Is acupuncture a risk factor for hepatitis? Systematic review of epidemiological studies

OBJECTIVE

Acupuncture has been repeatedly associated with infectious hepatitis. The aim of the present systematic review was therefore to critically evaluate such data from epidemiological investigations.

METHODS

Four independent literature searches were carried out to identify all epidemiological evidence linking acupuncture with hepatitis. All studies were validated by the authors and data extracted according to predefined criteria.

RESULTS

Fifteen investigations fulfilled our inclusion criteria. Most studies originated from Asia. One study included markers to hepatitis A virus, three to hepatitis B virus, and 13 to hepatitis C virus. Five investigations reported associations between acupuncture and seropositivity to hepatitis C virus. In those studies, acupuncture increased the risk only modestly.

CONCLUSION

A modest association between hepatitis C and acupuncture has been reported in some countries. This emphasizes the importance of exclusively using disposable acupuncture needles.

The benefits of Arnica: 16 case reports

Following the publication of a randomised controlled trial of Arnica in hand surgery, a number of reports of apparently beneficial effects of Arnica came to the author's attention. Many of these apparent responses could have been due to other factors including the use of herbal (non-diluted) Arnica, placebo response and natural course of disease.

Avocado-soybean unsaponifiables (ASU) for osteoarthritis - a systematic review

Patients suffering from osteoarthritis (OA) are often tempted to try 'alternative' treatment options. Avocado/soybean unsaponifiables (ASU) have shown some promise for OA. This systematic review is aimed at critically evaluating the data from rigorous clinical trials of ASU. Six databases were searched for randomised, placebo-controlled, double-blind trials of ASU. Four studies could be included. Key data were extracted according to predefined criteria and tabulated as well as discussed in narrative form. The methodological quality of the four studies was high. They included patients with OA of the knee and hip. The dose of ASU was 300 mg/day and one trial also included a group treated with 600 mg/day. Three of the four trials suggested efficacy of ASU for improving the symptoms of OA. The majority of rigorous trial data available to date suggest that ASU is effective for the symptomatic treatment of OA and more research seems warranted. However, the only real long-term trial yielded a largely negative result.

Systematic review: hepatotoxic events associated with herbal medicinal products

BACKGROUND

Large proportions of patients use herbal medicinal products, and encouraging data in terms of effectiveness exist for some of these. One aspect, however, which is still largely under-investigated is the question of potential harm.

AIM

To review the recent evidence on hepatotoxic events associated with the use of herbal medicinal products.

METHODS

Systematic literature searches were performed on Medline, Embase, The Cochrane Library, Amed and Ciscom. To identify additional data, searches were conducted by hand in relevant medical journals and in our own files. The screening and selection of articles and the extraction of data were performed independently by the two authors. There were no restrictions regarding the language of publication. In order to be included articles were required to report data on hepatotoxic events associated with the therapeutic use of herbal medicinal products.

RESULTS

Single medicinal herbs and combination preparations are associated with hepatotoxic events. Clinically, the spectrum ranges from transient elevations of liver enzyme levels to fulminant liver failure and death. In most instances hepatotoxic herbal constituents are believed to be the cause, while others may be due to herb-drug interactions, contamination and/or adulteration.

CONCLUSIONS

A number of herbal medicinal products are associated with serious hepatotoxic events. Incidence figures are largely unknown, and in most cases a causal attribution is not established. The challenge for the future is to systematically research this area, educate all parties involved, and minimize patient risk.

A systematic review of herbal medicinal products for the treatment of menopausal symptoms

OBJECTIVE

Many women have turned to complementary and alternative medicines for relief from their menopausal symptoms. The prevalence of herbal medicinal product use among menopausal women highlights the need for investigation into these interventions. The aim of this study was to evaluate the benefit of herbal medicinal products for the treatment of menopausal symptoms by performing a systematic review of randomized clinical trials.

DESIGN

Literature searches of four computerized databases were done to identify randomized clinical trials of herbal medicinal products for the treatment of menopausal symptoms. Manufacturers of herbal products were contacted, and our own files were also searched. There were no restrictions on the language of publication. Trials were considered if the outcome measures related to the physical or psychological impact of menopause, whether by compendium scores, questionnaires, or women's symptom diaries, excluding studies describing artificially induced menopause. This review was not concerned with biochemical or pathological data.

RESULTS

Eighteen randomized clinical trials that fit our criteria were identified. These studies investigated black cohosh (n = 4), red clover (n = 4), kava (n = 3), dong quai (n = 1), evening primrose oil (n = 1), ginseng (n = 1), and combination products (n = 4). Trial quality was generally good, with 16 of 18 studies scoring 3 or more (maximum 5) on the Jadad Scale.

