"The History of Chinese Medicine Really Is Very Detailed Regarding Pandemics": A Qualitative Analysis of Evidence-Based Practice and the Use of Chinese Herbal Medicine by Licensed Acupuncturists During the COVID-19 Pandemic in the United States

Objective: The objective of this qualitative study was to understand how licensed acupuncturists determined treatment strategies for patients with symptoms likely related to COVID-19 using Chinese herbal medicine (CHM) and the impact of the pandemic upon their clinical practice. Methods: A qualitative instrument was developed with questions aligned with when participants started treating patients with symptoms likely related to COVID-19 and the availability of information related to the use of CHM for COVID-19. Interviews took place between March 8 and May 28, 2021, and were transcribed verbatim by a professional transcription service. Inductive theme analysis and ATLAS.ti Web software were used to determine themes. Results: Theme saturation was achieved after 14 interviews lasting 11-42 min. Treatment predominantly started before mid-March 2020. Four themes emerged (1) information sources; (2) diagnostic and treatment decision-making; (3) practitioner experience; (4) resources and supplies. Conclusion: Primary sources of information informing treatment strategies came from China through professional networks and were widely disseminated throughout the United States. Scientific studies evaluating the effectiveness of CHM for COVID-19 were generally not deemed useful for informing patient care because treatment had been initiated before they were published and because of limitations associated with the research and the ability to apply it to real world practice.

Cross-Sectional Survey of Acupuncturists in the United States Who Prescribed Chinese Herbal Medicine for Patients with Symptoms Likely Related to COVID-19

Objective: The objective of this study was to examine the prescribing of Chinese herbal medicine (CHM) by licensed acupuncturists in the United States during the COVID-19 pandemic. Methods: A 28-question survey with nine branching questions was disseminated through collegial networks, paid advertisements, and a study website in April-July 2021. Participants indicated that they were licensed acupuncturists who treated more than five patients for symptoms likely related to COVID-19 to gain entry to the full survey. Surveys were undertaken electronically through the Research Electronic Data Capture (REDCap) system. Results: The survey was undertaken by 103 participants representing all US geographic regions and had an average of 17 years in practice. Sixty-five percent received or intended to receive the COVID-19 vaccine. Phone and videoconference were the predominant methods of patient contact; granules and pill forms of CHM were the most prescribed. A wide variety of information sources were used in devising patient treatments inclusive of anecdotal, observational, and scientific sources. Most patients were not receiving biomedical treatment. Ninety-seven percent of participants reported that they had no patients die of COVID-19, and the majority reported that <25% of their patients developed long hauler syndrome (post-acute sequelae SARS-CoV-2 infection). Conclusions: This study demonstrates that licensed acupuncturists were treating COVID-19 infected individuals in the United States during the early stages of the pandemic, and for many such patients this was the only therapeutic intervention they had access to from a licensed health care provider. Information disseminated from China through collegial networks, along with published sources including scientific studies, informed the approach to treatment. This study provides insight into an unusual circumstance in which clinicians needed to establish evidence-based approaches to the treatment of a new disease during a public health emergency.

Women in Acupuncture Research: Interviews with Leaders of the Field

When Tu Youyou was awarded the Nobel Prize for her discovery of artemisinin (qīnghāosù) extract to treat malaria, she became the first female scientist from the Peoples Republic of China to win the Nobel Prize, and her prize was the first awarded for a Traditional Chinese Medicine preparation. Inspired by Tu's accomplishment, this special issue in Medical Acupuncture aims to highlight the great contributions of women in the development of acupuncture and Chinese herbal medicine evidence base. We sought to interview some of the key women in acupuncture research whose contributions have moved the science forward. We asked each person: Were there barriers that you had to overcome in your education and career trajectory? What were the facilitators or successes that you have experienced? What lessons might you impart to the next generation of acupuncturists, researchers, and others? Due to time constraints and limited resources, we were not able to interview every woman we know who has made significant and lasting contributions to acupuncture research. We were honored to spend time with the following noted experts: Drs. Debra Betts, Lisa Conboy, Helene Langevin, Kate Levett, Arya Nielsen, and Rosa Schnyer.

