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Background Despite the increasing annual incidence of hepatocellular carcinoma (HCC) in the USA, now estimated at 2.7 cases per 100 000 population, only a small proportion of patients receive treatment and 5-year survival rates range from 9% to 17%. Objectives The present study examines the effects of multimodal treatment on survival in a mixed-stage HCC cohort, focusing on the impact of radical therapy in patients with Barcelona Clinic Liver Cancer (BCLC) stage B disease. Methods A retrospective review of the medical records of 254 patients considered for HCC treatment between 2003 and 2011 at a large tertiary referral centre was conducted. Results A total of 195 (76.8%) patients were treated with a median of two liver-directed interventions. Median survival time was 16 months. In proportional hazards analysis, radiofrequency ablation (RFA) and resection were associated with significantly improved 1- and 5-year survival among patients with BCLC stage 0-A disease. In patients with BCLC stage B disease, RFA conferred a survival benefit at 1 year and resection was associated with significantly improved survival at 5 years. Conclusions As one of few studies to track the complete course of sequential HCC therapies, the findings of the present study suggest that HCC patients with intermediate-stage (BCLC stage B) disease may benefit from aggressive interventions not currently included in societal guidelines. © 2014 International Hepato-Pancreato- Biliary Association.

An increasing number of people in the United States are using holistic therapies. Both encouraging and informing this trend in growth, printed leaflets are a popular and important medium for holistic health practitioners. Using a discourse analytic approach, the author analyzed pamphlets and printed texts distributed at a holistic health fair. These texts reflect and construct specific understandings of holistic health and proper health care. Understood through the notion of boundary-work, pamphlets demarcated holism as the proper way of conceptualizing health and health care. However, holistic medicine's boundaries are quite porous, as these practices are also legitimized through the use of scientific conventions and the practice of integration, both commonly associated with biomedicine. [ABSTRACT FROM AUTHOR]

Traditional Chinese medicine (TCM) has recently gained a great deal of popular and scholarly attention. However, little work in this area has examined how people actually talk about TCM as a health care system and its implicit assumptions about health, illness, and treatment. Based on ethnographic fieldwork conducted in an acupuncture community, I describe a Qi-based speech code examining the importance and necessity of Qi (most simply translated as energy) in acupuncture discourse. Proper descriptions of acupuncture require explicit mention and acknowledgment of Qi as well as a grounding in its philosophy and explanatory system. Practitioners are taught to feel Qi and use this phrase as a discursive marker of expertise. Finally, Qi is also used in the competing rhetorics of Chinese and Japanese acupuncture. This study has important implications for understanding the culturally situated nature of health and illness in the United States and the consequences of these particular constructions as elucidated through close examination of conversations between practitioners. [ABSTRACT FROM AUTHOR]

Aim: To describe where clinical information is contemporarily and commonly found in UK primary care, what is favoured by clinicians, and whether this is (1) publicly funded (2) has commercial potential conflicts of interest., Design and Setting: A mixed methods study, consisting of (1) site visits to general practices in Scotland, (2) online questionnaire, focused on UK general practice (3) analysis of materials cited by professionals., Methods: Data about sources of clinical information used was obtained verbally, visually and via search histories on computers from visits. This was used to inform a questionnaire in which primary care clinicians in the four nations of the UK were invited to participate. This obtained data about the information sources used and preferred by clinicians. This information was searched for data about funding and conflicts of interest., Results: Over 2022, four practices were visited. 337 clinicians, 280 of whom were general practitioners completed an online questionnaire. 136 different resources were identified. These were mainly websites but sources of information included colleagues, either in practice or through online networks, apps, local guidelines, health charities, and learning resources aimed at GPs. Of these, 70 were not publicly funded, and were a mixture of membership organisations, charities, or sponsored venues., Conclusions: Primary care clinicians obtain information for themselves and patients from a wide variety of sources. Funding is from a variety of sources and some contain advertising and/or sponsorship, risking commercial bias., Protocol: Pre-published at https://osf.io/wrzqk ., (© 2024. The Author(s).)

Competing Interests: The authors have no conflicts of interest with exception to the following: M.R. holds the position of Editor-in-Chief for Crohn’s & Colitis 360 and has been recused from reviewing or making decisions for the manuscript. E.M. holds the position of Associate Editor for Crohn’s & Colitis 360 and has been recused from reviewing or making decisions for the manuscript.

