Reflective practice enriches clerkship students' cross-cultural experiences.

AIM: To describe a curriculum incorporating written reflection followed by reflective discussion with the goal of enhancing students' recognition and handling of cross-cultural and health disparity issues in different healthcare delivery settings. PROGRAM AND SETTING: This required curriculum was implemented within a 4-week family medicine clerkship (n = 188 students, 6 to 12 per rotation) in 23 successive rotations over 2 years. Electronic submission of a written assignment in response to structured questions was followed by in-class discussion in week 4. PROGRAM EVALUATION: Outcomes were students' session evaluations, thematic analysis of student responses, and analysis of faculty facilitators' reflections about discussion sessions. Students' cultural knowledge about their patients' health beliefs around diabetes was assessed using multiple choice questions at the beginning and end of the clerkship. RESULTS: One hundred percent of students submitted narratives. Student evaluations demonstrated high acceptance, appreciation of sessions and faculty. Analyses of written assignments and in-class discussions identified recurring themes. Students achieved greater synthesis and more nuanced understanding of cross-cultural encounters after discussion. Self-rating of confidence in addressing cultural issues after the curriculum was high at 3.17 +/- SD 0.57 (1-4). Cultural knowledge scores improved significantly. Core components for success were clerkship director support, required participation, experienced faculty facilitators without evaluative roles, a structured assignment and formal forum for trigger question discussion. DISCUSSION: Written reflection followed by facilitated peer discussion adds value to simple 'exposure' to cross-cultural clinical experiences for medical students.

Anti-microbial Activity of Urine after Ingestion of Cranberry: A Pilot Study.

We explore the anti-microbial activity of urine specimens after the ingestion of a commercial cranberry preparation. Twenty subjects without urinary infection, off antibiotics and all supplements or vitamins were recruited. The study was conducted in two phases: in phase 1, subjects collected the first morning urine prior to ingesting 900 mg of cranberry and then at 2, 4 and 6 h. In phase 2, subjects collected urine on 2 consecutive days: on Day 1 no cranberry was ingested (control specimens), on Day 2, cranberry was ingested. The pH of all urine specimens were adjusted to the same pH as that of the first morning urine specimen. Aliquots of each specimen were independently inoculated with Escherichia coli, Klebsiella pneumoniae or Candida albicans. After incubation, colony forming units/ml (CFU ml(-1)) in the control specimen was compared with CFU ml(-1) in specimens collected 2, 4 and 6 h later. Specimens showing ≥50% reduction in CFU ml(-1) were considered as having 'activity' against the strains tested. In phase 1, 7/20 (35%) subjects had anti-microbial activity against E. coli, 13/20 (65%) against K. pneumoniae and 9/20 (45%) against C. albicans in specimens collected 2-6 h after ingestion of cranberry. In phase 2, 6/9 (67%) of the subjects had activity against K. pneumoniae. This pilot study demonstrates weak anti-microbial activity in urine specimens after ingestion of a single dose of commercial cranberry. Anti-microbial activity was noted only against K. pneumoniae 2-6 h after ingestion of the cranberry preparation.

S-adenosyl methionine (SAMe) versus celecoxib for the treatment of osteoarthritis symptoms: a double-blind cross-over trial. [ISRCTN36233495].

