Ahead of Their Time: How doctors are rethinking the growing problem of preterm births--by focusing on the moms, not the babies.

Coco Masters

In the U.S., one of the richest countries in the world, the number of babies born too early keeps going up--and with all their medical savvy, doctors can't figure out why. Today nearly 13 out of every 100 births are premature, an increase of 30% over the past 20 years. Part of that rise is due to the advent of modern fertility treatments, which caused a sharp jump in the number of twins, triplets and higher multiples--most of whom are born early.
But it turns out that 83% of preemies in the U.S. are singletons whose prematurity can be caused by any number of factors, including bacterial infections, ruptured membranes, cervical abnormalities, high blood pressure, stress, inflammation and the effects of smoking and alcohol consumption.
So now doctors are starting to rethink their approach to the problem of prematurity, which is defined as being born at least three weeks shy of a full 40-week term. Rather than focusing primarily on the care of the newborn, they are going back to the beginning of pregnancy and paying a lot more attention to the health of the mother.
You can see the new approach in action at the University of Kentucky's Chandler Medical Center in Lexington, one of six hospitals to be named this week as lead participants in a 3 1/2-year, $1.5 million joint project aimed at reducing preterm birth, sponsored by the March of Dimes and the Johnson & Johnson Pediatric Institute.
What immediately draws your eye at the hospital is the neonatal intensive care unit (NICU)--where up to 30 babies at a time spend their first days and weeks tangled in tubes and wires, struggling to keep warm and learning what full-term babies already know: how to breathe, suckle and swallow. Zachary Sean Noble is one of the smallest. Born three months early at 1 lb. 7 oz.--as light and fragile as a carton of eggs--he can breathe only with the
help of a ventilator. As he sleeps, his tiny chest heaves and the translucent fingertips of his right hand open and close over his crumpled face.
Zach represents what used to be the cutting edge in pediatrics: the heroic effort to keep younger and younger babies alive. Today neonatal specialists can ensure the survival of up to 95% of infants born preterm. But as Dr. William Callaghan of the Centers for Disease Control and Prevention's Division of Reproductive Health puts it, "We're reaching down to the limits
of our viability." That is why he, like many other experts in the field, is advocating a shift in focus from survival to prevention.
The change in philosophy comes not a moment too soon. Preterm births account for more than a third of all infant deaths in the U.S. and cost Americans $26.2 billion a year. And although many of the half a million preemies born in the U.S. each year go on to live long, healthy lives, for too many the problems of their entry into the world are compounded by long-term complications ranging from mental retardation and cerebral palsy to hyperactivity and respiratory disorders. "We all bear the costs," says Dr. RuthAnn Shepherd, director of the Kentucky department of health's division of adult and child health improvement.
One of the reasons Kentucky was singled out for special attention is that its rate of preterm births--1 in 7--is one of the highest in the nation. The Chandler Medical Center's is even higher, a stunning 27%. But that's in large part because so many high-risk patients are transported to its state-of-the- art NICU facility, designed to accommodate the most vulnerable newborns. Like many other teaching hospitals, the medical center could be viewed as a victim of its success. But Dr. James Ferguson, chair of the University of Kentucky's department of obstetrics and gynecology and a seasoned professor who flashes a smile when he says things you should pay attention to, sees an opportunity in his hospital's large number of preemies. As part of the March of Dimes project, Chandler has set a goal of reducing late preterm singleton births 15%.
Taking a cue from earlier interventions that singled out one factor or another and failed to make a dent in the problem, the March of Dimes is trying what medical director Dr. Nancy Green calls a "kitchen-sink approach." Much of its focus is on the nuts and bolts of a healthy pregnancy: screening for bacterial infections, watching for signs of domestic violence, discouraging alcohol consumption, encouraging smoking cessation (1 in 4 pregnant women in Kentucky smokes), monitoring weight gain and nutritional intake and, when necessary, giving drugs to prevent preterm labor. Weekly injections of a progesterone- based drug after week 16, for example, can reduce the recurrence of premature births by one-third.
A major emphasis of the new project is on educating the public about the dangers of preterm labor--and reminding physicians that a vacation, for instance, isn't a good-enough reason to schedule an early delivery. The assumption: if mothers knew the real risks of prematurity, they would be less likely to request induced labor or a C-section and would stick out the pregnancy to term.
The project is also focused on the final three weeks of pregnancy, a time when most mothers-to-be assume they are out of the woods. But as Dr. Henrietta Bada, chief of neonatology at the University of Kentucky, explains, those last few weeks in the womb are critical for a newborn's development. The health risks for a baby born at week 35, she says, are more like those of a baby born at week 30 than one born at week 37. "The perception is that a big baby--even if he's premature--is going to act like a term baby. He's not."
Nobody understands those risks better than Zach's parents, Sean and Terri Noble. Terri, 34, suffered from pregnancy-induced high blood pressure, a condition that can often be treated if caught early enough but that in Terri's case led to severe preeclampsia and the emergency C-section that saved her life--and that of her tiny son. His life, she says, "is a miracle." The true miracle, however, might be to keep babies like Zach from being born too soon. (Time)

The Long & the Short of Pregnancy

Jeffrey Kluger

Parents have always had a lot of reasons to plan carefully how far apart they space their kids.
Now there's one more: Get the timing wrong and you can dramatically increase the risk of having a premature or underweight baby (less than 5.5 pounds). That's the conclusion of a massive meta-analysis- a sort of study of studies-in the April 19 issue of the Journal of the
American Medical Association.

Around the world, more than four million children die each year in the first four weeks of life and 28% of those deaths are thought to be related to prematurity or low birth weight. Those numbers don't take into consideration the impact preterm birth or small size can have on overall health and mental development of the babies who do survive.

Investigators gathered research papers on childbirth published across a 40-year period from 1966 to 2006-reflecting more than 11 million pregnancies- to determine the role birth spacing played in the babies' size.
In general, the study authors found that there was a wide sweet-spot of 18 to 59 months in which timing does not have much effect.

