Homeopathic treatment of patients with chronic sinusitis: A prospective observational study with 8 years follow-up

Claudia M Witt, Rainer Lüdtke, and Stefan N Willich

Abstract
Background: An evaluation of homeopathic treatment and the outcomes in patients suffering from sinusitis for 12 weeks in a usual care situation.

Methods: Subgroup analysis including all patients with chronic sinusitis (ICD-9: 473.9; 12 weeks duration) of a large prospective multicentre observational study population. Consecutive patients presenting for homeopathic treatment were followed-up for 2 years, and complaint severity, health-related quality of life (QoL), and medication use were regularly recorded. We also present here patient-reported health status 8 years post initial treatment.

Results: The study included 134 adults (mean age 39.8 ± 10.4 years, 76.1% women), treated by 62 physicians. Patients had suffered from chronic sinusitis for 10.7 ± 9.8 years. Almost all patients (97.0%) had previously been treated with conventional medicine. For sinusitis, effect size (effect divided by standard deviation at baseline) of complaint severity was 1.58 (95% CI 1.77; 1.40), 2.15 (2.38; 1.92), and 2.43 (2.68; 2.18) at 3, 12, and 24 months respectively. QoL improved accordingly, with SF-36 changes in physical component score 0.27 (0.15; 0.39), 0.35 (0.19; 0.52), 0.44 (0.23; 0.65) and mental component score 0.66 (0.49; 0.84), 0.71 (0.50; 0.92), 0.65 (0.39; 0.92), 0.74 (0.49; 1.00) at these points. The effects were still present after 8 years with SF-36 physical component score 0.38 (0.10; 0.65) and mental component score 0.74 (0.49; 1.00).

Conclusion: This observational study showed relevant improvements that persisted for 8 years in patients seeking homeopathic treatment because of sinusitis. The extent to which the observed effects are due to the life-style regulation and placebo or context effects associated with the treatment needs clarification in future explanatory studies.

Background
Chronic sinusitis is generally accepted to be a common illness incurring considerable costs, despite limited epidemiological data. It is defined as an inflammation of the nasal mucosa and paranasal sinuses for at least 12 weeks which may cause nasal blockage or congestion, mucous discharge, facial pain or pressure, and/or impaired smell. Polyps, which may or may not be present are increasingly recognized as part of the sinusitis pathology. Several factors have been found to contribute to the disease, namely, insufficient ciliary motility, allergy and asthma, bacterial infection, and more rarely, morphological anomalies, immune deficiencies and Samter's triad (salicylate sensitivity, asthma, nasal polyps). While the role of fungi and hormonal changes during pregnancy are unclear, it may also be an early symptom of systemic disease.

Standard treatment recommendations are to suppress the inflammatory process with corticosteroids, antibiotics may be also necessary to combat opportunistic infections, and possible underlying diseases may require their own specific medication. Saline douching can provide some symptomatic relief. Surgical intervention was found to be as effective as medical treatment, but should be reserved for refractory cases. Some complementary and alternative medical (CAM) treatments might be helpful as adjuvants. It appears that homeopaths are consulted more frequently by patients with acute and chronic sinusitis (13% of the homeopathy group vs. 7% of the conventional group in an observational comparison study), but to date no research has looked into the effects of homeopathy for chronic sinusitis.

Homeopathy is practised in many regions of the world, especially in high-income countries, where it is the most popular treatment form among the traditional, complementary, or alternative medical therapies. Homeopathic prescribing accounts for concomitant symptoms in addition to the predominant pathology, therefore the same main diagnosis may be treated with different remedies in different patients ('individualisation'). The prescribed drugs ('remedies') are under constant debate. They are produced by alternating steps of diluting and agitating a starting substance ('potentiating'). After several repetitions, dilutions beyond Avogadro's number are reached, and the probability approaches zero that even a single molecule of the starting substance
remains present in the drug. Such 'high potencies' are often used, however their effects are the subject of scientific controversy.

Apparently, the inconsistent results seen in meta-analyses of placebo-controlled trials pooling a great variety of diseases and ailments might be a consequence of trial selection. We analyzed the data from our prospective observational study, which globally evaluated details and effects under homeopathic treatment in a usual care situation (3981 patients over 8 years) with respect to diagnosis. This paper presents the 134 adults consulting a homeopathic physician because of chronic sinusitis.

DOWNLOAD COMPLETE PDF HERE

Read More..