BACKGROUND: S-adenosylmethionine (SAMe) is a dietary supplement used in the management of osteoarthritis (OA) symptoms. Studies evaluating SAMe in the management of OA have been limited to Non Steroidal Anti-inflammatory Drugs (NSAIDs) for comparison. The present study compares the effectiveness of SAMe to a cyclooxygenase-2 (COX-2) inhibitor (celecoxib) for pain control, functional improvement and to decrease side effects in people with osteoarthritis of the knee. METHODS: A randomized double-blind cross-over study, comparing SAMe (1200 mg) with celecoxib (Celebrex 200 mg) for 16 weeks to reduce pain associated with OA of the knee. Sixty-one adults diagnosed with OA of the knee were enrolled and 56 completed the study. Subjects were tested for pain, functional health, mood status, isometric joint function tests, and side effects. RESULTS: On the first month of Phase 1, celecoxib showed significantly more reduction in pain than SAMe (p = 0.024). By the second month of Phase 1, there was no significant difference between both groups (p < 0.01). The duration of treatment and the interaction of duration with type of treatment were statistically significant (ps < or = 0.029). On most functional health measures both groups showed a notable improvement from baseline, however no significant difference between SAMe and celecoxib was observed. Isometric joint function tests appeared to be steadily improving over the entire study period regardless of treatment. CONCLUSION: SAMe has a slower onset of action but is as effective as celecoxib in the management of symptoms of knee osteoarthritis. Longer studies are needed to evaluate the long-term effectiveness of SAMe and the optimal dose to be used.

Use of complementary and alternative medicine among the ethnic elderly.

OBJECTIVE: We sought to explore whether the elderly are high users of complementary and alternative medicine (CAM), and to determine which modalities they use. We also sought to describe patterns and positive predictors of CAM use among 3 ethnically diverse groups of community-residing elderly. DESIGN: A 7-page questionnaire was developed and translated into Spanish and Vietnamese. PARTICIPANTS: A population of 525 community-residing elderly completed personal interviews. RESULTS: Two hundred and fifty-one respondents (47.8%) reported using CAM over the past year. Dietary supplements (47.4%), chiropractic (16.3%), home remedies (15.9%), acupuncture (15.1%), and Oriental medicine (12.8%), were the most frequently cited therapies. The majority of CAM users (62.4%) did not inform their physicians that they were using it, but 58% consulted their physician for the same problem for which they used CAM. Family and friends were most relied upon for making the choice of therapy. Among the 3 ethnic groups studied, Asians were higher users of acupuncture (28%) and Oriental medicine (31%), Hispanics were higher users of dietary supplements (56%), home remedies (25%), and curanderos (8%), while white non-Hispanics were higher users of chiropractic (42%), massage (20%), vitamins (20%), diet (17%), and psychospiritual (15%) modalities. Pain was a higher indicator of CAM use among Asians, gastrointestinal problems and diabetes among Hispanics, and stress/fatigue and cardiovascular problems among white non-Hispanics. CONCLUSION: Findings indicated a high use of CAM among the elderly and emphasize the likelihood that elderly immigrants use those therapies with which they are familiar. Modalities and conditions varied with the ethnicity of respondents.

Content validity of manual spinal palpatory exams - A systematic review.

BACKGROUND: Many health care professionals use spinal palpatory exams as a primary and well-accepted part of the evaluation of spinal pathology. However, few studies have explored the validity of spinal palpatory exams. To evaluate the status of the current scientific evidence, we conducted a systematic review to assess the content validity of spinal palpatory tests used to identify spinal neuro-musculoskeletal dysfunction. METHODS: Review of eleven databases and a hand search of peer-reviewed literature, published between 1965-2002, was undertaken. Two blinded reviewers abstracted pertinent data from the retrieved papers, using a specially developed quality-scoring instrument. Five papers met the inclusion/exclusion criteria. RESULTS: Three of the five papers included in the review explored the content validity of motion tests. Two of these papers focused on identifying the level of fixation (decreased mobility) and one focused on range of motion. All three studies used a mechanical model as a reference standard. Two of the five papers included in the review explored the validity of pain assessment using the visual analogue scale or the subjects' own report as reference standards. Overall the sensitivity of studies looking at range of motion tests and pain varied greatly. Poor sensitivity was reported for range of motion studies regardless of the examiner's experience. A slightly better sensitivity (82%) was reported in one study that examined cervical pain. CONCLUSIONS: The lack of acceptable reference standards may have contributed to the weak sensitivity findings. Given the importance of spinal palpatory tests as part of the spinal evaluation and treatment plan, effort is required by all involved disciplines to create well-designed and implemented studies in this area.

