Medical Correspondents
When I am at home, I have a regular Sunday morning ritual: I watch the Fox News medical correspondent while working out. It’s a fair bet that every week he will make at least one major howler that is guaranteed to increase the amount that I can bench press by 50%!
I don’t personally know the Sunday Fox medical correspondent, and he seems a nice fellow. But why oh why doesn’t he do his research before going on the air?
A few weeks ago he was endorsing “Wilson’s syndrome” that was created by E. Denis Wilson, M.D., who practiced in Florida in the early 1990s. The syndrome’s supposed manifestations include a rag bag of fatigue, headaches, PMS, hair loss, irritability, fluid retention, depression, decreased memory, low sex drive, unhealthy nails, easy and excessive weight gain, and about 60 other symptoms. Wilson claimed to have discovered a type of abnormally low thyroid function in which routine blood tests of thyroid are often normal. He claimed that the main diagnostic sign is a low body temperature that is on average below 98.6° F and that the diagnosis could be confirmed if the patient responds to treatment with a "special thyroid hormone treatment." The American Thyroid Association published a position paper about this syndrome, saying that it probably does not exist. People have paid good money to be tested and treated, and though some may have benefited, most probably have not.
It is very easy to check these facts. So why didn’t the Fox medical correspondent do so?
Then a couple of weeks ago he talked about an herbal preparation without once mentioning that the FDA had just issued a warning about potential liver toxicity.
Then today he starts discussing a preparation called Airborne, that is purported to help prevent colds. It may or may not do so. The FDA has not evaluated the claims. The problem was that the correspondent then said that it could do no harm. Yet that is quite wrong. Though I could find no published cases of harm, the possibility most certainly exist, and the public needs to be made aware of the reasons to be a bit cautious:
- It contains 5,000 IUs of vitamin A. If you take it every three hours as recommended, some people could overdose on it.
- The same with vitamin C. If you take a lot, most is quickly passed out in the urine. But some people can get bladder irritation and could conceivably get kidney stones from taking that amount over a period of time.
- The remedy also contains seven herbs: Lonicera, Forsythia, Schizonepeta, Ginger, Chinese Vitex, Isatis Root, Echinacea. In a couple of hours I did a literature review looking at potential toxicity of these compounds. They all look fairly benign, but there are scattered reports of side effects with a couple of them.
- The difficulty is that side effects can be cumulative if several herbs and supplements are taken at the same time.
I have nothing at all against the Sunday Fox Medical Correspondent: he seems an affable and quite knowledgeable fellow. Neither do I have anything against Airborne. If it helps people, all well and good.
The trouble is that we have had at least three occasions in the last couple of months where advice has been given that had clearly not been checked. I think that unfortunate. Before I post any article I spend hours checking and re-checking. Even with all that checking, I’m quite sure that something could slip through, and if an error occurs, I shall be delighted if someone picks it up, so that I can correct it.
I only wish that everyone who writes or speaks about things medical would do the same kind of obsessive checking.
I really do believe that readers, listeners and watchers deserve nothing less.
Tips for Trips
I’ve not written any new items for a couple of days while I was in England and out of range of anything resembling a decent Internet connection.
But a grand total of seventeen hours on planes made me think that it’s high time to tell you about some of my tips and techniques for dealing with the rigors of flying.
I’ve got so many of them that my tips will stretch over more than one article.
By now most people will have heard about the importance of:
- Maintaining hydration: the low pressure and dry atmosphere on planes can quickly dehydrate us. I try to drink at least 20 fluid ounces every two hours that I’m in the air.
- Avoid drinking alcohol and coffee.
- Keep mobile. When it is safe to do so: walk up and down the aisle. Stretch your legs and arms and gently rotate your neck while sitting in you seat.
