Mainstream Medical Research Articles

Congenital myasthenic syndromes: beta adrenergic receptor agonist treatment

Acetylcholinesterase inhibitors, such as pyridostigmine, are the standard symptomatic treatment for myasthenia gravis, and so have naturally been applied to the genetic forms of myasthenia, termed congenital myasthenic syndromes (CMS). Although effective for many CMS in others there was no clear response and in some it was positively harmful. Now, with greater understanding of the mutations and molecular mechanisms underlying CMS, treatments can be tailored for the specific syndrome and depending on diseases severity and patient response this can include utilizing different combinations of the drugs. In CMS, over the last 15-20 years b2-adrenergic receptor agonists have moved from occasional use to a mainstream medication. Many cases show life-transforming improvement both when the b2-adrenergic receptor agonists are used alone or in combination. Here we feature how the identification of DOK7-CMS first highlighted the consistent benefit of b2-adrenergic receptor agonists as medication and how it’s application to many different CMS subtypes evolved. The molecular pathogenic mechanisms for many CMS subtypes are now established and this report will also discuss a hypothetical rationale for which forms of CMS are likely to benefit from the b2-adrenergic receptor agonists.

Cannabis, endometriosis, and a high time?

The article proposing cannabis for the treatment of endometriosis is superficially argued and shows disdain for concerned patient care.1 For the medical profession, the addition of another dangerous drug into the mainstream medication market is a serious consideration. Maybe the authors proposing it is ‘high time’ for wider cannabis use have a warped sense of humour? Maybe they have not read about the psychotic-inducing and detrimental mental health issues associated with cannabis consumption. Or its intoxication with consequent poor short-term decision-making, hindered social coordination and mounting driving errors. Or its demotivation and links to educational drop-out rates, or its habituation, addiction, and cannabis disorder potential. In calling for debate on the pros and cons of medicinal cannabis in gynaecology, even the most myopic protagonists would concede there are dangers in cannabis use as an analgesic. In choosing to focus on the narrow use of cannabis as an analgesic for endometriosis, the authors avoid any perspective. Their ‘considerable’ mention of the demerits of medications to treat endometriosis is fair, but their failure to mention any immediate or long-term side-effects of cannabis is hardly even-handed. As researchers ‘undertaking randomised controlled trials’ they will surely present the drawbacks for readers' consideration? There is not a single word to suggest there may be side-effects of cannabis for treating the pain of endometriosis – let alone any dangers in general gynaecology and obstetrics. Solid pharmaceutical evidence for the use of cannabis in the treatment of endometriosis (or any other gynaecological condition) is lacking and the authors agree it is ‘urgently’ needed. However, they argue that such trials ‘are by no means an essential prerequisite prior to prescription’ - the rationale of this disregard being their replacement ‘by a diversity of approaches that involve analysing the totality of the evidence base.’ Say what? But the evidence base is clear – cannabis is a dangerous drug, so failing to accept the facts when they go against your premise is illogical and unprofessional. Prescribing one analgesic agent rather than another that has no effect on the underlying cause of the pain can only hope to persuade the patient to think she is ‘better’. Homeopathy claims that ‘if you think you are better, then you are better.’ Analgesic roulette is homeopathy and not what endometriosis suffers should be offered.2 Evidence-based medicine rests on three pillars, the best available evidence, clinical expertise, and patient preferences. The evidence produced in favour of cannabis thus far is equivocal and anecdotal. The clinical experience in Australia and New Zealand is minimal and unpublished, with patient preferences only, in the protagonists' words, ‘worthy of continued investigation’. The latest systematic review concludes that interpreting existing studies precludes ‘a definitive statement about cannabis for gynaecologic pain relief’.3 Asking doctors not to ‘wait for higher level evidence’ before prescribing cannabis in gynaecology or obstetrics is speculative at best, but against the principles of good medicine, especially in view of the evidence which is available which demands caution.4 Let us weigh the benefits and harms of any progress in our discipline and then – and then only – act in our patients' best interests.

Predicting intervention use in autistic children: Demographic and autism-specific characteristics.

Autism is a condition that is characterised by social communication difficulties and restrictive and repetitive behaviours or interests. Autism can present in many different ways and various interventions are available. Some interventions are conventional, and they are recommended to be used for children with autism (guideline therapies) or for other disorders such as anxiety or attention-deficit hyperactivity disorder (mainstream therapies or medication), while others are less conventional (other therapies or medication, they are discouraged, unknown or alternative). Little is known about who chooses which intervention. This study found that most autistic children use some kind of intervention. Children who attend special education or have an additional diagnosis (other than autism) tend to receive more therapies, while children with a lower IQ receive fewer therapies. Older children, children with a higher IQ and girls are more likely to use conventional (mainstream or guideline) therapies. Children whose parents have a lower educational level are more likely to have used conventional medication. Whereas, children with more sensory issues (e.g. sensitivity to sound, smell or movement) were more likely to have used unconventional medication. This study found that other autism-related characteristics such as the number of autism symptoms, social skills and repetitive and restrictive behaviours were not related to the interventions used. More treatments focussed on multiple problems should be available for children with autism who have additional difficulties.

