An Alternative Approach to Atopic Dermatitis: Part II-Summary of Cases and Discussion

In the first part of this Review, we presented case-series whereKampo treatment was introduced for those atopic dermatitis (AD)patients who had failed with conventional therapy, in an attemptto prove that there exists a definite subgroup of AD patientsfor whom Kampo treatment is effective. In this second part,we will first provide the summary of the results for 140 ADpatients we treated in 2000. The results suggest that Kampotreatment is effective for more than half of AD patients whofail with conventional therapy. In the Discussion, we will examinethe evidential basis for conventional AD therapy and discusshow Kampo treatment should be integrated into the guidelinesfor AD therapy. We contend that Kampo treatment should be triedbefore systematic immunosuppressive agents are considered. Aseach Kampo treatment is highly individualized, it should beregarded more as ‘art’ than technology, and specialcare should be taken to assess its efficacy in clinical trial.     

The Systemic Theory of Living Systems and Relevance to CAM: The Theory (Part II)

This theory stems from observing the universe's ‘omniscient’nature, manifested in flows of energy and information of itslife plethora. A notorious example is the living cell's intelligentnature, which guides its basic goal: to maximize survival. Thislast motivated me to address the living system's intelligence,which constitutes a vital and controversial topic, its relationshipwith ‘incurable’ disease in general, including cancer,and to propose golden rules for therapeutics, as well as a definitionof ideal medicine. The scientific confirmation of these findingsis embedded in discoveries in cybernetics, biological theoryof information and modern thermodynamic concepts, concerningenergy and information exchange, within a living system. Thisapproach's practical application, denominated Systemic Medicine,has been substantiated by treatment and results obtained in>300 000 patients suffering from chronic degenerative diseases.     

Immunology and homeopathy. 5. The rationale of the 'Simile'

The foundation of homeopathic medicine is the ‘SimiliaPrinciple’, also known as the ‘Principle of Similarity’or also as the ‘Simile’, which reflects the inversionof pharmacological effects in healthy subjects as compared withsick ones. This article describes the inversion of effects,a widespread medical phenomenon, through three possible mechanisms:non-linearity of dose–response relationship, differentinitial pathophysiological states of the organism, and pharmacodynamicsof body response to the medicine. Based on the systemic networkswhich play an important role in response to stress, a unitaryand general model is designed: homeopathic medicines could interactwith sensitive (primed) regulation systems through complex information,which simulate the disorders of natural disease. Reorganizationof regulation systems, through a coherent response to the medicine,could pave the way to the healing of the cellular, tissue andneuro-immuno-endocrine homeodynamics. Preliminary evidence issuggesting that even ultra-low doses and high-dilutions of drugsmay incorporate structural or frequency information and interactwith chaotic dynamics and physical-electromagnetic levels ofregulation. From the clinical standpoint, the ‘simile’can be regarded as a heuristic principle, according to whichthe detailed knowledge of pathogenic effects of drugs, associatedwith careful analysis of signs and symptoms of the ill subject,could assist in identifying homeopathic remedies with high gradeof specificity for the individual case.     

Symposium on Pharmacovigilance of Herbal Medicines, London, March 28, 2006

On April 2006, the International Symposium ‘Pharmacovigilanceof Herbal Medicines. Current Status and Future Directions’,was held in London, organized by the Royal Pharmaceutical Societyof Great Britain (RPSGB) in conjunction with the most importantinternational societies involved in the field. The Chairpersonof the Congress was Prof. Joanna Barnes of the School of Pharmacyof the University of Auckland, NZ. Major topics of the conference were: evaluation of main concernsabout correct reports of adverse reactions to herbal extractsand possible future directions in organizing an internationaland affordable signaling system and to build a definitive internationalnetwork on the WHO database. Compelling problems are due to the wide differences that existall over the world in nomenclature, administration, extractionand use of medicinal     

