[Complementary and Alternative Medicine Offers of Teaching Practices for General Medicine]. / Komplementär- und alternativmedizinische Angebote von Lehrpraxen für Allgemeinmedizin.

OBJECTIVE: Germany's new medical licensure act has increased the importance of general practice in academic medical education. This study gives an overview of complementary and alternative medicine in general teaching practices in Germany and their adherence to evidence-based criteria which is required in order to qualify as a teaching practice. METHODS: After a systematic search for German teaching practices, we assessed their diagnostic and therapeutic offers via their websites. We calculated the various frequencies of treatments and differentiated between evidence-based complementary medicine and alternative medicine with little to no evidence. RESULTS: Of 4102 practices, more than half offered complementary and/or alternative treatment. Most of those were treatments approved of by the German medical association. Alternative medicine was offered by 18.2% of the practices. CONCLUSION: Collective terms and conflicting evidence complicate the classification of treatments. Teaching practices offering non-evidence-based treatment raise the question whether recruitment of additional teaching practices stands at odds with the quality of medical education. Explicit offers of alternative treatment should disqualify a teaching practice as such. Controversial treatment may be taught academically and during residency with a focus on evidence-based guidelines and communication skills in order to prepare young medical practitioners for talks with their patients about the subject.

Seasonal allergic rhinitis and the role of apitherapy.

BACKGROUND: Apitherapy represents a certain form of complementary and alternative medicine that uses bee products in combination with other methods from this field. One of the basic concepts of this type of medicine is that all diseases can be treated using apitherapy. This study was performed to assess the recommendations from authors of books on apitherapy regarding the treatment of seasonal allergic rhinitis and compare them to findings from the scientific literature. METHODS: One hundred and twenty-nine books on apitherapy were analysed regarding recommendations for allergic seasonal rhinitis. Scientific evidence regarding the efficacy of using various bee products was searched via PubMed and JUSTfind. RESULTS: Only 38.8% of the apitherapy books mentioned seasonal allergic rhinitis. Among these books, we found 29 different recommendations in favour of bee products and one against the use of honey. The most reasonable recommendation according to clinical studies on the subject, namely the use of a mix of honey and pollen, was only found once (0.8%). CONCLUSIONS: The large discrepancies and number of different recommendations demonstrate that apitherapy is not a consistent type of medicine. The recommendations regarding seasonal allergic rhinitis in the vast majority of apitherapy books cannot be considered adequate when compared to the scientific findings.

Apitherapy for menopausal problems.

PURPOSE: Apitherapy, a method from the field of complementary and alternative medicine, claims that all health problems including menopausal problems can be cured using bee products, especially honey, bee-collected pollen, propolis, and royal jelly. This study was to investigate the recommendations of protagonists of holistic apitherapy and compare these to the current evidence. METHODS: Since holistic apitherapy is only promoted in books and apitherapeutical congresses, we identified books on the topic in English, French, and German language via bookseller platforms and the JUSTfind system of the Justus-Liebig-University Gießen, Germany, which comprises 337 databases from the EBSCO Discovery Service. RESULTS: Only 29.5% (n = 38) of the apitherapy books mentioned the topic of menopausal problems. Among these, there were 24 different recommendations. Royal jelly is the number one recommended therapy, followed by pollen, the combination of pollen and royal jelly, and propolis. All other recommendations are mentioned just once. The recommendation regarding royal jelly must be regarded as correct. Strictly speaking, evidence regarding bee-collected pollen is poor, since all studies on pollen did not investigate pollen directly, but pollen extracts and these pollens came from pollen that was anemophilous but not entomophilous. CONCLUSION: Royal jelly and pollen could be interesting treatment options in cases of menopausal symptoms. In order to promote bee products for menopausal symptoms with a good conscience trials, comparing bee products against other options, such as selective serotonin reuptake inhibitors, C. racemosa extracts, and/or yoga should be initiated, since these methods have already proven their value.

