Titel der Arbeit

Project “Singing Kindergartens” in Germany: A Cross-Sectional Multicenter Analysis of Education Through Singing

Comparing Effectiveness of HRV-Biofeedback and Mindfulness for Workplace Stress Reduction: A Randomized Controlled Trial. Applied Psychophysiology and Biofeedback, 2020.


Background: Accumulating evidence indicates that music promotes healthy development in young children. However, singing with children has decreased in modern western societies. Children spend increasingly more time in day care centers. Thus, educational institutions such as kindergartens or schools bear increased responsibility for music education.

Objective: To examine the experiences of German kindergarten teachers trained in the multicenter project “Singing Kindergartens” (SiKi).

Methods: This was a multicenter cross-sectional study carried out in Germany. Kindergarten teachers, employed in various locations throughout Germany, were asked to complete a web-based questionnaire anonymously regarding changes in their team, in themselves and in the children with respect to the time before (t0), during the training (t1), as well as the present (t2). Primary outcomes were “children’s joy” and their own “self-confidence” concerning singing. To benchmark the actual status regarding team atmosphere, commitment to work and job satisfaction, the AQUA questionnaire (“Workplace quality in children´s day care centers”) was used. Music teachers (trainers) and parents completed the questionnaire only with respect to the present status (t2).

Results: 578 participants completed the questionnaires—407 were kindergarten teachers, 80 were parents, with the remaining 91 being music teachers. For the primary outcomes statistically significant improvements occurred for “children´s joy” (mean difference t0-t1: -0.51; 95%CI: -0.57/-0.45; p<.001; d=.81; t0-t2: -0.59; 95%CI: -0.65/-0.52; p<.001; d=.80) and “self-confidence” (mean difference t0-t1: -0.70; 95%CI: -0.77/-0.62; p<.001; d=.79; t0-t2: -0.92; 95%CI: -1.00/-0.84; p<.001; d=.89) over time. When comparing SiKi to the AQUA study final report, results were similar for team atmosphere and job satisfaction (Cohen´s d <0.2), but higher for work commitment in the SiKi group (AQUA: M=4.2, SD=0.7; SiKi: M=4.4, SD=0.9; d=-.31). Kindergarten teachers, parents, and music teachers rated SiKi as “very good” (57.5-66.6%), with the highest grading from the kindergarten teachers’ group.

Conclusion: Singing programs appear to have a positive effect on students from the perspective of all adult participants (teachers, parents, and music teachers). Although encouraging, the retrospective nature of this pilot investigation and the absence of measures obtained from the kindergarten students themselves indicate further, more well-controlled investigations with longer term follow-up

Psychophysiological disorders due to work-related stress continue to be highly costly for health systems and approaches for cost-effective and easily accessible interventions are much needed. Both heart rate variability-biofeedback (HRV-Bfb) and mindfulness-based interventions (MBI) have been empirically shown to reduce stress. This study compares these two interventions in the work context to a wait-list-control-group (WLC). In this three-armed randomized controlled trial (RCT), 69 healthy adults employed in the same organization were randomized to participate in HRV-Bfb, MBI or the WLC. Participants were assessed for psychophysiological parameters of stress (stress perception, coping, HRV parameters and cortisol) and stress related symptoms (depressive symptoms, psychological wellbeing, mindfulness and self-compassion). Participants trained using either HRV-Bfb or MBI for 6 weeks on a daily basis. Outcomes were assessed at baseline, after the intervention and at follow-up 12 weeks later. Results did not show any statistically significant differences between HRV-Bfb and MBI groups, and neither of the intervention groups (IGs) differed from the WLC. Findings suggest an overall reduction in stress for all groups, including the WLC, with mostly small to medium effect sizes. However, it is important to note that participants with higher baseline stress levels might benefit more from mindfulness and biofeedback-based stress reduction interventions. The results have to be interpreted with caution due to the relatively small sample size. MBI might have a slightly stronger effect on stress reduction in comparison to HRV-Bfb, as suggested by the effect sizes. This study highlights issues and challenges of the implementation of such interventions in corporate health management.

Restrictive antibiotic use in children hospitalized for pneumonia: A retrospective inpatient study. European Journal of Integrative Medicine, 2020, 34 (2020), Article ID 101068.


Reducing antibiotic use is a global priority, but the extent to which antibiotic prescriptions can be reduced in children hospitalized for community-acquired pneumonia is unknown. This study aimed to analyse the prescribing experience from a facility with a long-standing practice of restrictive antibiotic use.


We conducted a retrospective analysis of children from birth to 18 years, hospitalized for pneumonia at an integrative medicine hospital in Germany. Antibiotic prescription rate and clinical outcomes were analyzed. The Moreno Bacterial Pneumonia Score, a composite laboratory, clinical and radiologic score, was applied to estimate the proportion of viral and bacterial pneumonia.


252 pneumonia episodes were included, with 172 categorized as probably viral and 80 as bacterial pneumonia. Antibiotic prescription rate was 32 % overall, 26 % for presumed viral and 51 % for presumed bacterial pneumonia. Children with probable bacterial pneumonia who were managed with antibiotics had higher CRP values than those managed without antibiotics (p < 0.001). 13 % of bacterial pneumonia episodes initially managed without antibiotics received antibiotics after hospital day 2. Hospitalization duration was longer for bacterial pneumonia episodes managed with antibiotics than those managed without (7.0 versus 4.9 days, p = 0.003).


The observed antibiotic prescription rate of 32 % was much lower than rates reported in the literature – 88–98 %. Children were safely managed with a restrictive antibiotic prescription strategy when physicians judged this to be appropriate. Our findings suggest that a delayed prescription strategy for childhood pneumonia deserves further study.