An Overview of Traditional Chinese Herbal Formulae and a Proposal of a New Code System for Expressing the Formula Titles

Traditional Chinese herbal therapy can be characterized by theuse of a large number of multi-herb formulae. To provide modernand Western scientists without knowledge of Chinese literatureand cultural background easy access to information, a databasewith a total of 11 810 traditional Chinese herbal formulae wasconstructed. All the information was then translated into understandablescientific terms in English. While coining the formula titlesin English, we discovered some principles governing the namingof titles by using computer analysis. In addition, we observedthat about 92% of the formulae are in the range of single-herbformulae to thirteen-herb formulae. Most large number-herb formulaeare formulated by combining pre-existing smaller number-herbformulae. The King herbs ()with major therapeutic activity in a multi-herb formula wereidentified by the formulation concept using two parameters:the herbal dose and the herbal drug property (the degree oftoxicity). Based on such analytical data, we established anEnglish code system representing all formula titles writtenin ideographic Chinese characters: an array of important keywords such as ‘Herbal name in Latin + Efficacy (Targetorgans) + Preparation form + Number of herbs.’ By searchingthe English version of the database with any of the above keywords, a variety of information on the status of traditionalChinese herbal therapy can be accessed.     

Myocardial Infarction and Antiphospholipid Antibodies in SLE and Related Disorders

The clinical and serological findings in 13 patients with myocardialinfarction and antiphospholipid antibodies (the ‘lupusanticoagulant’, antibodies to cardiolipin, antibodiesto phosphatidylethanolamine (one patient)) seen by our unitand other units from 1984 to 1989, are presented (eight malesand five females, ages ranging from 20 to 52 years). Five sufferedmyocardial infarction before the age of 30; four of these fivewere in their early 20s. Other risk factors such as excessivesmoking (>> 20 cigarettes a day) (two patients), long-termtreatment with steroid (one) and use of oral contraceptives(one) were present. One patient had demonstrated a plasminogenactivator deficiency and one a deficiency of protein C. Twopatients developed myocardial infarction six to eight weeksafter warfarin was discontinued for recurrent deep vein thrombosis.Six patients had SLE as defined by the revised 1982 criteria,three suffered from ‘lupus-like’ disease, whilefour patients conformed to a ‘primary’ antiphospholipidsyndrome.     

In Vitro Anti-Cytomegalovirus Activity of Kampo (Japanese Herbal) Medicine

We examined the effect of three types of Kampo medicines onhuman cytomegalovirus (CMV) replication in the human embryonicfibroblast cell line, MRC-5. Treatment of cells with at least0.01 µg/ml of Kampo medicines inhibited the cytopathiceffects of CMV-infected MRC-5 cells. Moreover, Kampo medicinedecreased the replication of CMV without affecting the inhibitionof host cells, with a concomitant decrease in CMV DNA levels.However, Kampo medicine demonstrated no virocidal effect oncell-free CMV. Furthermore, western blotting analysis demonstratedthat the Kampo medicine decreased the amount of 65 kDa lateantigen expression in the infected cells. These results suggestthat Kampo medicine may be sufficient to inhibit viral DNA replicationand late protein synthesis, resulting in anti-CMV effects. Therefore,these three Kampo medicines have the potential of being a sourceof new powerful anti-CMV compounds.     

Insulin and C-peptide secretion in non-insulin-dependent diabetes mellitus and its response to dietary therapy

