Top Ten Tips Palliative Care Clinicians Should Know About Integrative Palliative Care.

Integrative medicine (IM) use is widespread among individuals living with serious illness. There is a natural alignment between the fields of IM and palliative care (PC) rooted in their shared core values. Integrative palliative care (IPC) is an emerging focus within the field of PC that aims to broaden the healing toolkit available to patients with serious illness by combining standard-of-care biomedical treatments with evidence-informed integrative and complementary medicine practices with the goal of enhancing quality of life at every stage of a person's health journey. This article is an evidence-based guide to incorporating IPC practices into the care of seriously ill individuals.

Exploratory Analysis of Racial/Ethnic and Educational Differences in a Randomized Controlled Trial of a Mindfulness-Based Weight Loss Intervention.

OBJECTIVE: People of color and lower socioeconomic groups have higher obesity prevalence, lose less weight compared with Whites and higher socioeconomic groups, and are underrepresented in randomized controlled trials of mindfulness-based interventions. We examined whether mindfulness approaches reduce disparities in weight loss interventions. METHODS: We analyzed data from a randomized controlled trial of 194 participants with obesity (41% participants of color, 36% without college degree) comparing a 5.5-month mindfulness-based weight loss intervention to an active-control with identical diet-exercise guidelines. We assessed attendance, 18-month attrition, and weight change at 6, 12, and 18 months by race/ethnicity and education level using linear mixed models, adjusting for baseline body mass index, age, and education or race/ethnicity, respectively. RESULTS: Participants without versus with a college degree attended fewer sessions and had higher attrition across interventions. Participants of color attended fewer intervention sessions in the mindfulness compared with the control intervention. Overall, participants of color lost significantly less weight at 12 and 18 months compared with Whites. However, during the 6- to 18-month maintenance period, we found an interaction of intervention arm, race/ethnicity, and time (p = .035), indicating that participants of color compared with Whites regained more weight in the control (0.33 kg/mo; p = .005) but not mindfulness intervention (0.06 kg/mo; p = .62). Participants without a college degree had greater initial weight loss in the mindfulness compared to control intervention from 0 to 6 months (-0.46 kg/mo; p = .039). CONCLUSIONS: Although disparities persist, mindfulness approaches may mitigate some racial/ethnic and socioeconomic differences in weight loss compared with conventional diet-exercise programs.Trial Registration: Clinicaltrials.gov registration: NCT00960414.

"It Gave Me Hope" Experiences of Diverse Safety Net Patients in a Group Acupuncture Intervention for Painful Diabetic Neuropathy.

Purpose: To explore the experiences of living with painful diabetic neuropathy (PDN) and with a group acupuncture intervention in a sample of low-income, diverse patients. Methods: We conducted a randomized clinical trial of a 12-week group acupuncture intervention for PDN. Data included validated measures of patient-reported outcomes, including pain and quality of life (QOL), as well as semistructured qualitative interviews about participants' experiences with PDN and the intervention. Interview transcripts were coded and analyzed using an inductive thematic framework. Results: We recruited 40 participants from diverse racial/ethnic backgrounds from a public hospital and conducted in-depth qualitative interviews with a subset of 17 participants. Participants randomized to acupuncture experienced greater decreases in pain compared with usual care as well as improved QOL. In interviews, they described a myriad of socioeconomic and personal life stressors that compounded the significant suffering and disability brought on by PDN. Those who received acupuncture were able to decrease reliance on pain medication, improve their sleep and daily function, reduce stress, and engage more with their own self-care. They noted that the acupuncture intervention also gave them hope in the face of their chronic disease. Conclusion: Acupuncture is a valuable adjunct treatment for low-income and marginalized populations with PDN. In addition to reducing pain and improving QOL, acupuncture may offer powerful benefits by increasing patient activation and hope.

A Randomized Clinical Trial of Group Acupuncture for Painful Diabetic Neuropathy Among Diverse Safety Net Patients.