For every month shorter than 18 months, however, there was a 1.9% greater risk of a preterm baby and a 3.3% jump in the likelihood of a low-birthweight baby. For each month beyond 59 months, those same risks increased 0.6% and 0.9%, respectively. None of those figures by themselves is overly troubling. But the months go quickly and if you fall even a bit too far on either side of the divide, the danger grows just as fast.
What it Means: The answer, as with so many other childbirth worries, is family planning. Nothing will entirely eliminate the risk of the unplanned pregnancy-the so-called oops baby. But simple measures can help: good contraception, for example, and awarenes of mom's ovulatory cycles and how those cycles can change over time.

Breastfeeding exclusively for the first six months of the child's life can also make an enormous difference. Not only does breast milk confer all manner of nutritional and immune advantages on a newborn, but it also delays the resumption of the mother's menstrual cycle. While this is not by itself an effective means of birth control, it does make conception a lot harder.
(Time)

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TRANSLATE VIA TRANSTOOL VER. 9.000
Maaf belum sempat diedit. Moderator
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[Panjang/Lama] & Kekurangan Kehamilan
Jeffrey Kluger

Orang tua sudah selalu mempunyai banyak pertimbangan untuk merencanakan secara hati-hati berapa banyak terpisah mereka [ruang;spasi] anak kambing mereka.
Sekarang ada satu lagi: Dapat/Kan pemilihan waktu [itu] bersalah [kepada] dan kamu dapat secara dramatis meningkat/kan resiko mempunyai;nikmati suatu bayi terlalu ringan atau prematur ( kurang dari 5.5 pon). Itu kesimpulan suatu meta-analysis- a raksasa(masive) sort; jenis studi studies-in April 19 isu Jurnal Asosiasi Medis Amerika.

Di seluruh bumi, lebih dari empat juta anak-anak mati tahun masing-masing di (dalam) yang dulu empat minggu hidup dan 28% kematian itu semua adalah pikir untuk dihubungkan dengan prematuras atau kelahiran rendah menimbang. Angka-Angka itu tidak mempertimbangkan dg seksama dampak [itu] preterm kelahiran atau ukuran kecil dapat mempunyai pada [atas] keseluruhan kesehatan dan mental pengembangan bayi [siapa] yang survive.

Penyelidik mengumpulkan dokumen riset tentang kelahiran bayi yang diterbitkan selama periode 40 tahun (dari 1966 - 2006) yang mewakili lebih dari 11 juta kehamilan untuk menentukan peran jeda kehamilan dapat mempengaruhi ukuran babies'.

Secara umum, pengarang studi menemukan bahwa ada suatu sweet-spot [yang] lebar/luas 18 [bagi/kepada] 59 bulan di mana pemilihan waktu tidak mempunyai banyak efek.

Karena tiap bulan lebih pendek dibanding 18 bulan, bagaimanapun, ada suatu 1.9% [yang] lebih besar resiko suatu preterm bayi dan suatu 3.3% melompat kemungkinan a low-birthweight bayi. Karena masing-masing bulan di luar 59 bulan, [mereka/yang] resiko sama yang ditingkatkan 0.6% dan 0.9%, berturut-turut. Tidak satupun dari figur itu dengan sendirinya adalah sangat mengganggu. Tetapi bulan pergi dengan cepat dan jika kamu jatuh bahkan suatu bit [yang] [yang] jauh sebelah menyebelah membagi, bahaya tumbuh sama [halnya] puasa/cepat/ rapat].

Apa maknanya: Jawaban, [seperti/ketika] dengan sangat banyak lain keraguan kelahiran bayi, keluarga berencana. Tidak ada apapun akan seluruhnya menghapuskan resiko yang tidak direncanakan [itu]
pregnancy-the yang disebut oops bayi. Tetapi ukuran sederhana dapat membantu: baik kontrasepsi, sebagai contoh, dan awarenes ovulatory ibu beredar dan bagaimana siklus itu dapat bertukar waktu.

Breastfeeding eksklusif untuk yang pertama enam bulan hidup anak dapat juga membuat suatu perbedaan mahabesar. [Yang] tidak hanya mengerjakan susu dada menganugerahkan semua cara [dari;ttg] keuntungan kebal dan perihal gizi pada [atas] suatu baru lahir, tetapi [itu] juga keterlambatan penerusan siklus ibu haid. [Selagi/Sedang] ini adalah tidak dengan sendirinya suatu [alat/ makna] pembatasan kelahiran efektif, [itu] membuat konsepsi banyak lebih keras.
( TIME )

Alternative medicine

Dr. George Smith

Alternative medicine began to flourish at the end of the 1970s. Before then, therapies such as homeopathy, acupuncture, osteopathy and herbal medicine had dedicated adherents but were considered distinctly suspect and unconventional. In 1914 the UK General Medical Council (GMC) issued a warning notice to newly qualified doctors, directing that there should be no associating with unqualified persons or collusion with therapists using conventional or alternative therapies without appropriate qualifications and registration with the GMC.
The 1980s saw mushrooming interest in and practice of alternative therapies with medical and nursing journals such as The Practitioner and Nursing Times devoting increasing space to them. British Medical Association (BMA) commissioned various investigations. Although significant evidence for the efficacy and safety of such therapies did not emerge, official attitudes changed surprisingly. In 1991, Stephen Dorrell, UK Minister of Health, issued GP guidelines for the use of such therapies and relationships with alternative therapists.
Recent surveys suggest that almost half of the population in the UK use alternative therapies and over half of GPs practise or advise such treatments. Interest in alternative medicine has been closely paralleled with an interest in the New Age and Holistic Movement. Alternative medicine has been called its 'medical arm'.

