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John D. Mark MD
اهی‌اصنات ۸95۵6 ۳۲۵۲۵55۵۲ ۵0۲ ۳6۵۱۵۲۲۱6۵
Pediatric Pulmonary Medicine
Lucile Packard Children’s Hospital at
Stanford
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ل ©
= A 14 yr old athlete with moderate, persistent
asthma comes to clinic. He has an asthma action
plan and has been adherent with his controller
medication. Now he wants to try a breathing
technique (Buteyko) so he can “get off” his meds.
= A 3 yr old comes to the clinic for a well-child
check-up. On exam you find a right otitis media.
She is asymptomatic and you recommend
watchful waiting. The parents would like to try.a
homeopathic remedy because they had heard
that homeopathy worked better than placebo for
children with an ear infection.
Answer: Everywhere
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gen
pleefentary
paAlternative
Medicine
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Ot ea Weve
Dying Woman Loses Marijuana Appeal
March 14, 2007
Evidence Mounts That Coping Skills Can
Boost HIV Survival March 14, 2007
Omega-3 in Fish Oils Might Ease
Depression March 7, 2007
Insomnia: Alternative Medicine Popular
* 1.6 Million Adults Use Complementary Or
Alternative Medicine For Insomnia September
2006
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6 ais ۳ لاک رن رک
(C@O)
= Complementary and alternative medicine
* A group of diverse medical and health care
systems, practices, and products
* Not considered part of conventional medicine
* Some scientific evidence exists regarding CAM
therapies
* For most, questions of safety and efficacy
persist
= Complementary medicine is used together with
conventional medicine. Alternative medicine is
used in place of conventional medicine.
DN Re LS
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ری لاک ما٩ رت ۹
= Integrative combines mainstream medical
۲16730166 ۵00 6۸۵۳ (۱6۲3016۶ ۲ n)
there is some high-quality scientific
evidence of safety and effectiveness.
= “Healing-oriented medicine that takes account of
the whole person (body, mind, and spirit),
including all aspects of lifestyle. It emphasizes
the therapeutic relationship and makes use of all
appropriate therapies, both conventional and
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exper hee! 0ك
اده كس كلسم ست سر ‘hap lhuananas
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)۱( رت 0 COM
و مسا
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بر 9/۹۷
Reasons for using CAM:
= Consistent with patient’s and families
values: natural, and empowering
= CAM providers are “patient-centered”,
dedicated to promoting health.
= Conventional therapies are perceived to be
emotionally or spiritually without benefit
= Conventional therapies are not effective or
are associated with side effects.
= CAM use is a circular: usage determines
number of CAM practitioners
09009:6069 ۰ یو 6
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۱۷ سح مر
| Figure 4. 10 Most Common CAM Therapies
30
ercent
20
10
Ol prayer’ Prayer/ Natural Deep Prayer Mecita- —Chio- Yoga Massage Diets
self others products breathing group tion practic
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تس مت COO
Figure 5. Top 10 Natural Products”
٩ مره Gnserg Ginkgo واه ۲۵ 505 مرا ماه Ginger ۵
Biota supple amine wor megs supple supple
mens fanyenss ments ments
The peroentage fos each product represents is rate of use among U.S. adults who use natural products
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Pedatric Ose oP OOO
Asthma 80% 8620, 53
(Bronx, NY)
Adolescents 54-69% ۱ bg)
(لالنا) 2005 ,ةاناة81
Special Needs 64% 52000/553
Az) (Tucson,
Rheumatology 64% ۵96 3
ا
3 م,اأةغأه مولع 54% ADHD
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Children’s)
Emergency ۱
celery eT ae
2003 (Atlanta)
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Pedatric Ose oP OOO
Oncology 47-84% McCurdy, 2003 (WFU)
Neuhouser, 2001 (Seattle)
Kelly, 2000 (NYC)
Cerebral Palsy 56% Hurvitz,
2003
بأوطلق نمق
IBD 41% 0
London, Boston, Detroit
Autism Spectrum 30% ۱
ات
Preoperative 29.5% 1
1 كنا ec ed
۳۲۱۲۳۱۵۲۷ 6 12-21% Sawni, 2002 (Detroit)
Ottolini, 2001 (Wash D.C.)
