John D. Mark MD

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John D. Mark MD

• Pediatric Pulmonary and Integrative Medicine
• University of Arizona

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History of Medicine

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

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Health Expo

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

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Complementary and Alternative Medicine (CAM)

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

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Positive Motivation for CAM

• Perceived effectiveness and safety
• Philosophical congruence Zeitgeist, holism,
  natural, active role of patient
• Good patient/therapist relationship
• Non-invasive, accessibility
• High touch, low tech
• Affluence, Control

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Negative Motivation for CAM

• Dissatisfaction with aspects of conventional
  health care, adverse side effects
• Ineffective for certain condition, time
• High tech, low touch
• Rejection of science and technology
• Rejection of the establishment
• Desperation

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Why is CAM use common in chronic illness?

• Chronic inflammatory illness
• Paradox increasing despite advances
• Belief that external exposures as cause
• Belief that emotions can be important
• Meds like using a boulder to kill an ant
• Holism and Empowerment of patients

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The Integrative Approach

• Whole person and family
• Healing oriented not Disease
• Patient/Physician partnership
• Mind/Body/Spirit
• Family and patients belief system
• Holistic in approach, multilevel, and
  multifactorial

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Integrative Approach to Health

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

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Medicine

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

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Chronic Respiratory Conditions

• Asthma
• Chronic Obstructive Pulmonary Disease (COPD) and
  Emphysema
• Cystic Fibrosis
• Other

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Asthma in the United States

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

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Paradox in Asthma Care

• NHLBI Expert Panel Guidelines (9297)
• Understanding airway inflammation
• Early use of anti-inflammatory meds
• Home management/ peak flow monitors
• Practice Guidelines- both for ER Outpts.
• Morbidity and Mortality- increased?

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Asthma Education-MDs

• Study of 108 MDs and Guidelines
• Asthma Faculty-78
• Asthma Fellows-69
• Family Practice-55-60
• Internal Medicine Residents-51
• Just understanding classification-problem

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Asthma Triggers

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

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Nutrition and Asthma

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

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Fat Classification

• Saturated Fats
• Monounsaturated Fats
• Omega-9 family
• Polyunsaturated Fats
• Essential Fatty Acids (EFAs)
• Omega-6 Family Omega-3 Family
• Linoleic Acid (LA) Alpha linolenic acid (ALA)
• Gamma linolenic acid (GLA) Eicosapentaenoic
  acid (EPA)
• Arachidonic acid (AA) Docosahexaenoic acid (DHA)
  

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Omega 6 Fatty Acid (Linoleic Acid)
Omega 3 Fatty Acids (alpha-linolenic acid)
?6-Desaturase
Gamma-linolenic acid (GLA) Evening Primrose
Oil Borage Oil Black Current Oil
Eicosapentaenoic Acid (EPA)
COX
Lipoxygenase
?5-Desaturase
Arachidonic Acid
Prostaglandins PGE1, PGE3 (Favorable)
Less Inflammatory Leukotrienes
Cyclo-oxygenase (COX)
Lipoxygenase
Docosahexaenoic acid (DHA)
Prostaglandins (PGE2) Inflammatory
Leukotrienes
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Arachidonic Acid (in cell membrane)
Phospholipase A-2
Steroids
Free AA
Colchicine
Aspirin
Cyclo-oxygenase Pathway
Lipoxygenase Pathway
Sulfasalazine
NSAIDs
Leukotriene Inhibitors Accolate, Singulair,
Zyflo
COX II Inhibitors Celebrex, Vioxx, Mobic
Prostaglandins Thromboxanes
Leukotrienes
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1985 (251)
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Omega 63 Ratio
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15
10
1909 (41)
5
0
Omega 6
Omega 3
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Polyunsaturated
Partially Hydrogenated
30 year shelf life
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Sources of Omega-3 Fatty Acids

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

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Sources of Omega-3 Fatty Acids

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

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What to Recommend for chronic inflammation.

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

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Dietary Supplements

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

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Dietary Supplements

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

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Ma Huang (Ephedra sinica)

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

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Licorice (Glycyrrhiza glabra radix)

• Folk medicine- treat cough
• Glycyrrhetinic acid and carbenoxolone-potent
  inhibitors of cortisol metabolism
• Enhances endogenous and exogenous steroids
• Also shown to elevate blood pressure, peripheral
  edema, headaches, low K, lethargy , muscle
  weakness

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Coleus forskohlii

• Ayurvedic medicine
• Acts like theophylline (increases cAMP)
• Another Ayurvedic herbal remedy seems to be an
  effective bronchodilator- Tylophora indica-
• No studies yet on children, some on adults

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Ginkgo Biloba

• Study of asthmatics using Ginkgo leaves
  concentrate showed decrease airway hyperactivity
  (plt0.05) and pulmonary function improved (plt0.05)
• Problem- 1997 study, in Chinese and do not
  specify the type of airway measurements used.

