Richard G. Petty, MD

Acupuncture for Hay Fever

A study from Melbourne, Australia has found that acupuncture can significantly reduce the symptoms of persistent allergic rhinitis (PAR), a.k.a. hay fever. This was a randomized, single-blind, sham-controlled trial included 80 patients with PAR aged 16-70 years, who were randomly assigned to real or sham acupuncture. Three key acupuncture points, Yingxiang L.I.-20, Yintang M-HN-3 and Fengchi GB-20, plus one supplementary point (determined individually on the basis of traditional Chinese Medicine pattern differentiation) were used for each participant. After a one-week baseline period, participants were treated twice weekly for eight weeks and followed up for another 12 weeks. Nasal obstruction, sneezing, rhinorrhea and nasal itch were each self-assessed daily on a 5-point scale, and individual symptom scores were added to give a sum of the symptom scores: total nasal symptom score (TNSS). A secondary outcome was use of PAR relief medication. At the end of eight weeks' treatment, the weekly mean difference in TNSS from baseline was significantly greater with real (-17.2) than with sham acupuncture (-4.2) and these benefits persisted three months after the end of treatment. Comparisons of relief medication scores revealed a significant decline in the use of medication in the real acupuncture group between baseline and Week 8 of treatment, the reduction being still apparent at the end of follow-up.

This research is convincing. The effect size is not enormous, and we do not know how long the effect will last, but it does suggest another approach for people who have chronic symptoms and for whom medications are ineffective, or who do not want to take medications, or have side effects from them.

It may be relevant that some years ago it was shown that needling the Fengchi point - which lies at the base of the skull at the back of the head - increases some components of cerebral blood flow. That may give us a mechanism of action of the acupuncture in this trial.

“I am pretty sure that, if you will be quite honest, you will admit that a good rousing sneeze, one that tears open your collar and throws your hair into your eyes, is really one of life's sensational pleasures.”
--Robert Charles Benchley (American Humorist, Critic and Parodist, 1889-1945)

“The nose is for breathing, the mouth is for eating.”
--English Proverb

“Warmth, moisture, food-these are the causes that activate latent germs and arouse them to activity. They exist, all except the food, in the mouth, nose and throat at all times. The food is thrown out into these, as excretions, in disease. The germs feed on the excretions. They are scavengers. They were never anything else and will never be anything else. They break up and consume the discharge from the tissues. This is the function ascribed to germs everywhere in nature outside the body and is their real and only function in disease. They are purifying and beneficial agents. The medical profession has worked itself into hysteria over the germ theory and is using it to exploit an all too credulous public. Germs are ubiquitous. They are in the air we breathe, the food we eat, the water we drink. We cannot escape them. We can destroy them only to a limited extent. It is folly to attempt to escape disease by attempting to destroy or escape germs. Once they are in the body, the physician has no means of destroying them that will not, at the same time, destroy the patient. We cannot avoid germs. We must be proof against them. We have to accept them as one of the joys of life.”
--Herbert Shelton (English Evolutionary Philosopher, 1820-1903)

Non-pharmacological and Lifestyle Approaches to Attention-Deficit/Hyperactivity Disorder: 1. Diet

You can find some articles on Attention-Deficit/Hyperactivity Disorder (ADHD) here, and also some of the evidence that ADHD is a “real” illness and not just a label for socially unacceptable behavior. That being said, it is essential to take extra care when making the diagnosis. Mud sticks, and diagnostic mud sticks like glue. It can be hard to “unmake” a diagnosis.

As with any problem, the most effective way of helping it is to address the physical, psychological, social, subtle and spiritual aspects of the situation.

Medicines can definitely have a place in the management of ADHD, and the reason for treating ADHD is not so that people get better grades in school or do better at their jobs. It is to prevent the long term problems that may follow from inadequately treated ADHD.

There is a large and growing body of research on non-pharmacological approaches to treating ADHD. A literature search has turned up over two hundred papers, over half of which report some empirical research. Some of the research is summarized in a short paper aimed at health care professionals.

Research has shown that more than 50% of American families who receive care for ADHD in specialty clinics also use complementary or alternative medical (CAM) therapies, if you include things like modifying their diet or other aspects of their lifestyle. Despite that, only about 12% of families report their use of CAM to their clinician. Despite that low rate of families reporting the use of unorthodox therapies, a national survey of pediatricians showed that 92% of them had been asked by parents about complementary therapies for ADHD. The trouble is that many pediatricians have not been taught very much about the pros and cons of these approaches.

The most commonly used CAM therapies for ADHD are dietary changes (76%) and dietary supplements (> 59%). I have talked about food additives and one type of diet in the past. Now let’s look in a little more detail.

The 3 main dietary therapies for ADHD are:

• The Feingold diet,

• Sugar restriction, and

• Avoiding suspected allergens.

Sometimes these diets are used in combination.

The Feingold Diet
The Feingold diet is the most well known dietary intervention for ADHD. It aims to eliminate 3 groups of synthetic food additives and 1 class of synthetic sweeteners:
Synthetic colors (petroleum-based certified FD&C and D&C colors);

Synthetic flavors;

BHA, BHT and TBHQ ; and

The artificial sweeteners Aspartame, Neotame, and Alitame.

Some artificial colorings such as titanium dioxide are allowed.

During the initial weeks of the Feingold program, foods containing salicylates (such as apples, almonds, and grapes) are removed and are later reintroduced one at a time so that the child can be tested for tolerance. Most of the problematic salicylate-rich foods are common temperate-zone fruits, as well as a few vegetables, spices, and one tree nut.

During phase 1 of the Feingold diet, foods like pears, cashews, and bananas are used instead of salicylate-containing fruits. These foods are slowly reintroduced into the diet as tolerated by the child.

The effectiveness of this diet is controversial. In an open trial from Australia, 40 out of 55 children with ADHD had significant improvements in behavior after a 6-week trial of the Feingold. 26 of the children – 47.3% -  remained improved following liberalization of the diet over a period of 3-6 months.

In another study, 19 out of 26 of children responded favorably to an elimination diet. What  is particularly interesting is that when the children were gradually put back on to a regular diet, all 19 of them reacted to many foods, dyes, and/or preservatives.

