Science News Update Nov 11, 1998
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Science News Update

Week of November 11, 1998


American Medical Association Science News Updates are made available to the public after 3 p.m. Central time (U.S.) on the first four Tuesdays of each month. We also provide a list of previous news releases.

THIS WEEK'S CONTENTS

JAMA REPORTS: ALTERNATIVE MEDICINE THEME ISSUE

ARCHIVES REPORT (Alternative Medicine Articles)

SPECIAL RELEASE


4 OF 10 PEOPLE USE ALTERNATIVE MEDICINE IN THE UNITED STATES
Americans spent $27 billion out-of-pocket for alternative therapies in 1997

WASHINGTON, D.C.—Four out of 10 Americans used alternative medicine therapies in 1997; total visits to alternative medicine practitioners increased by almost 50 percent from 1990 and exceeded the visits to all U.S. primary care physicians. Americans paid an estimated $21.2 billion for services provided by alternative medicine practitioners, according to an article in the November 11 issue of The Journal of the American Medical Association (JAMA), a theme issue on alternative medicine.

David M. Eisenberg, M.D., of Beth Israel Deaconess Medical Center in Boston, and colleagues surveyed 2,055 adults by telephone in 1997 to study trends in alternative medicine use in the United States. They compared the 1997 data with results from their similar 1990 telephone survey of 1,539 adults. Dr. Eisenberg presented the findings of the study at an American Medical Association media briefing on alternative medicine here today.

The study reports that between 1990 and 1997, the prevalence of alternative medicine increased by 25 percent, with the total number of visits increasing by 47 percent from an estimated 427 million in 1990 to 629 million in 1997 - exceeding total visits to all primary care physicians in the United States (386 million in 1997). During this same period, expenditures for alternative medicine professional services increased by 45 percent. Expenses for these services, conservatively estimated at $21.2 billion, $12.2 billion of which were out-of-pocket, exceeded out-of-pocket expenses for all hospitalizations in 1997.

The researchers surveyed adults on the use of 16 alternative therapies, which included relaxation techniques, herbal medicine, massage, chiropractic, spiritual healing by others, megavitamins, self-help, imagery, commercial diet, folk, lifestyle diet, energy healing, homeopathy, hypnosis, biofeedback and acupuncture.

They report that in both the 1990 and 1997 surveys, alternative medicine was used most frequently for chronic conditions, including back and neck problems, anxiety, arthritis and headaches. The use of at least one of 16 alternative therapies increased from 33.8 percent in 1990 to 42.1 percent in 1997. The therapies that saw the largest increase in usage included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing and homeopathy.

Despite the dramatic increase, the researchers point out that the extent to which patients disclose their use of alternative therapies to their physicians remains low (less than 40 percent in both 1990 and 1997), a cause for some concern because an estimated 15 million Americans in 1997 took prescription medications and herbal remedies concurrently. With one in five people who take prescription medications also taking herbs, high-dose vitamin supplements, or both, the researchers report that millions of adults may be at risk for potential, unintended interactions involving prescription medications and herbs or high-dose vitamins.

"The market for alternative medicine is vast and growing," Dr. Eisenberg said in a separate interview. "This trend must be guided by scientific inquiry, clinical judgment, regulatory authority and shared decision-making. The 'don't ask and don't tell' approach to communication in this area must be abandoned."

Use of alternative therapies was significantly more common among women (48.9 percent) than men (37.8 percent) and less common among African Americans (33.1 percent) than other racial groups (44.5 percent). People aged 35 to 49 years reported higher rates of use (50.1 percent) than people either older (39.1 percent) or younger (41.8 percent) Use was higher among college-educated people (50.6 percent than people with no college education (36.4 percent), and more common among people with annual incomes above $50,000 (48.1 percent) than with lower incomes (42.6 percent). Use also was higher in the West (50.1 percent) than elsewhere in the United States (42.1 percent).

The total out-of-pocket expenditures for alternative therapies in 1997, including professional services, herbal products, vitamins, diet products, books and classes, were conservatively estimated to be $27 billion.

Because the demand for alternative therapies depends on how much patients must pay out-of-pocket, current use is likely to underrepresent utilization patterns if insurance coverage for alternative medicine increases in the future. Researchers also found that 42 percent of all alternative therapy use is attributed to the treatment of existing illness, while 58 percent is attributed to prevention of illness and/or health maintenance.

