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Sunday, February 26, 2012

Tale of Two Articles: Migraine and the Gut

Consider the article yesterday in the SF Chronicle "UCSF doctors see colic-migraine link."
And an elaborate study out of China looking at different acupuncture treatment approaches for migraine prophylaxis. Acupuncture for migraine prophylaxis: a randomized controlled trial (full text at link.)
What is of interest between the two? The UCSF study finds that mothers with migraines are more likely to have babies with colic. Of course, we still have no idea what causes colic, even though the name implies something to do with the GI system. But there is a link between migraines and abdominal pain in youths called "abdominal migraine." Some children suffer bouts of nausea or dizziness before developing more classic headache symptoms as adults. There clearly is some link between the gut and migraine.
Then consider the study out of China. It compares classic treatment for migraine using Shao Yang points (Gall Bladder, lateral points.) And Yang Ming or treatment using stomach points. Though Shao Yang had slightly better results, both showed a decrease in migraines compared to controls (sham acupuncture.)
So wouldn't it be fascinating, in light acupuncture's effect on the gut, to compare different electroacupuncture treatments using acupuncture points for the gut for migraine prophylaxis? (Too many studies to do, too little time.)

I would also like to mention a fascinating anecdote related to me by a patient. Her horse had a common type of colic in which they get distension, bloating and obstruction. An acupuncture veterinarian put some needles near the nostils of the horse (Large Intestine Meridian) and the horse was cured. Maybe a clue for migraine treatment??

(More on my practice here.)

Friday, February 24, 2012

Ha ha. Drug Makers Required to Show Benefit

The highlighted sentence in the second paragraph of this article could have been taken from the Onion.
(This article reminds me of an old New Yorker cartoon that showed a doctor talking to a patient at his desk saying. "I'm going to give you a new medication that works almost as well as aspirin but costs a whole lot more.")

Austerity in Europe Puts Pressure on Drug Prices
By STEPHANIE NOVAK

PARIS —Profits at pharmaceutical companies have been declining or showing little growth for the last year as austerity measures across Europe lead to cuts in health care spending. Some analysts say this trend could continue until at least 2014.

Budget cuts mean that many European governments are not willing to pay as much for pills. But new laws in some countries are also putting pressure on companies to prove their drugs are effective or risk having them dropped from the coverage list, or covered at a lower rate...


(There are then many paragraphs boo hooing about how hard this will be on the poor Big Pharma companies.)

“2011 is the first year recorded where R.& D. is down in the industry as a whole,” Mr. Bergström said...

Adding to the challenge for companies is the need to show newly cost-conscious governments that their drugs are cost effective.

Germany, Europe’s largest pharmaceutical market, has required drug companies since January 2011 to prove the added benefit of a new medication by producing documentation comparing it with other treatments on the market...
Partly as a result of these changes, the German government reported saving 1.9 billion euros on drugs in 2011, three times the savings in 2010, Business Monitor International said.

Drug companies worry that actions in Germany could hurt sales in other European markets.

My snark is borne of the great lengths that acupuncture research studies have had to go to to show benefit. An incredibly high bar that few other aspects of medicine have had to reach. Info on my practice here.


Neuromodulation in the Gut: Part II

Dr. Takahashi was kind enough to send me PDF of his paper discussed here.
It is a comprehensive look at the research, both animal and human, involved in acupuncture neuromodulation of the gastrointestional tract. There were many interesting tidbits, but I'll stick to the most usable ones, and the results pertaining to HRV (my area of interest.)
Electroacupuncture at Stomach 36 stimulates gastric motility. This is fascinating to me because when I was getting my acupuncture training, my teachers insisted that this point was contraindicated in someone dieting. The science confirms this teaching.
Acupuncture on the abdomen inhibits gastric motility. This is also of interest since the traditional treatment for profuse, watery diarrhea is moxa at the umbilicus. Takahashi reports that electroacupuncture at Stomach 25 inhibits gastric emptying.
Electroacupuncture at St36 and PC6 accelerates gastic emptying and increases the regularity of gastice slow waves in the stomach.
Electroacupuncture at St36 decreases the LF/HF HRV ratio in rats, suggesting that the gastric responses are mediated via the vagus nerves.
Electroacupuncture at St25 increases the LF/HF ratio in rats.

