It may come as a surprise to many patients, but a new study shows that primary care visits have actually gotten a little longer since the late 1990s.
This is particularly remarkable, say the researchers, given the increased pressure on primary care doctors to be efficient in the face of rising numbers of patients and declining income.
Nevertheless, based on quality measurements like whether physicians counseled patients on diet and exercise, they found that “overall performance…was poor.”
Any improvements in care quality will likely require multi-pronged efforts, the researchers say, including paying doctors for spending more time to counsel and screen patients.
Primary care physicians were making about 10 percent less in 2003 than they were in 1995, after taking inflation into account, Dr. Lena M. Chen, who is now with the University of Michigan Health System in Ann Arbor, and her colleagues note in their report in the Archives of Internal Medicine.
“Given the reimbursement environment and the pressures to improve efficiency,” they add, “one might worry that primary care physicians would respond by spending less time with each patient to see more patients, improve their efficiency, and boost their incomes.”
To see if this was actually true, and to look at whether the quality of care these docs were providing over time got better or worse, Chen and her team analyzed data from the National Ambulatory Medical Care Survey for 1997 through 2005. The survey, run by the National Center for Health Statistics, samples a nationally representative group of office-based physicians annually.
Over the study period, the number of adult visits to primary care physicians rose from 273 million to 338 million, a 10 percent increase on a per person basis. The average visit lasted 18 minutes in 1997, while visit time had increased to nearly 21 minutes by 2005.
While older patients and new patients had longer visits, non-Hispanic black patients and Hispanic patients had significantly shorter visits than whites, the researchers found. They say they were “surprised” by this finding, which “may explain why patients of minority groups do not always receive care that is comparable to that provided to white patients.”
During the study period, the quality of care doctors were providing showed “only modest improvements,” Chen and her colleagues say, with patients no more likely to get counseling on diet and exercise in 2005 than they were in 1997, even though there’s strong evidence that giving high-risk patients this advice is beneficial.
There were improvements in the likelihood of doctors prescribing medications with proven benefit for patients — for example beta blockers for coronary artery disease or appropriate medications for heart failure, the researchers found.
They conclude: “Improvements in quality of care will likely require a combination of investments in systems such as electronic health records, greater use of other professionals such as nurse practitioners, and better reimbursement to primary care physicians for the extra time spent.”
SOURCE: Archives of Internal Medicine, November 9, 2009
FYI : At Uptown Acupuncture San Diego, we spend1 1/2 hour on an initial evaluation and treatment, follow up visits are one hour long. We listen to our patients and tailor our services to their needs.
November 09, 2009 :: Posted by - kirk :: Category - Recipe Box
Asian Chicken Stir Fry
A quick fix for busy weeknights, this fragrant stir-fry of chicken, fresh ginger and bok choy is flavored with sesame oil, sherry, soy sauce and hoisin sauce and served over warm angel hair pasta.
Ingredients
1 (8 ounce) yam noodles
1 teaspoon coconut oil
1 teaspoon sesame oil
1/2 onion, chopped
1 clove garlic, minced
1 skinless, boneless chicken breast half – cut into bite-size pieces
1 tablespoon grated fresh ginger
2 leaves bok choy, diced
1/4 cup chicken broth
2 tablespoons dry sherry
1 tablespoon soy sauce
1-1/2 tablespoons hoisin sauce
1/8 teaspoon salt
2 green onions, minced
Cooking Instructions
In a large pot with boiling salted water cook yam pasta until al dente. Drain.
Meanwhile, in a large nonstick skillet heat coconut and sesame oil over medium high heat. Saute onion and garlic until softened. Stir in chopped chicken, and cook until chicken browns and juices run clear. Stir in ginger, bok choy, chicken stock, sherry, soy sauce, and hoisin sauce. Reduce heat, and continue cooking for 10 minutes.
Toss pasta with chicken mixture until well coated. Season with salt. Serve warm sprinkled with minced green onions.
Nutrition Facts
Servings per Recipe: 2
Kirk likes to double or triple the recipe and have left overs..
October 28, 2009 :: Posted by - kirk :: Category - Philosophy
October 24, 2009
Currents-New York Times
An Economy in Need of Holistic Medicine
By ANAND GIRIDHARADAS
CAMBRIDGE, MASSACHUSETTS —
The American economy is having what doctors call an acute episode.
Employment won’t throb. The circulation of capital remains weak. Industry is breathing, but barely. And if we can agree on anything one year into this mess, it is that there is little we can do when the patient arrives already this bad.
That is why the talk now is so often of prevention. Prevent the next crisis through health insurance and a green-energy sector, the American president says. Prevent it by cutting spending and nurturing personal responsibility, American conservatives retort.
But the truth is that politicians, and not just in the United States, are rarely willing to invest in a problem that hasn’t occurred.
Consensus and action are easier to come by after a 9/11 or a Lehman Brothers than before. Problems in the embryonic, soluble phase don’t interest us; and those that do interest us are often too big to solve.
Which is where acupuncture comes in.