Definition
The terminology has changed significantly over the years. When it was realised that alternative therapies could not replace conventional medicine, particularly in serious disease, 'alternative' gave way to 'complementary'. The term 'holistic' also became fashionable, implying treatment of the whole person (body, mind, emotions and spirit). At present 'Complementary and Alternative Medicine' (CAM) is generally being used but is now being superseded, particularly in the USA, by the term 'Integrative Medicine'.
Precise definition is very difficult. In the UK these therapies are described as 'those which are not widely used by orthodox medical professionals nor widely taught at undergraduate level in medical and paramedical courses'. A similar definition applies in the USA. However, these definitions are becoming blurred as an increasing variety of therapies are now being used in NHS primary care centres, wards and outpatient clinics.
CAM falls broadly into three categories:
Therapies such as acupuncture, yoga, reflexology and homeopathy, which have roots in either Eastern religion (Taoism or Hinduism) or in the concept of vital life force or energy. This is the largest group, often having New Age associations.
Medicines based on herbs such as St John's Wort and Ginko Biloba. These do not have spiritual associations in themselves; after proper evaluation, they could become part of conventional pharmacopoeia.
Systems of medicine such as naturopathy, ayurvedic medicine and Rudolph Steiner's anthroposophical medicine include perfectly sound advice on diet and lifestyle but are combined with one or more therapies from the first group.

Why is it so popular?
Disillusionment with Orthodox Medicine. Despite the pursuit of clinical excellence, there are problems in the NHS: inadequate finance and staffing, long waiting lists, postponement of operations and prevalence of resistant bugs (MRSA) in hospitals. Faults in the system contrast with easy access to alternative practitioners who give more time to patients, though at a price! Unfortunately, the personal doctor/patient relationship has become somewhat rushed and remote: reassuring touch has become less frequent than the click of a computer keyboard!
Iatrogenic Illness. This is understood as illness caused by doctors and their treatments and includes the toxic effect of drugs, allergic reactions, dosage mistakes and addiction to tranquilizers.
Royal Patronage. The Royal Family's interest in alternative therapies can be traced back to the use of homeopathy by Adelaide, wife of William IV, in the early nineteenth century. Homeopathy appears to have been practised by the Monarch until the present day and Prince Charles has been a strong advocate of this and other alternative therapies, drawing considerable attention to them during his term as President of the BMA. Much media attention has also
been focused on other members of the Royal Family as well as prominent figures in public and political life who use such therapies.
Religion and Culture. As a result of increasing transmigration between East and West, ethnic groups settling in the UK have brought their traditional cultures with them including methods of healing based on their religious beliefs.
Holism. By definition, holistic medicine includes caring for spiritual ill health. In these days, there is a greater awareness of the supernatural and spiritual, making the concept of 'whole person' medicine attractive. This means care under the direction and power of the Holy Spirit. Therefore, we need to beware of any opposing spiritual forces being involved through alternative therapies and therapists.

Comparison of essential principles
Conventional medicine is based on the facts of anatomy, physiology, biochemistry and pharmacology. Diagnosis depends upon symptoms, signs and scientific investigations such as blood tests and X-rays. The aim is to find a specific cause for the disease. Treatment aims to be evidence-based with a scientific evaluation of efficacy, dose and toxicity. Valid clinical trials
are very important and law strictly regulates it. It is essentially non-spiritual.
Alternative medicine is based on healing systems or concepts, folklore and 'individual revelations' . It is frequently rooted in Eastern religion, mysticism or vital force/energy. The diagnosis is essentially non-scientific (except when the practitioner is medically qualified) and may involve divination, the occult, astrology, dowsing or pendulum swinging. Treatment aims to be holistic, and the 'healing power' often relates to energies within oneself. Essentially, it involves a spiritual dimension but the concept of 'God' is of a cosmic force rather than a personal God. It is largely not regulated by law.
The underlying aim of treatment is to achieve a balance in the flow of energy: different cultures and therapies give these different names. The ch'i of acupuncture with its two components (yin and yang, representing negative and positive energy) is the most widely known.
In assessing individual therapies, there are some suspicious phrases: life force, cosmic/vital energy, flow of energy, blocked channels, lines of force, meridians, chakras, potentisation and natural magnetism. No valid scientific evidence has been presented for the existence of meridians, energy centres or chakras.
Practical assessment of alternative therapies needs to be considered from medical perspective, applying checklists to each therapy.

Checklist
Does it have a rational, scientific basis? Do the claims fit the facts? Does it work? Is there consistent, reliable evidence? Is it safe? Are there significant side effects? Taking into consideration the lack of scientific evidence available, can it be recommended with integrity?
What are its roots? Is it based on life force or vitalism?

Does it work?
Due to the admixture of techniques, rituals, medicines and belief systems involved in various therapies, it has been argued that standard forms of investigation and clinical trials (such as randomised controlled trials) cannot be applied to CAM. But what is the alternative? In the first British University Department of CAM at Exeter, Professor Edzard Ernst and his colleagues evaluate clinical trials and correlate information by meta-analysis with meticulous care producing FACT, a quarterly journal, as well as holding a yearly international conference.
Whilst investigations show varying degrees of promise, there is little conclusive evidence. When alternative therapies appear to work, this may be due to inaccurate diagnosis, natural remission, concurrent use of conventional treatments or to the placebo effect, when the patient may feel better without significant improvement in the pathological process.
Professor Ernst believes that there is 'an astonishing and embarrassing lack of knowledge and information' on the subject of CAM, even that relating to the most fundamental question: 'Does CAM work and is it safe?'
A 1986 BMA investigation into CAM concluded that the evidence for efficacy was scanty. This view was reiterated in 1997 when Health Watch interviewed Professor J Howell, chairman of the BMA's Board of Science and Education. The careful review in Which? Guide to Complementary Therapy is prefaced by the warning, 'Many complementary practitioners are well aware that they still have to prove to the world that their therapies work'.
Investigation of individual therapies produces little convincing evidence for their effectiveness. There are a few apparent exceptions such as acupuncture for dental pain, nausea and vomiting as well as chiropractic and manipulative treatment for back pain. St John's Wort seems helpful for depression and Saw Palmetto may improve prostate enlargement but unwelcome side effects have been observed.

Is it safe?
The popular view of CAM is that its therapies are advertised as being natural, safe, free from side effects and perhaps 'God given'. Complete safety is by no means assured. Some medicines (such as some Chinese herbal preparations and aromatic oils) have been demonstrated as having toxic properties, particularly on the liver. Physical complications such as pneumothorax may arise from acupuncture. Cerebrovascular accidents and neurological damage have been recorded following chiropractic and other manipulative therapies. Whilst these complications may be uncommon, a particularly worrying aspect is possible delay or incorrect diagnosis,
especially if serious organic disease is missed and conventional treatment delayed. Tragedies do occur as a result. The 1997 Which? Guide states, 'Complementary medicine can be extremely harmful if used as a substitute for proper diagnosis and treatment'.

