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1.  Disclosure of Complementary and Alternative Medicine Use to Health Care Providers among HIV-Infected Women 
AIDS patient care and STDs  2009;23(11):965-971.
To determine prevalence and predictors of complementary and alternative medicine (CAM) use disclosure to health care providers and whether CAM use disclosure is associated with highly active antiretroviral therapy (HAART) adherence among HIV-infected women, we analyzed longitudinal data collected between October 1994 and March 2002 from HIV-infected CAM-using women enrolled in the Women’s Interagency HIV Study. Repeated measures Poisson regression models were constructed to evaluate associations of selected predictors with CAM use disclosure and association between CAM use disclosure and HAART adherence. A total of 1377 HIV-infected women reported CAM use during study follow-up and contributed a total of 4689 CAM-using person visits. The overall prevalence of CAM use disclosure to health care providers was 36% across study visits. Women over 45 years old, with a college education, or with health insurance coverage were more likely to disclose their CAM use to health care providers, whereas women identified as non-Hispanic Black or other ethnicities were less likely to communicate their CAM usage. More health care provider visits, more CAM domains used, and higher health care satisfaction scores had significant relationships with increased levels of CAM use disclosure. Restricting analysis to use of herbal or nonherbal medications only, similar results were obtained. Compared to other CAM domains, mind–body practice had the lowest prevalence of CAM use disclosure. Additionally, CAM use disclosure was significantly associated with higher HAART adherence. From this study, we showed that a high percentage of HIV-infected women did not discuss their CAM use with health care providers. Interventions targeted towards both physicians and patients may enhance communication of CAM use, avoid potential adverse events and drug interactions, and enhance HAART adherence.
doi:10.1089/apc.2009.0134
PMCID: PMC2801553  PMID: 19821723
2.  Disclosure of Complementary and Alternative Medicine Use to Health Care Providers among HIV-Infected Women 
AIDS Patient Care and STDs  2009;23(11):965-971.
Abstract
To determine prevalence and predictors of complementary and alternative medicine (CAM) use disclosure to health care providers and whether CAM use disclosure is associated with highly active antiretroviral therapy (HAART) adherence among HIV-infected women, we analyzed longitudinal data collected between October 1994 and March 2002 from HIV-infected CAM-using women enrolled in the Women's Interagency HIV Study. Repeated measures Poisson regression models were constructed to evaluate associations of selected predictors with CAM use disclosure and association between CAM use disclosure and HAART adherence. A total of 1377 HIV-infected women reported CAM use during study follow-up and contributed a total of 4689 CAM-using person visits. The overall prevalence of CAM use disclosure to health care providers was 36% across study visits. Women over 45 years old, with a college education, or with health insurance coverage were more likely to disclose their CAM use to health care providers, whereas women identified as non-Hispanic Black or other ethnicities were less likely to communicate their CAM usage. More health care provider visits, more CAM domains used, and higher health care satisfaction scores had significant relationships with increased levels of CAM use disclosure. Restricting analysis to use of herbal or nonherbal medications only, similar results were obtained. Compared to other CAM domains, mind–body practice had the lowest prevalence of CAM use disclosure. Additionally, CAM use disclosure was significantly associated with higher HAART adherence. From this study, we showed that a high percentage of HIV-infected women did not discuss their CAM use with health care providers. Interventions targeted towards both physicians and patients may enhance communication of CAM use, avoid potential adverse events and drug interactions, and enhance HAART adherence.
doi:10.1089/apc.2009.0134
PMCID: PMC2801553  PMID: 19821723
3.  Patients in Northwestern Turkey Prefer Herbs as Complementary Medicine after Breast Cancer Diagnosis 
Breast Care  2008;3(4):269-273.
Summary
Background
A cross-sectional survey was conducted in order to define the prevalence, pattern, and predictors of complementary and alternative medicine (CAM) use in breast cancer patients in northwestern Turkey.
Patients and Methods
All patients admitted to the breast center between January 2005 and January 2006 were consecutively included in the study. Demographics and clinical data of study patients were noted. A 15-item questionnaire was used to document the attitude of breast cancer patients towards CAM modalities. Primary outcomes were prevalence, pattern, and predictors of CAM. Secondary outcomes were the reasons for CAM use, the number and type of adverse events related to CAM use, and the satisfaction level of CAM users.
Results
Nearly one third of breast cancer patients use at least one type of CAM in addition to conventional therapy. Most chose herbal medicines which they think support their general health status. Nettle (Urtica diocia/U. urens) was the most common herbal medicine that patients consume. Previous experience with CAM was the most significant factor for CAM use after breast cancer diagnosis. Being young and married as well as receiving radiotherapy were among other independent factors for using any CAM modality.
doi:10.1159/000144045
PMCID: PMC2974983  PMID: 21113280
Breast cancer; Complementary medicine; Supportive care; Therapy
4.  Relationship Between Complementary/Alternative Treatment Use and Illicit Drug Use Among a Cohort of Women with, or at Risk for, HIV Infection 
Abstract
Objectives
Two of the most pressing public health challenges in the United States are treating human immunodeficiency virus (HIV) infection and illegal substance use. High rates of complementary and alternative medicine (CAM) use have been reported by individuals who suffer from both of these diseases. The goal of this study was to examine the relationship between CAM use and illegal substance use in a cohort of women with HIV or at risk for HIV disease. Based on previous research, it was hypothesized that CAM use may decrease substance use.