Using Bee Products for the Prevention and Treatment of Oral Mucositis Induced by Cancer Treatment.

Oral mucositis is one of the most frequent complications after chemotherapy or radiotherapy or a combination of both. There is no standard therapy for its prevention or treatment. Considering that some bee products have been found to be of value in this situation, we decided to analyze the scientific literature on the subject. Scientific publications on bee products were identified by a literature search on Pubmed, Scopus and Google Scholar. There is a lot of evidence regarding the use of honey for oral mucositis due to chemotherapy or radiotherapy or a combination of both. Unfortunately, the quality of several meta-analyses on the topic is very low. There is some evidence on propolis, a little on royal jelly and none whatsoever on pollen and other bee products like apilarnil or bee venom. Bee products such as honey, propolis and royal jelly may be well suited to be integrated into a general concept for the prevention and treatment of oral mucositis which should also include other established concepts like oral care, oral cryotherapy, topical vitamin E and low-level-laser therapy. Bee products could become an integral part in the treatment of chemotherapy, radiotherapy and radio chemotherapy. High-quality meta-analyses and further studies, especially on the combinations of various strategies, are needed.

Erucin and benzyl isothiocyanate suppress growth of late stage primary human ovarian carcinoma cells and telomerase activity in vitro.

In the present study we analysed the effects of isothiocyanates (ITCs)--plant-derived sulphur-containing constituents known for their potential chemotherapeutic activity--on growth inhibition and programmed death in primary ovarian carcinoma cells from ascites of human patients. Twenty-four hour exposure of carcinoma cells to 5-50 µM erucin or benzyl ITC led to a concentration-dependent viability loss, as determined by erytrosin B cell staining. This concurred with an increase in internucleosomal DNA fragmentation, mitochondrial membrane depolarization and downregulation of Akt as indicator for apoptosis induction. Cell accumulation at the G2/M phase was evident after 48 h of erucin treatment. Telomerase, a selective target of cancer cells, was suppressed by erucin. Although pre-treatment of cells with the thiol antioxidant N-acetylcysteine could completely prevent initialization of the apoptotic process, it failed to abolish ITC-mediated telomerase suppression. Taken together, in our study, ITC exerted comparable cytotoxic efficacy against primary ovarian cancer cells as reported for corresponding cell lines. The clinical significance of this observation should be addressed in future studies and the role of telomerase further investigated.

Patients' considerations behind the use of methods from complementary and alternative medicine in the field of obstetrics in Germany.

BACKGROUND: Complementary and alternative methods (CAMs) are frequently used during pregnancy and delivery. We were interested to find out how frequently CAMs were used and if they were used for specific indications. METHODS: We assessed the use of various CAMs and the background of use. Here we differentiated between the treatment of psychological problems, physical problems and the treatment of foetal problems. RESULTS: The response rate was 49.2 % (229/465). Attendance of a delivery preparation class was significantly associated with a higher CAM use in general. Herbal teas and dietary interventions were most frequently used during pregnancy and predominantly for the treatment of physical problems (e.g. nausea, back pain). Earlier deliveries were associated with a significantly decreased demand for complementary methods during delivery but not during pregnancy. CONCLUSION: Although we found some correlations between some methods and certain treatment indications, most methods were used like panaceas. We believe that the fact that earlier deliveries were associated with a significantly decreased demand for CAM should lead to the question of whether women should receive more reassuring information on delivery and be offered methods like massage or relaxation techniques, which provide proven efficacy without potential side effects that may be associated with CAM methods.

[Alternative medicine in uro-oncology]. / Alternativmedizin in der Uroonkologie.