So what does this all mean? LF/HF ratio is a proxy for the subjects' stress repsonse. When LF/HF decreases, that means stress response is lowered. So it would make sense that if you're encouraging gastric emptying, you're encouraging the restorative arm of the autonomic nervous system, not the excitatory or "flight or fight" arm. Indeed, alert readers will recognize that the point combination of St36 and PC6 is the combination recommended to treat hypertension by Longhurst et al. (Personally, I can't imagine doing electroacupuncture at PC6, ouch!)

One other anecdote to share. In my poster for the ISAMS I charted one particular case where I was treating a patient for PCOS (Polycystic Ovary Syndrome.) The Stener-Vitorin protocol calls for strong electroacupuncture (2 HZ) on the abdomen at CV3 and CV4 and St25. My HRV monitoring showed an increase in LFR/HFR (increase stress response) with each treatment. When I stopped the electroacupuncture in an attempt to improve the stress response, the LFR/HFR decreased. Okay. Interesting and this is in line with the studies outlined here.
But even MORE interesting is that I've been treating a patient for intractable insomnia (many years duration.) She also has PCOS. She had been getting some benefit from the acupuncture treatments, but then I added in the electroacupuncture for the PCOS and she lost any of the calming benefit of the acupuncture. She figured this out and when she mentioned it to me, I remembered the previous case that I had presented at the ISAMS. We stopped doing the electroacupuncture and hopefully she'll get the improved response.

More information on my practice here.

Tuesday, February 21, 2012

Common Denominator Between Yoga and Acupuncture

I'm sure there is more than one common denominator, but in this Jane Brody blog post about yoga in the NY Times, she says,
"Possibly through its stimulation of the vagus nerve, yoga appears to counter inflammation throughout the body, and may reduce the effects of diseases like lupus and rheumatoid arthritis. And by relieving physical and mental stress, which can erode the tips of DNA, which are called telomeres and program cell death, yoga may slow biological aging and prolong life."


That is exactly the gist and purpose of my studies on the autonomic nervous system and acupuncture. She said it so succinctly and well. My studies suggest that in those people who benefit from acupuncture with a decrease in symptoms, you see their vagal activity increase, which is the restorative arm of the autonomic nervous system. This corresponds to decrease stress and an increase in health and slowing of the aging process.
More on my practice here.

Monday, February 20, 2012

The Puzzling Rise in Type I Diabetes

From Scientific American February 2012
"A Diabetes Cliff Hanger" Researchers are balled by the worldwide increase in type 1 diabetes, the less common form of the disease.
From the article, it says 90% of the 350 million people around the world who have diabetes mellitus have type 2 diabetes, or non-insulin dependent diabetes, as we used to call it. Type 1 diabetes requires insulin shots and often starts in childhood. This second type of diabetes has been rising by 3 to 5% per year. Type I diabetes has not classically been associated with obesity, so the reason for the rise in rates has scientists puzzled. Since the rise in Type 1 diabetes is world wide, the cause must be world wide also. Here are some of the hypotheses.
1. Gluten. Type 1 diabetics are more likely to have celiac disease which is caused by gluten intolerance. There has been a world wide increase in the amount of gluten most people consume over the decades.
2. Hygiene hypothesis. This is the hypothesis that links clean modern lifestyles and allergies. Since living hygienically deprives developing immune systems from early exposure to infections and soil organisms, it not only overreacts to allergens, but to the bodies own tissues, including insulin producing cells in the pancreas.
3. Fat. Perhaps there is a link between being overweight and developing Type I diabetes afterall. It may be possible to "burn out" your insulin producing cells by overtaxing them with too much food or the wrong kinds of food.

More Air Pollution Data: The Tiny Particles

Just a quick post and link to yet another article on air pollution. Please click on the title to read the whole article. Is it really time to defund public transportation and stop investment in high speed rail?? Really?? More on my practice here.
Scientists Find New Dangers in Tiny but Pervasive Particles in Air Pollution
By FELICITY BARRINGER

Fine atmospheric particles — smaller than one-thirtieth of the diameter of a human hair — were identified more than 20 years ago as the most lethal of the widely dispersed air pollutants in the United States. Linked to both heart and lung disease, they kill an estimated 50,000 Americans each year. But more recently, scientists have been puzzled to learn that a subset of these particles, called secondary organic aerosols, has a greater total mass, and is thus more dangerous, than previously understood...

