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|Synopsis of the lecture by Ronald L. Koratz - Chief, Division of Gastroenterology at UCLA, at the annual PG course of American Gastroenterological Association, May, 2003. This synopsis is authored by Dr. A Minocha , who is a practicing gastroenterologist and the author of "Natural Stomach Care: Treating and Preventing Digestive Disorders with Best of Eastern and Western Therapies".|
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Dr. Koratz started by reminded the audience that he does not practice nor advocate use of these therapies, but was merely reviewing the literature as an objective observer because he had been asked to. He focused on the following issues:
Definition: Those treatments and health care practices not taught widely in Medical Schools, not generally used in hospitals and not usually reimbursed by medical insurance companies.
Socioeconomic impact: One third of the public uses complementary and alternative medicines (CAM). The number of visits to CAM practitioners is comparable to the traditional practitioners. CAM accounts for about $15 billion in health care costs. Patients pay this almost entirely out of pocket with respect to CAM since most insurance companies do not cover them.
Criticism of CAM data: While there are numerous studies, they suffer from type I and II errors, as well significant dropouts. Many of the studies are not blinded.
EXAMPLES OF THERAPIES
Ginger root: Three randomized control trials have been done in pregnant women for treatment of nausea and vomiting. Ginger was effective in all the studies.
Two studies have been done for treatment of pre-operative nausea and one of them was positive. As such, the jury is out on the issue.
Peppermint oil: It has been studied in non-ulcer dyspepsia and irritable bowel syndrome in several studies and its "use appears to be beneficial".
Chinese herbs: These have been examined in patients with non-ulcer dyspepsia (Drs. Cash & Schoenfeld, in DYSPEPSIA, 2000) and irritable bowel syndrome (Journal of American Medical Association 1998 )and have been found affective in randomized controlled trials.
Herbs in viral hepatitis: Herbs including Milk Thistle have been studied with one review article and 16 randomized control trials, whereas other herbs have been studies in 3 reviews and 22 randomized controlled trials. The benefit has been "limited". Quality of the trials was low.
A shot at critics of CAM: Dr. Koratz showed a humorous slide that stated, "When a physician puts a needle into the back, we call it lumbar puncture. When a non- physician puts a needle into the back we call it acupuncture."
Acupuncture: Based on two systematic reviews of literature (NHS Center for Reviews and Dissemination. Acupuncture 2001; Alberta Heritage Foundation for Medical Research 2002), it can be stated that acupuncture is effective in nausea, vomiting, as well as, post-operative dental care. It has not been affective in substance abuse, obesity, tinnitus, chronic musculoskeletal pain, and asthma.
Homeopathy: This system of medicine defies logic since the medicine administered is so dilute, it hardly has any active drug in it. It is based on the principle, "If some is good, less is better". Dr. Linde et al (Lancet 1997) did a meta-analysis of 89 randomized controlled trials covering 9,283 patients. The conclusions were startling. The odds ratio in favor of homeopathy treatment was 2.54, and the authors stated that the affect of homeopathy cannot be attributed solely to placebo effect.
Similarly, Dr. Cucherat, et al, (European Journal of Clinical Pharmacology 2000) looked at 16 randomized controlled trials of over 5,000 patients. They concluded that there is evidence that homeopathy is more affective than placebo.
Distant or spiritual healing: Dr. Astin, et al. (Annals of Internal Medicine 2000) studied distant or spiritual healing, by systemic review of 23 randomized controlled trials of over 2,700 patients. The authors concluded that there was some type of benefit and it merited further study.
Remote Intercessory prayer in ill health has been studied (Dr. Roberts, et al, Cochran Reviews 2000). While several studies showed benefit, the authors concluded that dropouts created problems with data combination but results are "interesting enough" to justify further study of prayer. Similarly, Dr. Leibovici, (British Medical Journal 2001) did a retrospective randomized controlled trial of patients with septicemia. Patients were divided into 2 groups, one group received prayers (4-10 years after the fact). Although the mortality was similar, the length of stay in the hospital and duration of fever was shorter in the group that received prayers.
Quality of CAM versus traditional medicine studies: The criticism of many CAM trials has been that their quality is poor. A systemic review of 250 randomized controlled trials of complementary and alternative medicine was performed for elements of quality and the mean score was 44.7 out of 100. Dr. Bloom et al (Int Journal Tech Assess Health Care 2000) compared it to the quality of randomized controlled trials in mainstream or traditional medicine. Surprisingly, the score was 44.7 versus 45 out of a total of 100. They concluded that while they were more randomized controls in traditional medicine, their quality was no better either.
Example (cited by Dr. Koratz) : Angioplasty is a common intervention used by Cardiologists. Angioplasty has been shown to be equal to medical therapy and there is no difference in mortality or rate of infarction, but then why are we doing angioplasty?
Conclusion: A challenge to the thought process is, that we should not be dogmatic and maintain intellectual consistency. Acceptance of traditional medicine is okay and but physicians must be equally accepting and/or cynical of CAM.
Regarding physicians in mainstream medicine he asserted that that "..much of what they do in their own traditional practices also has no evidence of efficacy but is employed because dogmatic authorities say it should be done"…. "..one should be equally skeptical about what other colleagues in traditional medicine tout and practice"
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