Surveys of complementary and alternative medicine: Part II. Use of alternative and complementary cancer therapies.

The second part of this series on surveys of complementary and alternative medicine (CAM) in the United States provides a "point-of-information" summary of the studies on patients with cancer and their use of CAM therapies. Surveys of patients with cancer were the precursors of the recent wave of studies on CAM prevalence and use. Three tables summarize the findings from a total of 18 surveys categorized by Childhood Cancer, Adult Cancer, and Breast Cancer studies.     

A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective

A randomized controlled trial was carried out to measure the cost-effectiveness of realtime teledermatology compared with conventional outpatient dermatology care for patients from urban and rural areas. One urban and one rural health centre were linked to a regional hospital in Northern Ireland by ISDN at 128 kbit/s. Over two years, 274 patients required a hospital outpatient dermatology referral--126 patients (46%) were randomized to a telemedicine consultation and 148 (54%) to a conventional hospital outpatient consultation. Of those seen by telemedicine, 61% were registered with an urban practice, compared with 71% of those seen conventionally. The clinical outcomes of the two types of consultation were similar--almost half the patients were managed after a single consultation with the dermatologist. The observed marginal cost per patient of the initial realtime teledermatology consultation was 52.85 Pounds for those in urban areas and 59.93 Pounds per patient for those from rural areas. The observed marginal cost of the initial conventional consultation was 47.13 Pounds for urban patients and 48.77 Pounds for rural patients. The total observed costs of teledermatology were higher than the costs of conventional care in both urban and rural areas, mainly because of the fixed equipment costs. Sensitivity analysis using a real-world scenario showed that in urban areas the average costs of the telemedicine and conventional consultations were about equal, while in rural areas the average cost of the telemedicine consultation was less than that of the conventional consultation.     

Avoiding artificiality in teleconsultations

The ideal videoconferencing environment would produce the minimum feeling of artificiality for its users. We assessed nurse and patient perceptions of artificiality by varying the technical and operational procedures for telemedicine in a minor injuries unit. Twenty-five patients and eight emergency nurse practitioners (ENPs) participated in simulated teleconsultations under a variety of different conditions and completed a Likert-scale survey. There was a close correlation between the ENPs' ratings and the patients' ratings for the various factors (r > 0.99). In relation to technical factors, a flicker-free television screen and the user being seated close to the screen were preferred. Similarly, in relation to operational procedures, an initial explanation of telemedicine, introductions and adequate preparation were also preferred. The study suggests that careful attention to technical specifications and operational procedures can reduce the perceived artificiality of teleconsultations.     

Experience with a low-cost telemedicine system in three developing countries

The Swinfen Charitable Trust was established in 1998 with the aim of helping the poor, sick and disabled in the developing world. It does this by setting up simple telemedicine links based on email to support doctors in isolated hospitals. The first telemedicine link was established to support the lone orthopaedic surgeon at the Centre for the Rehabilitation of the Paralysed (CRP) in Savar, near Dhaka in Bangladesh, in July 1999. An evaluation of the 27 referrals made during the first year of operation showed that the telemedical advice had been useful and cost-effective. Based on the success of the Bangladesh project, the Swinfen Charitable Trust supplied digital cameras and tripods to more hospitals in other developing countries. These are Patan Hospital in Nepal (March 2000), Gizo Hospital in the Solomon Islands (March 2000), Helena Goldie Hospital on New Georgia in the Solomon Islands (September 2000) and LAMB Hospital in Bangladesh (September 2000).     

A comparison of real-time and store-and-forward teledermatology: a cost-benefit study

BACKGROUND: Increasing use of teledermatology should be based on demonstration of favourable accuracy and cost-benefit analysis for the different methods of use of this technique. Objectives To evaluate the clinical efficacy and cost-effectiveness of real-time and store-and-forward teledermatology. METHODS: Patients attended their own health centre and in the company of a general practitioner (GP) were seen by a hospital dermatologist over the videolink (real-time). Before the videolink consultation commenced, the GP took instant photographs of the skin lesion and posted them along with a standard referral letter to a different hospital dermatologist (store-and-forward). In total, 96 patients were seen by both real-time and store-and-forward teledermatology. Comparative diagnoses, clinical management plans, clinical outcomes and associated costs were made between the two types of teledermatology consultation. RESULTS: There was agreement between the videolink diagnosis and the still image diagnosis in 51% of cases. The same or similar management plan was recommended at both types of consultation in 44% of cases. Following the store-and-forward consultation the dermatologist recommended that 69% of patients required at least one hospital appointment compared with 45% of those patients seen in real-time. The net societal cost of the initial real-time consultation was pound132.10 per patient compared with £26.90 per patient for the initial store-and-forward consultation. CONCLUSIONS: The store-and-forward consultation was cheaper, but less clinically efficient, compared with the real-time consultation. The absence of interaction in a store-and-forward consultation limits the dermatologist's ability to obtain clinically useful information in order to diagnose and manage a patient satisfactorily.     

Comparison of in-vitro pharmacodynamics of once and twice daily ciprofloxacin.

The pharmacodynamics of ciprofloxacin were explored in an in-vitro continuous bacterial culture model of infection, by simulating two oral dosing regimens; 0.5 g 12-hourly (bd) and 1 g 24-hourly (od). Three strains of Escherichia coli (ciprofloxacin MICs 0.03, 0.5 and 2 mg/L); two strains of Pseudomonas aeruginosa (MICs 0.09 and 1.5 mg/L), two strains of Staphylococcus aureus (MICs 0.12 and 1 mg/L) and two strains of Streptococcus pneumoniae (MICs 0.5 and 2 mg/L) were used. Three pharmacodynamic parameters, T > MIC, C(max)/MIC and AUC/MIC (T = time, C(max) = peak serum concentration, AUC = area under the curve), were compared with area under the bacterial-kill curve (AUBKC) (after transformation of the AUBKC) using a simple E(max) or sigmoidal E(max) model. AUBKC was taken to be the main antibacterial effect measure. The models were compared by inspection of residuals and Akaike information criterion. E(max) models adequately described the relationship between AUC/MIC and AUBKC and between C(max)/MIC and AUBKC, but not between T> MIC and AUBKC. All three pharmacodynamic parameters are related to each other but multiple regression analysis indicated that AUC/MIC was the best individual predictor of AUBKC. Despite this, comparison of od and bd regimens indicates some advantage to od in terms of early antibacterial effect. Serum concentration-time curve shape has some importance in determining antibacterial effect. These data indicate that for ciprofloxacin AUC/MIC ratio is not the sole determinant of antibacterial effect.