Alternative, complementary or concurrent health care? A critical analysis of the use of the concept of complementary therapy

In this paper I critically address what is becoming the wholesale adoption of the concept of complementary medicine in researchers' analyses of lay participation in alternative therapies. This paper emerged out of a qualitative study of 21 Canadians who use and/or practice alternative therapies. I found that only seven informants used the term 'complementary' in describing their use of alternative therapies. Of those seven who did, five were alternative practitioners. I discuss the variability of meaning of the concept of 'complementary' and I argue that alternative practitioners have a professional interest in using the concept to avoid seeming in competition with medical professionals and to reduce the likelihood of being labelled 'quacks'. I conclude with a plea for researchers to define their terms in analyses of individuals' use of alternative and/or their dual use of alternative and allopathic health care.

Effect of hydrogen adsorption on the x-ray absorption spectra of small Pt clusters

Hydrogen adsorption on Pt(6)H(n) clusters leads to striking changes in the Pt L(2,3) x-ray absorption spectra. These effects are interpreted using a self-consistent real space Green's function approach. Calculations show that they are due largely to changes in the atomic background contribution to x-ray absorption (i.e., atomic x-ray absorption fine structure) and to reduced Pt-Pt scattering at the edge, while Pt-H multiple scattering is relatively weak. The origin of both effects is traced to the change in the local Pt potential due to Pt-H bonding.

Trisomy 12 mosaicism confirmed in multiple organs from a liveborn child

This patient, in whom trisomy 12 mosaicism was confirmed in multiple organs, is the fifth case diagnosed postnatally and the first reported for whom a meiotic origin of the trisomy, maternal meiosis I, was determined. Mosaic aneuploidy was suspected because of pigmentary dysplasia, a frequent but non-specific finding in chromosomal mosaicism. The severe phenotype of this child, who died in infancy with a complex heart malformation, was probably a result of the high percentage of trisomic cells. Cytogenetic and interphase fluorescent in situ hybridization analyses showed a highly variable distribution of aneuploid cells in the nine tissues studied, from none in blood and ovary to 100% in spleen and liver. The trisomy arose meiotically with apparent post-zygotic loss of one of the chromosomes 12; uniparental disomy for this chromosome in the diploid cell line was excluded. The phenotype of the cases reported in living or liveborn individuals has been extremely variable, ranging from the present case, in which the child died in infancy with multiple malformations and pigmentary dysplasia, to a fortuitous finding in an adult studied for infertility. The variation in severity is probably determined by the proportion and distribution of the trisomic cells, which is linked to the timing of the non-disjunctional error.

Single-versus multiple-dose antibiotics prophylaxis for cardiac surgery

BACKGROUND

This study was carried out to determine if single-dose antimicrobial prophylaxis is sufficient for cardiac surgery.

METHODS

The study was a prospective non-randomized trial of 353 consecutive patients undergoing cardiac surgery. Group A (n = 151) received 48 h of prophylaxis and Group B (n = 202) received a single dose. Cephazolin was used in all patients except those at high risk from methicillin-resistant Staphylococcus aureus (MRSA) who received teicoplanin and timentin.

RESULTS

There was an overall in-hospital infection rate of 2.8%. There was no significant difference in rate or type of infection between the two groups.

CONCLUSIONS

An in-hospital infection rate of 2.8% compares favourably with other reported series. Single-dose antimicrobial prophylaxis is as effective as a 48-h regimen. Targeting high-risk groups is effective.