Data from this survey, reflective of the U.S. population, are representative of a predominantly white population, according to the researchers. The authors note that parallel surveys modified to include therapies unique to minority populations and translated when appropriate should be conducted using necessary sampling strategies. The authors write: "As alternative medicine is introduced by third-party payers as an attractive insurance product, it would be unfair for individuals without health insurance and those with less expendable income to be excluded from useful alternative medical services or consultation (e.g., professional advice on use or avoidance of alternative therapies)."

Alternative medicine, functionally defined in the study as interventions that are neither taught widely in medical schools nor generally available in U.S. hospitals, have garnered increasing attention from the media, the medical community, government agencies and the public in recent years. Surveys and public opinion polls conducted since 1990 have confirmed the extensive use of alternative therapies in the United States.

As a result, an increasing number of U.S. insurance companies and managed care organizations now offer some alternative medicine programs and benefits, and the majority of U.S. medical schools now offer courses in alternative therapies.

The authors conclude: "In light of these observations, we suggest that federal agencies, private corporations, foundations and academic institutions adopt a more proactive posture concerning the implementation of clinical and basic science research, the development of relevant educational curricula, credentialing and referral guidelines, improved quality control of dietary supplements, and the establishment of postmarket surveillance of drug-herb (and drug-supplement) interactions."
Read the abstract or full text of the article.
(JAMA. 1998;280:1569-1575)

Note: This study was supported in part by the National Institutes of Health, the John E. Fetzer Institute, the American Society of Actuaries, the Friends of Beth Israel Deaconess Medical Center, the Kenneth J. Germeshausen Foundation and the JE and ZB Butler Foundation. Read the JAMA Patient Page regarding this article.

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ANCIENT CHINESE MEDICAL PRACTICE FOUND EFFECTIVE FOR CORRECTING BREECH PRESENTATION
Burning herbs to stimulate acupuncture points (moxibustion) increases fetal activity

WASHINGTON, D.C.—A traditional Chinese medical practice which involves the burning of herbs to stimulate acupuncture points (moxibustion) is found to be effective in stimulating fetal movement and in correcting breech presentation, according to an article in the November 11 issue of The Journal of the American Medical Association (JAMA), a theme issue on alternative medicine.

Francesco Cardini, M.D., a private practice physician in Verona, Italy, and Huang Weixin, M.D., of the Jiangxi Women's Hospital in Nanchang, China, found that 75 percent of fetuses in the group treated with moxibustion changed their position to the correct "head-first" position compared to 48 percent of the fetuses in the control group. Dr. Cardini presented the findings of this study here today at an American Medical Association media briefing on alternative medicine.

The researchers conducted the study to evaluate the efficacy of moxibustion to increase fetal activity and correct breech position. According to the authors: "Among primigravidas [women who are pregnant for the first time] with breech presentation during the 33rd week of gestation, moxibustion for one to two weeks increased fetal activity during the treatment period and cephalic [head first] presentation after the treatment period and at delivery."

The researchers found that there was more fetal activity on average for fetuses in the treatment group. The average fetal movement reported for a one-hour period for seven days was 48.4 for the treatment group compared to 35.4 for the control group. The researchers state: "The mechanism of action of moxibustion appears to be increased active fetal movements, which proved significantly stronger in the treated subjects." Although studies in China have investigated the neurologic effects of moxibustion therapy, the mechanism of action of moxibustion is still not entirely clear.

All 260 study participants from the outpatient department of two hospitals in Jiangxi Province, China, were pregnant for the first time and in the 33rd week of pregnancy. All participants had fetuses in the breech position, which was determined by ultrasound. The researchers prescribed moxibustion to stimulate an acupuncture point located on the pregnant woman's foot (located beside the outer corner of the fifth toenail). The therapy was performed on each foot for 15 minutes daily for 7 days in the first 87 participants and twice daily in the last 43 participants. The control group received routine care but no moxibustion treatment.

The first moxibustion treatment was in the hospital and after that the treatments took place in the home. If the fetus was not in the head-first position after the first week, a second week of the moxibustion treatment followed. Study participants whose fetuses continued to be in the breech position after two weeks (in either the treatment or control group) could choose external cephalic version (ECV) to correct the fetus's position. ECV is an attempt to change the fetus's position by placing the hands on the abdomen to slowly and firmly turn the fetus into the cephalic position.

