Faculty development initiatives to advance research literacy and evidence-based practice at CAM academic institutions.

OBJECTIVES: To present the varied approaches of 9 complementary and alternative medicine (CAM) institutions (all grantees of the National Center for Complementary and Alternative Medicine) used to develop faculty expertise in research literacy and evidence-based practice (EBP) in order to integrate these concepts into CAM curricula. DESIGN: A survey to elicit information on the faculty development initiatives was administered via e-mail to the 9 program directors. All 9 completed the survey, and 8 grantees provided narrative summaries of faculty training outcomes. RESULTS: The grantees found the following strategies for implementing their programs most useful: assess needs, develop and adopt research literacy and EBP competencies, target early adopters and change leaders, employ best practices in teaching and education, provide meaningful incentives, capitalize on resources provided by grant partners, provide external training opportunities, and garner support from institutional leadership. Instructional approaches varied considerably across grantees. The most common were workshops, online resources, in-person short courses, and in-depth seminar series developed by the grantees. Many also sent faculty to intensive multiday extramural training programs. Program evaluation included measuring participation rates and satisfaction and the integration of research literacy and EBP learning objectives throughout the academic curricula. Most grantees measured longitudinal changes in beliefs, attitudes, opinions, and competencies with repeated faculty surveys. CONCLUSIONS: A common need across all 9 CAM grantee institutions was foundational training for faculty in research literacy and EBP. Therefore, each grantee institution developed and implemented a faculty development program. In developing the framework for their programs, grantees used strategies that were viewed critical for success, including making them multifaceted and unique to their specific institutional needs. These strategies, in conjunction with the grantees' instructional approaches, can be of practical use in other CAM and non-CAM academic environments considering the introduction of research literacy and EBP competencies into their curricula.

AcuTrials®: an online database of randomized controlled trials and systematic reviews of acupuncture.

BACKGROUND: The growing quantity of Complementary and Alternative Medicine literature requires databases enabled with increasingly powerful search capabilities. To address this need in the area of acupuncture research, a bibliographic database of randomized controlled trials (RCTs) and systematic reviews called AcuTrials® has been developed by the Oregon College of Oriental Medicine. AcuTrials® introduces a comprehensive keyword thesaurus that categorizes details of treatment protocols and research design to an extent not currently available in MEDLINE or other databases. DESCRIPTION: AcuTrials®, which went live in January of 2010 and is updated monthly, currently contains over 1250 articles from more than 300 journals. Articles included are English language RCTs and systematic reviews that report on medical conditions in human subjects treated by needle acupuncture. Study details are indexed by 14 key domains, such as acupuncture style and needling protocol, to create an acupuncture-relevant, searchable keyword catalogue. Keywords follow the National Library of Medicine (NLM) MeSH terminology when possible, and new keywords were created in cases where no appropriate MeSH terms were available. The resulting keyword catalogue enables users to perform sensitive, targeted searches for particular aspects of acupuncture treatment and research design. CONCLUSIONS: AcuTrials® provides an extensive and innovative keyword catalogue of acupuncture research, allowing users to efficiently navigate, locate and assess the evidence base in ways not currently possible with other databases. By providing a more powerful suite of search options, the AcuTrials® database has the potential to enhance the accessibility and quality of acupuncture research.

Acupuncture and in vitro fertilization: a retrospective chart review.

OBJECTIVES: In 2007, Craig et al. reported the results of a randomized controlled trial in which a standardized acupuncture protocol performed on the day of embryo transfer (ET) resulted in lower pregnancy rates after in vitro fertilization (IVF). Between 2005 and 2007, the Craig protocol was used by one of the authors (LHR) at an infertility clinic unaffiliated with the Craig et al. trial. The objective was to retrospectively review clinic records to evaluate the effect of the Craig protocol in both donor and nondonor IVF cycles on four outcomes: (1) live births; (2) biochemical pregnancies; (3) adverse outcomes; and (4) live births in nondonor cycles across age groups established by the Society for Assisted Reproductive Technology. DESIGN: The study design was a retrospective chart review. SETTING: The study was conducted at a private infertility clinic. PATIENT(S): Patients underwent fresh, donor (N=70) or nondonor (N=402) IVF-ET. INTERVENTION(S): The Craig protocol included the following points before ET: GV-20, CV-6, ST-29, SP-8, PC-6, LV-3; Shenmen and Brain on the left ear; and Uterus and Endocrine on the right ear. After transfer the points were LI-4, SP-10, ST-36, SP-6, KI-3; Uterus and Endocrine on the left ear; and Shenmen and Brain on the right ear. MAIN OUTCOME MEASURE(S): Live births (LB) beyond 24 weeks' gestation was the main outcome measure. RESULT(S): In nondonor IVF cycles, there were no differences in LB across age groups (odds ratio [OR]=1.04, 95% confidence interval [CI] 0.68-1.57), biochemical pregnancies (OR=0.60, 95% CI 0.27-1.33), or adverse outcomes (OR=0.63, 95% CI 0.31-1.26). In donor cycles, LB were higher in the acupuncture group (relative risk=1.31, 95% CI 1.02-1.71). CONCLUSIONS: In this observational study, the Craig protocol was not found to lower IVF LB. In fact, the Craig protocol was associated with higher LB in donor cycles. These findings should be considered cautiously because more adequately powered, randomized research is needed.