In yet another study, this one a double-blind, placebo-controlled food challenge in 16 children, there was a significant improvement on placebo days compared with days on which children were given possible problem foods. Children with allergies had better responses than children who had no allergies.

Despite this research many pediatricians, particularly in the United States, do not believe the evidence regarding the effectiveness of elimination diets or additive-free diets warrants this challenging therapy for most children.

There is an interesting difference in Europe. In 2004 a large randomized, blinded, cross-over trial of over 1800 three-year-old children was published. The results showed consistent, significant improvements in the children's hyperactive behavior when they were on a diet free of benzoate-preservatives and artificial flavors. They had worsening behavior during the weeks when these items were reintroduced. On the basis of this and other studies, in 2004 schools in Wales banned foods containing additives from school lunches. It has been claimed that since the ban, there has been an improvement in the afternoon behavior of students.

The biggest problem with the Feingold and other elimination diets is that they are hard to follow and to maintain. But for some children and families, the inconvenience and stricter attention to food have worthwhile results.

It is also essential to ensure that children on any kind of diet maintain adequate nutrition: there have been many examples of that simple rule not being followed.

Sugar Restriction
The notion that sugar can make children “hyper” entered the mainstream over twenty years ago, and is now on the list of things that “everyone knows.” But happily it is not true. At least 12 double-blind studies have failed to show that sugar causes hyperactive behavior. Some researchers suggest that sugar or ingestion of high-carbohydrate "comfort foods" is actually calming, and that children who seek these foods may be attempting to "self-medicate."

There are plenty of very good reasons for children to avoid candy, but hyperactivity is not one of them.

Food Allergies
There is clear evidence that children, and perhaps adults with ADHD are more likely to have allergies. That lead to the obvious question whether children with ADHD allergic or sensitive to certain foods. (It is useful to differentiate “allergies” that are the result of abnormal reactivity of the immune system to proteins in food, from “sensitivities” that are the direct result of substances in food: the two have different treatments.)

It is certainly true that food allergies and food sensitivities can generate a wide range of biological and behavioral effects. Gluten sensitivity (celiac disease) is known to be linked to an increased risk of ADHD and other symptoms.

In an open study of 78 children with ADHD referred to a nutrition clinic, 59 improved on a few foods trial that eliminated foods to which children are commonly sensitive. For the 19 children in this study who were able to participate in a double-blind cross-over trial of the suspected food, there was a significant effect for the provoking foods to worsen ratings of behavior and to impair psychological test performance.

For more than 30 years one of the tests used to track allergies has been the radioallergosorbent test (RAST). It is not much used these days since technology has moved on. In an allergy testing study of 43 food extracts 52% of 90 children with ADHD had an allergy to one or more of the foods tested. Over the next few years several researchers carried out open-label studies in which children with ADHD and food allergies were treated with a medicine called sodium cromoglycate, that prevents the release of inflammatory chemicals such as histamine from mast cells. Some of the reports suggested that it could help in some children.

Other popular dietary interventions include eating a low glycemic index diet to avoid large swings in blood sugar. Another strategy has been to “go organic” to reduce the burden of pesticides, hormones, antibiotics, and synthetic chemicals in the child's system. These diets need more scientific study but they are probably safe if expensive.

There are plenty of practitioners and commercial entities who claim to be able to identify food sensitivities with all kinds of methods from blood and muscle testing to electrical and energetic techniques. Some may be helpful, but few have been proven to be effective.


What Should Parents do About Diet, Nutrition, Allergies and Sensitivities?
It is very difficult to predict whether an individual child will be helped by changes in diet. However, as long as the child’s needs for essential nutrients are met these diets should be safe.

It is an extremely good idea for parents to keep a diet diary for one to two weeks to see if anything obvious jumps out. Then trying an additive-free diet, low in sugar and avoiding foods that are suspected of exacerbating symptoms. You will normally find the answer - yes or no - within a few weeks.


What is the Evidence for Food Sensitivities and ADHD in Adults?
Not a lot!

There are plenty of people who have reported that dietary restrictions have helped them, but there is very little evidence. One of the problems about looking for food sensitivities is that there is a high placebo response rate. But if you have adult ADHD, it may be worth investigating. Just make sure that any diet that you use is nutritionally sound. And if you don't find anything reconsider another approach.

Asthma, Air and Allergies

After a couple of weeks away I was distressed to see that I was going to be returning to a city which has just been rated as the most challenging place in America for people with asthma.

This is the list according to the Asthma and Allergy Foundation of America:

1. Atlanta
2. Philadelphia
3. Raleigh, North Carolina
4. Knoxville, Tennessee
5. Harrisburg, Pennsylvania
6. Grand Rapids, Michigan
7. Milwaukee
8. Greensboro, North Carolina
9. Scranton, Pennsylvania
10. Little Rock, Arkansas

I am pleased to say that I do not have asthma, though I have a strong family history of it. If you live in one of these cities, or any other with a high rate of pollution, there is nothing much to be done apart from:

Staying indoors when the weather is bad

Using an air purifier

Keep to a diet designed to reduce your risk of inflammation

Use homeopathy and tapping therapies to help when necessary.

And sadly, for some people, medicines are the only option. But I always try the other approaches as well.

Self-hypnosis and Hay Fever

I first learned to do hypnosis in 1980, and I have always found it a useful adjunctive treatment for some people, though in recent years I have spent far more tie teaching people to use self-hypnosis.

The research data on hypnosis has also been growing, to the extent that nearly two years ago an article in the Mayo Clinic Proceedings, a fairly conservative journal, suggested that the time had come for an expanded role for hypnosis in general medicine as well as a study of different techniques that are in use.

Hypnosis and self-hypnosis may affect an illness directly, or it might reduce a trigger to the illness, say if anxiety triggers an asthma attack, we could use hypnotherapy to treat the anxiety. Hypnosis may improve a person’s subjective responses to the illness. It might also be useful to help counteract side effects in people who just have to be treated with conventional medications.

Many case reports of apparent cures with hypnosis have found their way into the popular press.  I have mentioned that over a period of five years I spent one to two days a week going through and checking most of these reports in all the languages that I can read. Sadly some of them turned out not to hold much water.

