Meditation or exercise for preventing acute respiratory infection (MEPARI-2): A randomized controlled trial.

BACKGROUND: Practice of meditation or exercise may enhance health to protect against acute infectious illness. OBJECTIVE: To assess preventive effects of meditation and exercise on acute respiratory infection (ARI) illness. DESIGN: Randomized controlled prevention trial with three parallel groups. SETTING: Madison, Wisconsin, USA. PARTICIPANTS: Community-recruited adults who did not regularly exercise or meditate. METHODS: 1) 8-week behavioral training in mindfulness-based stress reduction (MBSR); 2) matched 8-week training in moderate intensity sustained exercise (EX); or 3) observational waitlist control. Training classes occurred in September and October, with weekly ARI surveillance through May. Incidence, duration, and area-under-curve ARI global severity were measured using daily reports on the WURSS-24 during ARI illness. Viruses were identified multiplex PCR. Absenteeism, health care utilization, and psychosocial health self-report assessments were also employed. RESULTS: Of 413 participants randomized, 390 completed the trial. In the MBSR group, 74 experienced 112 ARI episodes with 1045 days of ARI illness. Among exercisers, 84 had 120 episodes totaling 1010 illness days. Eighty-two of the controls had 134 episodes with 1210 days of ARI illness. Mean global severity was 315 for MBSR (95% confidence interval 244, 386), 256 (193, 318) for EX, and 336 (268, 403) for controls. A prespecified multivariate zero-inflated regression model suggested reduced incidence for MBSR (p = 0.036) and lower global severity for EX (p = 0.042), compared to control, not quite attaining the p<0.025 prespecified cut-off for null hypothesis rejection. There were 73 ARI-related missed-work days and 22 ARI-related health care visits in the MBSR group, 82 days and 21 visits for exercisers, and 105 days and 24 visits among controls. Viruses were identified in 63 ARI episodes in the MBSR group, compared to 64 for EX and 72 for control. Statistically significant (p<0.05) improvements in general mental health, self-efficacy, mindful attention, sleep quality, perceived stress, and depressive symptoms were observed in the MBSR and/or EX groups, compared to control. CONCLUSIONS: Training in mindfulness meditation or exercise may help protect against ARI illness. LIMITATIONS: This trial was likely underpowered. TRIAL REGISTRATION: Clinicaltrials.gov NCT01654289.

Impact of a Clinical Educational Effort in Driving Transformation in Health Care.

BACKGROUND AND OBJECTIVES: The purpose of this study was to assess whether a 2.5 day clinical education course focused on integrative medicine (IM), complementary health (CH), and patient-centered care strategies delivered to staff at Veteran Health Administration (VHA) facilities resulted in changes in attitudes, self-efficacy, preparedness, intentions, and self-reported use of IM strategies. The study also assessed whether there were differential impacts by participant characteristics. METHODS: The study used a pre-post intervention group-only design with participants who completed self-report pre, post, and 2-month follow-up surveys. The course was delivered to 15 VHA facilities, reaching a total of 655 participants with 407 participants completing the 2-month follow-up survey (65% response rate). RESULTS: Findings suggest that the clinical course was associated with changes in all outcomes at the 2-month follow-up, including attitudes, self-efficacy to engage in IM strategies, institutional support, perceived preparedness to discuss non-pharmaceutical approaches to care, intentions to engage in IM strategies, and greater engagement in IM behaviors during clinical encounters. Differential impacts were found for younger participants, longer tenured staff, non-nursing compared to nursing staff, and among those who volunteered as opposed to those who were required to attend. DISCUSSION AND CONCLUSIONS: The study found significant positive changes in all outcomes measured at the 2-month follow-up. Positive impacts were found across a variety of participant characteristics. Findings suggest that this brief experiential course, designed to be a foundational strategy in driving transformation is effective in shifting attitudes, self-efficacy, preparedness, intentions, and self-reported use of IM strategies.

Procalcitonin Levels in Acute Respiratory Infection.