Conclusion
A salutary note was sounded in the New England Journal of Medicine: 'It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine - conventional and alternative.
There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. But assertions, speculation and testimonials do not substitute for evidence'.
Alternative medicine is a challenge to doctors and other care providers. Rather than being prejudiced, we need to be informed about therapies that are so popular and about which we are often asked. We need to respond with truth and integrity. Many of our patients are clutching at straws and we should be sensitive to this.
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What is Alternative Medicine?
Dr. Peter Saunders

One in four people in the UK use at least one form of alternative medicine; in the US and Germany the figures are even higher at 35% and 60% respectively. Three out of four people in the UK favour alternative therapies being available on the national health system (NHS).
One study cited by a recent BMA report suggested that there may be up to 15 million consultations to non-conventional therapists each year in the UK, with about 1.5 million people (2.5% of the population) each year receiving treatment.
The British Register of Complementary Practitioners has 1,000 members and the number is rising by 10% per year. A survey in the UK in 1980 suggested that there were 12.1 non-medically qualified practitioners per 100,000 population - 27% of the number of general practitioners. In addition, 35% of UK GPs have received some training in alternative medicine. In Denmark there are 2,000 registered complementary practitioners and only 3,200 general
practitioners.
In most member states of the European Union (eg Belgium, France, Spain, Italy and Greece) the practice of medicine by non-recognised health professionals is illegal. In Germany and Scandinavia there is some regulation but in the United Kingdom and Ireland there is virtually no regulation at all.
Two exceptions to this state of affairs are osteopathy and homeopathy. The Osteopaths Bill in 1993 established a statutory register and a governing body, the Osteopaths Council; and the UK faculty was set up in 1950 to train and examine homeopaths.
The United Kingdom is the only EU country with complementary medicine hospitals in the public sector. There are five such hospitals in London, Glasgow, Liverpool, Bristol and Tunbridge Wells.
In the main however, practitioners of alternative medicine are unregulated in the UK and when considering the tight controls on the training and practice of orthodox medical practitioners there is clearly a double standard operating.

What is alternative medicine?
Problems of definition
The report of the BMA's Board of Science and Education's working party, Complementary Medicine, New Approaches to Good Practice defines non-conventional therapies as 'those which are not widely used by orthodox medical professionals nor widely taught at undergraduate level in medical and paramedical courses' - but this varies throughout Europe. Some therapies which would be regarded as alternative in the UK are taught formerly elsewhere as part of the normal undergraduate syllabus.
The three terms complementary, alternative and holistic are used almost interchangeably - but convey different messages. The word 'alternative' implies an either/or relationship with orthodox medicine; 'complementary' a both/and relationship and 'holistic' implies that non-orthodox therapies treat the 'whole person'. All these presuppositions are controversial in
themselves.

The Diversity of Therapies
The BMA report says that as many as 160 different forms of non-conventional therapy have been identified. The most common and best known in an A to Z listing are:
Acupuncture - A branch of Chinese medicine involving insertion of needles beneath the skin at various pre-defined points.
Acupressure - Similar to acupuncture but involving finger massage rather than needles.
Alexander Technique - Teaching about the use of posture to relieve back or neck pain or headaches.
Aromatherapy - The use of plant oils for massage, bathing, inhaling or taking internally.
Auricular Therapy - Insertion of needles into the ear to treat illnesses all over the body.
Bach Flower Remedies - Infusions from wild plants and trees are taken internally.
Chiropractic - Manipulation and massage of joints, particularly in the spine to treat predominantly musculoskeletal disorders.
Crystal Therapy - Based on the idea that crystals and gems have healing properties; and involves placing them on various parts of the body or
meditating upon them.
Herbs - Plants or herb-based remedies are taken internally or rubbed in as creams.
Homeopathy - The treatment of diseases by compounds which produce the same symptoms, but which have been diluted many thousands of times.
Hypnosis - The use of suggestion, imagination or mind control to bring about a change in behaviour or conscious state.
Iridology - Diagnosis based on the analysis of colour patterns in the iris.
Macrobiotics - Diets consisting of combinations of vegetables which have been prepared in certain prescribed ways.
Massage - A variety of different forms.
Naturopathy - Based on the idea that the body can be stimulated to heal itself through a variety of means including herbal remedies and manipulation.
Osteopathy - Manipulation of spinal joints or soft tissues allegedly to stimulate nerve supply and/or lymphatic drainage.
Reflexology - Massaging of prescribed points on the sole of the foot which are believed to apply to certain internal organs, in order to treat disease.
Shiatsu - Essentially a Japanese form of acupressure involving manipulation of body surface points.
Therapeutic Touch- Use of the hands hovering several inches away from the body to discern the presence of disease and heal it.
Yoga and Transcendental Meditation - Healing through adopting different body positions or mental states.
Zone Therapy - Similar to reflexology; pressure on predefined body points to effect healing of internal organs.

'Life force' and 'vital energy'
On first glance there seems to be very little similarity between one form of alternative medicine and another; but what unifies most of them is the idea of 'life force' or 'vital energy' which ensures health, becomes disrupted in disease and can be manipulated by various means. For example let us consider acupuncture:
Underlying this form of Chinese alternative medicine is the belief that there is a vital force or energy called 'Chi' which flows freely through the body in twelve meridians or channels. The flow of this energy depends on the balance between two opposite forces: an active, 'male' force called 'yin' and a passive, 'female' force called 'yang'. There are supposedly 6 yin meridians passing through the 'storage' organs (eg heart, liver and spleen) and 6 yang meridians passing through the 'hollow' organs (eg intestine). For example the yang meridian serving the colon passes through the index finger, arm, neck and nose.
When the flow of the Chi energy is free and uninterrupted health is ensured but if the balance between yin and yang is disturbed or if there is any blockage to energy flow then disease results.
Acupuncture is based on the ancient Chinese religion of Taoism which has Chi, yin and yang as fundamental concepts.
Ideologies which underlie other forms of medicine use different words for the same general concept of 'life force'. Shiatsu is based on Shintoism and calls the energy 'Ki'. Yoga and TM are based on Hinduism and call the force 'prana'. Homeopathy uses the term 'vital energy', chiropractic 'innate intelligence' and Maori medicine terms the life force 'mana'.