Trial registration

the study was registered at clinicaltrials.org, NCT03256474.

Gut dysbiosis and serotonin: intestinal 5-HT as a ubiquitous membrane permeability regulator in host tissues, organs, and the brain. Reviews in the Neurosciences, 2020, 31 (4), pages 415-425.

The microbiota and microbiome and disruption of the gut-brain axis were linked to various metabolic, immunological, physiological, neurodevelopmental, and neuropsychiatric diseases. After a brief review of the relevant literature, we present our hypothesis that intestinal serotonin, produced by intestinal enterochromaffin cells, picked up and stored by circulating platelets, participates and has an important role in the regulation of membrane permeability in the intestine, brain, and other organs. In addition, intestinal serotonin may act as a hormone-like continuous regulatory signal for the whole body, including the brain. This regulatory signal function is mediated by platelets and is primarily dependent on and reflects the intestine's actual health condition. This hypothesis may partially explain why gut dysbiosis could be linked to various human pathological conditions as well as neurodevelopmental and neuropsychiatric disorders.

Increasing Warmth in Adolescents with Anorexia Nervosa: A Randomized Controlled Crossover Trial Examining the Efficacy of Mustard and Ginger Footbaths. Evidence-Based Complementary and Alternative Medicine, 2020, Vol. 2020, Article ID 2416582.

Objective: To analyze the thermogenic effects of footbaths with medicinal powders in adolescents with anorexia nervosa (AN) in comparison to healthy controls (HCs). Intervention and Outcomes. Forty-one female participants (21 AN, 20 HCs; 14.22 ± 1.54 years) received three footbaths-warm water and mustard (MU, Sinapis nigra), warm water and ginger (GI, Zingiber officinale), or warm water only (WA), in random order within a crossover design. Data were collected before (t1), immediately after foot immersion (maximum 20 minutes) (t2), and after 10 minutes subsequently (t3). Actual skin temperature (high resolution thermography) and perceived warmth (HeWEF questionnaire) were assessed at each time point for various body parts. The primary outcome measure was self-perceived warmth at the feet at t3. Secondary outcome measures were objective skin temperature and subjective warmth at the face, hands, and feet.

Results: Perceived warmth at the feet at t3 was significantly higher after GI compared to WA (mean difference -1.02) and MU (-1.07), with no differences between those with AN and HC (-0.29). For the secondary outcome measures, a craniocaudal temperature gradient for the skin temperature (thermography) was noted at t1 for patients with AN and HC (AN with colder feet). The craniocaudal gradient for subjective warmth was only seen for patients with AN.

Conclusion: Footbaths with ginger increased warmth perception at the feet longer than with mustard or warm water only for adolescents with AN as well as for HC. The impact of ginger footbaths on recovery of thermoregulatory disturbances in patients with AN repeated over extended periods merits further investigation.

Do patients of integrative anthroposophic pediatric inpatient departments differ? Comparative analysis to all pediatric inpatients in Germany considering demographic and clinical characteristics. BMC Public Health, 2019, 19 (1), Article ID 1623.

Background: Integrative medicine (IM) is a patient-centered, evidence-based, therapeutic paradigm which combines conventional and complementary approaches. The use of IM in pediatrics has increased in the past two decades and parents' demand for it is growing. An IM whole systems approach is anthroposophic medicine. Considering the growing demand for integrative approaches in children, it is relevant from a public health perspective to find out which kind of children use IM in Germany and whether they differ from the entirety of pediatric inpatients in Germany. Moreover, it would be interesting to known, whether these patients are willing to travel a longer distance to gain integrative treatment.

Methods: The present study investigates the standard ward documentation datasets of 29,956 patients of all German integrative anthroposophic pediatric inpatient wards from 2005 to 2016 and compares them systematically to collect data of the entirety of all pediatric inpatient wards in Germany. Apart from patients' age and gender, and the ICD-10 admission diagnoses, the geographical catchment area of the hospitals were analyzed.

Results: Sociodemographic characteristics of pediatric inpatients in the integrative anthroposophic departments (IAH) did not differ from the entirety of all pediatric inpatients. Regarding clinical characteristics, higher frequencies were found for endocrine, nutritional and metabolic diseases (IAH: 7.24% vs. 2.98%); mental, behavioral, and neurodevelopmental disorders (IAH: 9.83% vs. 3.78%) and nervous diseases (IAH: 8.82% vs. 5.16%) and lower frequencies for general pediatric diseases such as respiratory diseases (IAH: 17.06% vs. 19.83%), digestive diseases (IAH: 3.90% vs. 6.25%), and infectious and parasitic diseases (IAH: 12.88% vs. 14.82%) in comparison to the entirety of all pediatric inpatients in Germany. The IAH showed a broad catchment area, with most patients being from former, Western federal republic of Germany. Large catchment areas (> 100 km) for the IAH are merely covered by severe and chronic diseases.

Conclusion: Pediatric inpatients of IAH do not differ from the entirety of pediatric inpatients in Germany regarding sociodemographic characteristics but show differences regarding clinical characteristics. Parents are willing to travel further distance to get specialized integrative anthroposophic medical care for children with severe and chronic diseases.

Anthroposophic Medicine: A multimodal medical system integrating complementary therapies into mainstream medicine. Complementary Therapies in Medicine, 2019, Vol. 47, Article ID 102151.

No abstract available / Editorial

Personal perception and body awareness of dysmenorrhea and the effects of rhythmical massage therapy and heart rate variability biofeedback-A qualitative study in the context of a randomized controlled trail. Complementary Therapies in Medicine, 2019, Vol. 45, pages 280-288.