The most worrying things about flying is the risk of developing a Deep Vein Thrombosis (DVT). This is an important topic: one in 2,000 long-distance passengers will suffer a blood clot, which can be fatal if the clot detaches and reaches the lungs: this is known as pulmonary embolism. DVTs are more likely to occur if there is a change in the rate of blood flow, the character of the blood of the normal functioning of the walls of the large veins. There are a number of well-recognized risk factors for the development of DVTs:
- Obesity
- Immobility
- Oral contraceptives
- Some cancers
- Cigarette smoking
There is a great long list of potential causes, but our focus today is on factors that can increase your risk of developing a DVT if you fly.
DVTs have been recognized to occur not just in passengers on planes, but also in people at extremely high altitude.
For many years it has been assumed that the low pressure and the immobility together increase the risk of DVT. But new research from the Universities of Leicester and Aberdeen was published in the Journal of the American Medical Association in May.
In a study of 73 people, the researchers found that sitting for long periods was the main cause, and warned people about all forms of travel.
During the study, the volunteers spent eight hours sitting in chambers with reduced air pressure and oxygen. They were allowed to move around for a couple of minutes each hour. They were then also tested in a chamber without changes in the atmosphere. The idea was to simulate the conditions on a plane. Blood samples were taken before and after each “flight” to check for factors involved in blood clotting.
For all these factors, no significant differences were seen between blood samples taken from volunteers on a simulated flight or exposed to normal air pressure. So it is not the low air pressure and oxygen saturation that is to blame: it is the lack of movement.
It is also unlikely that the advice to take an aspirin before a flight is going to be much help.
During my travels I have seen people selling extracts of horse chestnut (Aesculus hippocastanum) to prevent DVTs. There is actually some research that horse chestnut can help with chronic venous insufficiency. But there is no credible evidence that taking a couple of horse chestnut capsules will prevent a DVT, or the less severe problem of ankle swelling. And horse chestnut is well known to have a number of side effects, so there doesn’t seem to be much point in taking it to prevent ankle swelling and DVTs when flying.
The smart move (ha!) is to do regular exercise during flight, and to avoid dehydration.
I’ll tell you some of my tips for turning flights into highly productive work time and how to avoid jet lag in other posts.
Peripheral Neuropathy and Integrated Medicine
We have already discussed some of the causes and conventional treatments for peripheral neuropathy.
Unfortunately many people are not much helped, and it is good to know what else may assist them. And also what may not: sadly people suffering from chronic illnesses often become the victims of people selling treatments that may have scant chance of success.
There is not much research to support most of these approaches, which we use in tandem with conventional medicine. However, I’ve used all of these approaches and found that each has helped some people. The problem, as with most of conventional medicine, is in knowing who will respond to what. Often the key is to use several approaches in combination. That is where you need a specialist in Integrated Medicine who can put together the right “package” of treatment for the individual. What we don’t want to do is use a kind of “blunderbuss approach,” where we hit people with everything at once.
- Diet and exercise may help, particularly in diabetic neuropathy, where improved metabolic control will reduce – but not abolish – the risk of neuropathy, and may improve pre-existing neuropathic pain.
- Some naturopaths in Europe recommend using parsley, celery and carrot juices. Not something that I’ve seen work, but some people tell me that they’ve found them helpful.
- There has been a lot of research on the use of alpha lipoic acid and vitamins B and E, particularly in diabetic neuropathy: some positive and some negative. Each has sometimes helped in clinical practice, though you have to be a little careful with vitamin E: it can impair the clotting system, and cause diarrhea and transient elevations in blood pressure.
- Acupuncture – traditional Chinese, “Western Medical,” and electro-acupuncture – have been used a lot in peripheral neuropathy. There have been some positive studies in painful diabetic, HIV-associated and chemotherapy-induced neuropathy. None of the studies has been perfect, but they tend to support the clinical impression that man people are helped – some greatly – but few are cured with acupuncture. There have also been negative studies. There are also some positive studies from China, but only a few have been translated in their entirety. There are often two big problems with research done in China: many Chinese investigators feel that it’s unethical to include a control group, and their studies tend to use endpoints like “cured” or “partially cured,” rather than objective rating scales. I have used it in peripheral neuropathy, but it’s extremely important to use scrupulous technique, since people with neuropathy are at increased risk of getting skin breakdown and ulcers, especially if they also have any vascular compromise. Many of us have also found that it can be helpful in compression neuropathies, like carpal tunnel syndrome. There’s recently been some fascinating research using brain imaging in acupuncture treated carpal tunnel syndrome.