Procalcitonin (PCT) is a biomarker of inflammation that is used to help make clinical decisions, like starting antibiotics or admitting a patient to the hospital. While PCT levels have been widely studied in pneumonia, levels in less severe acute respiratory infections (ARI) have not been well studied. To measure PCT levels in otherwise healthy adults during ARI, we followed 99 healthy adults during the cold and flu season, collecting blood specimens for PCT testing at baseline, and when participants presented with ARI. Ninety-six percent of the ARI samples had PCT levels <0.05 ng/mL. The remaining 4% were <0.25 ng/mL. These data suggest that PCT is not a useful test in ARI of mild-to-moderate severity.

Creating a Culture of Mindfulness in Medicine.

BACKGROUND: Well-documented challenges faced by primary care clinicians have brought growing awareness to the issues of physician wellness and burnout and the potential subsequent impact on patients. Research has identified mindfulness as a tool to increase clinician well-being and enhance clinician characteristics associated with a more patient-centered orientation to clinical care. OBJECTIVE: The overall goal of our intervention was to promote the cultivation of mindful awareness throughout our health system, creating a culture of mindfulness in medicine. METHODS: We developed a systems-level strategy to promote health and resilience for clinicians and patients by preparing a group of clinician leaders to serve as catalysts to practice and teach mindfulness. The strategy involved 3 steps: (1) select 5 primary care leaders to help foster mindfulness within both health care delivery and education; (2) provide funds for these leaders to attend advanced mindfulness training designed specifically for clinicians; and (3) foster mindfulness within our health system and beyond via collaborative planning meetings and seed money for implementation of projects. RESULTS: All 5 leaders endorsed the personal value of the mindfulness training, with some describing it as life-changing. Within 8 months, 4 of the leaders fostered a wide variety of mindfulness activities benefitting colleagues, medical students, and patients across our state and beyond. CONCLUSION: We found that the value received from our investment in mindfulness far exceeded our relatively low cost, although further evaluation is needed to prove this.

Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study.

PURPOSE: Burnout, attrition, and low work satisfaction of primary care physicians are growing concerns and can have a negative influence on health care. Interventions for clinicians that improve work-life balance are few and poorly understood. We undertook this study as a first step in investigating whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians. METHODS: A total of 30 primary care clinicians participated in an abbreviated mindfulness course. We used a single-sample, pre-post design. At 4 points in time (baseline, and 1 day, 8 weeks, and 9 months postintervention), participants completed a set of online measures assessing burnout, anxiety, stress, resilience, and compassion. We used a linear mixed-effects model analysis to assess changes in outcome measures. RESULTS: Participants had improvements compared with baseline at all 3 follow-up time points. At 9 months postintervention, they had significantly better scores (1) on all Maslach Burnout Inventory burnout subscales-Emotional Exhaustion (P =.009), Depersonalization (P = .005), and Personal Accomplishment (P <.001); (2) on the Depression (P =.001), Anxiety (P =.006), and Stress (P = .002) subscales of the Depression Anxiety Stress Scales-21; and (3) for perceived stress (P = .002) assessed with the Perceived Stress Scale. There were no significant changes on the 14-item Resilience Scale and the Santa Clara Brief Compassion Scale. CONCLUSIONS: In this uncontrolled pilot study, participating in an abbreviated mindfulness training course adapted for primary care clinicians was associated with reductions in indicators of job burnout, depression, anxiety, and stress. Modified mindfulness training may be a time-efficient tool to help support clinician health and well-being, which may have implications for patient care.

Value associated with mindfulness meditation and moderate exercise intervention in acute respiratory infection: the MEPARI Study.

