"Quality profiling" for complementary medicine: the example of a hospital for traditional Chinese medicine

OBJECTIVE: The goal of the methodological approach of "quality profiling" for complementary and alternative medicine (CAM) is to offer an empirical database that would enable different participants in the health care system to evaluate the quality of a medical provider. METHODS: Quality profiling is a structured way of describing quality on the levels of infra-structure, patients, medical interventions, outcomes, and quality assurance related to one specific provider. As part of a program called "quality management and research," this type of profiling constitutes one basic step for generating knowledge in terms of evidence-based medicine as well as confidence-based medicine. Quality profiling is exemplified by a hospital for Traditional Chinese Medicine in Germany. Within 1 year all in-patients were included in the database using questionnaires for physicians and patients at the time of admission, discharge from the hospital, and follow-up inquiries at intervals up to 1 year after discharge. The frequency of diagnostic and therapeutic interventions was recorded daily. RESULTS: Data for 1036 patients (mean age 53 years old, 73% female) were analyzed. The most frequent diagnostic categories were musculoskeletal disorders (30%) and neurologic disorders (26%). Therapeutic effects were shown in various outcome measures such as reduced intensity of complaints, improved quality of life, increased satisfaction in lifestyle areas, and fewer days off work. In 6.5% of the subjects, adverse events (mostly of minor severity) were recorded. CONCLUSIONS: Quality profiles can serve as a basic tool for evaluating provider quality when the results are compared with either a predefined standard or with profiles of other providers who are offering similar medical services.     

Treatment of resistant depression by adding noradrenergic agents to lithium augmentation of SSRIs

OBJECTIVE: To examine the efficacy of second-line augmentation with noradrenergic antidepressants (NAs) in depressed patients who partially responded to lithium augmentation of selective serotonin-reuptake inhibitors (SSRIs). CASE SUMMARY: Six patients with major depression or double depression (major depression and dysthymia) who were partially responsive to lithium and SSRI treatment were given either bupropion or desipramine, in an open clinical manner. Improvement was determined and rated by a psychiatrist based on clinical judgment guided by the Clinical Global Impression (CGI) improvement scale and by the Global Assessment of Functioning (GAF) as described in Axis V in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. RESULTS: Among the 6 depressed patients with partial remission (much improved in symptoms and moderate functional improvement: CGI score 2, GAF score 51-60) while taking the SSRI and lithium combination, 2 showed complete remission (very much improved in symptoms and good functioning: CGI 1, GAF 80-100) and 3 achieved near-complete remission (very much improved in symptoms and significant functional recovery: CGI 1, GAF 61-80) when given either bupropion or desipramine. One patient did not show any additional clinical or functional improvement. Second-line augmentation with bupropion was better tolerated than desipramine. CONCLUSIONS: This clinical observation suggests that second-line augmentation with NAs may be a viable option to optimize recovery in depressed patients with a partial response to lithium augmentation of SSRIs.     

WHOQOL-BREF在脑卒中偏瘫患者中的应用

目的　应用WHOQOL BREF研究脑卒中偏瘫患者不同时期生存质量的变化以及康复治疗对生存质量的影响。方法　 5 0例急性脑卒中患者被随机分为康复组和对照组 ,每组各 2 5例 ,两组患者均接受药物治疗 ,康复组同时进行以运动训练为主的康复治疗。采用WHOQOL BREF量表和生存质量主观感受评分分别于病程 1,3和 6个月对患者进行评估。结果　康复组病程 3个月、6个月与对照组病程 6个月时 ,WHOQOL BREF在生理、心理和环境领域评分均显著高于同组病程 1个月时 (P <0 .0 5 ) ,这 3个领域评分在康复组病程 3个月和 6个月时均显著高于同期对照组 (P <0 .0 5 )。康复组病程 6个月时主观感受评分显著高于同组病程 1个月时 (P <0 .0 5 ) ,与对照组同期比较 ,差异也有显著性意义 (P <0 .0 5 )。结论　临床上应用WHOQOL BREF可反映脑卒中偏瘫患者不同时期生存质量的变化 ,同时证明康复治疗有利于改善患者的生存质量。     

The legitimization of headache medicine

Simultaneous with the drive to ensure the acceptance of headache disorders as "real diseases," the field of headache medicine has strived for recognition as a subspeciality with itself. Efforts to gain such recognition eventually came to fruition in 2005.     

