David Spiegel

Bio: David Spiegel is an academic researcher from Stanford University. The author has contributed to research in topics: Medicine & Breast cancer. The author has an hindex of 106, co-authored 733 publications receiving 46276 citations. Previous affiliations of David Spiegel include Tel Aviv University & University of Adelaide.

Self-hypnotic relaxation during interventional radiological procedures: effects on pain perception and intravenous drug use.

Abstract: The authors evaluated whether self-hypnotic relaxation can reduce the need for intravenous conscious sedation during interventional radiological procedures. Sixteen patients were randomized to a test group, and 14 patients were randomized to a control group. All had patient-controlled analgesia. Test patients additionally had self-hypnotic relaxation and underwent a Hypnotic Induction Profile test. Compared to controls, test patients used less drugs (0.28 vs. 2.01 drug units; p < .01) and reported less pain (median pain rating 2 vs. 5 on a 0-10 scale; p < .01). Significantly more control patients exhibited oxygen desaturation and/or needed interruptions of their procedures for hemodynamic instability. Benefit did not correlate with hypnotizability. Self-hypnotic relaxation can reduce drug use and improve procedural safety.

A Support Group for Dying Patients

Abstract: Confrontation with the inevitability of one’s death has long been considered a necessary part of authentic living. Philosophers from Plato to the twentieth-century existential thinkers have held that in order to learn to live well, one must first learn to die. But only comparatively recently have clinicians sought to help dying patients and their families integrate the knowledge of impending death with they way they live their lives. The time of facing death is one of sadness and mourning, but it is also a time of reorientation and a time of reconsidering one’s values, one’s priorities, and one’s sense of meaning in life. In this article, we shall describe a group approach to the care of the dying patient, an approach which ministers both to the anguish of dying and to the vitality which a confrontation with death may stimulate in the life which remains to the patient.