“If the authors’ analysis is correct, the public is now facing a false sense of security in knowing whether the air they breathe is indeed safe,” said Bill Becker, of the National Association of Clean Air Agencies...

Paul Shepson, a professor of analytical and atmospheric chemistry at Purdue University and one of the reviewers of the Irvine paper, called it “highly significant in scientific terms,” adding that current models of fine particulates “grossly underpredict” their density, “sometimes by as much as a factor of 10...”

The Irvine study of the formation of secondary compounds in the atmosphere, which will be published in the Proceedings of the National Academy of Science, upends previous assumptions about the fate of the byproducts of the pollution from internal-combustion engines. These gaseous byproducts were thought to incorporate themselves into tiny airborne drops of liquid that would then dissipate quickly as the drops evaporated.

The new study finds instead that they attach themselves more tightly to airborne organic particles, creating tiny tar balls that evaporate more slowly and persist longer than anyone had thought. E.P.A. models built on these assumptions now appear to understate the total amount of fine particles, according to Barbara J. Finlayson-Pitts, a professor at Irvine and one of the study’s authors.

Saturday, February 18, 2012

Neuromodulation in the Gut: Acupuncture's Effect

To be filed under "Couldn't Have Said it Better Myself" file. I just love the conclusion, "According to traditional Chinese medicine, "Acupuncture is believed to restore the balance of Yin and Yang." This can be translated into the Western medicine terminology that "Acupuncture modulates the imbalance between the parasympathetic and sympathetic activity." Most excellent. More information on my practice here.


Mechanism of acupuncture on neuromodulation in the gut--a review.
Takahashi T.

Department of Surgery, Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, WI 53295, USA. ttakahashi@mcw.edu Neuromodulation. 2011 Jan;14(1):8-12; discussion 12. doi: 10.1111/j.1525-1403.2010.00295.x. Epub 2010 Oct 7.
Abstract
INTRODUCTION:

Acupuncture has been used for treating various gastrointestinal (GI) diseases. However, the mechanism of acupuncture remains unclear.
METHODS:

The aim of this article is to review the published literature on the mechanism of acupuncture on neuromodulation in the gut.
RESULTS:

Acupuncture treatment involves the insertion of thin needles into the skin and underlying muscle and the subsequent stimulation of the needles manually or electrically. Thus, acupuncture stimulates the somatic afferent nerves of the skin and muscles. The somatic Linksensory information from the body is carried to the cortex area of the brain. Somatic sensory fibers also project to the various nuclei at the brain stem and hypothalamus. Via somato-autonomic reflex, acupuncture modulates various biomechanical responses, such as prokinetic, antiemetic, and anti-nociceptive effects.
CONCLUSION:

According to traditional Chinese medicine, "Acupuncture is believed to restore the balance of Yin and Yang." This can be translated into the Western medicine terminology that "Acupuncture modulates the imbalance between the parasympathetic and sympathetic activity." Acupuncture may be effective in patients with functional GI disorders because of its effects on GI motility and visceral pain.

Friday, February 17, 2012

The Heavy Health Toll of Air Pollution: Recent studies

Not that we needed any more evidence of the negative effects of pollution, but three studies this week found that higher levels of air pollution not only increased risk of stroke, but of heart attacks and cognitive decline. A previous post on pollution here . There is a very disturbing trend on the conservative side to defund public transit which is abominable given these recent statistics on the health toll of traffic pollutants, let alone the threats from climate change. Info on the practice here.
February 15, 2012, 10:31 am
Air Pollution Linked to Heart and Brain Risks
By ANAHAD O'CONNOR
Keith Meyers/The New York TimesA layer of smog rests over Lower Manhattan.

It may be time to start paying more attention to those local air pollution alerts.

That is the message of three new studies this week that found, collectively, that people exposed to higher levels of air pollution have a greater risk of stroke, heart attacks and cognitive deterioration.