OBJECTIVE: Existing pharmacologic approaches for painful diabetic neuropathy (PDN) are limited in efficacy and have side effects. We examined the feasibility, acceptability, and effects of group acupuncture for PDN. DESIGN AND SETTING: We randomized patients with PDN from a public safety net hospital to 1) usual care, 2) usual care plus 12 weeks of group acupuncture once weekly, or 3) usual care plus 12 weeks of group acupuncture twice weekly. METHODS: The primary outcome was change in weekly pain intensity (daily 0-10 numerical rating scale [NRS] averaged over seven days) from baseline to week 12. We also assessed health-related quality of life and related symptoms at baseline and weeks 6, 12, and 18. RESULTS: We enrolled 40 patients with PDN (baseline pain = 5.3). Among participants randomized to acupuncture, 92% attended at least one treatment (mean treatments = 10.1). We observed no significant differences between once- vs twice-weekly acupuncture and combined those groups for the main analyses. Compared with usual care, participants randomized to acupuncture experienced greater decreases in pain during the 12-week intervention period (between-group differences from baseline = -2.06, 95% confidence interval [CI] = -3.01 to -1.10), but benefits were not maintained after acupuncture ended (baseline to week 18 = -0.61, 95% CI = -1.46 to 0.24). Quality of life improved for acupuncture participants (baseline to week 12 difference = 11.79, 95% CI = 1.92 to 21.66), but group differences were not significant compared with usual care (25.58, 95% CI = -3.90 to 55.06). CONCLUSIONS: Group acupuncture is feasible and acceptable among linguistically and racially diverse safety net patients. Findings suggest clinically relevant reduction in pain from PDN and quality of life improvements associated with acupuncture, with no differences based on frequency.

Implementing an Inpatient Acupuncture Service for Pain and Symptom Management: Identifying Opportunities and Challenges.

Objective: To explore an interprofessional group of health care providers' perspectives on the facilitators and barriers to implementation of an inpatient acupuncture service for pain and symptom management. Design: Qualitative. Setting: An urban, academic, tertiary care health system. Subjects: Key interprofessional health care providers, including physicians, nurses, and administrators. Methods/interventions: We used interviews and focus group with questions guided by the Promoting Action on Research Implementation in Health Services framework to explore three domains of implementation-evidence, context, and facilitation. Data were analyzed using content analysis. Results: Thirty health professionals participated in 11 interviews and 1 focus group. We identified 12 codes or topics, grouped into 3 categories: (1) facilitators to implementation, (2) barriers to implementation, and (3) strategies to promote successful implementation. Health professionals' awareness of acupuncture was high, and the positive support was based on beliefs that acupuncture fills a biomedical gap in treatment and adds institutional value by enhancing the reputation of the health system. Many thought that to provide comprehensive care, acupuncture should be available to inpatients, but opinions varied on the appropriateness and timing of acupuncture in patients' disease or care trajectory. Concerns about inconsistencies in insurance coverage and resulting expenses patients may incur were noted. Strategies to overcome implementation challenges included ensuring buy-in, setting appropriate expectations of the benefits of acupuncture, and educating patients and providers. Conclusions: Our study finds clear support for acupuncture. These strong endorsements were the foundation of facilitating factors that can guide implementation of acupuncture in the inpatient setting. Although we also identified potential barriers to implementation that must be addressed, we also report a number of actionable steps to operationalize evidence-based acupuncture to patients who are inpatients.

Does CenteringPregnancy Group Prenatal Care Affect the Birth Experience of Underserved Women? A Mixed Methods Analysis.

We examined the birth experience of immigrant and minority women and how CenteringPregnancy (Centering), a model of group prenatal care and childbirth education, influenced that experience. In-depth interviews and surveys were conducted with a sample of racially diverse Centering participants about their birth experiences. Interview transcripts were analyzed thematically. Study participants (n = 34) were primarily low-income, Spanish-speaking immigrants with an average age of 29.7. On a scale from 1 (not satisfied) to 10 (very satisfied), women reported high satisfaction with birth (9.0) and care (9.3). In interviews, they expressed appreciation for the choice to labor with minimal medical intervention. Difficulties with communication arose from fragmented labor and delivery care by multiple providers. Centering provided women with pain coping skills, a familiar birth attendant, and knowledge to advocate for themselves. High reported satisfaction may obscure challenges to providing high quality childbirth care for marginalized women. Further study should examine the potential of Centering to positively impact underserved women's birth experiences.