How the public classify complementary medicine: a factor analytic study

OBJECTIVES: To see how lay people group or classify various CAM therapies. DESIGN: Nearly 600 adults rated 39 relatively familiar branches of complementary medicine on four dimensions: whether they had heard of it, whether they think they know how it works; whether they had tried it; and a rating of efficacy on a 10-point scale. RESULTS: As predicted those most heard of were acupuncture, aromatherapy, herbal medicine, hypnosis, massage and yoga while those with lowest ratings were autogenic training, ayurveda, biochemic tissue salts, chelation cell therapy and ozone therapy. A number of multivariate statistical techniques were used to attempt to investigate the perceived dimensional structure of the different therapies. Slightly different structures emerged depending on the question asked and the analysis computed. CONCLUSION: The 'bottom-up' empirically derived taxonomization of therapies was interpretable and showed 10 different factors. The issue of classifying or taxonomizing complementary medicines is discussed.     

Clinically Meaningful Changes in Quantitative Measures of Asthma Severity

OBJECTIVE: To determine minimum clinically meaningful improvements in peak expiratory flow rate (PEFR) and dyspnea visual analog score (VAS) in patients with acute asthma exacerbation. METHODS: Patients presenting to the emergency department (ED) with acute asthma exacerbation were eligible. The PEFR and VAS were assessed at presentation and after initial asthma therapy. During reassessment, subjects were asked to describe their asthma symptoms as "much better," "a little better," "no change," "a little worse," or "much worse." Correspondence between self-reported improvement and changes in PEFR and VAS was assessed. The "minimum clinically significant change" in either index was defined as the difference between pre- and posttreatment measures in subjects reporting their symptoms "a little better." RESULTS: One hundred fifty-six subjects were included. Asthma symptoms were "much better" in 99 (64%), "a little better" in 41 (26%), and "unimproved" (composed of patients describing symptoms as "no change," "a little worse," or "much worse") in 16 (10%). The mean VAS change among the "a little better" subjects was 2.2 cm (95% CI = 1.1 to 3.4), significantly greater than the -0.4 cm (95% CI = -2.1 to 1.4) change in the "unimproved" subjects. The mean change in percent predicted PEFR among the "a little better" subjects was 11.9 (95% CI = 7.3 to 16.1), not statistically different from the change of 6.1 (95% CI = 1.1 to 11.3) in the "no change" subjects. The "much better" group showed significantly greater changes in both measures than either of the other groups. A VAS change of > or =0.5 cm reliably discriminated between subjects with and without symptom improvement. CONCLUSIONS: Improvements in VAS of 2.2 cm and in predicted PEFR of about 12 percentage points are minimal clinically significant improvements during ED asthma therapy. The dyspnea VAS is valid in assessing symptomatic changes and may detect small subjective improvements better than the PEFR.     

Factors associated with achieving minimally symptomatic status by patients with schizophrenia: results from the 3‐year intercontinental schizophrenia outpatients health outcomes study

Objective: The aim of this study was to describe factors associated with achieving a minimally symptomatic status outcome in outpatients with schizophrenia. Methods: Data were analysed from a 3‐year, prospective observational study that examined outcomes in 7658 patients with schizophrenia. Minimally symptomatic status was defined as a postbaseline score of 1 or 2 on the Clinical Global Impressions Severity Scale‐Schizophrenia version (CGI‐SCH). Results: Baseline CGI‐SCH score had the strongest association with minimally symptomatic status followed by age, geographical region and hospitalisation status. The probability of becoming minimally symptomatic was consistently higher in the olanzapine and clozapine monotherapy groups compared with the quetiapine, risperidone or haloperidol groups. The olanzapine group achieved the minimally symptomatic status in a shorter period of time than the other treatment groups (p ≤ 0.016). Conclusion: The likelihood of patients achieving a minimally symptomatic status was greater in younger patients with lower baseline clinical severity and in patients whose treatment included olanzapine.     