BACKGROUND AND OBJECTIVES: Acute respiratory infection (ARI) is among the most common, debilitating and expensive human illnesses. The purpose of this study was to assess ARI-related costs and determine if mindfulness meditation or exercise can add value. METHODS: One hundred and fifty-four adults ≥50 years from Madison, WI for the 2009-10 cold/flu season were randomized to (i) wait-list control (ii) meditation or (iii) moderate intensity exercise. ARI-related costs were assessed through self-reported medication use, number of missed work days and medical visits. Costs per subject were based on cost of generic medications, missed work days ($126.20) and clinic visits ($78.70). Monte Carlo bootstrap methods evaluated reduced costs of ARI episodes. RESULTS: The total cost per subject for the control group was $214 (95% CI: $105-$358), exercise $136 (95% CI: $64-$232) and meditation $65 (95% CI: $34-$104). The majority of cost savings was through a reduction in missed days of work. Exercise had the highest medication costs at $16.60 compared with $5.90 for meditation (P = 0.004) and $7.20 for control (P = 0.046). Combining these cost benefits with the improved outcomes in incidence, duration and severity seen with the Meditation or Exercise for Preventing Acute Respiratory Infection study, meditation and exercise add value for ARI. Compared with control, meditation had the greatest cost benefit. This savings is offset by the cost of the intervention ($450/subject) that would negate the short-term but perhaps not long-term savings. CONCLUSIONS: Meditation and exercise add value to ARI-associated health-related costs with improved outcomes. Further research is needed to confirm results and inform policies on adding value to medical spending.

Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial.

PURPOSE: This study was designed to evaluate potential preventive effects of meditation or exercise on incidence, duration, and severity of acute respiratory infection (ARI) illness. METHODS: Community-recruited adults aged 50 years and older were randomized to 1 of 3 study groups: 8-week training in mindfulness meditation, matched 8-week training in moderate-intensity sustained exercise, or observational control. The primary outcome was area-under-the-curve global illness severity during a single cold and influenza season, using the Wisconsin Upper Respiratory Symptom Survey (WURSS-24) to assess severity. Health care visits and days of missed work were counted. Nasal wash collected during ARI illness was assayed for neutrophils, interleukin-8, and viral nucleic acid. RESULTS: Of 154 adults randomized into the study, 149 completed the trial (82% female, 94% white, mean age 59.3 ± 6.6 years). There were 27 ARI episodes and 257 days of ARI illness in the meditation group (n = 51), 26 episodes and 241 illness days in the exercise group (n = 47), and 40 episodes and 453 days in the control group (n = 51). Mean global severity was 144 for meditation, 248 for exercise, and 358 for control. Compared with control, global severity was significantly lower for meditation (P = .004). Both global severity and total days of illness (duration) trended toward being lower for the exercise group (P=.16 and P=.032, respectively), as did illness duration for the meditation group (P=.034). Adjusting for covariates using zero-inflated multivariate regression models gave similar results. There were 67 ARI-related days of-work missed in the control group, 32 in the exercise group (P = .041), and 16 in the meditation group (P <.001). Health care visits did not differ significantly. Viruses were identified in 54% of samples from meditation, 42% from exercise, and 54% from control groups. Neutrophil count and interleukin-8 levels were similar among intervention groups. CONCLUSIONS: Training in meditation or exercise may be effective in reducing ARI illness burden.

Perception of empathy in the therapeutic encounter: effects on the common cold.

OBJECTIVE: To evaluate the effects of patient-practitioner interaction on the severity and duration of the common cold. METHODS: We conducted a randomized controlled trial of 719 patients with new cold onset. Participants were randomized to three groups: no patient-practitioner interaction, "standard" interaction or an "enhanced" interaction. Cold severity was assessed twice daily. Patients randomized to practitioner visits used the Consultation and Relational Empathy (CARE) measure to rate clinician empathy. Interleukin-8 (IL-8) and neutrophil counts were obtained from nasal wash at baseline and 48 h later. RESULTS: Patients' perceptions of the clinical encounter were associated with reduced cold severity and duration. Encounters rated perfect on the CARE score had reduced severity (perfect: 223, sub-perfect: 271, p=0.04) and duration (perfect: 5.89 days, sub-perfect: 7.00 days, p=0.003). CARE scores were also associated with a more significant change in IL-8 (perfect: mean IL-8 change 1586, sub-perfect: 72, p=0.02) and neutrophil count (perfect: 49, sub-perfect: 12, p=0.09). CONCLUSIONS: When patients perceive clinicians as empathetic, rating them perfect on the CARE tool, the severity, duration and objective measures (IL-8 and neutrophils) of the common cold significantly change. PRACTICE IMPLICATIONS: This study helps us to understand the importance of the perception of empathy in a therapeutic encounter.