Searching biomedical databases on complementary medicine: the use of controlled vocabulary among authors, indexers and investigators.

BACKGROUND: The optimal retrieval of a literature search in biomedicine depends on the appropriate use of Medical Subject Headings (MeSH), descriptors and keywords among authors and indexers. We hypothesized that authors, investigators and indexers in four biomedical databases are not consistent in their use of terminology in Complementary and Alternative Medicine (CAM). METHODS: Based on a research question addressing the validity of spinal palpation for the diagnosis of neuromuscular dysfunction, we developed four search concepts with their respective controlled vocabulary and key terms. We calculated the frequency of MeSH, descriptors, and keywords used by authors in titles and abstracts in comparison to standard practices in semantic and analytic indexing in MEDLINE, MANTIS, CINAHL, and Web of Science. RESULTS: Multiple searches resulted in the final selection of 38 relevant studies that were indexed at least in one of the four selected databases. Of the four search concepts, validity showed the greatest inconsistency in terminology among authors, indexers and investigators. The use of spinal terms showed the greatest consistency. Of the 22 neuromuscular dysfunction terms provided by the investigators, 11 were not contained in the controlled vocabulary and six were never used by authors or indexers. Most authors did not seem familiar with the controlled vocabulary for validity in the area of neuromuscular dysfunction. Recently, standard glossaries have been developed to assist in the research development of manual medicine. CONCLUSIONS: Searching biomedical databases for CAM is challenging due to inconsistent use of controlled vocabulary and indexing procedures in different databases. A standard terminology should be used by investigators in conducting their search strategies and authors when writing titles, abstracts and submitting keywords for publications.

Determining the attitudes and use of complementary, alternative, and integrative medicine among undergraduates.

OBJECTIVES: To (1) determine the attitudes, perceptions, and use of complementary, alternative, and integrative medicine among undergraduate students; (2) assess whether these students would benefit from more academic exposure to complementary and alternative medicine (CAM) and promotion of integrative medicine (IM); and (3) gauge the need and desire of undergraduates, particularly pre-health learners, to take courses about CAM/IM. METHODS: This cross-sectional electronic survey study was conducted on the campus of the University of California (UC) Irvine. Selection criteria included being at least 18 years of age and a current undergraduate at UC Irvine. All survey responses were collected between November 20, 2010, and June 1, 2011. The data were analyzed by using Stata software, version 11-SE (Stata Corp., College Station, TX). RESULTS: Completed surveys were received from 2839 participants (mean age of respondents, 20.2 years). Thirty-five percent had used CAM within the past 12 months, and 92.8% believed CAM to be at least somewhat effective; however, only 31% had prior education on CAM. After adjustment for variables, familiarity and belief in effectiveness were both highly linked to the use of CAM, with ascending odds ratios (ORs; 95% confidence interval [CI]) of 3.9 (3.1-4.9), 8.1 (5.7-11.5), 13.4 (6.0-30.2), 2.1 (1.3-3.4), 4.9 (3.0-7.8), and 12.7 (6.9-23.4) among increasing categories (all p<0.01). Sex (OR, 1.26 [95% CI, 1.01-1.56]; p<0.05), Asian ethnicity (1.46 [1.14-1.88]; p<0.01), and prior education (1.26 [1.01-1.57]; p<0.05) were also significantly correlated to the use of CAM after adjustment. Most respondents indicated that they were likely to take a CAM college course if it fulfilled a graduation requirement (63.6%) or was offered within their major (56.4%). CONCLUSIONS: Overall, this large-scale study supports the ideas that education plays a pivotal factor in the decision to use CAM and that there is a large demand for additional CAM knowledge among college students.

A Mediterranean-style, low-glycemic-load diet decreases atherogenic lipoproteins and reduces lipoprotein (a) and oxidized low-density lipoprotein in women with metabolic syndrome.