ObjectiveThe purpose was to involve women’s personal experiences of daily life with primary dysmenorrhea (PD) and their body perceptions of the dysmenorrhea-related symptoms in relation to the treatment procedure and to explore the perception of Heart Rate Variability Biofeedback (HRV-BF) or Rhythmical Massage (RM) according to Ita Wegman as a therapeutic intervention within the framework of Anthroposophic Medicine (AM).
DesignFrom 60 women who participated in our randomized controlled trial analyzing the effects of HRV-BF or RM, we examined 14 women to get an in-depth understanding of this prevalent disease, using a qualitative design. The women drew their body image before and after the 3-month-intervention on body silhouette diagrams and described their body-perceptions. Semi-structured interviews were conducted and analyzed using content analysis.


Women perceive dysmenorrhea as a disturbance of their daily lives. The body images showed the variations of experience, from misbalances of body perception to overwhelming attacks of pain hindering a normal life for several days per month. Perception of therapeutic interventions range from relaxing without effects on complaints to important changes and benefits on the physical, emotional, and/or social level. Both therapies can support stronger self-awareness through enabling a more differentiated sense of body-awareness, sometimes resulting in women experiencing fewer limitations in their daily lives. Effects may be influenced by the readiness to resonate with the therapeutic process. Qualitative interviews and body images can serve as tools to integrate individuality and help to integrate embodied more or less conscious aspects of complaints.


The body silhouette diagram could be used systematically to include reflections of embodiment in the therapeutic and research settings and help to diagnose in advance the ability of participants to resonate with interventions. RM and HRV-BF influence self-awareness and may enable salutogenic and self-management capacities. For more effective treatment it may be helpful to make treatment suggestions based on an integrative individual history that includes preferences, expectations and a body silhouette diagram.

An expert consensus-based guideline for the integrative anthroposophic treatment of acute gastroenteritis in children. Complementary Therapies in Medicine, 2019, Vol. 45, pages 289-294.

Objectives: Acute gastroenteritis is one of the major causes of hospital admission in childhood. The primary objective of the treatment is rehydration, but conventional drug therapies are limited. Therefore, several pediatricians supplement conventional treatment with complementary and alternative therapies. In the two German departments for pediatric integrative medicine, children suffering from an acute gastroenteritis are treated with supportive therapy based on anthroposophic medicine. However, up to now scientifically validated guidelines for these therapies are lacking.

Design: We consulted an expert pool of 50 physicians with expertise in anthroposophic medicine as well as pediatrics and invited them to participate in an online-based Delphi process. Results were analyzed by means of qualitative content analysis with two independent raters using MAXQDA. Using four rounds of questioning, a consensus-based guideline was developed.

Results: A strong consensus (>90%) or consensus (>75-90%) was achieved for 14 of 16 subsections. The guideline describes disease characteristics, the most useful diagnostics, drug as well as non-drug treatment recommendations and advises for a good physician-patient interaction.

Conclusion: The guideline will help clinicians, as well as family doctors, in their daily routine and make anthroposophic medicine more tangible for parents and health insurance companies.

Observational study on the influence of averaging time on oximetry results in infants and children. Acta Paediatrica, 2019, 108 (12), pages 2246-2252.


Oximetry values are influenced by the averaging time (AT) used. We aimed to evaluate the effect of different ATs on number, duration, mean single event and total integral of desaturations in preterm infants and children to convert between parameters obtained with different ATs.


In a prospective observational study, 49 children underwent sleep laboratory‐based polysomnography and 15 preterm infants were studied in the intensive care unit. Their raw red‐to‐infrared‐saturation‐data were reprocessed using seven different ATs (3–16 seconds). Desaturation thresholds were <80% (infants) and <90% (children), conversion formulas and their median percentage errors were calculated.


We found a linear relationship between the logarithms of the ATs and those of the desaturation parameters, leading to a conversion formula with different exponents. Based on this relationship, the number of desaturations decreased from AT = 3s to AT = 16s by factor 0.28 (children) and 0.18 (infants); total oxygen saturation integral decreased by factor 0.72 (children) and 0.48 (infants). The desaturation duration increased by factor 1.89 (children) and 3.34 (infants).


The number and total integral decreased, but the duration and mean single event integral increased with increasing AT. These changes were stronger in infants. Conversion formulas may facilitate comparisons between studies using different averaging times.

The Contribution of Complementary and Alternative Medicine to Reduce Antibiotic Use: A Narrative Review of Health Concepts, Prevention, and Treatment Strategies. Evidence-Based Complementary and Alternative Medicine, 2019, Vol. 2019, Article ID 5365608.


The aim of this narrative review was to explore the potential contributions of CAM to reduce antibiotic use.


We searched PubMed, Embase, and Cochrane Database of Systematic Reviews with a specific, limited set of search terms and collected input from a group of expert CAM researchers to answer the question: What is known about the contribution of CAM health and health promotion concepts, infection prevention, and infection treatment strategies to reduce antibiotic use? Results. The worldview-related CAM health concepts enable health promotion oriented infection prevention and treatment aimed at strengthening or supporting the self-regulating ability of the human organism to cope with diseases. There is some evidence that the CAM concepts of health (promotion) are in agreement with current conceptualization of health and that doctors who practice both CAM and conventional medicine prescribe less antibiotics, although selection bias of the presented studies cannot be ruled out. There is some evidence that prevention and some treatment strategies are effective and safe. Many CAM treatment strategies are promising but overall lack high quality evidence.