Use of traditional medicine among pregnant women in Lusaka, Zambia

OBJECTIVE: We studied the prevalence of and predictors for traditional medicine use among pregnant women seeking care in the Lusaka, Zambia public health system. SUBJECTS: We surveyed 1128 pregnant women enrolled in a clinical trial of perinatal human immunodeficiency virus (HIV) prevention strategies at two district delivery centers. OUTCOME MEASURES: Postpartum questionnaires were administered to determine demographic characteristics, behavioral characteristics, HIV knowledge, and prior use of traditional medicines. RESULTS: Of the 1128 women enrolled, 335 (30%) reported visiting a traditional healer in the past; 237 (21%) reported using a traditional healer during the current pregnancy. Overall, 54% believed that admitting to a visit to a traditional healer would result in worse medical care. When women who had used traditional medicines were compared to those who had not, no demographic differences were noted. However, women who reported use of traditional medicine were more likely to drink alcohol during pregnancy, have >or=2 sex partners, engage in "dry sex," initiate sex with their partner, report a previously treated sexually transmitted disease, and use contraception (all p < 0.01). HIV-infected women who reported using traditional healers were also less likely to adhere to a proven medical regimen to reduce HIV transmission to their infant (25% versus 50%, p = 0.048). CONCLUSIONS: Use of traditional medicine during pregnancy is common, stigmatized, and may be associated with nonadherence to antiretroviral regimens. Health care providers must open lines of communication with traditional healers and with pregnant women themselves to maximize program success.     

Ping wei san, a Chinese medicine for gastrointestinal disorders

OBJECTIVE: To describe the dilemma that American pharmacists face when their patient uses a traditional Chinese herbal formula. Ping wei san (PWS), an agent used to treat gastrointestinal disorders, is used to illustrate the problems encountered and to identify resources on Chinese herbal medicines available to pharmacists. DATA SYNTHESIS: In the US, Chinese herbal medicine is making its way into mainstream Western medicine. Patients may discover PWS in their search for a substitute for cisapride, which was partially withdrawn from the US market in July 2000. The pharmacist may be called on to assist in the management of patients who wish to use PWS for treatment of common gastrointestinal disorders like gastritis, esophageal reflux, gastric or duodenal ulcers, and acute or chronic enteritis. As with most other Chinese herbal formulas, English-language literature about PWS is limited and is often difficult to interpret. Pharmacists who are unfamiliar with the basic principles and terminology used in traditional Chinese medical practices will need to identify sources of information about this complementary alternative practice to be able to provide pharmaceutical care for patients taking a Chinese herbal formula like PWS. CONCLUSIONS: To develop a pharmaceutical care plan for patients using a Chinese herbal medicine therapy such as PWS, the pharmacist will need to become familiar with traditional Chinese medical practices and terminology describing indications, therapeutic effects, and risks. Fortunately, resources are available to pharmacists who need assistance in interpreting information on Chinese herbal therapies so that they can appropriately manage patients using them.     

Ethnic differences in complementary and alternative medicine use among cancer patients

OBJECTIVES: This study estimated the prevalence of complementary and alternative medicine (CAM) use and its relation to quality of life (QOL) among cancer patients from diverse ethnic backgrounds. Given the ethnically diverse population in Hawaii, we hypothesized that CAM use may be related to the ancestry and the cultural heritage of cancer patients. DESIGN AND SETTING: Participants for this mail survey were identified through the Hawaii Tumor Registry, a state-wide population-based cancer registry. SUBJECTS: Patients with invasive cancer diagnosed 1995-1996. Of the 2,452 questionnaires received, 1,168 (47.6%) were returned. OUTCOME MEASURES: Prevalence of CAM use and QOL measures. RESULTS: One in four respondents reported at least one CAM therapy since cancer diagnosis. CAM use was highest among Filipino and Caucasian patients, intermediate for Native Hawaiians and Chinese, and significantly lower among Japanese. Some ethnic preferences for CAM followed ethnic folk medicine traditions, e.g., herbal medicines by Chinese, Hawaiian healing by Native Hawaiians, and religious healing or prayer by Filipinos. CAM users reported lower emotional functioning scores, higher symptom scores, and more financial difficulties than nonusers. CONCLUSIONS: This study detected ethnic differences in CAM use, in particular a low use among Japanese patients, and supports the importance of cultural factors in determining the frequency and type of CAM therapies chosen. Consideration of patients' cultural heritage may facilitate communication between physicians and patients about CAM with the goal to achieve optimal cancer care.     

