Medical malpractice implications of alternative medicine

The prevalence and determinants of hepatitis B among Egyptian adults: a further analysis of a country-representative survey

Background

Hepatitis B virus (HBV) infection is a major worldwide healthcare problem with subsequent serious complications including cirrhosis and hepatocellular carcinoma (HCC). Hence, taking cognizance of HBV impact is critical for future planning of its control and prevention.

Objectives

To assess the prevalence of HBV in Egypt, analyse the demographic characteristics of HBV-infected patients and examine the common routes of its transmission.

Methods

This is a cross-sectional study of data from the Egyptian Health Issues Survey (EHIS), which employed a nationally representative sample of 16,004 individuals. The survey participants were categorized into two groups: group A, HBV positive, and group B, HBV negative. Comparative analysis was performed to identify demographic features and define possible risk factors.

Results

The total number of participants included in the study was 16,004. The mean age (± SD) was 33.5 (± 12.4) years. The prevalence of HBV was 1.52%. Demographic analysis showed that HBV was more prevalent among males, married people, people with jobs and smokers (P = 0.0011, 0.002, < 0.001 and 0.0036) respectively. Employing an adjusted multivariate logistic regression model, we observed an increased likelihood of HBV infection in married adults who received cupping without blood and who did not know if they had schistosomiasis injection therapy.

Conclusion

The application of special screening programs to highly susceptible patients and treatment optimization is recommended for the elimination of HBV. EHIS indicates the likely success of the previous Egyptian control plan for viral hepatitis through reducing several risk factors.

Traditional Medicine Utilisation Among Pregnant Women in Sub-saharan African Countries: A Systematic Review of Literature

Traditional medicine has the potential to boost the health and economies of many SSA countries, especially if regulatory mechanisms are deployed to govern their protection and utilisation. There is lack of knowledge regarding traditional medicines and their impact on pregnancy. This paper reviews the literature on traditional medicine utilisation among pregnant women in Sub-Saharan African countries. The paper, determined the proportion of pregnant women utilising traditional medicines in Sub-Saharan Africa, identified the different types of traditional medicine used during antenatal care and reasons for Use in Sub-Saharan Africa and also identified challenges that are faced by women who use traditional medicine in antenatal care. A systematic exploratory review was conducted guided by the PRISMA framework. The databases that were searched included Google Scholar, PubMed, Cochrane, HINARI and the World Health Organization. Forty-one literature sources were eligible and included in the review process. Reported traditional medicine utilisation ranged between 12 and 93% among pregnant women in Sub-Saharan Africa. Different types of traditional medicines have been utilised in Sub-Saharan Africa for different purposes. Safety and poor management of usage were reported to be some of the challenges associated with traditional medicine. There is a need to determine chemical components and mode of action of these herbs as some could be beneficial, whilst others harmful, leading to severe pregnancy complications.

Developing a Pharmacy Curriculum in Complementary and Alternative Medicine

Complementary and alternative medicine (CAM) is gaining in popularity, with one in three Americans reporting some use. The government has taken an interest in CAM research, establishing the National Center for Complementary and Alternative Medicine. However, most conventional health care providers lack knowledge of CAM practices, due in large part to the paucity of formal education in this area. Given these trends, many colleges of pharmacy are considering re-instituting pharmacognosy courses, as well as adding CAM course work to their curricula. The literature contains very little to guide faculty in teaching pharmacy students about CAM; therefore, proposed components of a pharmacy curriculum are discussed.

Safety Issues in the Interaction of Conventional, Complementary, and Alternative Health Care

This article reviews issues of safety in health care, applied particularly to the interface between conventional medicine and complementary and alternative medicine. These issues include errors in treatment and medical management, adverse effects of pharmaceuticals, and defining risk for patients. For complementary and alternative medicine, especially dietary supplements, problems of quality control, licensing, regulation, and misrepresentation are discussed. An important issue is the interface between conventional and complementary therapies, in terms of drug/herb interactions, laboratory diagnosis, and lack of communication between clinicians about patients. Improvements in safety and quality will come from a commitment to better education and understanding between both types of care.

Behaviors of providers of traditional korean medicine therapy and complementary and alternative medicine therapy for the treatment of cancer patients

Objectives:

In Korea, cancer is one of the most important causes of death. Cancer patients have sought alternative methods, like complementary and alternative medicine (CAM) together with Western medicine, to treat cancer. Also, there are many kinds of providers of CAM therapy, including providers of Korean oriental medicine therapy. The purpose of this study is to identify the behaviors of Korean oriental medicine therapy and CAM therapy providers who treat cancer patients and to provide background knowledge for establishing a new policy with the management and quality control of CAM.

Methods:

Structured and well organized questionnaires were made, and 350 persons were surveyed concerning the providers of CAM or Korean oriental medicine. The questionnaires were collected and analyzed.