The objective was to assess the impact of a Mediterranean-style, low-glycemic-load diet (control group, n = 41) and the same diet plus a medical food (MF) containing phytosterols, soy protein, and extracts from hops and Acacia (MF group, n = 42) on lipoprotein atherogenicity in women with metabolic syndrome. Plasma lipids, apolipoproteins (apos), lipoprotein subfractions and particle size, low-density lipoprotein (LDL) oxidation, and lipoprotein (a) were measured at baseline, week 8, and week 12 of the intervention. Three-day dietary records were collected at the same time points to assess compliance. Compared with baseline, women decreased energy intake from carbohydrate (P < .001) and fat (P < .001), whereas they increased energy intake from protein (P < .001). A significant increase in energy from monounsaturated fatty acids was also observed as well as increases in eicosapentaenoic acid and docosahexaenoic acid, whereas trans-fatty acid intake was reduced (P < .00001). The atherogenic lipoproteins, large very low-density lipoprotein (P < .0001) and small LDL (P < .0001), were reduced, whereas the ratio of large high-density lipoprotein to smaller high-density lipoprotein particles was increased (P < .0001). Apolipoprotein B was reduced for all women (P < .0001), with a greater reduction in the MF group (P < .025). Oxidized LDL (P < .05) and lipoprotein (a) (P < .001) were reduced in both groups at the end of the intervention. Consumption of a Mediterranean-style diet reduces the risk for cardiovascular disease by decreasing atherogenic lipoproteins, oxidized LDL, and apo B. Inclusion of an MF may have an additional effect in reducing apo B.

Peptic ulcer disease.

Peptic ulcer disease (PUD) is due mostly to the widespread use of low-dose aspirin and nonsteroidal anti-inflammator drugs. It occurs mostly in older patients and those with comorbidities. Pain awakening the patient from sleep between 12 and 3 a.m. affects two-thirds of duodenal ulcer patients and one-third of gastric ulcer patients. Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms.

A Mediterranean-style low-glycemic-load diet improves variables of metabolic syndrome in women, and addition of a phytochemical-rich medical food enhances benefits on lipoprotein metabolism.

BACKGROUND: The high prevalence of metabolic syndrome (MetS) has highlighted the need for effective dietary interventions to combat this growing problem. OBJECTIVE: To assess the impact of a Mediterranean-style low-glycemic-load diet (control arm, n = 44) or the same diet plus a medical food containing phytosterols, soy protein, and extracts from hops and acacia (intervention arm, n = 45) on cardiometabolic risk variables in women with MetS. METHODS: In this 12-week, 2-arm randomized trial, baseline, week 8 and 12, fasting blood samples were drawn to measure plasma lipids, apolipoproteins, and homocysteine. Dietary records were also collected and analyzed. RESULTS: There were decreases in fat and sugar intake (P < .001 for both) and increases in docosahexaenoic acid and eicosapentaenoic acid intake (P < .001 for both) over time, consistent with the prescribed diet. Regarding MetS variables, there were decreases in waist circumference, systolic and diastolic blood pressure, and plasma triglycerides in all subjects (P < .001 for all) with no differences between arms. Plasma low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein (apo) B, and apo B/apo A1 were reduced over time but to a greater extent in the intervention arm (P < .05 for all), indicating the medical food had a greater effect in altering lipoprotein metabolism. Further, medical food intake was associated with reduced plasma homocysteine (P < .01) compared to the control arm. CONCLUSION: A Mediterranean-style low-glycemic-load diet effectively reduces the variables of MetS. Addition of the medical food results in a less atherogenic lipoprotein profile and lower plasma homocysteine.

Waist circumference is positively correlated with markers of inflammation and negatively with adiponectin in women with metabolic syndrome.

