A randomized, controlled clinical trial of the homeopathic medication TRAUMEEL S in the treatment of chemotherapy-induced stomatitis in children undergoing stem cell transplantation

A Pilot, Randomized, Double-Blinded, Placebo-Controlled Trial of Individualized Homeopathy for Symptoms of Estrogen Withdrawal in Breast-Cancer Survivors

OBJECTIVE

To pilot an investigation of individualized homeopathy for symptoms of estrogen withdrawal in breast cancer survivors.

DESIGN

Randomized, double-blinded, placebo-controlled trial.

SETTING

Outpatient department of a National Health Service (NHS) homeopathic hospital.

PARTICIPANTS

Fifty-seven (57) women met inclusion criteria and 53 were randomized to the study.

INTERVENTION

After 2 weeks of baseline assessment, all participants received a consultation plus either oral homeopathic medicine or placebo, assessed every 4 weeks for 16 weeks.

OUTCOME MEASURES

The primary outcome measures were the activity score and profile score of the Measure Yourself Medical Outcome Profile (MYMOP).

RESULTS

Eighty-five percent (85%) (45/53) of women completed the study. There was no evidence of a difference seen between groups for either activity (adjusted difference =-0.4, 95% confidence interval CI -1.0 to 0.2, p = 0.17) or profile scores (adjusted difference = -0.4, 95% CI -0.9 to 0.1, p = 0.13) using this trial design, although post hoc power calculations suggests that 65-175 would be needed per group to detect differences of this magnitude with sufficient precision. Clinically relevant improvements in symptoms and mood disturbance were seen for both groups over the study period.

CONCLUSION

Improvements were seen for symptom scores over the study period. However, presuming these improvements were caused by the individualized homeopathic approach, the study failed to show clearly that the specific effect of the remedy added further to the nonspecific effects of the consultation. Future trial design must ensure adequate power to account for the nonspecific impact of such complex individualized interventions while pragmatic designs may more readily answer questions of clinical and cost effectiveness.

A Randomised, Double-Blind, Parallel, Placebo-Controlled Study to??Evaluate the Efficacy of MF 5232 (Mucotrol???), a Concentrated Oral Gel??Wafer, in the Treatment of Oral Mucositis

OBJECTIVE

Oral mucositis is a major complication of cytotoxic chemotherapy and radiotherapy associated with significant morbidity, pain, odynophagia, dysgeusia and subsequent dehydration and malnutrition, and effective prophylaxis and/or treatment of this condition is essential. The currently available palliative treatment shows improvement only in patients with mild to moderate mucositis. The primary aim of this study was to compare the clinical efficacy of MF 5232 (Mucotrol), a concentrated oral polyherbal gel wafer formulation, with placebo in the management of chemoradiation-induced mucositis in cancer patients.

PATIENTS AND DESIGN

In this randomised, double-blind, pilot study a total of 30 patients of either sex with chemoradiation-induced oral mucositis were randomised to receive MF 5232 (n = 15) or a matching placebo (n = 15) after food three times a day for 7-10 days. Patients were evaluated using validated and standardised scoring systems at baseline and after 7-10 days of treatment.

RESULTS

There were 11 evaluable patients in each treatment group. There was a significant reduction in mean mucositis scores with MF 5232 as follows: WHO (from 3.0 to 1.8), Radiation Therapy Oncology Group (gross score: from 2.8 to 1.8; functional score: from 2.9 to 1.0), and Objective Scoring System (ulceration score: from 7.4 to 4.4; erythema score: from 13.7 to 7.0). There were no significant changes in scores for placebo recipients. The treatments were well tolerated, with the exception of two patients in the treatment group who reported a burning sensation in the mouth after dissolving the wafer.

CONCLUSION

This pilot study provided positive evidence for the efficacy of MF 5232 therapy in chemoradiation-induced mucositis. This was probably a result of its local analgesic, antioxidant and immunomodulatory activity and wound-healing properties. Further in-depth analysis in a larger number of patients is required to confirm these positive results.

