Patients seek integrative medicine for preventive approach to optimize health.

CONTEXT: Despite the tremendous growth of integrative medicine (IM) in clinical settings, IM has not been well characterized in the medical literature. OBJECTIVE: To describe characteristics and motivation of patients seeking care at an IM clinic. DESIGN, SETTING, AND PARTICIPANTS: Patients from a nine-site practice-based research network participated in this cross-sectional survey. Clinicians documented patients' medical conditions. MAIN OUTCOME MEASURES: Patients provided information on demographics, lifestyle factors, and reasons for seeking care at an IM center. Clinicians documented the medical condition treated and procedures performed at the visit. RESULTS: A total of 4,182 patients (84.5% white; 72.7% college-educated; and 73.4% female) reported their most important reasons for seeking IM. Top-ranked reasons were (1) "to improve health and wellness now to prevent future problems" (83.9%); (2) "to try new options for health care" (76.7%); and (3) "to maximize my health regardless of whether or not my illness is curable" (74.6%). Interestingly, the same top reasons were reported by subgroups of patients who sought IM for wellness, acute care, or chronic illness. Patient reports of lifestyle also demonstrated healthier behaviors than national samples indicate. Patients seeking clinical care at IM centers desire an expanded paradigm of health care, one that seeks to maximize health.

An integrative medicine patient care model and evaluation of its outcomes: the University of Michigan experience.

BACKGROUND: The demand for integrative medicine care is increasing rapidly among patient consumers, yet the integrative medicine model is not the norm in clinical practice, nor is this approach a focus in traditional medical schools. Furthermore, patient well-being and satisfaction outcomes within an integrative care model are not common in the literature. OBJECTIVES: The purpose of this paper is to offer a summary of a model of integrative medicine patient care and its evaluation and outcomes from the University of Michigan Integrative Medicine Clinic. METHODS: Using three tools to evaluate patient outcomes and satisfaction, statistically significant outcomes were noted. The SF-12 showed positive change in the physical component score, the Holistic Health Questionnaire showed improvements in all of the subscales of body, mind, and spirit, and a unique Integrative Medicine Patient Satisfaction Tool suggested high satisfaction with an integrative approach to care. CONCLUSIONS: Findings, limitations, and implications are discussed.

Risk factors for pregnancy-related mortality: a prospective study in rural Nepal.

OBJECTIVES: This study examined the risk factors of mortality related to pregnancy for the first year post partum in a cohort of 25,580 pregnancies. STUDY DESIGN: Longitudinal cohort follow-up. METHODS: Details of socio-economic status, mid-upper arm circumference (MUAC), diet, illness, work, substance use and previous pregnancy history were collected during early to mid-gestation, and these women were followed for 1 year post partum. All-cause mortality rates per 100,000 pregnancies were calculated for deaths during pregnancy or up to 42 days post partum (early period) and 43-364 days post partum (late period). Odds ratios (OR) of mortality were estimated using five groups of risk factors: biological; morbidity; dietary; lifestyle; and socio-economic. Significant factors within each group were included in a single risk model for each time period. RESULTS: Early and late pregnancy-related mortality rates were 469 [95% confidence interval (CI) 385-553] and 254 (95% CI 192-316), respectively. Maternal age > or = 35 years was associated with a three- to four-fold increase in mortality, whereas increasing parity conferred increasing protection. In the final model, a larger MUAC and consumption of dark green leaves were associated with decreased risk of death in the early period (OR 0.76, 95% CI 0.67-0.87 and 0.64, 95% CI 0.41-0.99, respectively). A larger MUAC was also associated with a lower risk of death in the late period. Diarrhoea/dysentery and pre-eclampsia were associated with increased risk of death in the early period (OR 2.78, 95% CI 1.40-5.51 and 2.95, 95% CI 1.48-5.90, respectively). Factors weakly associated (P<0.1) with mortality in both periods included night blindness, strenuous work activity and cigarette smoking. No socio-economic factors were significant in the models. CONCLUSIONS: Maternal age, parity, MUAC, diet and illness in early to mid-gestation were associated with risk of death during pregnancy and the first year post partum in rural Nepal.