The common theme of 'correcting imbalance'
In most alternative therapies health is believed to be restored by relieving blockage and restoring flow in the 'life force', but the means whereby this is achieved vary widely. So for example the following modalities use the methods listed:
Modality Method
Acupuncture Needling
Homeopathy Minute doses of diluted medicine
Reflexology Foot massage
Aromatherapy Aromatic Oils
Yoga Adopting Body Postures
Transcendental Meditation Meditation
Therapeutic Touch Hovering hands
Macrobiotics Diet

Why is Alternative Medicine so popular?
There are seven main factors accounting for the rise in popularity of alternative medicine in the Western World.

The failings of orthodox medicine
There have been great advances in orthodox medicine over the last two centuries which have led to the eradication and alleviation of many diseases which were previously neither preventable nor curable: immunisations for smallpox, antibiotics for infection, anti-psychotics for schizophrenia, chemotherapy for cancer, drugs for heart failure and surgery for a whole
host of structural and anatomical problems.
But medicine also has its limits. We do not yet know what new treatments the genetic revolution will bring; but there are presently illnesses where we have a long way to go. Solid tumours (eg lung, breast and bowel) are in general difficult to treat if surgery fails. There is still much progress to be made in chronic diseases like multiple sclerosis and rheumatoid arthritis, and there is still no orthodox cure for musculoskeletal back pain and the common cold. If we also consider that 75% of people seeing their doctor do not have any defined organic illness, it is easy to see why people may decide to consult alternative practitioners. Patients may also become
impatient or disillusioned with the NHS system of referrals and waiting lists.
With some diseases alternative medicine fares no worse than orthodox medicine and it is in these areas that alternative medicine thrives.

Medical arrogance
Orthodox doctors have not always been ready to admit failure; and on occasions may go on using treatments of doubtful value, or with potential side-effects rather than simply stating that nothing else can be done. The inappropriate use of some chemotherapeutic agents or radical surgery for advanced cancer, for instance, may cultivate distrust in patients who then
seek other solutions.

The side-effects of orthodox medicine
Some orthodox medicines and surgery can produce side-effects; sometimes these are fatal. Such cases are widely publicised often by an unforgiving press.
The thalidomide disaster is one of the best-known events of medical history, when the children of mothers given a drug for pregnancy-related nausea and vomiting were born with limb defects.
The effects of non-steroidal anti-inflammatories in producing gastrointestinal bleeding, or chloramphenicol in producing pancytopenia are less well known, but horror stories in tabloid newspapers, instead of just inducing sensible caution, can lead patients to be suspicious of all
orthodox medicine or surgery.
Most alternative medicine has little in the way of side-effects (although there are notable exceptions which we will come to later). Sceptics may say that alternative medicine is generally ineffective in treatment as well, and that is why its side-effects are in general less marked.

Loss of a whole person perspective
Advances in the science of medicine may have been at the expense of the art of medicine. Doctors have less time for the patient, touch patients less often, and perhaps are tempted much more, now that they can do so such more, to treat their patients simply as anatomical structures or biochemical machines.
By contrast alternative medical practitioners generally are able to give much more in terms of time and touch, thereby engendering more trust. Whereas a famous text by Balint on medical consultation has been titled 'Six minutes for the patient', homeopaths may spend up to 90 minutes in a first consultation and 45 minutes on follow up.
There is much less in medicine now of the ritual handshake, pulse-taking, hand on the shoulder etc. Too often the doctor is now esconced behind his PC and perhaps a formidable desk; while many alternative therapies involve plenty of 'hands-on' diagnosis and treatment.
This volume of time and touch ultimately builds up trust. 'He must know what he is doing because he spends so much time with me'.

Costs of high-tech medicine
At the time the case of Tony Bland was going through the courts, the public were shocked to hear that the care of patients in persistent vegetative state (PVS) costs the country about £30 million every year. High-tech medicine is expensive, while often the only cost of alternative medicine is the therapist's time.
This is one feature making alternative therapies increasingly attractive to NHS managers looking to cut costs; as the poem with which we started cynically demonstrates.

Consumer demand
The final reason alternative medicine is more popular is consumer demand. Patients are prepared to pay for therapies which promise what orthodox medicine has failed to deliver; especially for incurable cancer or chronic pain. This demand has meant that there is plenty of room in the market place for more practitioners.

Why does Alternative Medicine seem to work?
Why is it that so many people are seeking alternative medicine therapies when so many of them have been shown not to work in clinical trials? Why do they seem to work? There are at least ten reasons why.

1. Genuine therapeutic effects
Some alternative medicines do genuinely work. Over half of prescription and over the counter drugs originate as natural compounds or are based on them (eg aspirin, digitalis, morphine, adrenaline, curare, all antibiotics except the quinolones etc); and reports from a recent New York Conference suggest that the natural world may hold many more therapeutic treasures.
Dramatic examples in the public health field this century have included iodide in preventing goitre, fluoride in preventing dental caries and folate in lowering the incidence of neural tube defects. Examples given of new natural compounds now under trial or in clinical use include the new anticancer agents paclitaxel (from tree bark) and eleutherobin (from a Caribbean sea squirt); the anticoagulant echistatin (from the Indian tree viper); the antibiotic apicidin (from a Costa Rican fungus) and the analgesic ziconotide (from a poisonous cone snail). It is quite conceivable that some alternative medicine practitioners are using compounds which are not yet known to orthodox medicine. But if this is the case then we need to discover what they are so that they can be isolated and given in the correct dose!

2. Belief in the therapist
Belief in the ability of the therapist can become a self-fulfilling prophecy. If we strongly believe that someone has the power to help us, then we are much more likely to experience a placebo effect.

3. Belief in the therapy (placebo)
It is a fact that one third of people given an inert compound to relieve a particular symptom will report relief of that symptom. This is called the placebo effect. Belief alone in the treatment will account for all the improvement seen in some people.