Botanical Therapeutics for Parkinson's Disease.

Parkinson's disease (PD) was first formally described by James Parkinson in 1817, but the shaking of limbs was described in the literature of several ancient civilizations, such as ancient Chinese civilization and ancient Indian civilization. Historically, botanical drugs were used as the main source for the treatment of such kind of disorders. In Western countries, plant extracts also occupied an important place in the earlier medications of PD. With the adventure of synthetic drugs, the role of plant-derived drugs in management of PD has been diminished. Nowadays, there is still no cure for PD, dopaminergic (DA) medication is the treatment of choice, which is just designed to ameliorate symptoms of PD, and long-term use of DA medication will result in reduced efficacy and severe adverse reactions. It is necessary to explore new methods for the treatment of PD. Chinese medicine (CM) developed a holistic and unique theoretical system, and botanical drugs are widely used in practice for more than two millennia. Modern pharmacological studies have proved that Chinese herbs have potential therapeutic effects on PD, such as enhancing neurotrophic activity, clearing protein aggregates, regulating neuroinflammation, etc. All the advances provide us with hope for developing CM as a mainstream medication for treating PD.

Functional food red yeast rice (RYR) for metabolic syndrome amelioration: a review on pros and cons.

Red yeast rice (RYR), the fermentation product of mold Monascus purpureus has been an integral part of Oriental food and traditional Chinese medicine, long before the discovery of their medicinal roles. With the identification of bioactive components as polyketide pigments (statins), and unsaturated fatty acids, RYR has gained a nutraceutical status. Hypercholesterolemic effect of this fermented compound has been validated and monacolin K has been recognized as the pivotal component in cholesterol alleviation. Functional similarity with commercial drug lovastatin sans the side effects has catapulted its popularity in other parts of the world as well. Apart from the hypotensive role, ameliorative benefits of RYR as anti-inflammatory, antidiabetic, anticancer and osteogenic agent have emerged, fueling intense research on it. Mechanistic studies have revealed their interaction with functional agents like coenzyme Q10, astaxanthin, vitamin D, folic acid, policosanol, and berberine. On the other hand, concurrence of mycotoxin citrinin and variable content of statin has marred its integration in mainstream medication. In this disputable scenario, evaluation of the scopes and lacunae to overcome seems to contribute to an eminent area of healthcare. Red yeast rice (RYR), the rice-based fermentation product of mold Monascus purpureus is a functional food. Its bioactive component monacolin K acts like synthetic drug lovastatin, without the severe side effects of the latter. RYR has been validated to lower cholesterol, control high blood pressure; confer anti-flammation, hypoglycaemic, anticancer and osteogenic properties. However, dose inconsistency and co-occurrence of toxin citrinin hampers its dietary supplementation prospect. Further research might facilitate development of RYR as a nutraceutical.

Location bias in controlled clinical trials of complementary/alternative therapies

Abstract To systematically investigate location bias of controlled clinical trials in complementary/alternative medicine (CAM). Methods: Literature searches were performed to identify systematic reviews and meta-analyses, which were used to retrieve controlled clinical trials. Trials were categorised by whether they appeared in CAM-journals or mainstream medical (MM)-journals, and by their direction of outcome, methodological quality, and sample size. Results: 351 trials were analysed. A predominence of positive trials was seen in non-impact factor CAM- and MM-journals, 58 / 78 (74%) and 76 / 102 (75%) respectively, and also in low impact factor CAM- and MM-journals. In high impact factor MM-journals there were equal numbers of positive and negative trials, a distribution significantly (P Conclusion: More positive than negative trials of complementary therapies are published, except in high-impact factor MM-journals. In non-impact factor CAM-journals positive studies were of poorer methodological quality than the corresponding negative studies. This was not the case in MM-journals which published on a wider range of therapies, except in those with high impact factors. Thus location of trials in terms of journal type and impact factor should be taken into account when the literature on complementary therapies is being examined.

Why Seek Complementary Medicine? An Observational Study in Homeopathic, Acupunctural, Naturopathic and Mainstream Medical Practice

There is a steady increase in patients seeking complementary medicine (CM). Little is known about Dutch CM patients and the extent in which they differ from those of mainstream health care seekers. 1839 consecutive new patients consulting one of 40 CM physicians completed a questionnaire before entering the consulting room. Resulting CM patient data was compared with that from 2784 mainstream general practice patients. Differences in patient profiles were tested using multilevel regression analysis. CM patients most often appeared to report general complaints. Half of them consulted a CM physician because they were looking for information and advice from a different angle. One fifth had doubts about mainstream healthcare. The CM patients foremost expected to be treated as a person and to get ample time to talk. The profiles of the patients attending the different types of CM physicians did not differ much. Compared to mainstream patients, CM patients more often appeared to be female and higher educated. We conclude that, contrary to expectations, patients do not consult a CM physician for reasons of disappointment with mainstream GP care. CM consulters primarily appear to seek a physician who takes time and who treats their complaints from a holistic viewpoint.

