Alternative Medical Therapies Research Articles

Epidemiology of complementary and alternative medicine therapy use in allogeneic hematopoietic stem cell transplant survivorship patients in Australia.

In addition to prescribed conventional medicines, many allogeneic hematopoietic stem cell transplant (HSCT) survivors also use complementary and alternative medical therapies (CAM), however, the frequency and types of CAMs used by allogeneic HSCT survivors remain unclear. Study participants were adults who had undergone an allogeneic HSCT between 1st January 2000 and 31st December 2012. Participants completed a 402‐item questionnaire regarding the use of CAM, medical complications, specialist referrals, medications and therapies, infections, vaccinations, cancer screening, lifestyle, and occupational issues and relationship status following stem cell transplantation. A total of 1475 allogeneic HSCT were performed in the study period. Of the 669 recipients known to be alive at study sampling, 583 were contactable and were sent study packs. Of 432 participants who returned the completed survey (66% of total eligible, 76% of those contacted), 239 (54.1%) HSCT survivors used at least one form of CAM. These included dietary modification (13.6%), vitamin therapy (30%), spiritual or mind–body therapy (17.2%), herbal supplements (13.5%), manipulative and body‐based therapies (26%), Chinese medicine (3.5%), reiki (3%), and homeopathy (3%). These results definitively demonstrate that a large proportion of HSCT survivors are using one or more form of CAM therapy. Given the potential benefits demonstrated by small studies of specific CAM therapies in this patient group, as well as clearly documented therapies with no benefit or even toxicity, this result shows there is a large unmet need for additional studies to ascertain efficacy and safety of CAM therapies in this growing population.

Outbreak of acute hepatitis B virus infection associated with exposure to acupuncture.

The most common risk factors for acute hepatitis B virus (HBV) infection are sexual contact, injection drug use and perinatal, or nosocomial exposure. Acupuncture, used in China for over 2,500 years, has been gaining popularity as an alternative medical therapy in the western world, but when associated with poor infection control practices, is also a risk for blood-borne infections. To describe the outbreak investigation following detection of two cases of acute HBV infection associated with acupuncture services from the same provider within four months of symptom onset. The outbreak investigation included genotyping of HBV from the identified cases, on-site assessment of the acupuncturist's infection prevention and control practices and chart review of known clients. Both cases had HBV genotype D1 with an identical fingerprint and both clients had visited the clinic on the same day denying other recent risk exposures. Inspection of the acupuncturist's practice revealed high-risk re-use and inappropriate storage of disposable needles. The Regional Health Authority ordered cessation of clinic practice until infection control measures were remediated. A public service announcement and mailed notifications to clients identified from practitioner records recommended that all clients be tested for HBV, human immunodeficiency virus (HIV) and hepatitis C. A clear epidemiological linkage of these two acute HBV infections to the same acupuncture clinic, evidence of substandard infection control practice in the clinic and identical HBV molecular and genotypic profiles of the two cases are highly suggestive that contaminated acupuncture needles likely resulted in at least two cases of acute HBV infection. This is the first known reported transmission of HBV from acupuncturists re-use of disposable needles and the first HBV outbreak associated with exposure to acupuncture reported this century in an industrialized country. Increased provider oversight and patient education may prevent future outbreaks.

The Right to Try and the Future of the FDA in the Age of Personalized Medicine

Do citizens have the right to determine their own courses of treatment and to use medicines and devices that they think could improve their health? And, to the extent regulators seek to restrict that freedom, what is the practicality and cost of doing so? These questions animate the debate over the so-called “right to try,” a growing movement to allow terminally ill individuals to experiment with alternative medical treatments, therapies, and devices that are tightly controlled by the Food and Drug Administration (FDA). This essay argues that such an expansion of the right-to-try notion may be happening already as technological innovation decentralizes and democratizes medical decisions. This expansion does not mean that all FDA regulation will fade away, but it will necessitate a move away from the agency’s command-and-control methods of the past and toward a new focus on patient empowerment through enhanced choice, improved risk education, and clearer consent mechanisms.

PTH-079 6-Thioguanine as An Alternative Therapy in Inflammatory Bowel Disease? - Experience in A London District General Hospital