Results:

The questionnaires (182) were collected. The questionnaires identified a total of 73 known providers, such as medicinal professionals or other providers of CAM suppliers, 35.6% of whom had had experience with treating cancer patients (52.6% vs. 29.6%). The treatment methods were a little different: alternative therapy and nutritional therapy being preferred by medicinal professionals and mind body modulation therapy and alternative therapy being preferred by other CAM providers. Four patients (7.4%) experienced side effects, and 6 patients (12.5%) experienced legal problems. As the method for managing the therapy, CAM providers, medicinal professionals, and other CAM providers had different viewpoints. For example, some CAM providers stated that both legislation and an official education on CAM or a national examination were needed as a first step to establish the provider’s qualifications and that as a second step, a license test was needed for quality control. To the contrary, medicinal professionals stated that a license test was needed before legislation.

Conclusion:

Adequate management and quality control of CAM providers is thought to involve both education and legislation.

The growing use of herbal medicines: issues relating to adverse reactions and challenges in monitoring safety

The use of herbal medicinal products and supplements has increased tremendously over the past three decades with not less than 80% of people worldwide relying on them for some part of primary healthcare. Although therapies involving these agents have shown promising potential with the efficacy of a good number of herbal products clearly established, many of them remain untested and their use are either poorly monitored or not even monitored at all. The consequence of this is an inadequate knowledge of their mode of action, potential adverse reactions, contraindications, and interactions with existing orthodox pharmaceuticals and functional foods to promote both safe and rational use of these agents. Since safety continues to be a major issue with the use of herbal remedies, it becomes imperative, therefore, that relevant regulatory authorities put in place appropriate measures to protect public health by ensuring that all herbal medicines are safe and of suitable quality. This review discusses toxicity-related issues and major safety concerns arising from the use of herbal medicinal products and also highlights some important challenges associated with effective monitoring of their safety.

Natural health product-drug interactions: evolving responsibilities to take complementary and alternative medicine into account

Natural health products (NHPs) (known as dietary supplements in the United States) are a popular form of self-care, yet many patients do not disclose their use to clinicians. NHP-drug interactions are known to occur and can harm patients and affect the efficacy of conventional treatment. Using the example of an HIV-positive adolescent who had been responding well to antiretroviral therapy but then experienced a sudden unexplained deterioration in her condition, we review (1) clinicians' obligation to inquire about complementary and alternative medicine (CAM) use when assessing, treating, and monitoring patients, (2) how clinicians' duty to warn about risks associated with treatment has evolved and expanded, and (3) patients' and parents' responsibility to disclose CAM use. It also addresses the responsibility of hospitals and health facilities to ensure that the reality of widespread CAM/NHP use is taken into account in patient care to effectively protect patients from harm.

Complementary and alternative medicine practitioners' standard of care: responsibilities to patients and parents

In this article we explain (1) the standard of care that health care providers must meet and (2) how these principles apply to complementary and alternative medicine practitioners. The scenario describes a 14-year-old boy who is experiencing back pain and whose chiropractor performed spinal manipulation but did not recognize or take steps to rule out serious underlying disease-in this case, testicular cancer--either initially or when the patient's condition continued to deteriorate despite treatment. We use chiropractic care for a patient with a sore back as an example, because back pain is such a common problem and chiropracty is a common treatment chosen by both adult and pediatric patients. The scenario illustrates the responsibilities that complementary and alternative medicine practitioners owe patients/parents, the potential for liability when deficient care harms patients, and the importance of ample formal pediatric training for practitioners who treat pediatric patients.

Referrals and shared or collaborative care: managing relationships with complementary and alternative medicine practitioners

In this article we discuss steps that clinicians should take after deciding to include a complementary and alternative medicine (CAM) treatment that is beyond the clinician's expertise in a patient's treatment plan. We use the example of an adolescent patient with chronic recurrent headaches that have not been relieved by medication or other therapies and whose physician refers her to an acupuncturist for treatment. We focus on (1) circumstances under which referral is appropriate, (2) the nature of the relationship between the referring clinician and the practitioner to whom the referral is made (considering conventional health care and CAM, regulated and unregulated practitioners), and (3) considerations when undertaking shared or collaborative care with other health care practitioners (conventional health care or CAM). We also suggest best practices in managing such relationships.

Hospitals and complementary and alternative medicine: managing responsibilities, risk, and potential liability

Patients and families increasingly press hospitals to facilitate provision of complementary and alternative medicine (CAM) therapies and products. At the same time, a growing number of hospitals and health care facilities have taken steps to integrate CAM and conventional care. In this article we consider institutional responsibilities when patients/parents use or are considering CAM. We (1) review hospitals' responsibilities to patients and parents, (2) explain how these principles apply in the case of CAM practitioners and products, (3) address institutional responsibilities for different models of service delivery, and (4) highlight issues that should be addressed when developing institutional policies to govern CAM use and propose ways to do so.

