Adrenal crisis is a medical emergency. If suspected treatment should
be started as soon as possible. Every emergency physician should be
familiar with adrenocortical insufficiency—a potentially life-threatening
entity. The initial diagnosis and decision to treat are presumptive and
are based on history, physical examination, and, occasionally, laboratory
findings. Delay in treatment while attempting to confirm this diag...
Adrenal crisis is a medical emergency. If suspected treatment should
be started as soon as possible. Every emergency physician should be
familiar with adrenocortical insufficiency—a potentially life-threatening
entity. The initial diagnosis and decision to treat are presumptive and
are based on history, physical examination, and, occasionally, laboratory
findings. Delay in treatment while attempting to confirm this diagnosis
can result in poor patient outcomes.
The predominant manifestation of adrenal crisis is shock, but the
patients often have nonspecific symptoms such as anorexia, nausea,
vomiting, abdominal pain, weakness, fatigue, lethargy, fever, confusion or
coma and hyperpigmentation [3]. Hypoglycemia is a rare presenting
manifestation of acute adrenal insufficiency; it is more common in
secondary adrenal insufficiency caused by isolated corticotropin (ACTH)
deficiency [1,2].
Treatment consists of starting an intravenous line, taking the
blood samples for plasma cortisol levels, acth, serum electrolytes and
glucose. Fluid deficit should be corrected with 5 percent DNS or normal
saline. Initially 2-3 litres may be required. Thereafter give IV fluids
according to the central venous pressure. Patients with addisons disease
have low cardiac reserve, so watch for fluid overload.
Give hydrocortisone 100-300 mg IV, there after 50-100mg every six hourly
for the first day. On the second day give the same amount of dose eight
hourly. Then according to the clinical response. Then switch to oral
hydocortisone 10-20 mg every six hours. Most patients settle with a BD
dose of 10-20mg of hydrocortisone daily. A few may need mineralocorticoid
therapy in the form of fludrocortisone. Instead of hydrocortisone,
dexamethasome can also be used. Hydrocortisone should not be given for
atleast eight hours before ACTH stimulation test. Correct the electrolyte
abnormalities as per the lab reports. Broad spectrum antibiotics should
be given at this time.
2. Stacpoole, PW, Interlandi, JW, Nicholson, WE, Rabin, D. Isolated
ACTH deficiency: a heterogeneous disorder. Critical review and report of
four new cases. Medicine 1982; 61:13.
3. Barnett, AH, Espiner, EA, Donald, RA. Patients presenting with
Addison's disease need not be pigmented. Postgrad Med J 1982; 58:690.
In reply to Dr Koprowski's letter, we would like to point out that
the absence of rigorous evidence supporting the efficacy of
individualised herbal medicine shown by our systematic review remains
fact - regardless of how the various types of individualised herbal
medicine are categorised. If we had examined only individualised
traditional oriental herbal medicine, we would have found even less
evidence. If there is "act...
In reply to Dr Koprowski's letter, we would like to point out that
the absence of rigorous evidence supporting the efficacy of
individualised herbal medicine shown by our systematic review remains
fact - regardless of how the various types of individualised herbal
medicine are categorised. If we had examined only individualised
traditional oriental herbal medicine, we would have found even less
evidence. If there is "actual knowledge of the efficacy of traditional
oriental medicine" in U.S. states this has certainly not been translated
into rigorous clinical trials with a positive result.
Response to:
R Guo, PH Canter, E Ernst. A systematic review of randomised clinical
trials of individualised herbal medicine in any indication. Postgrad Med J
2007;83:633-637
From:
Ally Broughton Bsc (Hons) MNIMH
Director of Research for, and Member of, the National Institute of Medical
Herbalists (NIMH)
Contact: ally.broughton@blueyonder.co.uk
I am a trained herbal practitioner of 12 years and teach resea...
Response to:
R Guo, PH Canter, E Ernst. A systematic review of randomised clinical
trials of individualised herbal medicine in any indication. Postgrad Med J
2007;83:633-637
From:
Ally Broughton Bsc (Hons) MNIMH
Director of Research for, and Member of, the National Institute of Medical
Herbalists (NIMH)
Contact: ally.broughton@blueyonder.co.uk
I am a trained herbal practitioner of 12 years and teach research
methodology on BSc and MSc courses in herbal medicine.