We studied insulin and C-peptide levels in patients with non-insulin-dependentdiabetes mellitus (NIDDM) during standard oral or intravenousglucose tolerance tests (GTT) at the time of diagnosis and after3 months dietary therapy. On the second occasion they also hadan ‘augmented’ GTT, in which slow intravenous infusionof glucose raised basal plasma glucose to a level similar tothat at the time of diagnosis. Eight patients had oral tests,and seven patients intravenous tests. In both groups, dietarytherapy significantly reduced fasting and peak plasma glucose(p<0.05 for oral; p<0.01 for intravenous GTT). Serum insulinlevels during conventional oral GTT were not significantly differentafter dietary therapy compared to diagnosis, but were significantlyhigher during the ‘augmented’ oral GTT (p<0.05).In those patients who underwent intravenous GTT, there was asignificant increase in both the total amount of insulin secreted(0–60 min) and in first-phase insulin secretion (0–10min) during the ‘augmented’ test compared to diagnosis(p<0.01), but first-phase insulin secretion during the conventionalintravenous GTT was unchanged. Serum C-peptide responses werealso greater during ‘augmented’ tests (p<0.05),similar in pattern to serum insulin. There is a relative deficiencyin insulin secretion in untreated NIDDM, which can be reversedby dietary therapy. It is essential to study insulin and C-peptidesecretion in controlled ‘fasting’ glucose conditions.     

Renin Subgroups in Essential Hypertension: an Analysis and Critique

It has been claimed that measurement of renin levels in patientswith essential hypertension enables identifiable subgroups ofpatients to be demarcated and that these subgroups exhibit importantdifferences in prognosis and response to therapy. Accordingly,plasma renin activity (PRA) was measured in 181 patients referredto hospital outpatients for treatment of hypertension. Fifteenof these were excluded from study because of abnormality ofrenal function, an abnormal pyelogram or incidental disease.PRA of the remainder showed a smooth unimodal distribution witha ‘tail’ of high values (17 per cent) which layabove the range of values observed in normotensive subjects.Following seven days treatment with bendrofluazide the percentagerise in PRA was much less than that of age-matched controls.A group of 55 patients (33 per cent) fell below the range encounteredin normotensive matched subjects treated similarly, althoughthe distribution of PRA was still smooth and unimodal. Patientswere divided into ‘high’, ‘normal’ and‘low’ renin subgroups. Whilst there were significantdifferences in age between the high, normal and low renin groups,there were no significant differences in basal blood pressure,response to diuretics or beta blockers. It is concluded thatrenin levels in hypertension are influenced by several factorsand that any attempt to subdivide patients into renin subgroupsis therefore arbitrary. Measurement of renin does not significantlyassist predicting the blood pressure response to either diureticsor beta-blockers combined with diuretics.     

Evaluating complex healthcare systems: a critique of four approaches

The purpose of this paper is to bring clarity to the emergingconceptual and methodological literature that focuses on understandingand evaluating complex or ‘whole’ systems of healthcare.An international working group reviewed literature from interdisciplinaryor interprofessional groups describing approaches to the evaluationof complex systems of healthcare. The following four key approacheswere identified: a framework from the MRC (UK), whole systemsresearch, whole medical systems research described by NCCAM(USA) and a model from NAFKAM (Norway). Main areas of congruenceinclude acknowledgment of the inherent complexity of many healthcareinterventions and the need to find new ways to evaluate these;the need to describe and understand the components of complexinterventions in context (as they are actually practiced); thenecessity of using mixed methods including randomized clinicaltrials (RCTs) (explanatory and pragmatic) and qualitative approaches;the perceived benefits of a multidisciplinary team approachto research; and the understanding that methodological developmentsin this field can be applied to both complementary and alternativemedicine (CAM) as well as conventional therapies. In contrast,the approaches differ in the following ways: terminology used,the extent to which the approach attempts to be applicable toboth CAM and conventional medical interventions; the prioritizationof research questions (in order of what should be done first)especially with respect to how the ‘definitive’RCT fits into the process of assessing complex healthcare systems;and the need for a staged approach. There appears to be a growinginternational understanding of the need for a new perspectiveon assessing complex healthcare systems.     