Sustainability, synthetic chemicals, and human exposure.

Public concerns regarding exposures to synthetic chemicals are increasing. Globally, there are increasing concentrations of many synthetic chemicals within the environment. The ubiquitous extent of some chemicals makes human exposure unavoidable. Biomonitoring has emerged as the optimal method for assessing exposures. The extent of human exposure and contamination occurs throughout the life cycle and is widespread. Although there is limited information on health risks for the majority of chemicals within our environment, and those identified with biomonitoring, many are known or suspected to cause human harm. Continued global and national unsustainable development regarding synthetic chemicals will increase the extent of environmental and human contamination unless precautionary action is implemented. Precautionary legislation may protect ecological and public health until societal sustainability is achieved.

Integrative medicine and patient-centered care.

Integrative medicine has emerged as a potential solution to the American healthcare crisis. It provides care that is patient centered, healing oriented, emphasizes the therapeutic relationship, and uses therapeutic approaches originating from conventional and alternative medicine. Initially driven by consumer demand, the attention integrative medicine places on understanding whole persons and assisting with lifestyle change is now being recognized as a strategy to address the epidemic of chronic diseases bankrupting our economy. This paper defines integrative medicine and its principles, describes the history of complementary and alternative medicine (CAM) in American healthcare, and discusses the current state and desired future of integrative medical practice. The importance of patient-centered care, patient empowerment, behavior change, continuity of care, outcomes research, and the challenges to successful integration are discussed. The authors suggest a model for an integrative healthcare system grounded in team-based care. A primary health partner who knows the patient well, is able to addresses mind, body, and spiritual needs, and coordinates care with the help of a team of practitioners is at the centerpiece. Collectively, the team can meet all the health needs of the particular patient and forms the patient-centered medical home. The paper culminates with 10 recommendations directed to key actors to facilitate the systemic changes needed for a functional healthcare delivery system. Recommendations include creating financial incentives aligned with health promotion and prevention. Insurers are requested to consider the total costs of care, the potential cost effectiveness of lifestyle approaches and CAM modalities, and the value of longer office visits to develop a therapeutic relationship and stimulate behavioral change. Outcomes research to track the effectiveness of integrative models must be funded, as well as feedback and dissemination strategies. Additional competencies for primary health partners, including CAM and conventional medical providers, will need to be developed to foster successful integrative practices. Skills include learning to develop appropriate healthcare teams that function well in a medical home, developing an understanding of the diverse healing traditions, and enhancing communication skills. For integrative medicine to flourish in the United States, new providers, new provider models, and a realignment of incentives and a commitment to health promotion and disease management will be required.

Practitioner empathy and the duration of the common cold.

OBJECTIVE: This study's objective was to assess the relationship of empathy in medical office visits to subsequent outcomes of the common cold. METHODS: A total of 350 subjects ? 12 years of age received either a standard or enhanced physician visit as part of a randomized controlled trial. Enhanced visits emphasized empathy on the part of the physician. The patient-scored Consultation and Relational Empathy (CARE) questionnaire assessed practitioner-patient interaction, especially empathy. Cold severity and duration were assessed from twice-daily symptom reports. Nasal wash was performed to measure the immune cytokine interleukin-8 (IL-8). RESULTS: Eighty-four individuals reported perfect (score of 50) CARE scores. They tended to be older with less education but reported similar health status, quality of life, and levels of optimism. In those with perfect CARE scores, cold duration was shorter (mean 7.10 days versus 8.01 days), and there was a trend toward reduced severity (mean area under receiver-operator characteristics curve 240.40 versus 284.49). After accounting for possible confounding variables, cold severity and duration were significantly lower in those reporting perfect CARE scores. In these models, a perfect score also correlated with a larger increase in IL-8 levels. CONCLUSIONS: Clinician empathy, as perceived by patients with the common cold, significantly predicts subsequent duration and severity of illness and is associated with immune system changes.

