PPCInteg01JMwoutpics

Document Sample
PPCInteg01JMwoutpics Powered By Docstoc
					John D. Mark MD
Pediatric Pulmonary and Integrative Medicine University of Arizona

History of Medicine
TB: Hang cans of dog fat over your shoulder  Ulcers: Goat dung  Snake bite: Apply ½ of severed mouse  Baldness: Drink Sea water  Everything: Enemas (3/wk- Egypt)  Galen: Blood letting- 1500 yrs!-1910


Health Expo
Supplements, blue green algae, copper bracelets, vitamin sprays, juicers, foot massage dowels, water revitalizers, colloidal silver generators, aromatherapy, crystal kingdoms, gems for “balance”, copper embedded wristwatches, aura photos, diets, books, “dolphin energy”  Are you a believer??????????


Complementary and Alternative Medicine (CAM)
Medical interventions not taught in medical school in the US or generally accepted at hospitals or routine clinics.  Includes ideas from cultures or ethnic groups not considered to be part of conventional care  40-60% of adults use CAM  Over $12 billion dollars spent-public!


Positive Motivation for CAM
Perceived effectiveness and safety  Philosophical congruence: “Zeitgeist”, holism, natural, active role of patient  Good patient/therapist relationship  Non-invasive, accessibility  “High touch, low tech”  Affluence, Control


Negative Motivation for CAM
Dissatisfaction with aspects of conventional health care, adverse side effects  Ineffective for certain condition, time  “High tech, low touch”  Rejection of science and technology  Rejection of “the establishment”  Desperation


Why is CAM use common in chronic illness?
Chronic inflammatory illness  Paradox: increasing despite advances  Belief that “external” exposures as cause  Belief that “emotions” can be important  Meds: “like using a boulder to kill an ant”  Holism and Empowerment of patients


The Integrative Approach
Whole person and family  Healing oriented not Disease  Patient/Physician partnership  Mind/Body/Spirit  Family and patient’s belief system  Holistic in approach, multilevel, and multifactorial


Integrative Approach to Health

  

Conventional vs. Integrative Healing- restoration vs. evolution Disease-entity vs. aberrant organiz. pattern Study of health- linear causality vs. circular causality Study of healing-looks at single variables vs. looks at how all are linked to form a pattern

Medicine
Medicine is not merely a science but an art. The character of the physician may act more powerfully upon the patient than the drugs employed.
Philippus Aureolus Paracelsus (1493-1541)

Chronic Respiratory Conditions
Asthma  Chronic Obstructive Pulmonary Disease (COPD) and Emphysema  Cystic Fibrosis  Other


Asthma in the United States



 


17 million, over 5 million children Most common chronic illness in children 100 million restrictive activity days per year Over 470,000 hospitalizations per year Over 5,000 deaths per year-highest in Blacks and children (ages 15-24)

Paradox in Asthma Care
NHLBI Expert Panel Guidelines (92’&97’)  Understanding airway inflammation  Early use of anti-inflammatory meds  Home management/ peak flow monitors  Practice Guidelines- both for ER & Outpts.  Morbidity and Mortality- increased?


Asthma Education-MD’s
Study of 108 MD’s and Guidelines  Asthma Faculty-78%  Asthma Fellows-69%  Family Practice-55-60%  Internal Medicine Residents-51%  Just understanding classification-problem


Asthma Triggers
  

 

Imbalance of T-helper lymphocytes type-2 (Th2) system Respiratory viruses and Exercise Allergens and Irritants: grass, trees, molds, indoor and outdoor pollution, dust-mites, cockroach, animal dander Emotional (laughing/conflict) and Weather Shift in omega-6/omega-3 fatty acids in diet

Nutrition and Asthma
Dietary habits influence lung function  Increased incidence in countries with PUSFA intake  Allergen exposure to foods and additives  Dietary intake of fruits, fresh fish and antioxidants decreased in asthmatics


Fat Classification
Saturated Fats  Monounsaturated Fats


Omega-9 family


Polyunsaturated Fats
Essential Fatty Acids (EFAs)

Omega-6 Family

Omega-3 Family

Linoleic Acid (LA) Alpha linolenic acid (ALA) Gamma linolenic acid (GLA) Eicosapentaenoic acid (EPA)
Arachidonic acid (AA) Docosahexaenoic acid (DHA)

Omega 6 Fatty Acid
(Linoleic Acid)

Omega 3 Fatty Acids
(alpha-linolenic acid)