Design
This was a longitudinal cohort study.
Subjects
The subjects comprised Women in the Women's Interagency HIV Study.
Outcome measures
The role of CAM use in illegal substance use was examined. Due to the hierarchical structure of the dataset, logistic regression analysis adjusting for repeated measurements (generalized estimating equation model) was carried out to assess associations of CAM use and illicit drug use.
Results
There were 2176 women included in the analysis. After excluding for marijuana use, CAM use was associated with less drug use (odds ratio 0.82; 95% confidence interval: 0.73, 0.90).
Conclusions
The results supported our hypothesis that CAM users are more health conscious and thus less likely to use illicit drugs. Future studies should target both specific drugs and CAM modalities to help finalize this association.
doi:10.1089/acm.2009.0584
PMCID: PMC3110837  PMID: 20738164
5.  Effects of highly active antiretroviral therapy and its adherence on herpes zoster incidence: a longitudinal cohort study 
Background
Herpes zoster (HZ) is common among HIV-infected individuals, but the impacts of highly active antiretroviral therapy (HAART) and HAART adherence on HZ risk have not been well studied.
Methods
The effects of HAART and HAART adherence on HZ incidence were evaluated by comparing HIV-infected women on HAART (HAART use group) with the HIV-infected women remaining HAART naïve (HAART naïve group) in the Women’s Interagency HIV Study (WIHS). A 1:1 matching with propensity score for predicting HAART initiation was conducted to balance background covariates at index visit, including HIV disease stage. Kaplan-Meier method was used to compare the risk of HZ development between the matched pairs. Cox proportional hazard models were used to assess the effects of HAART and HAART adherence on HZ incidence.
Results
Through propensity score matching, 389 pairs of participants were identified and they contributed 3,909 person years after matching. The background covariates were similar between the matched pairs at the index visit. The participants had a mean age around 39 years old, and about 61% of them were Black and 22% were Latina. No significant difference in HZ risk was observed between the HAART use group and the HAART naïve group during the first year of follow-up in any analyses. In the univariate analysis, the HAART use group had marginally lower HZ risk (Hazard Ratio (HR): 0.72; 95% Confidence Interval (CI): 0.48-1.1) over the entire follow-up period. However, women with a HAART adherence level of ≥95% had significantly lower HZ risk (HR: 0.54; 95% CI: 0.31, 0.94) compared to the HAART naïve women. The association remained significant after adjusting for quality of life score and acyclovir use, but it attenuated and was no longer statistically significant after adjusting for an intermediate variable, either CD4+ T cell counts or HIV viral load.
Conclusions
Among adult women, we observed a significant preventive effect of long-term HAART use on HZ incidence when a HAART adherence level of ≥95% was attained, and this effect was mediated through reduction of HIV viral load and improvement of CD4+ T cell counts.
doi:10.1186/1742-6405-10-34
PMCID: PMC3904465  PMID: 24373482
HAART; Adherence; Herpes zoster; Incidence; Propensity score
6.  The Impact of Kidney Function at HAART Initiation on Mortality in HIV-infected Women 
Background
In the early highly active antiretroviral therapy (HAART) era, kidney dysfunction was strongly associated with death among HIV-infected individuals. We re-examined this association in the later HAART period to determine whether chronic kidney disease (CKD) remains a predictor of death after HAART-initiation.
Methods
To evaluate the effect of kidney function at the time of HAART initiation on time to all-cause mortality, we evaluated 1415 HIV-infected women initiating HAART in the Women’s Interagency HIV Study (WIHS). Multivariable proportional hazards models with survival times calculated from HAART initiation to death were constructed; participants were censored at the time of the last available visit or December 31, 2006.
Results
CKD (eGFR <60 ml/min/1.73 m2) at HAART initiation was associated with higher mortality risk adjusting for age, race, hepatitis C serostatus, AIDS history and CD4+ cell count (hazard ratio [HR]=2.23, 95% confidence interval [CI]: 1.45–3.43). Adjustment for hypertension and diabetes history attenuated this association (HR=1.89, CI: 0.94–3.80). Lower kidney function at HAART initiation was weakly associated with increased mortality risk in women with prior AIDS (HR=1.09, CI: 1.00–1.19, per 20% decrease in eGFR).
Conclusions
Kidney function at HAART initiation remains an independent predictor of death in HIV-infected individuals, especially in those with a history of AIDS. Our study emphasizes the necessity of monitoring kidney function in this population. Additional studies are needed to determine mechanisms underlying the increased mortality risk associated with CKD in HIV-infected persons.
doi:10.1097/QAI.0b013e3181e674f4
PMCID: PMC3243740  PMID: 20581688
kidney disease; mortality; HIV; WIHS; antiretroviral therapy
7.  Complementary and Alternative Medicine Use and Quality of Life in Pediatric Diabetes 
Abstract
Objectives
The objectives of this study were to explore the association between complementary and alternative medicine (CAM) use as reported by youth, and parents' and children's reported quality of life in youth with diabetes.
Design
The study design was a cross-sectional survey.
Setting
Youth in Washington State participated in the SEARCH for Diabetes in Youth study, a national, multisite epidemiological study designed to assess the prevalence and incidence of diabetes in U.S. youth. Surveys assessing CAM utilization were mailed in January and April 2006.
Participants
One thousand four hundred and thirty-nine (1439) youth were mailed a CAM survey. The final sample consisted of 467 youth with both CAM survey results and quality-of-life data.