But now the quality of the research has improved enormously. I have been particularly impressed with some of the studies on allergy: it is very remrakable to think that we can make specific suggestions that produce demonstrable effects on the immune system. I particularly liked a study from Switzerland that was published in the journal Psychotherapy and Psychosomatics.

A team from Basel University taught 66 people with hay fever how to do self-hypnosis and found that it helped them to alleviate symptoms such as runny nose.

The volunteers also took their regular hay fever medicines, but the effect of hypnosis appeared to be additive so that they could reduce the doses that they needed to take.

The study took place over two years and included two hay fever seasons. During the first year, one group of the volunteers with hay fever were taught and asked to regularly practice hypnosis as well as take their usual allergy medicine. The training consisted of one two-hour session with an experienced trainer. The remaining volunteers had no other treatment apart from their normal allergy medication.

After a year, the researchers found the volunteers who had been using self-hypnosis had reported fewer symptoms related to hay-fever than their fellow volunteers.

During the second year, the researchers taught the remaining "untrained" volunteers how to use hypnosis. By the end of this year, these volunteers also reported improvement in their hay-fever symptoms.

Although the improvement in symptoms was not statistically significant the researchers also found that the volunteers had cut down on the amount of hay fever medication they used after learning self-hypnosis.

There is another interesting piece of research on this topic. You will probably have experienced a histamine reaction: the typical wheal, flare and swelling that can occur after, say, an insect bite. Researchers form Denmark used hypnosis to induce emotions of sadness, anger, and happiness, to see whether these emotions would have any effect on the skin’s response to histamine. Not only did mood have an effect on the skin reactions, but also people who were more susceptible to hypnosis were more reactive to histamine.

Hypnosis is being used with many clinical conditions, from asthma to migraine and irritable bowel syndrome. It is not a panacea, but it can be a very useful tool. And it tells us a lot about the power of the mind to influence virtually every system of the body.

Food Additives and Behavior

Few things generate as much heat and as little light as the debate about a possible association between food additives and cognition, mood and behavior.

There are a number of ways in which food may influence all three, including:

1. Malnutrition
2. Composition of the diet
3. Nutrient quality of the diet
4. Eating habits
5. Pharmacological effects of foods
6. Food allergy
7. Food sensitivity
8. Contamination of food with heavy metals, hormones and pesticides
9. Fatty acid deficiency
10. Food additives

It is often surprising to learn that many people do not realize that in children – particularly if malnourished – omitting breakfast can have a marked effect on cognitive functioning. But it is the last of those that I want to look at today.

Until the 1950s if food manufacturers wanted to add color to a food it was done primarily with natural plant and vegetable based compounds: pale red colors could be achieved from beets; green from chlorophyll-containing vegetables; yellows and orange could be achieved from extracts from a number of other plants and spices.  But then things began rapidly to change as we outlined in Healing, Meaning and Purpose.   

The notion that food additives could be a cause of hyperactivity is at least 30 years old. I think that Ben Feingold was the first to introduce the idea and with it his notoriously difficult diet.

Over the years there have been some positive clinical trials of the diet and some negative. But I think that every clinician working with behavior problems has seen some startling improvements in some children and adolescents when they go on an elimination diet.

In 1985 a controversial study published in the Lancet claimed to show that 79% of hyperactive children had symptomatic improvement when food chemicals were removed from their diet. Then when the food chemicals were re-introduced the symptoms returned. No other study has ever produced figures anything like that high.

It is also important that in young children, though additives may cause a problem in some, there does not seem to be a link between allergies and food sensitivities, and parents often pick up behavior changes that simple clinical screening tools do not. So mom and dad may really know best.

Several years ago we tried to look at the impact of food additive not on behavior, but on headache. When the additives were administered double blind, we were unable to replicate most people’s symptoms, even when they were sure that a certain food caused a problem.

However, unsupervised restriction diets are not without their dangers. And we also need to make sure that practitioners know what they are doing: I once saw a young woman who had seen by an “alternative allergist,” who had left her on a diet consisting of spring water, rice and lettuce. And nothing else.

Another problem is that many of us do not know what additives are lurking in the food that we eat. There was a recent study in the United Kingdom indicated that on average, Britons consume 20 different food additives every day, with some eating up to 50. Yet most people were unaware of this figure, with nearly half of the 1,006 people surveyed thinking they ate only 10 additives each day.
The research also found that many people did not understand which foods are most likely to contain additives. I have not yet seen the raw data from this study, but I shall have more to say about it once it becomes available.

A number of large independent studies are currently underway (for example, here) which should help us to better identify who is susceptible to additives, how to test for sensitivity to additives and who might benefit from their withdrawal.

The trouble with a lot of the discussion about food additives, behavior, mood and cognition is that it usually begins from a false premise: that there is a single cause for a behavior.

When I am teaching it continues to astonish me that most health care professionals still expect there to be one “cause” for a problem. Yet as I have mentioned before, this is rarely clinical reality.

A food additive may be associated with problems, but only in a minority of children, and only if they are genetically predisposed and if the right set of environmental circumstances are in place.

If you suspect a problem, first, learn to look at labels. And see if simple exclusion helps. An allergist is the next stop, but also ask whether an additive could be causing a biochemical rather than an allergic problem. If it is a biochemical effect, it may not show up on routine allergy tests, but there are other ways of testing.

The Red Tide

There is an important report about the impact of environmental change in this month's issue of the journal Chest.

Red tide is a common name for a phenomenon known as an algal bloom, a well known event in which marine algae accumulate rapidly in the water column, or "bloom". These algae, more correctly termed phytoplankton, are microscopic, single-celled, plant-like organisms that can form dense, visible patches near the water's surface. We know that red tides have been occuring in the Gulf of Mexico for centuries, but they appear to be spreading and to be becoming more common and severe.

The main type of plankton is a species of dinoflagellate known as Karenia brevis, that is  concentrated along shorelines and produce highly potent aerosolized toxins. The new research shows that Florida red tide toxins - called brevetoxins can impact respiratory function and increase respiratory symptoms in patients with asthma.