4. The use of other therapies concurrently
Belief in an alternative therapy's effectiveness may develop when it is used concurrently with another more effective orthodox therapy. The effect is then wrongly ascribed to the alternative therapy.
For example, acupuncture may be used in conjunction with anaesthesia for pain, a macrobiotic diet in conjunction with radiotherapy for cancer or homeopathic remedies in conjunction with prescription drugs.

5. Psychosomatic illness
Many illnesses are psychosomatic; in other words a patient's stress level or mental state can aggravate the symptoms. Asthma, eczema, peptic ulcer and rheumatoid arthritis fall into this category. Any alternative therapy which induces relaxation may then improve the
symptoms.

6. Spontaneous remissions
Many diseases spontaneously remit, in other words they get better by themselves. This is particularly true of viral infections. The common cold is an obvious example; a less obvious one is warts. People may well then attribute the therapeutic effect to the remedy they were trying at the time of recovery, when in fact their improvement at that time may just have been coincidence. This is called the post hoc, propter hoc fallacy; in other words 'because B followed A, the A must have caused B'.
Other diseases, like malignant melanoma - an aggressive skin cancer, may sometimes spontaneously regress. Again wrong inferences can be made.

7. Dietary influences
There is a strong link between diet and health, and many alternative therapists, in addition to recommending, say, homeopathic remedies may suggest a change of diet. The resulting improvement may then be due to the change in diet, rather than the alternative therapy.
Many alternative therapists will, like doctors, recommend that a patient drinks less coffee or alcohol, eats less fat or more fibre or vitamins etc.

8. Same world-view shared by patient
Patients who share the therapist's belief in New Age pantheism, or the existence of 'life force', 'energy fields' or auras will be more likely to benefit from the placebo effect.

9. Imagined improvement
Some patients, especially if open to suggestion from others that they 'look better', may simply imagine that they 'feel better'; especially if the symptoms were of a vague nature in the first place. Alternatively they may simply grow used to tolerating the symptoms and deduce that it is the symptoms rather than their tolerance of them which has changed.

How do we assess individual modalities?
It is not possible to comment in detail here on each and every branch of alternative medicine; my intention is to give seven principles that can be applied when assessing any given therapy.

1. Does it work? (ie Do the claims fit the facts?)
Any new orthodox medicine has to undergo extensive pharmacological testing to assess its therapeutic potential, side-effects and interactions with other drugs. Tests are first carried out in animals, then in human volunteers and only then are short and long term studies carried out on real patients.
The drug, if it passes these tests, must then be passed by the appropriate drug regulatory authorities. In the UK this responsibility lies with the Health Ministers for England, Scotland, Wales and Northern Ireland who together form the Licensing Authority. The Medicines Control Agency is an agent of the licensing authority and has the power to ensure that legal requirements are met. These safeguards ensure that drugs reaching the public are both safe and effective.
In the same way medical practitioners must undergo a five year undergraduate training and then work for a further year before they are registered and able to practice independently of an NHS institution.
Similar safeguards for alternative medicines and practitioners are largely absent in the UK. There is simply no comparison between the double-blind, randomised, placebo-controlled cross-over trials which many orthodox drugs undergo and the subjective anecdotal 'evidence' supporting much alternative medicine.
Some alternative therapies may not lend themselves to this level of rigorous investigation but it is mandatory that good evidence is sought of their safety and efficacy. When such trials are employed the results are often inconclusive:
For example, recently published research has demonstrated that practitioners of 'therapeutic touch' are unable to detect the 'human energy fields' they claim to rely on for diagnosis and treatment. In the study 21 practitioners detected the presence of a human hand behind a screen less than 50% of the time.
Therapeutic touch involves passing hands a few inches above a patient's body to 'repattern energy flow'. Despite the lack of objective evidence for its efficacy, proponents say that more than 100,000 people world-wide have been trained in the technique, including 43,000 healthcare professionals.
Likewise a 1990 French review of 40 controlled trials on homeopathy concluded that the majority were flawed by small sample size and subjective measures of improvement. A 1991 review of 107 trials was similarly inconclusive.
By contrast there is some evidence that patients with low back pain treated with chiropractic derive more benefit and long term satisfaction than those treated by hospitals; and acupuncture is an effective treatment for nausea and vomiting induced by anaesthesia, pregnancy or chemotherapy, according to a consensus panel of the US National Institutes of Health.
A Department of Complementary Medicine has recently been set up at the University of Exeter to review trials on alternative and complementary therapies. The contents pages of their quarterly journal FACT (Focus on Alternative and Complementary Therapies) are available on the internet and make interesting reading. But it would be fair to say that many of the published studies give inconclusive results.
The injunction to 'enquire, probe and investigate thoroughly' must surely be relevant here. We should always ask, 'What is the evidence that it really works?'

2. Does it have a rational scientific basis?
We know how most orthodox drugs work. They may stimulate receptors (eg bagonists in asthma), modify cell transport (eg probenecid), block enzymes (eg allopurinol) , replace missing compounds (eg vitamin B12) or chelate toxins (eg penicillamine) .
The action of any given drug is determined by its concentration at the site of action; and the actions are understandable in view of their known biochemical and physiological effects.
By contrast the majority of alternative medicines have no rational scientific basis.
Homeopathy involves diluting an active compound to such a degree that the resulting 'potency' contains not even a molecule of the original active ingredient.
Iridology claims to link each area of the iris with a separate part of the body when it is known that no such connections exist. This is not to deny that the iris can give clues to such conditions as ochronosis, Wilson's disease or hypercholesterolemi a; but in these cases there is a good scientific explanation for the iris' changes.
Reflexology is based on the belief that there are connections between the sole of the foot and internal organs; again in the absence of any scientific evidence.
There is similarly no evidence for the existence of the 'meridians' (energy channels) of acupuncture, the 'chakras' (psychic spinal centres) of yoga or the 'innate intelligence' of chiropractic.
In some cases an alternative therapy may be working because of some scientific reason unknown to the therapist. It has been suggested, for instance that the therapeutic effects of acupuncture could be explained by the release of endogenous (naturally produced) pain-killers called endorphins. If this is indeed confirmed, then acupuncture will be shown to have a scientific basis, but this will not, by any means prove that Taoist ideology is true or that Chi energy exists.