BACKGROUND: Alternative medicine is used instead of conventional therapy. Some patients use it in parallel with conventional medicine. OBJECTIVE: Narrative compilation of the evidence on alternative medicine in the (uro)oncological context. MATERIALS AND METHODS: A selective literature search in MEDLINE via PubMed was performed. RESULTS: The data on 3­bromopyruvate, Miracle Mineral Supplement (MMS), insulin-potentiated therapy, base therapy, hyperthermia, Artemisia annua, amygdalin (vitamin B17), Amanita therapy, homeopathy, apitherapy, dendritic cells, galavit, Germanic new medicine, and spiritual healing show either no or little clinical evidence of efficacy or clearly exhibit a negative benefit-risk profile. CONCLUSIONS: Alternative medicine is pseudo-medicine that may have a positive effect on mental well-being in the short term, but is mostly associated with disadvantages for the patient in the long term.

Body weight changes after the diagnosis of endometrial cancer and their influences on disease-related prognosis.

OBJECTIVES: Obesity is associated with the incidence of endometrial cancer. At present it is unclear whether it is also associated with cancer recurrence. This analysis evaluated the consequences of weight changes after diagnosis of endometrial cancer during the follow-up. METHODS: Records of patients with endometrial cancer (n = 705) were reviewed for body weight after the diagnosis of cancer during the follow-up and related to recurrence-free survival. RESULTS: About two-thirds of all endometrial patients gained more or less weight after the diagnosis of endometrial cancer. Patients with moderate weight gain (≤ 1 kg/m(2)) 6 months after the diagnosis had the best prognosis, followed by patients with greater weight gain (>1 kg/m(2)) and those with moderate weight loss (≤ 1 kg/m(2)). The fact that weight loss was associated with poor prognosis also persisted when the analysis was restricted to recurrences which occurred more than 18 months later. CONCLUSIONS: Weight loss after the diagnosis and treatment of cancer may be an adverse prognostic factor. Although it was impossible to distinguish between intentional and non-intentional weight loss, these results argue against weight loss for risk reduction in patients with confirmed endometrial cancer. However, it may be reasonable regarding the risk reduction of non-cancer related morbidity and mortality. Detailed, prospective randomised trials are warranted.

Survey on the Necessity, Sensibility, and Timing of Psycho-Oncological Counseling and the Willingness to Discuss Various Topics During the Inpatient Stay in the Case of Breast Cancer.

After the diagnosis of cancer patients require a lot of information because the disease affects all aspects of life. Some important issues regarding optimal counseling remain to be determined. This includes the time-related relevance of various topics and questions regarding who and when to consult on the topics. We analyzed the answers of 155 women with non-metastatic breast cancer undergoing primary surgery, primary chemotherapy, and having completed adjuvant treatment regarding the above-mentioned issues. We found that counseling must consider the treatment situation. Breast cancer patients in the follow-up phase reported that they preferred being counseled by female consultants. Our results largely support a counseling concept which puts the breast care nurse at the center of interest rather than psychologists and social service workers. A breast care nurse centered counseling system for women with non-metastatic breast cancer appears to meet patients' needs best.

Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) - Part 2 with Recommendations on Psycho-oncology, Rehabilitation, Follow-up, Recurrence, Palliative Therapy and Healthcare Facilities.

Aim This is an update of the interdisciplinary S3-guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL), published in March 2021. The work on the updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics ( Deutsche Gesellschaft für Gynäkologie und Geburtshilfe , DGGG) and the Working Group on Gynecological Oncology ( Arbeitsgemeinschaft Gynäkologische Onkologie , AGO) of the German Cancer Society ( Deutsche Krebsgesellschaft , DKG). Method The process used to update the 2014 S3-guideline was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or - if evidence was lacking - on the consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which would take account of more recently published literature and the recent appraisal of new evidence. Recommendations The short version of this guideline consists of recommendations and statements on palliative therapy and follow-up of patients with cervical cancer. The most important aspects included in this updated guideline are the new FIGO classification published in 2018, the radical open surgery approach used to treat cervical cancer up to FIGO stage IB1, and the use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.

Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) - Part 1 with Recommendations on Epidemiology, Screening, Diagnostics and Therapy.