Complementary and integrative health (CIH) use is diverse and highly prevalent worldwide. Prior research of CIH communication in biomedical encounters address safety, efficacy, symptom management, and overall wellness. Observational methods are rarely used to study CIH communication and avoid recall bias, preserve ecological validity, and contextualize situated clinical communication. Following PRISMA guidelines, we systematically reviewed studies at the intersection of social scientific observational research and findings about CIH communication between clinicians, patients, and caregivers in biomedical settings. We identified international, peer-reviewed publications from seven databases between January 2010 and December 2020. Titles and abstracts were first screened for inclusion, then full studies were coded using explicit criteria. We used a standard checklist was modified to assess article quality. Ten of 11,793 studies examined CIH communication using observational methods for CIH communication in biomedical settings. Studies used a range of observational techniques, including participant and non-participant observation, which includes digital audio or video recordings. Results generated two broad sets of findings, one focused on methodological insights and another on CIH communication. Despite methodological and topic similarities, included studies addressed CIH communication as a process and as proximal and intermediate health outcomes. We recommend how observational studies of CIH communication can better highlight relationships between communication processes and health outcomes. Current research using observational methods offers an incomplete picture of CIH communication in biomedical settings. Future studies should standardize how observational techniques are reported to enhance consistency and comparability within and across biomedical settings to improve comparability.

Addressing patient-clinician communication barriers to improve multiple chronic disease care is a public health priority. While significant research exists about the patient-clinician encounter, less is known about how to support patient-clinician communication about lifestyle changes that includes the context of people's lives. Data come from a larger photo-based primary care study collected from 13 participants who were adults 60 or older with at least two chronic conditions, in English, Chinese (Cantonese or Mandarin), or Spanish. We use discourse analysis of three examples as anchor points demonstrating different interactional pathways for the photo-based communication. Patients and clinicians can move smoothly through a pathway in which photos are shared, clinicians acknowledge and align with the patient's explanation, and clinicians frame their medical evaluations of food choices, nutrition suggestions, and shared goal-setting by invoking the voice of lifeworld (VOL). On the other hand, when clinicians solely press the voice of medicine (VOM) in their evaluations of patients' pictures with little attention to patients' presentations, it can lead to patient resistance and difficulty moving to the next activity. Because photo-sharing is still relatively novel, it offers unique interactional spaces for both clinicians and patients. Photo-sharing offers a sanctioned moment for a primary care visit to operate in the VOL and promote goal-setting that both parties can agree upon, even if clinicians and patients framed the activity as one in which patients' lifeworld choices should be assessed as medically healthy or unhealthy based on the ultimate judgment of clinicians operating from the VOM.

Objective: Patient-physician communication patterns may influence discussions around depressive symptoms and contribute to engagement in depression care among racial/ethnic minority adults. We examined patient-physician communication about depressive symptoms during routine primary care visits with Chinese and Latino patients with and without language barriers., Methods: We examined 17 audio-recorded conversations between primary care physicians and Chinese (N = 7) and Latino (N = 10) patients who discussed mental health during their visit and reported depressive symptoms on a post-visit survey. Conversations (in English, Cantonese, Mandarin, Hoisan-wa, Spanish) were transcribed and translated by bilingual/bicultural research assistants and analyzed using inductive and deductive thematic and discourse analysis., Results: Patients initiated mental health discussion in eleven visits. Physicians demonstrated care in word choice and sometimes avoided openly mentioning depression; this could contribute to miscommunication around symptoms and treatment goals. Interpreters had difficulty finding single words to convey terms used by either patients or physicians., Conclusion: Patients and doctors appeared willing to discuss mental health; however, variability in terminology presented challenges in mental health discussions in this culturally and linguistically diverse sample., Practice Implications: Further understanding patient preferred terminology about mental health symptoms and interpreter training in these terms could improve patient-physician communication about depressive symptoms and treatment preferences., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

The ongoing COVID19 pandemic is having detrimental effects on the mental and emotional well-being of many adults and children. It is relevant therefore to explore the combination of personal strengths and attributes that can help an individual develop resilience to such stress. Little is known about how psychological strength assets such as social connectedness, grit, hope, life meaning, and life satisfaction are inter-related, and if certain factors play a central role. This study involved a sample of 1,405 school-aged children in Hong Kong (50% female) from seven schools that participated in an online survey of psychological strengths. Data were analyzed by constructing a psychological network that found strength factors are inter-connected, and that 'school connectedness' and 'agency thinking' are central to the network. The information gained can be of value in any schools that are planning to provide strength-based interventions to help students maintain their psychological well-being during and after the COVID-19 pandemic., Competing Interests: Conflict of interest All authors have approved the final article and declare that there is no conflict of interest to disclose., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Objective: Chinese-American patients use CIH at high rates but disclosure of CIH use to clinicians is low. Further, the content of CIH talk between patients and their clinicians is not well described. We aimed to characterize CIH talk between Chinese-American patients and their primary care clinicians., Methods: Discourse analysis of 70 audio-recordings of language concordant and discordant-interpreted visits., Results: Nearly half of all visits (48.6%) had some form of CIH communication. 'Simple CIH talk' focused on a single CIH topic resulting in a positive, neutral, or negative response by clinicians. 'CIH-furthering talk' was characterized by clinicians and patients addressing more than one CIH topic or including a combination of orientations to CIH by both clinicians and patients. CIH-furthering talk characterized by clinician humility could enhance rapport, cultural understanding, and open communication. CIH-furthering talk also led to miscommunication and retreat toward biomedicine., Conclusion: CIH communication occurred frequently during language concordant and discordant-interpreted visits with Chinese-American patients. Both patients and clinicians used CIH-furthering talk as a conversational resource for managing care., Innovation: This discourse analysis of visits between Chinese-American patients and their clinicians advances understanding of CIH communication beyond disclosure, illustrating the complexity of linguistic and cultural nuances that affect patient care., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Leah Karliner reports financial support was provided by Patient-Centered Outcomes Research Institute. Leah Karliner reports financial support was provided by National Institutes of Health. Jane Jih reports financial support was provided by National Institutes of Health.