Informed consent in complementary and alternative medicine

The objective of this study was to examine complementary and alternative medicine (CAM) practitioners' (i) attitudes toward informed consent and (ii) to assess whether standards of practice exist with respect to informed consent, and what these standards look like. The design and setting of the study constituted face-to-face qualitative interviews with 28 non-MD, community-based providers representing 11 different CAM therapeutic modalities. It was found that there is great deal of variability with respect to the informed consent process in CAM across providers and modalities. No unique profession-based patterns were identified. The content analysis yielded five major categories related to (i) general attitude towards the informed consent process, (ii) type and amount of information exchange during that process, (iii) disclosure of risks, (iv) discussions of alternatives, and (v) potential benefits. There is a widespread lack of standards with respect to the practice of informed consent across a broad range of CAM modalities. Addressing this problem requires concerted and systematic educational, ethical and judicial remedial actions. Informed consent, which is often viewed as a pervasive obligation is medicine, must be reshaped to have therapeutic value. Acknowledging current conceptions and misconception surrounding the practice of informed consent may help to bring about this change. More translational research is needed to guide this process.

Complementary and alternative medicine: herbs, phytochemicals and vitamins and their immunologic effects

Complementary and alternative medicines (CAMs) are used in more than 80% of the world's population and are becoming an increasing component of the US health care system, with more than 70% of the population using CAM at least once and annual spending reaching as much as $34 billion. Since the inception of the National Center for Complementary and Alternative Medicine, there has been an enormous increase in the number of basic science and therapy-based clinical trials exploring CAM. The subspecialty of allergy and immunology represents a particularly fertile area with a large number of CAM therapies that have been shown to affect the immune system. Recent work has uncovered potential biochemical mechanisms involved in the immunomodulatory pathway of many supplemental vitamins (A, D, and E) that appear to affect the differentiation of CD4(+) cell T(H)1 and T(H)2 subsets. Other research has shown that herbs such as resveratrol, quercetin, and magnolol may affect transcription factors such as nuclear factor-kappaB and the signal transducer and activator of transcription/Janus kinase pathways with resultant changes in cytokines and inflammatory mediators. Clinically, there have been hundreds of trials looking at the effect of CAM on asthma, allergic rhinitis, and atopic dermatitis. This article reviews the history of CAM and its use among patients, paying special attention to new research focusing on herbals, phytochemicals, and vitamins and their potential interaction with the immune system.

Complementary and alternative medicine for the allergist-immunologist: where do I start?

Complementary and alternative medicine (CAM) therapies present a growing information management challenge for physicians because nearly 40% of their patients may be using and another 50% may be considering use of CAM as part of their healthcare regimen. The National Health Statistics Reports for 2007 described the most commonly used nonvitamin, nonmineral therapy as natural products (eg, herbals at 17.7%). More than 5% of children under the age of 18 years used CAM for allergic conditions including asthma. The amount and quality of information available and concerns about liability risk represent a challenge for most physicians. This review focuses on considerations for approaching a CAM-related consultation, incorporating legal and logistic factors affecting how such an encounter should be approached. A 10-step process is presented that addresses different components of CAM consultations and what should be documented. Access to timely, high-quality information regarding product specific efficacy and safety data, as found in the Natural Medicines Comprehensive Database, is needed to support CAM consultation efficiently. Understanding of serious adverse events associated with CAM is limited; an international need exists for improved safety surveillance and information sharing. Allergy-immunology, as a specialty with expertise in adverse drug reaction evaluation and management, has a unique opportunity to support enhanced CAM-related adverse events evaluations, reporting, and research.

Treatment Advice on the Internet Leads to a Life-Threatening Adverse Reaction: Hypotension Associated with Niacin Overdose

We describe a case of massive oral niacin overdose that resulted in severe persistent hypotension without the manifestation of cutaneous flushing. This case is the highest overdose of niacin reported in the literature to date and the first time severe persistent hypotension has been attributed to niacin. A 56-year-old male with a history of schizophrenia presented to the emergency department after orally ingesting 11,000 mg of niacin. The patient cited an Internet resource that recommended high-dose niacin for therapy of schizophrenia as the reason for his ingestion. He stopped his psychiatric medications several weeks prior to his niacin overdose. At presentation, the patient was alert and normothermic. His pulse was 68 beats per minute and his blood pressure was initially 92/41 mmHg. Hypotension with a blood pressure of 58/40 developed over the next few hours and persisted despite intravenous infusion of over 4 liters of normal saline. The physical exam was otherwise unremarkable, specifically without signs of an allergic reaction or cutaneous flushing. He required intravenous dopamine infusion for 12 hours to support a mean arterial blood pressure greater than 60 mmHg. Evaluation for other etiologies of hypotension was unrevealing. Serum niacin levels were 8.2 ug/ mL and 5.6 ug/mL at 48 and 96 hours post ingestion, respectively, giving an apparent T1/2 of 87 hours. Massive overdose of niacin appears to be capable of causing severe, persistent hypotension in the absence of cutaneous flushing. In this case, the ingestion of a dietary supplement based on Internet advice led to a severe adverse reaction.

