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Complementary and Alternative Medicine (CAM) Resources for the Practitioner

Where to look and Who to Trust_tabaye

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Complementary and Alternative Medicine (CAM) Resources for the Practitioner

اسلاید 1: www.tabaye.ir

اسلاید 2: Complementary and Alternative Medicine (CAM) Resources for the Practitioner: Where to look and Who to TrustJohn D. Mark MDClinical Assoc Professor of PediatricsPediatric Pulmonary MedicineLucile Packard Children’s Hospital at Stanford

اسلاید 3: CAM- Where is it?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

اسلاید 4: CAM- every where you look

اسلاید 5: CAM in the NewsDying Woman Loses Marijuana Appeal March 14, 2007Evidence Mounts That Coping Skills Can Boost HIV Survival March 14, 2007Omega-3 in Fish Oils Might Ease Depression March 7, 2007Insomnia: Alternative Medicine Popular1.6 Million Adults Use Complementary Or Alternative Medicine For Insomnia September 2006

اسلاید 6: Ernst MJA 2006; 185 (11/12): 680-681

اسلاید 7: Complementary and Alternative Medicine (CAM)Complementary and alternative medicine A group of diverse medical and health care systems, practices, and products Not considered part of conventional medicineSome scientific evidence exists regarding CAM therapies For most, questions of safety and efficacy persistComplementary medicine is used together with conventional medicine. Alternative medicine is used in place of conventional medicine. http://nccam.nih.gov/health/whatiscam/

اسلاید 8: Integrative or Holistic Medicine Integrative combines mainstream medical therapies and CAM therapies for which 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 alternative.” http://nccam.nih.gov/health/whatiscam/http://www.integrativemedicine.arizona.edu/about2.html

اسلاید 9: Enhance themind’s capacityto affect bodilyfunction andsymptomsChiropracticeOsteopathyMassageMajor Classes of CAMAlternative medical systemsMind-bodyinterventionsManipulative & body-based methodsEnergytherapiesHomeopathicNaturopathicTraditional Chinese and Ayurvedic treatmentsDietary suppHerbsFoodsVitaminsNatural substancesBiofield therapyBioelectro- magnetic therapyBiologically-basedtherapieshttp://nccam.nih.gov/

اسلاید 10:

اسلاید 11: CAM UtilizationReasons for using CAM: Consistent with patient’s and families values: natural, and empoweringCAM providers are “patient-centered”, dedicated to promoting health. Conventional therapies are perceived to be emotionally or spiritually without benefitConventional therapies are not effective or are associated with side effects.CAM use is a circular: usage determines number of CAM practitioners Archives of Disease in Childhood 2006;91:96-97

اسلاید 12: CAM Therapieshttp://nccam.nih.gov/news/camsurvey_fs1.htm#domain

اسلاید 13: CAM Therapies

اسلاید 14: Pediatric Use of CAMAsthma 80% Reznik, 2003(Bronx, NY)Adolescents54-69% Wilson, 2002 (NY) Braun, 2005 (MN)Special Needs 64% Sanders, 2003 (Tucson, AZ)Rheumatology 64% Hagen, 2003 (Toronto)ADHD 54% Chan et al, 2003 (Boston Children’s)Emergency13-45% Losier, 2005 (Ottawa) Lanski, 2003 (Atlanta)

اسلاید 15: Pediatric Use of CAMOncology 47-84% McCurdy, 2003 (WFU)Neuhouser, 2001 (Seattle)Kelly, 2000 (NYC)Cerebral Palsy 56% Hurvitz, 2003Ann Arbor, MIIBD 41% Heuschkel, 2002London, Boston, DetroitAutism Spectrum 30% Levy, 2003 CHOP, PAPreoperative 29.5% Lin, 2004Boston Children’sPrimary Care 12-21% Sawni, 2002 (Detroit)Ottolini, 2001 (Wash D.C.)