Aim This update of the interdisciplinary S3 guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL) was published in March 2021. This updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics ( Deutsche Gesellschaft für Gynäkologie und Geburtshilfe , DGGG) and the Working Group on Gynecological Oncology ( Arbeitsgemeinschaft Gynäkologische Onkologie , AGO) of the German Cancer Society ( Deutsche Krebsgesellschaft , DKG). Method The process of updating the S3 guideline dating from 2014 was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or - if evidence was lacking - on a consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which took account of more recently published literature and the appraisal of the new evidence. Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, screening, diagnostic workup and therapy of patients with cervical cancer. The most important new aspects included in this updated guideline include the newly published FIGO classification of 2018, the radical open surgery approach for cervical cancers up to FIGO stage IB1, and use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.

Complementary and Alternative Medicine: Comparison of Current Knowledge, Attitudes and Interest among German Medical Students and Doctors.

Although it has been agreed that complementary and alternative medicine (CAM) should be included in the German medical curriculum, there is no consensus on which methods and how it should be taught. This study aimed to assess needs for CAM education by evaluating current knowledge, attitudes and interests of medical students, general physicians and gynecologists. Two instruments based on established and validated questionnaires were developed. One was given to seventh semester medical students and the other to office-based doctors. Data were analyzed by bivariate correlation and cross-tabulation. Altogether 550 questionnaires were distributed-280 to doctors and 270 to medical students. Completed questionnaires were returned by 80.4% of students and 78.2% of doctors. Although 73.8% (160/219) of doctors and 40% (87/217) of students had already informed themselves about CAM, neither group felt that they knew much about CAM. Doctors believed that CAM was most useful in general medicine, supportive oncology, pediatrics, dermatology and gynecology, while students believed that dermatology, general medicine, psychiatry and rheumatology offered opportunities; both recommended that CAM should be taught in these areas. Both groups believed that CAM should be included in medical education; however, they believed that CAM needed more investigation and should be taught "critically". German doctors and students would like to be better informed about CAM. An approach which teaches fundamental competences to students, chooses specific content based on evidence, demographics and medical conditions and provides students with the skills they need for future learning should be adopted.

Small cell carcinoma of the ovary of the hypercalcaemic type: an analysis of clinical and prognostic aspects of a rare disease on the basis of cases published in the literature.

PURPOSE: Ovarian small cell carcinoma of the hypercalcaemic type is a very rare and highly aggressive malignant disease, mainly affecting young women. Due to the rarity of this tumour entity, prospective randomised trials are unlikely to be conducted, and the only retrospective analysis based on a large case series is from 1994. Since diagnostic and treatment modalities may have changed, we initiated this analysis. METHODS: The aim of our study was to review and analyse cases published since 1975 to validate former findings and to gather more information about therapy options, diagnostic and prognostic factors. A systematic literature search of the PubMed/Medline database was performed assessing all articles until September 2010. All retrieved articles were evaluated and cross-checked for references on the topic. In total, 135 cases were included, selected from 62 case reports and smaller case studies. RESULTS: Small cell carcinoma mostly affects women with a mean age of 23.4 years. They present with unspecific symptoms like abdominal pain or palpable mass, sometimes accompanied by an elevated calcium or CA-125 serum concentration. The tumour appears nearly almost unilaterally, mostly affecting the right ovary. Tumour stage is a clearly prognostic factor. Adjuvant chemotherapy consisting of etoposide, cisplatinum/carboplatinum or vinca alkaloids has shown improved survival, whereas radiotherapy has not. CONCLUSIONS: In spite of limitations this analysis provides new insights especially with respect to therapeutic aspects. This review underlines the importance of case reports in rare tumour entities in order to answer open questions.

Use of complementary and alternative medicine during pregnancy and delivery.