- Herbal remedies are used by about a fifth of people with neuropathy, but I’ve never had much luck with them. Some herbalists tell me that they have good results with an array of different herbs, though there is little objective evidence that they work.
- There have been clinical reports and at least one research study on the use of magnet therapy in neuropathy. Earlier this year there was an article in the British Medical Journal that was critical about magnet therapy in general. The article provoked one of the most vigorous debates that I’ve seen in along time. I’ve not seen it help, but there are some people who swear by it. And other who swear at it!
- There have been many attempts to use electrical fields to help neuropathy, from the conventional transcutaneous electrical nerve stimulation (TENS) boxes, to yet more variations on electro-acupuncture. Some people are helped, and these are good extra tools.
- Many homeopathic remedies have been used in neuropathy. Homeopathy is a highly individualized form of therapy: no two patients will get the same remedies. But some of the most commonly used remedies are Agaricus, Alumina, Arsenicum album, Natrum muriaticum, Phosphorus and Plumbum. If you live somewhere that there are good homeopaths, homeopathy is an option to consider, despite the dearth of good research into its use in neuropathy.
- It is important not to neglect the psychological aspects of neuropathy: people can become profoundly depressed by the intractable pain, and sometimes psychotherapy and antidepressants can be a helpful.
- Finally, ask yourself what the neuropathy is trying to teach you. There is no problem that comes out of a clear blue sky, and it is always valuable to look beyond the physical problem itself to its meaning and purpose.
If you are not having success from conventional medicine alone, or if you don’t care for conventional medicine, then discuss these options with a professional, use your intuition to guide you, and let us know if you have success.
Restless Legs Syndrome and Integrated Medicine
In the last entry we looked at RLS: what it is, and some of the conventional approaches to treating it. I now want to spend a moment talking about some of the other approaches that we have tried. For most of these there is very little evidence, so we use them in conjunction with conventional medicine.
If you want to try any of them, discuss them with your health care provider, so that he or she can guide you toward the best ways of putting treatments together.
- Diet: A low sugar diet helps some people, and it is always worth keeping a food diary for a week to see if there’s any association between something that you’ve eaten and a worsening of your symptoms.
- If you like juicing, there have been a number of anecdotal reports of the use of carrot, celery and spinach juices helping some people. (I am writing this while we are still in the middle of the spinach/E. coli scare, so leave this one out until the FDA has given us the all clear.
- There have been publications about the use of vitamins E and B and folic acid in RLS. Vitamin E can cause a GI upset in some people and if used in too high a dose (above 800IU/day) may elevate blood pressure; folic acid has to be used with caution in people on anticonvulsants. If you try these options, bear in mind that no supplement is likely to work unless it is taken for at least a month.
- Acupuncture sometimes helps: there are three acupuncture points in the legs that come up in the prescription: Urinary bladder 57, Spleen 6 and Stomach 36.
- Homeopathic remedies have been reported to help, and I’ve had some success. The precise remedy always depends on the precise characteristics of the individual, but the most common ones have been Rhus Toxicodendron, Causticum, Tarentula Hispanica and Zincum Metallicum. If you live in a place in which there are good homeopaths available for consultation, it’s another option.
- Several herbal remedies have been reported to help: Passion Flower, Cimicifuga, Valerian, Black Cohosh and Piper Methysticum. Just remember that some of the herbs sold in health food stores don’t contain what they should, and Valerian and Black Cohosh have recently been associated with liver toxicity in some people.
- Here is an old trick from China: take a one inch piece of fresh ginger root and grate it into a bowl of warm water. Then soak your feet in the water for about ten minutes. I’ve never seen that one work myself, by some people whom I respect have.