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ور ۹ 02۹۵۹۱ ار ٩ مس ز COU
رد ره 1
= Effectiveness well documented:
¢ Acupuncture for nausea and vomiting
۶ Biofeedback for constipation
* Biofeedback for headache
* Hypnotherapy for headache
* Hypnotherapy for irritable bowel
syndrome
* Lemon balm for herpes simplex
* Massage for constipation
0ك
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4 a iezzs
= Effectiveness
= Effectiveness unlikely
توح زو
* Acupuncture for body
weight reduction
Acupuncture for
smoking cessation
Flower remedies for
اروت
Homeopathy for anxiety
Spinal manipulation for
asthma
Spinal manipulation for
infantile colic
Acupuncture for asthma
Acupuncture for hay
اعلاع]
Acupuncture for
rheumatoid arthritis
Chromium for diabetes
Echinacea for common
cold prevention or
(۴
Evening primrose for
eczema
09009:6069 ۰ و60 ۶ م6
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۹۱ ار (piictercirsette
= Alternative Health supplement of the 2002
National Health Interview Survey: data on
10 common herbs
= Of 30,616 adults, 19% used herbs in past
12 mo, 57% for a specific condition
= Approximately 2/3 used herbs (except
Echinacea) not in accordance with
evidence based indications
Mayo Clin Proc, May 2007;82(5): 561-566
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607 را Qediviae, (Poi iessiete
Most conventional physicians believe in unconventional
medicine because It is not scientific
What is evidence-based medicine? Treatment that will
improve patient outcomes by well-designed, appropriately
powered, randomized, controlled clinical trials.
There is not good evidence (Grade A) that many of the
commonly used therapies in conventional medicine are
effective (ex: heparin, aspirin, and warfarin).
The principal distinguishing characteristic of unconventional
and conventional medicine therapies is the source of
introduction.
Conventional therapies are introduced by mainstream
Western physicians and scientists, whereas most
unconventional modalities are introduced by "outsiders."
One of the reasons that most unconventional modalities are
not evidence based is that the majority of them were
introduced prior to the 20th Century
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©
Evidence is lacking even for the most popular, if
there is evidence, most is in adults
However, the Institute of Medicine states: “the
same principles and standards of evidence of
treatment effectiveness apply to all treatments
whether currently labeled as conventional
medicine or CAM”.
Only 1/3-1/3 of patients or their parents reported
CAM use to their doctors. Indicates a need to
promote dialogue about CAM use between
patients and their health care providers.
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ee ور و)
= Survey sent to 660 physicians at the Mayo
Clinic (233 responded)
= Three areas: utilization, familiarity and
attitudes
= Utilization:
* 75% had never referred to CAM practitioner
* 44% said they would consider if available at
the Mayo (<46 years or female more likely)
٠ Less 25% discussed benefits or risks with CAM
* 57% thought incorporation of CAM would be
have a positive impact on pt satisfaction
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ور و)
= Familiarity:
* Biofeedback, massage, chiropractic and
relaxation therapies were the most familiar
59% were unfamiliar with energy healing, 53%
with naturopathic medicine
Of the 13 herbs listed, only 3 were commonly
listed as familiar
66% were not familiar with feverfew and 52%
were not familiar with Kava
49% of the physicians felt it was difficult or
Meng difficult to find reliable information about
erbs
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ee ور و)
41% of the suas neither agreed or
disagreed that physician knowledge had an
impact on patient’s health
52% felt physician’s spiritual beliefs were
important and 87% felt patients spiritual beliefs
and practices were important
67% agreed some CAM therapies hold promise
but 70% felt current practices of CAM was a
“threat” to the public health
Most important factors in changing physician’s
attitudes were RCT’s and evidence demonstrating
mechanism
70% of the physicians felt Mayo clinic should
provide proven CAM therapies
مرف رد
50
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Pederson oP و راک یی Ovard
Patient evaluation: Includes the use of non-
conventional methods of diagnosis and treatment
Consultation and/or referral to licensed or
otherwise state-regulated health care
practitioner- the Physician is responsible for
monitoring the results
Medical records should also document: What
conventional medical options have been
discussed, offered, tried, or refused
Education- All physicians must be "able to
demonstrate a basic understanding of the
medical scientific knowledge" connected with any
CAMtherapy ww sets
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ده
Be aware of the growing scientific evidence
concerning the safety and effectiveness of relevant
complementary, as well as mainstream, therapies.