Western medical practices have attracted similar criticisms in recent years, for an emphasis on intervening in disease rather than preventing it beforehand and promoting quotidian well-being. But in health, unlike politics, an alternative approach called wellness has emerged, focused on investing in health before it breaks down.
What can wellness tell us about our present economic malady? As it moves from fringe to mainstream — with wellness programs in the health care reform proposals now in Congress, wellness manifestos on the best-seller lists and a U.S. Army wellness program that asks soldiers to introspect and meditate — I asked experts about the approach’s core tenets and how they might be applied to the body politic.
Nip it in the bud. Wellness argues for cultivating health a little every day, not just restoring it during calamities.
We increasingly accept that it is better to monitor a diabetic’s blood sugar with regular clinic visits than to amputate her limbs. We accept that businesses can avoid costly cancer treatments by encouraging workers to stop smoking. But in our political life, we prefer to wait until things reach the emergency room.
We barely regulate financial markets for years, thinking regulation oppressive, until we are compelled to nationalize private firms. We avoid expensive investments and controversial new methods in public education, then pay the price in lower social mobility and vast prison populations. We neglect building roads and bridges and Internet highways, fearing the cost, and then reap the much greater costs of whole regions falling off the economic grid.
“With a lot of social problems, we’re not sure how to prevent it, and therefore we don’t spend money on it, because we always have a lot of other priorities,” said David Cutler, a Harvard economist who has advised both the Clinton and Obama White Houses on health care.
Go to the roots. Western medicine tends to fight symptoms, whether suppressing coughs or flooding the brains of the depressed with serotonin. Wellness is interested in underlying causes. It is inclined to see an infertile woman, for example, as a stressed woman rather than a woman with defunct ovaries, and may suggest that she eat and work differently rather than take ovary-manipulating pills.
In public policy, a symptom bias rules. A housing crisis? Enact a tax credit! Bank failures? Bail them out!
There is nothing wrong with such steps — except for what they leave out, as most economists will tell you.
Even amid all this action, we have virtually ignored the complex weave of issues beneath the issues: meager savings, a debt addiction, a congenitally spendthrift political system, an almost pathological craving for stuff. And, with our topical cures, we should not be surprised to see new symptoms of the old maladies appearing: insurance again being packaged into derivatives, bonuses again soaring on Wall Street.
“We treat symptoms, and we do not look at the causes of the symptoms,” Deepak Chopra, the famed alternative-medicine and wellness guru, said when asked to extend the wellness metaphor to the economy. “We are totally at this moment looking at it in a reductionist manner. The reductionist manner is a bailout. And somehow that’s supposed to solve the problem, whereas the problem occurred because we were thinking reductively.”
Look within.
Wellness sees the causes of and remedies for ailments as lying within us.
Avoid infection by building immunity. Defeat disease by eating foods that help the body heal itself.
With the economy, we look everywhere but within. It’s the fault of greedy Wall Street bankers. It’s Washington’s fault. Bush’s fault. Obama’s fault. Greenspan’s fault. Somebody fix it!
But what about us? Why can’t we acknowledge that it was us who bought all those unaffordable houses, us who listened to that zero-gravity financial “advice,” us who bought and bought and never kept a rainy-day fund? And why, in solving the problem, do we expect the state to create substitute dynamism instead of renewing the culture of decentralized dynamism that made the U.S. economy so vital to begin with?
“Conventional medicine is very unbalanced in placing all its emphasis on external interventions rather than looking to advance that internal capacity to maintain healing,” said Andrew Weil, founder of the Arizona Center for Integrative Medicine and the author of several books on wellness. Likewise with the economy, he said: “Instead of simply identifying external threats and developing weapons and strategies against them, we should instead identify and strengthen immunity and resistance.”
A politics of wellness would transcend party. It would emphasize the up-front investments that Democrats like in order to achieve the long-run fiscal solvency on which Republicans insist. It would fulfill the liberal belief in a positive role for government in maintaining well-being but would honor the conservative conviction that government’s chief role is to help the social organism heal itself. It would acknowledge, with the left, the complex lattice of cultural and institutional influences that govern a society’s well-being, while emphasizing, with the right, the limits of what any external healer can do.
Think wellness in these hard times.
The most urgent problems, after all, may be the ones we haven’t had yet.
Parents who suspect that artificial ingredients in food are affecting their children’s behavior can now point to some cold, hard proof.
A carefully designed study released Thursday in The Lancet, a leading British medical journal, shows that a variety of common food dyes and the preservative sodium benzoate — an ingredient in many soft drinks, fruit juices, salad dressings and other foods — causes some children to become more hyperactive and distractible than usual.
“In terms of a question that’s been raging for years, it’s the best study to date — an extremely good study,” says Dr. Philip Shaw, a research psychiatrist in the Child Psychiatry branch of the National Institute of Mental Health.
The study prompted Britain’s Food Standards Agency to issue an immediate advisory to parents to limit their children’s intake of additives if they notice an effect on behavior. In the U.S., there’s been no such official response, but doctors say it makes sense for parents to be on the alert.
Meanwhile, the food industry is awaiting further research. “We take our responsibility to consumers seriously and will study the research finding in great detail,” says Cathy Cook, spokesperson for the International Association of Color Manufacturers.