Intravenous Glucose Tolerance and Mortality in Non-insulin-dependent Diabetes Mellitus

Two hundred and forty-nine patients with non-insulin-dependentdiabetes were entered into a prospective study at diagnosisand examined at presentation and one, three, and five yearslater. Ten years after diagnosis, 34 patients were known tobe dead and 214 alive. A number of factors were significantlyassociated with survival on univariate analysis and appearedto form two independent intra-related groups: a ‘metabolic’group and a ‘degenerative condition’ group. Multivariateanalysis of these two groups showed that glucose tolerance (therate constant K_G for decrease in plasma glucose concentrationafter its intravenous injection) was significantly related tosurvival in the ‘metabolic’ group, and age, bloodpressure and anti-hypertensive therapy were significant in the‘degenerative’ group of factors. A low K_G valuewas more strongly associated with prognosis than any other factor.Values from the one year review were prognostically more usefulthan initial or later values. Indices of insulin secretion weresimilar irrespective of whether patients survived or died, andso we believe the lower K_G values of dead patients were dueto impaired insulin sensitivity. A regression, equation usingthe above factors correctly allocated survival outcome in 81%of subjects.     

ACUTE BARBITURATE POISONING--A REVIEW OF TWO YEARS EXPERIENCE

The results of therapy in 776 patients with acute barbituratepoisoning over a two-year period are studied. The mortalitywas 0.8 per cent. 94.9 per cent. were treated successfully by a régimeof supportive therapy. This routine is described in detail andthe differences from the ‘Scandinavian Method’ arediscussed. Only 5.1 per cent. required measures to enhance removalof the poison. The indications for instituting this therapyare considered in the light of present knowledge and with regardto current practice elsewhere. The results show that the vast majority of these patients canbe managed adequately by supportive treatment and that additionalmeasures should be reserved for very severely poisoned patients.     

Do not disturb

The waiting room was clean and tidy but rather drab, and lackingin any friendly touches like paintings or historical photos.What particularly caught my attention were the notices on thewalls and around the reception desk. ‘Don't consume foodand drink, or chew gum in the waiting room.’ ‘Don'task the doctors for housing letters as we do not issue them.’‘Unused drugs cost the NHS £5.2 billion pounds ayear’ (how does anyone know, I wondered) ‘so don'task for items that you don't really need’. ‘Rememberthat appointment slots are only for ten minutes. Don't compromise     

Exercise and Life-Satisfactory-Fitness: Complementary Strategies in the Prevention and Rehabilitation of Illnesses

Moderate training of an endurance nature, but also other exerciseactivities, not only has a preventive effect on various illnessesand pre-illness states such as the metabolic syndrome and cancer,but is also effective in treating patients in the rehabilitationphase after illness, e.g. cardiovascular or cancer. Our investigationdemonstrates that even low level physical activity has a verygood preventive effect too, which is enhanced when it is accompaniedby mental activity and psychological well-being. In total, weinvestigated 13 000 people on the basis of socio-economic panelpolls with respect to life contentment, health status and leisure-timeactivities. Life contentment is positively linked to contentmentwith labor, which seems to be an essential aspect with regardto the increasing number of unemployed people in Europe. Thesecond important factor is health-promoting activities duringleisure time. Exercise, especially, has a significant influenceon life satisfaction as a feeling of physical fitness feelingis regarded as synonymous with good health. The results underlinethe psycho-neuroimmunological network, which stabilizes ourhealth and shows that different activities in older adults havea significant effect on the aging process and age-related illnesses.Besides the various activities that are important in this arena,namely muscle and mental mobility (‘brawn and brain’),a third component must be taken into consideration: life contentmentin the form of a successful retrospective view and a positiveoutlook, embedded in a psychosocial family environment (‘brood’)and integrated in a stress-free biotope, where life does makesense. Alternative and complementary strategies should be consideredin light of these three aspects when we think about additionalanti-inflammatory strategies in preventing diseases or treatingthem and their relapses. Sport has made a few healthy people ill, but sport has alsomade a good few of ill people healthy! (Gerhard Uhlenbruck,Aphorisms)     