<h3>Introduction</h3> Conventional thiopurines (Azathioprine/6 Mercaptopurine) remain the cornerstone of maintaining remission in steroid-dependent inflammatory bowel disease (IBD). Despite the well-documented efficacy of these drugs, more than 50% of patients discontinue treatment due to adverse events or therapy resistance. Over the past decade, there has been renewed interest in the use of 6 thioguanine (TG), an agent historically used in haematological malignancy. With a shorter metabolic pathway, TG possesses a favourable side effect profile and it’s use as an alternative thiopurine in IBD is growing. We report our experience in tolerability, safety and efficacy of TG use in a London District General Hospital. <h3>Methods</h3> A retrospective review of electronic patient records including clinic letters, blood tests and endoscopic findings were carried out on patients commenced on TG between 2012 and 2015. Data was collected on patient demographics, indication and duration of therapy, response rates and reasons for treatment failure. <h3>Results</h3> A total of 28 patients received TG 20 mg once daily and median treatment duration was 14 months (range 1–40). Therapy was equally distributed amongst males and females (14:14), and mean age was 44 years (range 19–67). 14 (50%) patients had Ulcerative colitis (UC), 13 (46%) Crohn’s disease (CD) and 1 (4%) Indeterminate colitis. 24 patients (86%) received TG due to adverse reactions to conventional thiopurines vs. 3 patients (11%) who were non-responders. Treatment with TG resulted in clinical remission in 86% (19/22) patients at 6 months and 75% (12/16) at 12 months. In total, 6 patients (21%) discontinued TG – 4 failed treatment (2 continued alternative medical therapy and 2 had surgery) and 2 suffered adverse events (headaches and confusion). Tolerability and efficacy rates were similar in both UC and CD groups. All patients underwent blood monitoring and no abnormalities in liver function tests were detected. Of those who underwent MRI liver there was no evidence of nodular regenerative hyperplasia. <h3>Conclusion</h3> TG was well tolerated with comparable remission rates to conventional thiopurine therapy. We advocate the use of TG therapy in selected cases where conventional thiopurine therapy has failed or resulted in adverse reactions. Larger prospective trials are required to further evaluate the efficacy and safety of TG, with a view to potentially incorporate it’s use into clinical guidelines. <h3>Disclosure of Interest</h3> None Declared

Principles of Clinical Management of Patent Ductus Arteriosus in Extremely Preterm Neonates.

The clinical management of a patent ductus arteriosus (PDA) in preterm newborns is a controversial topic, and despite nearly three decades of research, varying opinions remain. This dilemma stems from uncertain causal linkage between PDA and neonatal comorbidities, as well as the lack of clear evidence showing that benefits of treatment outweigh risks. There has been a general shift in the management of PDA in preterm newborns from early and aggressive closure to a more conservative approach of watchful waiting and spontaneous closure. However, a firm recommendation cannot be made due to a lack of randomized controlled trials validating either treatment strategies. Although cyclooxygenase inhibitors, namely indomethacin and ibuprofen, are approved pharmacological treatments for PDA, there is a need to explore alternative medical therapies in view of lack of clinical response in many newborns and concerns over adverse effects. One such recent interest is the use of acetaminophen as a pharmacological agent. This present review tries to address the questions at hand, integrate the current evidence, highlight the principles of PDA management in preterm newborns, and suggest areas for possible future research.

Acupuncture and Acupuncture-Related Therapies Are Well-Tolerated and Can Effectively Provide Pain Relief in the Pediatric Population

Abstract Introduction: Acupuncture, a complementary and alternative medical therapy, has become a viable treatment option for patients in Western society during the last few decades. Objective: The aim of this research was to analyze acupuncture and acupuncture-related therapies (ARTs) performed in a pediatric population. Materials and Methods: A 3-year retrospective review was performed on all inpatient and outpatient pediatric acupuncture services. Results: During the 3-year study period, 174 patients were seen 1090 times. The average patient age was 13.9 years. Patients were seen an average of 6.3 times. Of these encounters, 95.6% occurred in the clinic and 4.4% occurred in the hospital. Headache or migraine was the most common diagnosis. Acupuncture and ARTs performed included: 96% acupuncture body needling; 90% electroacupuncture; 49% laser therapy; 32% auricular acupuncture; and 27% moxibustion. Active pain was present in 72% of the patients encountered. The average pain score was 5.5 prior to inter...

Complementary and alternative medical therapies for interstitial cystitis: an update from the United States.

The diagnosis and treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) has shifted from organ-specific to a multifactorial, multidisciplinary and individualized approach. Patients with refractory and debilitating symptoms may respond to complementary and alternative medical treatments (CAM). Through CAM therapies, practitioners assist the patient to be at the center of their care, empowering them to be emotionally and physically involved. Multi-disciplinary care, including urology, gynecology, gastroenterology, neurology, psychology, physiotherapy and pain medicine, is also identified to be the crux of adequate management of patients with chronic pelvic pain because of its variable etiology. The purpose of this review is to emphasize these changes and discuss management strategies.