A prospective patient-centered data collection program at an acupuncture and oriental medicine teaching clinic.

OBJECTIVE: Large-scale patient-reported outcomes research investigating the role of acupuncture and Oriental medicine (AOM) in general practice is limited, despite the growing use of AOM in the United States. This article describes the development and refinement of a prospective, patient-centered outcomes data collection program at an Oriental medicine college and presents demographic and clinical data. SETTING/LOCATION: Individualized acupuncture treatment at the Oregon College of Oriental Medicine teaching clinic in Portland, Oregon. METHODS: A prospective patient-centered data collection program was implemented in 2007 using the Measure Your Medical Outcomes Profile (MYMOP) questionnaire and college-developed demographic and conditions forms. The forms were completed by patients on the first and fifth clinic visit. The program was revised after two years to streamline the data entry process and to include three Patient Reported Outcome Measurement Information System (PROMIS) questionnaires measuring pain, general health, and physical functioning. OUTCOME MEASURES: Outcome measures were patient demographics, chief complaints, MYMOP, and PROMIS data collected at first visit. RESULTS: Demographics were similar to those reported in other AOM settings. The majority of patients were Caucasian females and expressed confidence in acupuncture treatment. The most common chief complaint was joint and muscle pain. Additionally, we found that mean scores at baseline for global physical and mental health and physical functioning were all lower than U.S. averages. In contrast to some studies, we found that the majority of patients had previous experience with acupuncture. CONCLUSIONS: An ongoing, prospective data collection program can be successfully developed and implemented at an AOM college. The program will ultimately provide large-scale, patient-reported outcomes on patients seeking AOM treatment at the student clinic.

Prenatal diagnosis of Down syndrome: a systematic review of termination rates (1995-2011).

OBJECTIVE: The objective of this study was to review the published literature on pregnancy termination following a prenatal diagnosis of Down syndrome in the United States. METHOD: A systematic search of US English-language articles (1995-2011) was conducted to identify primary research studies that reported data for pregnancies with definitive prenatal diagnosis of Down syndrome with subsequent pregnancy termination. Studies that provided indirect estimates of pregnancy termination, such as mathematical models, were excluded. The weighted mean termination rate was calculated across studies. RESULTS: Twenty-four studies were accepted. The weighted mean termination rate was 67% (range: 61%-93%) among seven population-based studies, 85% (range: 60%-90%) among nine hospital-based studies, and 50% (range: 0%-100%) among eight anomaly-based studies. Evidence suggests that termination rates have decreased in recent years. Termination rates also varied with maternal age, gestational age, and maternal race/ethnicity. CONCLUSION: This systematic review presents the largest synthesis of United States data on termination rates following a prenatal diagnosis of Down syndrome. Evidence suggests that termination rates are lower than noted in a previous review that was based on less contemporary studies and had an international focus. Heterogeneity across studies suggests that a summary termination rate may not be applicable to the entire US population.

Mindfulness meditation training in adults and adolescents with ADHD: a feasibility study.

OBJECTIVE: ADHD is a childhood-onset psychiatric condition that often continues into adulthood. Stimulant medications are the mainstay of treatment; however, additional approaches are frequently desired. In recent years, mindfulness meditation has been proposed to improve attention, reduce stress, and improve mood. This study tests the feasibility of an 8-week mindfulness training program for adults and adolescents with ADHD. METHOD: Twenty-four adults and eight adolescents with ADHD enrolled in a feasibility study of an 8-week mindfulness training program. RESULTS: The majority of participants completed the training and reported high satisfaction with the training. Pre-post improvements in self-reported ADHD symptoms and test performance on tasks measuring attention and cognitive inhibition were noted. Improvements in anxiety and depressive symptoms were also observed. CONCLUSION: Mindfulness training is a feasible intervention in a subset of ADHD adults and adolescents and may improve behavioral and neurocognitive impairments. A controlled clinical study is warranted.