Correlating the site of tympanic membrane perforation with Hearing loss

Titus S Ibekwe, Onyekwere G Nwaorgu2 and Taiwo G Ijaduola

Abstract
Background: It is recognized that the size of tympanic membrane(TM) perforation is proportional to the magnitude of hearing loss, however, there is no clear consensus on the effect of the location (site) of the perforation on the hearing loss. Hence the study is set to investigate the relationship between the location of perforation on TM and hearing loss.

Methods: A cross-sectional prospective study of consecutive adult patients with perforated TM
conducted in the ENT clinic of University College Hospital Ibadan between January 1st 2005 and July 31st 2006. Instruments used for data collection/processing include questionnaires, video and micro-otoscopy, Pure tone audiometer, image J and SPSS packages.

Results: Sixty-two patients (22-males, 40-females), aged 1675 years (mean = 35.4 +/- 4) with 77 perforated ear drums were studied and 15(24.2%) had bilateral TM perforations, 21 (33.9%) right unilateral and 26(41.9%) left unilateral. The locations of the TM perforations were 60(77.9%) central, 6 (9.6%) antero-inferior, 4(5.2%) postero-inferior, 4(5.2%) antero-superior and 3(3.9%) postero-superior respectively with sizes ranging from 1.51%89.05%, and corresponding hearing levels 30 dB 80 dB (59% conductive and 41% mixed). Fifty-nine percent had pure conductive hearing loss and the rest mixed. Hearing losses (dBHL) increased with the size of perforations (P = 0.01, r = 0.05). Correlation of location of perforations with magnitude of hearing loss in acute TM perorations was (P = 0.244, r = 0.273) and for chronic perforations (p = 0.047 & r = 0.31).

Conclusion: The location of perforation on the tympanic membrane (TM) has no effect on the magnitude of hearing loss in acute TM perforations while it is significant in chronic ones.

Background
Apart from conduction of sound waves across the middle ear, the tympanic membrane, also sub-serves a protective function tothe middle ear cleft and round window niche. Intact tympanic membrane protects the middle ear cleft from infections and shields the round window from direct
sound waves which is referred to as 'round window baffle'. This shield is necessary to create a phase differential so that the sound wave does not impact on the oval and round windows simultaneously. This would dampen the flow of sound energy being transmitted in a unilateral direction from the oval window through the perilymph. It has been found that the effect of the enhanced ratio of the surface area of the tympanic membrane to that of the oval window increases the sound pressure by about 27 decibel (dB) whereas the lever action of ossicles contributes about 3 decibel (dB).

A perforation on the tympanic membrane reduces the surface area of the membrane available for sound pressure transmission and allows sound to pass directly into the middle ear. As a result, the pressure gradient between the 'inner' and 'outer' surfaces of the membrane virtually becomes insignificant. The effectiveness with which the tympanic membrane transmits motion to the ossicular chain is thus impaired along with the level of hearing. It has been established that the larger the perforation on the tympanic membrane, the greater the decibel loss in sound perception. A total absence of the tympanic membrane would lead to a loss in the transformer action of the middle ear. The location of the perforation is believed by some schools of thought to have a significant effect on the magnitude of hearing loss.
For instance, posterior quadrant perforations are believed to be worse than the anterior ones because of the direct exposure of the round window to sound waves and perforations at or near the site of tympanic membrane attachment to manubrium have more severe effects than those of comparable size at different sites. However, some workers believe that there is no significant effect associated with location of the perforation.This divergent opinion, informed undertaking the study, set to investigate the relationship between the location of perforation on TM and the magnitude of conductive hearing loss with a view to contributing to the body of knowledge on this subject.

DOWNLOAD COMPLETE PDF HERE

Read More..

Treatment of Acne Scarring

M. Alam, MD, MSCI; J. S. Dover, MD, FRCPC, FRCP

Abstract
Acne scarring is common but surprisingly difficult to treat. Scars can involve textural change in the superficial and deep dermis, and can also be associated with erythema, and less often, pigmentary change. In general, treatment of acne scarring is a multistep procedure. First, examination of the patient is necessary to classify the subtypes of scarring that are present. Then, the patient´s primary concerns are elicited, and the patient is offered a menu of procedures that may address the various components of the scarring process. It is important to emphasize to the patient that acne scarring can be improved but never entirely reversed.

Classification of Acne Scars
There are several classifications of acne scars. A recent, comprehensive and functional scheme was proposed, whereby scars are classified as rolling, ice-pick, shallow box-car, and deep box-car. Rolling scars are gently undulating, appearing like hills and valleys without sharp borders. Ice-pick scars, also known as pitted scars, appear as round, deep depressions culminating in a pinpoint base; in cross-section, they are shaped like a "v. Box-car scars have a flat, "u-shaped base. Broader than ice-pick scars, they are round, polygonal, or linear at the skin surface. Shallow box-car scars terminate in the shallow-to mid-dermis, and deep box-car scars penetrate to the reticular dermis.