The research, led by Jim Stevenson, a professor of psychology at England’s University of Southampton, involved about 300 children in two age groups: 3-year-olds and 8- and 9-year-olds. Over three one-week periods, the children were randomly assigned to consume one of three fruit drinks daily: one contained the amount of dye and sodium benzoate typically found in a British child’s diet, a second drink had a lower concentration of the additives, and a third was additive-free. All the children spent a week drinking each of the three mixtures, which looked and tasted alike. During each weeklong period, teachers and parents, who did not know which drink the kids were getting, used a variety of standardized behavior-evaluation tools — some observational and one computer-based — to size up such qualities as restlessness, lack of concentration, fidgeting, and talking or interrupting too much.
Stevenson found that children in both age groups were significantly more hyperactive when drinking the stuff containing additives.
Three-year-olds had a bigger response than the older kids to the lower dose of additives — roughly the same amount of food coloring as in two 2-oz. bags of candy. And, there were big individual differences in sensitivity. While the effects were not nearly so great as to cause full-blown ADHD, Stevenson nonetheless warns that “these adverse effects could affect the child’s ability to benefit from the experience of school.”
He notes that a separate pilot study found that kids can become more hyperactive within one hour of consuming food additives.
The Lancet study is the first to nail down a link between artificial ingredients and hyperactivity, though the connection has long been suspected and was the basis for the Feingold Diet, which eliminates all artificial colors, flavors, sweeteners and preservatives and was popularized in the 1970s as a treatment for ADHD. Though such a diet alone is not a proven treatment for ADHD, some clinicians routinely advise parents of kids with ADHD to stick with a more natural diet.” I’m not maniacal about it, but I tell parents that your kid will do better if they are on a diet that is free of additives and junk food,” says psychiatrist Edward Hallowell, author a several books on ADHD. “I urge them to eat whole foods; they’ll be healthier anyway.”
Now that a link has been found, researchers will be looking to confirm the British study and build upon it. “My guess is that if we do similarly systematic work with other additives, we’d learn they, too, have implications for behavior,” says Dr. James Perrin, professor of pediatrics at Harvard. “My friends who study the food industry say we have about 70,000 new products a year, so children are facing tremendous numbers of new opportunities for things that may not be good for them.” The study, he says, is one more reason to cheer the movement toward organic and natural foods.
When it comes to dieting, most of us are willing to resort to a trick or two to help us curb our appetite and eat less
— drinking water to fill up when we’re hungry, for example, or opting for artificial sweeteners instead of sugar to get the same satisfying sweetness without the offending calories.
But new research suggests that the body is not so easily fooled, and that sugar substitutes are no key to weight loss —
perhaps helping to explain why, despite a plethora of low-calorie food and drink, Americans are heavier than ever.
In a series of experiments, scientists at Purdue University compared weight gain and eating habits in rats whose diets were supplemented with sweetened food containing either zero-calorie saccharin or sugar. The report, published in Behavioral Neuroscience, presents some counterintuitive findings: Animals fed with artificially sweetened yogurt over a two-week period consumed more calories and gained more weight — mostly in the form of fat — than animals eating yogurt flavored with glucose, a natural, high-calorie sweetener. It’s a continuation of work the Purdue group began in 2004, when they reported that animals consuming saccharin-sweetened liquids and snacks tended to eat more than animals fed high-calorie, sweetened foods. The new study, say the scientists, offers stronger evidence that how we eat may depend on automatic, conditioned responses to food that are beyond our control. (See a special report on the science of appetite.)
What they mean is that like Pavlov’s dog, trained to salivate at the sound of a bell, animals are similarly trained to anticipate lots of calories when they taste something sweet — in nature, sweet foods are usually loaded with calories. When an animal eats a saccharin-flavored food with no calories, however — disrupting the sweetness and calorie link — the animal tends to eat more and gain more weight, the new study shows. The study was even able to document at the physiological level that animals given artificial sweeteners responded differently to their food than those eating high-calorie sweetened foods. The sugar-fed rats, for example, showed the expected uptick in core body temperature at mealtime, corresponding to their anticipation of a bolus of calories that they would need to start burning off — a sort of metabolic revving of the energy engines. The saccharin-fed animals, on the other hand, showed no such rise in temperature. “The animals that had the artificial sweetener appear to have a different anticipatory response,” says Susan Swithers, a professor of psychological sciences at Purdue University and a co-author of the study. “They don’t anticipate as many calories arriving.” The net result is a more sluggish metabolism that stores, rather than burns, incoming excess calories.
Swithers stops short of saying that the animals in her study were compelled to overeat to compensate for phantom calories. But she says that the study does suggest artificial sweeteners somehow disrupt the body’s ability to regulate incoming calories. “It’s still a bit of a mystery why they are overeating, but we definitely have evidence that the animals getting artificially sweetened yogurt end up eating more calories than the ones getting calorically sweetened yogurt.”