In otherwise healthy people inhaled aerosolized red tide toxins can lead to eye irritation, runny nose,  postnasal drip, nonproductive cough, and wheezing. The symptoms usually subside after leaving beach areas. But things can be far more serious for people with asthma, who may experience respiratory problems and decreased lung function after just one hour of beach exposure to the toxins.

This was a fine piece of research funded by the National Institute of Environmental Health Sciences, and makes it clear that not only that asthma sufferers need to be aware of this potential source of trouble but that we all need to be alert to the possibility that human activities are increasing the red tide and with it, the risk of further health problems.

Parkinson's Disease and Cholesterol

Within the last week we have talked about the association between Helicobacter pylori and Parkinson's disease and the way in which Parkinson's disease may often get better if people are treated with a cocktail of antibiotics. We have also discussed the association between Parkinson's disease, allergies and inflammation.

Now new research from the University of North Carolina at Chapel Hill has  found that people with low levels of LDL cholesterol are more likely to have Parkinson's disease than people with high LDL levels. This is the form of cholesterol sometimes referred to as "bad cholesterol." This study followed the strange observation that people with Parkinson's disease have a lower rates of heart attack and stroke than people who do not have the disease. It is also known that known that cigarette smoking, which increases a person's risk for cardiovascular disease, is also associated with a decreased risk of Parkinson's disease. 

Few scientific stories are clear cut: it usually takes a while to get things right. Just to prove it, a study from the Netherlands found that high total cholesterol levels were associated with lower rates of Parkinson's disease, but only in women.

So what to make of all this: infections, allergies and now cholesterol?

To try and understand this, I think that we need to introduce another actor to the stage. Since the early 1950s the medical community has been concerned about a striking concentration of amyotrophic lateral sclerosis (ALS) and Parkinsonism-dementia among the Chamorro people on the island of Guam. A number of lines of evidence have suggested that this group of illnesses has been caused by some neurotoxic agent in the environment, though nobody has been able to work out exactly what it is. One of the most attractive recent theories is that it might have something to do with toxins from Cycas plants. So the idea is that similar cholesterol-containing neurotoxins can come either from Helicobacter or from eating Cycas plants, or animals that have fed on the plants.

There is a complex inter-relationship between LDL- and HDL-cholesterol, and HDL-cholesterol appears to be anti-inflammatory: high levels of HDL-cholesterol are associated with low levels of inflammation. And it has recently been shown that simvastatin may cut the risk of developing Parkinson's and Alzheimer's diseases. Not just by lowering cholesterol but from its inflammatory activity.

It may also be that low levels of cholesterol may impair the activity of another factor: one that interests me is coenzyme Q10.

From a practical perspective, this new evidence reinforces a point that I made in Healing, Meaning and Purpose and on this blog: "boosting" one component of the blood or lowering another is not sensible. Whether dealing with cholecterol or immunity, we need to moduate and harmonize all the systems of our bodies and our minds.

Follow our systems for modulating the inflammatory mediators in your body and that alone should - theoretically - reduce your risk of many illnesses.

I shall keep you posted as this story continues to develop.

Stress and the Skin

You have probably noticed how stress can have an impact on some people’s skin. Increasing stress can initiate or worsen skin disorders such as psoriasis and atopic dermatitis. There has also been a lot of discussion about whether stress can also exacerbate acne and cause cold sores to erupt.

A new study published in the December issue of the American Journal of Physiology-Regulatory, Integrative and Comparative Physiology sheds important light on this association.

It is well known that one of the physical effects of stress is to increase levels of a range of steroid hormones called glucocorticoids. The best known glucocorticoid is cortisol or hydrocortisone. So the question was whether the missing link between stress and skin problems might be one or other of the glucocorticoids.

Researchers from the Veterans Affairs Medical Center, San Francisco and the University of California at San Francisco and Yonsei University Wonju College of Medicine, Wonju, Korea decided to study this possible connection.

You may have heard that the skin is the largest organ in the body and provides the critical barrier between the environment and the internal organs. Its most important function is providing a permeability barrier that prevents us from drying out. When we are healthy we are approximately 65-70 percent water. We are able to survive and function in dry environments because the skin forms a permeability barrier that prevents the loss of water.

The physical location of the permeability barrier is in the outermost layer of the epidermis that is known as the stratum corneum. The stratum corneum is composed of dead cells surrounded by lipid membranes. The stratum corneum layer continuously sloughs off, and therefore has to be constantly regenerated. The epidermal cells in the lower epidermis are continuously proliferating to provide new cells, which then differentiate, move toward the surface and ultimately die, to form a new the stratum corneum. This process is going on in your skin right now, though it can be disrupted by damage such as sunburn. If the process becomes overactive, it can lead to the development of thick, hardened skin.

It was already known that psychological stress disturbs this elegantly balanced system by decreasing the proliferation of epidermal cells and inhibiting their differentiation. As a result the function of the permeability barrier is impaired.

To test the hypothesis that glucocorticoids would have adverse effects on skin function, they stressed some hairless mice by putting them in small cages in constant light and forcing them to listen to the radio for 48 hours.

Before being stressed one group of mice was treated with mifepristone, which you may know by its two other names, RU-486, or the “morning after” pill, which blocks the action of glucocorticoids. A second group was given a drug called antalarmin, which blocks glucocorticoid production. A third group was stressed but received neither drug and a fourth group remained unstressed in ordinary cages and without the continuous light and sound to which the other groups were exposed.

The mice that received mifepristone or antalarmin showed significantly better skin function compared to the stressed mice that did not receive either treatment.

The experiment demonstrated the important role that glucocorticoids play in inducing the skin abnormalities brought on by psychological stress. Although we hope that the study will lead to a way to treat people who suffer from these skin conditions, there is still a long way to go. It’s always difficult to extrapolate from mice to people. Second, there may be serious side effects of modulating glucocorticoid activity. Glucocorticoids are essential hormones that play many important roles. Blocking their action could have negative outcomes. This is one of the reasons why we are skeptical about advertisements that claim that some herbal concoction can “cure” cortisol-related obesity. If something could really modify the activity of cortisol or other glucocorticoids in the body, it would likely have many most undesirable effects.