Acupuncture therapy as an Evidence-Based Nonpharmacologic Strategy for Comprehensive Acute Pain Care: the Academic Consortium Pain Task Force White Paper Update

Background

A crisis in pain management persists, as does the epidemic of opioid overdose deaths, addiction, and diversion. Pain medicine is meeting these challenges by returning to its origins: the Bonica model of multidisciplinary pain care. The 2018 Academic Consortium White Paper detailed the historical context and magnitude of the pain crisis and the evidence base for nonpharmacologic strategies. More than 50% of chronic opioid use begins in the acute pain care setting. Acupuncture may be able to reduce this risk.

Objective

This article updates the evidence base for acupuncture therapy for acute pain with a review of systematic reviews and meta-analyses on postsurgical/perioperative pain with opioid sparing and acute nonsurgical/trauma pain, including acute pain in the emergency department.

Methods

To update reviews cited in the 2018 White Paper, electronic searches were conducted in PubMed, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials for “acupuncture” and “acupuncture therapy” and “acute pain,” “surgery,” “peri-operative,” “trauma,” “emergency department,” “urgent care,” “review(s) ,” “systematic review,” “meta-analysis,” with additional manual review of titles, links, and reference lists.

Results

There are 22 systematic reviews, 17 with meta-analyses of acupuncture in acute pain settings, and a review for acute pain in the intensive care unit. There are additional studies of acupuncture in acute pain settings.

Conclusion

The majority of reviews found acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid reliance. Future multicenter trials are needed to clarify the dosage and generalizability of acupuncture for acute pain in the emergency department. With an extremely low risk profile, acupuncture therapy is an important strategy in comprehensive acute pain care.

SEAttle-based Research of Chinese Herbs for COVID-19 Study: A Whole Health Perspective on Chinese Herbal Medicine for Symptoms that may be Related to COVID-19

Introduction

East Asian Medicine (EAM) is a Whole System medicine that includes Chinese herbal medicine (CHM). Chinese herbal medicine has been utilized to reduce symptom burden in infectious disease, with notable theoretical reformulations during pandemics of the 3rd, 13th, and 17th centuries. Today, Licensed Acupuncturists trained in CHM have utilized it to treat symptoms and sequelae of COVID-19. However, little is known about its use or efficacy by the public and health practitioners. Understanding and evaluating whole medicine systems of healthcare is inherently complex; there is international consensus for a descriptive, pragmatic approach. We are conducting a feasibility pilot study using a prospective, pragmatic, observational design using Whole Health and Whole Person perspectives. The complexity of COVID-19 reflects the impact on multiple homeoregulatory systems and provides a unique opportunity to assess the impact of interventions such as EAM on whole health. Observation of these EAM encounters will provide valuable qualitative and quantitative data on the interface of an extant Whole System medicine with a novel complex illness as a precursor to a randomized clinical trial.

Methods

This ongoing study observes a CHM clinic offering telehealth consultations to a diverse patient population since April, 2020. Patients who report symptoms potentially related to COVID-19 disease are consented for standardized collection and analysis of demographic and clinical data from each clinical encounter.

Results

To date, 61 patients engaged in 195 consultations (mean 3.3) with 49 reporting symptom resolution sufficient to complete treatment, and 4 withdrawals. Just over half (62%) were female, with an average age of 45.7 years. A wide variety of CHM formulas and EAM dietary and lifestyle modifications were provided.

Discussion

Adequate recruitment and retention suggest feasibility of the intervention and data collection. The rich dataset may facilitate the construction of Whole Health models of CHM’s clinical impact, as well as integrative inquiry into CHM’s effects on symptoms.