Outcome measures
Difference in mean scores on Pediatric Quality of Life Inventory (PedsQL) between CAM users and nonusers overall, and specific CAM therapies were the outcome measures.
Results
Of the 1439 participants approached, 587 (40.8%) returned the CAM survey. In adjusted analyses, children reported any CAM use as associated with more barriers to treatment (difference in mean scores −3.48, 95% confidence interval [CI] −6.65, −0.31). Children following a CAM diet reported higher quality of life (PedsQL Core Total difference 4.01, 95% CI [0.10–7.91]; Core Psychosocial difference was 6.45, 95% CI [1.95 to 10.95]), but those using stress-reduction activities reported poorer quality of life (Diabetes Total difference −4.19, 95% CI [−8.35 to −0.04]). Parent-reported quality of life was lower for children who used “other supplements” (Core Total difference −6.26, 95% CI [−11.29 to −1.24]; Core Psychosocial difference was −5.92, 95% CI [−11.65 to −0.19]).
Conclusions
CAM diets were associated with increased quality of life in youth with diabetes, whereas supplement use and stress-reduction activities were associated with decreased quality of life. The temporal sequence between CAM use and quality of life requires further study.
doi:10.1089/acm.2008.0566
PMCID: PMC3110095  PMID: 20180689
8.  Assessing the effect of HAART on change in quality of life among HIV-infected women 
Background
The impact of highly active antiretroviral therapy (HAART) on health-related quality of life (QOL) of HIV-1 infected individuals in large prospective cohorts has not been well studied.
Objective
To assess the effect of HAART on QOL by comparing HIV-infected women using HAART with HIV-infected women remaining HAART naïve in the Women's Interagency HIV Study (WIHS), a multicenter prospective cohort study begun in 1994 in the US.
Methods
A 1:1 matching with equivalent (≤ 0.1%) propensity scores for predicting HAART initiation was implemented and 458 pairs were obtained. HAART effects were assessed using pattern mixture models. The changes of nine QOL domain scores and one summary score derived from a shortened version of the MOS-HIV from initial values were used as study outcomes.
Results
The background covariates of the treatment groups were well-balanced after propensity score matching. The 916 matched subjects had a mean age of 38.5 years and 42% had a history of AIDS diagnosis. The participants contributed a total of 4,292 person visits with a median follow-up time of 4 years. In the bivariate analyses with only HAART use and time as covariates, HAART was associated with short-term improvements of 4 QOL domains: role functioning, social functioning, pain and perceived health index. After adjusting for demographic, socioeconomic, biological and clinical variables, HAART had small but significant short-term improvements on changes in summary QOL (mean change: 3.25; P = 0.02), role functioning (6.99; P < 0.01), social functioning (5.74; P < 0.01), cognitive functioning (3.59; P = 0.03), pain (6.73; P < 0.01), health perception (3.67; P = 0.03) and perceived health index (4.87; P < 0.01). These QOL scores typically remained stable or declined over additional follow-up and there was no indication that HAART modified these trends.
Conclusion
Our study demonstrated significant short-term HAART effects on most QOL domains, but additional use of HAART did not modify long-term trends. These changes could be attributed to the direct effect of HAART and indirect HAART effect mediated through clinical changes.
doi:10.1186/1742-6405-3-6
PMCID: PMC1459186  PMID: 16549012
9.  Antiretroviral Therapy Initiation Before, During, or After Pregnancy in HIV-1-Infected Women: Maternal Virologic, Immunologic, and Clinical Response 
PLoS ONE  2009;4(9):e6961.
Background
Pregnancy has been associated with a decreased risk of HIV disease progression in the highly active antiretroviral therapy (HAART) era. The effect of timing of HAART initiation relative to pregnancy on maternal virologic, immunologic and clinical outcomes has not been assessed.
Methods
We conducted a retrospective cohort study from 1997–2005 among 112 pregnant HIV-infected women who started HAART before (N = 12), during (N = 70) or after pregnancy (N = 30).
Results
Women initiating HAART before pregnancy had lower CD4+ nadir and higher baseline HIV-1 RNA. Women initiating HAART after pregnancy were more likely to receive triple-nucleoside reverse transcriptase inhibitors. Multivariable analyses adjusted for baseline CD4+ lymphocytes, baseline HIV-1 RNA, age, race, CD4+ lymphocyte count nadir, history of ADE, prior use of non-HAART ART, type of HAART regimen, prior pregnancies, and date of HAART start. In these models, women initiating HAART during pregnancy had better 6-month HIV-1 RNA and CD4+ changes than those initiating HAART after pregnancy (−0.35 vs. 0.10 log10 copies/mL, P = 0.03 and 183.8 vs. −70.8 cells/mm3, P = 0.03, respectively) but similar to those initiating HAART before pregnancy (−0.32 log10 copies/mL, P = 0.96 and 155.8 cells/mm3, P = 0.81, respectively). There were 3 (25%) AIDS-defining events or deaths in women initiating HAART before pregnancy, 3 (4%) in those initiating HAART during pregnancy, and 5 (17%) in those initiating after pregnancy (P = 0.01). There were no statistical differences in rates of HIV disease progression between groups.
Conclusions
HAART initiation during pregnancy was associated with better immunologic and virologic responses than initiation after pregnancy.
doi:10.1371/journal.pone.0006961
PMCID: PMC2734183  PMID: 19742315
10.  Complementary and Alternative Medicine Use Among HIV+ People: Research Synthesis and Implications for HIV Care 
AIDS care  2008;20(8):1002-1018.
