The role of health care communication in the development of complementary and integrative medicine

In recent years, complementary medicine (CM) approaches are integrated within a growing number of health care services worldwide. Implementation of CM within primary, secondary and tertiary settings of health care requires attention to a variety of communication challenges. In this special issue of Patient Education and Counseling 23 articles are presented about the patient–provider communication on complementary approaches, and the implementation and integration of CM in health care. Parallel to CM integration in the clinical arena, this special issue emphasizes the importance of two complementary axes: in medical education and in research, particularly on management of chronic illness and life-threatening diseases. The three legs of the integrative stool – research, education, and clinical practice – are perceived in the light of open, non-judgmental patient–health care provider–CM practitioner communication and a patient-centered bio-psycho-social–cultural–spiritual agenda.     

Inhaled glucocorticosteroids in the treatment of asthma and chronic obstructive pulmonary disease

Molecular mechanisms of actions, pharmacokinetics and anti-inflammatory potency of inhaled glucocorticosteroids (ICS) are described. Differences in clinical effectiveness of ICS in asthma and chronic obstructive pulmonary disease (COPD) therapy and up-to-date recommendations for treatment with ICS in asthma and COPD patients are discussed. Finally there are presented data on safety of long-term treatment with ICS, specially in asthmatic children.     

The role of health care communication in the development of complementary and integrative medicine

In recent years, complementary medicine (CM) approaches are integrated within a growing number of health care services worldwide. Implementation of CM within primary, secondary and tertiary settings of health care requires attention to a variety of communication challenges. In this special issue of Patient Education and Counseling 23 articles are presented about the patient–provider communication on complementary approaches, and the implementation and integration of CM in health care. Parallel to CM integration in the clinical arena, this special issue emphasizes the importance of two complementary axes: in medical education and in research, particularly on management of chronic illness and life-threatening diseases. The three legs of the integrative stool – research, education, and clinical practice – are perceived in the light of open, non-judgmental patient–health care provider–CM practitioner communication and a patient-centered bio-psycho-social–cultural–spiritual agenda.     

Consumer/provider communication research: directions for development

Communication between health care providers and consumers is a critical part of effective health care delivery. Yet, the strategic use of interpersonal communication in health care delivery is most complex, multifaceted, and often problematic, necessitating careful study of the communication process in health care to increase understanding and help improve health communication practices. The National Cancer Institute (NCI) sponsored an expert symposium on consumer/provider communication research to examine progress and identify gaps in the research literature on doctor/patient communication. This paper and this special issue of Patient Education and Counseling reviews several of the key perspectives and suggestions presented at the symposium for directing future research and applications concerning consumer/provider communication.     

Impact of long-term inhaled corticosteroid therapy on bone mineral density: results of a meta-analysis.

BACKGROUND: The impact of long-term inhaled corticosteroid (ICS) therapy on bone mineral density (BMD) is poorly understood. OBJECTIVE: To evaluate the impact of long-term ICS use on BMD. METHODS: Random-effects meta-analysis. Published and unpublished literature were identified by searches of MEDLINE and EMBASE databases and consultation with experts. Studies reporting BMD among adult asthma and chronic obstructive pulmonary disease (COPD) patients using ICS and non-ICS controls were identified. Studies selected for review included at least 1 year of follow-up. Two independent reviewers evaluated studies; data from those meeting specified inclusion criteria were abstracted for inclusion in the meta-analysis. RESULTS: Fourteen (5.3%) of 266 reviewed studies met specified inclusion criteria. Sufficient data were available to perform meta-analysis on 3 measures for ICS-using patients (lumbar, femoral neck, and major trochanter BMD) and 1 measure (lumbar BMD) for non-ICS-using controls. Using current National Asthma Education and Prevention Program definitions, the majority of studies (12 of 14) included patients receiving moderate to high doses of ICSs. Among ICS users, annual changes from baseline in lumbar, femoral neck, and major trochanter BMD (-0.23%, -0.17%, and +1.46%, respectively) were not statistically significant. Mean changes in lumbar BMD were also not significantly different from controls (-0.02%). Further, annual changes in lumbar BMD were not statistically significant for subgroups of patients with asthma or COPD. CONCLUSIONS: Long-term use of ICSs in patients with asthma or COPD was not associated with significant changes in BMD.     