Doctored: The Medicine of Photography in Nineteenth-Century America by Tanya Sheehan (review)

Reviewed by: Doctored: The Medicine of Photography in Nineteenth-Century America by Tanya Sheehan Julie K. Brown Tanya Sheehan. Doctored: The Medicine of Photography in Nineteenth-Century America. University Park: Pennsylvania State University Press, 2011. xiv + 202 pp. Ill. $39.95 (978-0-271-03793-6). Historians of photography in recent years have moved beyond conventional single-focused approaches to their subject as technology, art, or even social history in favor of a more inclusive cultural history, which delves deeper and more broadly into the factors that pervade all aspects of this elusive visual medium. For historians of medicine familiar only with the mechanistic role of “photography in medicine,” Tanya Sheehan inverts this paradigm in her new book The Medicine of Photography, a cultural history of commercial portrait photography set in nineteenth-century Philadelphia. Drawing on recent literary and visual studies for theoretical underpinnings in her lengthy introduction, Sheehan argues that photography “as a discrete concept and institution” contributed “to the formation of a cultural discourse on the diseased and disordered body in America” (p. 11). Sheehan draws her evidence for historically linking photography with health and medicine from textual metaphors, similes, analogies, and personifications that appeared in selected professional photographic trade journals and manuals between 1860 and 1890. This figurative language, Sheehan argues, was not just a linguistic expression, but was meant to implement a series of specific strategies directly identifying photography with the work of medicine and health as a profession, practice and process. In chapter 1, for example, she examines the medical metaphors used to enhance the professional status, authority, and educational efforts of commercial portrait photographers and describes similar experiences facing professional medicine in this period. Chapter 2 focuses on the medical metaphors used to characterize the practical work of physical posing by commercial portrait photographers in studio settings. This includes a discussion of the Army Medical Museum’s photographic documentation of the war injured along with the work of commercial studio photographers in the manipulation of bodies and their “surgical rehabilitation” (p. 68). In chapter 4 Sheehan connects Philadelphia’s urban health reforms with efforts to improve the safety of the laboratory/ darkroom and the use of medical metaphors to refer to photographic processes and their use in personifying traditional photographic materials. Chapter 3, “Light as Medicine in the Photographic Studio,” is a more broadly conceived essay on the similarities of light technologies used in alternative medical therapy (e.g., “blue glass” phototherapy associated with “quack medicine” of the period p. 83) and lighting in studio portrait photography. Sheehan acknowledges that this analogy “was never explicitly articulated by photographers or their public” (p. 84). A detailed discussion on the facial lightening for African American photographic portraiture underlines the strong social and cultural pressures of divisive racial and ethnic anxieties current in Philadelphia in this period. Sheehan’s final chapter, the fifth, shifts her time frame abruptly to contemporary issues centered on the transitions from analog to digital photography and the use of medical metaphors to characterize the practices of photographic “doctoring” and image manipulation. Sheehan sees this as a “reemergence” of the [End Page 610] metaphor of “medicine as photography” (p. 135) especially in the prevalence of medicalized language adapted from cosmetic surgery descriptions appearing in digital “how-to-do” manuals, articles, and popular entertainments that contribute to our current “makeover culture” (p. 143). I endorse Sheehan’s efforts to develop a much needed and broader cultural investigation of how photographic authority is constructed, the factors affecting its practice, and the various ways in which the public engages as subject and spectator. However, I find that Sheehan’s reliance exclusively on figurative language and metaphorical strategies for textual evidence of “photography as medicine” has its limitations. Sheehan’s literal transcription of these metaphors often lead to overstatements, and her own language often merges too easily with the rhetoric of the texts on which she relies for evidence. Photography certainly had to contend with competing models from both science and the arts in the nineteenth century, and as Sheehan acknowledges, this issue remained an open question, which did not prevent commercial portrait photographers from engaging “in fantasies of competition with” the American medical profession (p. 47...

A Therapeutic Fast for Lymphoma Resulting in Wernicke Encephalopathy

BackgroundWernicke encephalopathy is an acute neurological emergency caused by thiamine (vitamin B1) deficiency. The syndrome is associated with a significant morbidity and mortality, and prompt recognition and treatment of the syndrome in the emergency department (ED) is essential to improving patient outcomes. Numerous factors and clinical settings have been identified that predispose a patient to thiamine deficiency and subsequent Wernicke encephalopathy. Case ReportWe present the rare case of a 42-year-old man with a recent diagnosis of non-Hodgkin lymphoma who opted against chemotherapy in favor of a 60-day therapeutic water-only fast. On day 53 of his fast, the patient arrived to our ED in a coma and respiratory failure. Moments after the administration of thiamine, the patient's mental status and respiratory status improved significantly. Prior to admission and transport to the medical intensive care unit, the patient was awake, alert, and following basic commands. He was ultimately diagnosed with Wernicke encephalopathy. Why Should An Emergency Physician Be Aware of This?With the increasing incidence of patients choosing alternative medical therapies to treat a variety of diseases, numerous electrolyte, metabolic, and nutritional disorders are becoming increasingly more common in the ED setting. In some cases, patients may choose a therapeutic fast in an effort to combat a malignancy; the danger being that patients with cancers such as lymphoma are already at risk for thiamine deficiency as a result of the increased thiamine consumption associated with rapid cellular turnover. Wernicke encephalopathy is a life-threatening neurological emergency, and the emergency physician must be aware of the numerous predisposing factors to the condition, as early identification and treatment improves patient outcomes.

