Peter Fisher

Complementary medicine in Europe.

Complementary or unconventional treatments are used by many doctors and other therapists throughout Europe. The major forms are acupuncture, homoeopathy, manual therapy or manipulation, and phytotherapy or herbal medicine. The relative popularity of therapies differs between countries, but public demand is strong and growing. Regulation of practitioners varies widely: in most countries only registered health professionals may practice, but in the United Kingdom practice is virtually unregulated. Germany and some Scandinavian countries have intermediate systems. Legal reforms are in progress in the Netherlands and the United Kingdom. European institutions are starting to influence the development of complementary medicine. Harmonisation of training and regulation of practitioners is the challenge for the future.

Coeliac disease in primary care: case finding study

Abstract Objectives: To provide evidence of underdiagnosis of coeliac disease and to describe the main presenting symptoms of coeliac disease in primary care. Design: Case finding in a primary care setting by testing for coeliac disease by using the endomysial antibody test. Setting: Nine surgeries in and around a market town in central England, serving a population of 70 000. Participants: First 1000 patients screened from October 1996 to October 1997. Outcome measures: Determination of endomysial antibody titre of patients fulfilling the study criteria, followed by small intestine biopsy of those with positive results. Results: The 30 patients (out of 1000 samples) with positive results on the endomysial antibody test all had histological confirmation on small intestine biopsy. The commonest mode of presentation (15/30) was anaemia of varying severity. Most patients (25/30) presented with non-gastrointestinal symptoms. Specificity of the endomysial antibody test was 30/30. Conclusions: Underdiagnosis and misdiagnosis of coeliac disease are common in general practice and often result in protracted and unnecessary morbidity. Serological screening in primary care will uncover a large proportion of patients with this condition and should be made widely available and publicised. Coeliac disease should be considered in patients who have anaemia or are tired all the time, especially when there is a family history of the disease.

NHS bonds could be alternative to private finance initiative for NHS

Editor—Concern is growing as more detail is revealed about the private finance initiative in the NHS.1Negotiations over the initiative are conducted under terms of commercial confidentiality. Health professionals and the public are effectively shut out as commercial imperative takes precedence over social purpose.nnThe private finance initiative is a costly option. Participating consortiums expect an annual return on investment of 15% or more, to be met by taxpayers (or charges on patients) locked in for 30–60 …

Should doctors recommend homeopathy

Peter Fisher criticises the methods of a recent review that found no evidence to support homeopathy. But inconclusive evidence, lack of rational explanation, and questions about safety make Edzard Ernst question Europe’s €1bn annual spend on such remedies

Complementary medicine: Authors' reply

recurrence of symptoms with much suffering. It may also be a dangerous action in women with depression responsive to oestrogen. This approach might be used to justify a study of the pharmacokinetics of implants, but we would argue that this is inhumane management of individual patients. We would agree that there is currently no evidence that such high oestradiol concentrations are dangerous, but we need more information about those patients who seem to need increasingly frequent hormone implants. On the other hand, we do know that treatment with percutaneous oestradiol produces a greater density in vertebral and femoral bone than does oral treatment. This difference is directly related to oestradiol concentrations.< Indeed, in a prospective study we found an 8% increase in spinal bone density and a significant correlation between the incremental increase in vertebral bone density and the oestradiol concentrations achieved after one year of treatment with percutaneous implants (unpublished data). Oestrogen replacement therapy in postmenopausal women is probably the most important advance in preventive medicine in the Western world for half a century. There is much evidence that oestradiol implants, by virtue of the higher oestradiol concentrations achieved, are the most effective and acceptable mode of hormone replacement therapy. The occasional finding of supraphysiological concentrations of oestradiol does not encourage us to change this view. JOHN STUDD

Points: Complementary medicine

Dr J J JONES (Department of Community Medicine, Leicestershire Health Authority, Leicester LE1 6TP) writes: Professor Brian Jarman and colleagues (25 June, p 1775) make a multiple regression analysis, but the results shown in table III seem to represent each factors association with immunisation when considered separately. Details of the interaction between factors are not given. I made a similar analysis of diphtheria immunisation in 92 postcode sectors of Leicestershire using information obtained from the child health register by Dr Brigender Rana. Eleven factors considered together explained 73% of the variance, but only two were significant-local authority housing and ethnic group. The risk of not being immunised was increased by 25% (95% confidence interval 3% to 510%) by an increase of one standard deviation in local authority housing. The risk of not being immunised was reduced by 22% (4% to 36%) by an increase of one standard deviation in the number of people from the new Commonwealth and Pakistan. Unemployment, population mobility, and distance from a clinic when considered as part of the multiple regression had a small but non-significant association with not being immunised.

Pregnancy outcome in relation to the concentration and concanavalin A reactivity of α-fetoprotein and the presence of acetylcholinesterase activity in amniotic fluid

SummaryReactivity of α-fetoprotein with concanavalin A and detection of acetylcholinesterase activity in amniotic fluid were evaluated as secondary tests for fetal neural tube defect in pregnancies with a high or a low risk of such a defect. A retrospective study was done on 72 fluids and a prospective study on selected samples from 342 fluids in all of which total a-fetoprotein had been measured. Both additional tests were useful in discriminating between normal and abnormal outcome in pregnancies with raised total α-fetoprotein.In the prospective series there were four false positive total α-fetoprotein tests and one false positive acetylcholinesterase test in viable pregnancies without fetal abnormality. None of the three tests was falsely negative for fetal neural tube defect.Specific abnormality and other poor pregnancy outcomes were much commoner when amniocentesis followed from high maternal serum α-fetoprotein than any other indication.