Moxibustion is the use of heat generated by burning herbal preparations containing Artemisia vulgaris (the Japanese name is moxa), rather than needles, to stimulate acupuncture points. Moxibustion is a popular treatment for breech position in China. As the researchers note: "Moxibustion in the early third trimester and ECV in late pregnancy are the standard care for breech presentation in both the centers involved in the trial." According to the researchers, this is the first randomized controlled clinical trial to evaluate the efficacy of this therapy for correcting breech position.

Breech occurs when the fetus is in a position other than the head-first position, usually with the buttocks, legs or feet emerging first for delivery. Breech position at the time of delivery is associated with complications and risks including physical injury for both the mother and the fetus or newborn. The complications of a breech birth are usually diminished by a cesarean delivery.

According to the authors: "If the results of this trial are confirmed, moxibustion should be extensively used on account of its noninvasiveness, low cost and ease of execution. In fact, it is easy to train expectant mothers (either alone or with their partners) to administer the therapy at home."
(JAMA. 1998;280:1580-1584)

Note: The research performed in China was financed by Centro di Orientamento Educativo in Milan, Italy, and by the Commission des Communautées Européennes, Brussels in Belgium.

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WIDELY-USED HERBAL COMPOUND NOT EFFECTIVE FOR WEIGHT LOSS
Study does not support using Garcinia cambogia as weight loss facilitator

WASHINGTON, D.C.—A widely used herbal compound failed to produce significant weight loss and fat mass loss beyond that observed with placebo in a study among overweight men and women, according to an article in the November 11 issue of The Journal of the American Medical Association (JAMA), a theme issue on alternative medicine.

Steven B. Heymsfield, M.D., and colleagues from the Obesity Research Center of St. Luke's-Roosevelt Hospital in New York conducted a randomized, double-blind, placebo-controlled study to find out if the herbal compound Garcinia cambogia would produce a greater reduction in body weight and total body fat mass than placebo. The use of herbal weight loss products is a rapidly growing therapeutic area, and one widely embraced by the general public. Dr. Heymsfield presented the findings here today at an American Medical Association media briefing on alternative medicine.

The authors write: "The present study, carried out during a 12-week evaluation period and using accepted experimental design and in vivo analytic methods, failed to support the hypothesis that hydroxycitric acid [the active ingredient in G cambogia] as prescribed promotes either additional weight or fat mass loss beyond that observed with placebo. Specifically, body weight and fat mass change during the 12-week study period did not differ significantly between placebo and treatment groups."

According to the authors, at least 14 separate products containing hydroxycitric acid are currently sold over-the-counter to consumers, even though before this study the effectiveness of hydroxycitric acid was unclear.

The researchers enlisted 135 overweight, but otherwise healthy, men and women, aged 18 to 65. After an evaluation that included a physical examination, electrocardiogram and screening blood studies, 66 subjects were randomized to receive a total of 1,500 milligrams daily of hydroxycitric acid taken in caplet form 30 minutes before meals. The other 69 study participants followed the same protocol, but the active compound was replaced with a placebo. Both groups were prescribed a high-fiber, low-energy diet, and were asked to maintain a stable physical activity level.

Forty-two patients taking hydroxycitric acid and 42 from the placebo group completed 12 weeks of treatment. Their body weight was evaluated every other week, and fat mass was measured at the beginning and end of the treatment period. The researchers found that patients in both groups lost a significant amount of weight. There were no significant differences between the two groups in weight loss or the estimated percentage of body fat loss. The estimated mean weight loss for the placebo group was nine pounds (4.1 kg) and for the treatment group was seven pounds (3.2 kg).

Hydroxycitric acid is obtained from plants native to India. Investigators have demonstrated that the effects of hydroxycitric acid on animals include the suppression of food intake and decreasing body weight gain. Previous studies in humans have been limited, and results have been contradictory.

The authors conclude: "Our findings, obtained in a prospective, randomized, double-blind study, failed to detect either weight loss or fat-mobilizing effects of hydroxycitric acid beyond those of placebo. These observations, the first, to our knowledge, to appear in a peer-reviewed article using currently accepted experimental and statistical methods, do not support a role as currently prescribed for the widely used herb G cambogia as a facilitator of weight loss."
(JAMA. 1998;280:1596-1600)

Note: This study was supported by grants from the National Institutes of Health and a contract with Thompson Medical Company, manufacturer of products that include G cambogia.