A herbal practitioner undergoes a 3-4 year degree level accredited
training course which includes clinical skills and differential diagnosis,
materia medica (plant medicine), and clinical experience in accredited
training clinics. Professional bodies are currently self regulating and
exist to ensure professional and best clinical practice.
In teaching, I use critical appraisal tools developed by the Critical
Appraisal Skills Programme (CASP)(i) , I used a tool to evaluate this
review to minimise bias.
Study validity
Only 3 small scale clinical studies are included for review, one of which
is a pilot study. The review can have no statistical significance.
The studies have very different outcome measures and investigate
entirely different conditions, making comparison difficult.
Selection criteria
From the 1345 references identified, 3 studies were selected. There was
no clear pre-determined strategy used to determine which studies were
included.
The reviewers recognise this limitation saying they had ‘difficulties
designing a search strategy to locate RCTs of individualised herbal
medicine because of the large number of potential descriptors for such
studies’. This is a strong limitation in the review methodology.
Statistical Analysis
The results for each of the studies are assessed by statistical
significance, however there is no clear indication given of p values or
confidence intervals used by any of the studies.
Critical Analysis
The analysis focus is on statistical data. Some potentially valid points
are not reviewed. For example in the Bensoussan trial(ii) there was no
significant difference between the individualised and standard treatments
at 16 weeks were reported, however, on follow-up 14 weeks after treatment,
only the individualised treatment group maintained improvement. The
reviewers entirely dismissed this as statistically non significant. It is
an important point considering that individualised, holistic treatment
addresses underlying causes of illness which takes longer to resolve but
often with longer lasting benefit compared to symptomatic treatments.
Discussion Analysis
In the discussion analysis there is consistently inadequate links made
between the review evidence and the conclusions made by the authors.
Discussion on herbal practice and safety issues are not substantiated or
referenced, in fact there are only 7 references for the entire review.
Conclusions
There is a lack of scientific rigour in the review methodology. Based on
the evidence presented in the review the conclusions made by the authors
appear arbitrary and insufficiently based on the evidence presented.
Designing a randomised controlled trial to investigate individual
treatment is highly complex and not without limitations. Within the field
of complementary medicine current research is looking for new or adapted
research paradigms appropriate to holistic medicine (iii,iv) .
(i)Oxman AD, Cook DJ, Guyatt GH, Users’ guides to medical literature.
VI. How to use an overview. JAMA 1994; 272(17): 1367-1371
(ii) Bensoussan A et al. Treatment of irritable bowel syndrome with
Chinese herbal medicine. JAMA 1998;280:1585-9
(iii)Boon H et al. Evaluating complex healthcare systems: A critique
of four approaches. eCAM Advance Access 2006; doi:10.1093/ecam/nel079
(iv) Fonnebo V et al. Researching complementary and alternative
treatments – the gatekeepers are not at home. BMC Medical Research
Methodology 2007;7:7
Thank you, Peter Canter, for your e-letter in the Postgraduate
Medical Journal.
We find it somewhat shocking that you think herbal medicines are no
better than a "placebo." This belies the facts.
In America, in states like Florida, acupuncturists are licensed as
"acupuncture physicians" and are considered by medical regulatory
authorities to be primary care practitioners, who can also dispense
herbs, a...
Thank you, Peter Canter, for your e-letter in the Postgraduate
Medical Journal.
We find it somewhat shocking that you think herbal medicines are no
better than a "placebo." This belies the facts.
In America, in states like Florida, acupuncturists are licensed as
"acupuncture physicians" and are considered by medical regulatory
authorities to be primary care practitioners, who can also dispense
herbs, and provide other therapies. This is not the case now in the U.K.
One certainly hopes that U.K. regulators, however, make contact
with American regulators in Florida and other U.S. states where there is
actual knowledge of the efficacy of traditional oriental medicine when
making their decisions on new policies.
Your claim that "we therefore reject the notion that different
schools of individualised herbal medicine cannot be included in a single
review," is as we say in Latin, ipse dixit. Just because you say it,
does not make it so.