Stakeholder advisory boards are recognized as an essential and useful part of patient-centered research. However, such engagement can involve exchanges of diverse individual experiences, multiple opinions, and strong feelings in the face of researchers' limitations, deadlines, and agendas. Yet, little work examines how these potential tensions occur and are resolved in actual advisory board meetings. This perspective article describes and employs a communication framework for analyzing a patient advisory council (PAC) for a comparative effectiveness study on acupuncture and pain counseling for inpatients with cancer. The framework, Action-Implicative Discourse Analysis (AIDA), is an observational method that examines challenges through recorded and transcribed, naturally occurring interaction. Our analysis focused on two short excerpts from the first PAC meeting to demonstrate members' navigation of advice-giving and advice-receiving-one in which advice was ultimately implemented by the study team and another in which it was deemed unfeasible. Although advice is inherent to the work of all PACs, it often emerges unannounced as negotiated moments, made up of seemingly minor conversation moves. As a recurring event, advice can and should be analyzed and discussed within PACs to improve communication and team dynamics., (© 2021. Society of General Internal Medicine.)

Objectives: A systematic review to analyze communication rates of complementary and integrative health (CIH) and analyze how communication terms, such as "disclosure," are measured and operationalized., Methods: We searched seven databases for studies published between 2010 and 2018 with quantitative measurements of patients' communication of CIH to a biomedical clinician. We analyzed communication terms used to describe patients reporting CIH usage. We also examined the conceptual and operational definitions of CIH provided and whether those terms were explicitly operationalized. We aggregated the percentage, rate, or ratio of CIH users that communicated about CIH with their clinicians by disease type and geographical region., Results: 7882 studies were screened and 89 included in the review. Studies used a wide range of conceptual and operational definitions for CIH, as well as 23 different terms to report communication related to reporting CIH usage. Usage varied by disease type and geographical region., Conclusions: Studies of CIH and CIH communication may measure different kinds of social and communicative phenomena, which makes comparison across international studies challenging., Practice Implications: Future studies should employ standardized, replicable measures for defining CIH and for reporting CIH communication. Clinicians can incorporate questions about prior, current, and future CIH use during the medical visit., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Article Title: A microsimulation model to determine the cost-effectiveness of treat to target strategies for Crohn's disease., (Copyright © 2021 by The American College of Gastroenterology.)

Objectives: This study describes the development and feasibility of Integrative Nutritional Counseling (INC), a Chinese medicine (CM)+biomedicine-based nutrition curriculum for Chinese Americans with type 2 diabetes. Although Chinese Americans often incorporate CM principles into their diet, scant research has explored how to integrate CM with biomedical nutrition standards in a culturally appropriate manner or if such a program could improve diabetes self-management. Design: This is a 1-month pre-post study design including three points of contact: baseline, in-person class, and 1-month follow-up. Subjects: Participants ( n  = 15) were Cantonese-speaking/reading Chinese Americans diagnosed with type 2 diabetes who had used some form of CM/medicinal foods in the last 12 months. Interventions and Outcome Measures: The INC program included baseline surveys and a CM intake interview conducted by a licensed acupuncturist. The acupuncturist generated a CM diagnosis, which was shared with the participant, and used this diagnosis to tailor brief nutrition education. To bolster this brief education, a bilingual registered dietitian provided a 2-h group education class in Cantonese to all participants, during which time participants also received a Chinese/English INC booklet. Participants completed surveys immediately after the class and at 1-month follow-up, with qualitative exit interviews. Results: Participants reported improved attitudes and dietary habits aligning directly with INC, and improvement in biomedically valued measures of type 2 diabetes, such as weight loss, and CM-valued measures of digestion/elimination and hot/cold feeling. Satisfaction with INC was high, but challenges included confusion with some INC information, structural barriers, and comorbidities. Conclusions: Chinese Americans with type 2 diabetes and interventionists found integrative nutrition approaches acceptable and feasible. Future research should examine INC with a larger population and explore optimal delivery of INC given reported challenges.