CAM prevention and treatment strategies may contribute to reducing antibiotic use, but more rigorous research is necessary to provide high quality evidence of (cost-)effectiveness

Celiac plexus block increases quality of life in patients with pancreatic cancer. Journal of Pain Research, 2019, Vol. 12, pages 307-315.

Background: Pancreatic cancer is a malignant disease with a high mortality rate and severe pain that is challenging to manage. To reduce the excruciating abdominal pain, opioids and adjuvant agents are conventionally used.

Objectives: PRNCPB is a treatment of neural therapy. The number of studies assessing the effect on patients' QoL is limited and inconsistent. With this study, we intended to address this issue.

Study design: A prospective nonrandomized study with a series of cases of unresectable pancreatic cancer was conducted.

Setting: The study was performed at our pain clinic under real life conditions.

Materials and methods: A total number of 16 patients with severe abdominal pain were enrolled in the study all of whom had responded to combined systemic analgesic therapy inadequately and had intolerable side effects contraindicating further increase in dose. The efficacy of this invasive, palliative analgesic procedure was evaluated 35 days after PRNCPB was performed. Primary outcomes were changed in pain intensity using the VAS questionnaire. Secondary outcomes were improved in QoL using the SF-36 questionnaire. Changes in pain medications and adverse reactions were monitored.

Results: After PRNCPB patients experienced a significant decrease (P=0.002) in pain intensity as shown by the VAS score, and a decreased opiate demand. Their QoL scores considering effect sizes also improved (P<0.001). No complications attributable to PRNCPB were observed during the study period. Additionally, no adverse drug reactions were observed.

Limitations: Detection, observation, and reporting bias can be estimated as moderate. Selection bias was not detected.

Conclusion: Our results give preliminary evidence that PRNCPB might be helpful as an additional treatment to conventional pain management in end-stage pancreatic cancer patients. PRNCPB seems to improve QoL in these patients in a time frame of at least 5 weeks after intervention.

Efficacy of rhythmical massage in comparison to heart rate variability biofeedback in patients with dysmenorrhea-A randomized, controlled trial. Complementary Therapies in Medicine, 2019, Vol. 42, pages 438-444.


20–90% of all women suffer from dysmenorrhea. Standard therapy of primary dysmenorrhea (PD) are NSAIDs and oral contraceptives, effective but not without possible side effects.


To examine the efficacy of rhythmical massage (Anthroposophic Medicine) and heart rate variability biofeedback compared to usual care (control group) on pain intensity in women with primary dysmenorrhea.


This was a three-arm randomized controlled study. Both interventions (rhythmical massage once a week or HRV biofeedback 15 min daily) were carried out over a period of three months. The third group (control) applied usual care. The primary outcome were between-group differences in mean pain intensity (detected by a Numeric Rating Scale, NRS) during menstruation after three months (post-assessment, t2). Secondary outcomes were the use of analgesics, quality of life (SF-12) and heart rate variability.


The study involved 60 women, mean age 29.7 years, SD 8.0 (n = 23 rhythmical massage, n = 20 biofeedback, n = 17 control). For the primary outcome there was a significant difference between the groups after three months (p = .005). Bonferroni adjusted post-hoc tests revealed a significant difference between rhythmical massage and control group (mean difference: -1.61; 95 CI: -2.77/-0.44; p = .004; ES: -0.80). No significant differences were found between rhythmical massage and biofeedback (mean difference: -0.71; 95 CI: -1.82/ 0.40; p = .361; ES: -0.34) and between biofeedback and control group (mean difference: -0.90; 95 CI: -2.10/-0.30; p = .211; ES: -0.51). For the secondary outcomes no significant differences were found between the groups at t2. The drop-out rate was higher in the biofeedback group (n = 6) than in the massage (n = 2) or the control group (n = 4).


Preliminary evidence suggests that rhythmical massage might improve pain intensity after 12 weeks compared to usual care.

Effects of Footbaths with Mustard, Ginger, or Warm Water Only on Objective and Subjective Warmth Distribution in Healthy Subjects: A Randomized Controlled Trial. Complementary Therapies in Medicine, 2018, Vol. 41, pages 287-294.

Objective: To analyze the short-term thermogenic effects of footbaths with warm water alone (WA) versus when combined with medicinal powders.

Design: Randomized controlled trial with cross-over.

Interventions and outcomes: Seventeen healthy volunteers (mean age 22.1 years, SD = 2.4; 11 female) received three footbaths with WA or WA combined with mustard (MU) or ginger (GI) in a randomized order. Self-perceived warmth (Herdecke warmth perception questionnaire) and actual skin temperatures (thermography) were assessed before (t0), immediately after footbaths (t1), and 10 minutes later (t2). The primary outcome was perceived warmth in the feet. Secondary outcomes were warmth perception in the face, hands and overall, as well as actual skin temperature in the feet, face, and hands.

Results: Perceived warmth at the feet (primary outcome) increased significantly (all p's < .001) for MU and GI at t1 as well as for GI at t2 when compared to t0 with high effect sizes. At t2, GI differed significantly from WA (p < .001) and MU (p = .048). With regards to the secondary measures of outcome, no significant effects were seen for perceived warmth at the face or hands. Overall warmth was significantly higher at t1 compared to t0 (p = .01). Thermography assessments of skin temperature at the feet at t1 increased after all conditions (p < .001). No effects were seen in the face. At the hands, temperature decreased at t1 (p = .02) and t2 compared to t0 (p < .001).

Conclusion: The present study provides preliminary evidence that mustard and ginger increase warmth perception at the feet more than warm water alone, with only the effects for GI enduring at the brief follow-up.