PURPOSE: To assess the use of complementary and alternative medicine (CAM) during pregnancy and birth and the reasons behind it from the patient's perspective. METHODS: In a prospective study, we assessed the use of CAM before and during pregnancy as well as during delivery in women by means of a self-report questionnaire. RESULTS: Some 205 patients completed the questionnaire at a response rate of 43.2% (205/475) and 104 women used CAM during pregnancy, especially homoeopathy, acupuncture, and phytotherapy. Stepwise regression analysis identified CAM use prior to pregnancy, greater income, and nationality as the most important predictors of CAM use. CONCLUSIONS: In accordance with earlier studies from Germany, we determined the most important methods used in the field of obstetrics. Interestingly, these are not evidence-based and those methods which are evidence-based are not now used. Also, the predictors of CAM use in pregnancy were similar to those in oncology. Future studies should focus on the safety and efficacy of CAM in pregnancy.

Complementary and alternative medicine in obstetrics: a survey from Iran.

PURPOSE: This survey assessed the use of complementary and alternative medicine (CAM) methods by obstetricians in the Islamic Republic of Iran. METHODS: Obstetricians in the province of Tehran were identified using the "Ketabe 118 Mashaghel" (2008), a source of medical department information. A survey on the use of CAM methods during childbirth and the reasons behind their application was conducted on site. RESULTS: CAM methods are by in 37.3% (62/166) of the obstetricians. Acupressure, massage, and phytotherapy were found to be the most frequently used methods. Use of CAM was influenced by the employment status of the midwives and inversely correlated with the number of deliveries in the hospital. CONCLUSIONS: CAM methods are used in Iran to some extent. With evidence-based medicine in mind it is interesting to note that in Iran mainly CAM methods which already have some proven benefit are used.

Do breast cancer patients adapt CAM methods according to the therapeutic situation?

BACKGROUND: and purpose: Complementary and alternative medicine (CAM) is frequently used among cancer patients. It is unclear whether and how far patients adapt CAM to the treatment situation. The objective is to assess the changes of CAM use between radiotherapy for breast cancer and the follow-up. MATERIALS AND METHODS: 107 patients who participated in a study assessing the possible effects of vitamin D and selenium on radiation-induced skin toxicity completed the CAM-PRIO (Working Group for Prevention and Integrative Oncology of the German Cancer Society) questionnaire during and after radiotherapy. The results were compared. RESULTS: Overall, 79.8% of the patients used at least one CAM method. Supplementation with vitamin D (49.4%) and selenium (28.7%) and prayer (37.1%) were the methods most used. After completing radiotherapy, many patients started using selenium, vitamin D, relaxation techniques, and yoga to a greater extent. Prior chemotherapy or concurrent endocrine treatments were not associated with the changes in CAM use. CONCLUSION: CAM use is mainly reported to be a static phenomenon. However, this study shows that this is not the case and that after the end of radiotherapy patients started using new CAM methods or increased the number of methods used.

Clinical efficacy and safety of oral and intravenous vitamin C use in patients with malignant diseases.

BACKGROUND: Vitamin C, also called ascorbic acid, is a water-soluble antioxidant and free radical scavenger. It is required in the body for numerous metabolic functions and is involved in the development of proteins and connective tissue. METHODS: In April 2020, a systematic search was carried out on five electronic databases (Medline, Embase, Cochrane, Cinahl, PsycINFO) to find studies on the use, efficacy and safety of a complementary therapy with vitamin C in oncological patients. RESULTS: Out of the initial 23,195 search results, 21 studies with 1961 patients were included in this review. Five of the included studies (n = 417) were randomized controlled trials (RCTs). The remaining 16 studies belonged to a lower class of evidence. The patients who were treated with vitamin C suffered from various malignant diseases, some in an advanced and palliative stage. Vitamin C was applied intravenously or orally. It was either the only treatment or was combined with chemo- or radiotherapy. Endpoints included the development of the disease-related symptoms, quality of life, mortality, progression-free survival and safety of vitamin C. The studies were of moderate quality and showed either no effect of vitamin C or a positive trend, although this has rarely been statistically proven in group comparisons. No or only slight side effects with both oral and intravenous administration of vitamin C were reported. CONCLUSION: Oral intake of vitamin C does not appear to have any effect in patients with malignancies. Data are heterogeneous for intravenous administration. There are no RCTs with statistical group comparisons.