Mind Matters in Cancer Survival

Abstract: The field of psycho-oncology is hung up on the hyphen in its name. How do we understand the link between mind and body? Is that hyphen merely an arrow to the left, indicating that cancer in the body affects the mind? Can it be an arrow to the right as well, mind affecting the course of cancer? We know that social support affects survival, 1 including that with cancer.2 Also, people tend to die after rather than before their birthdays and major holidays.3,4 Depression worsens survival outcome with cancer.5,6 Yet we have been understandably delicate about mind-body influence, not wanting to claim too much, or to provide unwitting support for overstated claims that wishing away cancer or picturing white blood cells killing cancer cells would actually do it. That arrow to the right is a connection, not a superhighway. Yet in our desire to be respected members of the oncology community we have often minimized a natural ally in the battle against cancer – the patient’s physiological stress coping mechanisms. Even at the end of life, helping patients face death, make informed decisions about level of care, and controlling pain and distress is not only humane but appears to be medically more effective than simply carrying on with intensive anti-cancer treatment alone.7 A recent randomized clinical trial of palliative care for non-small cell lung cancer patients8 makes that case strongly. The authors reported a clear but apparently paradoxical finding: “Despite receiving less aggressive end-of-life care, patients in the palliative care group had significantly longer survival than those in the standard care group (median survival, 11.65 vs. 8.9 months; P=0.02)” (p. 738). Those randomized to palliative care became less depressed as well. The palliative care condition consisted of an average of 4 visits that focused on choices about resuscitation preferences, pain control, and quality of life. The study suggests that at the end of life the most aggressive treatments may not be the most effective, not only psychologically, but also medically. How could living better at the end of life lead to living longer? When we began to investigate the effects of support groups for people with cancer in the 1970’s, we and others were concerned that watching others die of the same disease would demoralize patients, and might even hasten their death. We evaluated mood and discussion content minute-by-minute to determine whether bad news about other group members was despressogenic. We found that these women with advanced breast cancer talked more seriously about death and dying, but showed no signs of depression or panic.9 Indeed our initial studies, confirmed by many others, indicated that we reduced distress and pain.10,11 But now the results are showing something more profound than reduced distress and pain or feeling better, they are showing that facing death better helps people to live longer with cancer. We reported in 1989 the results of a clinical trial demonstrating that women with metastatic breast cancer randomized to a year of weekly group therapy lived 18 months longer than control patients, and that the difference was not due to differences in initial disease severity or subsequent chemo- and radiotherapy. The result of this 10 year study, cited at last count on Google Scholar 2,222 times, was first greeted with great excitement and later skepticism. Now 21 years later, the findings are being confirmed. A decade later we conducted an IRB-approved replication study that showed no overall effect of a similar group therapy on breast cancer survival, but a significant interaction with tumor type, such that those with estrogen receptor negative cancers who were randomized to group therapy lived significantly longer than did ER negative patients receiving standard care alone.12 While this is a clear disconfirmation of the hypothesis that facing death together could improve survival, major advances in hormonal and chemotherapies had improved overall survival for women with metastatic breast cancer in the interim.13 However, women with ER negative tumors were largely excluded from the benefit of hormonal treatments, which could account for the difference in findings.13 Further support for this explanation comes from the fact that overall survival of our cohorts of women with metastatic breast cancer has improved over the decades (See Figure 1). Figure 1 Comparison of Survival across 3 Spiegel Metastatic Breast Cancer Studies More recently, a randomized trial of psychoeducational groups for women with primary breast cancer found both significantly reduced rates of relapse and longer survival. 14,15 In addition to this, our original study16, and the recent palliative care study referred to above,8 three other published randomized psychotherapy trials17–20 and one matched cohort trial21 have reported that psychosocial treatment for patients with a variety of cancers enhanced both psychological and survival outcome (See Table 1). However, six other published studies, 22–27 four involving breast cancer patients,24–27 found no survival benefit for those treated with psychotherapy. (See Table 2) Three of these six studies reported no emotional benefit from the interventions,23–25 making enhanced survival unlikely. In another major multicenter replication trial,26 Supportive-Expressive Group Psychotherapy did significantly reduce depression, but did not improve survival. However, the odd thing about this study is that the women randomized to treatment were more depressed to begin with, making their medical prognosis worse at baseline.6 Furthermore, the outcome of all of these studies is not random: no studies show that gathering cancer patients together in groups and directing their attention to emotional expression and mortality shortens survival.28 Table 1 Randomized Trials Showing Survival Benefit from Psychotherapy Table 2 Randomized Trials Showing No Survival Benefit of Psychotherapy The most provocative but also discordant results have occurred in studies of women with breast cancer, where treatment for ER positive and also human epidermal growth factor receptor 2-positive (HER2+) tumors has improved substantially. Among cancers with poorer medical prognosis, such as ER negative breast cancer, malignant melanoma, non-small cell lung cancer, leukemia, and gastrointestinal cancers, intensive emotional support seems to extend survival. Patients who benefit from a targeted and highly effective chemotherapeutic approach obtain less apparent survival benefit from emotional support than do those with less effective biomedical interventions. Thus, especially in the palliative settling in which aggressive anti-tumor treatments are less efficacious, supportive approaches become more useful. One would think that psychosocial support would have the least biomedical effect in more advanced cancers, and yet our original observation involved women with metastatic breast cancer. By the time someone dies with cancer, they usually have a kilogram of tumor in their body. Yet this may be when the body’s resources for coping with physiological as well as psychological stress matter the most.

Adjunctive vancomycin powder in pediatric spine surgery is safe.

Abstract: STUDY DESIGN Therapeutic level II cohort study. OBJECTIVE To evaluate the safety of adjunctive local application of vancomycin powder (VP) for infection prophylaxis in posterior instrumented thoracic and lumbar spine wounds in pediatric patients weighing more than 25 kg. SUMMARY OF BACKGROUND DATA Spine surgeons have largely turned to vancomycin prophylaxis in an attempt to decrease the incidence of late surgical site infection and acute surgical site infection from methicillin-resistant Staphylococcus aureus. In adult patients, the adjunctive local application of VP with an intravenous cephalosporin has been shown to decrease postsurgical wound infection rates significantly; however, the safety of VP as an adjunct in pediatric spine surgery has not been reported. METHODS We reviewed data collected under a systematic protocol specifically designed to monitor the safety profile of VP. We measured changes in creatinine and systemic vancomycin levels after intrawound application of 500 mg of unreconstituted VP during spine deformity correction surgery in patients weighing more than 25 kg (patients also received routine intravenous cephalosporin prophylaxis). Laboratory values were measured preoperatively and on postoperative days 1 and 4. Any adverse reactions and infections through available follow-up (2-8 mo) were recorded. RESULTS Eighty-seven consecutive pediatric patients with spinal deformity weighing more than 25 kg who received intraoperative VP during a 9-month period were identified. Sixty-three percent of the patients in this series had adolescent idiopathic scoliosis, 15% congenital scoliosis, 15% neuromuscular scoliosis, and 5% spondylolisthesis. The average change in creatinine levels between the preoperative and postoperative day 1 draw was -0.03 and between the preoperative and postoperative day 4 draw was -0.075. The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome. Three of the 87 patients developed a surgical site infection. CONCLUSION In this cohort there were no clinically significant changes in creatinine level or systemic vancomycin level caused by use of intraoperative VP. LEVEL OF EVIDENCE 2.