Chinese medicine differs distinctly from European herbalism and
Ayurveda.
I enjoyed reading the article on 'testis cancer' by Khan et al.I
agree with the authors that the survival rate has increased over the past
few years.The authors have rightly pointed out the role of chromosome in
causing such anomalies while the primordial germ cells are undergoing cell
division.While going through the risk factors,I would certainly like to
highlight the exposure of dyes and paints.The dyeing agents are kn...
I enjoyed reading the article on 'testis cancer' by Khan et al.I
agree with the authors that the survival rate has increased over the past
few years.The authors have rightly pointed out the role of chromosome in
causing such anomalies while the primordial germ cells are undergoing cell
division.While going through the risk factors,I would certainly like to
highlight the exposure of dyes and paints.The dyeing agents are known to
cause such cancers.The website addresses mentioned in the text are
beneficial for clinicians.Overall, the article is informative and the
authors need to be praised for their lucid style of presentation.
Editor - We carefully read the recent Wheatley and Baker paper. (1)
As they emphasised, the place of death persists at present as a very
important issue for every person and for health care services.
One of the most typical signs of western societies during the past
century was the ever-increasing proportion of patients who died at
hospitals. This new panorama was due to several reasons, but undoubtedly
it was...
Editor - We carefully read the recent Wheatley and Baker paper. (1)
As they emphasised, the place of death persists at present as a very
important issue for every person and for health care services.
One of the most typical signs of western societies during the past
century was the ever-increasing proportion of patients who died at
hospitals. This new panorama was due to several reasons, but undoubtedly
it was a significant factor the popular extended thinking about the
powerful of new scientific and technological advances incorporated in
modern medical services to improve quality of life for all, in any
circumstances. (2)
Nowadays, this picture is changing because of the end of demographic
and epidemiological transitions in many countries like ours, and new
political answers are needed. Last stages of Non Communicable Diseases are
now the common causes of death, the age of the dying persons is
continuously increasing, and there are other cultural and socioeconomic
related factors. Moreover, it is necessary to face the higher cost of
institutional services with limited benefits for a greater group of
patients who definitively will die, with the possibility to offer
appropriate services near domiciles of dying persons, and the ever present
feelings of human beings to stay close to their relatives and friends at
the end of their lives. (3)
We reviewed 244 035 adult deaths (15 years and over) occurred in 1990
-1999, in three Cuban provinces: Ciudad Habana (190 734) the capital of
the nation and in the western part of the island, Cienfuegos (26 405) in
the southern and central part, and Las Tunas (26 896) in the east. The
main causes of deaths in those regions were: ischaemic heart diseases
(27.4%, 29.4% and 28.6%, of all deceased persons in each province,
respectively), malignant tumours (19.3%, 19.9% and 21.6%),
cerebrovascular diseases (10.2%, 10.3% and 10.2%) and pneumonia (6.0%,
7.8% and 6.7%). The general trend during these years was to increase the
proportion of out of hospital deaths, with higher figures in Cienfuegos:
44.0 % in 1990 and 54.6% in 1999. A significant augment of domiciliary
deaths was found in the older groups and in those who died due to cancer,
with some differences among provinces. So, only 28.3% with cancer died at
home in Ciudad de La Habana, compared with 61.8% in Cienfuegos and 34.4%
in Las Tunas. (2)
Additionally, we conducted a survey among relatives or proxies of a
randomised sample of 226 adults (>15) who had lived in the Cienfuegos
City and died in 2003. Of 171 who were classified as terminally ill, 91
(53%) had died at home - in 58% of cases because of the patient's or
relatives' choice. (4 )
In order to face this new situation, for the last years of the past
decade we have implemented a comprehensive and successfully programme of
palliative care in primary care in Cienfuegos which included trained
primary care teams, integrated by family physicians, nurses, social
workers, psychologists, pharmacists, and community care givers. Also
original guidelines were developed by our group according the local
context and based on the best available evidences. (5)
We concluded that even in a highly organised national health system
such as Cuba's - universal, accessible, equitable, and free to all -
looking for local answers to specific and emerging conditions seems to be
effective and desirable (4)
Alfredo A Espinosa-Roca, coordinator, palliative care programme
Municipal Health Division of Cienfuegos, Ave 56 No 2917 altos, Cienfuegos
55100, Cuba. Email: espinosa@gal.sld.cu
Alfredo D Espinosa-Brito, professor, Frank C. Álvarez-Li, doctor,
Ángel J. Romero-Cabrera, associate professor
Teaching Hospital "Dr Gustavo Aldereguía Lima," Cienfuegos, Ave 5 de
Septiembre and Calle 51A, Cienfuegos 55100
References
1. Wheatley V, Baker FI. "Please, I want to go home": ethical issues
raised when considering choice of place of care in palliative care.