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CHINESE HERBAL MEDICINE EFFECTIVE FOR IRRITABLE BOWEL SYNDROME
Benefits can last up to 14 weeks after cessation of treatment

WASHINGTON, D.C.—Patients with irritable bowel syndrome (IBS) report improvement in symptoms after using Chinese herbal medicine (CHM), according to an article in the November 11 issue of The Journal of the American Medical Association (JAMA), a theme issue on alternative medicine.

Alan Bensoussan, M.Sc., of the University of Western Sydney Macarthur in Australia, and colleagues studied the impact of Chinese herbal medicine in the treatment of irritable bowel syndrome. The study also sought to determine the effectiveness of an individual therapy plan against the standard Chinese herbal formulation.

Bensoussan presented the findings here today at a America Medical Association media briefing on alternative medicine.

The researchers found: "For all five main outcome measures - total mean Bowel Symptom Scale (BSS) scores [measurement of the overall severity of the main symptoms of IBS for each patient] and global improvement [did a patient's condition improve, stay the same or worsen since beginning the trial] as assessed by patients and gastroenterologists, and interference with life as assessed by patients, patients receiving the standard CHM formulation responded significantly better than patients in the placebo group. Patients receiving the individualized CHM treatment also responded significantly better on four of five scores than patients receiving the placebo."

The 116 participants were screened by a gastroenterologist, and met the standard diagnosis of IBS. They were further diagnosed, according to Chinese medicine principles (treatment should be tailored to the individual clinical presentation of patients, even though they may all have the same medical diagnosis), and treated in three Chinese herbal clinics by three different Chinese medicine practitioners.

Patients were randomly selected to receive one of three treatments: an individualized Chinese herbal formulation, a standard Chinese herbal formulation, or placebo. Patients received five capsules three times daily for 16 weeks and were evaluated regularly by a traditional Chinese herbalist and by a gastroenterologist.

According to the authors, Chinese herbal formulas are complex and are viewed as a number of active ingredients working together, rather than one active substance. The standard formulation used in this study is not a sedative or anxiolytic preparation in traditional CHM terms but is a formulation considered to regulate and strengthen bowel function.

The Bowel Symptom Scale was the major instrument used to assess change and measure severity of IBS symptoms during the course of treatment. The authors found: "Patients receiving the standard herbal formulation improved by 44 percent (according to patients) and 59 percent (according to gastroentrologists), in contrast to patients in the placebo group who improved 22 percent (according to patients) and 19 percent (according to gastroenterologists.) Patients receiving the individualized preparations improved by 42 percent (according to patients) and 40 percent (according to gastroenterologists.)"

The researchers write: "There was a significant association between the active treatment groups and the change in the degree to which IBS symptoms caused interference with life and activities by the end of treatment. Of patients receiving the standard formulation and of those receiving individual formulations, 63 percent and 54 percent, respectively, stated that treatment resulted in IBS causing less interference in their lives and activities, compared with 37 percent of patients in the placebo group."

The researchers comment: "There was significant association between the treatment group and how patients felt at the 14-week follow-up. Of patients who had received the standard CHM formulation and of those who had received individual CHM formulations, 63 percent and 75 percent, respectively, stated that they still felt an improvement compared with 32 percent of patients who received placebo."

According to the authors, herbalism, acupuncture, homeopathic medicine, and manual therapies (e.g., chiropractic) frequently rely on a second diagnosis process distinct from Western medicine and on a high degree of interaction between patient and practitioner during the treatment. These alternative therapies lead to a clinical distinction between what seem to be similar diagnostic cases in Western medicine (individualization of therapy), which demands that the therapeutic invention be continuously modified in response to patient feedback.

The researchers continue: "Treatment needs to be tailored to the individual at the outset and also modified at differing stages of the patient's illness. Rigorous clinical trial methods frequently impose standardization of treatment for trial subjects. To our knowledge, this is the first clinical trial in Chinese herbal medicine that fully adheres to the traditional Chinese diagnostic and treatment processes while using a strict and accepted methodological protocol."