Acceptance, satisfaction and cost of an integrative anthroposophic program for pediatric respiratory diseases in a Swiss teaching hospital: An implementation report. Complementary Therapies in Medicine, 2018, Vol. 40, pages 179-184.


For the pilot phase of an integrative pediatric program, we defined inpatient treatment algorithms for bronchiolitis, asthma and pneumonia, using medications and nursing techniques from anthroposophic medicine (AM). Parents could choose AM treatment as add-on to conventional care.

Material and methods

To evaluate the 18-month pilot phase, parents of AM users were asked to complete the Client Satisfaction Questionnaire (CSQ-8) and a questionnaire on the AM treatment. Staff feedback was obtained through an open-ended questionnaire. Economic data for project set-up, medications and insurance reimbursements were collected.


A total of 351 children with bronchiolitis, asthma and pneumonia were hospitalized. Of these, 137 children (39%) received AM treatment, with use increasing over time. 52 parents completed the questionnaire. Mean CSQ-8 score was 29.77 (95% CI 29.04–30.5) which is high in literature comparison. 96% of parents were mostly or very satisfied with AM; 96% considered AM as somewhat or very helpful for their child; 94% considered they learnt skills to better care for their child. The staff questionnaire revealed positive points about enlarged care offer, closer contact with the child, more relaxed children and greater role for parents; weak points included insufficient knowledge of AM and additional nursing time needed. Cost for staff training and medications were nearly compensated by AM related insurance reimbursements.


Introduction of anthroposophic treatments were well-accepted and led to high parent satisfaction. Additional insurance reimbursements outweighed costs. The program has now been expanded into a center for integrative pediatrics.

Effect of topical rosemary essential oil on Raynaud phenomenon in systemic sclerosis. Complementary Therapies in Medicine, 2018, Vol. 40, pages 191-194.

Introduction: Raynaud's phenomenon is the earliest manifestation of systemic sclerosis. Nitroglycerin gel is the only proven topical therapy.

Methods: A 53-year-old woman with systemic sclerosis had topical Rosamarinus officinalis (rosemary) oil, often used in anthroposophic medicine, applied to her hands over 3days and then, separately, olive oil.

Results: Thermography images showed significant warming of fingers after rosemary oil, but not after olive oil, coinciding with the patient's subjective experience.

Conclusions: Topical Rosamarinus officinalis oil had a vasodilator and warming effect in a patient with systemic sclerosis and Raynaud's phenomenon.

Feeling the sound – short-term effect of a vibroacoustic music intervention on well-being and subjectively assessed warmth distribution in cancer patients-A randomized controlled trial. Complementary Therapies in Medicine, 2018, Vol. 40, pages 171-178.

Objectives: So far, the effects of vibroacoustic music therapy in cancer patients are unknown. However, used in anthroposophic medicine, it could be an approach to enhance well-being. The goal of this study was to evaluate the immediate effects of a sound-bed music intervention with respect to the subjective well-being as well as body warmth and pain.

Patients and methods: We treated 48 cancer patients with 10 min of sound-bed intervention in a cross-over design. Primary outcome was the total sum of the Basler Mood Questionnaire (BMQ), secondary outcomes were subscales of the BMQ and questions addressing body warmth and pain. The EORTC-QLQ C30 was used as baseline assessment for quality of life (QOL).

Results: Patients had lower QOL values than the EORTC reference samples (p < .001, d = 0.90). The primary outcome increased after music (p < .001, d = 0.47), no changes were seen in the control condition (p = .73, d = 0.04), the time by condition interaction was significant (p < .05).

Secondary outcomes: Increase after music for the BMQ subscales inner balance (p < .001, d = 0.73), vitality (p < .001, d = 0.51) and vigilance (p < .001, d = 0.37) as well as for the additional questions satisfaction (p < .001, d = 0.43), current mood (p < .001, d = 0.43), body warmth (p < .05, d = 0.44) and warmth distribution (p < .01, d = 0.49). No significant changes were seen in pain levels and social extroversion.

Conclusion: Sound-bed intervention improved momentary well-being and caused self-perceived physiological changes associated with relaxation beyond the benefits of simple resting time (control condition). Thus, it might be a promising approach to improve well-being in cancer patients.

High-resolution infrared body surface temperature and self-perceived warmth distribution in adolescent anorexia nervosa patients. Journal of Psychophysiology, 2018, 33 (3), pages 139-147.

Anorexia nervosa (AN) is associated with thermoregulatory disturbances such as hypothermia. However, few studies have explored body warmth in AN patients. In this study, we assessed the body surface temperature distribution in adolescent AN patients using high-resolution infrared thermal imaging and through a patient questionnaire, and explored how this differed between intervention and control group and length of treatment. Adolescent AN patients admitted to a multimodal inpatient treatment programme based on an integrative perspective were assessed at three time-points: admission (t1), 6 weeks post-admission (t2), and 3 months after t2 (t3). Healthy control participants were assessed once at baseline. In both groups we assessed participants’ surface temperature and the perception of warmth, using thermal imaging and a questionnaire, in the face, hands, abdomen, and feet. We recruited 40 AN patients and 40 healthy controls, who were admitted to the treatment programme for an average of 70 days (SD = 24.07). The AN patients were significantly colder in all chosen body domains, except the abdomen area, at t1 compared to healthy controls at baseline. The questionnaire findings supported this result. Differences between the intervention and control groups noted at t1 were significantly reduced by t2 and t3. Our findings suggest that abnormities in the body warmth distribution of AN patients are reversible after having received an AN-specific treatment. Reducing the loss of warmth could improve therapeutic outcomes in AN patients and be a predictor of recovery, and should be investigated in further studies. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

Physiological and emotional effects of pentatonic live music played for preterm neonates and their mothers in the newborn intensive care unit: a randomized controlled trial. Complementary Therapies in Medicine, 2018, 41 (1), pages 240-246.