The purpose of this study was to correlate biomarkers of metabolic syndrome (MetS), with markers of inflammation and macronutrient intake in 89 women (25-72 years) with MetS. We hypothesized that waist circumference (WC) would have the stronger correlations with inflammatory parameters and would correlate with carbohydrate intake. Values for WC (108.7 ± 11.1 cm) and plasma triglycerides (202.7 ± 52.1 mg/dL) were elevated, whereas plasma glucose levels varied from 66 to 179 mg/dL, with 42% of women having insulin resistance. Plasma levels of interleukin 6 (0.2-15.9 mg/L), tumor necrosis factor α (1.47-12.3 mg/L), and high-sensitivity C-reactive protein (0.06-3.08 mg/dL) varied widely, with most women being above values considered normal. Subjects had high intake of total sugar (92.3 ± 56.4 g/d), high glycemic index (59.8 ± 6.5), and glycemic load (127.2 ± 56.1), whereas dietary fiber (17.1 ± 9.1 g/d) was below recommended intake. Waist circumference was positively correlated with insulin (r = 0.275, P < .01) and with the inflammatory markers interleukin 6 (r = 0.307, P < .01) and tumor necrosis factor α (r = 0.228, P < .05) and negatively correlated with plasma adiponectin (r = -0.309, P < .0001). In addition, WC was positively correlated with total carbohydrate, added sugar, and glycemic load (P < .05) but not with fat or protein. These results are consistent with central obesity being a key marker of the inflammatory state, and they also suggest that carbohydrates, particularly those that are digested rapidly, contribute to increased risk of central obesity and development of MetS.

Herbals used for diabetes, obesity, and metabolic syndrome.

Diabetes mellitus and particularly noninsulin-dependent diabetes (type 2 diabetes) is an increasingly prevalent condition worldwide with serious consequences of multiorgan involvement and in particular cardiovascular and renal disease. Obesity is a significant risk factor for type 2 diabetes, and its incidence has doubled in the past 2 decades among younger adults, adolescents, and children globally. Inflammation and insulin resistance are the underlying mechanisms for metabolic syndrome (MetS) and its increased risk of cardiovascular, renal, and pulmonary morbidity and mortality. MetS is affecting younger populations with adverse consequences seen in later years. Dietary supplements and herbals are often marketed for these conditions. This article review common herbals and supplements marketed or used by patients with diabetes, obesity, and MetS.

Common respiratory diseases.

The self-medication phenomenon in upper respiratory tract infections, rhinosinusitis, asthma, and chronic obstructive pulmonary disease are significant and will continue to increase. Current level of evidence is poor because of the small number of good quality studies, small sample size, short duration, and variation in the composition of the herbal interventions or therapies. The current review points to several potential therapies that could be effective either alone, or as adjuncts to conventional therapies.

Low HDL cholesterol is associated with increased atherogenic lipoproteins and insulin resistance in women classified with metabolic syndrome.

Both metabolic syndrome (MetS) and elevated LDL cholesterol (LDL-C) increase the risk for cardiovascular disease (CVD). We hypothesized that low HDL cholesterol (HDL-C) would further increase CVD risk in women having both conditions. To assess this, we recruited 89 women with MetS (25-72 y) and LDL-C ≥ 2.6 mmol/L. To determine whether plasma HDL-C concentrations were associated with dietary components, circulating atherogenic particles, and other risk factors for CVD, we divided the subjects into two groups: high HDL-C (H-HDL) (≥ 1.3 mmol/L, n = 32) and low HDL-C (L-HDL) (< 1.3 mmol/L, n = 57). Plasma lipids, insulin, adiponectin, apolipoproteins, oxidized LDL, Lipoprotein(a), and lipoprotein size and subfractions were measured, and 3-d dietary records were used to assess macronutrient intake. Women with L-HDL had higher sugar intake and glycemic load (P < 0.05), higher plasma insulin (P < 0.01), lower adiponectin (P < 0.05), and higher numbers of atherogenic lipoproteins such as large VLDL (P < 0.01) and small LDL (P < 0.001) than the H-HDL group. Women with L-HDL also had larger VLDL and both smaller LDL and HDL particle diameters (P < 0.001). HDL-C was positively correlated with LDL size (r = 0.691, P < 0.0001) and HDL size (r = 0.606, P < 0.001), and inversely correlated with VLDL size (r = -0.327, P < 0.01). We concluded that L-HDL could be used as a marker for increased numbers of circulating atherogenic lipoproteins as well as increased insulin resistance in women who are already at risk for CVD.