The authors write: "We conclude that Chinese herbal formulations may offer symptom improvement to some patients with IBS. In this randomized, double-blinded, placebo controlled trial CHM was shown to be effective in the management of IBS. Patients receiving the standard CHM formulation fared the best during the course of the treatment, while patients receiving the individualized treatments found that the benefit gained lasted beyond the treatment period. Although not all patients responded to this therapy, our findings support the consideration of further investigation of Chinese herbal medicine as a treatment option for IBS."

According to information cited in the study, irritable bowel syndrome is a common functional bowel disorder that accounts for a significant proportion of patients seen in gastroenterology offices and is characterized by chronic and recurrent abdominal pain and disturbed defecation. Studies in the United States and Australia suggest that between 10 percent and 20 percent of the population have this disorder. No single available treatment is reliably effective for this condition, and patients use a variety of approaches for symptom management, including drugs, dietary modifications, counseling, and recently, Chinese herbal medicine.

The authors add that before this study, no strong scientific evidence available supported the use of Chinese herbal agents in IBS. However, CHM has been used for centuries in the treatment of functional bowel disorders and is routinely used for this purpose in China.
(JAMA. 1998;280:1585-1590)

Note: This study was supported a contribution from the University of Western Sydney Macarthur, Sydney, Australia. Mei Yu Imports supplied the herbal medicines and Pan Laboratories prepared the placebo.

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SPINAL MANIPULATION APPEARS TO NOT BE HELPFUL FOR TENSION HEADACHES

No better than placebo for reducing headache duration, intensity or medication use

WASHINGTON, D.C.—Spinal manipulation — as an isolated intervention — does not significantly improve the outcome for episodic tension-type headaches (ETTH), according to an article in the November 11 issue of The Journal of the American Medical Association (JAMA), a theme issue on alternative medicine.

Geoffrey Bove, D.C., Ph.D., formerly of Odense University, Odense, Denmark, now at Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and Niels Nilsson, D.C., M.D., Ph.D., from Odense University, studied 75 people with episodic tension-type headaches to determine the effects of spinal manipulation therapy on tension headache.

Dr. Bove discussed the findings of the study here today at an American Medical Association media briefing on alternative medicine.

The researchers said: "This study showed that spinal manipulation did not significantly improve the outcome of ETTH. ... In practice, ETTH and cervicogenic headache can be difficult to differentiate, and often occur together. Our conclusions are in stark contrast to those of an earlier and very similar study of cervicogenic headache, in which the effect of spinal manipulation was quite dramatic. These data thus underline the importance of accurate diagnosis in the selection of headache patients for spinal manipulation."

In the study, participants were randomized into two groups, one receiving soft tissue therapy and spinal manipulation (the manipulation group), and the other receiving soft tissue therapy and a placebo laser treatment (the control group).

The researchers write: "Based on intent-to-treat analysis, no significant differences between the manipulation and control groups were observed in any of the three outcome measures [daily hours of headache, pain intensity per episode and analgesic use]. However, by week seven, each group experienced significant reductions in mean daily headache hours (manipulation group, reduction from 2.8 to 1.5 hours; control group, reduction from 3.4 to 1.9 hours) and mean number of analgesics per day (manipulation group, reduction from 0.66 to 0.38; control group, reduction from 0.82 to 0.59)."

The participants reported between five and 15 tension-type headaches (TTHs) a month with a reported headache intensity between 25 and 85 on a scale of 100. The patients were divided into the manipulation group or the control group. The manipulation group received cervical joint manipulation based on the chiropractor's exam and massage to the upper back muscles. The control group received the massage plus an application of laser light, as placebo, to the upper neck. Both groups received eight treatments over four weeks. All treatments were performed by the same chiropractor and lasted approximately 15 minutes. The entire trial including follow-up lasted 19 weeks.

Tension-type headaches are extremely common, affecting more than one-third of the population and accounting for more than two-thirds of all headache episodes. Tension headaches are described as pressing or tightening, and the pain is typically mild to moderate and is felt on both sides of the head. The one-year prevalence of episodic tension-type headache is more than 38 percent. Episodic tension-type headache interferes with lifestyle and has a significant socioeconomic impact, according to the study. Though episodic tension-type headache is typically medically treated with nonprescription analgesics, many people with ETTH seek hands-on therapy, delivered by various groups of practitioners.

