Cow's milk and constipation
Sixty-five children (aged 11-72 months) with chronic
constipation (defined as having one bowel movement every 3-15 days)
who had failed to respond to laxatives received, in double-blind fashion,
cow's milk or soy milk for two weeks. After a one-week washout period,
the feedings were reversed for an additional two weeks. Forty-four of
the 65 children (68%) had a resolution of constipation while receiving
soy milk. Anal fissures and pain with defecation also resolved in patients
who suffered from these problems. In contrast, none of the patients
showed a positive response while receiving cow's milk. Children who
improved had a higher frequency of coexistent rhinitis, dermatitis or
bronchospasm, compared with children who did not improve (11 of 44 vs
1 of 21; p = 0.05).
COMMENT: This study strongly suggests that intolerance
to cow's milk is a common cause of chronic constipation, as well as
anal fissures and pain on defecation, in young children. In an editorial
accompanying this report, it was suggested that a diet free of cow's-milk
protein should be considered for children with chronic constipation
who do not respond to laxatives. This reporter would respectfully venture
to suggest that a more appropriate recommendation would be to consider
laxatives in patients who do not respond to avoidance of cow's milk
or to other natural remedies.
Iacono G, et al. Intolerance of cow's milk and chronic
constipation in children. N Engl J Med 1998;339:1100-1104.
Vitamin E for hepatitis B
Twenty-four patients with chronic hepatitis B (19 of
whom had failed to respond to interferon-alpha) were randomly assigned
to receive vitamin E (300 mg twice daily) for three months or no treatment.
The patients were followed monthly for nine months. Four patients receiving
vitamin E discontinued treatment because of marked increases in ALT
levels. A similar increase in ALT levels was seen in two control patients.
Five (41.7%) of the 12 patients receiving vitamin E had a complete response,
defined as normalization of ALT levels and clearance of hepatitis B
virus DNA from the serum. Three of the five patients with a complete
response had not responded to previous interferon-alpha treatment. None
of the patients in the control group had a complete response. No side
effects were seen.
COMMENT: The results of this small pilot study suggest
that vitamin E is of value in the treatment of chronic hepatitis B.
Although the mechanism of action is not known, vitamin E does have some
hepatoprotective effects and may also enhance immune function. A larger,
placebo-controlled study is needed to confirm this report; however,
vitamin E is inexpensive and safe and could reasonably be included as
part of the treatment regimen for patients with hepatitis B.
Andreone P, et al. Vitamin E for chronic hepatitis B.
Ann Intern Med 1998;128:156-157.
Vitamin D deficiency
Of 290 consecutive hospital inpatients on a general
medical ward, 57% were found to be deficient in vitamin D (serum concentration
of 25-hydroxyvitamin D of 15 ng/ml or lower) and 22% were considered
severely deficient (serum concentration of 25-hydroxyvitamin D less
than 8 ng/ml). Significant predictors of vitamin D deficiency were low
vitamin D intake, less exposure to ultraviolet light, anticonvulsant-drug
therapy, renal dialysis, nephrotic syndrome, hypertension, diabetes
mellitus, and winter season. Of patients who consumed more than the
RDA for vitamin D, 43% were found to be deficient in the vitamin.
COMMENT: This study demonstrates that vitamin D deficiency
is extremely common among general medical inpatients, even among those
whose vitamin D intakes exceed the RDA. Vitamin D deficiency can result
in osteoporosis or osteomalacia and may also contribute to the development
of cancer. Individuals who are risk of developing vitamin D deficiency
should have their vitamin D status assessed or should be supplemented
empirically with vitamin D and/or sunlight.
Thomas MK, et al. Hypovitaminosis D in medical inpatients.
N Engl J Med 1998;338:777-783.