Though it’s premature to generalize based on animal results that the same phenomena would hold true in people, Swithers says, she notes that other human studies have already shown a similar effect. A University of Texas Health Science Center survey in 2005 found that people who drink diet soft drinks may actually gain weight; in that study, for every can of diet soda people consumed each day, there was a 41% increased risk of being overweight. So even though her findings were in animals, says Swithers, they could lead to a better understanding of how the human body responds to food, and explain why eating low-calorie foods doesn’t always lead to weight loss. “There is lots of evidence that we learn about the consequences about eating food,” she says. “And we have physiological responses to food that are conditioned.”
So does that mean you should ditch the artificial sweeteners and welcome sugar back into your life?
Not exactly. Excess sugar in the diet can lead to diabetes and heart disease, even independent of its effect on weight. But it’s worth remembering that when it comes to counting calories, it’s not just the ones you eat that you have to worry about. The calories you give up matter too, and they may very well reappear in that extra helping of pasta or dessert that your body demands. Your body may actually be keeping better count than you are.
Artificial Sweeteners: How Bad Are Saccharin, Aspartame?
By CLAIRE SUDDATH Claire Suddath – Tue Oct 20, 3:20 pm ET
Too much sugar will make you fat, but too much artificial sweetener will … do what exactly?
Kill you? Make you thinner? Or have absolutely no effect at all? This week marks the 40th anniversary of the Food and Drug Administration’s decision to ban cyclamate, the first artificial sweetener prohibited in the U.S., and yet scientists still haven’t reached a consensus about how safe (or harmful) artificial sweeteners may be. Shouldn’t we have figured this out by now?
The first artificial sweetener, saccharin, was discovered in 1879 when Constantin Fahlberg, a Johns Hopkins University scientist working on coal-tar derivatives, noticed a substance on his hands and arms that tasted sweet. No one knows why Fahlberg decided to lick an unknown substance off his body, but it’s a good thing he did. Despite an early attempt to ban the substance in 1911 – skeptical scientists said it was an “adulterant” that changed the makeup of food – saccharin grew in popularity, and was used to sweeten foods during sugar rationings in World Wars I and II. Though it is about 300 times sweeter than sugar and has zero calories, saccharin leaves an unpleasant metallic aftertaste. So when cyclamate came on the market in 1951, food and beverage companies jumped at the chance to sweeten their products with something that tasted more natural. By 1968, Americans were consuming more than 17 million pounds of the calorie-free substance a year in snack foods, canned fruit and soft drinks like Tab and Diet Pepsi. (See nine kid foods to avoid.)
But in the late 1960s, studies began linking cyclamate to cancer. One noted that chicken embryos injected with the chemical developed extreme deformities, leading scientists to wonder if unborn humans could be similarly damaged by their cola-drinking mothers. Another study linked the sweetener to malignant bladder tumors in rats. Because a 1958 congressional amendment required the FDA to ban any food additive shown to cause cancer in humans or animals, on Oct. 18, 1969, the government ordered cyclamate removed from all food products. (See the 10 worst fast-food meals.)
Saccharin became mired in controversy in 1977, when a study indicated that the substance might contribute to cancer in rats. An FDA move to ban the chemical failed, though products containing saccharin were required to carry warning labels. In 2000, the chemical was officially removed from the Federal Government’s list of suspected carcinogens. (Read TIME’s 1974 article on cyclamate and saccharin.)
In 1981, the synthetic compound aspartame was approved for use, and it capitalized on saccharin’s bad publicity by becoming the leading additive in diet colas. In 1995 and 1996, misinformation about aspartame that linked the chemical to everything from multiple sclerosis to Gulf War syndrome was widely disseminated on the Internet. While aspartame does adversely effect some people – including those who are unable to metabolize the amino acid phenylalanine – it has been tested more than 200 times, and each test has confirmed that your Diet Coke is safe to drink. Nor have any health risks been detected in more than 100 clinical tests of sucralose, a chemically altered sugar molecule found in food, drinks, chewing gum and Splenda.
The fear-mongering and misinformation plaguing the faux-sweetener market seems to be rooted in a common misconception.
No evidence indicates that sweeteners cause obesity; people with weight problems simply tend to eat more of it. While recent studies have suggested a possible link between artificial sweeteners and obesity, a direct link between additives and weight gain has yet to be found.
The general consensus in the scientific community is that saccharin, aspartame and sucralose are harmless when consumed in moderation.
And while cyclamate is still banned in the U.S., many other countries still allow it; it can even be found in the Canadian version of Sweet’n Low. Low-calorie additives won’t make you thinner or curb your appetite. But they help unsweetened food taste better without harming you. And that’s sweet enough.
A UA.Net note, In Chinese medicine the perception of the taste of sweet triggers the brain to respond to sweet and effects the body in an individual way, depending on body type and personal makeup.
The Neuroimmune Basis of Anti-inflammatory Acupuncture
Ben Kavoussi, MS
Southern California University of Health Sciences, College of Acupuncture and Oriental Medicine, Whittier, CA, kavoussi@ucla.edu
B. Evan Ross, DOM, LAc
Cedars-Sinai Medical Center, Department of Medicine, Los Angeles, CA
This review article presents the evidence that the anti-inflammatoryactions of acupuncture are mediated via the reflexive centralinhibition of the innate immune system.