In a separate interview Dr. Bove said: "This study shows that tension-type headaches do respond to hands-on therapy, but that cervical spinal manipulation is unlikely to be the factor that effects the change."
(JAMA. 1998;280:1576-1579)

Note: This project was supported by the Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark; The foundation for chiropractic research and postgraduate education, Copenhagen, Denmark; the Faculty of Health Science of Odense University; and the Foundation for Chiropractic Education and Research, Boston.

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Archives Briefs

  • ECHINACEA NO MORE EFFECTIVE THAN PLACEBO IN PREVENTING COLDS
    The investigated root extracts from E angustifolia and E purpurea could not be shown to prevent upper respiratory tract infections, according to an article in the November/December issue of the AMA's Archives of Family Medicine. The authors noted that participants in the treatment groups believed that they had more benefit from the medication than those in the placebo group. Based on the results of this and two other studies, one could speculate that there might be an effect of echinacea products in the order of magnitude of 10 percent to 20 percent relative risk reduction.
    (Arch Fam Med. 1998;7:541-545)
  • MAJORITY OF PEDIATRICIANS BELIEVE SOME OF THEIR PATIENTS SEEK ALTERNATIVE CARE
    Approximately 84 percent of pediatricians believe a small percentage of their patients use complementary and alternative medicine (CAM) therapies, according to an article in the November issue of the AMA's Archives of Pediatrics & Adolescent Medicine. Half would consider referring patients for CAM, and most were interested in continuing medical education courses on CAM.
    (Arch Pediatr Adolesc Med. 1998;152:1059-1064)
  • SMOKING MARIJUANA NOT RECOMMEND BECAUSE OF HEALTH HAZARDS
    Smoking marijuana to reduce intraocular pressure in glaucoma is not advised because of its toxicological profile, according to an article in the November issue of the AMA's Archives of Ophthalmology. Clinical effects associated with long-term marijuana use include respiratory, hormonal and pulmonary toxic effects, because tars, carcinogens and other volatile materials are more concentrated in marijuana smoke than in tobacco smoke. The authors call for development of drugs based on the cannabinoid molecule for use as topical or oral antiglaucoma medications.
    (Arch Ophthalmol. 1998;116:1433-1437)