Postgrad Med J 2007;83:643-8.
2. Espinosa A, Quintero Y, Cutiño Y, Romero AJ, Bernal JL. Mortalidad del
adulto en tres provincias cubanas. In: Iñiguez L, Pérez OE. Heterogeneidad
social en la Cuba actual. Ciudad de La Habana: Centro de Estudio de Salud
y Bienestar Humano, Universidad de La Habana, 2004: 163-94.
3. Murray SA, Boyd K, Thomas K, Higginson IJ. Developing primary
palliative care. BMJ 2004;329: 1056-7
4. Espinosa-Roca AA, Espinosa-Brito AD, Fernández-Casteleiro E. Sabatés-
Llerandi T. Where patients with cancer die in Cuba. BMJ 2006;332:668
5. Espinosa AA, Romero AJ, Misas M, Fresneda O. Asistencia al enfermo
terminal en la atención primaria de salud. Rev Finlay 2005;10 (número
especial): 133-43.
In their helpful review article, Kearney and Dang advocate giving
hydrocortisone to suspected adrenal crisis pending ACTH stimulation
testing. Many authorities suggest the use of dexamethasone prior to
testing as it does not interfere with cortisol assay (eg. Webb et al 1999,
Shenker et al 2001). Can the authors justify their postponement of
confirmatory tests?
In their helpful review article, Kearney and Dang advocate giving
hydrocortisone to suspected adrenal crisis pending ACTH stimulation
testing. Many authorities suggest the use of dexamethasone prior to
testing as it does not interfere with cortisol assay (eg. Webb et al 1999,
Shenker et al 2001). Can the authors justify their postponement of
confirmatory tests?
Yours sincerely
Mark Jadav
Kearney T and Dang C. Diabetic and endocrine emergencies.
Postgraduate Medical Journal 2007:83:79-86
Webb A, Shapiro M,Singer M and Suter P. Oxford Textbook of Critical
Care. Oxford University Press 1999 p.603
Shenker V and Skatrud JB. American Journal of Respiratory and
Critical Care Medicine, Volume 163, Number 7, June 2001, 1520-1523
We thank E. J. Koprowski for her/his comments on our recent
systematic review of individualised herbal medicine which reveal that s/he
has totally misunderstood the nature of our review in several respects.
Firstly, we were not at all interested in homeopathy as s/he seems to
believe. We can only surmise that s/he is confusing homeopathy with
Western medical herbalism which was included....
We thank E. J. Koprowski for her/his comments on our recent
systematic review of individualised herbal medicine which reveal that s/he
has totally misunderstood the nature of our review in several respects.
Firstly, we were not at all interested in homeopathy as s/he seems to
believe. We can only surmise that s/he is confusing homeopathy with
Western medical herbalism which was included.
Secondly, our review is not a "thinly veiled call for regulation". In
the UK, consultation has already started to begin the regulation of herbal
medicines and herbal medicine practitioners. Part of this process,
coordinated by the MHRA, is a working party consisting of herbal
practioners, the Department of Health and other interested parties who
acknowledge the serious risks associated with individualised herbal
medicine. Our concern is that the the issue of efficacy will be left to
the "professional" judgement of the practitioners. Given that there is
presently no convincing evidence for the efficacy of the individualised
approach, any safety risks are unacceptable. Regulation may therefore
serve to give the practice an undeserved air of respectability. We would
urge policy makers to consider whether a therapy with known safety risks
and no evidence of efficacy should be allowed to be practised at all.