Group medical visits as a teaching tool in a family medicine clerkship.

OBJECTIVE: We sought to determine medical students' learning outcomes following exposure to a 4-hour group medical visit (GMV) curriculum that focused on Spanish-speaking patients who had diabetes. The GMV was part of a 4-week block family medicine clerkship for third-year medical students. METHODS: We conducted a 1-year longitudinal, prospective study using a before and after survey and a qualitative analysis of end-of-clerkship reflective essays. Eleven survey questions captured change in knowledge about GMV resources, cultural knowledge, and attitudes toward the GMV model. RESULTS: Ninety students completed the surveys. Fifty students chose to write about the GMV experience in their reflective essays. On the survey, a significant change was found in students' knowledge about culture-specific diabetic resources, cultural knowledge, and self-reported knowledge and attitude about GMVs. Qualitative analysis of the narratives and essays supported and strengthened this finding of positive attitudes about the importance of cultural competency and physician role modeling in the context of the patient-doctor relationship. CONCLUSIONS: Exposure to a 4-hour GMV curriculum is associated with knowledge gain. It is also associated with a positive attitude change, congruent with learning about the relevance of patient-doctor relationship within a cross-cultural setting.

Dietary supplements commonly used for prevention.

The use of complimentary and alternative medicine is on the rise. This article reviews some of the commonly used herbal supplements and others focusing mainly on disease prevention. A summary table of medical conditions is provided, and when possible, a summary of efficacy and safety is provided to facilitate decision making.

A focus Group Study of Medical Students' Views of an Integrated Complementary and Alternative Medicine (CAM) Curriculum: Students Teaching Teachers.

BACKGROUND: Student views of new curricula can shape training outcomes. This qualitative study elicited student opinions of CAM instruction to examine and distill best strategies. METHODS: 49 second, third and fourth year students participated in focus groups using a predefined question route. Interviews were audio taped and transcribed. RESULTS: Students successfully differentiated CAM curricula from other academic content and were supportive of a longitudinal integrated approach. They had positive disposition toward CAM use for themselves but this did not necessarily translate into patient recommendations. They agreed that goals of the CAM curriculum should center on awareness of patient use and evidence and information relevant to clinical practice. They advocated a case-based, hands-on, experiential strategy vs lectures. Students proposed greater institutional commitment to strengthen curricular effectiveness. The majority did not intend to practice CAM modalities but valued skills to assess them. Patient-centeredness was recognized. As training progressed, students exhibited a growing tendency to evaluate CAM efficacy, and therefore value, exclusively according to evidence. CONCLUSIONS: In-depth student input allowed examination of the effectiveness of a CAM curriculum, permitting improvement and assessment of program effectiveness.

Phytoestrogens and breast cancer prevention: what is the evidence?

The use of phytoestrogens as a natural source of estrogen has been rapidly accepted by consumers for various remedial or preventive purposes, including breast cancer prevention. Phytoestrogens exhibit mixed weak estrogen agonist/antagonist properties and antioxidative activity. They may play a significant inhibitory role during the initiation and promotional phases of cancer development. Experimental and physiologic studies provide much of the evidence on the inverse association between breast cancer risk and phytoestrogen intake. Research in humans has been limited to observational (case-control) epidemiologic studies and is far from conclusive. A critical evaluation through controlled trials of phytoestrogens' breast cancer-protective role needs to be performed before they are adopted as chemopreventive agents.