"There's a problem, now what's the solution?": suggestions for technologies to support the menopausal transition from individuals experiencing menopause and healthcare practitioners

OBJECTIVE

To elicit novel ideas for informatics solutions to support individuals through the menopausal transition. (Note: We use "individuals experiencing menopause" and "experiences" rather than "symptoms" when possible to counter typical framing of menopause as a cisgender women's medical problem.).

METHODS

A participatory design study was conducted 2015-2017 in the Western US. Two sessions were held with individuals experiencing menopause recruited from the general public; and 3 sessions with healthcare practitioners (HCPs) including nurses, physicians, and complementary and integrative health (CIH) practitioners were held. Participants designed technologies addressing informational needs and burdensome experiences. HCPs reflected on designs from participants experiencing menopause. Directed content analysis was used to analyze transcripts.

RESULTS

Eight individuals experiencing menopause (n = 4 each session) and 18 HCPs (n = 10 CIH, n = 3 nurses, n = 5 physicians) participated. All participants provided ideas for solution purpose, hardware, software, features and functions, and data types. Individuals experiencing menopause designed technologies to help understand and prevent burdensome menopause experiences. HCPs designed technologies for tracking and facilitating communication. Compared to nurses and physicians, CIH practitioners suggested designs reframing menopause as a positive experience and accounted for the complex lives of individuals experiencing menopause, including stigma; these ideas corresponded to comments made by participants experiencing menopause. Participants from both populations were concerned about data confidentiality and technology accessibility.

CONCLUSIONS

Participant generated design ideas included novel ideas and incorporated existing technologies. This study can inform the development of new technologies or repurposing of existing technologies to support individuals through the menopausal transition.

Maternity Care for Pregnant Women with Opioid Use Disorder: A Review

Opioid misuse is a problem that is complex and widespread. Opioid misuse rates are rising across all US demographics, including among pregnant women. The opioid epidemic brings a unique set of challenges for maternity health care providers, ranging from ethical considerations to the complex health needs and risks for both woman and fetus. This article addresses care for pregnant women during the antepartum, intrapartum, and postpartum periods through the lens of the opioid epidemic, including screening and counseling, an interprofessional approach to prenatal care, legal considerations, and considerations for care during labor and birth and postpartum. Providers can be trained to identify at-risk women through the evidence-based process of Screening, Brief Intervention, and Referral to Treatment (SBIRT) and connect them with the appropriate care to optimize outcomes. Women at moderate risk of opioid use disorder can be engaged in a brief conversation with their provider to discuss risks and enhance motivation for healthy behaviors.  Women with risky opioid use can be given a warm referral to pharmacologic treatment programs, ideally comprehensive prenatal treatment programs where available (a warm referral is a term used when a provider, with the patient's permission, contacts another provider or another service him or herself rather than providing a phone number and referral number). Evidence regarding care for the pregnant woman with opioid use disorder and practical clinical recommendations are provided.

Characterizing Websites That Provide Information About Complementary and Integrative Health: Systematic Search and Evaluation of Five Domains

Background

In recent years, there has been an increase in the utilization of complementary and integrative health (CIH) care, and an increase in information-seeking behavior focused on CIH. Thus, understanding the quality of CIH information that is available on the internet is imperative. Although there have been a limited number of studies evaluating the quality of websites providing information about specific CIH-related topics, a broad evaluation of CIH websites has not been conducted.

Objective

This study was designed to fill that gap. We set out to assess website quality in 5 CIH domains: (1) acupuncture, (2) homeopathy, (3) massage, (4) reiki, and (5) yoga. This study aimed to 1) characterize the websites by type and quality; 2) evaluate website characteristics which may affect readers’ perceptions, specifically message content, structural features, and presentation style, and 3) investigate the extent to which harms, benefits and purposes of use are stated on websites.

Methods

This study employed a systematic search strategy to identify websites in each of the target domains to be evaluated. The websites were then classified by type, and a set of checklists focusing on quality, message content, structural features, and presentation style was used to evaluate the websites. Lastly, we performed content analysis to identify harms, benefits, and perceived purposes of use.