I also think it important not to neglect the psychological aspects of this problem, and sometimes some psychotherapy can be a helpful adjunct.
Finally, ask yourself what the RLS is trying to teach you.
These are all options that have been tried and have helped some people. If you are not having success from conventional medicine alone, or if you don’t care for conventional medicine, then discuss these options with a professional, use your intuition, and let us know if you have success.
Arnica Montana and Bruising
One of the best known homeopathic remedies is Arnica montana. Also known as Leopard’s Bane, mountain tobacco and sneezewort, it is found mainly in the mountains of Europe and in Siberia. The homeopathic remedy is made from the dried roots or sometimes the dried flowers of the plant.
It is the classical remedy for bruising, though homeopaths also use it in many other conditions. It was one of the first remedies that I ever learned about. In England we play a lot of rugby football, a game that can get rough. Most rugby clubs keep homeopathic Arnica in the dressing room, and it has always been said that it reduces the number of bruises after the game.
Yesterday, in the early afternoon, a ladder fell on my ankle: one of the perils of doing farm work. It was a very large heavy object and the injury bad enough that everyone wanted to cart me off to the ER for X-Rays. A swelling the size of half a grapefruit would tell most normal people that an X-Ray would be a good plan. But I decided to stick with Arnica and elevation of the offending article.
And as I was trying to limp around, I lamented the fact that I have only two legs and not four.
This morning – less than 18 hours later – the swelling has gone and there’s no bruising.
So that’s an "N of One" study.
Is there any decent research on Arnica?
One study claimed to find no benefit, but if you click on the link, you will see that there was some spirited argument about the experimental design.
Two other pieces of research have looked at the effects of using Arnica around the time of operation. One examined people having surgery for carpal tunnel syndrome, and reported benefit. Another looked at the use of Arnica in people having face lifts, and again reported less bruising.
A study from Israel indicated that it might reduce bleeding after childbirth.
It did not help muscle soreness after long distance running.
A study from Switzerland suggested that an Arnica-containing gel might help with the pain of mild to moderate osteoartritis of the knees. This wsa not a homeopathic preparation, but a herbal one, and occasionally contact dermatitis can occur if the herb is used. It’s uncommon, but worth knowing about. I’ve not heard of contact dermatitis occuring with homeopathic remedies.
I’ve always been most impressed by sudies of the use of homeopathy in animals, where the placebo effect is small. And we have seen excellent results in dogs, cats, horses and fish. There’s a study from India re-examining the treatment of bovine mastitis, and claiming that Arnica is one of a number of helpful remedies.
Arnica has also been shown to reduce swelling in a rat model.
The conclusion from all this?
Apart from my experience today, the balance of evidence suggests that Arnica can help prevent bruising. It may have many other uses in the hands of an experienced homeopath.
I always keep some handy and use it as an adjunctive treatment to more conventional approaches.
Blueberries
One of the principles of integrated medicine is that anything that’s good for you should have more than one benefit. So omega-3 fatty acids may help with cardiovascular health, mood, memory, attention deficit disorder, as well as the health of skin and bones.
Another one is the blueberry. I’ve been sufficiently impressed by the data on the health benefits of blueberries to have been a regular grower and consumer for years. They contain a number of potentially healthful compounds including polyphenols and anthocyanins, which can help modulate and balance the free radical systems of the body. Remember what I said recently about the value of keeping some free radicals in the body? The last thing that we want to do is to be rid of all of them!
There is reasonably good evidence that regularly eating blueberries can support cardiovascular health and there have been suggestions that they may reduce the risk and aggression of cancers of the prostate and colon.
There is also some evidence in animals that some of the components of blueberries may reduce inflammation and the effects of strokes – interruptions to the blood flow in the brain.
As a consumer, I’ve been carefully watching the growing evidence indicating that blueberries – or some of their constituents may have effects on animal cognition, brain aging and the normal neuroprotective mechanisms in the hippocampal region of the brain.