Objective: Despite attempts to increase calmness in the Newborn Intensive Care Unit (NICU), preterm neonates still experience stress. The question arises how to further promote the infants' wellbeing. Therefore, the immediate effects of pentatonic live music on preterm infants and their mothers were examined.

Design and methods: In a two-centre randomized controlled trial with crossover design preterm infants were exposed sequentially to two conditions: live pentatonic harp music (LPHM) used in Anthroposophic Medicine or standard care. The order of the conditions was randomized within each subject. The primary outcome was change of the number of oxygen desaturations < 90%/h, whereas secondary outcomes were: heart rate, respiratory rate, oxygen saturation, heart rate variability (HRV), the perfusion index, pulse-transit-time and maternal anxiety and others not reported on in this article.

Results: 21 preterm infants were randomized (14 girls), mean gestational age at measurement 35 + 0 weeks (SD 1 week). The primary outcome parameter showed no significant changes. Regarding the secondary outcomes the comparison of the pre-post-differences between the conditions showed significant effects for the HRV parameters pNN50 (ΔpNN50 = 1.46%, z = -2.47, p = .001) and SDNN (ΔSDNN=-0.06 ms, z = -2.25, p = .002). The music intervention significantly increased the values of pNN50 (Mdn 1.2% vs. 2.6%, p = 0.04) and marginally those of SDNN (Mdn 31.7 ms vs. 36.4 ms, p = 0.05). No changes were found in the other parameters.

Conclusions: While the use of music in the NICU had no effect on the number of oxygen desaturations, it increased two HRV parameters indicative of infants' parasympathetic tone.

A General Pediatrics and Integrative Medicine Approach to Pervasive Refusal Syndrome: A Case Report. The Permanente journal, 2016, 20 (4), pages 15-238.

Introduction: Pervasive refusal syndrome (PRS) describes children with social withdrawal who become unable to walk, eat, or care for themselves. This case report examines whether an integrative medicine approach is useful for treating PRS.
Case Presentation: A seven-year-old girl with symptoms most consistent with PRS and depression was admitted to a pediatric ward in Germany that integrates conventional pediatric and psychosomatic care with anthroposophic medicine. She was integrated into the structured activities of the ward and received massages, movement therapy, and color light therapy. Her parents were fully integrated into her care. After four weeks, she talked again, showed increased appetite, and supported herself when moved passively. She made a full recovery within four weeks after hospital discharge.
Discussion: Integration of parents and an integrative medicine approach providing a variety of comforting sensory experiences was helpful for this patient with PRS.

Anti-Inflammatory Effects of Agrimoniin-Enriched Fractions of Potentilla erecta. Molecules, 2016, 21 (6), Article ID 792.

Potentilla erecta (PE) is a small herbaceous plant with four yellow petals belonging to the Rosaceae family. The rhizome of PE has traditionally been used as an antidiarrheal, hemostatic and antihemorrhoidal remedy. PE contains up to 20% tannins and 5% ellagitannins, mainly agrimoniin. Agrimoniin is a hydrolyzable tannin that is a potent radical scavenger. In this study we tested the anti-inflammatory effect of four PE fractions with increasing amounts of agrimoniin obtained by Sephadex column separation. First, we analyzed in HaCaT keratinocytes the expression of cyclooxygenase-2 (COX-2) induced by ultraviolet-B (UVB) irradiation. As COX-2 catalyzes the metabolism of arachidonic acid to prostanoids such as PGE2, we also measured the PGE2 concentration in cell culture supernatants. PE inhibited UVB-induced COX-2 expression in HaCaT cells and dose-dependently reduced PGE2. The PE fraction with the highest agrimoniin amount (PE4) was the most effective in this experiment, whereas fraction PE1 containing mainly sugars had no effect. PE4 also dose dependently inhibited the phosphorylation of the epidermal growth factor receptor (EGFR) which plays a crucial role in UVB-mediated COX-2 upregulation. A placebo-controlled UV-erythema study with increasing concentrations of PE4 demonstrated a dose dependent inhibition of UVB-induced inflammation in vivo. Similarly, PE4 significantly reduced UVB-induced PGE2 production in suction blister fluid in vivo. In summary, PE fractions with a high agrimoniin content display anti-inflammatory effects in vitro and in vivo in models of UVB-induced inflammation

External Nursing Applications in the Supportive Management of Prolonged Postoperative Ileus: Description of Interventions and Case Report. Holistic Nursing Practice, 2016, 30 (4), pages 216-221.

Prolonged postoperative ileus is a common but clinically challenging problem that leads to patient discomfort and prolonged hospitalization; the condition is managed through a multimodular program of supportive measures. In anthroposophic nursing, the management of prolonged postoperative ileus involves additional tools, including external abdominal compresses and massages with plant or silver-containing oils and ointments. We describe 3 typical techniques: Oxalis tincture compresses, Thuja/Argentum ointment compresses, and massage with “Wala Melissenöl" (containing Melissa officinalis, Carvum cari, Foeniculum amari, and Origanum majorana). A 61-year-old man with chronic pain from adhesions after multiple abdominal surgical procedures developed a prolonged postoperative ileus after an elective ileostomy reversal. Following slow recovery during the first postoperative days, he began vomiting. A nasogastric tube was inserted, and daily Oxalis tincture compresses and massage with “Wala Melissenöl" and Thuja/Argentum ointment compresses were applied on the abdomen. The patient's symptoms gradually improved over the next 10 days. No prokinetic medications were needed to manage this episode. External abdominal nursing applications with plant substances and silver can be an additional tool in the management of prolonged postoperative ileus.