Why Do Patients Choose to Consult Homeopaths

Background: Patients are using homeopathy in increasing numbers and not telling their doctors about it. It is important as family physicians that we understand the reasons why patients choose to consult homeopaths. It is important to know what our patients are looking for that they do not find in Western medicine. This information will provide valuable insights and enable us to engage with our patients in an informed and empathetic way such engagement being vital to maintaining an open relationship and providing the best possible care and advice. Methods: The aim of this study was to understand the reasons why patients choose to consult homeopaths. Eight free-attitude interviews were conducted with purposefully selected patients who consulted a particular homeopath in Gauteng province. The exploratory question was ‘Why do you choose to consult a homeopath?'. The interviews were all conducted in English, transcribed verbatim, and analysed for categories and themes using the ‘cut and paste' method. Member checks were done by verifying the transcribed data with the interviewees by e-mail. Triangulation of the data was done by audio-recording of the interviews, and using transcribed notes and field notes collected during the interviews. Results: All the participants initially consulted a homeopath after their health problems were not solved by mainstream medical treatment. Most were also concerned about the side effects of long-term mainstream medication. Many were frustrated with main-stream consultation or relationship factors, including rushed consultations, being asked too few questions and doctors being too quick to prescribe. Some participants said that doctors had a poor bedside manner, were difficult to talk to, and were judgemental or uncaring. The participants continued to consult homeopaths because they felt that the treatment was effective, natural and did not have side effects. They indicated that homeopathic treatment works with the body and health problems therefore are solved in the long term. This makes homeopathic treatment cheaper, because the same problem does not need to be treated repeatedly. Homeopathic con- sultations were longer, and homeopaths were easier to talk to and formed an equal partnership with them. In addition, problems were managed holistically mind, emotions and body, as well as work and family factors were considered. Homeopaths were considered competent and ethical and knew their limitations. Conclusion: From the reasons given for consulting homeopaths, we, as family physicians, can learn a lot about what patients con- sider important in their consultations and management. Frustration with some aspect of mainstream care has pushed them to look for solutions elsewhere Much of what the patients did not find with doctors but found with homeopaths can be found in the principles of family medicine. It will be important to validate the findings of this study by developing a hypothesis that can be tested using a quantitative paradigm. South African Family Practice Vol. 50 (3) 2008: pp. 69-69c

Dipyridamole Therapy Improves Long-Term Survival After Complete Revascularization in Patients With Impaired Cardiac Function A Propensity Analysis

Although dipyridamole is no longer used as a mainstream medication for coronary artery disease because of the coronary steal phenomenon, recent studies have shown that the elevation of serum adenosine levels caused by dipyridamole improves cardiac function in heart failure patients. In the present study it was investigated whether use of dipyridamole at the time of complete revascularization affects long-term mortality in patients with impaired left ventricular (LV) function. The 1,836 consecutive patients who underwent complete revascularization between 1984 and 1992 were assessed; 254 patients with impaired LV function (ejection fraction < 50%) were enrolled. Cox proportional hazards regression adjusted for baseline covariates and the propensity score were used to compare the risks for mortality between patients who did and did not take dipyridamole. The mean follow-up period was 12 years; 178 patients (70.1%) took dipyridamole and there were 66 (37.1%) all-cause and 22 (12.4%) cardiac deaths in that group. In the multivariate analysis, the dipyridamole group had a lower risk for both all-cause (hazard ratio (HR) 0.54; p = 0.005) and cardiac mortality (HR 0.42; p = 0.010). The use of dipyridamole reduced both all-cause and cardiac mortality in patients with impaired LV function.

Hepatotoxicity of commonly used drugs: nonsteroidal anti-inflammatory drugs, antihypertensives, antidiabetic agents, anticonvulsants, lipid-lowering agents, psychotropic drugs.