Use of complementary and alternative medicine (CAM) is prevalent among HIV+ individuals despite the success of antiretroviral treatments and limited evidence of CAM's safety and efficacy. To characterize the potential impact of CAM use on HIV care, we conducted a systematic review of 40 studies of CAM use among HIV+ people. The goals of this review are to: (a) describe the demographic, biomedical, psychosocial, and health behavior correlates of CAM use; (b) characterize patient-reported reasons for CAM use; and (c) identify methodological and conceptual limitations of the reviewed studies. Findings confirm that a high proportion of HIV+ individuals report CAM use (M = 60%). Overall, CAM use is more common among HIV+ individuals who are men who have sex with men (MSM), non-minority, better educated, and less impoverished. CAM use is also associated with greater HIV symptom severity and longer disease duration. HIV+ CAM users commonly report that they use CAM to prevent or alleviate HIV-related symptoms, reduce treatment side-effects, and improve quality of life. Findings regarding the association between CAM use, psychosocial adjustment, and adherence to conventional HIV medications are mixed. While the reviewed studies are instrumental in describing the characteristics of HIV+ CAM users, this literature lacks a conceptual framework to identify causal factors involved in the decision to use CAM or explain implications of CAM use for conventional HIV care. To address this concern, we propose the use of health behavior theory and discuss implications of review findings for HIV care providers.
doi:10.1080/09540120701767216
PMCID: PMC2570227  PMID: 18608078
11.  Prevalence and determinants of complementary and alternative medicine use among infertile patients in Lebanon: a cross sectional study 
Background
Complementary and alternative medicine (CAM) is widely used for the treatment of infertility. While the Middle East and North Africa region has been shown to house one of the fastest growing markets of CAM products in the world, research describing the use of CAM therapies among Middle-Eastern infertile patients is minimal. The aim of this study is to examine the prevalence, characteristics and determinants of CAM use among infertile patients in Lebanon.
Methods
A cross sectional survey design was used to carry out face-to-face interviews with 213 consecutive patients attending the Assisted Reproductive Unit at a major academic medical center in Beirut. The questionnaire comprised three sections: socio-demographic and lifestyle characteristics, infertility-related aspects and information on CAM use. The main outcome measure was the use of CAM modalities for infertility treatment. Determinants of CAM use were assessed through the logistic regression method.
Results
Overall, 41% of interviewed patients reported using a CAM modality at least once for their infertility. There was a differential by gender in the most commonly used CAM therapies; where males mostly used functional foods (e.g. honey & nuts) (82.9%) while females mostly relied on spiritual healing/prayer (56.5%). Factors associated with CAM use were higher household income (OR: 0.305, 95% CI: 0.132–0.703) and sex, with females using less CAM than males (OR: 0.12, 95% CI: 0.051–0.278). The older patients were diagnosed with infertility, the lower the odds of CAM use (p for trend <0.05). Almost half of the participants (48%) were advised on CAM use by their friends, and only 13% reported CAM use to their physician.
Conclusions
The considerably high use of CAM modalities among Lebanese infertile patients, added to a poor CAM use disclosure to physicians, underscore the need to integrate CAM into the education and training of health professionals, as well as enhance infertile patients' awareness on safe use of CAM products.
doi:10.1186/1472-6882-12-129
PMCID: PMC3512516  PMID: 22901284
Complementary and alternative medicine; Infertility; Lebanon
12.  The Assessment of Complementary and Alternative Medicine Use Among Individuals with HIV: A Systematic Review and Recommendations for Future Research 
Abstract
Objectives
The use of complementary and alternative medicine (CAM), a group of health care practices and products that are not considered part of conventional medicine, has increased in recent years, particularly among individuals with human immune deficiency virus (HIV). Assessing the prevalence and predictors of CAM use among HIV-positive populations is important because some CAM therapies may adversely affect the efficacy of conventional HIV medications. Unfortunately, CAM use is not comprehensively or systematically assessed among HIV-positive populations. Therefore, the aim of the present study was to evaluate the quality of the instruments employed in observational studies assessing CAM use among HIV-positive populations by examining the degree to which these studies (1) evaluated the psychometric properties of their CAM instruments and (2) assessed the multidimensional nature of CAM use.
Design
A systematic review of studies was undertaken and specific review criteria were used to guide the inclusion of studies. Specifically, articles were included that were published in English and in a peer-reviewed journal between 1997 and 2007, recruited HIV-positive study participants, and assessed CAM use. Thirty-two (32) studies met these inclusion criteria.
Results
Results suggest that CAM assessment among HIV-positive populations continues to be problematic. For example, approximately 20% of the studies assessed the reliability and 3% assessed the validity of the CAM instrument employed.
Conclusions
CAM assessment—regardless of the specific study population—is a complex and challenging task. However, CAM instruments will not become more refined over time in the absence of rigorous psychometric evaluation. Future research must assess reliability and validity and report these data in a clear and nuanced manner.
doi:10.1089/acm.2010.0669
PMCID: PMC3197081  PMID: 21875350
13.  Prevalence and Correlates of Postdiagnosis Initiation of Complementary and Alternative Medicine Among Patients at a Comprehensive Cancer Center 
Journal of Oncology Practice  2012;9(1):34-41.