Infection of the Central Nervous System by Listeria monocytogenes: a Review of 54 Adult and Juvenile Cases

The clinical features in 54 juvenile and adult patients withListeria monocytogenes infection of the central nervous systemare described. Thirty-one of the patients had pre-existing chronicdisease; the remainder were previously healthy. Twenty of thepatients, the ‘meningo-encephalitic group’ developedfocal neurological signs. The remaining 34, the ‘meningiticgroup’ exhibited no focal signs other than those causedby increased intracranial pressure. The ‘meningitic group’ differed from the ‘meningo-encephaliticgroup’ in that the cerebro spinal fluid white cell count,protein and glucose levels were markedly more abnormal and theprognosis worse. Evidence of septicaemia was found only in the‘meningitic group’. Meningo-encephalitis may represent a modified response to listerialinfection typified by granulomatous rather than a suppurativeresponse. The predominance of this response that was demonstratedin females may indicate partial immunity, the result of previousListeria monocytogenes colonisation of the female genital tract. Listeria monocyrogenes infection is treatable and should beconsidered in patients with meningitic or encephalitic illness.Repeated blood cultures may be required to establish the diagnosis.     

Beclomethasone Dipropionate Aerosol in Treatment of Chronic Asthma

In a population of 400 patients with chronic asthma treatedwith beclomethasone dipropionate aerosol (BDA) 371 continuedthis treatment for a period of at least one year. Of these 371patients 55 had not previously received any form of corticosteroidtherapy, but the remaining 316 had been on regular systemictreatment with either corticosteroids or corticotrophin forat least six months. A standardized grading of the response to BDA was used to evaluatethe contribution of this form of treatment to the control ofeach patient's asthma. On that basis BDA therapy was eithercompletely effective (Grade 1 response) or fairly effective(Grade 2 response) in 63 per cent of cases, and totally ineffectivein only 10 per cent. BDA was significantly more effective as‘primary’ than as ‘secondary’ treatment,presumably because it was used as ‘primary’ treatmentin less severe cases. Although a slightly better response to BDA therapy was recordedin males, in patients between the ages of 20 and 40, and inthose who had been on regular treatment with systemic corticosteroidsfor less than five years, none of these differences was statisticallysignificant. Factors which had no influence on the responseto treatment included age at onset of asthma, history of otherallergic disorders, atopic status (as determined by cutaneousprick tests) and skin sensitivity to Aspergillus fumigatus.A signifcantly better response to BDA was, however, recordedin those patients who had been receiving a maintenance doseof prednisolone in excess of 10 mg per day than in those ona smaller maintenance dose. After one year of treatment with BDA 288 (78 per cent) of 371patients with chronic asthma were well either without regularsystemic corticosteroid therapy (33 per cent) or with only asmall, and probably harmless maintenance dose of less than 5mg of prednisolone per day. In patients previously on regulartreatment with corticosteroids the introduction of BDA permitteda reduction in the mean maintenance dose of prednisolone from8·5 mg to 3·3 mg per day. Although 6·5 per cent of the 400 patients treated withBDA developed oropharyngeal thrush and 3·2 per cent developedhoarseness, it was necessary to withdraw this treatment in only10 of the 39 patients in whom these side effects were recorded. The results of this study indicate that aerosol corticosteroidtherapy alone or supplemented by systemic corticosteroids ina dose small enough not to cause side effects can control thesymptoms of chronic asthma in more than 75 per cent of patients.The study failed to identlfy any specific factors which couldbe used to predict an individual patient's response to BDA,and this treatment is therefore worth a trial in every caseof chronic asthma.     