Chemotherapy-induced and/or radiation therapy-induced oral mucositis--complicating the treatment of cancer

The term mucositis is coined to describe the adverse effects of radiation and chemotherapy treatments. Mucositis is one of the most common adverse reactions encountered in radiation therapy for head and neck cancers, as well as in chemotherapy, in particular with drugs affecting DNA synthesis (S-phase-specific agents such as fluorouracil, methotrexate, and cytarabine). Mucositis may limit the patient's ability to tolerate chemotherapy or radiation therapy, and nutritional status is compromised. It may drastically affect cancer treatment as well as the patient's quality of life. The incidence and severity of mucositis will vary from patient to patient. It will also vary from treatment to treatment. It is estimated that there is 40% incidence of mucositis in patients treated with standard chemotherapy and this will not only increase with the number of treatment cycles but also with previous episodes. Similarly, patients who undergo bone marrow transplantation and who receive high doses of chemotherapy have a 76% chance of getting mucositis. Patients receiving radiation, in particular to head and neck cancers, have a 30% to 60% chance. The exact pathophysiology of development is not known, but it is thought to be divided into direct and indirect mucositis. Chemotherapy and/or radiation therapy will interfere with the normal turnover of epithelial, cells leading to mucosal injury; subsequently, it can also occur due to indirect invasion of Gram-negative bacteria and fungal species because most of the cancer drugs will cause changes in blood counts. With the advancement in cytology, a more precise mechanism has been established. With this understanding, we can select and target particular mediators responsible for the mucositis. Risk factors such as age, nutritional status, type of malignancy, and oral care during treatment will play important roles in the development of mucositis. Many treatment options are available to prevent and treat this condition, but none of them can completely prevent or treat mucositis. More and more pathological methods are being developed to understand this condition so that better therapeutic regimens can be selected. Emphasis also should be made in assessing the patient's psychologic condition, particular depressive disorders. This is important because treatment with antidepressants will not only contribute in lifting depression but also reduces pain somatization. Although mucositis is rarely life-threatening, it will interfere with treatment of cancer to a great extent.

Complementary and alternative medical therapies for children with cancer

Complementary and alternative medical therapies (CAM) are treatments that generally fall outside of the mainstream of conventional medicine. CAM therapies are used by 31-84% of children with cancer, including many children enrolled on clinical trials. CAM therapies are often used for the treatment of side-effects of cancer or cancer therapy, and only rarely as an alternative to conventional therapy. Regulation of CAM therapies varies worldwide, and many therapies have not been subject to scientifically conducted analyses. Adverse events have been described, especially from the contamination of herbs. Only rare reports of interactions of CAM therapies with conventional anticancer treatments have been reported. Several research studies of CAM in children with cancer are underway. In the interim, non-pharmacological therapies such as mind-body medicine, manipulative and body-based therapies and energy therapies may be used for supportive therapy. Research is needed before biologically based CAM therapies may be recommended in conjunction with conventional therapy.

Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis

BACKGROUND

Oral and gastrointestinal (GI) mucositis can affect up to 100% of patients undergoing high-dose chemotherapy and hematopoietic stem cell transplantation, 80% of patients with malignancies of the head and neck receiving radiotherapy, and a wide range of patients receiving chemotherapy. Alimentary track mucositis increases mortality and morbidity and contributes to rising health care costs. Consequently, the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology assembled an expert panel to evaluate the literature and to create evidence-based guidelines for preventing, evaluating, and treating mucositis.

METHODS

Thirty-six panelists reviewed literature published between January 1966 and May 2002. An initial meeting in January 2002 produced a preliminary draft of guidelines that was reviewed at a second meeting the same year. Thereafter, a writing committee produced a report on mucositis pathogenesis, epidemiology, and scoring (also included in this issue), as well as clinical practice guidelines.

RESULTS

Panelists created recommendations from higher levels of evidence and suggestions when evidence was of a lower level and there was a consensus regarding the interpretation of the evidence by the panel. Panelists identified gaps in evidence that made it impossible to recommend or not recommend use of specific agents.