The impact of pollution on the heart and brain was seen over both the short and the long term. One nationwide study that followed nearly 20,000 women over a decade found that breathing in levels of polluted air like those commonly found in most parts of the country greatly accelerates declines in measures of memory and attention span. Another study in Boston found that on days when concentrations of traffic pollutants went up, so did the risk of stroke. The odds climbed by more than 30 percent even on days classified by the federal air quality index as “moderate” pollution days, which is intended to correspond to a minimal danger to health.

“At levels that the Environmental Protection Agency says are safe, we’re seeing real health effects,” said Gregory A. Wellenius, an associate professor of epidemiology at Brown University and lead author of the study linking pollution to stroke. “We saw these effects within 12 to 14 hours of when pollution levels went up...”.

After controlling for age, hypertension and a slew of other risk factors for stroke, the researchers found a 34 percent higher risk at times when pollution levels climbed from “good” to “moderate.” (In the Boston area, where the study was conducted, pollution levels rarely climb very high, Dr. Wellenius said.) The effect was particularly strong when the researchers looked at levels of so-called black carbon and nitrogen dioxide, two markers of pollution from traffic.

Reducing air pollution levels by just 20 percent, an “achievable” goal, Dr. Wellenius said, “would have prevented about 6,000 of the 184,000 hospitalizations for stroke in the Northeast region” in 2007 alone, he said. The results were published this week in The Archives of Internal Medicine.

In a separate report published Tuesday in The Journal of the American Medical Association, scientists at the University Paris Descartes in France helped bolster the link between short-term exposure to air pollution and cardiovascular disease. They found that a variety of common pollutants — carbon monoxide, nitrogen dioxide, sulfur dioxide and others — raised a person’s immediate risk of having a heart attack...

Saturday, February 11, 2012

Autonomic Nervous System:Acupuncture and Low Back Pain

This study evaluates the autonomic nervous system (stress response) in patients with low back pain comparing electroacupuncture (10 sessions) and an antiinflammatory medication. What they found was that both groups had pain relief, but the acupuncture group more so. There was an improvement in the stress response in the acupuncture group also. (For info on my practice please click here.)

Autonomic status and pain profile in patients of chronic low back pain and following electro acupuncture therapy: a randomized control trial.
Shankar N, Thakur M, Tandon OP, Saxena AK, Arora S, Bhattacharya N.Indian J Physiol Pharmacol. 2011 Jan-Mar;55(1):25-36.
Department of Physiology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi.

Pain is a syndrome characterized by several neurophysiological changes including that of the autonomic nervous system. Chronic low back pain (LBP) is a major health problem and is a frequent reason for using unconventional therapies especially acupuncture. This study was conducted to evaluate the autonomic status and pain profile in chronic LBP patients and to observe the effect of electro acupuncture therapy. Chronic LBP patients (n=60) were recruited from the Department of Orthopaedics, GTB Hospital, Delhi. Age and sex matched healthy volunteers were selected as controls (n=30). Following a written consent, LBP patients were randomly allocated into two study groups - Group A received 10 sittings of electro acupuncture, on alternate days, at GB and UB points selected for back pain, while the Group B received a conventional drug therapy in the form of oral Valdecoxib together with supervised physiotherapy. Controls were assessed once while the patients were assessed twice, before and after completion of the treatment program (3 weeks). The autonomic status was studied with non-invasive cardiovascular autonomic function tests which included E: I ratio, 30:15 ratio, postural challenge test and sustained handgrip test. Pain intensity was measured with the visual analogue scale (VAS) and the global perceived effect (GPE). Statistical analysis was performed using repeated measure's ANOVA with Tukey's test. Pain patients showed a significantly reduced vagal tone and increased sympathetic activity as compared to the controls (P<0.05 to P<0.001 in different variables). Following treatment, both the study groups showed a reduction in vagal tone together with a decrease in the sympathetic activity. There was also a considerable relief of pain in both groups, however, the acupuncture group showed a better response (P<0.01). We conclude that there is autonomic dysfunction in chronic LBP patients. Acupuncture effectively relieves the pain and improves the autonomic status and hence can be used as an alternative/additive treatment modality in these cases.