Objectives: To examine audio-recorded primary care interactions with patient-initiated photo sharing around food and diet choices., Methods: Data were 13 audio recordings of primary care visits with English-, Chinese-, or Spanish-speaking patients 60+ with two or more chronic conditions. Patients and clinicians completed pre-intervention surveys and some training on photo-taking / photo-sharing discussion. Data were analyzed using discourse analysis., Results: Photo-based communication interactions lasted 3:34-28:37 min and averaged one-third of the visit. Clinicians and patients both initiated the photo-based talk and transition to other topics occurred smoothly. In eight of 13 interactions, the photo-based communication task was raised, but conversation did not occur at that moment. When discussed, the photos raised opportunities to talk about patient's decision-making which led to dietary suggestions including clinical nutrition suggestions and referrals to other specialty clinics., Conclusion: Photo-based communication in primary care can be used to promote patient activation and facilitate collaborative decision making that accounts for the patients' lived experiences and lifeworld., Practice Implications: By setting the agenda early, clinicians or patients can designate the photo-sharing as a relevant part of the visit. Photos may be most relevant as part of the problem presentation, diagnosis, or treatment recommendation sections of the visit., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: As part of a pragmatic effectiveness trial of integrative pain management among inpatients with cancer, the authors sought to understand the clinical context and adaptations to implementation of two study interventions, acupuncture and pain counseling (i.e., pain education and coping skills). Design: The larger study uses a 2 × 2 factorial design with inpatients randomized to: (1) usual care (UC), (2) UC with acupuncture, (3) UC with pain counseling, and (4) UC with acupuncture and pain counseling. The study is being conducted in two hospitals (one academic and one public) and three languages (Cantonese, English, and Spanish). The authors conducted a process evaluation by interviewing study interventionists. Analysis included deductive coding to describe context, intervention, implementation, and inductive thematic coding related to intervention delivery. Results: Interviewees included seven acupuncturists and four pain counselors. Qualitative themes covered adaptations and recognizing site-specific differences that affected implementation. Interventionists adhered closely to protocols and made patient-centered adaptations that were then standardized in broader implementation (e.g., including caregivers in pain counseling sessions; working in culturally nuanced ways with non-English-speaking patients). The public hospital included more patients with recent diagnoses and advanced disease, more ethnically and linguistically diverse patients, less continuity of staffing, and shared patient rooms. At the academic medical center, more patients were familiar with integrative therapies and all were located in single rooms. Providing acupuncture to hospital staff was a key strategy to establish trust, experientially explain the intervention, and create camaraderie and staff buy-in. Conclusions: Providing nonpharmacologic interventions for a pragmatic trial requires adapting to a range of clinical factors. Site-specific factors included greater coordination and resources needed for successful implementation in the public hospital. The authors conclude that adaptation to context and individual patient needs can be done without compromising intervention fidelity and that intervention design should apply principles such as centering at the margins to reduce participation barriers for diverse patient populations.

Purpose: Current biomedical cardiovascular disease nutrition counseling does not incorporate Chinese medicine principles., Methods: A heart-healthy integrative nutritional counseling (H2INC) curriculum consistent with Chinese medicine principles and biomedical nutrition guidelines was taught to Chinese Americans in group education sessions. Chinese-speaking patients with cardiovascular disease or risk factors from an urban general medicine practice were recruited to attend a 90-minute group session. Participants completed pre-post surveys to assess the impact of H2INC on their perceived heart-healthy nutrition knowledge and empowerment, as well as the cultural relevance of H2INC., Results: A total of 47 participants (mean age: 74 years; 63.8% female) attended a session. In response to the statement "I am able to choose heart-healthy Chinese foods to eat," on a 5-point Likert scale for which "strongly disagree" = 1 and "strongly agree" = 5, the presession survey mean response was 3.87 ± 0.69 and the postsession survey mean response was 4.13 ± 0.58 (P=0.05). Postsession, 87% of participants agreed or strongly agreed that they felt confident using what they learned and 94% agreed or strongly agreed that H2INC fit their culture., Conclusions: H2INC had a positive impact on perceived heart-healthy nutrition knowledge and empowerment and rated high in cultural relevance. Culturally relevant education sessions like H2INC could be a promising primary care health education intervention., Competing Interests: Conflicts of Interest None., (© 2021 Aurora Health Care, Inc.)

Purpose: Chinese Americans (CAs) with diabetes and limited English proficiency often struggle to adhere to standard diabetes diets focused on food measurement/restriction. Chinese medicine principles commonly inform food choices among CAs but are rarely acknowledged in nutritional interventions. We developed and tested feasibility of a theoretically informed integrative nutritional counseling (INC) program that combines Chinese medicine principles with biomedical nutrition standards. Methods: We randomized diabetes self-management education (DSME) classes to include either: (1) usual nutrition curriculum based on American Diabetes Association (ADA) recommendations delivered by a diabetes educator (control) or (2) INC curriculum based on a combination of ADA recommendations and Chinese medicine principles delivered by a diabetes educator and a licensed acupuncturist (intervention). All DSME enrollees were invited to participate in research entailing data collection at three time points: baseline, after the DSME nutrition class, and at 6-month follow-up. Using validated measures, we collected dietary self-efficacy, diabetes distress, diet satisfaction, and dietary adherence. We also measured weight and glycemic control. Results: Study participants were 18 Cantonese-speaking patients with diabetes who were predominantly female and older, with low levels of income and acculturation. Intervention and control groups were similar at baseline. INC performed similarly to usual DSME with 100% of participants reporting the INC booklet helped their learning. Dietary adherence significantly improved in participants who received the INC curriculum. Conclusion: INC is feasible to implement as part of DSME classes and shows promise as a complementary culturally sensitive addition to usual diabetes nutrition education for CA patients., Competing Interests: No competing financial interests exist., (© Evelyn Y. Ho et al., 2020; Published by Mary Ann Liebert, Inc.)

