Clinical Briefs
October 1, 1999 6 minutes read
Clinical Briefs
Infant Unconscious After Ingesting Herbal Tea
October 1999; Volume 2: 119
Source: Sewell AC, et al. False diagnosis of maple syrup urine disease owing to ingestion of herbal tea. N Engl J Med 1999;341:769.
We describe a case of "pseudo-maple syrup urine disease" caused by drinking fenugreek tea.
A five-week-old Egyptian infant had a 10-minute episode of unconsciousness while drinking bottled tea. On admission, the child was alert, and the physical examination was unremarkable. The child exuded an aroma similar to that of Maggi (a widely available flavoring), and a spontaneously voided urine sample had a similar aroma. This observation initiated emergency evaluations of metabolic amino acids and organic acids to rule out maple syrup urine disease. All tests were normal.
The parents mentioned that they had given their child an herbal tea (Helba tea) to reduce flatulence and to prevent fever. The tea contains seeds of fenugreek (Trigonella foenum-graecum L.). Analysis of the infant’s urine by enantioselective multidimensional gas chromatography and mass spectrometry revealed the presence of sotolone, the compound responsible for the aroma in maple syrup urine disease. The tea prepared from fenugreek seeds was found to contain sotolone.
Comment
These doctoral investigators from the University of Frankfurt note that maple syrup urine disease is an (rare) inborn error of metabolism of branched chain amino acids. The sweet aroma emanating from the body fluids of infants unlucky enough to suffer this error of fate is enough to send up crisis signals among neonatologists. Fortunately, it was only fenugreek.
The sweet odor from fenugreek ingestion has been previously reported, but association and confirmation of the compound responsible (and an associated episode of unconsciousness) has not. Tan, pebble-like, and pungent, fenugreek seeds are used in Indian and southeastern European cooking. Toasted and ground, they are often a component of Southern Indian curries, and contribute aroma and heat.
Fenugreek seed has medicinal associations. Andrew Weil suggests it for lowering insulin dosage in diabetics. The German Commission E lists it as an approved herb for loss of appetite and as a poultice for local inflammation. The Commission notes "The drug contains mucilage and bitter principles." There is too little hard data to make an evidence-based, general recommendation about its medical use.
Recommendation
Infants need the 12% fat that mother’s milk provides. Reserve fenugreek and other pungent dried seeds for the kitchen.
Topical Vitamin E Application: Does It Improve Cosmetic Scar Appearance?
October 1999; Volume 2: 119-120
Source: Baumann LS, Spencer J. The effects of topical vitamin E on the cosmetic appearance of scars. Dermatol Surg 1999;25:311-315.
Vitamin e is a generic term for a group of tocol and tocotrienol derivatives. Since the discovery that vitamin E is the major lipid soluble antioxidant in skin, this substance has been tried for the treatment of almost every type of skin lesion imaginable. Anecdotal reports claim that vitamin E speeds wound healing and improves the cosmetic outcome of burns and other wounds. Several physicians recommend topical vitamin E after skin surgery or resurfacing.
We attempted to determine whether topically applied vitamin E has any effect on the cosmetic appearance of scars as suggested by multiple anecdotal reports. Fifteen patients who had undergone skin cancer removal through Mohs surgery were enrolled in the double-blinded study. All wounds were primary closed in two layers. After the surgery, the patients were given two ointments labeled A (Aquaphor®, a regular emollient) or B (Aquaphor mixed with vitamin E, added at a concentration of 320 IU/g of d-alpha-tocopherol). The scars themselves were randomly divided into two parts, A and B. Patients were asked to put the A ointment on part A and the B ointment on part B twice daily for four weeks. Evaluation criteria were subjective, and the opinions of patients and treating physicians were recorded at weeks 1, 4, and 12. A third blinded investigator was shown photographs of the outcomes, and rated each side of the scar.
In 90% of the cases in this study, topical vitamin E either had no effect on or actually worsened the cosmetic appearance of scars; 33% of patients developed a contact dermatitis. We conclude that the use of topical vitamin E on surgical wounds should be discouraged.
Comment
These University of Miami investigators put to a brief test the hypothesis that vitamin E improves cosmetic appearance of surgical scars. But three of their 15 patients dropped out after 48 hours, and two of the 12 remaining dropped out after a week. A sharply marginated, pruritic, erythematous rash erupted on the vitamin E side of five patients’ scars. After 12 weeks, most of the 10 remaining patients and the treating physicians felt that there was no difference in the sides of the scar.
The theory that antioxidants enhance wound healing by reducing the damage by free radicals released by neutrophils may be applicable inside the body. But topical vitamin E has been associated with contact urticaria, eczematous dermatitis, and erythema multiform-like reactions. The authors cite a Swiss study of 1,000 cases of contact dermatitis associated with vitamin E linoleate, added to a cosmetic. The irritant effect may be dose-related or form-related, but is clearly present.
Recommendation
Discourage patients who want to use oral vitamin E capsules to promote wound healing or those who want to use cosmetics with added vitamin E. Encourage high-risk patients to use oral vitamin E supplements to help prevent myocardial infarction.
Exercise Therapy as Treatment for Osteoarthritis
October 1999; Volume 2: 120
Source: van Baar ME, et al. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: A systematic review of randomized clinical trials. Arthritis Rheum 1999;42:1361-1369.
To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee, a computerized literature search of MEDLINE, Embase, and Cinahl was carried out. Randomized clinical trials (RCTs) on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patients’ global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power.
Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patients’ global assessment of effect.
Comment
Alternative medicine needs studies like this: rigorous, careful, well-intended, apparently without bias, specific, clear, detailed.
These Dutch analysts note that although exercise therapy appears in recent treatment guidelines for OA of the hip and knee, newly published RCTs and more rigorous review methodology yield better recommendations. So these authors carefully picked over the evidence for an intervention that relatively few physicians even find in their therapeutic arsenal—exercise therapy. They found only six trials that met accepted, thoughtful validity criteria. Sufficient sample size, adherence to recommendations, controls for co-interventions, and an intention to treat analysis, together with blinded outcome assessments were recommended for future investigators.
Exercise therapy is defined as a range of activities intended to improve strength, range of motion, endurance, balance, coordination, posture, motor function, or motor development. It can be performed actively, passively, or against resistance. Aerobic, resistance, and other types of exercise were included. Only four trials studied the differences between different exercise therapies, and none pointed to one type of exercise or one location being better than another. In addition to the benefits above, a small beneficial effect on walking performance was also gleaned.
Little systematic data were available on long-term effects of exercise therapy, and since "use it or lose it" is so commonly observed in clinical practice and at the gym, a relevant clinical question is "Does a little help?" Muscles atrophy if they are not used, and everyone who has taken a few weeks off and then moved back to a previous workout knows that muscle strength fades all too quickly.
Recommendation
If exercise were a pill, it would be called penicillin. If only it could be bottled, instead of planned, structured, and repeated over and over again. There are no shortcuts, however. Your patients with OA should try different exercises of any type until they find one, and then another, and then another that they can do—even for a few minutes each day. Their hips and knees (and hearts and minds) will be healthier for it.
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