Dietary and herbal supplements use among patients hospitalized in internal medicine departments.

OBJECTIVES: To assess consumption of dietary and herbal supplements (DHS) among patients in internal medicine departments and determine whether such use is documented in their medical files. METHODS: 267 patients from three internal medicine departments of an academic medical center in Haifa, Israel were assessed prospectively with questionnaires about their DHS use in the month preceding hospitalization. DHS were categorized into vitamins & minerals, herbal supplements and others. Further data was then collected from patients' medical records on socio-demographic and medical characteristics, as well as documentation of DHS use. RESULTS: 123 patients (50.6 %) used DHS on a daily basis. Most of them (53.7 %) were using more than one DHS. DHS use was more prevalent in older (OR = 1.02 [1.001-1.036], p = 0.034) and educated (OR = 0.482 [0.252-0.923], p = 0.028) patients. Vitamins & minerals were used mainly to enhance vitality and address laboratory abnormalities, whereas herbal supplements were used mainly for gastrointestinal problems (p < 0.001). DHS use was reported to the physicians by 42 % of the patients, mostly at the patients' initiative [92 (82.1 %), p < 0.001)]. Vitamins and minerals were the most reported category of DHS (94 (57.3 %), p < 0.001). The use of DHS was reported to physicians for 112 DHS (41.8 %) but only 32 DHS (11.9 %) were documented in their medical files. The documentation of vitamins and minerals was significantly higher compared to herbal supplements documentation (29 (17.7 %) & 3 (2.9 %) respectively, P < 0.001). CONCLUSIONS: DHS are commonly used by patients hospitalized in the internal medicine departments. Many patients do not report such use to the physicians, and more strikingly, physicians do not document DHS use in patient medical files. This communication gap may have serious medico-legal ramifications due to DHS side effects and DHS interactions with other DHS and with conventional drugs.

Contributing to Global Health: Development of a Consensus-Based Whole Systems Research Strategy for Anthroposophic Medicine.

BACKGROUND: Whole medicine and health systems like traditional and complementary medicine systems (T&CM) are part of healthcare around the world. One key feature of T&CM is its focus on patient-centered and multimodal care and the integration of intercultural perspectives in a wide range of settings. It may contribute to good health and well being for people as part of the Sustainable Development Goals of the United Nations. The authentic, rigorous, and fair evaluation of such a medical system, with its inherent complexity and individualization, imposes methodological challenges. Hence, we propose a broad research strategy to test and characterize its possible contribution to health. METHODS: To develop a research strategy for a specific T&CM system, Anthroposophic Medicine (AM), applying multimodal integrative healthcare based on a four-level concept of man, we used a three-phase consensus process with experts and key stakeholders, consisting of (1) premeeting methodological literature and AM research review and interviews to supplement or revise items of the research strategy and tailor them to AM research, (2) face-to-face consensus meetings further developing and tailoring the strategy, and (3) postmeeting feedback and review, followed by finalization. RESULTS: Currently, AM covers many fields of medical specialties in varied levels of healthcare settings, such as outpatient and inpatient; primary, secondary, and tertiary care; and health education and pedagogy. It is by definition integrated with conventional medicine in the public healthcare system. It applies specific medicines, nursing techniques, arts therapies, eurythmy therapy, rhythmical massage, counseling, and psychotherapy, and it is provided by medical doctors, nurses, therapists, midwives, and nutritionists. A research strategy authentic to this level of complexity should comprise items with a focus on (I) efficacy and effectiveness, divided into (a) evaluation of the multimodal and multidisciplinary medical system as a whole, or of complex multimodal therapy concept, (b) a reasonable amount of methodologically rigorous, confirmatory randomized controlled trials on exemplary pharmacological and nonpharmacological therapies and indications, (c) a wide range of interventions and patient-centered care strategies with less extensive formats like well-conducted small trails, observational studies, and high-quality case reports and series, or subgroup analyses from whole-system studies, or health service research; (II) safety; (III) economics; (IV) evidence synthesis; (V) methodologic issues; (VI) biomedical, physiological, pharmacological, pharmaceutical, psychological, anthropological, and nosological issues as well as innovation and development; (VI) patient perspective and involvement, public needs, and ethics; (VII) educational matters and professionalism; and (IX) disease prevention, health promotion, and public health. CONCLUSION: The research strategy extends to and complements the prevailing hierarchical system by introducing a broad "evidence house" approach to evaluation, something many health technology assessment boards today support. It may provide transparent and comprehensive insight into potential benefits or risks of AM. It can serve as a framework for an evidence-informed approach to AM for a variety of stakeholders and collaborating networks with the aim of improving global health.