Steps toward massage therapy guidelines: a first report to the profession

The massage profession has grown rapidly since the late 1980s. As with business startups that begin informally and successfully mature into larger enterprises, growth brings new organizational challenges, together with greater visibility and opportunity. The maturation of massage as a health care profession increases the need for a process to formalize the synthesis of massage therapy knowledge from clinical experience and research-to collect what we know and to make such baseline knowledge widely available to practitioners, consumers, and other health care stakeholders. In short, we need to create a process for setting guidelines.The present paper lays out the motivations and framework for creating massage therapy guidelines that are informed both by research and by clinical experience. It also acts as a report to the massage therapy profession and to other stakeholders about the work of the Best Practices Committee of the Massage Therapy Foundation since 2006. And it has the additional goal of providing a health care literature basis for future academic discussions of massage.The discussion here is based on a definition from the Institute of Medicine and on research into the nature of expertise. Guidelines are targeted for submission to the National Guideline Clearinghouse. Challenges in creating guidelines for massage therapy are discussed. Various stakeholders are considered. Current literature from the wider scope of health care is extensively reviewed. Topics addressed include guideline creation, credentialing of complementary and alternative medicine practitioners, definition of competence, and the increasing role of technology (that is, informatics) in managing training and task-necessary competencies. Finally, a process for creation of massage therapy guidelines is proposed. A central feature of the proposal is the use of a "World Café" symposium to elicit knowledge and solutions from diverse experts. The role of transparency and broad and open peer review is emphasized as essential to the usability and credibility of guidelines.

Legal Parameters of Alternative-Complementary Modalities in Nursing Practice

Complementary and alternative healing modalities are increasing in popularity. Partially in response to client demand and partially because of a strong history in providing care encompassing the whole person, nurses have responded by incorporating selected alternative therapies within select professional services. There are questions, however, as to whether some or all of these modalities are within the boundaries of nursing practice. Because most professional practice acts are vague in relation to specific therapies, a model for legal analysis is presented.

Status of Credentialing Alternative Providers Within a Subset of U.S. Academic Health Centers

BACKGROUND

Complementary and alternative medicine (CAM) clinical services are increasingly provided within conventional health care settings.

OBJECTIVE

To determine how a subset of U.S. academic health centers is credentialing CAM providers.

DESIGN

An electronic survey was created focusing on the credentialing method utilized for six specific types of CAM clinical practitioners within academic medical settings.

METHODS

This survey was electronically distributed to 33 academic health centers in the United States during the summer 2004.

RESULTS

Ninety-five percent (95%) of academic centers surveyed provide some CAM clinical care. Acupuncture and massage are most common, with naturopathy and homeopathy least common. State licensure requirements for CAM providers appear to not be well-understood. Most commonly, CAM professionals do not receive full medical staff credentials.

LIMITATIONS

Results cannot be extrapolated to remaining academic health centers within the United States. Mind-body practitioners were not included in the survey.

CONCLUSIONS

Credentialing and privileges are most commonly granted via indirect methods. Variability in state licensure compounds the challenge of credentialing CAM practitioners. Suggestions for beginning discussions on guiding principles for integrating CAM practitioners within conventional settings are proposed.

Legal and ethical issues relating to use of complementary therapies in pediatric hematology/oncology

Pediatricians increasingly are asked to advise pediatric patients and their families concerning integration into conventional care (including hematology and oncology) of complementary and alternative medical (CAM) therapies such as chiropractic, massage therapy, and herbal medicine. Inclusion of CAM therapies in pediatric oncology and hematology--as in any medical subspecialty--is not itself "unethical," clinically inadvisable, or legally risky; the danger comes from over-reliance on one or more CAM therapies (particularly those with evidence of danger and/or paltry evidence of success) to the exclusion of conventional care that is curative and imminently necessary. Pediatricians can help address potential malpractice liability issues by evaluating the level of clinical risk, engaging the patient in shared decision making and documenting this in the medical record, continuing to monitor conventionally, and being prepared to intervene conventionally when medically required.

Referral patterns and attitudes of primary care physicians towards chiropractors

Background

Despite the increasing usage and popularity of chiropractic care, there has been limited research conducted to examine the professional relationships between conventional trained primary care physicians (PCPs) and chiropractors (DCs). The objectives of our study were to contrast the intra-professional referral patterns among PCPs with referral patterns to DCs, and to identify predictors of PCP referral to DCs.

Methods

We mailed a survey instrument to all practicing PCPs in the state of Iowa. Descriptive statistics were used to summarize their responses. Multivariable logistic regression analyses were conducted to identify demographic factors associated with inter-professional referral behaviors.