Analgesic effects of botulinum toxin A: a randomized, placebo-controlled clinical trial

Postoperative pain in children with spastic cerebral palsy (CP) is often attributed to muscle spasm and is difficult to manage using opiates and benzodiazepines. Adductor-release surgery to treat or prevent hip dislocation in children with spastic CP is frequently performed and is often accompanied by severe postoperative pain and spasm. A double-blinded, randomized, placebo-controlled clinical trial of 16 patients (mean age 4.7 years) with a mainly spastic type of CP (either diplegic or quadriplegic in distribution) was used to test the hypothesis that a significant proportion of postoperative pain is secondary to muscle spasm and, therefore, might be reduced by a preoperative chemodenervation of the target surgical muscle by intramuscular injection of botulinum toxin A (BTX/A). Compared with the placebo, BTX/A was found to be associated with a reduction in mean pain scores of 74% (P<0.003), a reduction in mean analgesic requirements of approximately 50% (P<0.005), and a reduction in mean length of hospital admission of 33% (P<0.003). It was concluded that an important component of postoperative pain in the patient population is due to muscle spasm and this can be managed effectively by preoperative injection with BTX/A. These findings may have implications for the management of pain secondary to muscle spasm in other clinical settings.

Anaesthesia and pain management in cerebral palsy

Cerebral palsy is the result of an injury to the developing brain during the antenatal, perinatal or postnatal period. Clinical manifestations relate to the area affected. Some of the conditions associated with cerebral palsy require surgical intervention. Problems during the peri-operative period may include hypothermia, nausea and vomiting and muscle spasm. Peri-operative seizure control, respiratory function and gastro-oesophageal reflux also require consideration. Intellectual disability is common and, in those affected, may range from mild to severe. These children should be handled with sensitivity as communication disorders and sensory deficits may mask mild or normal intellect. They should be accompanied by their carers at induction and in the recovery room as they usually know how best to communicate with them. Postoperative pain management and the prevention of muscle spasm is important and some of the drugs used in the management of spasm such as baclofen and botulinum toxin are discussed. Epidural analgesia is particularly valuable when major orthopaedic procedures are performed.

Acetabular fractures. Clinical outcome of surgical treatment

Sixty patients with acetabular fractures were treated surgically. All fractures were a result of high energy trauma, most with significant associated injuries. Fifty-three of the patients were followed up for at least 2 years. Clinical outcome was analyzed clinically using the Harris hip score and radiographically. In 41 (77.4%) of the patients, the surgical procedure was judged successful (Harris hip score greater than 80 points). Three factors were found to be statistically significant predictors of such an outcome: patient age younger than 40 years; simple fractures based on the classification of Letournel and Judet; and absence of damage to the femoral head. Possible influential factors that were not found to be statistically significant in this population included additional injuries, immediate complications, quality of reduction, heterotopic ossification, ipsilateral femoral fracture, and sciatic nerve damage. Open reduction and internal fixation of the displaced acetabular fracture, although a demanding procedure, can result in a satisfactory clinical outcome given a consistent approach with a dedicated team.

Unpacking the black box of therapy -- a pilot study to describe occupational therapy and physiotherapy interventions for people with stroke

OBJECTIVE

To describe the components used in the practice of occupational therapy and physiotherapy for people with stroke and to examine variability between services.

DESIGN

A time-sampling strategy in which therapists recorded their face-to-face interventions with stroke patients during 12 weeks over a total of 17 months.

SETTINGS AND SUBJECTS

Six occupational therapists and seven physiotherapists from four services (three day hospitals and one domiciliary stroke rehabilitation service) recorded interventions with 89 stroke patients recruited to a larger randomized controlled trial.

MAIN OUTCOME MEASURES

Frequencies of use of interventions, together with other details about delivery of therapy, were recorded using a data collection booklet and coding system designed by the participating therapists.

RESULTS

The median treatment time for a session was 45 minutes. The most frequently recorded components of physiotherapy intervention were 'walking', 'standing balance' and 'upper limb movement pattern', and of occupational therapy 'physical function', 'social and leisure activities' and 'other'. There was variability between the services in terms of median treatment time, use of intervention codes, frequency of treatment sessions, amount of time spent working with assistance and amount of group work.

CONCLUSIONS

The findings support the view that occupational therapy and physiotherapy with people with stroke are not homogeneous activities, and vary between therapists and services. Recommendations include further development of the tool, and use of other methodologies to explore the process and nature of stroke rehabilitation.