Can complementary medicine enhance doctor-patient communication skills? Insights from an international medical student project.

INTRODUCTION: Communication is an essential component of patient care, and although medical schools provide training on this topic, patients and physicians alike express the need to improve their communication skills. An international medical student collaboration explored whether complementary medicine (CM) has the ability to further enhance patient-doctor communication. METHODS: Twenty-two medical students, nine mentors and two public representatives from Israel and Germany participated in this 18-month international group project. The goal was to explore CM methods that could enrich doctor-patient communication in several aspects. The group eventually chose to focus on four CM modalities, which included Chinese medicine; Mind-Body medicine; Touch therapies; Mindfulness and Herbal medicine. One workshop took place in Haifa and two workshops in Berlin, with continued inter-group work in-between. The workshops included interactive group formats such as "World Café", self-experience sessions in CM, working in small groups and delivering presentations to the entire group. RESULTS: Besides benefitting from cultural exchange and networking, students learned various aspects of CM, with a particular focus on their relevance for enriching their communication skills. The main CM aspects that were highlighted included patient characterization in the context of Chinese medicine diagnosis, mindfulness, anamnesis regarding herbal use, and a physical exam based on concepts from touch therapies. Students summarized and condensed their observations into five educational modules, which are available online: http://www.b-zion.org.il/pages_e/6683.aspx. CONCLUSION: The cultural exchange and explorative process in this international medical student collaboration led to insights regarding the potential contribution of CM to patient-doctor communication. The outcomes of this international collaboration, specifically the educational modules it produced, should be further explored by medical schools, and assessed in clinical trials.

A tongue's tale - a case report of traditional Chinese medicine integration in the cardiology department.

The purpose of this case study is to provide a unique perspective on the integration of traditional Chinese medicine (TCM) in an acute care hospital setting. This case report tells the story of a patient who was hospitalized in the cardiac intensive care unit and received both western and TCM treatments. The patient's medical narrative is illustrated using pictures of her tongue that were taken along the course of her hospitalization. Analysis of the medical file, and each picture provide in-depth understanding of her medical condition from both western and TCM perspectives respectively.

Stepping from traditional to integrative medicine: perspectives of Israeli-Arab patients on complementary medicine's role in cancer care.

BACKGROUND: Limited research is available on the perspectives of patients with cancer regarding integration of complementary medicine (CM) in conventional supportive cancer care. The purpose of this study was to explore patients' perspectives concerning CM integration within conventional oncology settings. PATIENTS AND METHODS: A 27-item questionnaire was constructed and administered to a convenient sample of Arab patients receiving cancer care in three oncology centers in northern Israel. RESULTS: Of the 324 respondents (94.7% response rate), 124 of 313 (39.6%) reported the use of CM for cancer-related outcomes. A logistic regression model indicated that CM was used with active chemo- or radiotherapy treatment [EXP [B], 2.926, 95% confidence interval (CI) 1.276-6.708; P=0.011] and a higher degree of spiritual quest (EXP [B], 3.425, 95% CI 1.042-11.253; P=0.043). Herbal medicine was the leading CM modality (87.9% of CM users), which included the use of 28 plants and traditional remedies, of which 17 were used to improve QOL, with 5 of the herbs having potential interactions with chemotherapy. 83.1% of respondents stated that they would consult with a CM provider if CM were to be integrated into the oncology department. Patients' expectation of CM consultation was clearly associated with expectations of QOL improvement, coping with cancer, and alleviating chemotherapy's side-effects when compared with expectations of cancer cure (P<0.0001). The three leading concerns which patients expected to be improved by integrative CM treatment were gastrointestinal symptoms (63.2%), fatigue (51.9%), and pain (40.5%). CONCLUSIONS: Integrative CM consultations should focus on the improvement of QOL concomitant with safety concerns regarding potential drug-herb interactions. The need to integrate a nonjudgmental yet evidence-based CM consultation service may also be applicable to oncology institutions challenged with culturally diverse populations with a high prevalence of traditional medicine use.

Integrative oncology in the Middle East: from traditional herbal knowledge to contemporary cancer care.

