Nitrous oxide for early analgesia in the emergency setting: a randomized, double-blind multicenter prehospital trial..

Although 50% nitrous oxide (N(2) O) and oxygen is a widely used treatment, its efficacy had never been evaluated in the prehospital setting. The objective of this study was to demonstrate the efficacy of premixed N(2) O and oxygen in patients with out-of-hospital moderate traumatic acute pain.

METHODS: This prospective, randomized, multicenter, double-blind trial enrolled patients with acute moderate pain (numeric rating scale [NRS] score between 4 and 6 out of 10) caused by trauma. Patients were assigned to receive either 50/50 N(2) O and oxygen 9 L/min (N(2) O group) or medical air (MA) 9 L/min (MA group), in ambulances from two nurse-staffed fire department centers. After the first 15 minutes, every patient received N(2) O and oxygen. The primary endpoint was pain relief at 15 minutes (T15), defined as a NRS
RESULTS: Sixty patients were included with no differences between groups in age (median = 34 years, interquartile range [IQR] = 23 to 53 years), sex (37 males, 66%), and initial median NRS of 6 (IQR = 5 to 6). At T15, 67% of the patients in the N(2) O group had an NRS score of 3 or lower versus 27% of those in the MA group (delta = 40%, 95% confidence interval [CI] = 17% to 63%; p < 0.001). The median pain scores were lower in the N(2) O group at T15, 2 (IQR = 1 to 4) versus 5 (IQR = 3 to 6). There was a difference at 5 minutes that persisted at all subsequent time points. Four patients (one in the N(2) O group) experienced adverse events (nausea) during the protocol.
CONCLUSIONS: This study demonstrates the efficacy of N(2) O for the treatment of pain from acute trauma in adults in the prehospital setting.

Source: Acad Emerg Med.

 

If Your Doctor Is Healthy, You Probably Are Too.

Story at-a-glance

• When a physician was perceived to be overweight or obese, patients viewed him or her as less credible and trustworthy, and they were less inclined to follow the given medical advice.
• Patients whose physicians were compliant with certain preventative health practices were more likely to have undergone these procedures themselves.
• Research has also shown that physicians with healthy lifestyles are more likely to discuss healthful personal habits to motivate you to do the same
• Choosing a physician shouldn’t only be about credentials and educational background, but also about their personal lifestyle choices
• If your physician leads a healthy lifestyle there’s a good chance these positive habits will get passed on to you.
• 

If your physician is overweight or obese, does it make him or her less able to give you sound medical advice?

Logically you would say no, yet a new study published in the International Journal of Obesity¹ found that excess body weight impacts patients’ views of their physician.

When a physician was perceived to be overweight or obese, patients viewed him or her as less credible and trustworthy, and they were less inclined to follow the given medical advice.

This bias may not be fair; as mentioned, body weight obviously has little bearing on a physician’s ability to practice medicine. However, are such reservations justifiable?

It is most unfortunate that the vast majority of physicians who finish medical school are not highly motivated to follow truly healthy lifestyles, but more or less succumb to the powerful brainwashing influence of Big Pharma in their curriculum.

Research Shows Healthier Doctors Have Healthier Patients

You probably wouldn’t knowingly take driving lessons from an instructor who had carelessly totaled his car. Likewise, you may be less inclined to accept health advice from someone you perceive to be unhealthy.

An overweight physician may still be healthy but is likely to be perceived as less so than a physician who is fit. According to the recent study, overweight physicians were less trusted by both normal weight and overweight patients alike. The study’s lead author told the New York Times:²

“The bias against overweight people is so socially accepted that despite all the doctor’s training and expertise, it can jeopardize the doctor’s ability to have a conversation about health care with the patient.”

It’s a harsh finding, but there may be some reason to seek out the healthiest physicians. Separate research has shown, in fact, that healthier physicians tend to have healthier patients.³

Unfortunately, that particular study used practices like mammography and annualvaccinations, which are poor measures of true health as the markers, finding that patients whose physicians were compliant with these practices were more likely to have undergone these procedures themselves.

This suggests that other preventive measures practiced by physicians, such as healthful eating and exercise, may also transfer over to patients as well.

So the secret to finding the best health care provider for you may lie in seeking someone who is like-minded, more inclined to use natural therapies and lifestyle strategies before medicine, if that is important to you, as well as someone who practices what they preach. The study’s author noted:⁴

“It’s human nature. People usually preach what they practice. Personal adoption of a practice suggests that the doctors are sufficiently convinced of the importance of the intervention that they are motivated enough to even do it themselves, and perhaps they’ve figured out how to overcome access barriers that can enable patients, as well.”