Recurrent respiratory papillomatosis: current and future perspectives.

Although recurrent respiratory papillomatosis is a benign disease of the upper aerodigestive tract caused by infection with human papillomavirus, the disease process is unpredictable, ranging from mild disease and spontaneous remission to an aggressive disease with pulmonary spread and requirement for frequent surgical debulking procedures. It can present a protracted clinical course and cause potentially life-threatening compromise of the airways. Over recent decades, a number of alternative medical therapies to standard surgical treatment have been investigated, with modest outcomes overall. Currently, some additional therapies are being explored, together with novel surgical instrumentation that can help to avoid inevitable long-term stenotic complications, ultimately affecting quality of life. Hopefully, clinicians might soon be able to significantly improve the quality of treatment and outcomes for patients affected with recurrent respiratory papillomatosis, with human papillomavirus vaccination having a potentially important role.

Inhibitory Effects of Quinoline Isolated from Ruta chalepensis and Its Structurally Related Derivatives against α-Amylase or α-Glucosidase

Abstract This study was to isolate an active component of thechloroform fraction from the methanol extract of Ruta chalepensisleaves and to measure inhibitory effects against α-glucosidase orα-amylase. The inhibitory compound of R. chalepensis leaves wasisolated using chromatographic methods and identified as quinoline.Quinoline and its structurally related derivatives were tested fortheir inhibitory activities by evaluating the IC 50 values against α-amylase or α-glucosidase and were compared with that of acarbose.Based on the IC 50 values, quinazoline exhibited the greatestinhibitory activity (20.5µg/mL), followed by acarbose (66.5µg/mL), and quinoline (80.3µg/mL) against α-glucosidase. In caseof α-amylase, quinazoline had potent inhibitory activity, followedby quinoline (179.5µg/mL) and acarbose (180.6µg/mL). Theseresults indicate that R. chalepensis extract, quinoline, and quinazolinecould be useful for inhibiting α-glucosidase or α-amylase.Keywords α-amylase · α-glucosidase · inhibitory activity · quin-oline · Ruta chalepensis IntroductionDiabetes mellitus is the most serious global health problem andresults in considerable morbidity and mortality (Nilubon et al.,2006). Complications of diabetes such as terminal nephritis andcardiovascular disorders are the principal cause of irreversibleblindness (Perez et al., 1998; Jeong et al., 2012). Diabetes fallsinto two etiopathogenetic categories, types 1 and 2 (AmericanDiabetes Association., 2005; Nilubon et al., 2006). Diabetes type1 is resulted in absolute deficiency of insulin secretion (Nilubon etal., 2006; Frode and Medeiros, 2008). Diabetes type 2 is causedby insufficient compensatory insulin secretion and a combinationof resistance to insulin action (Nilubon et al., 2006; Frode andMedeiros, 2008). Attention to herbal remedies has increasedbecause of the side effects associated with treatment of oralhypoglycemic agents and insulin (Holman and Turner, 1991; Lee,2005; Kim et al., 2006; Jeong et al., 2012; Lee et al., 2014).Ruta chalepensis L. (Rutaceae) is a perennial herb that isextensively used in folk medicine. R. chalepensis is well-knownas an alternative medical therapy (antispasmodic, antirheumatic,aphrodisiac) and a treatment for snakebites, headache, andwounds (Ghazanfar, 1994). Furthermore, this plant is a rich sourceof several acridones and coumarins, as well as quinoline alkaloids(Ulubelen and Guner, 1988; Ulubelen and Terem, 1988; Lee andAhn, 1998; Lee, 2002). R. chalepensis exhibits insecticidalactivity against pests, with no noxious effects on parasitoids (Al-mazraawi and Ateyyat, 2009) and shows antibacterial, antifungal,anthelmintic, and anthelmintic effects (Di Stasi et al., 2002;Alzoreky and Nakahara, 2003; Iauk et al., 2004; Yarnell andAbascal, 2004; Cho et al., 2005; Rigat et al., 2007; Barrera-Nechaet al., 2009). However, no report on the inhibitory activity ofactive compound isolated from R. chalepensis leaves andstructurally related derivatives against α-amylase or α-glucosidaseis available. Therefore, we isolated an active constituent from R.chalepensis leaves and assessed the inhibitory effects of quinolinederivatives against α-glucosidase or α-amylase.Materials and MethodsIsolation and identification. R. chalepensis leaves were collectedfrom a market in Korea. R. chalepensis leaves (3.0 kg) were

Berberine blocks the relapse of Clostridium difficile infection in C57BL/6 mice after standard vancomycin treatment.