Results

A total of 517 PCPs (33%) participated in the study. PCPs enjoyed strong intra-professional referral relationships with other PCPs. Although patients exhibited a great deal of interest in chiropractic care, PCPs were unlikely themselves to make formal referral relationships with DCs. PCPs in a private practice arrangement were more likely to exhibit positive referral attitudes towards DCs (p = 0.01).

Conclusion

PCPs enjoy very good professional relationships with other PCPs. However, the lack of direct formalized referral relationships between PCPs and chiropractors has implications for efficiency, continuity, quality, and patient safety in the health care delivery system. Future research must focus on identifying facilitators and barriers for developing positive relationships between PCPs and chiropractors.

Ophthalmological adverse effects of (chiropractic) upper spinal manipulation: evidence from recent case reports

OBJECTIVE

Upper spinal manipulation (USM) is frequently used by chiropractors and other health care professionals to treat minor complaints. This systematic review aimed to summarize ophthalmological adverse effects of USM recently reported in the medical literature.

METHODS

Five electronic databases were searched for all case reports of ophthalmological adverse effects after USM published between January 1995 and April 2003. No language restrictions were applied. Key data from the primary publications thus located were extracted and critically evaluated.

RESULTS

Fourteen case reports were found. Clinical symptoms and signs were diverse and included loss of vision, ophthalmoplegia, diplopia and Horner's syndrome. The underlying mechanism was arterial wall dissection in most cases. The eventual outcome varied and often included permanent deficits. Causality was frequently deemed likely or certain.

CONCLUSION

Upper spinal manipulation is associated with ophthalmological adverse effects of unknown frequency. Ophthalmologists should be aware of its risks. Rigorous investigations must be conducted to establish reliable incidence figures.

Perceived poisons

Perceived poisoning may manifest in numerous ways; however, all cases share certain characteristics. All are fostered by the wide availability of unreliable information about chemical safety, poor understanding of scientific principles, and ineffective risk communication. Although this problem is still incompletely understood, some approaches have been demonstrated to be useful, such as education about risk, appropriate reassurance, and empathy on the part of the practitioner. Successful management may curtail the spread or exacerbation of symptoms, whereas unsuccessful treatment may cause the problems to escalate, with detrimental effects on both society and patient.

Legal issues in caring for patients with kidney disease by selectively integrating complementary therapies

Clinical integration of complementary and alternative medical (CAM) therapies, such as acupuncture and traditional oriental medicine, chiropractic, herbal medicine, massage therapy, and "mind-body" therapies, into conventional health care raises important legal and risk management issues. Understanding which CAM therapies patients use is legally prudent, as conventional treatment advice may interact with patients' own efforts toward self-care. In addition, nephrologists may limit potential liability for medical malpractice by classifying any given therapy as follows: (1) the medical evidence supports both safety and efficacy--recommend; (2) the medical evidence supports safety, but evidence regarding efficacy is inconclusive-accept but monitor; (3) the medical evidence supports efficacy, but evidence regarding safety is inconclusive-accept but monitor; and (4) the medical evidence indicates either serious risk or inefficacy--avoid and discourage. Applying this framework whether a therapy is labeled "conventional" or "CAM" is consistent with the key recommendation of the recent report by the Institute of Medicine at the National Academy of Sciences on Complementary and Alternative Medicine, namely, to apply the same principles and standards of evidence of treatment effectiveness to all treatments. Liability risk management also includes going beyond legal and ethical informed consent requirements by engaging the patient in shared decision making concerning all material treatment options, including CAM therapies, if supported by evidence. Physicians further should familiarize themselves with documentation standards suggested by the Federation of State Medical Board Guidelines and whether these are applicable in their state or home institution. These steps aim to enable nephrologists to respond to patient interest in CAM therapies in a way that is clinically responsible, ethically appropriate, and legally defensible.

Content analysis of holistic ethics

Although biomedical ethical principles are appropriate to evaluate the practice of conventional or Western medicine, they may not be appropriate to evaluate the practice of complementary therapies (CTs) because the world view of CTs has different goats than those of Western medicine. This qualitative research study examined the suggestions of 11 practicing RNs from across the United States as to what principles should be included in a list of holistic ethical principles. Six themes were extracted from the data, which include safety, scope of practice, cultural diversity, access, collaboration, and spirituality. To validate their utility, the identified set of holistic ethical principles where applied to case studies of holistic ethical dilemmas that involving specific CTs. The authors suggest that the set of six holistic ethical principles could be used to evaluate the virtues and potential infractions of the use of CTs.