We do not yet have proof that these same effects occur in humans, and there are always three questions when we look at nutritional data:
- Can we extrapolate from the animal to humans? Mice are not men
- Are the amounts of blueberries or blueberry extracts even close to what humans could consume without spending all day eating, or getting a terribly upset intestine? There have been countless reports of the benefits of supplements that had to be taken in the most enormous doses to do any good. I’ve mentioned before the problem of L-arginine, which is sold as a “Natural Viagra.” Except that you need to take around nine grams for it to do much good, and most supplements contain less than a tenth of that. Regular readers will also remember my report concerning an article on coffee and sex. It was said that coffee would raise a woman’s libido. And indeed it does, if she drinks at least ten large cups of coffee at once. And coffee is a marvelous diuretic.
- When extracts are used, are we sure that we are getting the correct ingredient of the fruit? Many beneficial fruits contain just the right combination of nutrients to help us, so each can be taken in a small dosage or concentration. As with so much in integrated medicine, combinations are key. Take out one extract of a fruit, and you may lose the clinical effect that you wanted.
All that being said, the evidence is becoming progressively more interesting, and there is enough suggestive evidence for me to keep packing away the blueberries.
And just to show that I leave no stone unturned when checking the literature on your behalf, I rejoiced to learn that supplementing the diet of Arctic char with various supplements – including blueberries – improved the quality of his, ahem, semen. I do not know how this information will help any of us yet. Neither do I really know why a fish would want to eat blueberries or any of the other supplements that they were tried on. Though I’m sure that people have often asked similar off the wall questions about some of my research….
Black Cohosh and Liver Damage
After discovering that some of the Black Cohosh sold in the United States contains precious little of the active ingredient, we now learn that that may not have been such a bad thing.
In 2004, a Conference sponsored by National Center for Complementary and Alternative Medicine and Office of Dietary Supplements, National Institutes of Health indicated that Black Cohosh appeared to be safe. However, earlier this year, the regulatory authorities in Australia issued a policy statement about adding warnings about liver toxicity to all herbal products containing Black Cohosh. The European and British regulatory authorities followed suit.
This highlights a problem with which we’ve struggled before: are the reports of hepatotoxicity due to a “bad batch?” Adulterated perhaps, or collected incorrectly? Yet that highlights both the strength of natural remedies and also their Achilles’ heel. We have so little information about the purity of individual products.
The standardization of herbal medicines is difficult, particularly since herbals usually contain complex mixtures of constituents, some of which are active, and some not. We often do not know exactly which component of an herbal medicine is responsible for clinical effects. There are often also differences in the composition of herbal preparations among manufacturers and lots. There are also enormous variations in the identification of plants by the manufacturers, how they are handled and the presence of other chemicals. Just think of the variations in the taste of different types of coffee, and you will see the point.
This variation has important consequences in clinical trials, many of which have failed to address the question of whether the herbs that they were using were of high quality.
The information on the label does not always reflect the actual content of the preparation and it is difficult to give one standard dose for an herbal medicine.
I thought that I should give you the wording from The European Medicines Agency (EMEA) and the Committee on Herbal Medicinal Products (HMPC)”
“Following review of all available data, the HMPC considered that there is a potential connection between herbal medicinal products containing Cimicifugae racemosae rhizoma (Black Cohosh, root) and hepatotoxicity.
The EMEA therefore wishes to give the following advice to patients and healthcare professionals:
Advice to patients:
— Patients should stop taking Cimicifugae racemosae rhizoma (Black Cohosh, root) and consult their doctor immediately if they develop signs and symptoms suggestive of liver injury (tiredness, loss of appetite, yellowing of the skin and eyes or severe upper stomach pain with nausea and vomiting or dark urine).
— Patients using herbal medicinal products should tell their doctor about it
— Advice to healthcare professionals:
— Health care professionals are encouraged to ask patients about use of products containing Cimicifugae racemosae rhizoma (Black Cohosh, root).
— Suspected hepatic reactions should be reported to the national adverse reaction reporting schemes."