Prognostic relevance of granulocyte colony-stimulating factor in ovarian carcinomas.

PURPOSE: Granulocyte colony-stimulating factor (G-CSF) producing tumours were found associated with poor prognosis. Unfortunately, this finding is based on several case reports only. Thus, we investigated the expression of G-CSF in the tumour cells and the tumour stroma in a large collective of patients with ovarian cancer with long-term follow-up. METHODS: Tissue and clinical records of 175 patients with histologically confirmed ovarian carcinoma were analysed for G-CSF expression in tumour cells and the surrounding stroma. The results were compared with peripheral blood counts and other prognostic factors in ovarian cancer. RESULTS: No correlations were found between both G-CSF expression in tumour cells and the surrounding stroma and prognosis as well as peripheral blood counts. We only found a positive influence of granulocytes in the tumour stroma on prognosis, which however, was not significant in multifactorial analyses. CONCLUSIONS: In contrast to the many case reports from other entities, G-CSF expression in tumour cells and the surrounding stroma is not an adverse prognostic factor. To find out the safety of G-CSF administration for the prevention or treatment of febrile neutropenia, it is suggested for clinical trials to include long-term follow-up and immunohistochemical characterisation of the tumour.

What is wrong with the meta-analyses on honey and oral mucositis due to cancer therapies?

OBJECTIVES: The results of meta-analyses currently represent the highest level of evidence in modern medicine. Taking the example of radiotherapy and radiochemotherapy-induced oral mucositis and the effects of honey, we analysed six meta-analyses on the topic to assess the quality of the meta-analyses. DESIGN: We analysed the various meta-analyses in detail and compared whether the authors have correctly included the various trials or not. RESULTS: We found that the quality of these meta-analyses was low. Especially the more recent meta-analyses included trials in which radiotherapy was not part of the medical intervention or where substances other than pure honey were used. CONCLUSIONS: It is impossible to determine the underlying reasons why these meta-analyses were able to pass the peer-review system without the request for adequate improvements prior to publication. According to the literature at least 7% of the included meta-analyses revealed false results, but it was assumed that due to limitations of external validity and to the decreased likelihood of updating positive meta-analyses, the true proportion of false positives in the meta-analysis was likely to be higher. However, it is crucial that when severe flaws in meta-analyses are detected that they be reported or the meta-analyses are withdrawn, otherwise the normal reader will take the results as given.

Bee products and their role in cancer prevention and treatment.

OBJECTIVES: Apitherapy, a method from the field of complementary and alternative medicine, promises better survival and even cure in cases of cancer. DESIGN: 129 books on apitherapy in English, French and German languages were analysed regarding the recommendations concerning cancer. The recommendations were compared to the results from clinical studies in the literature. RESULTS: Eighteen books recommend apitherapy for cancer prevention, thirty-nine for complementary cancer treatment and seventeen books considered apitherapy able to cure cancer. Pollen and Propolis were mainly recommended in order to stimulate the immune system and/or to improve cancer nutrition. Interestingly, few books provided specific information and no book provided adequate information in comparison to what is known from clinical studies on bee products. Data on relevant aspects of cancer treatment were not mentioned. This especially refers to data of bee products and radiotherapy, chemotherapy and radio-chemotherapy-induced oral mucositis, radiotherapy-induced skin toxicity, radiotherapy-induced xerostomia, cancer-related fatigue, febrile neutropenia, cisplatin-induced nephrotoxicity, tyrosine kinase inhibitor-induced toxicity, side effects of antihormonal treatment and cancer-related wounds. CONCLUSIONS: Apitherapeutic books are not good advisors regarding all aspects of cancer. However, the potential of some bee products justifies further trials, especially on cancer prevention and complementary treatment.