    An accompanying editorial states: "To rationally determine marijuana's potential place in the antiglaucoma armamentarium, we should study cannabinoids as we would any other interesting class of compounds, rather than simply allowing or abandoning their use at present. ... In short, science rather than emotion should set the standard."
    (Arch Ophthalmol. 1998;116:1512-1513)
  • HOME-BASED REMEDIES COMMONLY USED TO TREAT CHILDHOOD COLDS
    Home-based remedies for colds in childhood are commonly used by a variety of ethnic groups, according to an article in the November issue of the AMA's Archives of Pediatrics & Adolescent Medicine. Many of the treatments used, such as over-the-counter cold remedies and fluids, are complementary to biomedical treatment. Mothers from ethnic minorities use similar amounts of home-based therapies when compared with mothers from the majority culture.
    (Arch Pediatr Adolesc Med. 1998;152:1083-1088)
  • HOMELESS YOUTHS FREQUENTLY USE AND ACCEPT COMPLEMENTARY AND ALTERNATIVE MEDICINE
    Complementary and alternative medicine (CAM) was used by 70 percent of homeless youths who filled out a survey at a youth health clinic in Seattle, according to an article in the November issue of the AMA's Archives of Pediatrics & Adolescent Medicine. Approximately 44 percent of the youths reported using CAM because it was "natural." Most believed it helped "some" or "a lot." When given a choice of providers to seek care from when they were ill, approximately 52 percent would see a physician, about 40 percent would visit a CAM provider and about 11 percent would treat themselves. The authors conclude: "Integrating CAM into allopathic health centers may serve as an incentive to entice youth into mainstream health care."
    (Arch Pediatr Adolesc Med. 1998;152:1071-1075)
  • MAJORITY OF PHYSICIANS REFER THEIR PATIENTS TO CLERGY AND PASTORAL CARE PROVIDERS
    More than 80 percent of the physicians studied reported that they refer or recommend their patients to clergy and pastoral care providers, according to an article in the November/December issue of the AMA's Archives of Family Medicine. More than 30 percent stated that they refer more than 10 times a year. Approximately 75 percent chose conditions associated with end-of-life care as reasons for referral; and approximately 73 percent of physicians referred patients for marital and family counseling. In addition, physicians who were in practice for more than 15 years were more likely to refer to clergy.
    (Arch Fam Med. 1998;7:548-553)
  • PATIENTS NEED TO BE AWARE OF BENEFITS AND SIDE EFFECTS OF MEDICINAL HERBS
    An article in the November/December issue of the AMA's Archives of Family Medicine reviews existing data on history, safety and efficacy of the following 12 commonly used medicinal herbs: chamomile, echinacea, feverfew, garlic, ginger, ginkgo, ginseng, goldenseal, milk thistle, St. John's wort, saw palmetto and valerian.
    (Arch Fam Med. 1998;7:523-536)
  • WHICH HERBAL PREPARATIONS WORK IN DERMATOLOGICAL THERAPEUTICS
    An article in the November issue of the AMA's Archives of Dermatology reviews herbal approaches to four common dermatological conditions: acne, dermatitis, psoriasis, and herpes simplex labialis. The authors conclude: "Many herbs are already being used by patients who seek care by dermatologists. Understanding their use and action helps the dermatologist integrate all elements of the patient's skin care regimen."
    (Arch Dermatol. 1998;134:1401-1404)
  • ALTERNATIVE STRATEGIES IN MANAGEMENT OF PRIMARY BREAST CANCER
    An article in the November issue of the AMA's Archives of Surgery reviews current alternative strategies in the management of primary breast cancer with an emphasis on the reasons particular strategies are preferred. The researchers also forecast new alternatives expected to emerge from molecular biology, as well as other technological advances. They warn: "One should be particularly wary of alternative treatments when their proponents claim they have an unusual or secret treatment, or a treatment that has been overlooked by medical
    science."
    (Arch Surg. 1998;133:1182-1186)
  • DIFFICULT-TO-CONTROL SEIZURES CAN BE EFFECTIVELY DECREASED BY THE KETOGENIC DIET
    Fifty-five percent of children with difficult-to-control seizures decreased their seizures by at least 50 percent after six months on the ketogenic diet, according to an article in the November issue of the AMA's Archives of Neurology. Developed in the 1920s, the ketogenic diet is an individually calculated and rigidly controlled, high-fat, low-protein, low-carbohydrate diet used for the treatment of difficult-to-control seizures. As new anticonvulsant medications became available, the diet was used less frequently and lack of experience led to widespread opinion that the diet did not work and was difficult to tolerate. The researchers conclude: "The ketogenic diet is effective in substantially decreasing difficult-to -control seizures and can successfully be administered in a wide variety of settings."
    (Arch Neurol. 1998;55:1433-1437)

    An accompanying editorial states: "Many parents are initially drawn to the ketogenic diet because they assume that a diet must somehow be more natural and less risky than a medication. They are soon to find that there is nothing at all normal or natural about the ketogenic diet! But it is a reasonable option, particularly for children who have not responded to medication or who have excessive adverse effects from medication ... If the ketogenic diet can be systematically examined, then other forms of nontraditional therapy could and should also be investigated. Those who champion new tests and treatments ultimately have an obligation to study these procedures thoroughly before promoting them for general use with patients."
    (Arch Neurol. 1998;55:1403-1404)

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AMA SCIENTIFIC JOURNALS, AMNEWS LAUNCH E-MAIL ALERTS
New feature offers users tables of contents, news summaries

CHICAGO—Visitors to the AMA's World Wide Web site (www.ama-assn.org) can now register to receive tables of contents from the Association's scientific journals, plus news summaries from American Medical News, via e-mail.

The new service is free of charge. There is a short registration process that requires users to provide limited personal information, such as their profession and e-mail address. This information is collected for internal AMA purposes only and will not be reused or sold for commercial purposes without visitor consent.

The e-mail alert service allows Web site visitors to choose alerts from any or all of the publications in the AMA's Scientific Information and Multimedia group, including The Journal of the American Medical Association (JAMA), American Medical News (AMNews), and the Archives specialty journals. Alerts from the journals consist of the latest issue's table of contents; AMNews alerts consist of news summaries.

Alerts will be e-mailed to registered users at the same time that the Web editions of each publication is updated. To register for these updates, visit the publications home page on the AMA Web site at www.ama-assn.org/scipub.htm, or any of the individual publication's home pages.

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