Informing the model of care for an academic integrative healthcare centre : a qualitative study exploring healthcare consumer perspectives

Objectives: To engage with local primary care stakeholders to inform the model of care for a proposed academic integrative health care center incorporating evidence-informed traditional, complementary, and integrative medicine (TCIM) in Sydney, Australia. Design: In-depth semistructured interviews, informed by community-based participatory research principles, were conducted to explore primary care stakeholder preferences and service requirements regarding the proposed Western Sydney Integrative Health (WSIH) center in their local district. Setting: Telephone and face-to-face interviews at primary care clinics in Sydney. Subjects: Thirteen participants took part in the study: eight general practitioners (GPs) and five primary care practice managers (PMs). Methods: GPs were recruited through local GP newsletters, closed GP Facebook groups, and snowballing. PMs were recruited through a national PM newsletter. The semistructured interviews were audiorecorded and transcribed verbatim before conducting a thematic analysis. Results: Three main themes emerged: (1) the rationale for “why” the WSIH center should be established, (2) “what” was most important to provide, and (3) “how” the center could achieve these goals. Participants were willing to refer to the service, acknowledging the demand for TCIM, current gaps in chronic disease care, and negligible Government funding for TCIM. They endorsed a model of care that minimizes out-of-pocket costs for the underserved, incorporates medical oversight, integrates evidence-informed TCIM with conventional health care, builds trust through interprofessional communication and education, and provides sound clinical governance with a strong focus on credentialing and risk management. It was proposed that safety and quality standards are best met by a GP-led approach and evidence-based practice. Conclusions: Our findings demonstrate that participants acknowledged the need for a model of care that fits into the local landscape through integrating conventional health care with TCIM in a team-based environment, with medical/GP oversight to ensure sound clinical governance. Findings will be used with input from other stakeholder groups to refine the WSIH model of care

Shared medical appointments and mindfulness for Type 2 diabetes : a mixed-methods feasibility study

Introduction: Type 2 diabetes (T2DM) is a major health concern with significant personal and healthcare system costs. There is growing interest in using shared medical appointments (SMAs) for management of T2DM. We hypothesize that adding mindfulness to SMAs may be beneficial. This study aimed to assess the feasibility and acceptability of SMAs with mindfulness for T2DM within primary care in Australia. Materials and Methods: We conducted a single-blind randomized controlled feasibility study of SMAs within primary care for people with T2DM living in Western Sydney, Australia. People with T2DM, age 21 years and over, with HbA1c > 6.5% or fasting glucose >7.00 mmol/L within the past 3 months were eligible to enroll. The intervention group attended six 2-h programmed SMAs (pSMAs) which were held fortnightly. pSMAs included a structured education program and mindfulness component. The control group received usual care from their healthcare providers. We collected quantitative and qualitative data on acceptability as well as glycemic control (glycated hemoglobin and continuous glucose monitoring), lipids, anthropometric measures, blood pressure, selfreported psychological outcomes, quality of life, diet, and physical activity using an ActiGraph accelerometer. Results: Over a 2-month period, we enrolled 18 participants (10 females, 8 males) with a mean age of 58 years (standard deviation 9.8). We had 94.4% retention. All participants in the intervention group completed at least four pSMAs. Participants reported that attending pSMAs had been a positive experience that allowed them to accept their diagnosis and empowered them to make changes, which led to beneficial effects including weight loss and better glycemic control. Four pSMA participants found the mindfulness component helpful while two did not. All of the seven participants who contributed to qualitative evaluation reported improved psychosocial wellbeing and found the group setting beneficial. There was a significant difference in total cholesterol levels at 12 weeks between groups (3.86 mmol/L in intervention group vs. 4.15 mmol/L in the control group; p = 0.025) as well as pain intensity levels as measured by the PROMIS-29 (2.11 vs. 2.38; p = 0.034). Conclusion: pSMAs are feasible and acceptable to people with T2DM and may result in clinical improvement. A follow-up fully-powered randomized controlled trial is warranted. Clinical Trial Registration: Australia and New Zealand Clinical Trial Registry, identifier ACTRN12619000892112

Synoptic analysis of a decade of daily measurements of SO2 emission in the troposphere from volcanoes of the global ground-based Network for Observation of Volcanic and Atmospheric Change

Volcanic plumes are common and far-reaching manifestations of volcanic activity during and between eruptions. Observations of the rate of emission and composition of volcanic plumes are essential to recognize and, in some cases, predict the state of volcanic activity. Measurements of the size and location of the plumes are important to assess the impact of the emission from sporadic or localized events to persistent or widespread processes of climatic and environmental importance. These observations provide information on volatile budgets on Earth, chemical evolution of magmas, and atmospheric circulation and dynamics. Space-based observations during the last decades have given us a global view of Earth's volcanic emission, particularly of sulfur dioxide (SO2). Although none of the satellite missions were intended to be used for measurement of volcanic gas emission, specially adapted algorithms have produced time-averaged global emission budgets. These have confirmed that tropospheric plumes, produced from persistent degassing of weak sources, dominate the total emission of volcanic SO2. Although space-based observations have provided this global insight into some aspects of Earth's volcanism, it still has important limitations. The magnitude and short-term variability of lower-atmosphere emissions, historically less accessible from space, remain largely uncertain. Operational monitoring of volcanic plumes, at scales relevant for adequate surveillance, has been facilitated through the use of ground-based scanning differential optical absorption spectrometer (ScanDOAS) instruments since the beginning of this century, largely due to the coordinated effort of the Network for Observation of Volcanic and Atmospheric Change (NOVAC). In this study, we present a compilation of results of homogenized post-analysis of measurements of SO2 flux and plume parameters obtained during the period March 2005 to January 2017 of 32 volcanoes in NOVAC. This inventory opens a window into the short-term emission patterns of a diverse set of volcanoes in terms of magma composition, geographical location, magnitude of emission, and style of eruptive activity. We find that passive volcanic degassing is by no means a stationary process in time and that large sub-daily variability is observed in the flux of volcanic gases, which has implications for emission budgets produced using short-term, sporadic observations. The use of a standard evaluation method allows for intercomparison between different volcanoes and between ground- and space-based measurements of the same volcanoes. The emission of several weakly degassing volcanoes, undetected by satellites, is presented for the first time. We also compare our results with those reported in the literature, providing ranges of variability in emission not accessible in the past. The open-access data repository introduced in this article will enable further exploitation of this unique dataset, with a focus on volcanological research, risk assessment, satellite-sensor validation, and improved quantification of the prevalent tropospheric component of global volcanic emission