Both laboratory andclinical evidence have recently shown the existence of a negativefeedback loop between the autonomic nervous system and the innateimmunity.
There is also experimental evidence that the electricalstimulation of the vagus nerve inhibits macrophage activationand the production of TNF, IL-1ß , IL-6, IL-18, andother proinflammatory cytokines.
It is therefore conceivablethat along with hypnosis, meditation, prayer, guided imagery,biofeedback, and the placebo effect, the systemic anti-inflammatoryactions of traditional and electro-acupuncture are directlyor indirectly mediated by the efferent vagus nerve activationand inflammatory macrophage deactivation.
In view of this commonphysiological mediation, assessing the clinical efficacy ofa specific acupuncture regimen using conventional double-blindplacebo-controlled trials inherently lacks objectivity due to(1) the uncertainty of ancient rules for needle placement, (2)the diffuse noxious inhibitory control triggered by control-needlingat irrelevant points, (3) the possibility of a dose-responserelationship between stimulation and effects, and (4) the possibilityof inadequate blinding using an inert sham procedure. A moreobjective assessment of its efficacy could perhaps consist ofmeasuring its effects on the surrogate markers of autonomictone and inflammation.
The use of acupuncture as an adjuncttherapy to conventional medical treatment for a number of chronicinflammatory and autoimmune diseases seems plausible and shouldbe validated by confirming its cholinergicity.
Sick but at work? Study finds it’s worse in the long-run
Thu Jun 11, 1:03 am ET
SYDNEY (Reuters Life!) – Sick but still going to work?
You’ll probably end up taking more sick days in the future than colleagues who stay at home when unwell,
according to a Swedish study.
Researchers at the Karolinska Institutet of Stockholm found that employees who often go to work feeling sick — termed “sickness presenteeism” – have higher rates of future work absences due to illness.
Gunnar Bergstrom, who led the study, said these findings suggest that measures attempting to decrease work absences could inadvertently have the opposite effect and show that taking sick-leave when appropriate benefited the workplace.
“Discouraging workers from staying home when they are sick could lead to increased sickness presenteeism, and thus inadvertently increase sick leave,” Bergstrom said in a statement.
“This underscores the importance of sickness presenteeism in the evaluations of such interventions and considering the effects from a long-term perspective.”
The study, published in the June issue of the Journal of Occupational and Environmental Medicine, was based on research involving two groups of workers — about 3,750 public sector employees who were mainly female, and 2,500 private-sector employees who were mainly male. In the first year of the study, 19 percent of public sector workers and 13 percent of private sector workers had more than five “sickness presenteeism” days.
For these workers, the risk of having more than 30 days of sickness absenteeism the following year was 40 to 50 percent higher that for employees who had less days sick in the office, after adjustment for other factors.
Bergstrom said recent studies have shown that sickness presenteeism is common, with most employees saying they go to work sick at least sometimes.
Poor health is one likely risk factor for sickness presenteeism, but other job-related and personal factors could also play a role, according to the researchers.
(Writing by Belinda Goldsmith, Editing by Miral Fahmy)
Psychological Stress Impairs Early Wound Repair Following Surgery
Elizabeth Broadbent, MSc, Keith J. Petrie, PhD, Patrick G. Alley, MBChB, FRACS and Roger J. Booth, PhD
From the Departments of Health Psychology (E.B., K.J.P.) and Molecular Medicine and Pathology (R.J.B.), Faculty of Medical and Health Sciences, University of Auckland; and the Department of Surgery (P.G.A.), Waitemata Health, Auckland, New Zealand.
ABSTRACT
OBJECTIVE: Laboratory studies have demonstrated that psychologicalstress is associated with slower healing of small superficialwounds. The application of this finding to the clinical environmenthas not yet been undertaken. In order to do this, we investigatedthe relationship between psychological stress and wound repairin patients following routine surgery.
METHODS: Forty-seven adults with an inguinal hernia were givena standardized questionnaire assessing psychological stressand worry about the operation before undergoing open incisionrepair. Wound fluid was collected from 36 participants overthe first 20-hour postoperative period. Wound healing was assessedby levels of interleukin-1, interleukin-6, and matrix metalloproteinase-9in the fluid. Other outcome measures included patient self-reportsof recovery, as well as cytokine response to lipopolysaccharidestimulation of peripheral blood.
RESULTS: Greater preoperative perceived stress significantlypredicted lower levels of interleukin-1 in the wound fluid (ß= -0.44, p = 0.03). Greater worry about the operation predictedlower levels of matrix metalloproteinase-9 in the wound fluid(ß = -0.38, p = 0.03) as well as a more painful (ß= 0.51, p = 0.002), poorer (ß = -0.36, p = 0.04),and slower recovery (ß = 0.43, p = 0.01).
CONCLUSIONS: Psychological stress impairs the inflammatory responseand matrix degradation processes in the wound immediately followingsurgery. This finding generalizes previous laboratory researchto surgical patients and expands the known influence of stressto connective tissue matrix remodelling processes. These resultssuggest that in clinical practice, interventions to reduce thepatient’s psychological stress level may improve woundrepair and recovery following surgery.