Since the 1st discovery of transcriptional enhancers in 1981, their textbook definition has remained largely unchanged in the past 37 years. With the emergence of high-throughput assays and genome editing, which are switching the paradigm from bottom-up discovery and testing of individual enhancers to top-down profiling of enhancer activities genome-wide, it has become increasingly evidenced that this classical definition has left substantial gray areas in different aspects. Here we survey a representative set of recent research articles and report the definitions of enhancers they have adopted. The results reveal that a wide spectrum of definitions is used usually without the definition stated explicitly, which could lead to difficulties in data interpretation and downstream analyses. Based on these findings, we discuss the practical implications and suggestions for future studies., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Article Title: Inflammatory Bowel Disease: A Practical Path to Transitioning from Pediatric to Adult Care.

To receive CME/MOC credit for this activity, please go to: http://acgjournalcme.gi.org/Article Title: Diagnosis and Treatment of Rumination Syndrome: A Critical Review.

Objectives: Current cardiovascular disease (CVD) nutrition guidelines do not take into account Chinese medicine (CM) principles. We created a heart healthy integrative nutritional counseling (H2INC) curriculum consistent with CM principles and current nutrition guidelines., Methods: We conducted three phases of semi-structured interviews with key stakeholders (CM and biomedical providers and Chinese American (CAs) patients with CVD) followed by iterative development of H2INC. First, we interviewed licensed CM providers (n = 9) and laypeople with CM foods expertise (n = 1). Second, we interviewed biomedical providers (n = 11) and licensed CM providers (n = 3). Third, we conducted four focus groups with CAs (n = 20) with CVD., Results: Stakeholders emphasized different principles for creating H2INC. Phase one emphasized alignment of CM diagnoses to biomedical CVD conditions. Phase two overlaid CM concepts like the nature of foods and constitution (hot/neutral/cool) with heart healthy nutrition recommendations such as MyPlate, and avoiding excess salt, fat, and sugars. Phase three demonstrated patient acceptability., Conclusion: By integrating CM foods principles with biomedical nutrition, this integrative approach yields culturally relevant health education for an underserved population., Practice Implications: Integrative nutritional counseling shows promise for CAs and could support biomedical providers with little knowledge about patients' use of CM for CVD., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: Older Chinese Americans often defer end-of-life care discussions. Researchers sought to explore how to engage older Chinese Americans and their families in end-of-life care discussions and to understand the optimal timing to initiate such discussions., Methods: Individual, semistructured interviews were conducted with 14 community-dwelling older Chinese Americans, 9 adult children, and 7 clinicians. The data were collected and analyzed using focused ethnographic methodology., Results: Older Chinese Americans and their families would discuss end-of-life care when introduced at "optimal times," which included after-triggering events (e.g., death of loved ones, fall accidents), changes in health status, or advanced age., Discussion: Adult children are not expected to initiate end-of-life care discussions with their parents. Thus, culturally congruent health care that could better engage Chinese Americans in such discussions would be optimized by having clinicians proactively assess their patients' readiness and initiate such discussion at optimal times.

Background: Health-care providers (HCPs) find facilitating end-of-life (EOL) care discussions challenging, especially with patients whose ethnicities differ from their own. Currently, there is little guidance on how to initiate and facilitate such discussions with older Chinese Americans (≥55 years) and their families., Objective: To explore communication strategies for HCPs to initiate EOL care discussions with older Chinese Americans in the San Francisco Bay Area., Design: This qualitative (focused) ethnographic study included field observations and individual semistructured interviews with 14 community-dwelling older Chinese Americans who lived independently at home, 9 adult children, and 7 HCPs. Responses were analyzed using open coding, memos, and comparison across participants., Results: The study participants emphasized the importance of assessing readiness for early EOL care discussions. All recommended using indirect communication approaches to determine older Chinese Americans' readiness. Indirect communication can be culturally targeted and applied at both system-wide (ie, health-care system) and individual (ie, HCP) levels. To institutionalize the practice, health-care facilities should implement EOL care discussion inquiries as part of routine during check-in or intake questionnaires. In individual practice, using depersonalized communication strategies to initiate the discussion was recommended to determine older Chinese Americans' readiness., Conclusion: Assessing readiness should be an essential and necessary action for early EOL care discussions. Culturally targeted assessment of older Chinese Americans includes using indirect communication approaches to initiate an EOL care discussion to determine their readiness. In addition to health-care system integration, providers should implement and evaluate proposed EOL discussion initiation prompts with their older Chinese American patients.