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

A case report of a novel, integrative approach to Hashimoto's thyroiditis with unexpected results

Background: Hashimoto's thyroiditis (HT) is an autoimmune illness of the thyroid gland. The presence of thyroid antibodies (Thyroglobulin Antibodies and Peroxidase Antibodies) is suggestive of the diagnosis. Patients can have Hashimoto's thyroiditis without the presence of thyroid antibodies. The treatment of Hashimoto's thyroiditis is usually expectant observation of the thyroid function and subsequent exogenous thyroid hormone replacement, if deemed appropriate. This case report outlines a novel approach that led to an improvement in symptoms, and a reduction in one thyroid antibody, for a young woman. Case: A 23 year old woman diagnosed with Hashimoto's thyroiditis, 8 months prior, presented at her initial visit with symptoms of extreme fatigue, anxiety and hair loss. Her thyroid antibodies were strongly positive, with a normal TSH. She was commenced on a three-tiered integrative treatment plan, implemented by the clinic naturopath and general practitioner, working in a collaborative care model. This involved a gluten and grain free diet, support of her methylation cycle and anti-oxidant capacity with micronutrients, and stress management. Conclusion: Over a treatment period of 15 months, using an integrative approach, she experienced clinical improvement in her symptoms and return to functional daily life, as well as a significant reduction in thyroid antibodies

Informing the model of care for an Academic Integrative Health Care Center : a qualitative study of primary care stakeholder views

Objectives: To engage with local primary care stakeholders to inform the model of care for a proposed academic integrative health care center incorporating evidence-informed traditional, complementary, and integrative medicine (TCIM) in Sydney, Australia. Design: In-depth semistructured interviews, informed by community-based participatory research principles, were conducted to explore primary care stakeholder preferences and service requirements regarding the proposed Western Sydney Integrative Health (WSIH) center in their local district. Setting: Telephone and face-to-face interviews at primary care clinics in Sydney. Subjects: Thirteen participants took part in the study: eight general practitioners (GPs) and five primary care practice managers (PMs). Methods: GPs were recruited through local GP newsletters, closed GP Facebook groups, and snowballing. PMs were recruited through a national PM newsletter. The semistructured interviews were audiorecorded and transcribed verbatim before conducting a thematic analysis. Results: Three main themes emerged: (1) the rationale for "why" the WSIH center should be established, (2) "what" was most important to provide, and (3) "how" the center could achieve these goals. Participants were willing to refer to the service, acknowledging the demand for TCIM, current gaps in chronic disease care, and negligible Government funding for TCIM. They endorsed a model of care that minimizes out-of-pocket costs for the underserved, incorporates medical oversight, integrates evidence-informed TCIM with conventional health care, builds trust through interprofessional communication and education, and provides sound clinical governance with a strong focus on credentialing and risk management. It was proposed that safety and quality standards are best met by a GP-led approach and evidence-based practice. Conclusions: Our findings demonstrate that participants acknowledged the need for a model of care that fits into the local landscape through integrating conventional health care with TCIM in a team-based environment, with medical/GP oversight to ensure sound clinical governance. Findings will be used with input from other stakeholder groups to refine the WSIH model of care

Complementary medicines and therapies in clinical guidelines on pregnancy care: A systematic review

Background: There is a need for evidence-based guidance on complementary medicines and therapies (CMT) use during pregnancy due to high prevalence of use and lack of guidance on the balance of benefit and harms. Aim: Evaluate the extent to which current clinical practice guidelines relevant to Australian healthcare professionals make clear and unambiguous recommendations about CMT use in pregnancy, and synthesise these recommendations. Methods: The search included EMBASE, PubMed, the National Health and Medical Research Council’s Clinical Practice Guidelines Portal, and websites of Australian maternity hospitals and professional/notfor-profit organisations for published guidelines on pregnancy care. Data were synthesised narratively. Guidelines were appraised by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Findings: A total of 48 guidelines were found, of which 41% provided recommendations that were not limited to routine vitamin and mineral supplementation. There were wide variations in recommendations, particularly for vitamin D and calcium. There was some consensus on recommending ginger and vitamin B6 for nausea and vomiting, and additional supplementation for women with obesity. Guidelines generally scored poorly in the domains of editorial independence and rigour of development. Discussion: There is a lack of guidance with regard to appropriate CMT use during pregnancy, which may result in less-than-optimal care. Inconsistency between guidelines may lead to variations in care. Conclusion: Guidelines should include clear and unambiguous guidance on appropriate CMT use during pregnancy, be based on a structured search of the evidence and informed by stakeholder engagement. © 2021 Published by Elsevier Ltd on behalf of Australian College of Midwives

Effect of Antiplatelet Therapy on Survival and Organ Support–Free Days in Critically Ill Patients With COVID-19

International audienc