Vancomycin is a preferred antibiotic for treating Clostridium difficile infection (CDI) and has been associated with a rate of recurrence of CDI of as high as 20% in treated patients. Recent studies have suggested that berberine, an alternative medical therapy for gastroenteritis and diarrhea, exhibits several beneficial effects, including induction of anti-inflammatory responses and restoration of the intestinal barrier function. This study investigated the therapeutic effects of berberine on preventing CDI relapse and restoring the gut microbiota in a mouse model. Berberine was administered through gavage to C57BL/6 mice with established CDI-induced intestinal injury and colitis. The disease activity index (DAI), mean relative weight, histopathology scores, and levels of toxins A and B in fecal samples were measured. An Illumina sequencing-based analysis of 16S rRNA genes was used to determine the overall structural change in the microbiota in the mouse ileocecum. Berberine administration significantly promoted the restoration of the intestinal microbiota by inhibiting the expansion of members of the family Enterobacteriaceae and counteracting the side effects of vancomycin treatment. Therapy consisting of vancomycin and berberine combined prevented weight loss, improved the DAI and the histopathology scores, and effectively decreased the mortality rate. Berberine prevented CDIs from relapsing and significantly improved survival in the mouse model of CDI. Our data indicate that a combination of berberine and vancomycin is more effective than vancomycin alone for treating CDI. One of the possible mechanisms by which berberine prevents a CDI relapse is through modulation of the gut microbiota. Although this conclusion was generated in the case of the mouse model, use of the combination of vancomycin and berberine and represent a novel therapeutic approach targeting CDI.

Attitude of Residents of a Rural Community in South-South, Nigeria towards Alternative Medical Therapy

Background: Up to 80 percent of Africans are reported to use some form of alternative medical therapy (AMT) to meet their health needs. There are gaps in knowledge relating to attitude towards AMT in southsouth Nigeria. An understanding of beliefs and the prevailing factors that influence the patronage of traditional medicine in this environment may help inform policy interventions. Objectives: This study aimed to assess the awareness of and attitude towards AMT amongst the inhabitants of a rural community in south-south Nigeria. Materials and Methods: This was a cross sectional survey involving 300 respondents selected by a two stage sampling technique, using a self-designed interviewer administered structured questionnaire. Results were presented as proportions with chi-squared test done to determine associations. Level of significance was set at 0.05. Results: Mean age of the 300 respondents was 35.7±11.7 with 237 persons (79.0%) earning less than $250 monthly and 168 (56.0%) having secondary education. Majority 297 (99%) were aware of AMT and 287 (95.7%) cited herbal concoctions as the most prevalent method. Few were aware of side effects of AMT 71 (23.7%). Majority 208 (69.3%) preferred AMT to orthodox treatment, and Original Research Article Maduka and Ejimkaraonye; BJMMR, 8(4): 334-342, 2015; Article no.BJMMR.2015.456 335 were willing to refer others to AMT practitioners. Of these 159 (76.4%) claimed AMT to be more effective and 140 (67.3%) more affordable. Age of respondents, educational status, occupation and average monthly income were all found to be associated with preference of AMT (p<0.5). Conclusion: Alternative medical therapy is favoured by majority of the respondents in spite of the risks. Public enlightenment campaigns, better regulation, and implementation of community health insurance for affordable health care are advocated.

Improvement in Sperm DNA Quality Following Simple Life Style Intervention: A Study in Fathers of Children with Non-Familial Sporadic Heritable Retinoblastoma

Introduction and objectives: Genomic integrity of gametes is important for birth of healthy offspring. As compared to ova the sperm is more susceptible to mutation due to limited DNA damage detection and repair mechanism. Life style habits adopted by father before conception may adversely affect genomic DNA integrity in male gametes. Oxidative stress damages sperm nuclear and mitochondrial DNA. Complementary and alternative medical therapies such as yoga/meditation are being increasingly used as adjuncts to modern medicine in treatment of several clinical conditions. Therefore, in this pilot study, we analyzed the effects of yoga and meditation on seminal oxidative stress and sperm DNA integrity in fathers of children with non-familial sporadic heritable retinoblastoma (Rb) after intervention (3 and 6 months). Methods: A total of 10 men (father of children with sporadic non-familial Rb) were recruited in this study. Semen samples were collected at base line (day 0), 3 months and after 6 months of yoga practice. Reactive oxygen species (ROS), DNA fragmentation index (DFI) and 8-hydroxy-2’-deoxyguanosine (8-OHdG) levels were estimated at day 0.3 months and 6 months interval. Results: There was reduction in mean DFI levels [p>0.05] at 3 months and 6 months [p 0.05] 6 months [p<0.05] with respect to the base line levels (day 0). Conclusions: Yoga/meditation significantly lowers oxidative stress and oxidative nuclear DNA damage, and levels of the mutagenic base 8OHdG. Thus yoga and meditation are simple life style interventions which are therapeutic for maintaining/restoring sperm DNA integrity

Medical and alternative therapies in urinary tract stone disease.