Hepatotoxic adverse drug reactions have contributed to the decline of many promising therapies, even among mainstream medication classes (bromfenac and troglitazone are recent examples). The spectrum of nonsteroidal anti-inflammatory drug-related liver toxicity continues to expand, with reports in children, interactive toxicity in persons with hepatitis C, and recognition of the toxicity of both the preferential and selective cyclooxygenase-2 inhibitors. Of the antihypertensive agents, methyldopa is now rarely prescribed and adverse effects are reported infrequently, whereas cases of liver injury associated with the angiotensin receptor and converting enzyme inhibitors are increasingly reported. Of the antidiabetic agents, acarbose, gliclazide, metformin, and human insulin have been implicated in causing liver injury. To date, the newer thiazolidinediones do not appear to share the hepatotoxic potential of troglitazone, although a few reports of acute hepatitis have accrued. Although liver injury has been associated with the "statins," the frequency of such toxicity is lower than that of the background population and the value of biochemical monitoring remains unproved. Newer concepts in anticonvulsant hepatotoxicity have been the recognition of the reactive metabolite syndrome, delineation of the risk factors for valproic acid toxicity, the potential role of carnitine in preventing valproic acid hepatotoxicity, and the toxicity of second-line antiepileptic drugs. Liver injury associated with newer psychotropic agents, particularly the selective serotonin reuptake inhibitors, is also discussed. The focus of the review is the hepatotoxicity of commonly used drugs with particular reference to recent and novel reports of toxicity. Well-known causes of liver injury such as chlorpromazine, phenytoin, and methyldopa are not discussed.

Native American Physician Incorporates Tradition Into Mainstream Medical Care

Native American Physician Incorporates Tradition Into Mainstream Medical Care

Native American Physician Incorporates Tradition Into Mainstream Medical Care

Native American Physician Incorporates Tradition Into Mainstream Medical Care

Location bias in controlled clinical trials of complementary/alternative therapies

To systematically investigate location bias of controlled clinical trials in complementary/alternative medicine (CAM). Methods: Literature searches were performed to identify systematic reviews and meta-analyses, which were used to retrieve controlled clinical trials. Trials were categorised by whether they appeared in CAM-journals or mainstream medical (MM)-journals, and by their direction of outcome, methodological quality, and sample size. Results: 351 trials were analysed. A predominence of positive trials was seen in non-impact factor CAM- and MM-journals, 58 / 78 (74%) and 76 / 102 (75%) respectively, and also in low impact factor CAM- and MM-journals. In high impact factor MM-journals there were equal numbers of positive and negative trials, a distribution significantly (P < 0.05) different from all other journal categories. Quality scores were significantly lower for positive than negative trials in non-impact factor CAM-journals (P < 0.02). A similar trend was seen in low-impact factor CAM journals, but not to a level of significance (P = 0.06). There were no significant differences between quality scores of positive and negative trials published in MM-journals, except for high impact factor journals, in which positive trials had significantly lower scores than negative trials (P = 0.048). There was no difference between positive and negative trials in any category in terms of sample size. Conclusion: More positive than negative trials of complementary therapies are published, except in high-impact factor MM-journals. In non-impact factor CAM-journals positive studies were of poorer methodological quality than the corresponding negative studies. This was not the case in MM-journals which published on a wider range of therapies, except in those with high impact factors. Thus location of trials in terms of journal type and impact factor should be taken into account when the literature on complementary therapies is being examined.

Articles on complementary medicine in the mainstream medical literature: an investigation of MEDLINE, 1966 through 1996.

To investigate the growth of interest, if any, in complementary or alternative medicine by the professional scientific community from the number of MEDLINE-listed and clinical trial-type articles for January 1, 1966, through December 31, 1996. Systematic literature searches of the MEDLINE database, using the expanded terms "alternative medicine," "traditional medicine," "acupuncture," "homeopathy," and "chiropractic," were conducted in January 1998 to evaluate the number of all articles. The number of clinical trial-type articles on the above was obtained by conducting searches for those indexed as 1 or more of the following publication types: clinical trial; clinical trial phase 1, 2, 3, or 4; controlled clinical trial; metaanalysis; randomized controlled trial; and limited to "human" trials only. Articles indexed as alternative medicine formed a small proportion (0.4%) of the total number of MEDLINE-listed articles throughout the period studied. From 1966 through 1996, the total number of articles listed in MEDLINE rose significantly to a peak of 400000 additions per annum in 1996 (r = 0.97; P<.001). By contrast, the number of articles indexed under alternative medicine rose progressively only from 1972 through 1986 and since then has been relatively stable at around 1500 additions per annum. For this period, the proportion of clinical trial-type alternative medicine articles was low (mean, 2.1% per annum) but increased significantly from 1987 through 1996, reaching around 10% of the total in 1996 (r = 0.79; P<.001). Patterns of growth in the number of publications for individual therapies have varied during the period studied, and clinical trial-type articles form only a small part of any increase. Interest in and awareness of complementary medicine among orthodox health care professionals has increased in the past 30 years. The increase in the number and proportion of reports of clinical trials indicates an increasing level of original research activity in complementary medicine and suggests a trend toward an evidence-based approach in this discipline. The cumulative number of clinical trial-type articles is small, however, and more high-quality original research in complementary medicine is required.