Effects of Psychosocial Treatment in Prolonging Cancer Survival May Be Mediated by Neuroimmune Pathways

Abstract: Research has provided growing evidence of links between the social environment and cancer progression. Indeed, social support in the form of marriage, frequent daily contact with others, and the presence of a confidant may all have protective value against cancer progression. Furthermore, retrospective data suggest that major stressful life events are more prevalent in patients with relapse or malignancy, and thus may contribute to cancer morbidity. Initial studies of the effects of psychosocial intervention with cancer patients have provided some promising results. In three randomized prospective trials, protective effects of psychosocial interventions on cancer progression have been confirmed, while one matching and one randomized study showed no survival effect after psychosocial treatment. Though more research is clearly needed in this area, this body of evidence suggests that psychosocial factors have potentially powerful modulating effects on the course of disease. Here we review evidence of one possible mechanism whereby psychosocial factors may influence disease-resistance capabilities: the neuroimmune connection. Suppressive effects of stress on immune function are well documented, and these effects have been shown to be modulated by social support. Thus, it is reasonable to hypothesize that supportive social relationships may buffer the effects of cancer-related stress on immunity, and thereby facilitate the recovery of immune mechanisms that may be important for cancer resistance. Data addressing this hypothesis are reviewed.

疟原虫var基因转换速率变化导致抗原变异[英]／Paul H, Robert P, Christodoulou Z, et al//Proc Natl Acad Sci U S A

Abstract: 抗原变异可使得多种致病微生物易于逃避宿主免疫应答。表达在感染红细胞表面的恶性疟原虫红细胞表面蛋白1（PfPMP1）与感染红细胞、内皮细胞、树突状细胞以及胎盘的单个或多个受体作用，在黏附及免疫逃避中起关键的作用。每个单倍体基因组var基因家族编码约60种成员，通过启动转录不同的var基因变异体为抗原变异提供了分子基础。

The Benefits of Being Present: Mindfulness and Its Role in Psychological Well-Being

Abstract: Mindfulness is an attribute of consciousness long believed to promote well-being. This research provides a theoretical and empirical examination of the role of mindfulness in psychological well-being. The development and psychometric properties of the dispositional Mindful Attention Awareness Scale (MAAS) are described. Correlational, quasi-experimental, and laboratory studies then show that the MAAS measures a unique quality of consciousness that is related to a variety of well-being constructs, that differentiates mindfulness practitioners from others, and that is associated with enhanced selfawareness. An experience-sampling study shows that both dispositional and state mindfulness predict self-regulated behavior and positive emotional states. Finally, a clinical intervention study with cancer patients demonstrates that increases in mindfulness over time relate to declines in mood disturbance and stress. Many philosophical, spiritual, and psychological traditions emphasize the importance of the quality of consciousness for the maintenance and enhancement of well-being (Wilber, 2000). Despite this, it is easy to overlook the importance of consciousness in human well-being because almost everyone exercises its primary capacities, that is, attention and awareness. Indeed, the relation between qualities of consciousness and well-being has received little empirical attention. One attribute of consciousness that has been much-discussed in relation to well-being is mindfulness. The concept of mindfulness has roots in Buddhist and other contemplative traditions where conscious attention and awareness are actively cultivated. It is most commonly defined as the state of being attentive to and aware of what is taking place in the present. For example, Nyanaponika Thera (1972) called mindfulness “the clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception” (p. 5). Hanh (1976) similarly defined mindfulness as “keeping one’s consciousness alive to the present reality” (p. 11). Recent research has shown that the enhancement of mindfulness through training facilitates a variety of well-being outcomes (e.g., Kabat-Zinn, 1990). To date, however, there has been little work examining this attribute as a naturally occurring characteristic. Recognizing that most everyone has the capacity to attend and to be aware, we nonetheless assume (a) that individuals differ in their propensity or willingness to be aware and to sustain attention to what is occurring in the present and (b) that this mindful capacity varies within persons, because it can be sharpened or dulled by a variety of factors. The intent of the present research is to reliably identify these inter- and intrapersonal variations in mindfulness, establish their relations to other relevant psychological constructs, and demonstrate their importance to a variety of forms of psychological well-being.

Standards of Medical Care in Diabetes

Abstract: XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.