Patients with cancer increasingly use complementary and alternative medicine (CAM) in conjunction with conventional oncology treatments. This study looks at the prevalence and correlates of individual CAM modalities initiated after cancer diagnosis.
Purpose:
Patients with cancer increasingly use complementary and alternative medicine (CAM) in conjunction with conventional oncology treatments. Previous studies have not investigated postdiagnosis initiation of CAM therapies or independent correlates of use of individual CAM modalities. The purpose of this study was to determine the prevalence and correlates of individual CAM modalities initiated after cancer diagnosis.
Methods:
A cross-sectional survey was conducted of a random sample of adults with a cancer diagnosis (N = 1,228) seeking care at a National Cancer Institute–designated comprehensive cancer center within a 12-month period.
Results:
The majority of patients were female (64.7%), white (86.9%), and married (72.8%).Three-quarters (75.2%) used at least one CAM modality, and 57.6% of those using CAM initiated use after cancer diagnosis. For all CAM therapies combined, women were 1.7 times more likely than men to initiate any CAM therapy after cancer diagnosis. However, when CAM modalities were differentiated by type, men and women were equally likely to initiate all therapies except for psychotherapy and mind-body approaches. Postdiagnosis initiation of every CAM modality, except mind-body therapies, differed by cancer type.
Conclusion:
A significant proportion of patients initiated CAM use after diagnosis. However, specific type of CAM initiated varied by demographics and cancer type, suggesting there is not a “typology” of CAM user. Optimal comprehensive cancer treatment, palliation, and survivorship care will require patient and provider education regarding CAM use by modality type; improved provider-patient communication regarding potential benefits, limitations, and risks; and institutional policies to support integrated conventional and CAM treatment.
doi:10.1200/JOP.2012.000634
PMCID: PMC3545661  PMID: 23633969
14.  Complementary and Alternative Medicine Use Was Associated with Higher Perceived Physical and Mental Functioning in Early Systemic Sclerosis 
Explore (New York, N.Y.)  2008;4(4):259-263.
Objective
This study assessed the use of complementary and alternative medicine (CAM) therapies in patients with early systemic sclerosis (scleroderma, SSc).
Methods
At the annual visit, SSc patients enrolled in the Genetics versus Environment in Scleroderma Outcomes Study (GENISOS) were queried about their use of CAM therapies and intended symptom target, including herbal or nutriceutical therapy, acupuncture, transcutaneous electrical neural stimulation (TENS) and mind-body therapy (relaxation, meditative, imagery). The CAM user SSc patients were compared to matched non-CAM users over two years for database results of demographic, clinical and health-related quality of life SF-36 questionnaires by analysis of covariance.
Results
25% of the university GENISOS group were CAM users: age: 54 years; female: 89%; diffuse cutaneous involvement: 47%; total skin score: 13.5; Medsger severity index: 5.8. Over 70% used ≥1 CAM therapies for over 1 year, independent of health insurance. Symptoms targeted included arthritis/arthralgia, pain, GI dysmotility and fatigue. CAM users had significantly higher mean mental component summary (MCS) scores on SF-36 at Baseline and Year 2, (49 and 49.9), compared to non-CAM users (42 and 40.2, respectively, p<0.01). At Year 2, the CAM user group had significantly higher scores of SF-36 domains physical component score, role-physical, bodily pain and vitality, whereas scores declined in the non-CAM user group.
Conclusion
In SSc, 70% of those in the CAM user group reported a long-term commitment to CAM therapies. Higher perceived mental functioning in CAM users might reflect more self-motivation to manage symptoms and subsequently, promote practices that result in higher perceived physical functioning.
doi:10.1016/j.explore.2008.04.004
PMCID: PMC2875784  PMID: 18602619
CAM; SF-36; Integrative Medicine; Pain; Arthritis; GI Hypomotility; Scleroderma; GENISOS
15.  Predictors of complementary and alternative medicine use among older Mexican Americans 
To determine predictors of complementary and alternative medicine (CAM) use, we used a cohort of 1,445 non-institutionalized Mexican Americans aged 65 and older from the first wave (1993–1994) of the Hispanic Established Population for the Epidemiologic Study of the Elderly, followed until 2000–2001. The main outcome was use of any CAM (herbal medicine, chiropractic, acupuncture, massage therapy, relaxation techniques or spiritual healing) in the past 12 months and was assessed at 7 years of follow-up. Potential predictors of CAM use at baseline included sociodemographics, acculturation factors, and medical conditions. The overall rate of CAM use among older Mexican Americans was 31.6%. Independent predictors of higher CAM use were female gender, being on Medicaid, frequent church attendance and higher number of medical conditions. In contrast, subjects who were born in US and spoke either Spanish or English at interview had lower CAM use compared with subjects who were born in Mexico.