Improvement of Asthma and Gastroesophageal Reflux Disease With Oral Pulvis stomachicus cum Belladonna, a Combination of Matricaria recutita, Atropa belladonna, Bismuth, and Antimonite: A Pediatric Case Report. Global Advances in Health and Medicine, 2016, 5 (1), pages 107-111.

The association between gastroesophageal reflux disease (GERD) and asthma, although well established in adults, is less strong in the pediatric age group. Benefits of proton pump therapy are limited across age ranges. While there is a growing body of literature on the use of complementary treatments for both asthma and GERD, few studies have focused on treatment benefits for the GERD-asthma association. We present the case of a 2-year-old boy with asthma and GERD who was not responding to inhaled, low-dose corticosteroids, beta-mimetic therapy, and a 6-week course of proton pump inhibitor treatment. We noted a gradual disappearance of symptoms when he was given an oral preparation of Pulvis stomachicus cum Belladonna, an anthroposophic medication containing Matricaria recutita, Atropa belladonna, bismuth, and antimonite. Matricaria recutita and bismuth have known gastric protective properties, and Atropa belladonna contains anticholinergic agents that have a bronchodilatory effect. These complementary medications appear promising in terms of relieving the symptoms of GERD-associated asthma.

High-Dose Viscum album Extract Treatment in the Prevention of Recurrent Bladder Cancer: A Retrospective Case Series. Permanente Journal, 2015, 19 (4), pages 76-83.

Introduction: Viscum album extract (European mistletoe), containing immuno-active compounds with dose-dependent cytotoxic activity, is being used as an adjuvant cancer treatment in Europe. Few studies have yet been done with high-dose, fever-inducing Viscum album treatment.

Objective: To explore whether subcutaneous injections of high-dose Viscum album have a preventive effect on risk of recurrence of bladder cancer.

Methods: We retrospectively analyzed the case records of patients with resectable bladder cancer who underwent initiation of high-dose Viscum album treatment at our clinic between January 2006 and December 2012.

Main outcome measures: We calculated tumor recurrence and progression risk and explored case records to assess whether treatment had a likely, possible, or unlikely beneficial effect.

Results: Eight patients were identified, 7 of whom had nonmuscle-invasive bladder cancer and 1 with muscle-invasive cancer. Four patients had frequently recurring tumors before treatment. Among the 8 patients, 28 episodes of recurrence were observed. Median tumor-free follow-up duration was 48.5 months. High-dose Viscum album showed a possible beneficial effect in 5 of 8 patients, could not be assessed in 2 patients, and had an uncertain effect in 1 patient. No tumor progression was observed. Treatment was generally well tolerated and no patient stopped treatment because of side effects.

Conclusion: High-dose Viscum album treatment may have interrupted frequently recurring tumors in individual patients with recurrent bladder cancer. Prospective studies are needed to assess whether this treatment offers an additional, bladder-sparing preventive option for patients with intermediate- to high-risk nonmuscle-invasive bladder cancer.. Treatment was generally well tolerated and no patient stopped treatment because of side effects.

Viscum Album in the Treatment of a Girl With Refractory Childhood Absence Epilepsy. Journal of Child Neurology, 2015, 30 (8), pages 1048-1052.

Viscum album (European mistletoe) extracts have known immunomodulatory effects but little data exist on anticonvulsant activity despite its usefulness having been reported for centuries. A 4½-year-old girl with childhood absence epilepsy and global developmental delay was treated with different antiepileptic drugs and ketogenic diet but failed to become seizure free over a 2-year period. She also received different herbal remedies as part of an integrative medicine approach. Initial improvement occurred on valproate-ethosuximide, a further improvement was seen after adding clobazam to valproate. Final cessation of absence activity occurred after a dose increase of V album. She was still seizure free at the 12-month follow-up. V album appears to have been a necessary adjunct treatment for this child to become seizure free. We call on physicians to report their experiences of V album in epilepsy and suggest further study.

Disappearance of an advanced adenomatous colon polyp after intratumoural injection with Viscum album (European mistletoe) extract: a case report. Journal of Gastrointestinal and Liver Diseases, 2014, 23 (4), pages 449-452.

Background and aim: Extracts of Viscum album (European mistletoe) have immune-stimulatory and cytotoxic effects, with trials showing a well-established effect on the quality of life and prolonged survival in patients with advanced pancreatic cancer. Regression of tumours following intratumoural injection with Viscum album extract has been documented in individual cases. However, its influence on colon polyps has not been investigated.

Case presentation: We present the case of a 78-year-old Caucasian male who had undergone hemi-colectomy for a stage IIIC colon cancer but who refused adjuvant chemotherapy. Five years later a newly detected high-grade dysplasia colon adenoma was discovered; however, the adenoma could not be resected endoscopically and the patient did not consent to surgery. Intratumoural injections with Viscum album L extract (Quercus; Iscador®Qu) were administered twice in an attempt to limit tumour growth. Eight months after the second intratumoural injection the adenoma had disappeared and biopsy revealed no intraepithelial dysplasia or adenoma.

Conclusions: This is the first report showing complete regression of a colon adenoma after intratumoural injection with Viscum album extract. Prospective studies should evaluate if the treatment effect is reproducible and if this approach could be a useful pre-operative measure for colon adenomas too large for endoscopic resection.

A conversion formula for comparing pulse oximeter desaturation rates obtained with different averaging times. PLoS One, 2014, 9 (1), Article ID e87280.