اسلاید 16: Evidence Based CAM Therapies in PediatricsEffectiveness well documented: Acupuncture for nausea and vomiting Biofeedback for constipation Biofeedback for headache Hypnotherapy for headache Hypnotherapy for irritable bowel syndrome Lemon balm for herpes simplex Massage for constipation Archives of Disease in Childhood 2006;91:96-97

اسلاید 17: CAM Treatments Commonly Thought Effective in PediatricsEffectiveness uncertain Acupuncture for asthma Acupuncture for hay fever Acupuncture for rheumatoid arthritis Chromium for diabetes Echinacea for common cold prevention or treatment Evening primrose for eczema Effectiveness unlikelyAcupuncture for body weight reduction Acupuncture for smoking cessation Flower remedies for anxiety Homeopathy for anxiety Spinal manipulation for asthma Spinal manipulation for infantile colic Archives of Disease in Childhood 2006;91:96-97

اسلاید 18: Use of Herbs- Evidence?Alternative Health supplement of the 2002 National Health Interview Survey: data on 10 common herbsOf 30,616 adults, 19% used herbs in past 12 mo, 57% for a specific conditionApproximately 2/3 used herbs (except Echinacea) not in accordance with evidence based indicationsMayo Clin Proc, May 2007;82(5): 561-566

اسلاید 19: Conventional Medicine, Evidence?Most conventional physicians believe in unconventional medicine because it is not scientificWhat 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 Arch Intern Med. 1998;158:2179-2181

اسلاید 20: CAM & Pediatric CareEvidence is lacking even for the most popular, if there is evidence, most is in adultsHowever, 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.

اسلاید 21: Physician’s AttitudesSurvey sent to 660 physicians at the Mayo Clinic (233 responded)Three areas: utilization, familiarity and attitudesUtilization:75% had never referred to CAM practitioner44% said they would consider if available at the Mayo (<46 years or female more likely)Less 25% discussed benefits or risks with CAM57% thought incorporation of CAM would be have a positive impact on pt satisfaction

اسلاید 22: Physician’s Attitudes Familiarity:Biofeedback, massage, chiropractic and relaxation therapies were the most familiar59% were unfamiliar with energy healing, 53% with naturopathic medicineOf the 13 herbs listed, only 3 were commonly listed as familiar66% were not familiar with feverfew and 52% were not familiar with Kava49% of the physicians felt it was difficult or very difficult to find reliable information about herbs

اسلاید 23: Physician’s Attitudes41% of the physicians neither agreed or disagreed that physician knowledge had an impact on patient’s health52% felt physician’s spiritual beliefs were important and 87% felt patients spiritual beliefs and practices were important67% agreed some CAM therapies hold promise but 70% felt current practices of CAM was a “threat” to the public healthMost important factors in changing physician’s attitudes were RCT’s and evidence demonstrating mechanism70% of the physicians felt Mayo clinic should provide proven CAM therapieseCAM 2006;3(4) 495-501

اسلاید 24: Federation of State Medical Board Guidelines (excerpts) Patient evaluation: Includes the use of non-conventional methods of diagnosis and treatmentConsultation and/or referral to licensed or otherwise state-regulated health care practitioner- the Physician is responsible for monitoring the resultsMedical records should also document: What conventional medical options have been discussed, offered, tried, or refusedEducation- All physicians must be able to demonstrate a basic understanding of the medical scientific knowledge connected with any CAM therapywww.fsmb.org

اسلاید 25: What to do……….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

اسلاید 26: CAM Education in PediatricsCAM education in medical schoolsAmerican Academy of Pediatrics (AAP)Pediatric Integrative Medicine Leadership Initiative and Pediatric Integrative Medicine Conference (PIMC)International Pediatric Integrative Medicine Network (IPIM-N)Canadian network linking pediatric CAM researchers & educators (PedCAM)

اسلاید 27: CAM Education in Medical Schools1998 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 advocacyChange is occurring:Harvard: Division for Research and Education in Complementary and Integrative Medical TherapiesAlbert Einstein, Columbia, Duke, Mount Sinai, Stanford, Arizona, Maryland, Pennsylvania, and several branches of the University of California have included CAM in the curriculum

اسلاید 28: How to Include CAM in EducationTeach 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)Wetzel MS, et al. Ann Intern Med 2003; 138: 191–6

اسلاید 29: Current Status - AAPProvisional 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 therapiesMeetings:Super CME CoursesAAP National Conference October 2007Four sessions by CHIM members