The research team is now looking at the effect of psychological stress on the skin's production of antimicrobial peptides, which play a role in defense against infection. It has long been thought that psychological stress might also reduce the ability of the skin to protect from infections.

I never like to leave a report involving animal experiments without also saying a heartfelt thank you to the animals that participated in the experiments.

This research is interesting and may have a number of spin offs. But I have another rather obvious question: since we already know that there is a link between stress and some skin problems, why not focus on stress management techniques, rather than trying to find new medicines to help counteract the biochemical effects of stress?

Update on Pramipexole

I have mentioned pramipexole before. In the United States it is approved for the treatment of the signs and symptoms of idiopathic Parkinson’s disease.

I’m always on the look out for medicines that can be part of a package of healthcare, and we need to learn both the pros and cons of new medicines. This looks to be a medicine that can be incorporated into Integrated Medicine. And before you ask, I have no links at all with the manufacturer, Boehringer Ingelheim.

There have been a number of interesting papers presented at the 10th International Congress of Parkinson's Disease and Movement Disorders in Kyoto, Japan this week.

New data presented have shown that people taking pramipexole (Mirapexin®/ Sifrol®) can experience significant improvements in a broad range of symptoms associated with Restless Legs Syndrome (RLS). 

In all studies presented at the meeting, people taking pramipexole reported clinically meaningful improvements in both their night and day-time symptoms, as measured on the International Restless Legs Scale (IRLS). The IRLS measures several aspects of the condition, ranging from discomfort, the need to move around, relief by moving around and then more specific RLS symptoms such as sleep disturbance, day-time tiredness, mood disorder, as well as addressing overall severity, weekly frequency, daily severity, and impact on daily activities.

One of the big problems in the treatment of RLS is that people who have it frequently have other problems as well, such as hypertension, arthritis, gastroesophageal reflux disease, depression, anxiety, and diabetes. So it is essential that the physical component of treatment should not cause any deterioration in associated illnesses. One of the papers presented in Kyoto indicated that pramipexole could be used in people with RLS who are also taking an array of other medicines. That claim is going to have to be checked by the FDA, but the data look very encouraging.

Still, when using medications, there’s no such thing as a free lunch: The most commonly reported adverse reactions in clinical trials for RLS were nausea, headache, and tiredness.

In people with Parkinson’s disease, pramipexole may cause them to fall asleep without any warning, even while doing normal daily activities such as driving. This is obviously very serious, and before the medicine gets an RLS indication in the USA, the FDA will really check this out in great detail. When taking pramipexole hallucinations have been known to occur and sometimes patients may feel dizzy, sweaty or nauseated upon standing up. In Parkinson’s disease, there is also a warning that as with many other medicines used to treat it, including pramipexole may be associated with impulse control disorders/compulsive behaviors.

So we need to keep an eye on safety, but so far the data is very encouraging, and we may soon have something else to add to an integrated treatment program for people with RLS.

___________

Here's a P.S. On November 10th, 2006, pramipexole was approved for use in RLS by the FDA. Here's the announcement:

Ingelheim/Germany, 10 November 2006 - Boehringer Ingelheim announced today that the U.S. Food and Drug Administration (FDA) has approved pramipexole, a non-ergot dopamine agonist, for the treatment of moderate to severe primary Restless Legs Syndrome (RLS).1 This is an important milestone for pramipexole (Mirapexin® / Sifrol® / Mirapex®), which was already approved throughout the European Union in April 2006 for this second indication.

Women, Asthma and the Brain

There’s been a longstanding puzzle in medicine. Well actually there are lots of them, but here’s one that may be a puzzle no more.

For many years now, it’s been known that asthma is more common in women, and also that psychological stress can cause flare ups of asthma.

Many women experience “menstrual flaring:” a worsening of asthma around the time of their menstrual period. There is also a strange paradox: some women with asthma wheeze less if they take an oral contraceptive, while some non-asthmatic women begin to wheeze when they take it. In some women pregnancy makes asthma worse, and in others it affords months of relief of symptoms. Women who are obese are more likely to get asthma, presumably because their intra-abdominal fat stores are churning out inflammatory mediators.

Researchers from the University of Wisconsin have shed  some important light on this link between asthma and the brain. In research published in the Proceedings of the National Academy of Sciences. In the study, six patients with mild asthma were exposed to ragweed or dust-mite extracts. The subjects were shown three different categories of words: asthma-related (e.g., "wheeze"), non-asthma negative ("loneliness") or neutral ("curtains").

Using functional magnetic resonance imaging, they showed that activity in two regions, known as the anterior cingulate cortex and the insula showed increased activity when the asthma-related words were heard compared with the other types. What is more, this enhanced activity was specifically linked to physiologic signals from the ragweed and dust-mite extracts. So being exposed to asthma-relevant emotional stimuli is associated with markers of inflammation and airway obstruction in asthmatic people exposed to an asthma-producing antigen.

In people with asthma and other stress-related conditions, these brain regions may be hyper-responsive to disease-specific emotional and physiologic signals. Taken together, these could contribute to problems that worsen the asthma, such as inflammation.

And one of the ways of making these regions of the brain hyper-responsive? Bathe them in estrogen.

That still does not explain why pregnancy and the oral contraceptive makes some women’s asthma better, and does the opposite in others. But it may just have to do with the “set point” of the cells in these regions of the brain. In the same way that we might set the thermostat in out house. An already hyper-responsive brain might be normalized and an under-active one stimulated to be over-active.

We need to do some more experiments, but these are a great start.

If you ever wheeze, have a look to see if there are stressors or hormonal events that trigger you. Whether you are being treated with homeopathy, herbals or conventional therapy, knowing when to expect trouble gives you the power to adapt you treatment when you are entering a risky time in your life.

Vaccinating Against the Snivels?

I’m using a deliberately provocative title for a story that is quite serious, both medically and ethically.