Balance the risks and benefits of any therapy
before recommending a course of action, and
continue to monitor patients appropriately.
Discuss and document with patients and their
families any information regarding treatment
decisions, conventional or CAM.
Know professional guidelines including ethics
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۳۹۱ 2 و mexcieaies
= CAM education in medical schools
= American Academy of Pediatrics (AAP)
= Pediatric Integrative Medicine Leadership
Initiative and Pediatric Integrative
Medicine Conference (PIMC)
= |nternational Pediatric Integrative Medicine
Network (IPIM-N)
™ Canadian network linking pediatric CAM
researchers & educators (PedCAM)
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يي ©
1998 survey found 75 medical schools (out of 125) offered
CAM electives or including these topics in required courses
81% of the schools that included CAM in the curriculum did
so by adding stand alone courses or electives, 41% used
required courses, and 23% had both stand-alone and in
required courses JAMA. 1998;280:784-7
Barriers included: lack of money, lack of time to plan and
prepare, and outright animosity on the part of faculty.
* ...unscientific, lack of mechanistic explanation or demonstrated
clinical efficacy....if taught could be viewed as advocacy
Change is occurring:
* Harvard: Division for Research and Education in
Complementary and Integrative Medical Therapies
* Albert Einstein, Columbia, Duke, Mount Sinai, Stanford,
Arizona, Maryland, Pennsylvania, and several branches of the
University of California have included CAM in the curriculum
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رل م4 زر 0۹۹ 4 مر
Teach One Medicine
Create Opportunities for Cross-Fertilization
Develop Support and Commitment from the
Institution
Offer a Well-Designed Electives
Include an Experiential Component (acupuncture,
massage, homeopathy, craniosacral etc)
Plan across the Curriculum from Undergraduate
to Graduate and Continuing Medical Education
(often a void during residency and fellowships)
0000000 Peat eel otc accra)
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Curent Gtatus - BOC
= Provisional Section on Complementary,
Holistic & Integrative Medicine (CHIM)
* Kathi Kemper, Chair for Holistic and Integrative Medicine
and Professor of Pediatrics, Wake Forest University
* Section will promote policies to enhance patient-centered
care, integrating evidence-based, safe and effective
complementary therapies
= Meetings:
* Super CME Courses
¢ AAP National Conference October 2007
= Four sessions by CHIM members
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Curent status - PIDO
= Pediatric Integrative Medicine
Conference
= Collaboration of academic faculty at multiple
pediatric integrative medical centers in
US/Canada
* 15-2000, University of Arizona, Tucson
* 29-2001, University of Minnesota, Minneapolis
* 3'4- 2005, New York Academy of Medicine, NYC
* 4t- 2006 October, 27-29", Chicago
* 5tr- 2007, October 26-27", San Francisco
www. pangeaconference.com/index.as|
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Giotus - IPI0)-O وی(
= |nternational Pediatric Integrative Medicine
Network
= List serve connecting PIM practitioners and
organizations
* Facilitates communication and collaboration
* Promotes clinical, educational and research
initiatives
* Provides resources and links
= Secure electronic network
= Idrdoc@alum.mit.edu
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(eae را (a DeINeiesI
Introduction
Who runs this site?
Who pays for the site?
What is the purpose of the site?
Where does the information come from?
What is the basis of the information?
How is the information selected?
۱۵ ۱۵۱۹۵۱۱۵۸2۱۵۱۹۷۹ ۵۱2۷۱۸۱۱9۱۸۸۸۱۳۸
How does the site choose links to other sites?
What information about you does the site collect.
and why?