CONCLUSIONS

Oral/GI mucositis is a common side effect of many anticancer therapies. Evidence-based clinical practice guidelines are presented as a benchmark for clinicians to use for routine care of appropriate patients and as a springboard to challenge clinical investigators to conduct high-quality trials geared toward areas in which data are either lacking or conflicting.

Approaching Complementary and Alternative Medicine Use in Patients With Cancer

Complementary and alternative medicine (CAM) is becoming a significant factor in the arena of cancer care. There is an increasing body of research along with widespread popularity and use by patients with cancer. This article reviews current knowledge about the worldwide use of CAM in the treatment of cancer and patients' motives and reasoning for this use. Clinical research in CAM cancer treatments and physicians' attitudes toward this popular trend among patients with cancer are discussed as well. The physician-patient communication and its relevance to CAM use is emphasized. A step approach is suggested for primary care physicians including the discussion of CAM in the management of cancer in order to enrich the physician-patient dialogue and improve the quality of the clinical encounter.

An approach for integrating complementary-alternative medicine into primary care

BACKGROUND

Despite family practitioners frequently being requested to assist their patients with advice on or referrals to complementary-alternative medicine (CAM), there is an absence both of evidence about the efficacy of nearly all specific treatments or modalities and of guidelines to assist with the integration of conventional and CAM therapies.

OBJECTIVE

The aim of this article is to suggest a comprehensive and rational, best-evidence strategy for integrating CAM by primary care practitioners into primary care, within the context of the limitations of the current knowledge base and the local milieu.

METHODS

The suggested approach was developed by a combination of literature review, key informant interviews, focus groups, educational presentations for family practice residents and practitioners, and field testing. An iterative model was utilized whereby more refined drafts of the suggested approach were subjected to later discussants and groups, as well as further field testing. Drafts of the strategy were utilized in consultations of patients requesting advice on alternative medicine in a primary care setting and in a CAM clinic.

RESULTS

Both family physicians and CAM practitioners provided useful comments and recommendations throughout the process. These can be categorized in terms of knowledge, attitudes and skills. Our strategy suggests that patients requesting advice on the use and integration of CAM modalities as part of their health care should be evaluated initially by their primary care physician. The physician's responsibilities are to evaluate the appropriateness of that use, and to maintain contact, monitoring outcomes. Advice on referrals should be based on the safety of the method in question, current knowledge on indications and contraindications of that modality, and familiarity and an open dialogue with the specific therapist.

CONCLUSIONS

Given patients' demands and utilization of CAM therapies, despite the lack of evidence, there is an increasing need to address how CAM therapies can be integrated into conventional medical systems. These suggestions should respond to patient's expectations and needs, but at the same time maintain accepted standards of medical and scientific principles of practice.

The research evidence base for homeopathy: a fresh assessment of the literature

BACKGROUND

The claims made for the clinical effects of homeopathy are controversial. The results of several meta-analyses of clinical trials are positive, but they fail in general to highlight specific medical conditions that respond well to homeopathy.

AIMS

This review examines the cumulative research from randomised and/or double-blind clinical trials (RCTs) in homeopathy for individual medical conditions reported since 1975, and asks the question: What is the weight of the original evidence from published RCTs that homeopathy has an effect that is statistically significantly different from that in a comparative group?

METHOD

Analysis of the 93 substantive RCTs that compare homeopathy either with placebo or another treatment.

RESULTS

50 papers report a significant benefit of homeopathy in at least one clinical outcome measure, 41 that fail to discern any inter-group differences, and two that describe an inferior response with homeopathy. Considering the relative number of research articles on the 35 different medical conditions in which such research has been carried out, the weight of evidence currently favours a positive treatment effect in eight: childhood diarrhoea, fibrositis, hayfever, influenza, pain (miscellaneous), side-effects of radio- or chemotherapy, sprains and upper respiratory tract infection. Based on published research to date, it seems unlikely that homeopathy is efficacious for headache, stroke or warts. Insufficient research prevents conclusions from being drawn about any other medical conditions.

CONCLUSIONS

The available research evidence emphasises the need for much more and better-directed research in homeopathy. A fresh agenda of enquiry should consider beyond (but include) the placebo-controlled trial. Each study should adopt research methods and outcome measurements linked to a question addressing the clinical significance of homeopathy's effects.