Results

There were similarities across domains regarding their overall quality and their message content. Across all domains, a high proportion of websites received strong scores in terms of ownership, currency, interactivity and navigability. Scores were more variable concerning authorship, balanced presentation of information and the use of sources of information. However, there were differences regarding their structural features and presentation style. Acupuncture and reiki sites tended to include more external links, and yoga, fewer. There was variation across domains in the extent to which the websites contained domain-specific terminology. Websites tended to provide an extensive list of potential benefits, while reporting of harms was scarce.

Conclusions

This is the first study to perform a multidimensional assessment of websites in multiple CIH domains. This review showed that while there are similarities among websites of different CIH domains, there are also differences. The diverse distribution of website types suggests that, regardless of CIH domain, the public encounters information through many different types of media, and it would be useful to consider how the presentation of this content may differ depending on the medium. The characteristics for which variability exist are areas that warrant greater attention from researchers, policy makers, clinicians and patients. There is also a need to better understand how individuals may interact with CIH websites, and to develop tools to assist people to interpret the CIH-related information that they encounter.

Herbal fertility treatments used in North America from colonial times to 1900, and their potential for improving the success rate of assisted reproductive technology

This paper serves to fill a gap in the literature regarding evidence for the use of botanical remedies in the promotion of fertility. It examines the botanical remedies that were used in North America (1492-1900) for all stages of reproduction from preconception to birth, and discusses their potential for future use with present-day infertility treatments. Each medicinal plant discussed in this paper is assessed using an ethnomedicinal methodology that entails examining the published ethnobotanical, phytochemical and pharmacological data. A few clinical trials have shown that there is potential for medicinal plants to improve the success rate of assisted reproductive technology (ART) treatment if used in an integrated manner, similar to the integrated use of traditional Chinese medicine with ART treatment. For example, research has shown that older women who become pregnant have a high miscarriage rate, and this is one area that complementary and alternative medicines can address.

Matrix Analysis of Traditional Chinese Medicine Differential Diagnoses in Gulf War Illness

Objective: To qualitatively categorize Traditional Chinese Medicine (TCM) differential diagnoses in a sample of veterans with Gulf War Illness (GWI) pre- and postacupuncture treatment. Subjects and methods: The authors randomized 104 veterans diagnosed with GWI to a 6-month acupuncture intervention that consisted of either weekly or biweekly individualized acupuncture treatments. TCM differential diagnoses were recorded at baseline and at 6 months. These TCM diagnoses were evaluated using Matrix Analysis to determine co-occurring patterns of excess, deficiency, and channel imbalances. These diagnoses were examined within and between participants to determine patterns of change and to assess stability of TCM diagnoses over time. Results: Frequencies of diagnoses of excess, deficiency, and channel patterns were tabulated. Diagnoses of excess combined with deficiency decreased from 43% at baseline to 39% of the sample at 6 months. Excess+deficiency+channel imbalances decreased from 26% to 17%, while deficiency+channel imbalances decreased from 11% to 4% over the study duration. The authors observed a trend over time of decreased numbers of individuals presenting with all three types of differential diagnosis combinations. This may suggest that fewer people were diagnosed with concurrent excess, deficiency, and channel imbalances and perhaps a lessening in the complexity of their presentation. Conclusion: This is the first published article that organizes and defines TCM differential diagnoses using Matrix Analysis; currently, there are no TCM frameworks for GWI. These findings are preliminary given the sample size and the amount of missing data at 6 months. Characterization of the TCM clinical presentation of veterans suffering from GWI may help us better understand the potential role that East Asian medicine may play in managing veterans with GWI and the design of effective acupuncture treatments based on TCM. The development of a TCM manual for treating GWI is merited.

Effects of herbal preparations on symptom clusters during the menopausal transition

AIMS

To determine the effects of herbal therapies on hot flushes and at least one other symptom including, sleep, mood, cognition, and pain that women experience during the menopausal transition and early postmenopause.