Fertility and ovarian function after conservative surgery for germ cell tumours of the ovary

Malignant ovarian germ cell tumours (MOGCT) principally occur in girls and young women and are generally unilateral. Effective combination chemotherapy with conservative surgery has seen a dramatic improvement in survival rates. This increase has shifted the focus to long-term fertility and reproductive outcome. The present study describes 45 patients with MOGCT treated with conservative surgery to preserve fertility, with or without the addition of chemotherapy. The age range was 10 to 32 years with a mean of 20 years. The majority of the subjects had Stage 1 tumours; 44 underwent unilateral salpingo-oophorectomy and 1 patient ovarian cystectomy. Adjuvant chemotherapy was administered in 29 patients. Overall mean follow-up was 58.7 months. There were 4 recurrences and 2 deaths. Survival of those with Stage 1 disease was 97% and for advanced stages 87%. During chemotherapy 50% became amenorrhoeic but 96% resumed normal menstrual function on completion. Seven healthy babies were recorded in the chemotherapy group and no documented birth defects occurred in any of these. There was no case of persistent infertility; 3 patients experienced temporary problems. It is concluded that conservative fertility-sparing surgery is the treatment of choice in these young women and advanced disease is not necessarily a contraindication. The majority can anticipate normal menstrual function and fertility.

The concept of hardiness: persistent problems, persistent appeal

Despite increased critical debate, the concept of hardiness continues to be a popular focus of research, and little has changed in how hardiness is defined, measured, and applied. The article argues that the concept of hardiness remains inherently problematic. In particular, hardiness is plagued by definitional problems, problems of construct validity, measurement problems, and class, gender, and age bias. The persistent appeal of the hardiness construct lies partially in researchers' desire to discover why some people are able to withstand the health-damaging effects of stress. More important, the article argues that hardiness is appealing because it continues to be easier to focus on individual problems and solutions rather than look for and try to change the social factors that affect health status and well-being.

Erythrocyte sedimentation rate studies in whole human blood

Precise measurements have been made of the rate of sedimentation of whole blood in which the concentrations of red blood cells and the plasma proteins have been systematically varied. The contribution of each factor to the sedimentation process is expressed in terms of three parameters that describe the sedimentation curve: the set-up time, and the slopes of the first and second phases of settling. This analysis affords delineation between the onset and the degree of aggregation of the red blood cells as contributors to the usual ESR value, the height of plasma in a 200 nm blood column after 60 min. In terms of the 60 min ESR value, an increase in the haematocrit or albumin concentration inhibits sedimentation, the latter only slightly, whereas an increase in the concentration of globulin or fibrinogen accelerates sedimentation, with fibrinogen showing the more marked effect.

Inhibition of red cell aggregation prevents spontaneous echocardiographic contrast formation in human blood

BACKGROUND

Spontaneous echocardiographic contrast (SEC) is a pattern of blood echogenicity that has been attributed to ultrasonic backscatter from blood cell aggregates that form under low shear conditions. Patients with left atrial SEC have an increased thromboembolic risk. This study examined the role of red cell and platelet aggregates in the pathogenesis of SEC in human blood and the effects on SEC of antithrombotic therapy and red cell disaggregatory agents.

METHODS AND RESULTS

Blood echogenicity was examined with the use of quantitative videodensitometry over a controlled range of flow velocities in an in vitro model characterized by nonlaminar flow conditions. One hundred ninety study samples were prepared from single fresh blood donations (40 to 120 mL) from 24 healthy volunteers and 11 patients. Whole blood echogenicity was unaltered by depletion of platelets, stimulation of platelet aggregation with adenosine diphosphate, or inhibition of platelet aggregation with aspirin. Low flow-related echogenicity increased with increasing hematocrit (P<.001) but was abolished when red cells were lysed selectively with saponin (P<.001). In the presence of red cells, low flow-related echogenicity increased with increasing fibrinogen concentration (P<.001) and with plasma paraproteins. Low flow-related echogenicity in whole blood was unaltered by heparin and warfarin but was reduced in a dose-dependent manner by dextran 40 (40 mg/mL, 70% reduction, P<.001) and poloxamer 188 (8 mg/mL, 47% reduction, P<.001), which inhibited red cell aggregation.