Background: Practice guidelines recommend screening for hepatitis B virus (HBV) infection prior to initiating treatment of inflammatory bowel disease (IBD) with anti-tumor necrosis factor (anti-TNF) therapy. However, the adherence to these screening guidelines and the clinical outcomes of HBV reactivation following anti-TNF use are not well known., Methods: This is a retrospective cohort study using the Veterans Health Administration datasets for IBD patients with filled prescriptions for anti-TNFs from 2003 to 2011. Laboratory testing was used to define HBV screening status in the 12 months preceding anti-TNF initiation. Logistic regression models were used to identify predictors of HBV screening. Cases of potential HBV reactivation were identified using ICD-9 codes for HBV infection or acute liver failure or by medications used for HBV infection treatment, and manually reviewed for verification., Results: We identified 3357 IBD patients with filled prescriptions for anti-TNF medications. The HBV testing prior to anti-TNF initiation was 8.1% in 2003 and increased to 43.2% by 2011, with an overall rate of 23.7%. In multivariate analysis, African-American race, facilities with a higher volume of IBD patients, and facilities with an academic affiliation were associated with a higher probability of HBV screening. We did not identify a single case of confirmed clinically relevant HBV reactivation after anti-TNF initiation during 7210 patient-years of medication use., Conclusions: HBV screening rates prior to anti-TNF initiation are low among IBD patients, but have increased over time. Despite low rates of screening, clinically significant HBV reactivation after anti-TNF initiation in this US cohort was nonexistent.

This study aimed to describe the experiences of stress and burnout and sociodemographic factors associated with dimensions of stress among medical residents at Hamad Medical Corporation, Qatar. Medical residents participating in a stress management course were asked to complete an anonymous survey. The survey included demographic questions, the Abbreviated Maslach Inventory, and 4 open-ended questions on experiences with stress. Of the 150 residents participating in the stress management course, 142 responded to the survey, listing an average of 2.2 types of stressors, with workload and workplace relationships as the most frequent. They listed an average of 3.1 coping strategies, most frequently seeking out social support and entertainment. Responses indicated low depersonalization, high personal accomplishment, high satisfaction with medicine and high emotional exhaustion. Training to improve coping and reduce burnout is recommended.

In a period of only one decade in the United States, the neti pot shifted from obscure Ayurvedic health device to mainstream complementary and integrative medicine (CIM), touted by celebrities and sold widely in drug stores. We examine the neti pot as a case study for understanding how a foreign health practice became mainstreamed, and what that process reveals about more general discourses of health in the United States. Using discourse analysis of U.S. popular press and new media news (1999-2012) about the neti pot, we trace the development of discourses from neti's first introduction in mainstream news, through the hype following Dr. Oz's presentation on Oprah, to 2011 when two adults tragically died after using Naegleria fowleri amoeba-infested tap water in their neti pots. Neti pot discourses are an important site for communicative analysis because of the pot's complexity as an intercultural artifact: Neti pots and their use are enfolded into the biomedical practice of nasal irrigation and simultaneously Orientalized as exotic/magical and suspect/dangerous. This dual positioning as normal and exotic creates inequitable access for using the neti pot as a resource for increasing cultural health capital (CHC). This article contributes to work that critically theorizes the transnationalism of CIM, as the neti pot became successfully Americanized. These results have implications for understanding global health practices' incorporation or co-optation in new contexts, and the important role that popularly mediated health communication can play in framing what health care products and practices mean for consumers.

Objective: To characterize how providers respond to patient mentions of complementary and integrative medicine (CIM) during routine oncology visits., Methods: Ethnographic methods were used over a two and a half year period with 82 advanced cancer patients and their providers across four oncology clinics. Participant observation fieldnotes were analyzed using Discourse Analysis., Results: CIM was mentioned in 78/229 (34%) of the total observed visits. Patients initiated talk about CIM (76%) more than providers (24%). Patients mentioning CIM may indicate a preference for or interest in non-pharmacological adjunctive treatment options. Providers' responses inhibited further talk in 44% of observations and promoted talk in 56% of observations., Conclusion: How providers respond may indicate their willingness to discuss a range of treatment options and to collaboratively engage in treatment decision-making. Provider responses that inhibited CIM conversation passed on the opportunity to discuss patient preferences, and responses that promoted further conversation helped counsel patients about appropriate CIM use. Promoting discussion did not require additional time or extensive knowledge about CIM., Practice Implications: Providers can facilitate high quality communication without endorsing CIM to help patients make treatment decisions and to evaluate CIM appropriateness in response to patient values and preferences., (Published by Elsevier Ireland Ltd.)