Bibliometric analysis of randomized trials in complementary medicine

Objective:

To determine the following features of randomized trials in complementary medicine: the extent to which they are indexed on Medline, the journals in which they are published, dates of publication, the therapies and conditions most commonly the focus of study.

Design:

Bibliometric analysis of the registry of randomized trials of the Cochrane Collaboration field in Complementary Medicine. Outcome measures: The number of trials in each category.

Results:

There were 3774 randomized trials on the registry of which 3072 (81%) were indexed on Medline. However, only about a third of these references could be easily found with a Medline search. Trials were published in a total of 965 different journals. Most trials (84%) were published in a conventional medical journal. The number of trials is increasing rapidly, having approximately doubled every 5 year period since 1965. There was a large variation in the number of trials for different complementary therapies. There were a high number of trials in acupuncture (554), herbal medicine (804) and meditation and relaxation techniques (643) but few trials in aromatherapy (47) and osteopathy (18). There were many trials in cardiovascular disease (501), musculoskeletal disorders (386) and surgery-related symptoms (293), but few in fatigue disorders (11).

Conclusion:

Medline is an incomplete source of randomized trials in complementary medicine. Searching of Medline could be significantly enhanced by changes to keywords and improved data on type of publication. The conditions and therapies subject to trials in complementary medicine do not provide an accurate reflection of clinical practice.     

Resourcing the clinical complementary medicine information needs of Australian medical students: Results of a grounded theory study

The aim of this study was to identify Australian medical students’ complementary medicine information needs. Thirty medical students from 10 medical education faculties across Australian universities were recruited. Data were generated using in‐depth semi‐structured interviews and constructivist grounded theory method was used to analyze and construct data. Students sought complementary medicine information from a range of inadequate sources, such as pharmacological texts, Internet searches, peer‐reviewed medical journals, and drug databases. The students identified that many complementary medicine resources may not be regarded as objective, reliable, differentiated, or comprehensive, leaving much that medical education needs to address. Most students sought succinct, easily accessible, evidence‐based information to inform safe and appropriate clinical decisions about complementary medicines. A number of preferred resources were identified that can be recommended and actively promoted to medical students. Therefore, specific, evidence‐based complementary medicine databases and secondary resources should be subscribed and recommended to medical schools and students, to assist meeting professional responsibilities regarding complementary medicines. These findings may help inform the development of appropriate medical information resources regarding complementary medicines.     

盐酸多奈哌齐治疗血管性痴呆的临床研究

目的观察盐酸多奈哌齐治疗血管性痴呆患者轻、中度认知功能障碍的有效性和安全性。方法 60例血管性痴呆患者以SAS软件分为治疗组和对照组各 3 0例。治疗组服用盐酸多奈哌齐片 5mg ,4周后增至 10mg ,每晚睡前服 ;对照组服用吡拉西坦 80 0mg ,3次 /d ,饭前口服。疗程均为 12周。以简易精神状态检查 (MMSE)和中国修订成人韦克斯勒智力量表 (WAIS RC)为主要评价指标 ,日常生活活动能力量表 (ADL)和临床综合调查表 (CGI)为次要评价指标。结果两组MMSE评分在治疗后均明显提高 (P <0 0 1) ,治疗组提高 (2 88± 2 85 ) ,对照组提高 (1 62± 2 3 3 ) (P <0 0 5 ) ;WAIS RC评分治疗组治疗后明显提高 (P <0 0 1) ,对照组治疗前后WAIS RC评分无显著性差异 (P >0 0 5 ) ;两组治疗后ADL和CGI的SI均降低 ;盐酸多奈哌齐组总有效率为 80 % ,吡拉西坦组为 5 6% ,两组的药物相关的不良反应无显著性差异。结论盐酸多奈哌齐能改善血管性痴呆患者的认知功能 ,疗效可能优于吡拉西坦 ,应用盐酸多奈哌齐 10mg/d比较安全     

Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine

Complementary and alternative medicine (CAM) has been defined largely in relation to conventional biomedicine. CAM therapies that are used instead of conventional medicine are termed "alternative." CAM therapies used alongside conventional medicine are said to be "complementary." "Integrative medicine" results from the thoughtful incorporation of concepts, values, and practices from alternative, complementary, and conventional medicines. The evolving process of integration between CAM and conventional medicine evokes new conceptual frameworks, as well as new terminology. Interview-based qualitative research at the University of Wisconsin-Madison seeks to probe and develop this theoretical structure. Interviews with users and practitioners of CAM therapies have revealed four primary themes: holism, empowerment, access, and legitimacy (HEAL). These themes characterize CAM and contrast it with conventional medicine. CAM is said to be more holistic and empowering yet less legitimate than conventional medicine. CAM is more intuitive; conventional is more deductive. While CAM is perhaps more psychologically accessible to many patients in that it better reflects commonly held values, it is often less financially and institutionally accessible, at least for those with conventional health insurance and limited income. Substantive barriers--including economic, organizational and scientific differences, as well as an apparent widespread lack of understanding--continue to thwart attempts at integration. More and better evidence is needed if CAM therapies are to be accepted by mainstream medicine. State-of-the-art research methods developed by conventional science will be needed to test CAM therapies. Conventional medicine, however, has much to learn from CAM. By incorporating a more holistic, empowering and accessible therapeutic approach, conventional medicine could build on its present legitimacy, and thereby enhance its power to "HEAL."     

Alternative medicine use in dialysis patients: potential for good and bad!

Although alternative medicines are widely used within the general population, the extent of their use within the dialysis population is unknown. It is possible that dialysis patients may be more likely to turn towards alternative therapies in view of the chronicity of their disease. In addition, this particular patient population could be at an increased risk of toxicity from these therapies due to an absence of renal excretion. A detailed assessment of complementary and alternative medicine use in our dialysis patients revealed that 18% of our patients had used or were using some form of alternative medicine therapy. An additional 63% of our patients, however, were willing to use a complementary or alternative medication. Our results suggest that hemodialysis patients are extremely receptive to the use of such therapies and are therefore exposed to all their potential benefit and harm.     

老年慢性病住院患者生存质量及相关因素的研究

目的 了解住院老年慢性疾病患者生存质量现状,分析影响因素.方法 采用方便抽样方法,应用世界卫生组织生存质量测定量表简表（WHOQOL-BREF）对住院老年慢性病患者的一般资料及生存质量进行调查,并分析影响生存质量的因素.结果 77例患者生理领域QOL得分（56.91±11.84）,心理领域QOL得分（59.79±13.29）,社会关系QOL得分（68.94±12.94）,环境领域QOL得分（64.94±23.76）.单因素分析显示,不同年龄、文化程度、患病年限、住院次数及经济收入患者,其在某些领域生存质量得分差异有统计学意义（P＜0.05）;多元线性回归分析提示,经济收入、住院次数及患病年限均对多个领域生存质量得分有影响（P＜0.05）.结论 诸多因素均可影响住院老年慢性病患者的生存质量,应针对性地对其提供健康教育及预防保健等综合服务,尽力避免有关因素对该人群生存质量的影响.     

The marriage of conventional cancer treatments and alternative cancer therapies

The terms "alternative" or "unconventional" have been used to describe any therapy used instead of conventional approaches. Conventional approaches, known as "standard" or "traditional" or "biomedical" approaches, have had broad application in Western medicine. Complementary and alternative medicine has been referred to as "integrative," "integrated," or "complementary" when therapies are combined with conventional approaches, such as those for cancer.