to detect any statistically significant differences between the groups. One SF-36 domain showed a clinically relevant difference between groups that was also supported by a small distribution based effect size, i.e. vitality (-7.3 points, Cohen's d -0.34) which was in favour of IM. There was a clinical trend between groups showing that IM contributed to less use of prescription and non-prescription analgesics (-11.7 and - 9.7 percent units respectively) compared to conventional care. Exploring clinically relevant differences and the SF-36 as the basis for a main outcome measure showed that the sample sizes needed per arm to adequately power a full-scale trial depended on the target domain, i.e. ranging from 60 (vitality) to 339 (role emotion). CONCLUSION: This pilot study investigated the implementation of IM in the primary care management of non-specific back and neck pain. Recruiting patients and implementing IM in routine clinical practice was feasible. The results warrant further exploration into different perspectives and relevant combinations of outcome measures including the use of health resources, drugs and cost-effectiveness to help understand the relevance of IM in primary care. Future research should prioritize larger scale studies considering variability, pain duration and small to moderate treatment effects. TRIAL REGISTRATION: Clinical trials NCT00565942.

Changes in inflammatory plasma proteins from patients with chronic pain associated with treatment in an interdisciplinary multimodal rehabilitation program - an explorative multivariate pilot study.

It has been suggested that alterations in inflammation molecules maintain chronic pain although little is known about how these factors influence homeostatic and inflammatory events in common chronic pain conditions. Nonpharmacological interventions might be associated with alterations in inflammation markers in blood. This study of patients with chronic pain investigates whether an interdisciplinary multimodal rehabilitation program (IMMRP) was associated with significant alterations in the plasma pattern of 68 cytokines/chemokines 1 year after rehabilitation and whether such changes were associated with clinical changes. Blood samples and self-reports of pain, psychological distress, and physical activity of 25 complex chronic pain patients were collected pre-IMMRP and at 12-month follow-up. Analyses of inflammatory proteins (cytokines/chemokines/growth factors) were performed directly in plasma using the multiplex immunoassay technology Meso Scale Discovery. This explorative pilot study found that 12 substances, mainly pro-inflammatory, decreased after IMMRP. In two other relatively small IMMRP studies, four of these proinflammatory markers were also associated with decreases. The pattern of cytokines/chemokines pre-IMMRP was associated with changes in psychological distress but not with pain or physical activity. The present study cannot impute cause and effect. These results together with the results of the two previous IMMRP studies suggest that there is a need for larger and more strictly controlled studies of IMMRP with respect to inflammatory markers in blood. Such studies need to consider responders/non-responders, additional therapies, involved pain mechanisms and diagnoses. This and the two other studies open up for developing biologically measurable outcomes from plasma. Such biomarkers will be an important tool for further development of IMMRP and possibly other treatments for patients w ith chronic pain.

Exploring Sick Leave in Integrative Care-Retrospective Observations and Future Study Recommendations.

OBJECTIVES: To describe and contrast the prevalence and trends of sick leave in patients with pain or stress disorders referred to inpatient care that integrates conventional and complementary therapies, that is, integrative care (IC). METHODS: County council and social insurance data were used to retrospectively observe cross-sectional sick leave prevalence at four time points: 1 year before the first registered inpatient visit with the target diagnosis, after referral at index, and at 1 and 2 years after index. To contrast the IC findings, observations of patients with similar background characteristics referred to conventional care (CC) were used. RESULTS: The sick leave prevalence of IC pain patients and IC stress patients increased from the preceding year to peak at index, where after it decreased back toward preindex levels over 2 years. Overall sick leave prevalence was higher in IC than in CC, where analogous but lower prevalence trends of sick leave changes were observed. CONCLUSIONS: Observed sick leave prevalences, which were higher in IC than in CC, gradually decreased over time following IC or CC referral. While natural recovery or other reasons for change of sick leave cannot be excluded, future prospective and randomized clinical trials are recommended.

Quality of STIs and HIV/AIDS care as perceived by biomedical and traditional health care providers in Zambia: are there common grounds for collaboration?

OBJECTIVE: To explore biomedical and traditional health care providers' (BHPs and THPs, respectively) perceptions of good quality of care and opinions on weaknesses in the services they provide to patients with STIs and HIV/AIDS. METHODS: Using data from a cross-sectional survey, we post-coded two open-ended questions related to THPs' and BHPs' perceptions on good quality of care and on provided care. The post-coding was done following Donabedian's framework of assessment of quality of care, and allowed transformation of qualitative data into quantitative. The analysis is based on comparison of frequencies, proportions and subsequent chi-square tests and odds ratios. SETTING: Ndola and Kabwe, Zambia Main measures: Proportions of responses from 152 BHPs and 144 THPs. RESULTS: Substantial proportions of providers from both sectors perceived drugs availability (63% of BHPs and 70% of THPs) and welcoming attitude (73% of BHPs and 64% of THPs) as important components of good quality care. BHPs were more likely than THPs to mention proper examination, medical management (provider's technical ability) and explanation of causes and prognosis of the disease as important. More THPs than BHPs cited short waiting time and cost of care. A majority of BHPs (87%) and of THPs (80%) reported deficiencies in their STIs and HIV/AIDS-related services. Both groups regarded training of providers and nutritional support and health education to patients as lacking. None of the THPs alluded to voluntary counselling and testing (VCT) or supportive/home-based care as aspects needing improvement. CONCLUSION: Drugs availability and welcoming attitude were two aspects of quality highly valued by THPs and BHPs. Future collaborative interventions need to respond to aspects of joint concern including training of providers, nutritional support and health education to patients. Further, there is an imperative of expanding and adapting VCT, home-based care and palliative care to THPs for better care of STIs and HIV/AIDS.