Spinal Serotonin and Electroacupuncture: University of Maryland Group

University of Maryland with another elegant study exploring the precise spinal neuro-receptors involved in electroacupuncture. They employ the model that they have used repeatedly, iwhich is to inject Freund's adjuvant into the joint space of cats hind paws. This is an irritant which mimics arthritis. They then use hind paw withdrawal latency to measure the effects of acupuncture versus control.
But don't we all know that acupuncture is just placebo??
(Information on my practice here.)
Involvement of spinal serotonin receptors in electroacupuncture anti-hyperalgesia in an inflammatory pain rat model.
Zhang Y, Li A, Xin J, Lao L, Ren K, Berman BM, Tan M, Zhang RX.
Neurochem Res. 2011 Oct;36(10):1785-92.
Center for Integrative Medicine, School of Medicine, University of Maryland, 685 W Baltimore street, MSTF Rm 8-22, Baltimore, MD 21201, USA.



We previously showed that electroacupuncture (EA) activates medulla-spinal serotonin-containing neurons. The present study investigated the effects of intrathecal 5,7-dihydroxytryptamine creatinine sulfate, a selective neurotoxin for serotonergic terminals, the 5-hydroxytryptamine 1A receptor (5-HT1AR) antagonist NAN-190 hydrobromide and the 5-HT2C receptor (5-HT2CR) antagonist SB-242,084 on EA anti-hyperalgesia. EA was given twice at acupoint GB30 after complete Freund's adjuvant (CFA) injection into hind paw. CFA-induced hyperalgesia was measured by assessing hind paw withdrawal latency (PWL) to a noxious thermal stimulus 30 min post-EA. Serotonin depletion and the 5-HT1AR antagonist blocked EA anti-hyperalgesia; the 5-HT2CR antagonist did not. Immunohistochemical staining showed that spinal 5-HT1AR was expressed and that 5-HT2CR was absent in naive and CFA-injected animals 2.5 h post-CFA. These results show a correlation between EA anti-hyperalgesia and receptor expression. Collectively, the data show that EA activates supraspinal serotonin neurons to release 5-HT, which acts on spinal 5-HT1AR to inhibit hyperalgesia.

Friday, February 10, 2012

Focus on the Cause AND the Cure

The latest dust up with the Komen foundation exposed the rank partisanship in the organization. But I hope that it will also expose the bias towards finding the "cure" the magic bullet that will take away the horror that is cancer. The Komen foundation partners with business to sell products and raise money. But somehow looking for the possible cause may anger big business. I discussed the media blackout on this topic here. This issue is far from simple, and I don't want to portray it as such. Here is an excerpt from an article by Susan Love, NYTimes. Info on my practice here.

Real Race in Cancer Is Finding Its Cause
By SUSAN LOVE, M.D.

A decision by the nation’s leading breast cancer advocacy group, Susan G. Komen for the Cure, to largely cut off financing for breast cancer screenings at Planned Parenthood set off howls of outrage last week. Once again, it seemed, political gamesmanship was jeopardizing women’s health.

The widespread anger forced Komen to reverse its decision, and it has certainly reinvigorated the women’s health movement. But the furor misses an important fact: Women have been led to believe that screening is the best prevention.

In reality, we still do not know what causes breast cancer, which means we really do not know how to prevent it, either. That has pushed us to focus on looking for cancers that are already there, a practice long based on the assumption that all cancers were the same, grew at a similar rate and were visible in the breast for a period of time before spreading. It made sense: If you could find cancers earlier, you could save lives...

We should continue to speak up when we think health care services are in jeopardy, but we cannot be satisfied with the status quo. We must move breast cancer advocacy to the next level, beyond screening for cancers that are already there, even beyond the cure, to finding the cause. That is true prevention.

Dr. Susan Love is president of the Dr. Susan Love Research Foundation in Santa Monica, Calif.

Thursday, February 9, 2012

Acupuncture and Parasympathetic Activity and Enkephalins, Longhurst

Readers of this blog are familiar with Dr. Longhurst. I've blogged about Linkhis work on acupuncture and hypertension and his recent conference here, here, and here. I also mentioned how he is convinced that electro acupuncture is necessary, indeed in this study his control is manual acupuncture. This is a study looking at electro acupuncture in cats at PC 5 and 6, showing that stimulation in the neurons of the nucleus ambiguous may be responsible for the increase in parasympathetic activity induced by acupuncture. This area of inquiry is of keen interest to me since my research concerns the autonomic nervous system and acupuncture effectiveness. More info on my practice here.