doi:10.1016/j.ctcp.2007.03.002
PMCID: PMC2100426  PMID: 17950177
CAM use; elderly; Mexican Americans; Medicaid; religiosity; acculturation
16.  Demand for CAM Practice at Hospitals in Japan: A Population Survey in Mie Prefecture 
Complementary and alternative medicine (CAM) therapies have been provided at hospitals along with conventional medicine in industrialized nations. Previous studies conducted in Japan revealed high proportion of Japanese had experience of using CAM, but failed to discuss how it should be provided. The present study aims to clarify the demand for CAM practice at hospitals in Japan. A questionnaire consisting of 41 questions was mailed to 10 000 adults randomly selected from the electoral roll of Mie prefecture, Japan in January 2007. The questionnaire asked the subjects about demand for CAM practice at hospitals, types of CAM therapy to be provided and associated reasons. Sociodemographic characteristics, perceived health status, experience and purpose of CAM use, and information resource for CAM were also surveyed. Completed answers were collected from 2824 (28.6%) respondents. Two thousand and nineteen (71.5%) of the respondents demanded CAM practice at hospitals with the most likely reason of “patients can receive treatment under the guidance of a physicians". The three most popular CAM therapies were Kampo, acupressure/massage/Shiatsu and acupuncture/moxibustion. The demand was positively associated with gender, ages of 40–59 years, annual household incomes of 5–7 million yen, occupation of specialist and technical workers and sales workers and poor health status. Higher demand was observed among those who used both CAM and conventional medical therapies for curative purposes. In conclusion, Japanese show a high demand for CAM practice, hoping to use CAM for curative purposes with monitoring by physicians at hospitals.
doi:10.1093/ecam/neq049
PMCID: PMC3145489  PMID: 21811513
17.  Timing of Antiretroviral Therapy Initiation and its Impact on Disease Progression in Perinatal Human Immunodeficiency Virus-1 Infection 
Objective
Treatment with highly active antiretroviral therapy (HAART) reduces overall perinatal HIV-1 related mortality. The impact of timing of HAART initiation on reduction of morbidity is not well-defined. We evaluated the association of timing of HAART initiation on progression to moderate or severe disease.
Methods
Retrospective, population-based study of 196 perinatally HIV-infected children followed from birth in northern California from 1988 to 2009.
Results
Of 196 children, 58% received HAART and were followed for a median of 6.2 years after HAART initiation. HAART use was associated with improved survival to age 5 years: 50% no HAART vs. 88% HAART, p<0.0001. However, the advantage of initial HAART over mono or dual therapy transitioning to HAART was small and not statistically significant (p=0.23). Starting HAART before the development of moderate or severe disease delayed the median age of diagnosis of moderate disease from 0.4 years (IQR [0.3–0.8]) without HAART to 3.0 years ([IQR 1.9–5.8], p<.0001) with HAART. HAART initiation after progression to moderate or severe disease was associated with decreased progression to severe disease or death, respectively (moderate to severe: 8% (3/36) HAART vs. 84% (70/83) no HAART, p<0.0001; severe to death: 9% (6/68) HAART vs. 73% (49/67) no HAART, p<0.0001).
Conclusion
In perinatal HIV infection, HAART is associated with delayed progression and reduced mortality regardless of disease severity at HAART initiation. This finding reinforces U.S. guidelines regarding HAART initiation at>1 year of age if children present with most clinical category B diagnoses, regardless of CD4 measurements or plasma HIV RNA level.
doi:10.1097/INF.0b013e31823515a2
PMCID: PMC3252403  PMID: 21979798
perinatal; HIV-1; highly active antiretroviral therapy (HAART); timing of onset
18.  Is Antiretroviral Therapy Causing Long-Term Liver Damage? A Comparative Analysis of HIV-Mono-Infected and HIV/Hepatitis C Co-Infected Cohorts 
PLoS ONE  2009;4(2):e4517.
The effects of highly active antiretroviral therapy (HAART) on progression of hepatic fibrosis in HIV-hepatitis C virus (HCV) co-infection are not well understood. Deaths from liver diseases have risen in the post-HAART era, yet some cross-sectional studies have suggested that HAART use is associated with improved fibrosis rates. In a retrospective cohort of 533 HIV mono-infected and 127 HIV/HCV co-infected patients, followed between January 1991 and July 2005 at a university-based HIV clinic, we investigated the relationship between cumulative HAART exposure and hepatic fibrosis, as measured by the aspartate aminotransferase-to-platelet ratio index (APRI). We used a novel methodological approach to estimate the dose-response relationship of the effect of HAART exposure on APRI. HAART was associated with increasing APRI over time in HIV/HCV co-infected patients suggesting that they may be experiencing cumulative hepatotoxicity from antiretrovirals. The estimated median change (95% confidence interval) in APRI per one year of HAART intake was of −0.46% (−1.61% to 0.71%) in HIV mono-infected compared to 2.54% (−1.77% to 7.03%) in HIV/HCV co-infected patients. Similar results were found when the direct effect of HAART intake since the last visit was estimated on the change in APRI. HAART use associated is with increased APRI in patients with HIV/HCV co-infection. Therefore treatment for HCV infection may be required to slow the growing epidemic of end-stage liver disease in this population.
doi:10.1371/journal.pone.0004517
PMCID: PMC2637977  PMID: 19223976
19.  Classification of CAM Use and its Correlates in Early Stage Breast Cancer Patients 
Integrative cancer therapies  2011;10(2):138-147.
Hypothesis
Self-reported use of complementary and alternative medicine (CAM) has been shown to increase following a cancer diagnosis, and breast cancer survivors are the heaviest users among cancer survivors. The aim of this study was to determine whether the prevalence estimate of CAM use varied according to classification of CAM. We used a comprehensive system to classify CAM users and test differences in demographic, lifestyle, quality of life, and cancer characteristics among them.
Study Design and Methods
Participants were 2562 breast cancer survivors participating in the Women's Healthy Eating and Living (WHEL) Study, aged 28-74 years. A structured telephone interview assessed CAM use, questioning about specific CAM practices, and whether use was related to cancer. We examined CAM use in relation to demographics, health behaviors, and quality of life.