Augmentation of serotonin reuptake inhibitors in refractory obsessive-compulsive disorder using adjunctive olanzapine: a placebo-controlled trial.

BACKGROUND: The purpose of this study was to explore the efficacy of adding an atypical antipsychotic, olanzapine, to a serotonin reuptake inhibitor (SRI) in treatment-refractory obsessive-compulsive disorder (OCD). METHOD: Twenty-six patients aged between 18 and 65 (mean = 41.2, SD = 11.9) years meeting DSM-IV criteria for OCD, who had not responded to SRIs, were treated for 6 weeks in a double-blind, placebo-controlled augmentation study with either olanzapine (up to 20 mg/day) or placebo. Severity of illness was assessed biweekly by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Analysis of covariance with baseline Y-BOCS score included as a covariate was used to compare improvement in Y-BOCS scores in the 2 groups. Response was defined as a 25% or greater improvement in Y-BOCS score. Data were collected between April 2001 and May 2003. RESULTS: Outcome was assessed for all patients using the last observation carried forward. Subjects in the olanzapine group had a mean decrease of 4.2 (SD = 7.9) in Y-BOCS score compared with a mean increase in score of 0.54 (SD = 1.31) for subjects in the placebo group (F = 4.85, df = 2,23; p =.04). Six (46%) of 13 subjects in the olanzapine group showed a 25% or greater improvement in Y-BOCS score compared with none in the placebo group. The final mean dose of olanzapine was 11.2 (SD = 6.5) mg/day. Medication was well tolerated. Only 2 (15%) of 13 subjects who received olanzapine discontinued because of side effects: sedation (N = 1) or weight gain (N = 1). CONCLUSION: These results provide preliminary evidence that adding olanzapine to SRIs is potentially efficacious and well tolerated in the short-term treatment of patients with refractory OCD. Controlled studies with larger sample sizes are necessary to more definitively address this treatment strategy.

Inpatient treatment of depression and associated hospital charges.

OBJECTIVE: We evaluated inpatient treatment of depression, prescribing patterns for antidepressants, and associated hospital charges. METHODS: We reviewed administrative data of the UCLA Neuropsychiatric Hospital between July 1994 and July 1997 for all 1698 hospitalizations for mood disorders. We evaluated drug utilization patterns and hospital charges by analysis of variance and multiple regression, and by stratifying on diagnosis, severity, age, and other factors. RESULTS: Length of stay was the major contributor to total charges, which included room charges and charges for services, procedures, supplies, and tests. The selective serotonin reuptake inhibitors (SSRIs) were prescribed most often (to 47% of patients), followed by the atypicals (heterocyclics, 12%), the tricyclics (TCAs, 7%), venlafaxine (7%) and the monoamine oxidase inhibitors (MAOIs, < 1%). The atypicals were given to the oldest patients. After controlling for length of stay, patient age, genders and comorbidity, the atypicals were associated with the highest total inpatient charges: $2000 more than MAOIs, $600 more than SSRIs, and $600 more than venlafaxine. Higher charges were the result of more expensive procedures, especially ECT. DISCUSSION: The SSRIs were the most commonly used antidepressant. Charges for antidepressant medications contributed only 0.5% of total inpatient charges. Patients receiving atypicals had among the highest total charges, partly because of the higher use of ECT. They may represent a more severely depressed group who have not responded to other antidepressants.

Multivariate meta-analysis of controlled drug studies for obsessive-compulsive disorder.

Meta-analytic reviews of placebo-controlled studies for obsessive-compulsive disorder have found that clomipramine is more effective than drugs with more selective actions on serotonin reuptake, whereas in most direct comparisons, clomipramine's superiority has been less obvious. The authors used metaregression to identify sources of he-terogeneity in placebo-controlled trials of clomipramine, fluvoxamine, sertraline, and paroxetine. They evaluated such patient characteristics as age, gender, age of obsessive-compulsive disorder (OCD) onset, and baseline severity of OCD and depression, and such study characteristics as exclusion or inclusion criteria, length of single-blind prerandomization period, length of trial, number of subjects, and publication year. We found considerable heterogeneity across studies that was associated, in part, with publication year, length of single-blind prerandomization period, length of trial, and severity of patients' OCD. The apparent superiority of clomipramine persisted after controlling for these factors. The authors also confirmed previous reports that placebo response is higher in more recent studies. Meta-analyses can help characterize responders and nonresponders. The authors urge investigators to provide summaries of patient characteristics, especially baseline severity, age at onset, and duration of OCD, by patients' response.