3. Is it the methodology or the principle?
Transcendental Meditation lowers blood pressure, but why? Is it because it causes the Goddess Kundalini to migrate up the spine and unite with Brahman in the head (as Hindus believe), or is it simply that meditation induces relaxation and reduces the sympathetic output that raises blood pressure? Chiropractic has been shown to help low back pain, but is this because manipulation of the spine alters the flow of 'innate intelligence' or because it helps to alleviate musculoskeletal trigger points?
Recent research has demonstrated that close to 100% of pain sufferers benefit from sham acupuncture where needles are stuck into non-acupuncture points.
In each of these cases it seems to be the methodology rather than the principle of prana, innate intelligence or Chi that brings the therapeutic effect.
There is thus a world of difference between the GP who makes a diagnosis by taking a history and doing an examination and the alternative medicine practitioner who does it by examing an iris or swinging a pendulum. There is also a huge gulf between the GP who uses acupuncture on the basis of its proven effectiveness in clinical trials and the practitioner who uses it because he believes it alters the balance of yin and yang.

4. Is it medically safe?
Part of the attractiveness of alternative medicine is that the side-effects are generally minimal, however there are some exceptions.
Chiropractic manipulation of the neck can be associated with vertebral artery thrombosis and lateral medullary syndrome.
Acupuncture can cause pneumothorax and infection.
Herbal therapies are probably the most dangerous. An Indian eye remedy called surma was found to contain 85% lead and resulted in lead poisoning in children. In the UK in 1992 a traditional healer was sentenced to three years in prison after giving patients near fatal doses of mercury and arsenic; and some chinese herbal remedies have caused liver toxicity.
Other 'herbal' remedies have been shown to contain mixtures of prescription drugs; usually in below therapeutic or toxic quantities (eg antihistamines, steroids, antibiotics).
One of the main dangers of such remedies, even if they don't have toxic effects of their own, is that they delay diagnosis, produce a false sense of security and may interact with other prescription drugs that the patient may have obtained from orthodox sources.

5. Has it stood the test of time?
This is not a guarantee, as clearly many occult devices stand the test of time, but we can be equally sure that something which does not genuinely work and is not stand the test of time.

Applying the tests
As an example of applying the tests above let us consider homeopathy.
First, there is no clear evidence that it actually works.
Second, it has no rational scientific basis; there is no reason known to science why a solution containing not a single molecule of a given active substance should have any therapeutic effect.
Third, it is based on a pantheistic world-view with the concept of 'vital energy' playing a prominent role.
Fourth, practitioners will often use occult means (such as pendulums) in diagnosis. While it does appear to be safe and to have stood the test of time, these other considerations should make us very wary indeed.

Difficult Questions
Finally, let us finish by considering some of the objections which we might raise to the kind of critique I have just given.

1. Weren't many medical treatments initially 'natural' anyway?
This is correct (eg. aspirin (willow bark), digitalis (foxglove), Morphine (poppies)) but the natural ingredient needs to be clearly identified and given in the right dose. Many useful natural drugs are toxic if given in too high a dose (eg digitalis, opium).
Decisions about which compound to give must also not be based on occult practices (eg rituals, spells, charms, astrology, clairvoyance, pendulums, spirit guides etc) as previously mentioned.

2. How can something be wrong if it actually works?
We need to be sure that the given therapy does actually work. Have there been properly controlled clinical trials carried out showing that it is better than placebo, or is it supported simply by anecdotal testimony? We must be ready to test everything.

3. How do we know there's not some good in it?
It's often objected that we should not throw out the baby with the bath water; and there is some truth in this... but is the baby and bath water really a good analogy? It is very easy to see the difference between baby and bath water but often extremely difficult to separate out the good and bad in alternative medicine.
A better analogy is the poison mushroom. While poison mushrooms contain plenty of good fat, carbohydrate and protein we recommend that people don't eat them because it is impossible to separate out the good and the bad.

Summary
We have reviewed the rapid rise in popularity in alternative medicine, and seen that while therapies are diverse, there is a pantheistic ideology behind many of them.
Alternative medicine is popular because of changes in the Western world-view, the perceived failings, arrogance, costs and side-effects of orthodox medicine, and because it appears to bring a 'whole person' perspective.
While some therapies may genuinely work, apparent improvements are often due to other reasons such as spontaneous remissions, the use of concurrent orthodox medicine or the placebo effect.
Each branch of alternative medicine needs to be assessed individually to determine its effectiveness, scientific basis, mode of action, and safety.
We should use only those therapies which pass these tests.

Breast Disorders

Breast disorders may be noncancerous (benign) or cancerous (malignant). Most are noncancerous and not life threatening. Often, they do not require treatment. In contrast, breast cancer can mean loss of a breast or of life.
Thus, for many women, breast cancer is their worst fear. However, potential problems can be detected early when women regularly examine their breasts themselves and have mammograms.