We have today heard about two new developments. Researchers from the University of Rochester Medical Center announced that they are starting trials of a new vaccine aimed at eliminating childhood ear and sinus infections as well as many cases of bronchitis in adults. Second, and on the same day, the University of Rochester announced that it had won a $3.5 million grant from the National Institute of Deafness and Communication Disorders, one of the divisions of the National Institutes of Health, to develop the new vaccine. The team at Rochester helped to develop the vaccine marketed by Wyeth as Prevnar. It is used to protect infants and toddlers against some strains of bacteria that can cause pneumonia, meningitis and ear infections.

The vaccine will target Nontypeable Haemophilus influenzae or NTHi, which is the main remaining cause of ear and sinus infections and bronchitis, now that vaccines exist for various forms of streptococcal bacteria and Haemophilus influenzae B, the previous leading causes. NTHi is now the leading cause of ear and sinus infections, and of bronchitis in adults.

But why this news is so important for all of us, is that unlike virtually all other vaccines on the market, this one will not be aimed at saving lives, but at preventing what are usually nuisance illnesses. But please note my use of the word “usually.”

Dr. Michael Pichichero, a professor of microbiology, immunology, pediatrics, and medicine at the University of Rochester Medical Center who is leading the trial, was quoted as saying, “While ear infections are never fatal, they can cause serious damage in some children.” He went on to say that “83 percent of U.S. children experience one or more ear infections by age 3 and in some cases hearing loss becomes permanent.”

This is the point, and also why the National Institute of Deafness and Communication Disorders has chipped in. Most of these infections get better on their own, so an initial reaction might be to say, “why bother with this at all?” The trouble is that not only can they lead to long-term problems with hearing, I have seen more than one person develop a cerebral abscess as a result of a severe infection: the illness is not always innocuous.

Another problem is that infections of the sinuses and ears bring children to clinics and emergency rooms, and are the leading reason for antibiotic prescriptions. Even though many of the infections are viral, and viruses do not, of course, respond to antibiotics. Every expert agrees that antibiotics are overused in the United States, which wastes money and also helps the evolution of bacteria that ultimately resist all antibiotics.

What’s the downside of these announcements?

1. We have already run into a great many problems with previous vaccinations. Some long-term and some subtle; so we desperately need long-term safety data.I know many natural healers who blame many of our health woes on vaccinations.
2. I hope that the researchers have built into the contract a clause to allow them to report efficacy and safety data without having to clear everything with the study’s sponsor.
3. We are facing major resource problems, not just in the provision of health care, but also in the funding for research. So should we be diverting resources into these kinds of problems while every 30 seconds another child dies of malaria?
4. There has been a great deal of discussion about what is often called the “hygiene hypothesis:” the idea that the increasing rates of some allergic illnesses and asthma are a result of children having avoided minor infections early in life, that would have stimulated their immune systems. The hypothesis is not proven, but there is a great deal of circumstantial evidence.
5. If successful, would the vaccine create a host of secondary problems ten or twenty years from now?

Beer to Alleviate Allergies?

Web Mistress Carol Kirshner sent me this article, with the comment, "This is indeed good news!"

It seems that Sapporo Breweries Ltd., and Sapporo Beverages Co., Ltd. have proven that Sapporo beer is effective in mitigating hay fever symptoms. They are saying that hop flavonol glycoside extracted from the beer prevents the actions of histamine, an allergy-inducing substance.

Sapporo Group conducted a clinical trial of 20 patients with hay fever symptoms and found that 60% them noted less sneezing and 55% noted less runny nose with significant improvements on their symptom-medication scores.

According to the report, Sapporo has filed a patent application based on the effect of beer on hay fever symptoms. Going forward, the Group will explore the affect of beer on atopy and allergy symptoms related to house dust.

None of this is a far-fetched as it may sound. Hops have been used in Europe since the Middle Ages for their medicinal properties. We usually think of hops as a sedative, but one of my old herbals also talks about their value in allergic conditions.

A new study, also form Japan, showed that allergic mice don't sneeze or rub their noses as much when given hops.

Parkinson’s Disease, Allergies and Inflammation

The symptoms of Parkinson’s disease have been reported throughout history, but it was first described in the modern era by the great Scottish neurologist James Parkinson in 1817. Even after all these years, we still do not know all that much about what causes it. There’s an interesting study in the August issue of the journal Neurology, which is the official publication of the American Academy of Neurology.

Investigators from the Mayo Clinic used what is known as a case-control design (196 cases and 196 matched controls). What they found was that people who suffered from hay fever or allergic rhinitis, are 2.9 times more likely to develop Parkinson’s disease over a 20-year period.

The researchers did not find any association with autoimmune illnesses such as lupus, rheumatoid arthritis, pernicious anemia or vitiligo. They also did not find any association with asthma.

In addition, people who developed Parkinson’s disease used anti-inflammatory agents less frequently than controls, although this result was not statistically significant. The results may support the hypothesis that there is an inflammatory component in the causation of Parkinson’s disease.

You may ask, “Why on earth would anyone even look at a link like this?” The answer is that there have been previous reports of an association between the use of non-steroidal anti-inflammatories and lower rates of Parkinson’s disease in men but not in women and Alzheimer’s diseases.

This study does not suggest that hay fever causes Parkinson’s disease: it provides evidence for an association between the two. Parkinson’s is probably a group of illnesses with different causes. However, if chronic inflammation around the upper airways could produce inflammation in the brain, we might have a whole new way of preventing a degenerative brain disease.

In a future posting I’ll talk about some natural methods for reducing the burden of inflammation in your body.

Fibromyalgia

Fibromyalgia can be one of the most difficult of clinical problems. Sadly this illness or group of illnesses is often dismissed as no more than a series of symptoms caused by depression, and people then do not get the treatment that they need. Fortunately we are now seeing the emergence of consensus guidelines on how to diagnose the problem.

Fibromyalgia is a common syndrome of chronic pain and fatigue, but it is a great deal more than just pain. It may affect many systems of the body, and depression and cognitive symptoms are common.

One of the key difficulties in people with fibromyalgia is a disturbance in pain thresholds. There has also been a lot of interest in the idea that people with fibromyalgia are “hypervigilant,” as a result of disturbance in the serotonin pathways in the brain. Something similar happens in many people with other types of chronic pain, particularly low back pain. The problem with all of this research has always been the chicken and egg problem: how many of these abnormalities are due to having chronic pain, and how many might be the cause of the problem?