CONCLUSIONS

There is no convincing evidence for any herbal medical product in the treatment of menopausal symptoms. However, the evidence for black cohosh is promising, albeit limited by the poor methodology of the trials. The studies involving red clover suggest it may be of benefit for more severe menopausal symptoms. There is some evidence for the use of kava, but safety concerns mean this herbal product is not a therapeutic option at present. The evidence is inconclusive for the other herbal medicinal products reviewed.

The safety of massage therapy

OBJECTIVES

After many years out of the limelight, massage therapy is now experiencing a revival. The aim of this systematic review is to evaluate its potential for harm.

METHODS

Computerized literature searches were carried out in four databases. All articles reporting adverse effects of any type of massage therapy were retrieved. Adverse effects relating to massage oil or ice were excluded. No language restrictions were applied. Data were extracted and evaluated according to predefined criteria.

RESULTS

Sixteen case reports of adverse effects and four case series were found. The majority of adverse effects were associated with exotic types of manual massage or massage delivered by laymen, while massage therapists were rarely implicated. The reported adverse events include cerebrovascular accidents, displacement of a ureteral stent, embolization of a kidney, haematoma, leg ulcers, nerve damage, posterior interosseous syndrome, pseudoaneurism, pulmonary embolism, ruptured uterus, strangulation of neck, thyrotoxicosis and various pain syndromes. In the majority of these instances, there can be little doubt about a cause-effect relationship. Serious adverse effects were associated mostly with massage techniques other than 'Swedish' massage.

CONCLUSION

Massage is not entirely risk free. However, serious adverse events are probably true rarities.

Acupuncture Research - the First 10 Years in Exeter

For 10 years, our unit has intensively researched the efficacy and safety of acupuncture. This is a brief summary of our work in this area. Specifically, it deals with the development of a sham needle, with various systematic reviews and prospective studies in the area of safety, and with our clinical trials and systematic reviews on efficacy. We also hope in the future that we will be able to contribute to the understanding of acupuncture as a therapeutic modality.

CAM research funding in the UK: surveys of medical charities in 1999 and 2002

A custom-made questionnaire was sent to all UK medical charities in 1999 and again in 2002. Its primary aim was to assess the commitment of these institutions towards funding research in complementary and alternative medicine (CAM). Sixty-two (1999) and 60 (2002) answers were received corresponding to response rates of 62% and 55%. The total CAM research funds have increased from pound 70,000 in 1999 to pound 412,755 in 2002. In terms of total research budgets, this amounts to 0.05% and 0.31%, respectively. The number of CAM research projects has increased but so has the number of charities who do not fund CAM research. We conclude from these data that CAM research funding by UK medical charities has increased. In relative terms it does, however, remain low and out of proportion to the prevalence of CAM use in the UK.

Chiropractic manipulation for non-spinal pain--a systematic review

AIMS

Chiropractic manipulation is mostly used for spinal problems but, in an increasing number of cases, also for non-spinal conditions. This systematic review is aimed at critically evaluating the evidence for or against the effectiveness of this approach.

METHODS

Five electronic databases were searched for all randomised clinical trials of chiropractic manipulation as a treatment of non-spinal pain. They were evaluated according to standardised criteria.

RESULTS

Eight such studies were identified. They related to the following conditions: fibromyalgia, carpal tunnel syndrome, infantile colic, otitis media, dysmenorrhoea and chronic pelvic pain. Their methodological quality ranged from mostly poor to excellent. Their findings do not demonstrate that chiropractic manipulation is an effective therapy for any of these conditions.

CONCLUSIONS

Only very few randomised clinical trials of chiropractic manipulation as a treatment of non-spinal conditions exist. The claim that this approach is effective for such conditions is not based on data from rigorous clinical trials.

Health food store recommendations: implications for breast cancer patients

BACKGROUND

Many breast cancer patients use complementary and alternative medicine (CAM). We aimed to determine what advice health food store employees present to individuals seeking treatment options for breast cancer.

METHODS

Eight data gatherers asked employees of all retail health food stores in a major Canadian city, what they recommended for a patient with breast cancer. The data gatherers inquired about product safety, potential drug interactions, costs and efficacy. They also enquired about employee training related to the products.

RESULTS

Thirty-four stores were examined. A total of 33 different products were recommended, none of which are supported by sufficient evidence of efficacy. The average cost of the products they recommended was 58.09 dollars (CAD) (minimum 5.28 dollars, median 32.99 dollars, maximum 600 dollars) per month. Twenty-three employees (68%) did not ask whether the patient took prescription medications. Fifteen employees (44%) recommended visiting a healthcare professional (naturopaths (9), physicians (5), nutritionists (1). Three employees (8.8%) discussed potential adverse effects of the products. Eight employees (23.5%) discussed the potential for drug interactions. Two employees (5.9%) suggested a possible cure with the products and one employee (2.9%) suggested discontinuing Tamoxifen. Four employees (11.8%) recommended lifestyle changes and three employees (8.8%) recommended books for further reading on the products.