Nephrolithiasis is a serious problem for both patients and the health system. Recurrence stands out as a significant problem in urinary system stone disease, the prevalence of which is increasing gradually. If recurrence is not prevented, patients may go through recurrent operations due to nephrolithiasis. While classical therapeutic options are available for all stone types, the number of randomized controlled studies and extensive meta-analyses focusing on their efficiency are inadequate. Various alternative therapeutic options to these medical therapies also stand out in recent years. The etiology of urolithiasis is multifactorial and not always related to nutritional factors. Nutrition therapy seems to be useful, either along with pharmacological therapy or as a monotherapy. General nutrition guidelines are useful in promoting public health and developing nutrition plans that reduce the risk or attenuate the effects of diseases affected by nutrition. Nutrition therapy involves the evaluation of a patient's nutritional state and intake, the diagnosis of nutrition risk factors, and the organization and application of a nutrition program. The main target is the reduction or prevention of calculus formation and growth via decreasing lithogenic risk factors and increasing lithogenic inhibitors in urine. This review focuses briefly on classical medical therapy, along with alternative options, related diets, and medical expulsive therapy.

Developments in Neurovascular Diseases and Treatments

Vascular diseases of the cerebral circulation represent a complex and diverse spectrum of pathology. Within the cerebrovascular field, there have been numerous recent advances in patient diagnosis, evaluation, imaging analysis, medical therapies, microsurgical treatments, and minimally invasive therapeutic modalities. These improvements have been driven by research developments from in vitro, in vivo, translational, and clinical studies. We review and add to the primary literature concerning this special issue. Stroke is a major cause of morbidity and mortality. Although intravenous tissue plasminogen activator has been a validated medical therapy in patients with acute ischemic stroke, there are many patients who fail to meet the defined time window for treatment. Neuroprotective agents for acute stroke could provide a major therapeutic advantage for many patients. In this issue, H.-K. Liew et al. demonstrate that “Granulocyte-Colony Stimulating Factor Increases Cerebral Blood Flow via a NO Surge Mediated by Akt/eNOS Pathway to Reduce Ischemic Injury.” Further studies are indicated to better define potential alternative medical therapies in acute ischemic stroke patients. Although earlier randomized clinical trials (RCTs) challenged the use of endovascular therapy in acute cerebrovascular occlusion [1–3], refinements in patient selection and three recent RCTs have validated the benefit of endovascular mechanical thrombectomy, preferably with retrievable stents (i.e., stentrievers), in patients with large vessel occlusion [4, 5]. Limitations of prior RCTs of endovascular stroke intervention included the use of earlier generation thrombectomy devices. In this issue, O. Ozdemir et al. provide us with “Predictors of a Good Outcome after Endovascular Stroke Treatment with Stent Retrievers”. Long-term follow-up in the International Study of Unruptured Intracranial Aneurysms (ISUIA) [6] and the International Subarachnoid Hemorrhage Aneurysm Trial (ISAT) has validated both microsurgical clipping and endovascular coiling in the treatment of ruptured and unruptured aneurysms [7]. As these outcomes are based on patients who were primarily treated during the 1990s, they may be based on antiquated means of patient evaluation and treatment. Recently, there have been many advances in medical therapies, imaging, microsurgical treatment, and endovascular therapies for cerebral aneurysms [8]. In the current issue, N. Ajiboye et al. provide us with an update on “Unruptured Cerebral Aneurysms: Evaluation and Management.” Cerebral vasospasm continues to be a leading cause of morbidity and mortality following aneurysm rupture. Recent RCTs have not provided us with further therapeutic strategies [9]. Perhaps refinements in patient evaluation and selection will improve patient outcomes. S. H. Sheen et al. provide a protocol on “Intravenous Flat-Detector Computed Tomography Angiography for Symptomatic Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage.” These new imaging modalities may yield a less invasive means for the evaluation and treatment of patients with aneurysmal subarachnoid hemorrhage. Recent RCTs and prospective cohort studies have challenged current management strategies for unruptured cerebral arteriovenous malformations (AVMs), but these analyses have not been without limitations [10, 11]. When indicated, current AVM interventions include microsurgery, radiosurgery, and embolization. These therapeutic options are also often used individually or as part of a multimodality approach. In this issue N. Ajiboye et al. provide us with an update through “Cerebral Arteriovenous Malformations: Evaluation and Management.” Additionally, S. Peschillo et al. provide us with a review on treatment options in “Brain AVMs: An Endovascular, Surgical, and Radiosurgical Update.” Neurovascular diseases are a heterogeneous group of disorders that are often associated with poor clinical outcomes. S. Tabuchi provides us with a review on “Auditory Dysfunction in Patients with Cerebrovascular Disease” and A. Y. Lu et al. provide us with an assessment of “Hemifacial Spasm and Neurovascular Compression.” Although the majority of neurovascular diseases are primarily arterial pathologies, cerebral venous diseases may also incur significant morbidity. To round out this issue, we provide an update and review of “Endovascular Treatment of Venous Sinus Stenosis in Idiopathic Intracranial Hypertension: Complications, Neurological Outcomes, and Radiographic Results.” Although cerebrospinal fluid diversion has been a mainstay of treatment in patients with idiopathic intracranial hypertension (IIH) refractory to medical therapy, recent advances in endovascular therapies have provided an effective alternative treatment option. Specifically, venous sinus stenting has been shown to provide durable neurological improvement in IIH patients with venous sinus stenosis and a significant physiologic pressure gradient. Further studies regarding associated complications, neurological outcomes, and radiographic results are necessary. Improvements in clinical evaluation, imaging, and treatment will lead to better outcomes in patients with neurovascular disease. Although there continue to be many advances in neurovascular disease, these options must be carefully assessed and compared to existing modalities to ascertain the best practices for our patients. Within this compilation of studies, we hope to elucidate areas of uncertainty, recent developments, and clinical necessity. Robert M. Starke Stephen J. Monteith Andrew M. Southerland R. Webster Crowley Nohra Chalouhi Dale Ding David M. Hasan Aaron S. Dumont