Effect of Mindfulness-Based Stress Reduction in rheumatoid arthritis patients.

OBJECTIVE: To assess the effect of a meditation training program, Mindfulness-Based Stress Reduction (MBSR), on depressive symptoms, psychological status, and disease activity in patients with rheumatoid arthritis (RA) through a randomized, waitlist-controlled pilot study. METHODS: Participants were randomized to either an MBSR group, where they attended an 8-week course and 4-month maintenance program, or to a waitlist control group, where they attended all assessment visits and received MBSR free of charge after study end. Participants received usual care from their rheumatologists throughout the trial. Self-report questionnaires were used to evaluate depressive symptoms, psychological distress, well-being, and mindfulness. Evaluation of RA disease activity (by Disease Activity Score in 28 joints) included examination by a physician masked to treatment status. Adjusted means and mean changes in outcomes were estimated in mixed model repeated measures analyses. RESULTS: Sixty-three participants were randomized: 31 to MBSR and 32 to control. At 2 months, there were no statistically significant differences between groups in any outcomes. At 6 months, there was significant improvement in psychological distress and well-being (P = 0.04 and P = 0.03, respectively), and marginally significant improvement in depressive symptoms and mindfulness (P = 0.08 and P = 0.09, respectively). There was a 35% reduction in psychological distress among those treated. The intervention had no impact on RA disease activity. CONCLUSION: An 8-week MBSR class was not associated with change in depressive symptoms or other outcomes at 2-month followup. Significant improvements in psychological distress and well-being were observed following MBSR plus a 4-month program of continued reinforcement. Mindfulness meditation may complement medical disease management by improving psychological distress and strengthening well-being in patients with RA.

Risk of flood-related mortality in Nepal.

In July 1993, severe flooding devastated Sarlahi district in Nepal. The next month, a follow-up study of a large population cohort was undertaken. The study is unique in that a prospective research database was used to verify residency prior to the flood and to confirm vital status afterwards. It evaluated 41,501 children aged between two and nine years and adults aged 15-70 in 7,252 households. Flood-related fatality rates were 13.3 per 1,000 for girls and 9.4 per 1,000 for boys, 6.1 per 1,000 for women and 4.1 per 1,000 for men. Flood-related fatality rates for children were six times higher than mortality rates in the same villages a year before the flood (relative risk (RR) = 5.9, 95 per cent confidence interval (CI) 5.0-6.8). Flood-related fatality was associated with low socio-economic status preflood (RR = 6.4, 95 per cent CI 2.7-20.0), and having a house constructed of thatch (RR = 5.1, 95 per cent CI 1.7-24.5).

Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations.

OBJECTIVE: Hyperglycemia in intensive care unit patients has been associated with an increased mortality rate, and institutions have already begun tight glucose control programs based on a limited number of clinical trials in restricted populations. This study aimed to assess the generalizability of the association between hyperglycemia and in-hospital mortality in different intensive care unit types adjusting for illness severity and diabetic history. DESIGN: Retrospective cohort study. SETTING: The medical, cardiothoracic surgery, cardiac, general surgical, and neurosurgical intensive care units of the University of Maryland Medical Center. PATIENTS: Patients admitted between July 1996 and January 1998 with length of stay > or = 24 hrs (n = 2713). INTERVENTIONS: On intensive care unit admission, blood glucose and other physiologic variables were evaluated. Regular measurements were taken for calculation of Acute Physiology and Chronic Health Evaluation III scoring. Patients were followed through hospital discharge. Admission blood glucose was used to classify patients as hyperglycemic (> 200 mg/dL) or normoglycemic (60-200 mg/dL). The contribution of hyperglycemia to in-hospital mortality stratified by intensive care unit type and diabetes history while controlling for illness severity was estimated by logistic regression. MEASUREMENTS AND MAIN RESULTS: The adjusted odds ratios for death comparing all patients with hyperglycemia to those without were 0.81 (95% confidence interval, 0.37, 1.77) and 1.76 (95% confidence interval, 1.23, 2.53) for those with and without diabetic history, respectively. Higher mortality was seen in hyperglycemic patients without diabetic history in the cardiothoracic, (adjusted odds ratio, 2.84 [1.21, 6.63]), cardiac (adjusted odds ratio, 2.64 [1.14, 6.10]), and neurosurgical units (adjusted odds ratio, 2.96 [1.51, 5.77]) but not the medical or surgical intensive care units or in patients with diabetic history. CONCLUSIONS: The association between hyperglycemia on intensive care unit admission and in-hospital mortality was not uniform in the study population; hyperglycemia was an independent risk factor only in patients without diabetic history in the cardiac, cardiothoracic, and neurosurgical intensive care units.