Treatment with hydrochloric acid
Gastric analysis with histamine stimulation was performed
on 40 patients with chronic urticaria. Approximately 65% of the patients
had either hypochlorhydria or achlorhydria. Of the patients with reduced
acid output, 65% obtained almost complete or partial relief of symptoms
with hydrochloric acid (HCl) therapy. These patients previously had
been unresponsive to all other forms of treatment. The best results
were obtained in the 22 patients with achlorhydria. In this group, 18
patients (82%) were almost completely relieved by HCl therapy. In another
report, administration of dilute HCl altered the putrefactive flora
ordinarily present in the small intestine of achlorhydric individuals.
According to the second report, therapeutic use of dilute
HCl has fallen into disrepute, largely on theoretical grounds. However,
many capable internists and dermatologists remain convinced, on the
basis of clinical experience, that acid therapy is beneficial.
COMMENT: These reports from 50 years ago have been revived
in order to remind practitioners that hypochlorhydria is common and
that administration of HCl may be helpful for many patients. Inadequate
secretion of HCl can result in malabsorption of protein, vitamins and
minerals, and can facilitate the overgrowth of microorganisms in the
stomach or small intestine. Gastric analysis by radiotelemetry is a
fairly reliable method of diagnosing hypochlorhydria. If diagnostic
testing is not available, a trial (under medical supervision) of low-dose
betaine hydrochloride (such as 10-30 grains per meal) may be considered
for individuals with bloating after meals, poor digestion, weak fingernails,
rosacea, refractory iron deficiency, or other problems that are associated
with hypochlorhydria. People who are taking hydrochloric acid should
not use ulcer-inducing drugs such as aspirin (or other non-steroidal
anti-inflammatory drugs) or alcohol.
Rawls WB, Ancona VC. Chronic urticaria associated with
hypochlorhydria or achlorhydria. Rev Gastroenterol 1951;18:267.
Anonymous. A plug for acid therapy. Am J Dig Dis 1948;16:418.
Victor Herbert is still fighting
A landmark prospective, double-blind study was published
two years ago in JAMA (1996;276:1957-1963), demonstrating that supplementation
with 200 mcg/day of selenium (in the form of high-selenium brewer's
yeast) reduced the incidence of prostate, colorectal and lung cancer,
and reduced overall cancer mortality by 50%. A few months after the
article was published, a letter appeared in JAMA from Dr. Victor Herbert,
a well known critic of alternative medicine. Dr. Herbert pointed out
that, while selenium supplementation significantly reduced cancer mortality,
it did not significantly reduce all-cause mortality. According to Herbert,
that means that selenium increased mortality from diseases other than
cancer, and that selenium supplements may therefore be harmful to certain
COMMENT: While there were, in fact a few more non-cancer
deaths in the selenium group than in the placebo group, the total death
rate (from all causes) was 17% lower in the selenium group than in the
placebo group. Although that difference was not statistically significant
(p = 0.14), it was relatively large. When elderly individuals are followed
up for more than 6 years (as in the selenium study), some will die during
the follow-up period. If treatment with selenium helped prevent the
development of cancer, then an individual whose time is up will likely
succumb to another disease. However, that does not mean that taking
selenium increased that person's susceptibility to the other disease.
While Dr. Herbert may continue to search for a subgroup of individuals
who will be harmed by administration of 200 mcg/day of selenium, I'll
take my 17% reduction in overall mortality every morning along with
my high-selenium brewer's yeast.
Herbert V. Selenium supplementation and cancer rates.
Chemotherapy side effect: still in the dark
The cardiac toxicity of doxorubicin (adriamycin), a
drug used to treat cancer, was discussed in a recent review article
in the New England Journal of Medicine (1998;339:900-905). This drug
can cause severe and often irreversible cardiomyopathy. While various
strategies for prevention and treatment of cardiac toxicity have been
tried, none are particularly effective. Conspicuously absent from the
report was any mention of coenzyme Q10.
COMMENT: There is evidence that adriamycin may induce
cardiotoxicity by inhibiting coenzyme Q10-dependent enzymes. Pretreatment
of mice for four days with coenzyme Q10 (10 mg per kg intraperitoneally)
reduced the death rate from acute administration of adriamycin.