The Effect of Antirheumatic Drugs on Circulating Immune Complexes in Rheumatoid Arthritis

The relationship between antirheumatic drug treatment and levelsof circulating immune complexes (¹²⁵I-C1q binding activity)has been investigated in a prospective two-year study of patientswith rheumatoid arthritis using the erythrocyte sedimentationrate (ESR) and serum C-reactive protein concentration as indicesof disease activity. Twenty-eight patients were treated withnon-steroid anti-inflammatory drugs, 14 patients had ‘secondline’ drugs and 13 patients were treated with adrenalcorticosteroids. Serum ¹²⁵I-C1q binding activity did not change during non-steroidanti-inflammatory drug treatment; however, immune complex levelsdid fall during treatment with new (ICI 55,897, sulphasalazine)and established (gold, penicillamine) second line drugs. Serum¹²⁵I-C1q binding activity reflected the response to treatmentshown by serum C-reactive protein and ESR. Serum C-reactive protein concentration and ESR fell with alldoses of adrenal corticosteroids. In contrast, immune complexlevels did not fall when doses of adrenal corticosteroids werebelow 20 mg/day prednisolone. ¹²⁵I-C1q binding activity fellduring high dose adrenal corticosteroid therapy (>40 mg/dayprednisolone; 1 g methylprednisolone infusions). Serial measurements of ¹²⁵I-C1q binding activity correspondto ESR and the serum C-reactive protein concentration in distinguishingbetween anti-inflammatory drugs, which provide symptomatic reliefonly, and second line drugs which may retard disease progression.The fall in circulating immune complex levels during ‘high’dose corticosteroid treatment, but not during ‘low’dose treatment, suggests that corticosteroids have a dose-dependenteffect on the immune system in addition to their anti-inflammatoryproperties.     

An Ethical Argument for Integrated Palliative Care

‘In the midst of life, we are in death’ from TheBook of Common Prayer

The Palliative Care, or comfort care, movement in the USA ison the rise. Currently, palliative services are not integratedin an organized way throughout healthcare. If we accept theargument that palliative care is ethically desirable and thatall patients are entitled to palliative services regardlessof a terminal diagnosis, it follows that it needs to be integratedacross a wide range of healthcare services. Ethical questionsregarding palliative care and well-known ethical frameworksare discussed and an argument is made for integrating palliativehealthcare services throughout the healthcare system and notsimply at the end of life. Complementary and alternative medicine(CAM) therapies are discussed as useful and necessary componentsof palliative care. If we as a society look beyond separatingcures and palliation, we will come closer to incorporating compassionatecare throughout the disease process.     

Why do doctors find some patients difficult to help?

Almost all doctors encounter difficulties in managing some patients.Previous studies have examined the characteristics of such patients:we have additionally studied the reasons why hospital doctorsfind these patients ‘difficult to help’. Three clinics(two medical and one surgical) were studied. The consultantsrated 60 (22%) of 293 attenders as severely or extremely difficultto help. Difficulty was associated with greater patient distress(odds ratio 3.9; 95% Cl 2.0–7.7), less patient satisfaction(2.6; 1.3–5.0) and chronic attendance (5.0; 1.4–17.3).An interview study of 40 ‘difficult’ patients indicatedthat doctors considered psycho-social factors more importantin difficult patients (3.2; 1.3–7.7). Objective differencesbetween the doctor's and the patient's aims for care also occurredmore frequently for difficult patients ( 2.8; 1.1–7.2).Three common types of difficulty were identified; medicallyunexplained symptoms; co-existing social problems; and severeuntreatable illness. A review of the management aims for patientswhom doctors find ‘difficult to help’, combinedwith improved access to psycho-social care, could improve boththe quality and the cost-effectiveness of hospital out-patientservices.     

Worried about your diet?

Fruit is supposed to be enormously important in terms of our(ill-defined) general health. Although no-one knows what fiveportions are, and the data for specific disease risks are few,the public health message to eat fruit and vegetables is clear—ratherlike ‘Go to work on an Egg’ or ‘Drink a Pintof Milk a Day’. But this sceptical view does not concealthe fact that ripe fruits are an important part of the humandiet. The maturation and