The number of desaturations determined in recordings of pulse oximeter saturation (SpO2) primarily depends on the time over which values are averaged. As the averaging time in pulse oximeters is not standardized, it varies considerably between centers. To make SpO2 data comparable, it is thus desirable to have a formula that allows conversion between desaturation rates obtained using different averaging times for various desaturation levels and minimal durations.


Oxygen saturation was measured for 170 hours in 12 preterm infants with a mean number of 65 desaturations <90% per hour of arbitrary duration by using a pulse oximeter in a 2–4 s averaging mode. Using 7 different averaging times between 3 and 16 seconds, the raw red-to-infrared data were reprocessed to determine the number of desaturations (D). The whole procedure was carried out for 7 different minimal desaturation durations (≥1, ≥5, ≥10, ≥15, ≥20, ≥25, ≥30 s) below SpO2 threshold values of 80%, 85% or 90% to finally reach a conversion formula. The formula was validated by splitting the infants into two groups of six children each and using one group each as a training set and the other one as a test set.


Based on the linear relationship found between the logarithm of the desaturation rate and the logarithm of the averaging time, the conversion formula is: D2 = D1 (T2/T1)c, where D2 is the desaturation rate for the desired averaging time T2, and D1 is the desaturation rate for the original averaging time T1, with the exponent c depending on the desaturation threshold and the minimal desaturation duration. The median error when applying this formula was 2.6%.


This formula enables the conversion of desaturation rates between different averaging times for various desaturation thresholds and minimal desaturation durations.

Under-recognition of alarms in a neonatal intensive care unit. Archives of Diseases in Childhood. Fetal and Neonatal Edition, 2013, 98 (6), Article ID F524-7.

Background: Treatment decisions for apnoea of prematurity (AOP) are usually based on nursing staff's documentation of pulse oximeter and heart rate alarms.

Objective: In an observational study, to compare the accuracy of oxygen saturation (SpO2) and heart rate alarm documentation, and the resulting interventions by nursing staff, with objectively registered events using polysomnographic and video recording.

Methods: Data on 21 preterm neonates (12 male) with a diagnosis of AOP were analysed. Nursing staff's desaturation (<80% SpO2) and bradycardia (<80/min) alarm documentation was compared with events registered objectively using simultaneous polysomnography. Interventions by nursing staff were evaluated using 24 h video recordings and compared with their chart documentation. Nursing staff had been unaware that the polygraphic and video recordings would be used subsequently for this purpose.

Results: Median (minimum-maximum) postnatal age was 15.5 (3-65) days. 968 SpO2 desaturation events and 415 bradycardias were documented by polysomnography. Nursing staff registered 23% of these desaturation events, and 60% of bradycardias (n=223, and n=133, respectively). Intraclass correlation coefficient (95% CI) between objectively measured desaturation events and those documented by nursing staff was 0.14 (-0.31 to 0.53); and for bradycardias 0.51 (0.11 to 0.78). 225 nursing staff interventions were registered on video, of which 87 (39%) were documented.

Conclusions: The alarm documentation by neonatal intensive care unit staff does not appear to be sufficiently accurate to permit further understanding and treatment of AOP. It is unclear if the alarms missed here would have led to clinical consequences had they been documented.

Averaging time, desaturation level, duration and extent. Archives of Diseases in Childhood. Fetal and Neonatal Edition, 2013, 98 (3), Article ID F265-6.

Background: Pulse oximeter saturation values are usually obtained by averaging over preceding measurements. This study investigates the dynamics between the averaging time and desaturation level, duration and extent.

Methods and results: Prospective observational study of 15 preterm infants. Oxygen saturation was recorded for 168 h using a pulse oximeter. The raw red-to-infrared data were reprocessed using seven different averaging times to determine the number of desaturations below four thresholds and for seven different minimal desaturation durations. The total number of desaturations <80% was 339 with an averaging time of 16 s and 1958 with an averaging time of 3 s (minimal event duration >0 s). There was a significantly lower pulse oximeter saturation nadir with the shorter averaging time, while the maximum duration was significantly longer when using a 16 s averaging time.

Conclusions: When using pulse oximeters, more attention should be given to averaging time and duration of desaturations.

How accurate is pulse rate variability as an estimate of heart rate variability? A review on studies comparing photoplethysmographic technology with an electrocardiogram. International Journal of Cardiology, 2013, 166 (1), pages 15-29.

Background: The usefulness of heart rate variability (HRV) as a clinical research and diagnostic tool has been verified in numerous studies. The gold standard technique comprises analyzing time series of RR intervals from an electrocardiographic signal. However, some authors have used pulse cycle intervals instead of RR intervals, as they can be determined from a pulse wave (e.g. a photoplethysmographic) signal. This option is often called pulse rate variability (PRV), and utilizing it could expand the serviceability of pulse oximeters or simplify ambulatory monitoring of HRV.

Methods: We review studies investigating the accuracy of PRV as an estimate of HRV, regardless of the underlying technology (photoplethysmography, continuous blood pressure monitoring or Finapresi, impedance plethysmography).

Results/conclusions: Results speak in favor of sufficient accuracy when subjects are at rest, although many studies suggest that short-term variability is somewhat overestimated by PRV, which reflects coupling effects between respiration and the cardiovascular system. Physical activity and some mental stressors seem to impair the agreement of PRV and HRV, often to an inacceptable extent. Findings regarding the position of the sensor or the detection algorithm are not conclusive. Generally, quantitative conclusions are impeded by the fact that results of different studies are mostly incommensurable due to diverse experimental settings and/or methods of analysis.