BACKGROUND: Based on traditional, historical, ethnobotanical, laboratory, and clinical findings, we present research framework aiming to identify Middle Eastern herbs that are worthy of further research for their anticancer potential. METHODS: A comprehensive research project was developed by a multinational team comprising family physicians, medicine specialists, oncologists, an Islamic medicine history specialist, a traditional medicine ethnobotanist, and a basic research scientist. The project followed two consecutive phases: (i) historical and ethnobotanical search for cancer-related keywords and (ii) Medline search for in vitro and in vivo studies. RESULTS: This search yielded 44 herbs associated with cancer care. The Medline search yielded 34 herbs of which 9 herbs were reported in various clinical studies. CONCLUSIONS: This multidisciplinary survey was found to be a valuable way to identify herbs with potential clinical significance in cancer care. Based on this pilot study, it is suggested that the Middle East can serve as a valuable region for future multicultural-oriented cancer research.

Apparent life-threatening events in infants and homeopathy: an alternative explanation.

BACKGROUND: A recent report showed increased frequency of apparent life-threatening events (ALTEs) in infants treated with the homeopathic medication GaliCol-Baby (GCB). The premise was that the ALTEs resulted from toxic effects of the drug's components. We examine an alternative explanation. METHOD: The toxicological literature was searched for known reactions to the various GCB components, noting doses and reported symptoms. Dosage quantities and severity of reaction to the GCB were ranked independently by two groups of physicians, and a dose-response curve was generated. Reported toxic doses and symptoms were compared with those of the GCB series. The homeopathic literature was searched as well to determine the propensity of the GCB components to cause ALTE symptoms, when given in homeopathic doses to healthy volunteers (proving). RESULTS: Doses ingested in the GCB series were 10-13 orders of magnitude smaller than those reported to cause toxic reactions in humans. There was poor correlation between symptoms with GCB and toxic profiles of the components. A nonsignificant, inverse relationship between dose and severity of reaction was observed. Conversely, four GCB components (in homeopathic doses) had a high propensity to produce at least one of five symptoms which define ALTE, two of which had intermediate to high propensity to produce three symptoms. CONCLUSIONS: It is unlikely that the ALTE following ingestion of GCB was a toxic reaction to any of the drug's component. Homeopathic theory may explain this linkage, though further research is needed to understand the pathogenic effects of highly diluted homeopathic compounds.

Complementary medicine and psoriasis: linking the patient's outlook with evidence-based medicine.

BACKGROUND: There is increasing evidence for the extensive use of complementary and alternative medicine (CAM) by patients with psoriasis. Clinical research in the arena of CAM and psoriasis treatment is evolving and includes some randomized controlled trials. OBJECTIVE: To study CAM use among patients with psoriasis attending a dermatology clinic in a major university hospital in northern Israel. Prevalence, reasons for CAM use and its relevance to doctor-patient communication were emphasized. METHODS: Semistructured interviews were conducted with psoriasis patients in a dermatology clinic. Consent was obtained for 78 patients. Post-visit questionnaires were given to 5 physicians. RESULTS: Seventy-eight patients with psoriasis were interviewed and 77 were studied. Sixty-two percent used CAM. Fifty-eight percent of users had seen a CAM practitioner. The study found a trend of CAM use among patients with psoriasis from Arab compared to Jewish descent (p=0.087). CAM users reported on average 2 different CAM modalities. Herbal medicine and nutritional treatments ranked first, followed by homeopathy, traditional Chinese medicine and nutritional supplements. The main reason for CAM use was stated to be to do everything to heal the disease, followed by a quest for improved quality of life. Others mentioned an interest in a less toxic treatment, disappointment with conventional treatment and stress reduction. Well over half of the study participants and their dermatologists did not initiate a discussion about CAM use. The dermatologists' ability to predict CAM use in their patients was relatively low. CONCLUSION: There is growing evidence of extensive CAM use among patients with psoriasis. Most patients use CAM as a complementary treatment, rather than an alternative to conventional treatment. Teaching CAM should be integrated into the dermatology residency curriculum. Dermatologists need to increase their awareness of CAM use by their patients in order to improve therapeutic communication.

A novel treatment for constipation-predominant irritable bowel syndrome using Padma Lax, a Tibetan herbal formula.