METHODS

An extensive search of PubMed/Medline, CINAHL Plus, PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, AMED, and Alt-Health Watch for randomized, controlled trials reported in English between January 2004 and July was conducted by an experienced reference librarian. There were 1193 abstracts identified but only 58 trials examined effectiveness of therapies for hot flushes and at least one additional co-occurring symptom.

RESULTS

Seventeen studies used herbal preparation including seven studies of black cohosh, two studies of black cohosh mixed with other herbals, and eight studies of other herbals. Of these, one study of black cohosh, two studies of black cohosh mixed with other herbals, and four other herbal studies had significant effects on hot flushes and at least one additional co-occurring symptom. The adverse events of herbal therapies were various, ranging from mild to moderate and women were generally tolerant of the preparations.

CONCLUSIONS

Black cohosh mixed with other herbals, Rheum rhaponticum, and French maritime pine bark had significant effects on hot flushes and at least one other symptom. These herbal therapies may be a promising alternative treatment to hormonal treatment. Future studies should classify women based on their menopausal stages, report each symptom separately, have adequate sample size, focus on multiple co-occurring symptoms, and target symptom management of menopausal symptoms.

Effects of isoflavones and amino acid therapies for hot flashes and co-occurring symptoms during the menopausal transition and early postmenopause: a systematic review

AIMS

Review controlled clinical trials of isoflavones and amino acid preparation effects on hot flashes and at least one other symptom including mood, sleep, pain, and cognitive function that women report during the menopausal transition and early postmenopause.

METHODS

An experienced reference librarian searched PubMed/Medline, CINAHL Plus, PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, AMED, and Alt-Health Watch for English-language randomized controlled trials between 2004 and July 2011. Seventeen trials of isoflavones and amino acid effects on hot flashes and one additional symptom were identified.

RESULTS

In five trials of soy isoflavone preparations, two (6g soy germ extract and 25 g soy protein in soy nuts) significantly decreased hot flashes, but no other symptoms. In the seven trials of other isoflavones, six significantly reduced hot flashes; in addition, red clover (80 mg) significantly reduced mood symptoms; Rexflavone (350 mg) for women with Kupperman Index>20 significantly reduced sleep symptoms; two trials had significant reductions for pain: isoflavone powder (90 mg) and red clover (80 mg). The only trial in this systematic review that significantly reduced cognitive symptoms was red clover (80 mg). In one trial, red clover isoflavone (80 mg/day) significantly relieved hot flashes, mood, pain, and cognitive symptoms. Amino acids yielded no significant results. Equol supplements of 30 mg/day for non-Equol producing women significantly reduced mood symptoms in one trial. The magnolia bark extract combination significantly reduced hot flashes, mood, and sleep symptoms.

CONCLUSIONS

Isoflavone trials yielded significant reductions on hot flashes and co-occurring symptoms during the menopausal transition and postmenopause, but studies require replication with larger sample sizes and attention to measurement of outcomes.

Effects of mind-body therapies on symptom clusters during the menopausal transition

AIMS

Although most women experience symptom clusters during the menopausal transition and early postmenopause, investigators reporting clinical trial effects for hot flushes often omit co-occurring symptoms. Our aim was to review controlled clinical trials of mind-body therapies for hot flushes and at least one other co-occurring symptom from these groups: sleep, cognitive function, mood, and pain.

METHODS

An experienced reference librarian performed an extensive search of PubMed/Medline, CINAHL Plus, PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, AMED, and Alt-Health Watch for randomized controlled trials reported in English between 2004 and July 2011. Of 1193 abstracts identified, 58 trials examining effectiveness of therapies for hot flushes and at least one additional co-occurring symptom of interest were identified.

RESULTS

Eight trials (ten publications) examined relaxation, yoga, or exercise. Physical activity/exercise trials (six) yielded mixed results; only one significantly reduced hot flushes and mood symptoms. Of two relaxation therapy trials, only mindfulness-based stress reduction training reduced sleep and mood symptoms and had within-group treatment effects on hot flushes. Yoga (one trial) significantly reduced hot flushes and improved cognitive symptoms more than exercise, and also had within-group effects on sleep and pain symptoms.