Previous laboratory work with both animal and human subjectshas shown that stress decreases the speed of wound healing.
Stressed mice produce higher levels of glucocorticoids and displayless inflammation in the first 3 days after wounding, impairedbacterial clearance, and slower healing than their nonstressedcounterparts (1, 2). Laboratory studies have also shown thatpsychological stress impairs the healing of small puncture woundsin humans. Women caring for relatives with Alzheimer’sdisease reported greater stress and demonstrated 24% slowerhealing of dermal punch biopsy wounds than did matched controlsubjects (3). Similarly, punch biopsy wounds in the hard palatesof students healed on average 40% more slowly during an examinationperiod than in the same students during vacation time (4). Bothof these studies found that higher stress was associated witha poorer IL-1 response to LPS-stimulated peripheral blood. Thisis consistent with the hypothesis that stress impairs woundhealing via immune processes.
Wound repair involves a number of progressing stages.
In theinitial stages the pro-inflammatory cytokines, including IL-1and IL-6, attract phagocytes to the wound which remove infectiousagents and prepare the site for the growth of new tissue (5).The cytokines also regulate the production and activation ofmatrix metalloproteinase enzymes, which are involved in thedegradation of collagen. MMP-9 facilitates cellular invasionand migration in the wound by degrading basement membranes (6).This is necessary to allow the recruitment of cells involvedin tissue regeneration. Measuring cytokine and metalloproteinaseconcentrations in the wound provides an effective way to monitorrepair processes. Previous research has found that women whoreport higher psychological stress have lower levels of IL-1and IL-8 in laboratory-induced blister wounds than do otherwomen (7), suggesting that stress impairs the inflammatory stageof wound repair.
Wound healing is a critical outcome in surgery. Poor healingcan result in wound infections or complications, as well asprolong hospital stays, increase patient discomfort, and delayreturn to activity. While previous research has establishedthe deleterious effects of stress in laboratory settings, therehas previously been no work examining the effect of stress onwound healing in clinical settings. The aim of this study wasto investigate the effects of stress on wound repair in patientsfollowing surgery. Based on previous research, we hypothesizedthat higher levels of stress would be associated with reducedinflammatory and matrix degradation processes in the early stagesof repair.
METHODS
Participants
Participants were inguinal hernia patients booked for electiveopen surgery at North Shore Hospital, Auckland, New Zealand.Excluded from the study were those whose hernia was bilateralor recurrent because larger operations and those performed onprevious operation sites could adversely affect healing. Alsoexcluded were those who were on any form of medication thataffected their immune status and patients who had any illnessesknown to influence immune function or impair cognitive ability.Consecutive sampling of patients older than 16 years referredto the preoperative clinic was used. Fifty-five patients whomet the inclusion and exclusion criteria were invited to participatein the study. Four patients declined to take part in the research(93% participation rate). Refusers did not differ from participantson any demographic variables. Four patients who were enrolledin the study had their operation postponed beyond the completiondate of the study. The participants receiving surgery comprised41 males and 6 females, aged between 16 and 86 years (mean =63.36 years, SD = 16.42 years). They were predominantly Europeanand two were from other racial groups. Twelve of the participantswere smokers.
Of the 47 patients who received surgery, wound fluid data werenot available from eight participants because wound drains wereinadvertently not inserted by the surgeon. Three patients’wound fluids were excluded from the analysis: two due to blockagein wound drains and one due to a myocardial infarction whilerecovering in hospital, which has been shown to affect cytokinelevels (8). These patients did not differ from other participantson any variables. The final sample size used in wound fluidanalyses was therefore 36. Forty-two participants attended theirscheduled follow-up visit and returned their postoperative questionnaires(89%).
The study was granted ethics approval by the Ministry of HealthEthics Committee. Recruitment began in mid-April and continueduntil mid-October 2001.
Procedures
Patients with inguinal hernia were admitted through the surgicalunit by a standard protocol of preadmission and anesthetic assessment.At the preadmission clinic 1 week before surgery, participantscompleted a preoperative questionnaire and gave a blood sample.The surgical procedure followed a standard protocol in whichthe groin was exposed through a skin crease incision measuringapproximately 6 cm. The external oblique muscle was divided,and the ilioinguinal and iliohypogastric nerves were preserved.The hernial sac was excised and a nontension mesh repair usingprolene mesh was carried out. The mesh was sutured to the conjointtendon and the deep aspect of the inguinal ligament with prolene.The muscles were repaired with nonabsorbable suture and theskin closed with subcuticular absorbable suture. Before closure,a manovac drain (Medinorm, French gauge 6, 40 ml) was insertedabove the outer muscle layer to drain the wound. No significantlocal or general complications occurred in study participants.Pain was controlled by a standard range of narcotic and nonnarcoticanalgesics. In the first 6 hours intravenous morphine by patient-controlledpump (dosage range 1–3 mg/ml) was used. Thereafter untildischarge, nonsteroidal anti-inflammatory agents and paracetamolwere used. Thirty-seven of the operations were performed undergeneral anesthetic and 10 were performed using spinal anesthetic.