As an example, I was treating someone with fibromyalgia, and as part of the package of treatments, she was to have acupuncture. If practiced by a professional, acupuncture is usually painless. I had not seen anyone experience pain from the treatment in many years; however, this person was so sensitive that even gentle tapping was excruciatingly painful for her. I have colleagues who take this to be evidence that the whole thing is psychological. But I am sure that they are not correct. To a neurologist this is wrong on three counts:
1.    There is a lot of data indicating metabolic disturbances in people with fibromyalgia that is quite different from anything seen in anxiety or depression. These include reductions in the activity of the cellular powerhouses - the mitochondria - as well as subtle effects in blood flow.

2.    A number of other illnesses, like migraine, are associated with changes in pain threshold, indicating a disturbance in the mechanisms that control pain sensation, either in the brain stem on the thalamus.

3.    This notion that “it’s psychological rather than physical,” harks back to the kind of dualism that is not very helpful.

Recent research  indicates that although fibromyalgia is a little more common in women, the old view that it is predominantly a female illness is not correct. There are also some strong associations with other illnesses, including depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, and rheumatoid arthritis.

In the days that I treated a great many individuals myself, I always found that fibromyalgia and chronic fatigue syndrome were amongst the most difficult.

I’ve long been interested in the links between sleep disturbances and fibromyalgia as well as the modest improvement in people with a meditation program.  There is also another factor that is often not much talked about: people with chronic pain, from whatever cause can develop pain cycles: pain begins in some part of the body, but is then maintained by neurological circuits in the spinal cord and brain. Interfering with these pain cycles for even a day or two can sometimes be very helpful.

Fibromyalgia is one of the groups of conditions in which combinations are key. Trying just to use a medicine or just a diet is rarely likely to be crowned with success. The most helpful strategies that we have found have been combinations of:

1. Physical care:
   
   1. Appropriate medications to help with pain transmission and symptoms of depression
   2. Sleep hygiene, and some of the other approaches that I’ve suggested for dealing with disrupted sleep.
   3. Low intensity exercise
   4. Nutrition: this one of the clinical conditions that first persuaded  me that there are some people who have genuine food and environmental sensitivities, and, in some rare cases Candida overgrowth. There are quite a number of foods that may be very helpful, depending upon the individual’s likes and dislikes.   
   5. I’ve had colleagues who’ve had some great results with herbal remedies and supplements, but there is little published  evidence that these work.      
   6. Some people seem to have biochemical disturbances that can be  helped with some of the Schussler tissue salts.
2. Psychological support: there is some good evidence that some personality types and temperaments may be at increase risk of developing fibromyalgia, so any thing that helps build resilience and cope with negative cognitions can be very helpful. Some of the  tapping therapies can be very helpful adjunctive treatments, as can music therapy.
3. People with fibromyalgia are often very sensitive to the people around them, and their nearest and dearest often need help in understanding how best to support the person with the illness.
4. The subtle systems of the body are invariably compromised in people with fibromyalgia, and acupuncture – if people can tolerate it – as well as homeopathy can be very helpful. We have often used both together, though this is anathema to many classical homeopaths or acupuncturists. Perhaps they could not have been used in combination 50 years ago, but people have changed physically, psychologically, socially and energetically, and the rules have changed.
5. As with most people struggling with chronic illness, many people with fibromyalgia lose contact with their Source. And this is why - in my books and recordings – I spend so much time helping people  re-establish meaning and purpose in their lives, and help them use the illness not simply  as a barrier to be overcome, but as a stimulus for internal growth. I have also seen a number of indivudals in whom fibromyalgia was symptommatic of a spiritual awakening.       

One of my biggest worries with fibromyalgia, as with so many chronic illnesses, is that many desperate sufferers and their families can become victims of the unscrupulous. I have seen countless people selling advice and treatments that have no basis in fact.

Not everything that I have discussed here is evidence based: there is so little research on things like acupuncture and homeopathy. But those are treatments to be used in combination with more conventional approaches. Using all together is usually the best way forward. And everything that I’ve discussed here has been used in working with hundreds of people around the world.

Technorati tags: Fibromyalgia Chronic pain Integrated medicine Irritable bowel syndrome Sleep disturbance Candida

Attention Deficit Disorder, Allergies and Membranes

There has been a long-running debate about the relationship – if any – between allergies and attention deficit disorder (ADD).

As long ago as 1991 a paper seemed to indicate that there were higher rates of hyperactivity in the parents of children with allergies as well as increased rates of allergies in children with ADD. Recently a study from New York seemed to show higher rates of allergic rhinitis in children with ADD. The problem with all this is that we are looking at two common problems and trying to sort out a genuine connection can be tricky.

I started thinking about this problem again, after a recent report that some children had symptoms of hyperactivity, inattention, attention-deficit/hyperactivity disorder, and excessive daytime sleepiness as a result of sleep-disordered breathing. But what was remarkable was the number who improved after they had their tonsils taken out. The tonsils are one of the first lines of defense in the immune system, which is why they so often become enlarged with infections, or for that matter in any kind of immunological reaction. Now I’m not much of one to take out tonsils unless there’s a really good reason, but it is certainly an important observation for anyone who has a child with behavioral or cognitive difficulties: he or she may not be sleeping properly.

I have seen quite a number of people who had physical and psychological problems, including headaches, depression and attentional problems, who turned out to have either allergies or environmental sensitivities, and when those were addressed, the symptoms resolved. I have also seen some people who followed the notoriously difficult Feingold diet with some success, even though the research doesn’t seem to be very supportive of elimination diets. And I've seen just as many people who got no relief at all from elimination diets.

I have just done a detailed literature review on the topics of allergy and attention, and I don’t think that we have enough evidence to suggest that everybody with attention deficit needs to see an allergist. But what this highlights is that not all people with attentional problems or hyperactivity have ADD. They may have attentional problems because of sleep disturbance, depression, anxiety, obsessive compulsive disorder and a range of other problems.