Results
Approximately 80% of the women used CAM for general purposes but only 50% reported CAM use for cancer purposes. Visual imagery, spiritual healing, and meditation were the most frequently used practices for cancer purposes. CAM use, defined as consulting a CAM practitioner and regular use, was significantly related to younger age, higher education, increased fruit & vegetable intake, and lower body mass index (p < .05). CAM users who had seen a practitioner were also more likely to report poor physical and mental health than non-CAM users (p < .05). CAM use was not associated with changes in physical and mental health between study baseline and 1-year follow-up.
Conclusion
This study addressed important differences in the classification of CAM use among breast cancer survivors. Future studies need to further test the potential benefits and risks associated with CAM use.
doi:10.1177/1534735410392578
PMCID: PMC3126886  PMID: 21382963
20.  Complementary and alternative medicine use by patients visiting a free health clinic: A single-site, pilot study 
Background:
The rate of use of complementary and alternative medicine (CAM) has been documented to fluctuate widely, can greatly impact medical outcomes, and can influence patients' adherence to conventional medicines. Health care providers should assess the prevalence of CAM use (primarily herbal medicine) in individual settings to most accurately provide appropriate patient care.
Objectives:
The aim of this study was to determine the following: (1) differences in demographic characteristics between users and nonusers of CAM; (2) which CAM patients are using; (3) patients' sources of information concerning CAM; and (4) whether patients recall being asked about CAM use by their health care providers.
Methods:
In this single-center, pilot study, a self-administered survey concerning CAM use was made available to persons seeking care at an inner-city free health clinic (Kansas City Free Health Clinic, Kansas City, Missouri). Completed surveys were scanned into a database, and descriptive analyses were performed.
Results:
Three hundred eleven patients completed ≥1 question on the survey. Of those who reported race (n = 278), 168 (60.4%) were Caucasian/white, 73 (26.3%) were African American/black, and 24 (8.6%) were Hispanic/Latino. Of those who reported educational level (n = 287), 101 (35.2%) had some high school or were high school graduates or had a general equivalency development diploma, 102 (35.5%) had completed some college or vocational training, and 84 (29.3%) had completed college. Of those who reported personal annual income (n = 191), 107 (56.0%) reported up to US $15,000, and 54 (28.3%) reported >$15,000 to $30,000. A high rate of CAM use (past or present) was found among survey respondents (116/285 [40.7%]). No correlation was found between CAM use and any of the demographic characteristics studied. Of 98 patients reporting whether their CAM use was past or current, 64 (65.3%) were using CAM at the time of the survey. Friends and physicians were reported to be most supportive of CAM use (21/41 [51.2%] and 33/86 [38.4%] patients, respectively). The most common CAM products reported as being currently used were garlic and chamomile (both, 5 patients [7.1%]), and echinacea and ginseng (both, 3 patients [4.7%]).
Conclusion:
This survey of patients using an inner-city free health clinic showed a high rate of CAM use, which could significantly impact patient outcomes.
doi:10.1016/j.curtheres.2005.01.005
PMCID: PMC3964552
alternative; complementary; medically indigent; inner city; educational level
21.  Complementary and alternative medicine use among women at increased genetic risk of breast and ovarian cancer 
Background
Complementary and alternative medicine (CAM) use is well documented among breast cancer patients and survivors, but little evidence is available to describe rates and patterns of use among women at increased genetic risk of breast cancer.
Methods
A pre-visit telephone interview was conducted to ascertain CAM use among the BRCA mutation carriers enrolled in a high-risk breast cancer screening study. Participants were asked to report on their use of thirteen therapies within the year prior to enrollment into the study. Logistic regression was used to evaluate the association between various factors and CAM use in this population.
Results
Among the 164 BRCA1 or BRCA2 mutation-positive (BRCA+) women in this analysis, 78% reported CAM use, with prayer and lifestyle diet being the two most commonly reported modalities. Many subjects used multiple CAM therapies, with 34% reporting use of three or more modalities. The most commonly used modalities were mind-body therapies and biologically-based practices, 61.6% and 51.8%, respectively. High-risk women were more likely to use CAM if they were older, more educated, more worried about ovarian cancer risk, or had a previous cancer diagnosis.
Conclusion
This study suggests that the prevalence of CAM use is high among BRCA mutation carriers, with frequency of use comparable to that of breast cancer patients and survivors. Given the high prevalence of CAM use in our subjects, especially biologically-based therapies including herbal supplements, whose safety and efficacy in relation to cancer risk are unknown, our study suggests that future research is necessary to clarify these risks, and that it is important for providers to inquire about and to discuss the pros and cons of CAM use with their BRCA+ patients.