Establishing the relationship of inhaler satisfaction, treatment adherence, and patient outcomes: a prospective, real-world, cross-sectional survey of US adult asthma patients and physicians

Background Inhaled asthma medications are the mainstay of treatment for chronic asthma. However, nonadherence rates for long-term inhaler therapy among adults are estimated to exceed 50 %. Nonadherence is associated with unfavorable clinical outcomes and diminished quality of life. Research suggests that adherence is associated with patients’ satisfaction with their treatment regimen and other factors, such as concomitant allergic rhinitis and tobacco use.Methods This prospective, cross-sectional survey of physicians and their patients evaluated the relationship between patient satisfaction with attributes of inhaler devices, treatment adherence, and clinical outcomes. Primary care and specialist physicians completed a physician-reported patient record form for patients with a confirmed asthma diagnosis. Patients for whom a physician-reported form was completed were invited to complete a patient-reported form. Both surveys collected information about demographics, symptoms, exacerbation history, treatment, smoking status, comorbidities, type of inhaler device, and treatment adherence. Patients also indicated the degree to which they were satisfied with attributes of their currently prescribed inhaler device(s). Partial least squares path modeling quantified relationships between latent variables and clinical outcomes.Results A total of 243 patients were included in our analysis and 41 % had poorly controlled asthma. More favorable clinical outcomes were significantly associated with greater patient satisfaction with drug delivery (P = 0.002), higher medication adherence (P = 0.049), no history of tobacco use (P < 0.001), and absence of comorbid allergic rhinitis (P = 0.005). Attributes associated with device satisfaction included patient perceptions of consistency in the amount of drug delivery to the lungs, ease of use, and feedback about the number of remaining doses.Conclusions Higher patient satisfaction with their asthma drug delivery inhaler device is a significant predictor of more favorable clinical outcomes while allergic rhinitis and smoking history were negatively associated with optimal control of asthma. These findings provide clinicians with opportunities to improve patients’ clinical outcomes by tailoring choice of inhaler device therapy and providing education about the correct way to use the device to ensure optimal outcomes. Patients will likely benefit from medical therapy to manage comorbid allergic rhinitis and smoking cessation interventions. Patients unable to stop smoking may require alternative medical therapies to improve their clinical outcomes.

Long-term low-dose ketoconazole treatment in bilateral macronodular adrenal hyperplasia.