Healthy Personal Behaviors Improve Physicians’ Credibility

Research has shown not only that physicians with healthy lifestyles are more likely to discuss such practices with their patients, but also that talking about these healthful personal habits improves their credibility and ability to motivate their patients to do the same.⁵ The correlation was so strong that researchers concluded:

“Educational institutions should consider encouraging health professionals-in-training to practice and demonstrate healthy personal lifestyles.”

Another study similarly found that healthy physicians can help motivate positive change for entire communities, noting:⁶

“Physician-directed interventions that advance these [health] principles are most effective when directed by clinicians who regularly participate in such healthy behaviors themselves.”

What does this mean for you? Choosing a physician shouldn’t only be about credentials and educational background but also about their personal lifestyle choices. Does your physician exercise? Does he or she embrace healthy eating habits and stress-reduction techniques? If so there’s a good chance these positive habits will get passed on to you.

You Don’t Need a Doctor to Learn How to Take Control of Your Health

It may be especially motivating to have your physician tell you to eat more vegetables or get more exercise, but you don’t need a physician to learn some of the most important variables to reaching optimal health.

The vast majority of deaths in wealthier countries like our own are due to chronic, not acute, disease. And most chronic diseases, including cancer, heart disease, diabetes, and obesity, are largely preventable with simple lifestyle changes. Even infectious diseases like the flu can often be warded off by a healthy way of life.

The added bonus to this is that the healthier you are, the less you will need to rely on conventional medical care, which is aleading cause of death. So while it’s a good idea to choose a doctor who leads a healthy lifestyle, it’s even better to lead one yourself! So what does a “healthy lifestyle” entail?

• Proper Food Choices

For a comprehensive guide on which foods to eat and which to avoid, see my nutrition plan. It’s available for free, and is perhaps one of the most comprehensive and all-inclusive guides on a healthy lifestyle out there. Generally speaking, you should be looking to focus your diet on whole, ideally organic, unprocessed foods that come from healthy, sustainable, ideally local, sources.

For the best nutrition and health benefits, you will want to eat the majority of your food raw. Nearly as important as knowing which foods to eat more of is knowing which foods to avoid, and topping the list is fructose. Sugar, and fructose in particular, can have a multitude of toxic effects when consumed in excess, not the least of which is insulin resistance, a major cause of accelerated aging and a crucial factor in driving virtually all chronic disease.

For most people (although there are clearly individual differences), a diet high in healthful fats (as high as 50-70 percent of the calories you eat), moderate amounts of high-quality protein, which is far less than the average amount most people eat, with the bulk of carbohydrates coming from high-nutrient, low-carbohydrate vegetables and very little carbohydrates from grains and sugars, will set you on the right track toward health.

• Comprehensive Exercise Program, including High-Intensity Exercise

Even if you’re eating the healthiest diet in the world, you still need to exercise to reach the highest levels of health, and you need to be exercising effectively, which means including not only core-strengthening exercises, strength training, and stretching but also high-intensity activities into your rotation. High-intensity interval-type training like Peak Fitness boosts human growth hormone (HGH) production, which is essential for optimal health, strength and vigor.

• Stress Reduction and Positive Thinking

You cannot be optimally healthy if you avoid addressing the emotional component of your health and longevity, as your emotional state plays a role in nearly every physical disease — from heart disease and depression to arthritis and cancer. Effective coping mechanisms are a major longevity-promoting factor in part because stress has a direct impact on inflammation, which in turn underlies many of the chronic diseases that kill people prematurely every day. Meditation, prayer, energy psychology tools such as the Emotional Freedom Technique (EFT), social support and exercise are all viable options that can help you maintain emotional and mental equilibrium.

• Optimize Vitamin D with Proper Sun Exposure

We have long known that it is best to get your vitamin D from appropriate sun exposure during times when UVB rays are present. Vitamin D plays an important role in preventing numerous illnesses ranging from cancer to the flu. The important factor when it comes to vitamin D is your serum level, which should ideally be between 50-70 ng/ml year-round.

Sun exposure, or failing that, a safe tanning bed is the preferred method for optimizing vitamin D levels, but a vitamin D3 supplement can be used when necessary. Most adults need about 8,000 IU’s of vitamin D a day to achieve serum levels above 40 ng/ml, which is still just below the minimum recommended serum level of 50 ng/ml. Be aware that if you take supplemental vitamin D, you also need to make sure you’re getting enough vitamin K2, as these two nutrients work in tandem to ensure calcium is distributed into the proper areas in your body.

• High Quality Animal-Based Omega-3 Fats

Animal-based omega-3 fat like krill oil is a strong factor in helping people live longer, and some experts believe that it may be one reason why the Japanese are the longest lived race on the planet.

• Avoid as Many Chemicals, Toxins, and Pollutants as Possible

This includes tossing out your toxic household cleaners, soaps, personal hygiene products, air fresheners, bug sprays, lawn pesticides, and insecticides, just to name a few, and replacing them with non-toxic alternatives.