CONCLUSIONS

Studies of mind-body therapies for hot flushes increasingly measure multiple symptom outcomes, but few report treatment effects in ways that allow clinicians to consider symptom clusters when prescribing therapies. Future studies need to measure and report results for individual symptoms or group like symptoms together into subscales rather than use subscales with mixed dimensions. Trials with larger numbers of participants are essential to allow evaluation of these therapies on multiple co-occurring symptoms.

Acupuncture and in vitro fertilization: a retrospective chart review

OBJECTIVES

In 2007, Craig et al. reported the results of a randomized controlled trial in which a standardized acupuncture protocol performed on the day of embryo transfer (ET) resulted in lower pregnancy rates after in vitro fertilization (IVF). Between 2005 and 2007, the Craig protocol was used by one of the authors (LHR) at an infertility clinic unaffiliated with the Craig et al. trial. The objective was to retrospectively review clinic records to evaluate the effect of the Craig protocol in both donor and nondonor IVF cycles on four outcomes: (1) live births; (2) biochemical pregnancies; (3) adverse outcomes; and (4) live births in nondonor cycles across age groups established by the Society for Assisted Reproductive Technology.

DESIGN

The study design was a retrospective chart review.

SETTING

The study was conducted at a private infertility clinic.

PATIENT(S)

Patients underwent fresh, donor (N=70) or nondonor (N=402) IVF-ET.

INTERVENTION(S)

The Craig protocol included the following points before ET: GV-20, CV-6, ST-29, SP-8, PC-6, LV-3; Shenmen and Brain on the left ear; and Uterus and Endocrine on the right ear. After transfer the points were LI-4, SP-10, ST-36, SP-6, KI-3; Uterus and Endocrine on the left ear; and Shenmen and Brain on the right ear.

MAIN OUTCOME MEASURE(S)

Live births (LB) beyond 24 weeks' gestation was the main outcome measure.

RESULT(S)

In nondonor IVF cycles, there were no differences in LB across age groups (odds ratio [OR]=1.04, 95% confidence interval [CI] 0.68-1.57), biochemical pregnancies (OR=0.60, 95% CI 0.27-1.33), or adverse outcomes (OR=0.63, 95% CI 0.31-1.26). In donor cycles, LB were higher in the acupuncture group (relative risk=1.31, 95% CI 1.02-1.71).

CONCLUSIONS

In this observational study, the Craig protocol was not found to lower IVF LB. In fact, the Craig protocol was associated with higher LB in donor cycles. These findings should be considered cautiously because more adequately powered, randomized research is needed.

Thermometer of warmth in the patient-provider relationship (WARMOMETER)--theory-based development of a patient self-report measure and initial validation using cognitive interview methodology

OBJECTIVE

The aims of this study are twofold: (1) the theory-based development of a patient self-report measure of physician warmth and (2) the application of cognitive interview methodology to understand patients' perception and interpretation of this new measure.

METHODS

A draft measure was developed based on an in-depth literature review of the concept of human warmth by a multidisciplinary expert group. Sixteen cognitive probing interviews were conducted to examine how patients perceive and interpret this new measure and to identify potential problems. A content analysis of the interviews was used to evaluate findings.

RESULTS

Findings indicate that the WARMOMETER is a short patient self-report assessment of physician warmth, which seems easy and intuitive to understand. In addition, most respondents were found to share a common concept of physician warmth.

CONCLUSIONS

Verification of our study hypotheses and confirmation of the theoretical assumptions of human warmth give basic indications that the WARMOMETER seems to be a valid and sensitive patient self-report instrument for assessing the socio-emotional quality of physicians.

PRACTICE IMPLICATIONS

These first promising results of our cognitive interviews suggest that the WARMOMETER may also be used and further validated in future health communication studies, also with other healthcare professionals.