Treatment Modalities for Textural Change
Among the therapeutic tools for treatment of acne scarring are resurfacing methods, fillers, and other dermal remodeling techniques. These methods can be adapted to treat specific scar types.

Resurfacing
Resurfacing options include:

• Ablative resurfacing with carbon dioxide or erbium: yttrium aluminum garnet (Er:YAG) laser, medium- depth to deep chemical peel, dermabrasion, or plasma.

• Nonablative and partially ablative resurfacing with fractional laser, infrared laser (1,320nm neodymium:YAG (Nd:YAG), 1,450nm diode, or 1,540nm erbium:Glass)

Ablative Resurfacing
Ablative resurfacing entails removal of the epidermis and partial thickness dermis, and is considered by most as the gold standard for pitted scars and some box-car scars. While ablative resurfacing is most effective if it is deep, thereby removing as much as possible of the depressed scar, it cannot be so deep as to destroy the base of the hair follicles; such destruction could impede skin regrowth, and induce scar formation at the treated site. Carbon dioxide resurfacing is the most effective but also most operator-dependent method for deep ablative resurfacing.

Dermabrasion is possibly even more effective, but this is another procedure that is very technique dependent. Deep phenol (Baker-Gordon) peels, also highly effective, have fallen out of favor because of the associated cardiac risk and the frequency of porcelain-white postinflammatory hypopigmentation. Definitive ablative resurfacing results in 2 weeks of patient downtime, during which period re-epithelialization occurs. More superficial resurfacing with the Er:YAG laser or plasma can provide recovery within 1 week, but deeper acne scars may be less improved.

Nonablative Resurfacing
Nonablative resurfacing with laser and lights warms the dermis and can provide modest improvement of acne scarring bystimulating collagen remodeling. All subtypes of acne scars can be improved by nonablative therapy. Among the lasers used for this indication are devices originally developed for otheruses, such as pulsed-dye lasers, intense pulsed light devices, and Q-switched Nd:YAG lasers. However, more recently nonablative devices have been optimized to specifically target textural irregularities. For example, a series of treatments with infrared lasers can significantly improve uneven contour associated with acne scarring. These treatments are typically uncomfortable and may require oral and/or topical analgesics.

Similarly, fractional resurfacing is quite effective in the treatment of acne scarring. Fractional resurfacing is a minimally ablative technique that creates microscopic zones of dermal injury in a grid-like pattern. Because only a small proportion of the skin surface is treated at one time, and since the stratum corneum is not perforated, recovery is quick. However, a series of treatments is needed.

DOWNLOAD COMPLETE PDF HERE

Read More..

Topical Treatments for Melasma and Postinflammatory Hyperpigmentation

C.B. Lynde; J.N. Kraft, MD; C.W. Lynde, MD, FRCPC

Abstract
Hyperpigmentation disorders of the skin are common and can be the source of significant psychosocial distress for patients. The most common of these disorders are melasma and postinflammatory hyperpigmentation. Sunscreen use and minimizing sun exposure are crucial in all cases. Topical applications are the mainstay of treatment and include phenols, retinoids, corticosteroids, and their combinations.

Introduction
Hyperpigmentation of the skin is a very common problem, with many patients seeking therapies to improve their cosmetic appearance. It is the result of an increase in cutaneous melanin deposition either by increased melanin synthesis or, less commonly, by a greater number of melanocytes. The amount of color change depends on the location of the melanin deposition. Epidermal involvement appears as brown discoloration whereas dermal deposition appears as blue-grey.

Mixed epidermal and dermal depositions appear as brown-grey discolorations. The use of a Wood's lamp can often be very beneficial in determining the location of melanin deposition showing enhancement of color contrast in lesional skin for the epidermal type, but not the dermal types. The mixed type has enhancement in some areas of lesional skin, but not in other areas. Whether the melanin is deposited in the epidermis or dermis is important therapeutically because dermal hyperpigmentation is much more challenging to treat.

The most common pigmentation disorders for which patients seek treatment are melasma and postinflammatory hyperpigmentation (PIH). These conditions may have a major impact because disfiguring facial lesions can significantly affect a person's psychological and social wellbeing, contributing to lower productivity, social functioning, and self-esteem.