自我管理、健康素养对社区COPD患者生活质量影响的路径分析

目的 探讨社区慢性阻塞性肺疾病患者的自我管理、健康素养对生活质量的影响,探讨三者之间的关系并分析其影响路径。方法 采用便利抽样法,于2017年5月~10月抽取湖南省长沙市咸嘉湖、望月湖和定王台3个社区的100例COPD患者进行问卷调查。调查工具包括一般资料调查表、COPD患者自我管理量表、COPD患者健康素养量表及圣乔治呼吸问卷。结果 社区COPD患者的自我管理与生活质量总分呈负相关（P＜0.05）,自我管理水平越高,生活质量得分越低,生活质量越高;健康素养与生活质量总分呈负相关（P＜0.05）,健康素养越高,生活质量得分越低,生活质量越高。路径分析显示自我管理对生活质量总分有直接负向预测作用,路径系数为-0.36,且健康素养可通过自我管理间接影响生活质量。结论 社区COPD患者的自我管理水平、健康素养和生活质量处于中下水平,社区医护人员需完善COPD慢病管理制度,提高COPD患者的健康素养,提升自我管理水平,从而降低生活质量得分,提高生活质量水平。     

Budesonide/formoterol for maintenance and reliever therapy in the management of moderate to severe asthma

The Global Initiative for Asthma (GINA) guidelines aim at improving asthma control and preventing future risk. For patients with moderate to severe asthma an inhaled corticosteroid (ICS) or an ICS/long‐acting β₂‐agonist (LABA) combination with a short‐acting β₂‐agonist (SABA) as reliever is recommended. Despite the availability of effective maintenance therapies, a large proportion of patients still fail to achieve guideline‐defined asthma control, and overuse of SABA reliever medication at the expense of ICS is commonly observed. New simplified treatment approaches may offer a solution and assist physicians to achieve overall asthma control. One such treatment approach, which is recommended in the GINA guidelines, is budesonide/formoterol for both maintenance and reliever therapy. This treatment strategy significantly reduces the rate of severe asthma exacerbations compared with ICS/LABA plus SABA and achieves equivalent daily symptom control compared with higher doses of ICS/LABA plus separate SABA for relief. These benefits are achieved at a lower overall steroid load, and budesonide/formoterol maintenance and reliever therapy is well tolerated in patients with moderate to severe asthma. This review discusses current asthma management in patients with moderate to severe disease and examines the evidence for alternative asthma management approaches.     

The Patients' Perspective on the Self-management of Chronic Obstructive Pulmonary Disease

Little attention has been paid to the many behavioral issues involved in the management of chronic obstructive pulmonary disease (COPD). Using a patient- centered approach and drawing upon similar work in the area of diabetes self-management, this study evaluates factors related to the self-management behaviors of 65 patients with COPD. The primary focus was on patients' perceptions of the importance of COPD self-care activities, their recall of provider advice regarding COPD self-care, and the relationship of these factors to patient participation in self- care activities during the past month. The self-management behaviors assessed included smoking cessation, medication- taking, physical activity, diet, relaxation, breathing techniques, controlled coughing and bronchial drainage. Both patient- importance ratings and recall of provider advice showed moderate to strong correlations (r = 0.43-0.79) with the frequency of self-care in the past month, indicating that both the patient's perception (i.e. perceived-importance ratings) and the receipt of health-care provider advice may be important influences on the extent to which patients engage in the various COPD self-management behaviors. Implications for behaviorally-focused interventions are discussed.     

House dust mite allergen avoidance and self-management in allergic patients with asthma: randomised controlled trial

BACKGROUND: The efficacy of bed covers that are impermeable to house dust mites has been disputed. AIM: The aim of the present study was to investigate whether the combination of 'house dust mite impermeable' covers and a self-management plan, based on peak flow values and symptoms, leads to reduced use of inhaled corticosteroids (ICS) than self-management alone. DESIGN OF STUDY: Prospective, randomised, double blind, placebo-controlled trial. SETTING: Primary care in a south-eastern region of the Netherlands. METHOD: Asthma patients aged between 16 and 60 years with a house dust mite allergy requiring ICS were randomised to intervention and placebo groups. They were trained to use a self-management plan based on peak flow and symptoms. After a 3-month training period, the intervention commenced using house dust mite impermeable and placebo bed covers. The follow-up period was 2 years. Primary outcome was the use of ICS; secondary outcomes were peak expiratory flow parameters, asthma control, and symptoms. RESULTS: One hundred and twenty-six patients started the intervention with house dust mite impermeable or placebo bed covers. After 1 and 2 years, significant differences in allergen exposure were found between the intervention and control groups (P<0.001). No significant difference between the intervention and control groups was found in the dose of ICS (P = 0.08), morning peak flow (P = 0.52), peak flow variability (P = 0.36), dyspnoea (P = 0.46), wheezing (P = 0.77), or coughing (P = 0.41). There was no difference in asthma control between the intervention and control groups. CONCLUSION: House dust mite impermeable bed covers combined with self-management do not lead to reduced use of ICS compared with self-management alone.     

Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations

This review is the synthesis of a working group on mild asthma. Mild asthma includes intermittent and persistent mild asthma according to the Global Initiative for Asthma (GINA) classification, and affects between 50% and 75% of asthmatic patients. Mild asthma is more frequent, more symptomatic, and less well controlled in children than in adults. Cohort studies from childhood to adulthood show that asthma severity usually remains stable over time. Nevertheless, mild asthma can lead to severe exacerbations, with a frequency ranging from 0.12 to 0.77 per patient-year. Severe exacerbations in mild asthma represent 30-40% of asthma exacerbations requiring emergency consultation. In mild asthma, inflammation and structural remodelling are constant, of varying intensity, but nonspecific. Therapy with inhaled corticosteroids (ICS) decreases bronchial inflammation, but has only a slight effect on structural remodelling, and, when stopped, inflammation immediately recurs. Permanent low-dose ICS therapy is the reference treatment for persistent mild asthma. Effectiveness is to be reassessed at 3 months, and if it is insufficient the patient is no longer considered mildly asthmatic, and treatment has to be stepped up. As mild asthma is the most frequent form of the disease, diagnosis and management require physicians' particular attention.     

Asthma management: evidence based studies and their implications for cost-efficacy

This review attempts to infer a cost-effective strategy for the management of bronchial asthma based on evidence from randomized controlled trials. Acute severe asthma should be treated with short-acting inhaled beta-agonists followed by a short course of oral steroids. Decisions on hospital admission should be made within 1 to 2 hours and prolonged treatment in emergency departments avoided. A comprehensive educational and drug optimizing program will prevent chronic illness and relapse. Educational programs should be brief but intensive, supervised by asthma specialists and incorporate self monitoring of symptoms plus written action plans. Peak expiratory flow monitoring should not be mandated for all patients. Inhaled corticosteroids (ICS) are the most cost-effective drugs for the long term prevention of asthma. ICS should be started at low doses. If the symptoms of asthma are not well controlled by moderate doses of ICS, high dose ICS treatment should be avoided and add on medication prescribed instead. Oral bronchodilators are less expensive add on medication than long-acting inhaled beta-agonists.     

Computer-tailored interventions motivating people to adopt health promoting behaviours: introduction to a new approach

This issue of Patient Education and Counseling discusses the development, application and effectiveness of computer-tailored interventions. Computer-tailored interventions are a relatively new health education approach. The interventions are characterised by the fact that the content of the materials is adapted, with the aid of computers, to the specific characteristics of a particular person. The use of computers also facilitates addressing large segments of the population, who can now receive materials that are not general but highly individualized. This thematic issue features papers dealing with a wide range of topics. These articles describe the application of behavioural change theories to this new approach, the advantages of computer-tailored interventions over more general mass media approaches, their effectiveness and future directions for research on computer-tailored interventions. This editorial paper introduces computerised tailoring and provides a brief overview of its elements and applications as well as of the papers in this issue, and summarises the main conclusions and suggestions for future research on computer-tailored interventions.     

The influence of health education on family management of childhood asthma

The purpose of this study was to examine differences in asthma management among families with a child who has moderate to severe asthma. Half of the 50 families chosen for study had participated in an intensive in-patient asthma treatment program and half had participated in an out-patient day camp. Two broad categories of outcome were examined — illness and self-management skills. Families who participated in the in-patient program exhibited a pattern of illness behaviours which indicated asthma symptoms were better managed in comparison to those families that participated in the out-patient program. It was also observed that children who participated in the in-patient program had a tendency to feel more positive about having asthma with the more self-management behaviours they practised. On the other hand, children from the out-patient program reported a more negative attitude about having asthma with the more self-management behaviours they practised.     

Patient education in Europe: united differences

This issue of Patient Education and Counseling presents the state of the art of patient education in several European countries. It is based on papers presented at a meeting in Paris on the evolution and development of patient education in western, central and eastern Europe (May 1999). Also patient education in the US is presented in this issue. Patient education is defined as all the educational activities directed to patients, including aspects of therapeutic education, health education and clinical health promotion. Five important factors are identified in the development of patient education: (1) research and evidence based standards; (2) the organization of care; (3) training and methodological support; (4) professional values; and (5) acknowledgment, funding and place of patient education in health policy. Several of the discussed common orientations and priorities in the patient education in the reviewed countries are highlighted in this issue. And finally, an example of the possible integrated international practice in patient education in the field of diabetes is described in this issue. Several conclusions are drawn concerning future development of communication in health care within the framework of patient education in Europe.     

The application of behavioral procedures to childhood asthma: current and future perspectives

The development and application of behavioral procedures to childhood asthma during the past three decades is reviewed, with particular implications for researchers and practitioners. In particular, the article describes two major categories of procedures that comprise the current state of the art of behavioral intervention; prevention and management of attacks and self-management by patients of their asthma. Much of the discussion focuses on self-management skills, particularly the essential ingredients of data collection, information processing and evaluation, steps required to manage attacks and self-reaction to performance. A final section of the paper speculates on the future directions of applying behavioral techniques to childhood asthma. The need to analyze individual attacks suffered by individual patients is emphasized; in addition, the scientific skills required to successfully manage asthma, performed both by medical personnel and patients, are described. It is hoped that the future will see these skills applied in a manner so that each attack is treated as if it were an experiment.     