Patients stayed overnight in the ward where the drains wereremoved 20 hours following surgery. Patients attended an outpatientclinic 1 week after surgery. At this clinic, the research surgeontook a blood sample and gave the participants a postoperativequestionnaire to return by mail.
Preoperative Questionnaire
The 10-item Perceived Stress Scale (9) was used to assess thedegree to which participants found their daily lives over thepast 4 weeks to be unpredictable, uncontrollable, and overloading.Subjects rated their responses from “never” (0) to “very often”(4). Cronbach’s alpha for the scale was 0.87 (mean = 13.14,SD = 6.66).
Respondents rated how worried they were currently feeling abouttheir operation on a 100-mm visual analogue scale ranging from“not at all worried” (0) to “extremely worried” (100), (mean= 28.45, SD = 28.24).
The Mental Health Index (10) was used as an indicator of negativeaffect. Five items asked how frequently participants experienceddepression, anxiety, behavioral/emotional control, and positivemood states over the past month on a six-point Likert scalefrom “none of the time” to “all of the time.” Higher scoresindicate lower levels of negative affect. Cronbach’s alphafor the scale was 0.86 (mean = 74.65, SD = 21.29).
Data were also collected on whether participants smoked, theiralcohol consumption in the past 3 months, the amount of strenuousexercise they did in an average week, and the amount of sleepthey obtained in the past week because these variables all havethe potential to influence immune parameters (11). Age, gender,and ethnicity were recorded from medical records.
Postoperative Questionnaire
Outcome variables included two 100-mm visual analogue scalesfor pain experienced since the operation (ranging from “no pain”to “extreme pain”) and self-assessed surgical recovery (rangingfrom “poor” to “excellent”). Patients were also asked to estimatehow many days it would take them from that day forward to feellike they were back to normal.
Peripheral Blood Analysis
Blood samples were collected in 4-ml heparinized tubes. Theblood was divided into ten 250-µl aliquots and each wasadded to a 20-µl aliquot of 13.5 mg/l LPS in a 96-wellmicrotiter tray (Nunclon brand, cat. no. 163320, batch no. 057743)and incubated for 24 hours at 37°C (3% CO2 and 96% humidity).Culture supernatants were collected, pooled, and frozen at -20°Cuntil the end of data collection when they were analyzed fortheir IL-1ß and IL-6 content using a standard sandwichELISA technique using monoclonal capture antibodies and polyclonaldetection antibodies (R&D Systems, Minneapolis, MN).
Wound Fluid Analysis
Wound drain fluid was transferred to 10-ml plastic tubes, centrifugedat 2000 rpm for 5 minutes, and the plasma recovered and storedfrozen at -20°C. When all the samples had been collected,they were assayed for MMP-9 using an ELISA system (AmershamPharmacia Biotech UK Ltd, code RPN 2614, batch no. 185867) andfor their IL-1ß and IL-6 content using a standardsandwich ELISA technique.
Statistical Analysis
The data were analyzed using SPSS version 10 software. Meansand reliabilities of scales were calculated and data checkedfor normal distributions. The relationships between variableswere investigated using Pearson correlation coefficients, andscatter plots were run to check for linearity of relationships.Hierarchical multiple linear regression analyses were run toassess how stress and worry affected wound repair and self-ratedsurgical outcomes, after first controlling for possible confoundingfactors.
Within the distributions of the cytokine data, five cases wereidentified as outliers. Each outlier was on a different cytokinevariable, and each was a different participant. Thus cytokinedata were log-transformed to create normal distributions (12).
RESULTS
Hierarchical multiple regression analyses were conducted topredict the immune markers of wound repair from perceived stressand worry about surgery after controlling for age, gender, exercise,alcohol intake, sleep, smoking, and type of anesthetic . These control variables did not significantly predictany variance in IL-1 concentration in the wound fluid. Perceivedstress significantly accounted for 17% of the variance in IL-1in the wound fluid over and above the control variables. Higherstress predicted lower IL-1 in the wound fluid as shown in figure 1.
The concentration of MMP-9 in the wound fluid increased in alinear relationship with IL-6 (r = 0.59, p < 0.01), indicatingthat matrix remodelling was linked to inflammatory processes.The hierarchical multiple regression analysis showed that afterentering the control variables and perceived stress, worry aboutsurgery significantly predicted 12% of the variance in MMP-9concentration over and above the previous steps. As shown inTable 2, nonsmoking patients and those with greater worry aboutsurgery had a significantly lower concentration of MMP-9 intheir wound fluid.
A hierarchical regression analysis to predict IL-6 in the woundfluid from control variables, perceived stress, and worry aboutsurgery was not significant (all p values >0.05). Similarregression analyses conducted to predict the concentrationsof IL-1 and IL-6 in LPS-stimulated blood samples were also notsignificant (all p values >0.05).