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Ginkgo

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

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Vitamins

• Vitamin B6 (pyridoxine)- RCTs-helps for mild
  disease, 200 mg per day
• Vitamin C- RCTs-mixed results -over 1 gm
• Selenium- no studies, antioxidant
• Fish oil (omega 3 Fatty Acids)-RCTs- long term
  help

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Case Presentation Shannon

• 14 yr old with long standing asthma (moderate
  persistent), pets
• Meds Albuterol, AeoBid (Singulair,
  Pulmocort)-followed peds clinic
• PFTs- FEV1 (60/85), FEF25-75 (40/70)
• Treatment plan Meds, Environment, Nutrition,
  Dietary Supplements, Exercise

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Arizona Botanical Center

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

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Boswellia serrata gum resin

• European J Med Res 98 Nov3511
• 40 patients with asthma (double blind and placebo
  study)
• 70 had improved symptoms, increase in FEV1/PEFR,
  decrease eosinophils
• Control group- had 27 improvement
• Boswellia serrata gum resin for asthma

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Lung Support
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Lung Support

• Retinol, Fructus,Salvia, Cordyceps, Astragalus,
  Prunus, Morus, Ophiopogon, Cynachum, Ginseng,
  Ginkgo, Magnesium
• No amounts listed
• SAFE
• NO DRUGS
• NO SIDE EFFECTS
• 100 NATURAL

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Claims Made

• Ends..SOB, smoking damage, heart problems, sinus
  problems, emphysema, allergies, fatigue, asthma.
• Secrets to breathing disordered unlocked, End
  Bronchial disease
• Todays Medicine is Harmful
• Dramatic improvement few days
• 100 SATISFACTION RISK FREE

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• Mind-Body Influences on health

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Mind/Body Approach

• Placebo/Suggestion/Disclosure
• Hypnosis
• Guided Imagery
• Pediatric study proposal
• Diaphragmatic breathing
• Exercise, Yoga, Martial arts

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Accessing the Placebo Response

• Develop rapport and trust
• When able, recommend therapy based on the
  patients belief system
• Recommend any given therapy with enthusiasm and
  confidence
• Activate the patients expectation of the therapy
  with positive statements

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Disclosure Chronic Illness

• Smyth JM, et al. JAMA, 1999
• Effects of Writing About Stressful Experiences on
  Symptom Reduction in Patients with Asthma and
  Rheumatoid Arthritis.
• Study Group Wrote about a stressful life event
  for 20 mins/d for 3 days
• Control Group Wrote about daily events
• 107 patients.
• Asthma 20 improvement in lung function vs no
  improvement in control
• RA 28 reduction in disease severity vs no
  change in control.

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Hypnosis

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

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Tracy and the Laryngeal Warts
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Massage/Manipulative

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

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Osteopathy

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

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Other Therapies

• Mind/Body Medicine
• Massage Therapy
• Energy Medicine
• Healing touch
• Reiki
• Johrei
• Ethnocultural Medicine

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Homeopathy

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

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Traditional Chinese Medicine

• 5 Elements
• 5 Branches
• Acupuncture, moxibustion
• Diet
• Herbal therapy
• Physical Therapy
• QiGong, Kung Fu
• Different Systems Approach

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COPD

• Conventional Care??
• Inhaled steroids/Bronchodilators/Atovent
• Pharmacoeconomic impact- Chest 2000
• Regular use of Meds (albuterol?)
• Long-term Oxygen Therapy
• Home Ventilation
• Nutritional Intervention

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COPD and CAM

• Ginseng and chronic bronchitis
• Clin Drug Invest Jan 2001, 75 patients
• Increased bacterial clearance
• Music therapy and dyspnea
• Holistic Nursing 1999, 24 patients
• Less anxiety and dyspnea, better energy
• Nutritional
• Chest Feb 2001, 21 report review

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From Jerusalem to Jericho a study of situational
and dispositional variables in helping
behavior. J Personality and Social Psychol.
197327100-108
Group 1
Group 2
Group 3
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Healing

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