Melasma
Melasma is a common acquired pigmentary disorder that occurs mainly in women (more than 90% of cases) of all racial and ethnic groups, but particularly affects those with Fitzpatrick skin types IV-VI. While the cause of melasma is unknown, factors include: a genetic predisposition, ultraviolet light exposure, and estrogen exposure. Estrogen is thought to induce melasma as it often develops during pregnancy, with use of oral contraceptives, and with hormone replacement therapy (HRT) in postmenopausal women. Melasma in pregnancy usually clears within a few months of delivery.

Discontinuation of oral contraceptives or HRT, in combination with adequate sun protection, may also result in melasma clearance, although there is a paucity of literature with regard to HRT and the clearance of this condition. Melasma presents as brown to grey macules and patches, with serrated, irregular, and geographic borders. The pigmented patches are usually sharply demarcated and symmetrical. Melasma has a predilection for sun-exposed areas. The three major patterns of distribution are: centrofacial (cheeks, forehead, upper lip, nose, and chin) (66% of cases), malar (cheeks and nose) (20% of cases) and mandibular (rami of the mandible) (15% of cases). See Table 1 for the differential diagnosis.

DOWNLOAD COMPLETE PDF HERE

Read More..

Practical Management Strategies for Diaper Dermatitis

S. Humphrey, MD; J. N. Bergman, MD, FRCPC; S. Au, MD, FRCPC

Abstract
Common diaper dermatitis is an irritant contact diaper dermatitis(IDD) created by the combined influence of moisture,warmth, urine, feces, friction, and secondary infection. It is difficult to completely eradicate these predisposing factors in a diapered child. Thus, IDD presents an ongoing therapeutic challenge for parents, family physicians, pediatricians, and dermatologists. This article will focus on pratical management strategies for IDD.

Introduction
IDD is a common inflammatory eruption of the skin in the diaper area created by the presence of moisture, warmth, urine, feces, and friction, and is seen in 25% of children wearing diapers.

Pathogenesis
Four key factors contribute to the development of IDD :

• Wetness : Wet diapers result in excessive hydration and maceration of the stratum corneum leading to impaired barrier function, enhanced epidermal penetration by irritants and microbes, and susceptibility to frictional trauma.

• Friction : IDD is most commonly distributed in areas with the greatest skin-to-diaper contact. Mechanical trauma disrupts the macerated stratum corneum, exacerbating barrier dysfunction.

• Urine and feces : The interaction of urine and feces is key to the pathogenesis of IDD. Bacterial ureases in the stool degrade the urea that is found in urine, releasing ammonia and increasing local pH. Fecal lipases and proteases are activated by the increased pH. They cause skin irritation and disruption of the epidermal barrier. Ammonia does not irritate intact skin; it is thought to mediate irritation by contributing to the high local pH.

• Microorganisms : candida albicans (C. albicans) and, less commonly, Staphylococcus aureus (S. aureus) infections are associated with IDD. The warm, humid, and high pH environment in the diaper provides the ideal milieu for microbial proliferation. Innate antimicrobial microflora cannot survive in a high pH environment. There is a positive correlation between the clinical severity of IDD and the presence and level of C. albicans in the diaper, mouth, and anus of infants.

Clinical Features
IDD initially presents with localized asymptomatic erythema, and can progress to widespread painful, confluent erythema with maceration, erosions, and frank ulceration. IDD commonly spares the skin folds, and affects the convex skin surfaces in close contact with the diaper including the buttocks, genitalia, lower abdomen, and upper thighs. IDD complicated by Candida presents with beefy red intertriginous plaques and satellite papules and pustules in the diaper area.IDD complicated by S. aureus appears impetiginized, with erosions, honey-colored crust, and lymphadenopathy.

Granuloma gluteale infantum and Jacquet erosive diaper dermatitis are distinctive, severe variants of IDD. Granuloma gluteale infantum presents in the setting of IDD with violaceous papules and nodules on the buttocks and in the groin.The pathogenesis of granuloma gluteale infantum is not clear. Potential risk factors include treatment with topical steroids, candida infection, and occlusive plastic diaper covers. Granuloma gluteale infantum follows a self-limited course, resolving in weeks to months, often with residual scarring. The presence of punched-out erosions or ulcerations with heaped-up borders characterizes Jacquet erosive diaper dermatitis. This uncommon and severe presentation of IDD typically occurs in the context of frequent liquid stools, poor hygiene, infrequent diaper changes, or occlusive plastic diapers.

It is imperative to consider other conditions that may occur in the diaper area. Several excellent references are available that outline the differential diagnosis of IDD. Please see Table 1 for a review of the clinical features of relevant diaper dermatoses.

DOWNLOAD COMPLETE PDF HERE

Read More..