Complementary therapies in pediatrics: a legal perspective

Increasing use of complementary and alternative medicine (CAM) therapies such as chiropractic, massage therapy, and herbal medicine, raises questions about the clinically appropriate use of CAM in pediatrics. Nonjudicious use of CAM therapies may cause either direct harm or, by creating an unwarranted financial and emotional burden, indirect harm. When advising patients concerning CAM therapies, pediatricians face 2 major legal risks: medical malpractice and professional discipline. Pediatricians can incorporate these considerations into advising and clinical decision-making about CAM therapies to address the best interest of the pediatric patient while helping to manage potential liability risk. This article provides a suggested framework, including asking the following questions: (1) Do parents elect to abandon effective care when the child's condition is serious or life-threatening? (2) Will use of the CAM therapy otherwise divert the child from imminently necessary conventional treatment? (3) Are the CAM therapies selected known to be unsafe and/or ineffective? (4) Have the proper parties consented to the use of the CAM therapy? (5) Is the risk-benefit ratio of the proposed CAM therapy acceptable to a reasonable, similarly situated clinician, and does the therapy have at least minority acceptance or support in the medical literature? Such an approach ideally can help guide the pediatrician toward clinical conduct that is clinically responsible, ethically appropriate, and legally defensible.

Defining a standard of care in the practice of acupuncture

In 1971, New York Times journalist James Reston watched as brain surgery was preformed in the former Red Cross Hospital in Shanghai with acupuncture as the only anesthesia. “[Patients] were anesthetized merely by the insertion of very thin three-inch stainless steel needles into the body … and they were not only perfectly conscious while their skulls were laid open before us but remarkably alert within half an hour after the operation.” One patient, a fifty-four-year-old man named Chuan Leao, had been suffering from epilepsy as a result of a large tumor in the frontal lobe of his brain. “He seemed sensibly puzzled by being introduced to a couple of American strangers during his ordeal but was courteous and patient, and we listened to his comments while the tumor was removed and even watched him eat oranges slices and ask for more while the operation was going on.”

Ethical and legal issues in antiaging medicine

The development of specific antiaging treatments and the emergence of the practice of antiaging medicine have created new ethical and legal issues. The ultimate desirability of treatments designed to alter human aging is currently an actively debated issue that needs to emerge as an issue of public dialogue, given the potentially dramatic effect these therapies could have on both individual health and societal structure. Current therapies carry many doubts about their safety and effectiveness, which makes the practice of antiaging medicine with the prescription of these therapies a challenging issue from both a legal and ethical perspective. Finally, although the practice of antiaging medicine is not directly recognized and regulated by legislation, both anti-aging treatments and practice are regulated by emerging state and federal legislation that is evolving to address the emerging area of complementary and alternative medicine.

Regulatory issues concerning the safety, efficacy and quality of herbal remedies

Herbal remedies and alternative medicines are used throughout the world, and in the past herbs were often the original sources of most drugs. Today we are witnessing an increase in herbal remedy use throughout the Western world raising the question as to how safe are these preparations for the unborn fetus? Many women use herbal products during pregnancy. The dilemma facing most regulatory authorities is that the public considers these products as either traditional medicines or natural food supplements. The user sees no reason for regulation. Most countries have laws concerning foods, drugs, and cosmetics, the details of which seldom clearly define to what section of the law and regulations alternative remedies belong. In most countries alternative remedies are regulated as foods, provided that no medicinal claim is made on the label. The global regulatory sector, however, is changing rapidly. The Therapeutic Goods Administration (TGA) in Australia created a Complimentary Medicines Evaluation Committee in late 1997 to address this issue, and Canada has created a new Natural Health Products Directorate in the realigned Therapeutic Products and Foods Branch in 2000. In parallel, the European Agency for the Evaluation of Medicinal Products has drafted test procedures and acceptance criteria for herbal drug preparations and herbal medicinal products. In the US, the Food and Drug Administration classifies these natural products as dietary supplements. Manufacturers must label a dietary supplement thus: "this statement has not been evaluated by the FDA [, and] this product is not intended to diagnose, treat, cure or prevent any disease." Whether these products are foods or drugs is undecided. To add complexity to this issue, most of the potential deleterious effects of natural products on the unborn may be related to hormonal effects (e.g., phytoestrogens) and nutriceutical drug interactions (e.g., St. John's Wort and antidepressants), rather than direct embryotoxicity per se. We suggest that ensuring quality of herbal products should receive immediate attention by regulatory authorities, before embarking on the more arduous tasks of safety and efficacy.

Legal and ethical issues in complementary medicine: a United States perspective

The way forward involves not only preventing negligence and fraud, but also facilitating therapeutic exchanges between various healthcare providers and their patients.