Background: This proof-of-concept study compared lamivudine (LAM) with a newer antiviral agent, adefovir dipivoxil (ADF), in preventing hepatitis B virus (HBV) reactivation in chronic HBV patients undergoing chemotherapy., Methods: Hepatitis B surface antigen (HBsAg) positive patients intended to undergo chemotherapy were randomized to receive either LAM 100 mg daily or ADF 10 mg daily. Anti-viral therapy was started 1 week prior to chemotherapy and until 6 months after completing chemotherapy. The primary outcome was HBV reactivation rate. All patients with viral breakthrough were screened for resistance mutations by direct sequencing., Results: Seventy treatment-naïve patients were consecutively randomized 1:1 to LAM or ADF. The median baseline HBV DNA levels were similar (LAM 3.36 vs. ADF 3.17 log10 copies/mL, p = 0.860). The median duration was 8.3 months on LAM and 10.6 months on ADF (p = 0.220). HBV reactivation was observed in 13/35 (37.1%) on LAM compared with 10/35 (28.6%) on ADF (p = 0.611). The median time to HBV reactivation was 4.6 and 8.1 months, on LAM and ADF respectively. Among these 13 patients, 8/13 (61.5%) on LAM had developed drug resistance mutations but none on ADF had developed drug resistance mutations to ADF (p = 0.003). Both drugs were well tolerated and no severe drug-related toxicities were reported., Conclusion: In this randomized clinical study, adefovir and lamivudine demonstrated similar efficacy in preventing hepatitis B reactivation in HBsAg-positive patients undergoing chemotherapy. In patients whose hepatitis B reactivated, adefovir was associated with a lower resistance profile.

Opinion Statement: The treatment paradigms and therapeutic options for ulcerative colitis (UC) have rapidly evolved during the past decade. Traditionally, the treatment target has focused on achieving successful induction and maintenance of steroid-free clinical remission. This has been shown to provide a better quality of life and a reduction in complications, hospitalizations, and surgery. Recent studies, however, suggest that achieving "mucosal healing" or endoscopic remission may be the optimal treatment endpoint. In this review, we will examine the treatment goals for UC and the efficacy of each therapy to reach these targets. We will also review the therapeutic options available for UC: mesalamines, steroids, immunomodulators, and biologics, including the first anti-integrin inhibitor, approved in May 2014, for the treatment of UC. Therapeutic drug monitoring, which measures serum drug level and anti-drug antibody concentrations, is emerging as an important clinical decision tool in patients on tumor necrosis factor (TNF)-antagonists. These evolving treatment strategies allow gastroenterologists to optimize control of the disease and offer patients a better quality of life.

Type 2 diabetes affects Chinese Americans at an alarming rate. To address this health disparity, research in the area of cultural sensitivity and health literacy provides useful guidelines for creating culturally appropriate health education. In this article, we use discourse analysis to examine a group of locally available, Chinese- and English-language diabetes print documents from a surface level and deep structure level of culture. First, we compared these documents to research findings about printed health information to determine whether and how these documents apply current best practices for health literacy and culturally appropriate health communication. Second, we examined how diabetes as a disease and diabetes management is being constructed. The printed materials addressed surface level culture through the use of Chinese language, pictures, foods, and exercises. From a deeper cultural level, the materials constructed diabetes management as a matter of measurement and control that contrasted with previous research suggesting an alternative construction of balance. A nuanced assessment of both surface and deeper levels of culture is essential for creating health education materials that are more culturally appropriate and can lead to increased health literacy and improved health outcomes.

Type 2 diabetes affects Chinese Americans at an alarming rate and many Chinese Americans use Chinese medicine principles to deal with their diabetes. In this article, we examine interviews with Chinese medicine practitioners about the best ways to treat diabetes and xiaoke (Chinese medicine’s closest equivalent to diabetes). These interviews were conducted to examine how practitioners would promote a particular form of integrative medicine – in this case, using Chinese medicinal principles to suggest food treatments for diabetes or xiaoke. Our research expands understandings of integrative medicine and Chinese medicine recognizing that in practice, the static categories of Chinese and Western diagnosis and treatment are not very useful for understanding how integration occurs. Instead, Chinese medicine practitioners negotiate between the poles of individual and standardized on one dimension and physical and energetic on another dimension as a way of practicing Chinese medicine and enregistering their professional identities here in the U.S. Examining these interviews from a language and social interaction perspective, we present integration as a performance and enactment of social personae rather than a product. We highlight the need to attend to differences in what oftentimes is treated as a monolithic community of Chinese medicine in the U.S.

Valid, reliable, responsive and practical outcome measures are essential for treatment planning and outcome assessment. This study aimed to examine the measurement properties of Modified Rivermead Mobility Index (MRMI) and Modified Functional Ambulation Classification (MFAC) in Chinese stroke patients. The content validity, responsiveness, predictive validity, test-retest reliability, internal consistency and factor structure of the MRMI were examined. The content validity, discriminative power and inter-rater agreement of the MFAC were investigated. A total of 456 Chinese stroke patients were recruited. Evidence of good content validity, high responsiveness, adequate predictive validity, excellent test-retest reliability with 1.3-point as minimum detectable change in 95% confidence interval, high internal consistency and unidimensionality was obtained for the MRMI. Good content validity, sufficient discriminative power and excellent inter-rater agreement were demonstrated for the MFAC. Both the MRMI and MFAC have good to excellent measurement properties and are recommended as routine outcome measures for Chinese stroke patients.