Nucleus ambiguus cholinergic neurons activated by acupuncture: Relation to enkephalin.
Brain Res. 2012 Jan 12.
Guo ZL, Li M, Longhurst JC.

Acupuncture regulates autonomic function. Our previous studies have shown that electroacupuncture (EA) at the Jianshi-Neiguan acupoints (P5-P6, underlying the median nerve) inhibits central sympathetic outflow and attenuates excitatory cardiovascular reflexes, in part, through an opioid mechanism. It is unknown if EA at these acupoints influences the parasympathetic system. Thus, using c-Fos expression, we examined activation of nucleus ambiguus (NAmb) neurons by EA, their relation to cholinergic (preganglionic parasympathetic) neurons and those containing enkephalin. To enhance detection of cell bodies containing enkephalin, colchicine (90-100μg/kg) was administered into the subarachnoid space of cats 30h prior to EA or sham-operated controls for EA. Following bilateral barodenervation and cervical vagotomy, either EA for 30min at P5-P6 acupoints or control stimulation (needle placement at P5-P6 without stimulation) was applied. While perikarya containing enkephalin were observed in some medullary nuclei (e.g., raphé), only enkephalin-containing neuronal processes were found in the NAmb. Compared to controls (n=4), more c-Fos immunoreactivity, located principally in close proximity to fibers containing enkephalin was noted in the NAmb of EA-treated cats (n=5; P<0.01). Moreover, neurons double-labeled with c-Fos and choline acetyltransferase in the NAmb were identified in EA-treated, but not control animals. These data demonstrate for the first time that EA activates preganglionic parasympathetic neurons in the NAmb. Because of their close proximity, these EA-activated neurons likely interact with nerve fibers containing enkephalin. These results suggest that EA at the P5-P6 acupoints has the potential to influence parasympathetic outflow and cardiovascular function, likely through an enkephalinergic mechanism.

Thursday, February 2, 2012

Genetics of the Immune System: Dr. Medzhitov

An interesting story about a Russian scientist who has studied the immune system of vertebrates. There is an innate immune system and an adaptive immune system, and he with Dr. Janeway identified the mechanism whereby the innate system triggers the adaptive one. As I've mentioned repeatedly in this blog, my hunch is that this is part of the way that acupuncture works, by triggering the body's own immune mechanisms for healing. I will excerpt some of the article here. Info on my practice here.
A Long Journey to Immune System Insights
By CLAUDIA DREIFUS

Ruslan M. Medzhitov loves scientific puzzles. And this penchant has led him to tackle some of the big questions of modern biology.

At Yale University, where he is a professor of immunology and a Howard Hughes Medical Institute investigator, Dr. Medzhitov, 45, helped make key discoveries in the workings of vertebrates’ immune systems. ..

Let’s talk about the paper by the immunologist Charles A. Janeway Jr. that changed your life. When did you learn about it?

...The only library with anything was at the Academy of Natural Sciences, and it barred nonaffiliated people from their facilities. Luckily, I had made friends with some very kind young women who worked there and who permitted me to use the library, secretly.

And it was there, one day, that I stumbled upon this three-year-old paper by Janeway, where he proposed a theory of immunity. I read it and my eyes opened up. I thought, “Now I see.”

What was in the paper?

A revolutionary idea of how the immune system worked. In vertebrates, two immune systems protect against infection. There’s the evolutionarily older system that all organisms, even plants, have — the innate immune system. There is also another system that evolved relatively recently, the adaptive immune system, which only vertebrates have. Janeway proposed that the innate system detects invading microbes, distinguishes them from everything else and signals the adaptive immune system to move against the intruder...

How did you finally prove his theory?

Our main goal was to discover the gene in the cells of the innate immune system that activates the adaptive system. That would explain how our body knows we have an infection and translates it into an immune response. It took about two years, but we found it. Today, this gene is known at the human Toll-like receptor, and it is important in immunity and in inducing inflammation.