Δ6-Desaturase Gamma-linolenic acid
(GLA)
Evening Primrose Oil Borage Oil Black Current Oil

Eicosapentaenoic Acid

(EPA)
COX
Lipoxygenase

Δ5-Desaturase

Arachidonic Acid

Prostaglandins
PGE1, PGE3
(Favorable)

Less Inflammatory Leukotrienes

Cyclo-oxygenase
(COX)

Lipoxygenase

Docosahexaenoic acid

Prostaglandins (PGE2) Inflammatory

(DHA)
Leukotrienes

Arachidonic Acid (in cell membrane)
Phospholipase A-2

Steroids Free AA
Aspirin Colchicine
Cyclo-oxygenase Lipoxygenase

NSAIDs

Pathway

Pathway

COX II Inhibitors:

Sulfasalazine Leukotriene Inhibitors:
Accolate, Singulair, Zyflo

Celebrex, Vioxx, Mobic

Prostaglandins & Thromboxanes

Leukotrienes

1985 (25:1)
25

20

Omega 6:3 Ratio

15

10

5

1909 (4:1)

0

Omega 6

Omega 3

CH3 C=C

COOH

CH3 C=C COOH

Cis
H H H H HH H H H H C C C = C C C = C C COOH H H H H H

Trans
H H H H HH H H H H C C C C C C = C C C OOH H H H H H H H

Polyunsaturated

Partially Hydrogenated

30 year shelf life

Sources of Omega-3 Fatty Acids




Cold Water Fish Salmon Mackerel Sardines Herring Fish Oils EPA & DHA

Sources of Omega-3 Fatty Acids



  

Flax Seed Products Oil, ground seed. Walnuts/Oil Hemp seeds Soybeans/Oil* Dark Green Veges* algae

What to Recommend for chronic inflammation.
   

Reduce saturated fats that contain arachidonic acid (Animal products, dairy) Reduce use of Omega 6 products (vegetable oils, crackers, things with a long shelf life) Increase use of Omega 3 products (cold water fish, flax, dark greens and nuts) Avoid low-carbohydrate (high fat) diets for prolonged periods of time (Atkins, Zone).

Dietary Supplements
Confusing more than any other area  DSHEA Act of 1994  FDA lack of regulation  Regulating nature?  When, what, how much, how long, what form, interactions, who to ask?  Botanicals, phytomedicine, Internet?


Dietary Supplements
Echinacea  Coleus forskohlii (inhibits PAF)  Ma huang (ephedra) (bronchodilator)  Ginkgo biloba (PAF inhibitor)  Licorice, coltsfoot, tumerac (anti-inflam.)  Cordyceps (bronchodilator)  Green tea (antioxidants)


Ma Huang (Ephedra sinica)
Used in China over 5,000 years  Ephedrine- principle ingredient  Commonly used with licorice (mucolytic)  FDA-Over 600 complaints-22 deaths  Tighter State regulations-esp diet claims  Most problems stem from use with caffeine


Licorice (Glycyrrhiza glabra radix)
Folk medicine- treat cough  Glycyrrhetinic acid and carbenoxolonepotent inhibitors of cortisol metabolism  Enhances endogenous and exogenous steroids  Also shown to elevate blood pressure, peripheral edema, headaches, low K+, lethargy , muscle weakness


Coleus forskohlii
Ayurvedic medicine  Acts like theophylline (increases cAMP)  Another Ayurvedic herbal remedy seems to be an effective bronchodilatorTylophora indica No studies yet on children, some on adults


Ginkgo Biloba
Study of asthmatics using Ginkgo leaves concentrate showed decrease airway hyperactivity (p<0.05) and pulmonary function improved (p<0.05)  Problem- 1997 study, in Chinese and do not specify the type of airway measurements used.


Ginkgo
Pilot data in this country has been described  PAF antagonist  Antioxidant  Can interact with other drugs, esp coumadin type meds


Vitamins
Vitamin B6 (pyridoxine)- RCT’s-helps for mild disease, 200 mg per day  Vitamin C- RCT’s-mixed results -over 1 gm  Selenium- no studies, antioxidant  Fish oil (omega 3 Fatty Acids)-RCT’slong term help


Case Presentation: Shannon
14 yr old with long standing asthma (moderate persistent), pets  Meds: Albuterol, AeoBid (Singulair, Pulmocort)-followed peds clinic  PFT’s- FEV1 (60/85), FEF25-75 (40/70)  Treatment plan: Meds, Environment, Nutrition, Dietary Supplements, Exercise