Effects of maternal micronutrient supplementation on fetal loss and infant mortality: a cluster-randomized trial in Nepal.

BACKGROUND: We previously reported that maternal micronutrient supplementation in rural Nepal decreased low birth weight by approximately 15%. OBJECTIVE: We examined the effect of daily maternal micronutrient supplementation on fetal loss and infant mortality. DESIGN: The study was a double-blind, cluster-randomized, controlled trial among 4926 pregnant women and their 4130 infants in rural Nepal. In addition to vitamin A (1000 microg retinol equivalents), the intervention groups received either folic acid (FA; 400 microg), FA + iron (60 mg), FA + iron + zinc (30 mg), or multiple micronutrients (MNs; the foregoing plus 10 microg vitamin D, 10 mg vitamin E, 1.6 mg thiamine, 1.8 mg riboflavin, 2.2 mg vitamin B-6, 2.6 microg vitamin B-12, 100 mg vitamin C, 64 microg vitamin K, 20 mg niacin, 2 mg Cu, and 100 mg Mg). The control group received vitamin A only. RESULTS: None of the supplements reduced fetal loss. Compared with control infants, infants whose mothers received FA alone or with iron or iron + zinc had a consistent pattern of 15-20% lower 3-mo mortality; this pattern was not observed with MNs. The effect on mortality was restricted to preterm infants, among whom the relative risks (RRs) were 0.36 (95% CI: 0.18, 0.75) for FA, 0.53 (0.30, 0.92) for FA + iron, 0.77 (0.45, 1.32) for FA + iron + zinc, and 0.70 (0.41, 1.17) for MNs. Among term infants, the RR for mortality was close to 1 for all supplements except MNs (RR: 1.74; 95% CI: 1.00, 3.04). CONCLUSIONS: Maternal micronutrient supplementation failed to reduce overall fetal loss or early infant mortality. Among preterm infants, FA alone or with iron reduced mortality in the first 3 mo of life. MNs may increase mortality risk among term infants, but this effect needs further evaluation.

Effects of alternative maternal micronutrient supplements on low birth weight in rural Nepal: double blind randomised community trial.

OBJECTIVE: To assess the impact on birth size and risk of low birth weight of alternative combinations of micronutrients given to pregnant women. DESIGN: Double blind cluster randomised controlled trial. SETTING: Rural community in south eastern Nepal. PARTICIPANTS: 4926 pregnant women and 4130 live born infants. INTERVENTIONS: 426 communities were randomised to five regimens in which pregnant women received daily supplements of folic acid, folic acid-iron, folic acid-iron-zinc, or multiple micronutrients all given with vitamin A, or vitamin A alone (control). MAIN OUTCOME MEASURES: Birth weight, length, and head and chest circumference assessed within 72 hours of birth. Low birth weight was defined <2500 g. RESULTS: Supplementation with maternal folic acid alone had no effect on birth size. Folic acid-iron increased mean birth weight by 37 g (95% confidence interval -16 g to 90 g) and reduced the percentage of low birthweight babies (<2500 g) from 43% to 34% (16%; relative risk=0.84, 0.72 to 0.99). Folic acid-iron-zinc had no effect on birth size compared with controls. Multiple micronutrient supplementation increased birth weight by 64 g (12 g to 115 g) and reduced the percentage of low birthweight babies by 14% (0.86, 0.74 to 0.99). None of the supplement combinations reduced the incidence of preterm births. Folic acid-iron and multiple micronutrients increased head and chest circumference of babies, but not length. CONCLUSIONS: Antenatal folic acid-iron supplements modestly reduce the risk of low birth weight. Multiple micronutrients confer no additional benefit over folic acid-iron in reducing this risk.