doi:10.1186/1472-6882-8-17
PMCID: PMC2391138  PMID: 18447953
22.  Complementary and alternative therapies among very long-term breast cancer survivors 
Breast cancer patients may have different complementary and alternative medicine (CAM) usage rates and may turn to CAM for different reasons than healthy adults. CAM has mostly been studied in recently diagnosed women; no studies have included survivors 10 years post-diagnosis. We examined very long-term breast cancer survivors to determine whether CAM users had dissimilar patterns of association with survivorship factors. Interviews of 374 breast cancer case patients from a population-based case–control breast cancer study of young women from Los Angeles County, California, during the 1980s occurred at follow-up; 371 patients with complete information were included. CAM represented 28 herbal remedies. Quality-of-life originated from the Medical Outcomes Study Short Form 36 questionnaire (SF-36). Higher rates of CAM (59%) usage occurred compared to nationwide estimates. CAM users resembled non-users on follow-up age, exercise, original disease, treatment, smoking, body-mass index, alcohol, and fear of recurrence. CAM users had a higher prevalence of medical co-morbidities (P = 0.0005), and scored significantly lower on the SF-36 emotional well-being subscale than non-CAM users (P = 0.01). CAM users and non-users did not differ on the SF-36 physical sub-scale. Very long-term breast cancer survivors who use CAM may have poorer emotional functioning and more medical problems than non-users.
doi:10.1007/s10549-008-0158-3
PMCID: PMC3101874  PMID: 18712472
Breast neoplasms; Complementary therapies; Survivors
23.  Collecting Information About a CAM Practitioner’s Practice: A Preliminary Report of a Self-Interview Methodology 
To prepare allopathic providers to advise patients about complementary and alternative medicine (CAM) therapies, the University of Kentucky CAM curriculum integration project has identified and trained CAM practitioners to coteach, precept, and demonstrate their respective practices. This project is interested in integrating CAM practitioners as teachers into this university and has formed a multidisciplinary committee for advice. The committee has recognized the importance of increased understanding of CAM practices to enhance communication within itself and to decide to which CAM practices students should receive exposure. This article reports our attempt to create a CAM practice description, based on questions general to CAM practice and specific to a particular approach. Because there is limited existing systematic research on CAM practice characteristics, these questions may interest researchers conducting qualitative studies, especially those seeking an example of questions to ask CAM practitioners. We also believe this practice description will be of general interest.
doi:10.1177/1533210105280369
PMCID: PMC2772081  PMID: 19890441
complementary and alternative medicine; practice characteristics; herbs; interview
24.  The prevalence, patterns of usage and people's attitude towards complementary and alternative medicine (CAM) among the Indian community in Chatsworth, South Africa 
Background
The purpose of this study was to determine, among the Indian community of Chatsworth, South Africa, the prevalence and utilisation patterns of complementary and alternative medicine (CAM), attitudes associated with CAM use and communication patterns of CAM users with their primary care doctors.
Methods
Face-to-face structured interviews were conducted in Chatsworth, a suburb of Durban in which South Africans of Indian origin predominantly reside. Participants were 200 randomly selected adult English-speaking Indian residents.
Results
The prevalence of CAM usage for period 2000/2001 was 38.5% (95% confidence interval 31.7% to 45.6%). Spiritual healing and herbal/natural medicines, including vitamins were the most common types of CAM used, accounting for 42.8% and 48.1% respectively of overall CAM usage. People used CAM to treat conditions including diabetes mellitus, headaches, arthritis and joint pains, stress, skin disorders, backaches, hypertension and nasal disorders. Half of the CAM users used allopathic medicines concurrently. The cost of CAM utilization over this 1-year period, incurred by 80.5% of users for the duration of therapy for their most troublesome condition was below R500 (approximately US$50). Age, sex, marital status, religion, level of education and income were shown not to influence the use of CAM. Greater than half (51.9%) of CAM users did so either upon the advice of someone they knew, or after noticing a CAM advertisement in the local press. Seventy-nine percent of CAM users indicated that they had positive outcomes with their treatments. Fifty four percent of CAM users (excluding those using spiritual healing only) failed to inform their doctors that they used CAM. The main reason given by half of this group was that informing their doctors did not seem necessary.
Conclusion
The prevalence of CAM in Chatsworth is similar to findings in other parts of the world. Although CAM was used to treat many different ailments, this practice could not be attributed to any particular demographic profile. The majority of CAM users were satisfied with the effects of CAM. Findings support a need for greater integration of allopathic medicine and CAM, as well as improved communication between patients and caregivers regarding CAM usage.
doi:10.1186/1472-6882-4-3
PMCID: PMC356921  PMID: 15018622
25.  Use of complementary and alternative medicines by a sample of Turkish women for infertility enhancement: a descriptive study 
Background
Infertility patients are a vulnerable group that often seeks a non-medical solution for their failure to conceive. World-wide, women use CAM for productive health, but only a limited number of studies report on CAM use to enhance fertility. Little is known about traditional and religious forms of therapies that are used in relation to conventional medicine in Turkey. We investigated the prevalence and types of complementary and alternative medicine (CAM) used by infertile Turkish women for fertility enhancement.
Methods
A face-to-face questionnaire inquiring demographic information and types of CAM used for fertility enhancement were completed by hundred infertility patients admitted to a primary care family planning centre in Van, Turkey between January and July 2009.
Results
The vast majority of infertile women had used CAM at least once for infertility. CAM use included religious interventions, herbal products and recommendations of traditional "hodja's" (faith healers). Of these women, 87.8% were abused in the last 12 months, 36.6% felt not being supported by her partner and 80.5% had never spoken with a physician about CAM.
Conclusions
Infertile Turkish women use complementary medicine frequently for fertility enhancement and are in need of information about CAM. Religious and traditional therapies are used as an adjunct to, rather than a substitute for, conventional medical therapy. Physicians need to approach fertility patients with sensitivity and should be able to council their patients about CAM accordingly.
doi:10.1186/1472-6882-10-11
PMCID: PMC2853488  PMID: 20307291

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