CONCLUSION

This study draws attention to the heterogeneity of advice provided by natural health food stores to individuals seeking treatments for breast cancer, and the safety and cost implications of some of the products recommended. Physicians should enquire carefully about the use of natural health food products by patients with breast cancer. Regulators need to consider regulations to protect vulnerable patients from incurring significant costs in their purchasing of natural health food products lacking evidence of benefit and of questionable safety.

Multiple n = 1 trials in the identification of responders and non-responders to the cognitive effects of Ginkgo biloba

OBJECTIVE

A pilot study to assess multiple crossover n = 1 trials with verum/placebo discrimination as the outcome measure as a means of identifying responders and non-responders to the acute nootropic effect of Ginkgo biloba (G. biloba) among healthy volunteers.

METHOD

Multiple double-blind, placebo-controlled n = 1 trials with 8 treatments in randomized order and separated by minimum washout periods of 7 days. Treatments were acute 120 mg doses of G. biloba extract (GK501) or undistinguishable placebo. The frequency distribution of correct scores for verum-placebo discrimination was compared with the binomial distribution to identify putative responders, who were then tested for consistency of performance over a further 8 treatments.

RESULTS

The frequency distribution of scores (n = 11) was bimodal and a discontinuity defined 3 putative responders and 2 putative negative responders for re-test. Two of the putative responders again performed at above chance level and the probability of achieving their scores or better by chance was 0.013 and 0.052.

CONCLUSIONS

n = 1 trials with verum/placebo discrimination as outcome are a promising method for exploring response heterogeneity to treatments with a subjective effect. Preliminary evidence suggests that there are responders and non-responders to an acute G. biloba treatment among healthy subjects.

Complementary medicine: where is the evidence?

Herbal medicines have been submitted to systematic reviews more frequently than any other complementary therapy, and it is here where the most positive evidence can be found. There is not much research into potential serious risks of complementary medicine. Possible risks range from the toxicity of herbs to vertebral artery dissection or nerve damage after chiropractic manipulation. Currently the Cochrane Library contains 34 systematic reviews of complementary medicine: 20 of herbal medicines, 7 of acupuncture, 3 of homeopathy, 2 of manual therapies, and 2 of other forms.

Serious psychiatric and neurological adverse effects of herbal medicines -- a systematic review

OBJECTIVE

Psychiatric and neurological patients frequently try herbal medicines often under the assumption that they are safe. The aim of this systematic review was to provide a summary of recent data on severe psychiatric and neurological adverse effects of herbal remedies.

METHOD

Computerized literature searches were carried out to identify all reports of psychiatric and neurological adverse effects associated with herbal medicines. These data were subsequently extracted, validated and summarized in narrative and tabular form.

RESULTS

Numerous case reports comprise a diverse array of adverse events including cerebral arteritis, cerebral oedema, delirium, coma, confusion, encephalopathy, hallucinations, intracerebral haemorrhage, and other types of cerebrovascular accidents, movement disorders, mood disturbances, muscle weakness, paresthesiae and seizures. Several fatalities are on record. They are caused by improper use, toxicity of herbal ingredients, contamination and adulteration of preparations and herb/drug interactions.

CONCLUSION

Herbal medicines can cause serious psychiatric and neurological adverse effects.

Pharmacological effects of Cimicifuga racemosa

Cimicifuga racemosa is widely employed to relieve menopause symptoms for its hormonal-like action. However, recent experimental studies have not found an estrogenic action by this plant. The purpose of this systematic review is to analyse all experimental studies (in vivo and in vitro) performed on C. racemosa to elucidate its mechanism of action. Animal and in vitro experiments on C. racemosa were identified through a computerised literature searches performed on Medline (PubMed), Embase, Amed, CISCOM and Cochrane Library databases. In addition, bibliographies of the articles thus located were scanned for further relevant publications and manufactures of commercial C. racemosa preparations were asked to contribute published and unpublished material. No language restrictions were imposed. A total of 15 animal and 15 in vitro studies on C. racemosa have been found. Their results suggest that C. racemosa possesses a central activity instead of a hormonal effect. Further biological and chemical investigations are required to define its mechanism of action and to identify the compounds responsible of its actions.

St John's wort: a systematic review of adverse effects and drug interactions for the consultation psychiatrist

St. John's wort is an herb commonly used in Europe for decades and more recently the topic of scientific investigation in this country. St. John's wort has been found more effective than placebo and equally as effective as tricyclic antidepressants in the short-term management of mild-to-moderate depression. Comparisons to selective serotonin reuptake inhibitors have provided equivocal data. While it is generally well tolerated in clinical use, there is accumulating evidence of significant interactions with drugs. This evidence-based presentation of the literature includes a brief description of pharmacodynamics and clinical applications, followed by a systematic review of adverse effects, toxicity, and drug interactions.