Risk factors for early infant mortality in Sarlahi district, Nepal.

OBJECTIVES: Early infant mortality has not declined as rapidly as child mortality in many countries. Identification of risk factors for early infant mortality may help inform the design of intervention strategies. METHODS: Over the period 1994-97, 15,469 live-born, singleton infants in rural Nepal were followed to 24 weeks of age to identify risk factors for mortality within 0-7 days, 8-28 days, and 4-24 weeks after the birth. FINDINGS: In multivariate models, maternal and paternal education reduced mortality between 4 and 24 weeks only: odds ratios (OR) 0.28 (95% confidence interval (CI) = 0.12-0.66) and 0.63 (95% CI = 0.44-0.88), respectively. Miscarriage in the previous pregnancy predicted mortality in the first week of life (OR = 1.98, 95% CI = 1.37-2.87), whereas prior child deaths increased the risk of post-neonatal death (OR = 1.85, 95% CI 1.24-2.75). A larger maternal mid-upper arm circumference reduced the risk of infant death during the first week of life (OR = 0.88, 95% CI = 0.81-0.95). Infants of women who did not receive any tetanus vaccinations during pregnancy or who had severe illness during the third trimester were more likely to die in the neonatal period. Maternal mortality was strongly associated with infant mortality (OR = 6.43, 95% CI = 2.35-17.56 at 0-7 days; OR = 11.73, 95% CI = 3.82-36.00 at 8-28 days; and OR = 51.68, 95% CI = 20.26-131.80 at 4-24 weeks). CONCLUSION: Risk factors for early infant mortality varied with the age of the infant. Factors amenable to intervention included efforts aimed at maternal morbidity and mortality and increased arm circumference during pregnancy.

Risk of death following pregnancy in rural Nepal.

OBJECTIVE: To investigate the length of time following pregnancy during which the risk of mortality was elevated among women in rural Nepal. METHODS: An analysis was performed of prospective data on women participating in the control group of a large, population-based trial. Weekly visits were made for three years to 14805 women aged 14-45 years. Pregnancy and vital status were assessed. A total of 7325 pregnancies were followed. Mortality during and following pregnancy, expressed on a person-time basis, was compared to referent mortality unrelated to pregnancy (52 weeks after pregnancy) in the same cohort. FINDINGS: The relative risk (RR) of death during pregnancy but before the onset of labour was 0.93 (95% confidence interval (CI): 0.38-2.32). During the perinatal period, defined as lasting from the onset of labour until seven days after outcome, the RR of death was 37.02 (95% CI: 15.03-90.92). The RR for 2 to 6 weeks, 7 to 12 weeks, and 13 to 52 weeks after pregnancy were 4.82, 2.59 and 1.01 with 95% CI of 1.77-13.07, 0.81-8.26 and 0.40-2.53, respectively. The RR of death was 2.21 (95% CI. 1.03-4.71) during the conventional maternal mortality period (pregnancy until 6 weeks after outcome). It was 2.26 (95% CI: 1.05-4.90) when the period was extended to 12 weeks after pregnancy outcome. CONCLUSION: The risk of mortality associated with pregnancy should be assessed over the first 12 weeks following outcome instead of over the first 6 weeks.