Does patient education modify behaviour in the management of COPD?

With respect to the beneficial health effects of patient education in the treatment of asthma it might be expected that the active participation of COPD-patients in the management of their disease may reduce the burden of the disease. Self-management of chronic obstructive pulmonary disease (COPD) includes sufficient coping behaviour, compliance with inhaled medication, attention to changes in the severity of the disease, adequate inhalation technique, and self-adjustment of the medication in case of exacerbations. In contrast to the conflicting results of the current literature, the evaluation of our structured education programme for patients with mild to moderate COPD revealed a significant improvement of inhalation technique and self-control of the disease as well as a significant reduction of exacerbations. Therefore, it may be concluded that education may modify the behaviour of patients in the management of COPD by improving self-control and self-management of the disease and thus reducing morbidity.     

The use of inhaled corticosteroids for persistent asthma in infants and young children.

OBJECTIVE: To review pediatric trials of inhaled corticosteroid (ICS) therapy and summarize data on the pediatric use of devices to facilitate delivery of ICSs. DATA SOURCES: Relevant articles regarding ICS treatment of persistent asthma in children younger than 5 years were identified from MEDLINE and reference lists of review articles. STUDY SELECTION: Key articles were selected by the authors. RESULTS: Clinical trials from the United States and Europe consistently demonstrated that ICS therapy is the most favorable treatment option with regard to safety and efficacy for infants and young children with persistent asthma. This contention is supported by numerous trials of budesonide inhalation suspension in children ranging from 6 months through 8 years of age and data from older children treated with fluticasone propionate. CONCLUSIONS: As the only corticosteroid available in the United States as a nebulized formulation and the only ICS product extensively studied in young children and infants, budesonideinhalation suspension is an appropriate first-line therapy for treatment of persistent asthma in this population.     

Behavioral self-management in treating sleep-maintenance insomnia

Three controlled case studies are presented to demonstrate the application of behavioral self-management to two subtypes of sleep-maintenance insomnia. Patient 1 suffered from brief but frequent arousals to wakefulness and to NREM Stage 1 sleep. Patient 2 suffered from brief but frequent arousals and extended minutes awake after sleep onset. Patient 3 suffered from an extended latency to sleep onset and also extended minutes awake after sleep onset. The self-management treatment program was designed to teach these patients skills for identifying and modifying environmental, behavioral, physiological, and cognitive conditions related to poor sleep. Results are documented using home and laboratory all-night sleep recordings during treatment and at 3 and 12 months following the end of treatment.The research reported here was supported in part by Grant MH27551 from the Clinical Research Branch of the National Institute of Mental Health. The opinions and policies expressed herein do not necessarily reflect those of NIMH. We thank William C. Dement, M.D., Ph.D., Vincent P. Zarcone, M.D., and the staff of the Stanford University Sleep Disorders Center for their excellent cooperation in this research.     

Inhaled steroids are associated with reduced lung function decline in subjects with asthma with elevated total IgE

BACKGROUND: Few studies have investigated the long-term association between inhaled corticosteroids (ICSs) and lung function decline in asthma. OBJECTIVE: To evaluate whether prolonged treatment with ICSs is associated with FEV(1) decline in adults with asthma. METHODS: An international cohort of 667 subjects with asthma (20-44 years old) was identified in the European Community Respiratory Health Survey (1991-1993) and followed up from 1999 to 2002. Spirometry was performed on both occasions. FEV(1) decline was analyzed according to age, sex, height, body mass index, total IgE, time of ICS use, and smoking, while adjusting for potential confounders. RESULTS: As ICS use increased, the decline in FEV(1) was lower (P trend = .025): on average, decline passed from 34 mL/y in nonusers (half of the sample) to 20 mL/y in subjects treated for 48 months or more (18%). When adjusting for all covariates, there was an interaction (P = .02) between ICS use and total IgE: in subjects with high (>100 kU/L) IgE, ICS use for 4 years or more was associated with a lower FEV(1) decline (23 mL/y; 95% CI, 8-38 compared with nonusers). This association was not seen in those with lower IgE. CONCLUSION: Although confirming a beneficial long-term association between ICSs and lung function in asthma, our study suggests that subjects with high IgE could maximally benefit from a prolonged ICS treatment. CLINICAL IMPLICATIONS: This study adds further evidence to the beneficial effect of inhaled steroids on lung function in asthma; future studies will clarify whether calibrating the corticosteroid dose according to the level of total IgE is a feasible approach in asthma management.