اسلاید 30: Current status - PIMCPediatric Integrative Medicine ConferenceCollaboration of academic faculty at multiple pediatric integrative medical centers in US/Canada1st-2000, University of Arizona, Tucson2nd-2001, University of Minnesota, Minneapolis3rd- 2005, New York Academy of Medicine, NYC 4th- 2006 October, 27-29th, Chicago5th- 2007, October 26-27th, San Franciscohttp://www.pangeaconference.com/index.asp

اسلاید 31: Current Status - IPIM-NInternational Pediatric Integrative Medicine NetworkList serve connecting PIM practitioners and organizationsFacilitates communication and collaborationPromotes clinical, educational and research initiatives Provides resources and links Secure electronic network ldrdoc@alum.mit.edu

اسلاید 32: Resource EvaluationIntroduction 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? How current is the information? How does the site choose links to other sites? What information about you does the site collect, and why? How does the site manage interactions with visitors?

اسلاید 33: A Guide for Providers Using CAMGovernment sitesNational Center for CAM: http://nccam.nih.gov/ Office of Dietary Supplements: http://ods.od.nih.gov/Research/CARDS_Database.aspx MedWatch:http://www.fda.gov/medwatch CAM on PubMed: http://www.nih.gov/news/pr/feb2001/nccam-05a.html

اسلاید 34: NCCAM WebsiteAcupuncture Arthritis Black Cohosh Cancer Chelation Chiropractic Chondroitin Depression Dietary Supplements Echinacea Ephedra Ginkgo Ginseng Glucosamine Herbs at a Glance Homeopathy Menopause St. Johns Wort Introduction to Naturopathy New Herbs at a Glance: Grape Seed Extract AARP/NCCAM Report on Older Americans Past Highlights News from NCCAM:  Subscribe to quarterly newsletter Monthly e-bulletin

اسلاید 35: A Guide for Providers Using CAMAcademic sitesBoston-Longwood Herbal Task Force: http://www.longwoodherbal.org/University of Pittsburgh: http://www.pitt.edu/~cbw/database.html Beth Israel Medical Center NYC: http://www.healthandhealingny.org/ Columbia University: http://www.rosenthal.hs.columbia.edu/Botanicals.html University of California, Berkeley Newsletter: http://www.wellnessletter.com/html/ds/dsSupplements.php

اسلاید 36: Longwood WebsiteABCs 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 & Links About the LHTF | How to Support the LHTF

اسلاید 37: Courses and WebsitesHerbs and Dietary Supplements-Wake Forest Universityhttp://northwestahec.wfubmc.edu/learn/herbs/index.asp#CurrDesc Botanicals and Health series-University of Arizonahttp://integrativemedicine.arizona.edu/online_courses/#botanicals Botanical Medicine in Modern Clinical Practice (NYC)http://cait.cpmc.columbia.edu:88/dept/rosenthal/Botanicals_CME.htmlConsumer Labs http://www.consumerlab.com Natural Medicines Comprehensive Databasehttp://www.therapeuticresearch.net/(ctt54155qny2vs55ryiv2d32)/home.aspx?li=0&st=0&cs=&s=NDQuackwatch http://www.quackwatch.com.

اسلاید 38: Consumer LabsConsumerLab.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

اسلاید 39: Natural Medicine DatabaseSearch - enter natural product name, disease or condition, or drug name: objective product information, Effectiveness Ratings, or potential interactions with drugsNatural 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.

اسلاید 40: Fellowships and ResidenciesUniversity of Arizona Associate Fellowshiphttp://www.integrativemedicine.arizona.edu/af/index.html (residential and associate)Family Practice and CAM residenciesAlbert 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

اسلاید 41: CAM –Local ResourcesStanford Center for Integrative Medicine (SCIM)http://www.stanfordhospital.com/clinicsmedServices/clinics/complementaryMedicine/defaultOsher Center for Integrative Medicinehttp://www.osher.ucsf.edu//Five Branches Institutehttp://www.fivebranches.edu/College of Botanical Healinghttp://www.cobha.org/Ryan Ranch, Integrative Medicinehttp://www.ryanranchmedicalgroup.com/integrative_medicine.htm

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