There is some exciting research indicating that one of the problems in many cases of ADD is a disturbance in the normal functioning of cell membranes. If that is correct, it may be that there are disturbances in the membranes of both neurons in the brain and membranes of cells in the immune system. That link is not entirely proven. But it has received further credence by the finding that some children and adults with ADD seem to show improvements of both attention and immune function when they take omega-3 fatty acids. I have recently been hearing some encouraging reports from people who have used the Omega-3 Formula made by Omegabrite (And no, I have no link with the company!)

Technorati tags: Attention deficit disorder Allergy Atopy Hyperactivity Tonsils Cell membrane Omega-3 fatty acid 

Sick Building Syndrome

Sick building syndrome (SBS) was first recognized in 1982, and is a combination of symptoms associated with an individual's place of work - most often an office building -though there have also been instances of SBS in residential buildings. A 1984 World Health Organization report into the syndrome suggested up to 30% of new and remodeled buildings around the world might be linked to symptoms of SBS.

Many symptoms have been associated with SBS, including:

• Headache
• Dry or itchy skin
• Chronic fatigue
• Irritation of the eyes nose or throat, sometimes with a dry coughs
• Dizziness
• Nausea
• Difficulties in memory and concentration
• Extreme sensitivity to smells or bright lights

For SBS to exist, these symptoms must disappear soon after the occupants go outside.

There have been many explanations for these symptoms, primarily related to environmental pollutants. But I have something to add to that list. Some time ago I spent a happy year working at the Charing Cross Hospital in London during which I made an odd observation. On days that I worked in the laboratory on the tenth floor, I would be exhausted by the middle of the day, while on days when I worked in the outpatient clinic in the basement, I could easily get through a 5 hour clinic without difficulty. I mentioned it to a neurophysiologist friend who told me something very interesting: it had been discovered that on days when the wind blew at 5-10 miles an hour, the building began to vibrate like a giant tuning fork, and that the vibration was at its worst between the tenth floor and the top of the hospital. The vibration was imperceptible to most people, but I clearly had the misfortune to be sensitive to it. Yet without this experience, I might never have known of the potential adverse effects of vibration of the human body.

I have been consulted by a number of corporations and government organizations that have had trouble with people getting sick in certain buildings. Until now we have thought that it was all environmental, and that it could be anything from vibration to poor ventilation, chemicals, molds and many things in between. So I was very surprised to see a report published in the journal Occupational and Environmental Medicine from a first rate research group at University College London.

The British Inland Revenue Service demolished an entire 19-storey building in Bootle, Merseyside, after almost half of the employees had developed illnesses compatible with SBS. In a study published two and a half years ago, it was claimed that adding ultraviolet light to ventilation systems to kill microbes could vanquish the symptoms of SBS. But this new research suggests that the cure may actually be better management.

The new study included 4,052 civil service workers between the ages of 42 and 62 who were enrolled in a larger general health study. The men and women in the study worked at 44 different office buildings around London. The workers completed surveys designed to assess their general health and whether they had symptoms linked to SBS. They were also asked questions about the physical properties of the offices that they worked in and the stresses associated with their jobs.

As in earlier studies, women tended to have more symptoms associated with SBS than did men. Younger workers also had more of the symptoms than older workers. Almost one in five women and one in seven men reported five or more symptoms associated with sick building syndrome.

Now here was the surprise: the authors found little association between physical work environment and the symptoms. But there was a strong association between the symptoms and feelings of having high job demands and little support in the workplace. They also found that the more control people have over their workstation, the fewer symptoms were reported.

Though the findings fail to support "sick buildings" as a common cause of worker illness, the study should not be interpreted as meaning that the physical quality of the workplace is unimportant. It is most likely that we are dealing with a combination of physical and work related factors.

As I was reading the report and reviewing the rather vague but often quite severe symptoms, I was reminded of some recent work that I have been doing on burnout: I’ve just published an article about it. My interpretation of this study is that many cases of SBS are likely a form of burnout that is partially modulated by physical factors in the environment.

Technorati tags: sick building syndrome, workplace, occupational medicine, burnout, Stress

Fungal Contamination of Pillows

I recently came across a study from colleagues at the University of Manchester in the United Kingdom, that was published in the journal Allergy.

Fungal contamination of bedding was first studied seventy years ago, but there have been no reports in the last seventy years. In this new study, researchers sampled ten pillows with between 1.5 and 20 years of regular use. Each pillow was found to contain a substantial fungal load, with four to 16 different species being identified per sample and even higher numbers found in synthetic pillows. One of the most worrying things was that the microscopic fungus Aspergillus fumigatus was particularly common in synthetic pillows. And fungi as diverse as bread and vine moulds and those usually found on damp walls and in showers were also found in the pillows. Aspergillus is a very common fungus, carried in the air as well as being found in cellars, household plant pots, compost, computers and ground pepper and spices. I have treated many people with invasive Aspergillosis, a sometimes nasty illness that occurs mainly in the lungs and sinuses, although it can spread to other organs including the brain. It can be very difficult to treat, and as many as 1 in 25 patients who die in modern European teaching hospitals have the disease. In France and Germany, this is one of the occasions when unorthodox medicine is often used at the same time as high doses of antibiotics: proper integrated medicine.

Aspergillosis is a particular problem in people with compromised immune systems. Hospital pillows have plastic covers and so are unlikely to cause problems, but patients being discharged home - where pillows may be old and fungus-infected - could be at risk of infection. Aspergillus can also worsen asthma, particularly in adults who have had asthma for many years, and it can cause allergic sinusitis in patients with allergic tendencies. Constant exposure to fungus in bed could be problematic.

The moral of this story is be extra aware that pillows may harbor fungi that can cause or exacerbate allergies and more serious problems in people with other illnesses. If you have allergies, it is best to use foam rather than feather pillows. If you have synthetic pillows, wash them regularly in warm water and with a non-allergenic detergent. Dip the pillow one small section at a time in the solution and squeeze through the pillow. Once the pillow is clean, rinse it out at least three times to remove all of the soap and residue. Then lie the pillow out flat to dry, and turn it frequently. To fluff the pillow, take a couple of tennis balls and put them in the dryer with the pillow and air dry for about 30 minutes.

Technorati tags: fungus, integrated medicine, allergies, asthma