Naturoceutical agents in the management of cardiovascular disease

During the past decade, complementary and alternative medicine (CAM) has grown in attractiveness to the Western public, and in recognition by practitioners of traditional medicine. The incorporation of effective CAM therapies into traditional practice is termed 'integrative medicine'. One form of CAM demonstrating exponential growth through mass public consumerism is the use of naturoceuticals. Naturoceutical (or nutraceutical) agents are defined as mega-dose vitamins, herbal products or other 'natural' supplements purchased and consumed with premeditated 'pharmaceutical' intention to treat or prevent an illness or disease. Dietary supplements per se, are intended to supply adequate nutrients that may be lacking from the diet, and are thus, generally health promoting. A regulatory paradox exists since naturoceuticals are classified as dietary supplements although many possess measurable pharmacologic activity. In reference to cardiovascular disorders, consumers use naturoceuticals for three distinctly recognizable purposes. These are the primary and secondary prevention of cardiovascular diseases and the treatment of diagnosed disorders such as heart failure, angina pectoris or arrhythmia. The evidence base supporting the routine use of naturoceutical products for these intentions is sparse, although the likelihood of harm from their consumption is low for an average, healthy adult. Evidence of significant harm (including fatalities) has been observed when certain herbal products are used in excess or in combination with, other herbs or prescription drugs. The safety of use at the extremes of age, or by persons with cardiac, renal or hepatic impairment is also a concern. Healthcare professionals should routinely document patient naturoceutical use, be alert for and report suspected adverse effects. Until well-designed clinical trials determine the proper indication(s), dose safety profile and risk/benefit ratio for these products, their routine use should not be advocated. Thus, the role of naturoceutical agents in the integrative management of cardiovascular disorders remains undefined.

Complementary and integrative medical therapies, the FDA, and the NIH: definitions and regulation

The National Center for Complementary and Alternative Medicine (NCCAM) presently defines complementary and alternative medicine (CAM) as covering "a broad range of healing philosophies (schools of thought), approaches, and therapies that mainstream Western (conventional) medicine does not commonly use, accept, study, understand, or make available. The research landscape, including NCCAM-funded research, is continually changing and subject to vigorous methodologic and interpretive debates. Part of the impetus for greater research dollars in this arena has been increasing consumer reliance on CAM to dramatically expand. State (not federal) law controls much of CAM practice. However, a significant federal role exists in the regulation of dietary supplements. The U.S. Food and Drug Administration (FDA) regulates foods, drugs, and cosmetics in interstate commerce. No new "drug" may be introduced into interstate commerce unless proven "safe" and "effective" for its intended use, as determined by FDA regulations. "Foods", however, are subject to different regulatory requirements, and need not go through trials proving safety and efficacy. The growing phenomenon of consumer use of vitamins, minerals, herbs, and other "dietary supplements" challenged the historical divide between drugs and foods. The federal Dietary Supplements Health Education Act (DSHEA) allows manufacturers to distribute dietary supplements without having to prove safety and efficacy, so long as the manufacturers make no claims linking the supplements to a specific disease. State law regulates the use of CAM therapies through a variety of legal rules. Of these, several major areas of concern for clinicians are professional licensure, scope of practice, and malpractice. Regarding licensure, each state has enacted medical licensing that prohibits the unlicensed practice of medicine and thereby criminalizes activity by unlicensed CAM providers who offer health care services to patients. Malpractice is defined as unskillful practice which fails to conform to a standard of care in the profession and results in injury. The definition is no different in CAM than in general medicine; its application to CAM, however, raises novel questions. Courts rely on medical consensus regarding the appropriateness of a given therapy. A framework for assessing potential liability risk involves assessing the medical evidence concerning safety and efficacy, and then aligning clinical decisions with liability concerns. Ultimately research will or will not establish a specific CAM therapy as an important part of the standard of care for the condition in question. Legal rules governing CAM providers and practices are, in many cases, new and evolving. Further, laws vary by state and their application depends on the specific clinical scenario in question. New research is constantly emerging, as are federal and state legislative developments and judicial opinions resulting from litigation.

Regulation, religious experience, and epilepsy: a lens on complementary therapies

Complementary and alternative medical (CAM) therapies include chiropractic, acupuncture and traditional Oriental medicine, massage therapy, and herbal remedies; mind-body therapies (such as meditative practices and visualization); and folk practices and religious healing. Of these, modalities based on spiritual healing create a number of conundrums for the clinician, including legal, regulatory, and ethical issues. Further, the historic relationship between the study of epilepsy and religious experience suggests particular, potential associations between CAM therapies (and especially spiritual healing) and care for epileptic patients. There are at least two dimensions to this exploration: first, the widespread use of spiritual healing for treatment of epilepsy; and second, the hypothesized connection between epileptic seizures and mystical states. A number of legal rules help address potential abuse of authority by health care professionals, and include: (1) medical licensure; (2) scope of practice; (3) professional discipline; (4) malpractice; and (5) fraud. This article offers a preliminary resource for clinicians interested in these topics.

Alternative medicines and the liver

Complementary and Alternative Medicine (CAM) is a heterogeneous group of theories and practices that are becoming increasingly popular in the West - between 20% and 65% of patients use CAM on a regular basis. In the UK, CAM is provided by over a third of general practitioners as well as by hospitals. The subject of much debate in both the lay and medical press, CAM is subject to increasing scrutiny from clinical research. In this review, we discuss the available evidence for herbal medicines, including that for silymarin, glycyrrhizin, Chinese herbal medicines and other herbal mixtures. We also review evidence regarding the safety of herbal medicines, both in terms of hepatotoxicity and drug interactions. We conclude that although CAM may be of benefit in the treatment of liver disease, the available evidence is insufficient to recommend any of the available therapies. CAM has not yet been well studied in liver disease and rigorous evaluation with well-designed double-blind randomised controlled trails is required. Doctors need to be aware of the widespread use of CAM, ask their patients specifically regarding their use of CAM and be aware of the potential for hepatotoxicity and interactions.