BACKGROUND AND AIMS: Padma Lax, a complex Tibetan herbal formula for constipation was evaluated for safety and effectiveness in treating constipation-predominant irritable bowel syndrome in a 3-month double-blind randomised pilot study. METHODS: Patients were recruited from Hadassah Hospital's Gastroenterology clinic, using the Rome I Criteria for irritable bowel syndrome, and the international consensus criteria for constipation. Symptom severity was evaluated monthly by patients and gastroenterologist, using categorical and numerical rating scales. A patient diary recorded daily stool habit and trial medication. RESULTS: In 61 patients, (34 Padma Lax, 27 placebo), significant improvement was demonstrated after 3 months in the Padma Lax group compared to placebo in constipation, severity of abdominal pain, and its effect on daily activities, incomplete evacuation, abdominal distension and flatus/flatulence. A global assessment indicated that significantly more Padma Lax patients, compared to placebo, rated the current treatment superior to previous therapies tried for irritable bowel. Laboratory parameters displayed no clinically significant changes. Side effects, primarily loose stools in 7 Padma Lax patients responded well to lowering treatment dosage from 2 to 1 capsule/day. CONCLUSIONS: Padma Lax is a safe and effective treatment for constipation-predominant irritable bowel syndrome and may offer an alternative to the current multi drug approach.

Wheat grass juice in the treatment of active distal ulcerative colitis: a randomized double-blind placebo-controlled trial.

BACKGROUND: The use of wheat grass (Triticum aestivum) juice for treatment of various gastrointestinal and other conditions had been suggested by its proponents for more than 30 years, but was never clinically assessed in a controlled trial. A preliminary unpublished pilot study suggested efficacy of wheat grass juice in the treatment of ulcerative colitis (UC). METHODS: A randomized, double-blind, placebo-controlled study. One gastroenterology unit in a tertiary hospital and three study coordinating centers in three major cities in Israel. Twenty-three patients diagnosed clinically and sigmoidoscopically with active distal UC were randomly allocated to receive either 100 cc of wheat grass juice, or a matching placebo, daily for 1 month. Efficacy of treatment was assessed by a 4-fold disease activity index that included rectal bleeding and number of bowel movements as determined from patient diary records, a sigmoidoscopic evaluation, and global assessment by a physician. RESULTS: Twenty-one patients completed the study, and full information was available on 19 of them. Treatment with wheat grass juice was associated with significant reductions in the overall disease activity index (P=0.031) and in the severity of rectal bleeding (P = 0.025). No serious side effects were found. Fresh extract of wheat grass demonstrated a prominent tracing in cyclic voltammetry methodology, presumably corresponding to four groups of compounds that exhibit anti-oxidative properties. CONCLUSION: Wheat grass juice appeared effective and safe as a single or adjuvant treatment of active distal UC.

[Between metaphor and certainty: teaching an introductory course in complementary medicine].

In recent years it has been recognized that it is increasingly important to teach complementary medicine (CAM) in medical schools, residency programs and CME courses. We report our experience in teaching an elective introductory course in CAM to residents and specialists in the department of family medicine in the Bruce Rappaport Faculty of Medicine at the Technion, Haifa, Israel. Teaching four modules in CAM (herbal medicine, traditional Chinese medicine, homeopathy and nutritional medicine) during a 16-session course induced a positive change in the students attitude toward CAM and increased their interest in evidence-based CAM. In addition, the students increased their use of CAM for both themselves and their families, decreased their overall tendency to refer patients to CAM practitioners but increased their actual referral rate for patients who were considered to benefit from complementary treatment. The majority of the course participants considered teaching physicians CAM to be of great importance.

The growing need to teach about complementary and alternative medicine: questions and challenges.

With the increased popularity of complementary and alternative medicine (CAM), there is a growing interest in the topic among physicians, residents, and medical students, who feel an increased need to have proper instruction about CAM therapies. Medical schools and residency programs are starting to respond to this demand, having realized that to provide better care and foster an improved patient-doctor relationship, physicians should become informed consultants, and be able to provide educated advice about CAM to their patients and help them integrate any CAM therapies shown to be safe and effective into their health care. The authors acknowledge that opinions differ about the adequacy of research findings to certify the safety and efficacy of specific therapies, and stress that physicians' decisions about CAM use should be subject to the same exacting criteria employed by researchers to evaluate any new therapies. The authors report on CAM curriculum developments in Germany, Canada, and the United States that illustrate various approaches to the question, "What should be taught in a CAM course?" In most cases, the approach is to teach about CAM therapies, although in others, therapies that the curriculum planners considered useful and safe are being integrated into the medical curriculum.