Three hierarchical multiple regression analyses were run topredict self-rated postsurgical pain, recovery, and time toreturn to normal from perceived stress and worry about surgery,after controlling for age, gender, type of anesthetic, and negativeaffect. The regression analyses showed that none of the controlvariables nor perceived stress were significantly related toself-report outcomes. However, worry about surgery significantlypredicted 23% of the variance in postsurgical pain [R2 change= 0.23, F change (1,33) = 11.97, p = 0.002], 12% of the variancein quality of recovery [R2 change = 0.12, F change (1,33) =4.60, p = 0.04], and 16% of the variance in recovery time [R2 change = 0.16, F change (1,33) = 7.00, p = 0.01], over and abovethe control variables. Greater worry predicted greater pain(ß = 0.51, p = 0.002), poorer self-rated recovery(ß = -0.36, p = 0.04), and longer recovery time (ß= 0.43, p = 0.01). The correlations between the physiologicaloutcome variables and the self-reported outcome variables werenot statistically significant.
This study found that higher reported psychological stress beforesurgery predicted lower cellular wound repair processes in theearly postoperative period. Patients who reported greater perceivedstress for the month before surgery had lower levels of IL-1in their surgical wounds. Furthermore, patients reporting greaterworry about their upcoming surgery had lower levels of MMP-9in the wound site. These findings are consistent with earlierlaboratory research that has shown stress to impair inflammatoryprocesses in the wound (7) and extend the influence of stressto the matrix degradation stage of wound repair.
Consistent with earlier research (6), this study found a positivecorrelation between MMP-9 and IL-6 in the wound fluid. Thislink with the inflammatory response provides theoretical supportfor the association between worry about the operation and lowerMMP-9 levels. Stress-induced glucocorticoid secretion may nonspecificallyimpair the inflammatory response, which in turn may impair MMP-9production, although this argument is weakened by the lack ofrelationship between IL-1 and IL-6, and between IL-1 and MMP-9.It is also possible that glucocorticoids may directly influencethe production of MMP-9, although there is currently littleliterature on this proposed relationship. Some evidence suggeststhat norepinephrine and cortisol can modulate levels of anothermetalloproteinase involved in wound healing, MMP-2 (13). Theremay be different effects on immune function from acute worry(about the operation) and more longer-term stress.
The finding that worry was associated with lower levels of MMP-9is further evidence for the ability of psychological processesto impair wound healing because MMP-9 is an enzyme criticalto tissue reconstruction. However, the implications of thisfinding may extend to tissue remodelling in other processesnot associated with wound healing, such as airway remodelling(14). The impact of worry on MMP-9 may therefore affect medicalconditions outside of surgical wound healing.
The finding that MMP-9 concentration was higher among smokersis also consistent with earlier work. Airway macrophages insmokers have been found to produce more MMP-9 at baseline andin response to IL-1ß and LPS than those of nonsmokers(14). Smoking may be associated with higher baseline levelsof MMP-9 in a number of body tissues and therefore prolongedhigh levels of MMP-9 in the wound. Prolonged elevation of MMP-9levels has been associated with chronic nonhealing of wounds(15, 16). Slower wound repair has been well recognized in smokerson a clinical level for many years, and studies have found thatsmokers have an increased incidence of skin sloughing afterface-lift surgery, a higher rate of skin-flap and breast surgerycomplications, and worse scarring after surgery than nonsmokers(17). The mechanisms remain largely unknown, but nicotine isknown to increase catecholamine release, which causes vasoconstrictionand reduces oxygen flow to the wound, and to reduce fibroblastand macrophage production. Recent work in this area has foundsmokers to have significantly higher levels of MMP-8 and lowercollagen synthesis in blister wounds than nonsmokers (18).
It is important to recognize that levels of cytokines from LPS-stimulatedblood cultures may not necessarily reflect what is happeningat a local wound site. This is borne out by the stronger relationshipof stress to wound fluid markers than with blood-derived measures.However, the small sample size may have limited the abilityof the study to detect significant effects in blood-derivedmeasures. In previous work, higher preoperative stress has beenassociated with a lower lymphocyte response and lower lymphocytecounts in the blood following surgery (19).
In addition to lower wound remodelling processes, presurgicalworry was also associated with greater postoperative pain, poorerself-rating of recovery, and a longer recovery time. The findingthat worry about the procedure predicted these self-reportedrecovery outcomes while general stress and negative affect didnot do so suggests that it is not stress per se that causespeople to experience greater pain and distress after surgerybut more specifically it is concern about the operation. Thismay be related to previous work that suggests a mediating rolefor self-focused attention in symptom reporting (20). Patientswho are more worried may pay more attention to their woundsand notice signs of pain and discomfort more than their lessworried counterparts.
A limitation of this study is that participants’ use ofpain medication was not recorded and controlled for in the analyses.It is possible that the more stressed individuals used morepain medication, which could have influenced immune responses.However, we consider this unlikely as reported postsurgicalpain was not significantly related to either perceived stressor to any of the immune variables.
This study extends earlier laboratory wound healing researchto an everyday clinical surgical setting. By examining IL-1,IL-6, and MMP-9 (an enzyme not previously studied in stressresearch), the data provide further support for the influenceof stress on wound healing at the cellular wound repair level.This current study suggests that interventions designed to reducepresurgical stress, which have previously been found to shortenlength of hospital stay, and to reduce postoperative complications,pain, and distress (21), may also improve wound repair.
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