Measuring the "whole system" outcomes of an educational innovation: experience from the integrative family medicine program.

BACKGROUND AND OBJECTIVES: Six family medicine residency programs in the United States collaborated on the development and implementation of an integrative family medicine (IFM) program, which is a postgraduate training model that combines family medicine residency training with an integrative medicine fellowship. This paper reports on effects of IFM on residency programs and clinical systems in which it was implemented. METHODS: We used the Integrative Medicine Attitudes Questionnaire (IMAQ) to assess participants' attitudes toward integrative medicine before and after the program was implemented. We assessed residency program recruitment success before and after the program was implemented. We conducted interviews with key informants at each program to evaluate the effects of the IFM on the six participating residency programs. RESULTS: IMAQ scores demonstrated a significant increase in the acceptance of integrative medicine after implementation of IFM. Recruiting data showed that participating programs filled at a rate consistently above the national average both before and after implementation. Analysis of interview data showed that programs became more open to an integrative medicine (IM) approach and offered a wider range of clinical services to patients. CONCLUSIONS: Our mixed-methods strategy for evaluation of IFM showed that implementing the program increased acceptance of IM, did not affect residency fill rates, and increased use of IM in clinical practice. The combination of quantitative and qualitative methods was an effective strategy for documenting the "systems level" effects of a new educational program.

Healing the healer: a tool to encourage student reflection towards health.

BACKGROUND: Research has demonstrated that students' health falters while in medical school with healthy behaviors continuing to deteriorate during residency. Medical education can be focused toward helping students find health for themselves. Physicians who are most likely to practice healthy lifestyles are more likely to encourage their patients to do so. AIMS: Create a tool that encourages self-reflection, education and self-care for physicians-in-training. METHOD: Users completed a web-based tool that helped them create a personal health plan focusing on the themes of nutrition, lifestyle choices, family history, mind-body influences and spiritual connection. A six-question survey was completed by 500 users. RESULTS: The results support the main objectives of the tool, which were to encourage self-reflection, positive lifestyle habits and education towards key aspects of health and well-being. CONCLUSION: Having medical students and residents develop their own health plans can be an efficient method towards encouraging self-care, understanding foundational health concepts and instilling skills to teach health promotion to their patients.

Behavioral and complementary approaches for the treatment of irritable bowel syndrome.

Irritable bowel syndrome (IBS) is one of the most common conditions seen in primary care settings. Despite this, there is no consensus as to the pathogenesis of this disorder or a consistently effective therapeutic regimen for many patients. This has encouraged the use of various alternative therapies from behavioral or complementary medicine. This review will address the evidence for alternative therapies, including the following: cognitive behavior therapy, hypnosis, elimination diets based on food antibody testing, nutrition supplements (such as fiber, probiotics, and prebiotics), and, finally, peppermint, l-glutamine, zinc, and cromolyn sodium. The review also explores the evidence for and the therapeutic ramifications of the hypothesis that increased intestinal permeability underlies the symptoms of IBS in many patients, and how a therapeutic plan that addresses nutrition, elimination diets, and nutrition supplements may be useful in restoring the integrity of the gut immune barrier.

The salutogenesis-oriented session: creating space and time for healing in primary care.

Primary care in America is in need of a rescue. Clinicians are asked to see more patients in a day that only allows time to focus on a physical symptom or disease process. They do not have time or space to use their humanism to develop insight toward what the patient needs for the symptom to resolve, and they are often forced to suppress it with technology. This results in a very expensive medical system that leads to frustration for a clinician who realizes that this is not the way toward facilitating health. This clinically focused paper proposes the incorporation of a healing-oriented session into the delivery of primary care to bring focus toward the creation of health (salutogenesis). A salutogenesis-oriented session (SOS) honors relationship-centered care and will provide a unit that can then be studied to see if it has a positive influence on cost, quality of care, and provider satisfaction.