Arizona Botanical Center
One of 4 (UCLA, Chicago, Purdue)  Anti-inflammatories: Ginger, Tumeric, Boswellia  Botanical to Chemical to Animal, to Human studies  Ayruvedic- all used for asthma  Leukotriene inhibitors (esp. Boswellia)


Boswellia serrata gum resin
European J Med Res 98’ Nov:3:511  40 patients with asthma (double blind and placebo study)  70% had improved symptoms, increase in FEV1/PEFR, decrease eosinophils  Control group- had 27% improvement  Boswellia serrata gum resin for asthma


Lung Support

“Lung Support”
Retinol, Fructus,Salvia, Cordyceps, Astragalus, Prunus, Morus, Ophiopogon, Cynachum, Ginseng, Ginkgo, Magnesium  No amounts listed  SAFE  NO DRUGS  NO SIDE EFFECTS  100% NATURAL


Claims Made:
Ends..SOB, smoking damage, heart problems, sinus problems, emphysema, allergies, fatigue, asthma….  “Secrets to breathing disordered unlocked”, “End Bronchial disease”  “Today’s Medicine is Harmful”  “Dramatic improvement …few days”  “100% SATISFACTION & RISK FREE “


Mind-Body Influences on health

Mind/Body Approach
Placebo/Suggestion/Disclosure  Hypnosis:  Guided Imagery  Pediatric study proposal  Diaphragmatic breathing  Exercise, Yoga, Martial arts


Accessing the Placebo Response
Develop rapport and trust  When able, recommend therapy based on the patient’s belief system  Recommend any given therapy with enthusiasm and confidence  Activate the patient’s expectation of the therapy with positive statements


Disclosure Chronic Illness


Smyth JM, et al. JAMA, 1999


Effects of Writing About Stressful Experiences on Symptom Reduction in Patients with Asthma and Rheumatoid Arthritis.
• Study Group: Wrote about a stressful life event for 20 mins/d for 3 days • Control Group: Wrote about daily events • 107 patients.
• Asthma: 20% improvement in lung function vs no improvement in control • RA: 28% reduction in disease severity vs no change in control.

Hypnosis
Multidimensional  Induces an altered state of consciousness  Aids in developing a heightened concentration of an idea or image  Studies- many in the behavioral literature, helps if subjects are “susceptible” to hypnosis


Tracy and the Laryngeal Warts

Massage/Manipulative
Feels good, reduces stress and anxiety  Recent Asthma study: 20 minutes at bedtime by parents helped  Chiropractic Osteopathic- Used with anecdotal success


Osteopathy
Manipulative Medicine-Dr Still  Structure/Function relationship  Over 100 different types  Craniosacral, High-velocity-lowamplitude,muscle energy,counterstrain, myofascial release, lymphatic pump  Spiritual Component- Dr Viola Fryman


Other Therapies:
Mind/Body Medicine  Massage Therapy  Energy Medicine


Healing touch  Reiki  Johrei




Ethnocultural Medicine

Homeopathy
Law of Similars  Potency  Hahneman, homeopathy schools  Acute versus Chronic remedies  Classical versus “Modern”  Who, When and for what problems


Traditional Chinese Medicine
5 Elements  5 Branches


Acupuncture, moxibustion  Diet  Herbal therapy  Physical Therapy  QiGong, Kung Fu




Different Systems Approach

COPD
Conventional Care??  Inhaled steroids/Bronchodilators/Atovent



Pharmacoeconomic impact- Chest 2000

Regular use of Meds (albuterol?)  Long-term Oxygen Therapy  Home Ventilation  Nutritional Intervention


COPD and CAM


Ginseng and chronic bronchitis
Clin Drug Invest Jan 2001, 75 patients  Increased bacterial clearance




Music therapy and dyspnea
Holistic Nursing 1999, 24 patients  Less anxiety and dyspnea, better energy




Nutritional


Chest Feb 2001, 21 report review

From Jerusalem to Jericho: a study of

situational and dispositional variables in helping behavior.
J Personality and Social Psychol. 1973;27:100-108

Group #1 Group #2

Group #3

Healing
People come together to form a healing circle, But the power lies in the empty center. A person’s chest rises and falls But the breath that fills it cannot be seen. Muscle and bone join to make a body But the life force within is invisible to the eye. A child’s laugher bursts with joy And the source of it cannot be touched. What can one be But the instrument of unseen bliss?- Lao Tzu


				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:20
posted:9/26/2008
language:English
pages:55