Clinical Briefs
With Comments from John La Puma, MD, FACP
Writing Therapy to Reduce Asthma and RA Symptoms
June 1999; Volume 2: 71
Source: Smyth JM, et al. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: A randomized trial. JAMA 1999;281:1304-1309.
To determine if writing about stressful life experiences affects disease status in asthma or rheumatoid arthritis (RA) patients using standardized quantitative outcome measures, we conducted a randomized controlled trial between October 1996 and December 1997. A volunteer sample of 112 patients with asthma (n = 61) or RA (n = 51) enrolled; 107 completed the study.
As the intervention, patients were assigned to write either about the most stressful event of their lives (n = 71; 39 asthma, 32 RA) or, as a control, about their plans for the day (n = 41; 22 asthma, 19 RA).
Asthma patients were evaluated with spirometry and RA patients were examined by a rheumatologist at baseline, and at two weeks, two months, and four months. The evaluations were done blind to the experimental condition.
Of evaluable patients four months after treatment, asthma patients in the experimental group showed improvements in FEV1 (63.9% at baseline to 76.3% at four months; P < 0.001); controls showed no change. RA patients showed reduced mean disease severity from 1.65 to 1.19 (28% on a scale of 0 [asymptomatic] to 4 [very severe] at four months; P = 0.001); controls showed no change. Combining all completing patients, 33 of 70 (47.1%) experimental patients had clinically relevant improvement; nine of 37 (24.3%) controls also improved (P = 0.001).
COMMENT
Every writer knows that writing can be therapeutic, even if it hurts. But only when it hurts?
These Stony Brook investigators excluded patients with a defined psychiatric disorder, in psychotherapy, or on mood-altering medications (including prednisone, >10 mg/d). Patients were told that the investigators were interested in the patients’ experiences of stress. The patients did not discuss their writing with staff or other participants and wrote in private for 20 minutes on three consecutive days a week after completing baseline disease severity assessments, which were comparable.
Nearly all patients were Caucasian, well-educated (mean two to three years of college), and averaged a mean annual family income of $66K (RA) and $50K (asthma). Nearly all used medication regularly. Less than 10% of each group smoked, and 49% of each group got regular exercise.
The authors report that observation of participants in similar writing sessions show "considerable emotional upset during the writing sessions." These patients most commonly wrote about the death of a loved one, serious problems of a close other, and problems in relationships.
Not noted was whether and how medication regimens changed over time; to what mechanism physicians attributed patients’ assessed improvement; what patients thought of the intervention; or which symptoms specifically improved. Asthma patients’ FEV1 ratings improved at two weeks and at each follow-up visit; RA patients’ current clinical status assessment did not improve until four months.
Many physicians regularly receive long letters from patients describing household events and personal problems. The possibility of actually prescribing such writing assignments and asking patients to write expressively as part of their chronic disease management is intriguing and refreshing.
Recommendation
Structured, systematic trials assessing the usefulness of expressive writing are a logical, important next research step. Taking a pen in hand is low cost, noninvasive, and personal. Providing a writing tablet and 20 minutes free of other distractions are generous gifts. Prescribed by a caring clinician, the combination seems low risk and potentially therapeutic.
Dangers of Asian Patent Medicines
June 1999; Volume 2: 71-72
Source: Adult lead poisoning from an Asian remedy for menstrual cramps—Connecticut, 1997. MMWR Morb Mortal Wkly Rep 1999;48:27-29.
A case of adult lead poisoning attributed to an Asian remedy for menstrual cramps, "Koo Sar" pills, is reported. A 33-year-old Cambodian woman, her husband and their two children were screened at a free lead-screening event sponsored by a nursing school community health promotion center. The husband had a blood lead level (BLL) of <10 mcg/dL, and the children, aged eight and two years, had BLLs of 2 and 3 mcg/dL respectively. The woman, however, had a BLL of 44 mcg/dL and a confirmatory BLL two weeks later of 42 mcg/dL. The woman reported no symptoms associated with lead poisoning (e.g., muscle pains or weakness, headaches, or loss of appetite).
The woman had taken six red "Koo Sar" pills daily for seven days of each month to treat menstrual cramps. The Connecticut Department of Public Health (CDPH) analyzed her BLLs, which declined to 28 after one month, 21 after two months, 19 after three months, and 12 after six months. The CDPH regards adult BLLs <10 mcg/dL as normal. Lead was found in the pills in concentrations ranging from 1.2-12.5 parts per million (ppm), assayed in three different state health department laboratories. The pills were manufactured in Hong Kong and the accompanying literature was written in Chinese. The insert states, "These medical pills are good for general disability;" one pill is to be taken twice daily with warm water.