The Development of an Educational Workshop on Complementary and Alternative Medicine: What Every Nurse Should Know

As complementary and alternative medicine (CAM) is becoming more accepted in Western culture, healthcare consumers are choosing CAM as an adjunct to conventional healthcare practices. A variety of cultural backgrounds contributes to the need to advance knowledge and evaluate outcomes of healthcare practices related to CAM. The issues presented in this article provide critical information for nurses and other healthcare providers to integrate conventional medicine with CAM practices to improve healthcare outcomes for patients who use CAM.

Developing a measure of attitudes: the holistic complementary and alternative medicine questionnaire

We have developed an 11-item scale, the Holistic Complementary and Alternative Medicine Questionnaire (HCAMQ). Six of the HCAMQ items relate to beliefs about the scientific validity of complementary and alternative medicine (CAM), and five to beliefs about holistic health (HH). The HCAMQ was completed by 50 patients attending a CAM clinic and 50 attending rheumatology outpatients; the former completed it twice. Factor analysis (oblique rotation) showed that the CAM and HH items measured distinct but related constructs. The HCAMQ has good test retest reliability (r=0.86, 0.82 and 0.77 for the total, CAM subscale and HH subscale, respectively). The individuals attending CAM clinics were significantly more positive on the CAM but not the HH subscale of the HCAMQ and also used less antibiotics than those attending rheumatology outpatients. Positivity towards CAM on the total HCAMQ and subscales was significantly associated with lower age, increased vitamin use, reduced painkiller use, and, other than on the HH subscale, less antibiotic use. The reason why the HH subscale failed to distinguish between the two patient groups or predict less antibiotic use is unknown. The HCAMQ appears to have good internal validity, but its external validity remains to be established.

Scope of practice issues in the delivery of pediatric health care

In recent years, there has been an increase in the number of nonphysician pediatric clinicians and an expansion in their respective scopes of practice. This raises critical public policy and child health advocacy concerns. The American Academy of Pediatrics (AAP) believes that optimal pediatric health care depends on a team-based approach with coordination by a physician leader, preferably a pediatrician. The pediatrician is uniquely suited to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all practice settings. The AAP recognizes the valuable contributions of nonphysician clinicians, including nurse practitioners and physician assistants, in delivering optimal pediatric care. The AAP also believes that nonphysician clinicians who provide health care services in underserved areas should be supported by consulting pediatricians and other physicians using technologies including telemedicine. Pediatricians should serve as advocates for optimal pediatric care in state legislatures, public policy forums, and the media and should pursue opportunities to resolve scope of practice conflicts outside state legislatures. The AAP affirms that as nonphysician clinicians seek to expand their scopes of practice as providers of pediatric care, standards of education, training, examination, regulation, and patient care are needed to ensure patient safety and quality health care for all infants, children, adolescents, and young adults.

Addressing use of herbal medicine in the primary care setting

PURPOSE

To critically evaluate existing approaches to the integration of allopathic and complementary and alternative medicine (CAM) and develop a middle ground approach to addressing use of herbal medicine and other forms of CAM in the primary care setting.

DATA SOURCES

Extensive review of scientific literature and Internet sources supported by legal, philosophical, and ethical arguments.

CONCLUSIONS

A review of medical literature indicates that a growing number of people perceive both allopathic and CAM to be valued aspects of health care. Whether we agree with this perception or not, ethical, legal, clinical, and social considerations dictate that we assist patients in their efforts to derive benefit from use of CAM while helping them to minimize risks. Yet the current approach to addressing CAM in primary care is "don't ask, don't tell," with approaches to filling this clinical void ranging from "just say no" to CAM use, to allopathic practitioners who also are CAM practitioners.

IMPLICATIONS FOR PRACTICE

It is possible to occupy the middle ground, neither rejecting nor embracing CAM, but recognizing its significant impact on health care. In order to do this safely, clinicians need to be informed about herbs and other CAM practices, document thoroughly the informed consent and decision-making process, and monitor patients carefully for adverse effects.

The CAM movement and the integration of quality health care: the case of chiropractic

High and increasing consumer demand for complementary and alternative medicine (CAM) services necessitates a concerted focus to determine the effectiveness of such practices and to ensure that future possible integration of CAM with conventional medicine is founded on sound evidence-based principles of quality health care delivery. The example of chiropractic provides useful insights to guide further research and integration of evidence-based CAM into mainstream health care in the United States. A critical point of departure for this area of inquiry is identifying and addressing barriers to conducting scientifically sound and meaningful cross-disciplinary, practice-based research.