Thirdly, we would like to point out that rigorous clinical trials
testing efficacy can be conducted whatever diagnostic system is used by
the therapist. One outcome of our review is the demonstration that
clinical trials of good methodological quality are entirely feasible in
individualised herbal medicine. We therefore reject the notion that
different schools of individualised herbal medicine cannot be included in
a single review. We should also point out that if we were to separate
them, then each school would be supported by even less rigorous evidence
than that included in our review.
Fourthly, it is not our review which has set a new benchmark for
clinical trials of individualised herbal medicine, it is the results of
the clinical trial carried out by Bensoussan in Irritable Bowel Syndrome.
That study showed that their was no significant difference between
individualised and a standardised herb mixture and if anything the
standardised mixture produced better results. Herbalists need to show not
only that their treatments are better than placebo, but also that their
individualised approach adds value. Otherwise, exposure to the increased
risks and extra cost of the treatment are not justified.
References
R Guo, PH Canter and E Ernst. A systematic review of randomised
clinical trials of individualised herbal medicine in any indication.
Postgrad Med J 83: 633-637
Bensoussan A, Talley NJ, Hing M, Menzies R, Guo A, Ngu M. Treatment
of irritable bowel syndrome with Chinese herbal medicine. JAMA 1998; 280:
1585-89
A recent article, A systematic review of randomized clinical trials
of individualized herbal medicine in any indication, published in October,
2007 in the Postgraduate Medical Journal, by R. Guo , P. H. Canter , E.
Ernst, of the Peninsula Medical School, Universities of Exeter &
Plymouth, Exeter, U.K., warns public health authorities that the
effectiveness of individualized, herbal medicine...
A recent article, A systematic review of randomized clinical trials
of individualized herbal medicine in any indication, published in October,
2007 in the Postgraduate Medical Journal, by R. Guo , P. H. Canter , E.
Ernst, of the Peninsula Medical School, Universities of Exeter &
Plymouth, Exeter, U.K., warns public health authorities that the
effectiveness of individualized, herbal medicine has not been
scientifically established. “The findings of this review are particularly
pertinent because section 12(1) of the U.K.’s Medicines Act relating to
regulation of unlicensed herbal remedies made up to meet the needs of
individual patients is presently under review,” the authors note. But this
thinly-veiled call for regulation – publicized in the national media in
the U.K., in outlets including The Independent and The Guardian, inter
alia, is fatally flawed.
The authors fail to take into account the dramatic differences that
animate the diagnostic and prescriptive systems of Chinese medicine,
Ayurveda, and European homeopathy. The herbs used by doctors in this
complementary medical systems are not used in the same way, or for the
same purposes. Chinese medicine is energy medicine – and seeks to balance
the body and achieve harmony for the patient. But homeopathy is decidedly
different, as it uses herbs to create a catalytic reaction in the patient,
and thus stimulate his immune system. Ayurveda differs from both of these
approaches.
Lumping the herbal treatments of these three, separate medical
systems makes no scientific sense – and, may quite literally be comparing
apples to oranges. This is a disservice to readers.
To be sure, the article is not totally without merit. The authors
note that evidence of efficacy for some herbal medicines, has increased
substantially during the past 20 years. The authors also note that the
World Health Organization (WHO) has estimated that 80% of the population
in developing countries relies primarily upon herbal medicine for basic
health care.
But, the authors caution, most clinical trials of herbal medicine
have focused on standardized extracts of single herbs or standardized
formulae. “The individualized approach, in which patients receive tailored
prescriptions comprising a mixture of herbs, is emphasized in most forms
of practitioner based herbalism, including European medical herbalism,
Chinese herbal medicine and Ayurvedic herbal medicine,” the authors note.
“ Evidence from clinical studies of single herb extracts or standardized
formulae cannot be generalized to individualized herbal medicine, and
claims by practitioners that the latter has an evidence base requires
confirmation. The non-standardized nature of individually prepared herbal
prescriptions and the consequent increased potential for adverse events
and negative interactions means that safety and effectiveness need to be
firmly established before such practices can be endorsed.”