One well recognized and potentially serious complication of chronic immunosuppression in organ transplant recipients is post-transplantation lymphoproliferative disorders (PTLD). This accounts for 20% of all malignancies in transplant recipients, which is four times higher than the general population (1,2). The diagnosis of PTLD is often difficult, due to various manifestations resulting in late diagnosis. We report an unusual presentation of PTLD in a pediatric patient where the diagnosis was achieved only after extensive investigation.

Severe vitamin deficiency disease is rarely seen in developed countries. We present an atypical case of a young man with scurvy, pellagra, and hypovitaminosis A, caused by longstanding functional abdominal pain that severely limited his ability to eat.

Rapid non-genomic effects of 17β-estradiol are elicited by the activation of different estrogen receptor-α isoforms. Presence of surface binding sites for estrogen have been identified in cells transfected with full-length estrogen receptor-α66 (ER66) and the truncated isoforms, estrogen receptor-α46 (ER46) and estrogen receptor-α36 (ER36). However, the binding affinities of the membrane estrogen receptors (mERs) remain unknown due to the difficulty of developing of stable mER-transfected cell lines with sufficient mER density, which has largely hampered biochemical binding studies. The present study utilized cell-free expression systems to determine the binding affinities of 17β-estradiol to mERs, and the relationship among palmitoylation, membrane insertion and binding affinities. Saturation binding assays of human mERs revealed that [³H]-17β-estradiol bound ER66 and ER46 with Kd values of 68.81 and 60.72 pM, respectively, whereas ER36 displayed no specific binding within the tested concentration range. Inhibition of palmitoylation or removal of the nanolipoprotein particles, used as membrane substitute, reduced the binding affinities of ER66 and ER46 to 17β-estradiol. Moreover, ER66 and ER46 bound differentially with some estrogen receptor agonists and antagonists, and phytoestrogens. In particular, the classical estrogen receptor antagonist, ICI 182,780, had a higher affinity for ER66 than ER46. In summary, the present study defines the binding affinities for human estrogen receptor-α isoforms, and demonstrates that ER66 and ER46 show characteristics of mERs. The present data also indicates that palmitoylation and membrane insertion of mERs are important for proper receptor conformation allowing 17β-estradiol binding. The differential binding of ER66 and ER46 with certain compounds substantiates the prospect of developing mER-selective drugs.

Objective: To empirically investigate the ways in which patients and providers discuss Complementary and Alternative Medicine (CAM) treatment in primary care visits., Methods: Audio recordings from visits between 256 adult patients aged 50 years and older and 28 primary care physicians were transcribed and analyzed using discourse analysis, an empirical sociolinguistic methodology focusing on how language is used to negotiate meaning., Results: Discussion about CAM occurred 128 times in 82 of 256 visits (32.0%). The most frequently discussed CAM modalities were non-vitamin, non-mineral supplements and massage. Three physician-patient interactions were analyzed turn-by-turn to demonstrate negotiations about CAM use. Patients raised CAM discussions to seek physician expertise about treatments, and physicians adopted a range of responses along a continuum that included encouragement, neutrality, and discouragement. Despite differential knowledge about CAM treatments, physicians helped patients assess the risks and benefits of CAM treatments and made recommendations based on patient preferences for treatment., Conclusion: Regardless of a physician's stance or knowledge about CAM, she or he can help patients negotiate CAM treatment decisions., Practice Implications: Providers do not have to possess extensive knowledge about specific CAM treatments to have meaningful discussions with patients and to give patients a framework for evaluating CAM treatment use., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: The goal was to examine the feasibility and impact of a face-to-face communication skills training intervention based on a current public health campaign to encourage patients to talk about complementary and alternative medicine (CAM) with their biomedical health providers., Methods: Current CAM users were invited to complete a survey about current/past CAM use and communication with biomedical providers before beginning a communication skills training workshop. In the 6-month period following the training, participants were asked to record information on any CAM conversations with those providers., Results: Of the 38 participants who received training, 32 finished the entire study. Over half of those participants reported discussing CAM in post-training visits with biomedical providers. Participants initiated the conversation in most cases, and were more likely to disclose CAM use than they were to ask questions about CAM. Participants who talked about CAM were significantly more likely to perceive CAM as relevant to their visit, compared with individuals who did not talk about CAM., Conclusions: Participants positively evaluated this patient communication workshop. Consistent with previous research, most CAM conversations were patient-initiated., Practice Implications: These findings reinforce the importance of patient education interventions for improving patient-provider communication in general, and CAM communication specifically., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)