9 does the site manage interactions with visito
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® Guide Por Providers Oxia COO
Government sites
الل عه؟ معغمعن bem Talat
http://nccam.nih.gov/
= Office of Dietary Supplements:
۱۳۴۹۴۰ //۹۹۳۰0۵۴۳۱۱۳0۵۹/۹۵۹۰۵۱۳ ۱/۵ Database.asp
=" MedWatch:
http://www.fda.gov/medwatch
= CAM on PubMed:
http://www.nih.gov/news/pr/feb2001/nccam-05a.html
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۱۹۱/۱6۹۶۹ ۱2
Introduction to Naturopath = عبا‌میاویه۸ ون
۳۹۹ . 5
Black Cohosh vey (ele at a Glance: Grape
تسه
Chelation
Chiroprac = AARP/NCCAM Report on Older
Chiropractic AARP/NCCAM Report on Older
ره americans
a ۳۳۳ ۱9-7-71
Past Highlights كمع ممع اممنا؟ /20غ216
= Echinacea
Ephedra
nea = News from NCCAM:
Ginseng _ 3
Glucosamine subscribe to quarterly newslet
Herbs at a Glance =
Hennes = Monthly e-bulletin
St. John's Wort
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Academic sites
= Boston-Longwood Herbal Task Force:
= http://www.longwoodherbal.or
LUT روز ارت «ززتوت یرل
http://www. pitt.edu/~cbw/database.html
" Beth Israel Medical Center NYC:
http://www. healthandhealingny.org/
= Columbia University:
wo stele dalle ارزو ویر باس مزر
= University of California, Berkeley Newsletter:
//www.wellnessletter.com/html/ds/dsSuppleme
htt
nts.
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رز( ۱
= ABC's of Herbal Medicine | Herbs |
Dietary Supplements | Vitamins & Minerals
In-depth Monographs (71) |
Clinician Information Summaries
Patient Fact Sheets |
Articles by LHTF Members
Interactions and Toxicity Information |
Resources & LinksAbout the LHTF |
How to Support the LHTF
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Oousses und Oebsites
Herbs and Dietary Supplements-Wake Forest
University
ee
Botanicals and Health series-University of Arizona
Hose iste! Seventies a alata بسانت بجنا courses/#bo
Botanical Medicine in Modern Clinical Practice (NYC)
http://cait.cpmc.columbia.edu:88/dept/rosenthal/
Botanicals_CME.htm|
Consumer Labs
http://www.consumerlab.com
“bu Medicines SOUT ل Database
0 http: Terai 0 com.
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ConsumerLab.com, is a provider of independent
test results and information to evaluate health,
wellness, and nutrition products.
2.5 millions visits/year and as a certification
company, CL enables companies of all sizes to
have their products voluntarily tested for inclusion
in its list of Approved Quality products and bear
the CL Seal.
In the past 7 years, tested more than 1,800
products, representing over 350 different brand
and supplements. One-year (12 months)
subscription is $27.00
Natural Products Encyclopedia and free newsletter
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٩۱2 زر راک زر ٩
Search - enter natural product name, disease or
condition, or drug name: objective product
information, Effectiveness Ratings, or potential
interactions with drugs
Natural Product Effectiveness Checker - tells you
the level of effectiveness for natural products
used for various medical conditions.
Natural Product / Drug Interaction Checker - tells
you potential interactions between any natural
product and any drug.
Disease / Medical Conditions Search - shows you
medical conditions, and allows you to see which
natural products might be effective.
Search Colleagues Interact - shows you questions,
answers, and comments posted by other health
professionals.
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= University of Arizona Associate Fellowship
recon /MWIW Intate)ralniVerrieclieinie \rizorie) selvi/elr/
02.55%) (residential and associate)
= Family Practice and CAM residencies
* Albert Einstein College of Medicine
* Maine Medical Center
* Middlesex Hospital Family Practice Residency
Program
* Oregon Health & Science University
* University of Arizona College of Medicine
* University of Wisconsin - Madison
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OO مها
Stanford Center for Integrative Medicine (SCIM)
* http://www.stanfordhospital.com/
clinicsmedServices/clinics/
complementaryMedicine/default
Osher Center for Integrative Medicine
* http://www.osher.ucsf.edu//
Five Branches Institute
* http://www.fivebranches.edu/
College of Botanical Healing
* http://www.cobha.org/
Ryan Ranch, Integrative Medicine
* http://www.ryanranchmedicalgroup.com/
integrative_medicine.hAtm
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