It’s an interesting statement, on the surface, but seems to be a bit
of pettifoggery when examined closely. The drugs dispensed by allopathic
physicians cannot withstand similar scrutiny – and it has been
demonstrated, for example, individual patients react differently to the
same, allopathic prescriptions. Some have side effects. Some do not. Some
have adverse reactions. Some do not. Some are aided in their healing. Some
are not. Is this fact cause for concern? Yes. It has given rise to the
field of molecular medicine, wherein scientists are seeking to develop
individualized therapies for individual patients. But it is far from the
norm for conventional, Western medicine.
As the article’s authors show, they scanned Medline and other medical
databases and picked studies of randomized, controlled clinical trials of
different herbal treatments – and only three studies that they found
featured individualized herbal medicine. This was of 1,345 references in
the scientific literature.
The study claims that this methodology is rigorous and that the
authors have set a new standard that all herbalists must now follow.
“This study sets a new benchmark for the tailored approach: not only
must herbalists demonstrate that individualized treatment is superior to
placebo, they must also show, for reasons of cost and safety, that it is
superior to standardized treatment,” the authors write. “
We respectfully disagree with the authors of the study that their
review has somehow set a “new benchmark” for herbalism. Far from it. In
fact, we are concerned that the study design, as we outlined above, is so
poorly conceived that it renders its findings and recommendations for
public policy makers virtually useless. To lump Chinese medicine,
Ayruvedic medicine and European homeopathy into one, undistinguishable
category is, simply put, poor scholarship.
Education is needed to explain to allopathic medical practitioners
and scientists whose work purports to inform allopaths and public health
authorities of the differences between Chinese medicine, Ayurveda and
homeopathy. The risk of failing to do so is great – regulators may be
driven by hysteria, engendered by ill-conceived studies, into restricting
the practice of complementary medicine, to the great disadvantage of
patients.
FURTHER READING
1. R. Guo , P. H. Canter , E. Ernst, A systematic review of
randomized clinical trials of individualized herbal medicine in any
indication, Postgraduate Medical Journal (U.K.), October 2007.
2. Ernst E, Pittler M, Wider B, eds. The desktop guide to complementary
and alternative medicine, an evidence based approach , 2nd ed. Mosby
Elsevier, 2006.
It is with interest that I have read the article by Dr Wanis Ibrahim
titled Recent advances and controversies in adult cardiopulmonary
resuscitation (1) in which the changes to the guidelines and the evidence
for these is summarised.
I note that the differences in the cardiopulmonary resuscitation
(CPR) guidelines between the American Heart Association (AHA) and the
European resuscitati...
It is with interest that I have read the article by Dr Wanis Ibrahim
titled Recent advances and controversies in adult cardiopulmonary
resuscitation (1) in which the changes to the guidelines and the evidence
for these is summarised.
I note that the differences in the cardiopulmonary resuscitation
(CPR) guidelines between the American Heart Association (AHA) and the
European resuscitation council (ERC) are not mentioned in this article.
This difference relates to the delivery of rescue breaths if the victim is
not breathing. The AHA recommends two rescue breaths if the victim is not
breathing (2) and the ERC (3) as well as the Resuscitation Council of the
United Kingdom (4) (RCUK) recommend that chest compressions should be
started immediately if there are no signs of life.
Regarding the pulse check during CPR by healthcare providers the AHA
recommends that the pulse check occur for not more than 10 seconds after
it has been established that the patient is not breathing and the two
rescue breaths have been delivered (2). The RCUK recommends simultaneous
check for breathing and carotid pulse whilst looking for signs of life
(lack of movement, normal breathing or coughing) in not more than 10
seconds (4). This ensures CPR is promptly started. Studies have shown that
even healthcare providers checks of pulses can have low accuracy (5, 6).
Another change to the guidelines has been that rescuers should be
taught to place their hands on the center of the chest, rather than to
spend more time using the ‘rib margin’ method (3, 4).
1. Ibrahim W H. Recent advances and controversies in adult
cardiopulmonary resuscitation. Postgraduate Medical Journal 2007;83:649-
654
2. Part 4: Adult basic life support. Circulation. 2005;112:IV-19 – IV
-34.)