In a pilot study, seven patients received coenzyme Q10
(100 mg per day), beginning three to five days before adriamycin treatment,
while another seven patients (controls) received adriamycin alone. Cardiac
function (as determined by heart rate, stroke index, cardiac index and
ejection fraction) deteriorated significantly in the control group.
Coenzyme Q10-treated patients, on the other hand, showed little or no
cardiotoxicity, even though their cumulative adriamycin dose was 50%
greater than that of the controls. Despite the preliminary nature of
this study, prophylactic administration of coenzyme Q10 seems warranted,
considering the seriousness of adriamycin toxicity and the safety and
relatively low cost of coenzyme Q10.
Combs AB, et al. Reduction by coenzyme Q10 of the acute
toxicity of adriamycin in mice. Res Commun Chem Pathol Pharmacol 1977;18:565-568.
Judy WV, et al. Coenzyme Q10 reduction of adriamycin
cardiotoxicity. In Folkers K, Yamamura Y (eds.). Biomedical and Clinical
Aspects of Coenzyme Q, vol. 4, Elsevier Publ., 1984, pp. 231-241.
Therapeutic touch does work
In a single-blind randomized trial, 25 patients with
osteoarthritis of the knee received either therapeutic touch, mock therapeutic
touch or standard care. The main outcome measures were pain, general
well-being and health status (as determined by standardized assessment
criteria). The patients receiving therapeutic touch had significantly
decreased pain and improved function, as compared with the patients
receiving mock therapeutic touch or standard care.
COMMENT: A recent report published in JAMA purported
to "debunk" claims that therapeutic touch is of value. However,
the JAMA study did not really assess the effectiveness of therapeutic
touch. Rather, it tested the ability of certain individuals to detect
a human "energy field."
Double-blind trials are extremely difficult (if not
impossible) to perform when the treatment being studied is influenced
by the person administering it. An alternative method of studying such
treatments is the "n of 1" trial, in which a patient with
a condition that is chronic and stable alternately receives treatment
and no treatment. "N of 1" trials are considered acceptable,
as long as a single intervention is being tested and the probability
of spontaneous improvement occurring is very low. The more "good
anecdotes" we submit to medical journals, the sooner alternative
medicine will find its way into the mainstream.
Gordon A, et al. The effects of therapeutic touch on
patients with osteoarthritis of the knee. J Fam Pract 1998;47:271-277.
Folic acid and cancer
To evaluate the relation between folate intake and incidence
of colon cancer, a prospective cohort study was performed on 88,756
women participating in the Nurses' Health Study who were free of colon
cancer in 1980 and provided information about diet and multivitamin
use from 1980 to 1994. During the follow-up period 442 new cases of
colon cancer were diagnosed. After controlling for age, family history,
and intake of meat, alcohol and fiber, intake of more than 400 mcg/day
of folate was associated with a 31% lower incidence of colon cancer,
compared with intake of 200 mcg/day or less. Further controlling for
intake of vitamins A, C, E and calcium did not significantly change
the results. Use of a folate-containing multivitamin for more than 15
years was associated with a 75% reduction in colon cancer risk, whereas
shorter-term use of multivitamins was not associated with significantly
lower risk. Folate from dietary sources alone was related to a modest
reduction in risk of colon cancer.
COMMENT: This study suggests that long-term use of a
multivitamin supplement may substantially reduce the risk of developing
colon cancer and that this effect may be due largely to the folic acid.
It is likely that other nutrients present in multivitamins and in high-folate
foods (such as vitamin C and vitamin E) also exert a protective effect.
One cannot rule out the possibility of selection bias in the present
study (i.e., people who take supplements probably take generally better
care of themselves). However, the results are consistent with previous
studies demonstrating an anticancer effect of folate. Although additional
studies need to be done, eating a high-quality diet and taking a multivitamin
seems like a good insurance policy.
Giovannucci E, et al. Multivitamin use, folate, and
colon cancer in women in the nurses' health study. Ann Intern Med 1998;129:517-524.