CONCLUSIONS

These results support protein-mediated red cell aggregation as the mechanism of SEC in human blood. Inhibition of red cell aggregation, indexed by resolution of SEC, may provide an alternative to anticoagulant and antiplatelet therapy to reduce cardiac thromboembolic risk.

The concept of hardiness: a brief but critical commentary

This paper is a brief critique of the concept of hardiness. While the concept is appealing in its potential to elucidate the relationships between stress, health and illness, I argue that there are problems with how the concept is defined, measured and applied. In particular, the usefulness of the concept is diminished through class and gender bias.

An automated high capacity data capture and analysis system for the in vitro assessment of leukocyte adhesion under shear-stress conditions

Parallel-plate flow chambers have been used to model the vascular microcirculation and study the in vitro dynamic adhesive interactions of leukocytes and human umbilical vein endothelial cells (HUVECs). We describe here a high capacity system which can simultaneously monitor the adhesive interaction of neutrophils and HUVECs in ten flow chambers. Automated data collection was achieved with an image analyzer controlling the autostage and autofocus attachments of an inverted microscope. Images from the flow chambers were captured via phase-contrast microscopy using a video camera and laser videodisk recorder. The images were downloaded off-line into an image analyzer for automated counting of rolling and adherent cells. Neutrophils were detected by their "phase bright' characteristics. An automated optimization procedure allowed the computer to choose the best setting for the selective detection of neutrophils. In addition, a method which utilized image averaging was used to distinguish between rolling and adherent cells. A comparison of the results obtained from the manual and automated counting methods revealed linear relationships for the counting of both adherent (r = 0.98) and rolling cells (r = 0.96) with counting efficiencies of 59% and 46%, respectively. The utility of the system was demonstrated by its ability to measure the adhesive interaction between neutrophils and HUVEC in response to stimulus such as interleukin-1 alpha (IL-1 alpha), histamine, or formyl-1-methionyl-1-leucyl-1-phenylalanine (fMLP). In conclusion, we have developed an automated assay which combines the capacity of ten flow chambers with a computerized data analysis system; the result is an efficient and reproducible assay which minimizes operator associated errors and biological variability.

Anti-invasion drugs

Most of the pharmaceuticals in clinical practice today for treatment of breast and other cancers are cytotoxic or cytostatic inhibitors of tumor growth. While this type of drug has found its place, along with surgery and radiotherapy, in treatment of disease, the breast cancer death rate has not decreased. This appears to be the result of rising incidence, resistance to therapy, and metastasis of the disease. Since distant metastasis (usually indicated by lymph node involvement) of breast cancer is related only indirectly to tumor size, it would appear that a concerted effort should be made to discover drugs which directly interfere with this complex process. Metastasis appears to depend upon tumor cell motility, dedifferentiation, local invasion, and angiogenesis. Significant progress has been recently made in the creation of new animal models of metastasis and in identifying several new drugs which may be suitable for clinical inhibition of this process. This article reviews current findings on anti-invasion/metastasis drugs with a focus on breast cancer.

Phase I trial of a novel matrix metalloproteinase inhibitor batimastat (BB-94) in patients with advanced cancer

Degradation of basement membrane and extracellular matrix by matrix metalloproteinases (MMPs) is believed to be required for tumor invasion, tumor-induced angiogenesis and vascular invasion. A synthetic hydroxamate, batimastat (also known as BB-94), inhibits MMPs by binding the zinc ion in the active site of the MMP. Batimastat inhibits at least 50% of MMP activity at concentrations less than or equal to 10 ng/ml in vitro. Batimastat retarded ascites accumulation and increased survival in mice with human ovarian tumor xenografts. Acute and long-term toxicological studies revealed no major toxicity in animals. Batimastat is poorly soluble and was administered intraperitoneally (i.p.) as a suspension. Previous studies in patients with malignant ascites have shown no major toxicities at doses as high as 1350 mg/m2.