3. Nolan J P, Deakin C D, Soar J, Bottiger W, Smith G. European
Resuscitation Council Guidelines for Resuscitation 2005. Section 4:
Advanced Life Support. Resuscitation (2005) 67S1, S39—S86
4. Adult basic life support. http://www.resus.org.uk/pages/bls.pdf
5. Lapostolle F, Le Toumelin P, Agostinucci JM, Catineau J, Adnet F.
Basic cardiac life support providers checking the carotid pulse:
performance, degree of conviction, and influencing factors. Acad Emerg
Med. 2004; 11: 878–880
6. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I.
Checking the carotid pulse check: diagnostic accuracy of first responders
in patients with and without a pulse. Resuscitation. 1996; 33: 107–116
Adrenal crisis is a medical emergency. If suspected treatment should be started as soon as possible. Every emergency physician should be familiar with adrenocortical insufficiency—a potentially life-threatening entity. The initial diagnosis and decision to treat are presumptive and are based on history, physical examination, and, occasionally, laboratory findings. Delay in treatment while attempting to confirm this diag...
In reply to Dr Koprowski's letter, we would like to point out that the absence of rigorous evidence supporting the efficacy of individualised herbal medicine shown by our systematic review remains fact - regardless of how the various types of individualised herbal medicine are categorised. If we had examined only individualised traditional oriental herbal medicine, we would have found even less evidence. If there is "act...
Response to: R Guo, PH Canter, E Ernst. A systematic review of randomised clinical trials of individualised herbal medicine in any indication. Postgrad Med J 2007;83:633-637
From: Ally Broughton Bsc (Hons) MNIMH Director of Research for, and Member of, the National Institute of Medical Herbalists (NIMH) Contact: ally.broughton@blueyonder.co.uk
I am a trained herbal practitioner of 12 years and teach resea...
Thank you, Peter Canter, for your e-letter in the Postgraduate Medical Journal.
We find it somewhat shocking that you think herbal medicines are no better than a "placebo." This belies the facts.
In America, in states like Florida, acupuncturists are licensed as "acupuncture physicians" and are considered by medical regulatory authorities to be primary care practitioners, who can also dispense herbs, a...
I enjoyed reading the article on 'testis cancer' by Khan et al.I agree with the authors that the survival rate has increased over the past few years.The authors have rightly pointed out the role of chromosome in causing such anomalies while the primordial germ cells are undergoing cell division.While going through the risk factors,I would certainly like to highlight the exposure of dyes and paints.The dyeing agents are kn...
Editor - We carefully read the recent Wheatley and Baker paper. (1) As they emphasised, the place of death persists at present as a very important issue for every person and for health care services.
One of the most typical signs of western societies during the past century was the ever-increasing proportion of patients who died at hospitals. This new panorama was due to several reasons, but undoubtedly it was...
Editor,
In their helpful review article, Kearney and Dang advocate giving hydrocortisone to suspected adrenal crisis pending ACTH stimulation testing. Many authorities suggest the use of dexamethasone prior to testing as it does not interfere with cortisol assay (eg. Webb et al 1999, Shenker et al 2001). Can the authors justify their postponement of confirmatory tests?
Yours sincerely
Mark...
Dear Editors
We thank E. J. Koprowski for her/his comments on our recent systematic review of individualised herbal medicine which reveal that s/he has totally misunderstood the nature of our review in several respects.
Firstly, we were not at all interested in homeopathy as s/he seems to believe. We can only surmise that s/he is confusing homeopathy with Western medical herbalism which was included....
Dear Editors,
A recent article, A systematic review of randomized clinical trials of individualized herbal medicine in any indication, published in October, 2007 in the Postgraduate Medical Journal, by R. Guo , P. H. Canter , E. Ernst, of the Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, U.K., warns public health authorities that the effectiveness of individualized, herbal medicine...
Dear Editor,
It is with interest that I have read the article by Dr Wanis Ibrahim titled Recent advances and controversies in adult cardiopulmonary resuscitation (1) in which the changes to the guidelines and the evidence for these is summarised.
I note that the differences in the cardiopulmonary resuscitation (CPR) guidelines between the American Heart Association (AHA) and the European resuscitati...
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