A New Warning from the FDA about Some “Sexual Enhancers”
On Wednesday of this week the Food and Drug Administration issued a warning to consumers not to purchase or consume Zimaxx, Libidus, Neophase, Nasutra, Vigor-25, Actra-Rx, or 4EVERON. These products are promoted and sold on web sites as "dietary supplements" for treating erectile dysfunction (ED) and enhancing sexual performance, but they are in fact illegal drugs that contain potentially harmful undeclared ingredients. Chemical analysis by FDA revealed that Zimaxx contains sildenafil, which is the active pharmaceutical ingredient in Viagra. The other products contain chemical ingredients that are analogues of either sildenafil or a pharmaceutical ingredient called vardenafil, which is the active ingredient of Levitra.
These undeclared ingredients can interact with some prescription drugs, in particular nitrates. In combination with nitrates, they can cause a catastrophic fall in blood pressure. You may have seen Keanu Reeves warn Jack Nicholson about that in the 2003 movie Something’s Gotta Give.
We have seen so many examples of adulteration of herbal remedies and supplements, and I’ve written a previous item about this huge problem. Huge, not in terms of numbers of cases, but in terms of the potential for harm.
I always recommending reading the label whenever you buy anything. The problem with the products mentioned in this latest FDA warning, is that there was no indication that the products contained drugs. Also be careful about whose advice you trust. Several years ago, a study done in health food stores in the United Kingdom showed that most of the staff knew very little about the products that they were promoting. Things have improved in recent years: we have a couple of health food stores in Atlanta with very knowledgeable staff. But it’s always a good idea to check before accepting the advice of someone in a store. Be doubly careful if you are buying things online: it’s you body.
So Caveat Emptor!
Technorati tags: Food and Drug Administration Sexual enhancers Herbal remedies Viagra Sildenafil Vardenafil Levitra Keanu Reeves Jack Nicholson
Black Cohosh for Menopausal Symptoms
Black Cohosh (Actaea racemosa or Cimicifuga racemosa) is a commonly used herb also known as baneberry, black snakeroot, bugbane, squawroot, rattle root. It is most often prescribed for the treatment of symptoms related to menopause. As with many herbs, the purity and constituents of most Black Cohosh products has generally not been well established.
There are three major active constituents of Black Cohosh:
Triterpene glycosides,
Phenolic constituents, and
Formononetin
The May 17 issue of the Journal of Agricultural & Food Chemistry reported that of 11 Black Cohosh products analyzed for these three constituents, 3 only contained an Asian adulterant (Asian Actaea) instead of Black Cohosh, and 1 contained both genuine Black Cohosh and Asian Actaea. For the products containing only Black Cohosh, there was significant product-to-product variability in levels of the selected triterpene glycosides and phenolic constituents and no formononetin was detected at all.
The way in which Black Cohosh is thought to work is by reducing the levels of luteinizing hormone (LH) and modulating estrogen. LH is a pituitary hormone that stimulates the ovary to produce estrogen and testosterone. As estrogen levels fall, the pituitary responds by increasing its production of LH. And the increasing levels of LH are implicated in the production of some menopausal symptoms. The Black Cohosh binds to the estrogen receptor, reducing the production of LH. Therefore by reducing LH, Black Cohosh reduces the production of estrogen that is responsible for some menopausal symptoms. It is useful to know this: three days ago I was asked to consult on the treatment of a woman who had her ovaries removed, was on hormone replacement therapy, but was taking Black Cohosh for menopausal symptoms. It had not helped her, which was not surprising: the evidence shows that you need at least one ovary for it to work.
I would also like to mention a program for professionals that I wrote late last year. It is available here. Although designed for health care professionals, it is one of the most comprehensive and up to date reviews on the uses, side effects and interactions of over twenty of the most commonly used herbal remedies. There is also a detailed discussion of how to work out if a remedy is likely to interact with prescription medicines and a comprehensive set of resources: scientific references, books and websites, together with advice on obtaining effective herbs.
Oh yes, and some really nice pictures of all the herbs that I discussed!
Technorati tags: Black Cohosh Menopause Herbal remedies