SummaryMedical therapy for Cushing's syndrome due to bilateral macronodular adrenal hyperplasia (BMAH) is generally administered for a limited time before surgery. Aberrant receptors antagonists show inconsistent efficacy in the long run to prevent adrenalectomy. We present a patient with BMAH, treated for 10 years with low doses of ketoconazole to control cortisol secretion. A 48-year-old woman presented with headaches and hypertension. Investigations showed the following: no clinical signs of Cushing's syndrome; enlarged lobulated adrenals; normal creatinine, potassium, and aldosterone; normal urinary aldosterone and metanephrines; elevated urinary free cortisol and steroid metabolites; and suppressed plasma renin activity and ACTH. A screening protocol for aberrant adrenal receptors failed to show any illegitimate hormone dependence. Ketoconazole caused rapid normalisation of cortisol and ACTH that persists over 10 years on treatment, while adrenals show no change in shape or size. Ketoconazole decreases cortisol in patients with Cushing's syndrome, and may prevent adrenal overgrowth. Steroid secretion in BMAH is inefficient as compared with normal adrenals or secreting tumours and can be controlled with low, well-tolerated doses of ketoconazole, as an alternative to surgery.Learning points Enlarged, macronodular adrenals are often incidentally found during the investigation of hypertension in patients harboring BMAH. Although laboratory findings include low ACTH and elevated cortisol, the majority of patients do not display cushingoid features.Bilateral adrenalectomy, followed by life-long steroid replacement, is the usual treatment of this benign condition, and alternative medical therapy is sought. Therapy based on aberrant adrenal receptors gives disappointing results, and inhibitors of steroidogenesis are not always well tolerated.However, ketoconazole at low, well-tolerated doses appeared appropriate to control adrenal steroid secretion indefinitely, while preventing adrenal overgrowth. This treatment probably constitutes the most convenient long-term alternative to surgery.

Complementary and Alternative Medical Therapies in Multiple Sclerosis–The American Academy of Neurology Guidelines: A Commentary

BackgroundComplementary and alternative medicine (CAM) use in individuals with multiple sclerosis (MS) is common, but its use has been limited by a lack of evidence-based guidance. MethodsIn March 2014, the American Academy of Neurology published the most comprehensive literature review and evidence-based practice guidelines for CAM use in MS. The guideline author panel reviewed and classified articles according to the American Academy of Neurology therapeutic scheme, and recommendations were linked to the evidence strength. FindingsLevel A recommendations were found for oral cannabis extract effectiveness in the short term for spasticity-related symptoms and pain and ineffectiveness of ginkgo biloba for cognitive function improvement in MS. Key level B recommendations included: Oral cannabis extract or a synthetic cannabis constituent, tetrahydrocannabinol (THC) is probably ineffective for objective spasticity improvement in the short term; Nabiximols oromucosal cannabinoid spray is probably effective for spasticity symptoms, pain, and urinary frequency, but probably ineffective for objective spasticity outcomes and bladder incontinence; Magnetic therapy is probably effective for fatigue reduction in MS; A low-fat diet with fish oil supplementation is probably ineffective for MS-related relapses, disability, fatigue, magnetic resonance imaging lesions, and quality of life. Several Level C recommendations were made. These included possible effectiveness of gingko biloba for fatigue; possible effectiveness of reflexology for MS-related paresthesias; possible ineffectiveness of the Cari Loder regimen for MS-related disability, symptoms, depression, and fatigue; and bee sting therapy for MS relapses, disability, fatigue, magnetic resonance imaging outcomes, and health-related quality of life. ImplicationsDespite the availability of studies evaluating the effects of oral cannabis in MS, the use of these formulations in United States may be limited due to a lack of standardized, commercial US Food and Drug Administration–regulated preparations. Additionally, significant concern about prominent central nervous system–related adverse effects with cannabis was emphasized in the review.

Therapeutic targets in subependymoma.

Subependymomas are usually treated with surgical resection; however, no standard, defined alternative medical therapy is recommended for patients who are not surgical candidates, owing to a paucity of molecular, immunological, and genetic characterization. To address this, an ex vivo functional analysis of the immune microenvironment in subependymoma was conducted, a subependymoma cytokine/chemokine microarray was constructed for the evaluation of operational immune and molecular pathways, and a subependymoma cell line was derived and used to test a variety of cytotoxic agents that target operational pathways identified in subependymoma. We found that immune effectors are detectable within the microenvironment of subependymoma; however, marked immune suppression is not observed. The subependymoma tissue microarrays demonstrated tumor expression of p53, MDM2, HIF-1α, topoisomerase II-β, p-STAT3, and nucleolin, but not EGFRvIII, EphA2, IL-13RA2, CMV, CTLA-4, FoxP3, PD-1, PD-L1, EGFR, PDGF-α, PDGF-β, PDGFR-α, PDGFR-β, PTEN, IGFBP2, PI3K, MDM4, IDH1, mTOR, or Jak2. A topoisomerase inhibitor (WP744, IC50=0.83 μM) and a p-STAT3/HIF-1α inhibitor (WP1066, IC50=3.15 μM) demonstrated a growth inhibition of the subependymoma cell proliferation. Cumulatively, these data suggest that those agents that interfere with oncogenes operational in subependymoma may have clinical impact.