Clinical Briefs
By Louis Kuritzky, MD
Health Food Store Recommendations for Breast Cancer
As many as two-thirds of cancer patients may turn to complementary or alternative medicine. Unfortunately, not only can some of these agents have significant toxic effects, they also might interact with traditional allopathic treatments. It is of some concern that quality control and adverse effect surveillance are not on parity with prescription drugs.
Health food store personnel generally do not possess a license to diagnose or prescribe, yet may not infrequently be called upon to consider giving such advice. The purpose of this study was to observe, by means of a simulated medical scenario, the personnel response to a young woman who posed as the daughter of a metastatic breast cancer patient. The details of the "case" included that the diagnosis had been made five years prior, lumpectomy had been performed, and radiation therapy had been done. Complaints of the patient (the mother) included bone pain, despite her medication regimen of tamoxifen. The story also included the detail that the mother wished to consider alternative treatment, since traditional treatment had not cured her cancer.
Of the 40 stores in which the scenario was enacted, only four stores did not make recommendations. The other 36 store employees suggested one or more products, and 20% of the personnel suggested participation in a structured program (usually provided by the store), such as consultation with their store specialist, a program of their products, or diagnostic tests (e.g., iridology, muscle testing). It was fairly common (35%) for indirect recommendations to be given by offering input that certain products were popular with cancer patients, for instance shark cartilage or maitake mushrooms.
Clinicians must be aware that cancer patients or their families may seek the advice of health food store personnel, and be prepared to respond in such a way as to best avoid potential adverse effects of such interventions, while not disallowing the possibility that some tools used in health food stores may be of benefit.
Gotay CC, Dumitriu D. Arch Fam Med 2000;9:692-698.
Rabies Postexposure Prophylaxis
In that there has been but a single confirmed rabies survivor in the United States in the last three decades, rabies may be acknowledged as a uniformly fatal disease. Thanks primarily to control of rabies in domestic animals, the number of annual cases has dropped from more than 100 at the beginning of the 20th century, to only 1-3 yearly.
Rabies among animals, especially raccoons, has increased almost 20% since 1996. No cases of human rabies have ever been documented subsequent to exposure to raccoon rabies. Appropriate administration of rabies prophylaxis treatment is important not only to prevent rabies, but also to avoid unnecessary administration to persons not at risk, since the process is not without discomfort, and is costly ($1500 for a treatment course alone, without physician or office/hospital fees). This trial is the first prospective one to assess appropriateness of rabies prophylaxis administration.
Of 2030 patients with rabies exposure, 6.7% received prophylaxis. Of 136 patients who received prophylaxis, 40% were considered inappropriate, most commonly due to the fact that the culprit animal was available for observation or testing, which could obviate intervention. Of 1894 persons not receiving prophylaxis, 6.3% were considered inappropriate, most commonly because the culprit animal was not available for observation.
Moran and colleagues conclude that enhanced adherence to appropriate use of rabies prophylaxis is needed, and may be advanced by provision of easy access to and availability of suggested locale-specific and circumstance-specific guidance, through health department assistance and guideline promulgation.
Moran GJ, et al. JAMA 2000;284: 1001-1007.
Ondansetron for Reduction of ETOH
The serotonin 5ht-3 receptor is important in mediating alcohol effects, and blockade of this receptor in a variety of animals has reduced alcohol consumption. There has been some support for the concept that early-onset alcoholism might be responsive to intervention with ondansetron, due to its modulation of serotonin.
This placebo-controlled trial of 321 persons suffering alcoholism (at least 3 drinks daily at the time of enrollment) used either 1, 4, or 16 mcg/kg of ondansetron twice daily, in addition to cognitive behavioral therapy for a total of 12 weeks (including run-in).
Early-onset alcoholism patients who were treated with ondansetron demonstrated a significantly decreased amount of alcohol consumption, and improved number of days abstinent. The most effective dose of ondansetron was 4 mcg/kg. Early-onset alcoholism is characterized by earlier onset of problem drinking behavior and antisocial behavior. Patients with late-onset alcoholism did not respond to ondansetron treatment.
Adverse effects of the treatment were infrequent, and none were serious. The most common side effects were gastrointestinal. A single fatality in the trial was not attributed to the medication: the subject fell down a flight of stairs at home.
The biology of early-onset alcoholism appears to be different from late-onset alcoholism, and responds differently to ondansetron modulation
Johnson BA, et al. JAMA 2000;284: 963-971.
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