Improving Patient-Centered Care: A Cross-Sectional Survey of Prior Use and Interest in Complementary and Integrative Health Approaches Among Hospitalized Oncology Patients.

OBJECTIVES: To describe cancer inpatients' prior-year use of complementary and integrative health (CIH) therapies and interest in receiving CIH therapies while in the hospital. DESIGN: Observational, cross-sectional survey of prior-year use of 12 different CIH approaches and interest in receiving any of 7 CIH services in the hospital. SETTING: Surgical oncology ward of an academic medical center. PARTICIPANTS: 166 hospitalized oncology patients, with an average age of 54 years. RESULTS: The most commonly used CIH approach was vitamins/nutritional supplements (67%), followed by use of a special diet (42%) and manual therapies (39%). More than 40% of patients expressed interest in each of the therapies if it was offered during their hospital stay, and 95% of patients were interested in at least one. More than 75% expressed interest in nutritional counseling and in massage. CIH use and interest varied somewhat by demographic and clinical characteristics. CONCLUSION: Rates of CIH use among patients with cancer were high, as were their preferences to have these services available in the inpatient setting. Hospitals have the opportunity to provide patient-centered care by developing capacity to provide inpatient CIH services.

"Am I cut out for this?" Understanding the experience of doubt among first-year medical students.

PURPOSE: Existing research shows that medical students experience high levels of distress. The purpose of this study was to understand how medical students experience doubt, and how doubt relates to distress. METHODS: A mixed-methods study was conducted among first-year students at the Johns Hopkins University School of Medicine in June 2012. Students answered survey questions and participated in focus groups about doubt and other forms of distress. RESULTS: Ninety-four percent (112) of students responded to the survey, with 49% reporting a moderate or high degree of doubt. Compared to those reporting no or low doubt, students with moderate/high doubt were significantly more likely to question their purpose and identity, struggle to cope with doubt, and experience depression and emotional hardening. Twenty-eight percent of students (34/112) participated in focus groups to explore their doubt, and three themes emerged: types of doubt, ways of coping with doubt, and impact of doubt. CONCLUSIONS: Doubt is highly prevalent among first-year medical students, affects their identity and purpose, and has positive and negative consequences. Doubt among medical students merits awareness and further study, as it may be an important mediator of students' emerging identity and sense of well-being.

Trauma, dissociation, and antiretroviral adherence among persons living with HIV/AIDS.

BACKGROUND: There are approximately 1,000,000 persons living with HIV/AIDS (PLH) in the United States; to reduce rates of new infection and curb disease progression, adherence to HIV medication among PLH is critical. Despite elevated trauma rates in PLH, no studies to date have investigated the relationship between dissociation, a specific symptom of trauma, and HIV medication adherence. We hypothesized that Post-Traumatic Stress Disorder (PTSD) symptoms would be associated with lower adherence, and that dissociation would moderate this relationship. METHODS: Forty-three individuals with HIV were recruited from community-based clinics to participate in a cross-sectional study. The relationship of trauma, dissociation, and their interaction to the probability of antiretroviral adherence was assessed using a hierarchical binary logistic regression analysis. RESULTS: Among 38 eligible participants, greater PTSD was associated with lower odds of adherence (OR = .92, p < .05). Dissociation moderated the effect of PTSD on adherence, resulting in lower odds of adherence (OR = .95, p < .05). PTSD symptoms were significantly associated with lower odds of adherence in individuals reporting high levels of dissociation (OR = .86, p < .05) but not in those reporting low levels of dissociation (OR = 1.02, p > .05). CONCLUSIONS: This is the first study to demonstrate a relationship between dissociation and medication adherence. Findings are discussed in the context of clinical management of PLH with trauma histories and the need for interventions targeting dissociative symptomatology to optimize adherence.