No other cases of lead poisoning associated with Koo Sar pills have been reported to California, Connecticut, New York, or any of the other 24 states covered by the Adult Blood Lead Epidemiology and Surveillance program. No recall has been initiated.
COMMENT
The contamination of Asian patent medicines has been reported previously, but lead poisoning from one has not been reported. Ko found that 24 of 260 Asian products gathered from California retail herbal stores contained a median of 30 ppm of lead (New Engl J Med 1998;339:847). The MMWR speculates that the red dye used to color the Koo Sar pills contains the lead.
As this patient’s case demonstrates, laboratory evidence of lead poisoning is readily documented, and is slow to disappear. Whether we have to rely on patients to come to screening centers, or continue to think of lead when anemia and lethargy are presenting complaints is up to bodies like the FDA and the FTC.
Recommendation
We have previously suggested that "Physicians who counsel patients who seek to use traditional Chinese medicine made in Asia should warn them of the high prevalence of toxic ingredients." (See Alternative Medicine Alert, November 1998, p. 132.) We also have advised against recommending any individually prepared Chinese herbal creams, as they may contain steroids. (See Alternative Medicine Alert, May 1999, p. 60.) Given the adulteration of many traditional Chinese medicines, we believe that physicians should advise their patients not to take Asian-made patent medicines of any kind until they are manufactured, labeled, and regulated for safety, purity, and consistency.
L-arginine for Cardiac Patients
June 1999; Volume 2: 72
Source: Lerman A, et al. Long-term L-arginine supplementation improves small-vessel coronary endothelial function in humans. Circulation 1998;97:2123-2128.
Coronary endothelial dysfunction is characterized by an imbalance between endothelium-derived vasodilating and vasoconstricting factors. The present double-blind randomized study was designed to test the hypothesis that six-month supplementation of L-arginine, the precursor of the endothelium-derived vasodilator nitric oxide (NO), reverses coronary endothelial dysfunction to acetylcholine in humans with nonobstructive coronary artery disease.
Twenty-six patients with recurrent chest pain but without significant coronary artery disease on coronary angio- graphy and intravascular ultrasound were randomized to either oral L-arginine or placebo, 3 g tid. Endothelium-dependent coronary blood flow reserve to acetylcholine was assessed at baseline and after six months of therapy. There were no baseline differences between the two study groups in clinical characteristics or in coronary blood flow. After six months, the coronary blood flow in arginine subjects increased compared with placebo subjects (149+/-20% vs. 6+/-9%, P < 0.05). This was associated with a decrease in plasma endothelin concentrations and an improvement in patients’ symptoms scores.
Oral L-arginine supplementation for six months in humans improves coronary small-vessel endothelial function in association with a significant improvement in symptoms and a decrease in plasma endothelin concentration. This study proposes a role for L-arginine as a therapeutic option for patients with coronary endothelial dysfunction and nonobstructive coronary artery disease.
COMMENT
How much coronary disease is nonobstructive? Much. What is endothelial dysfunction? Probably the mechanism of exercise-induced myocardial ischemia. It may be the mechanism of nonobstructive myocardial perfusion defects.
These Mayo Clinic authors hypothesized that L-arginine reverses coronary endothelial dysfunction in patients with angina and normal arteriograms. The investigators catheterized qualifying, consenting patients referred for recurrent chest pain, and excluded anyone with diffuse disease and anyone with a 40% or greater lesion. Those with an attenuated increase or actual decrease in coronary blood flow in response to an infusion of acetylcholine, and a normal coronary flow reserve in response to adenosine were recruited and randomized to L-arginine or control. Patients took no other medication, vitamins or amino acids. Six months later, the patients were catheterized again. Their chest pain was assessed monthly, and improved at the end of six months (as did that of the placebo group).
Whether arginine improves cardiac function and symptoms by enhancing production of NO or other vasoactive factors such as endothelin, or by slowing the progression of coronary atherosclerosis, no one knows. Unfortunately, arginine has been reported to activate herpes virus replication and interact, in animal models, with tumor growth.
Recommendation
Long-term controlled studies—longer than six months—are needed to determine the effects of arginine supplementation. Cardiac patients who want to add 3 g tid to a low-fat, antioxidant-rich, high-fiber diet, a regular aerobic exercise program, and their daily aspirin should be monitored closely.
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