Symptoms
Common symptoms include breast pain, lumps, and a discharge from the nipple. Breast symptoms do not necessarily mean that a woman has breast cancer or another serious disorder. However, if a woman has any of the following symptoms, she should see her family doctor:
a lump that feels distinctly different from other breast tissue or that does not go away swelling that does not go away puckering or dimpling in the skin of the breast scaly skin around the nipple changes in the shape of the breast changes in the nipple, such as turning inward discharge from the nipple, especially if it is bloody Breast Pain: Many women experience breast pain (mastalgia). Breast pain may be related to hormonal changes. For example, it may occur during or just before a menstrual period (as part of the premenstrual syndrome) or early in pregnancy. Women who take oral contraceptives or who take hormone therapy after menopause commonly have this kind of pain. The pain is due to growth of breast tissue. Such pain is usually diffuse, making the breasts tender to touch. Pain related to the menstrual period may come and go for months or years.
Other causes of breast pain include breast cysts, infections, and abscesses. In these cases, breast pain is usually felt in a particular place. Fibrocystic breast disease can also cause breast pain. Breast pain is occasionally due to breast cancer, but breast cancer does not usually cause
pain. Breast pain that persists for more than 1 month should be evaluated.
Mild breast pain usually disappears eventually, even without treatment. Pain that occurs during menstrual periods can usually be relieved by taking acetaminophen/ paracetamol or a nonsteroidal anti-inflammatory drug (NSAID).
For certain types of severe pain, danazol (a synthetic hormone related to testosterone) or tamoxifen (a drug used to treat breast cancer) may be used. These drugs inhibit the activity of estrogen and progesterone, which affect the breast. Because long-term use of these drugs causes side effects, the drugs are usually given for only a short time. Tamoxifen has fewer side
effects than danazol. Tamoxifen is used mainly for postmenopausal women but may benefit younger women.
If a specific disorder is identified as the cause, the disorder is treated. For example, if a cyst is the cause, draining the fluid from the cyst usually relieves the pain.
Breast Lumps: Lumps in the breasts are relatively common and are usually not cancerous. But because they may be cancerous, they should be evaluated by a family doctor without delay. Lumps may be fluid-filled sacs (cysts) or solid masses, which are usually fibroadenomas.
Other solid breast lumps include hardened glandular tissue (sclerosing adenosis) and scar tissue that has replaced injured fatty tissue (fat necrosis). Neither is cancerous. However, these lumps can be diagnosed only by biopsy. They require no treatment.
Nipple Discharge: One or both nipples sometimes discharge a fluid. A nipple discharge occurs normally during milk production (lactation) after childbirth or as a result of mechanical stimulation of the nipple by fondling, suckling, or irritation from clothing. During the last weeks of pregnancy, the breasts may produce a milky discharge (colostrum). A normal nipple discharge is a thin, cloudy, whitish or almost clear fluid that is not sticky. However, during pregnancy or breastfeeding, a slightly bloody discharge sometimes occurs normally.
Several disorders can cause an abnormal discharge. Abnormal discharges vary in appearance depending on the cause. A bloody discharge may be caused by a noncancerous breast tumor (such as a tumor in a milk duct, called an intraductal papilloma) or, less commonly, by breast cancer. Among women who have an abnormal discharge, breast cancer is the cause in fewer than 10%. A greenish discharge is usually due to a fibroadenoma, a noncancerous solid lump. A discharge that contains pus and smells foul may result from a breast infection. A large amount of milky discharge in women who are not breastfeeding may result from galactorrhea. Tumors of the pituitary gland or brain, encephalitis (a brain infection), and head injuries can also cause a
nipple discharge. Taking certain drugs, such as antidepressants and certain antihypertensives, can cause a nipple discharge. Taking oral contraceptives may cause a watery discharge.
A discharge from one breast is likely to be caused by a problem with that breast, such as a noncancerous or cancerous breast tumor. A discharge from both breasts is more likely to be caused by a problem outside the breast, such as a pituitary tumor, or by drugs. If a nipple discharge persists for more than one menstrual cycle or seems unusual to the woman, she should see a family doctor. Postmenopausal women who have a nipple discharge should see a family doctor promptly. Family doctors examine the breast, looking for abnormalities. Mammography and blood tests to measure hormone levels may be performed. Computed tomography (CT) or magnetic resonance imaging (MRI) of the head may be performed. The woman is asked for a complete list of drugs she is taking. Sometimes a specific cause cannot be identified.
If a disorder is the cause, the disorder is treated. If a noncancerous tumor is causing a discharge from one breast, the duct that the discharge is coming from may be removed. (Merck)

A New Breast Cancer Test

Dr. Sanjay Gupta

One of the toughest things I do as a physician is deal with uncertainty. Doctors are often only as good as their diagnostic tests, and those tests aren't perfect.
Too often we are forced to say, "You might have cancer"--which leads to lots of fear, anxiety and lost sleep.
It is also often the beginning of an arduous process of more tests and in some cases surgical procedures. The only way to be absolutely sure about cancer is to examine some of the suspicious cells under a microscope. That means a biopsy. And in the U.S. we perform more than a million breast biopsies a year. The results come back normal 8 times out of 10.
That may be good news for a lot of women, but it may also mean we are performing too many biopsies. For years, doctors have been looking for ways to cut that number down. That is why I was so encouraged by reports of a new technology unveiled last week at a meeting of the Radiological Society of North America.
It is called elasticity imaging and, unlike a biopsy, involves no needles or scalpels. Yet it appears--on the basis of an initial study--to be remarkably good at distinguishing benign lumps from cancerous growths.
For the patient, the test will feel and look no different from a standard ultrasound, in which a probe is used to peer deep into breast tissue and create an image using high-frequency sound waves. It takes two minutes longer to do a second scan and analyze the results with special software.
The initial ultrasound finds the lump, according to Dr. Richard Barr, author of the study. The second scan probes the lump's characteristics, including how much it moves or stretches--which is where the technology gets its name.
For reasons that aren't yet clear to Barr or anyone else, when the elasticity software is applied, the image of a suspicious lump becomes larger if the lump is cancerous. Conversely, a noncancerous lesion appears smaller in an enhanced image. Additionally, cancerous lesions have a characteristic pattern--a sort of stringy network--whereas benign cysts look like a well-defined bull's-eye.
It all sounds a little vague and subjective, but in Barr's hands, it seems to work. In a study of 80 women with 123 suspicious lumps in their breasts, elasticity imaging scored remarkably well. Subsequent biopsies showed that it correctly identified 17 out of 17 cancerous lesions and 105 out of 106 benign lesions. (There was one false positive.) Barr is understandably excited about the results. He envisions a day when this kind of technology might be able to eliminate biopsies altogether.
We are not there yet. One thing to consider is that ultrasound tests, unlike CT and MRI scans, are extremely operator dependent; the results could vary widely from facility to facility. Also, your doctor, like most other physicians, would probably want to see more studies of the new test before being comfortable with calling off a biopsy. Barr already has that in the works. He is preparing a multicenter international trial with 2,000 patients that will start in January and take about a year. In the interim, women should not forget a yearly mammogram starting at age 40. For now, it remains the gold standard of breast-cancer screening. (Time)