Patient approach and experience regarding complementary medicine: survey among hospitalized patients in a university hospital

PURPOSE

To characterize the local population that turns to complementary medicine.

METHODS

Participants were selected randomly: Medicine [A] (201 patients); Surgery [B] (100 patients); Control [C] (128 patients). The answers to the first two questions determined whether the questionnaire was to be completed.

RESULTS

More females sought complementary medicine treatment, with no significant demographic differences among the groups. Nearly 20% of the subjects had academic education while 43% had completed high school. The results of the 16 significant questions were statistically different when comparing groups C and A (p = 0.025) and B (p = 0.011) respectively. A total of 16%, 12.4% and 9% of the subjects respectively preferred a physician MD as their complementary medicine practitioner and 49% [C], 34% [A] and 29% [B] respectively, favored teaching complementary medicine in medical and nursing schools.

CONCLUSIONS

A total of 37% [C], 21% [B] and 27% [A] of the subjects experienced complementary medicine intervention at least once. The percentage of individuals holding academic degrees was higher in the group utilizing complementary medicine than those who did not. Only 21% of C and A groups and 12% of B group knew about adverse reactions to complementary therapies. More than 30% favored 'legalizing' complementary medicine.

A systematic review of systematic reviews of homeopathy

Homeopathy remains one of the most controversial subjects in therapeutics. This article is an attempt to clarify its effectiveness based on recent systematic reviews. Electronic databases were searched for systematic reviews/meta-analysis on the subject. Seventeen articles fulfilled the inclusion/exclusion criteria. Six of them related to re-analyses of one landmark meta-analysis. Collectively they implied that the overall positive result of this meta-analysis is not supported by a critical analysis of the data. Eleven independent systematic reviews were located. Collectively they failed to provide strong evidence in favour of homeopathy. In particular, there was no condition which responds convincingly better to homeopathic treatment than to placebo or other control interventions. Similarly, there was no homeopathic remedy that was demonstrated to yield clinical effects that are convincingly different from placebo. It is concluded that the best clinical evidence for homeopathy available to date does not warrant positive recommendations for its use in clinical practice.

Non-linear effects of cycloheximide in glutamate-treated cultured rat cerebellar neurons

Multiple cell types and organisms across a wide array of phyla and a variety of toxins demonstrate non-linear dose responses to low-level chemical exposures with high doses inhibiting cellular function and low doses stimulating function. We tested whether such non-linear responses to low and ultra-low dose N-methyl-D-aspartate (NMDA), 1-methyl-4-phenylpyridinium (MPP+) or cycloheximide moderated toxic glutamate exposure in cultured cerebellar granule cells. Neurons were incubated over 72 h with successive NMDA, MPP+ iodide or cycloheximide additions producing specified low (10(-5), 10(-7), 10(-9), 10(-11), and 10(-13) M) and ultra-low (10(-27),10(-29), 10(-63), and 10(-65) M) concentrations. Subsequently these neuronal cells were exposed to a 50% excitotoxic concentration of glutamate for 24 h. Neuronal viability was significantly reduced in neurons treated with micromolar (10(-5) M) cycloheximide whereas viability was enhanced in neurons treated with an ultra-low dose exposure of 10(-27) M cycloheximide. Neither NMDA nor MPP+ elicited harmful or protective responses. This is the first report demonstrating non-linear dose-response effects of cycloheximide in low and ultra-low concentration ranges.

Homeopathy: what is it and is it of value in the care of patients with cancer?

The underlying principles of homeopathy include treating 'like with like' by remedies which are potentized by serial dilution and succussion. These distinguish homeopathy from other forms of alternative or complementary therapy. Conventional scientific wisdom dictates that homeopathy should have no effect above and beyond placebo but experiments on ultra-high dilutions of solutes together with some clinical data suggest the intriguing possibility that it might do in some circumstances. However, most clinical evidence comes from treating relatively minor self-limiting diseases and little comes from treating life-threatening disorders such as cancer. This paper explains the principles of homeopathy and reviews the data on its use in cancer care.