Source: mercola.com

 

 

 

Preoperative Superselective Mesenteric Angiography and Methylene Blue Injection for Localization of Obscure Gastrointestinal Bleeding.

Localizing obscure gastrointestinal bleeding can be a clinical challenge, despite the availability of various endoscopic, imaging, and visceral angiographic techniques. We reviewed the management of patients presenting with obscure gastrointestinal bleeding during the period from 2005 to 2011. Four patients had preoperative localization of the bleeding site with superselective mesenteric angiography, which was confirmed by the use of intraoperative methylene blue injection. This novel technique allowed us to identify the abnormal pathology, and, consequently, resection of the implicated segment of small bowel was performed without any postoperative complications. Final histology showed that 2 patients had arteriovenous malformations: one had a benign hemangioma of the small bowel, and the other had chronic ischemic ulceration in the ileum. Superselective mesenteric angiography combined with intraoperative localization with methylene blue is an important and innovative technique in the management of patients with unclear sources of gastrointestinal bleeding and allows for effective hemorrhage control with a focused and therefore limited bowel resection.

Source: JAMA

 

 

Preoperative Superselective Mesenteric Angiography and Methylene Blue Injection for Localization of Obscure Gastrointestinal Bleeding.

Localizing obscure gastrointestinal bleeding can be a clinical challenge, despite the availability of various endoscopic, imaging, and visceral angiographic techniques. We reviewed the management of patients presenting with obscure gastrointestinal bleeding during the period from 2005 to 2011. Four patients had preoperative localization of the bleeding site with superselective mesenteric angiography, which was confirmed by the use of intraoperative methylene blue injection. This novel technique allowed us to identify the abnormal pathology, and, consequently, resection of the implicated segment of small bowel was performed without any postoperative complications. Final histology showed that 2 patients had arteriovenous malformations: one had a benign hemangioma of the small bowel, and the other had chronic ischemic ulceration in the ileum. Superselective mesenteric angiography combined with intraoperative localization with methylene blue is an important and innovative technique in the management of patients with unclear sources of gastrointestinal bleeding and allows for effective hemorrhage control with a focused and therefore limited bowel resection.

Source: JAMA

 

Acupuncture in 21st Century Anesthesia: Is There a Needle in the Haystack?.

 

Acupuncture, a component of Traditional Chinese Medicine, has developed over a period of more than 3000 years and is based on the concept of “” unification of the human with his environment.¹ Acupuncture practice has constantly evolved throughout history and has been based on the knowledge and ideas garnered from astronomy, nature, science, and technology.^2,3 In contrast to what was stated by Colquhoun and Novella,⁴ acupuncture consists of applying various stimuli (e.g., pressure, needle, heat, laser, suction cup, injection, and electrical stimulation⁵ as well as most recently ultrasound waves)⁶ on/into specific acupuncture points (acupoints) to restore a patient’s health. During the early 1970s, this traditional healing practice became more popular because of programs vigorously supported by the Chinese government⁷ leading to a greater international awareness of this therapeutic approach. A recent PubMed search of “acupuncture clinical trials” yields 3833 articles, demonstrating that acupuncture has been investigated as a treatment for many medical conditions. A potential reason for the popularity of acupuncture among patients may be the “individualistic” or “person-centered” approach.

Although >40 disorders have been recognized by the World Health Organization⁸as conditions that can benefit from acupuncture treatment, many within the field of science view acupuncture as “quackery” and “pseudoscience,” and its effect as “theatrical placebo.”^4,9–14 It seems somewhat naive to totally condemn the practice of acupuncture, while accepting orthodox medicine as the basis for treating all medical conditions. Herein, we describe evidence supporting the thesis that acupuncture, as part of anesthesia practice, can provide clinically meaningful benefits for patients. Postoperative nausea and vomiting (PONV),^15–17postoperative pain,^18,19 and chronic pain conditions^20,21 are 3 clinical problems pertinent to anesthesia practice and yet cannot be adequately treated owing to the ineffective or only partially effective pharmacological interventions. Unsuccessful conventional treatments for these clinical entities have caused significant financial burden, health care cost, and patient dissatisfaction. As a result, acupuncture has been investigated as a treatment or a complementary treatment for these 3 clinical entities.

To validate acupuncture efficacy, multiple sham techniques and placebo instruments have been developed and are used in clinical trials and experimental conditions. These techniques and instruments are thought to control the “nonspecific” effect of acupuncture and are broadly termed “sham” or “placebo” acupuncture in the literature. Sham acupuncture is defined as an intervention, which mimics the sensation of acupuncture stimulation; however, it is thought to lack the analgesic and antiemetic effects of acupuncture. In both clinical and experimental trials, sham acupuncture can be classified based on whether the intervention penetrates the skin. Penetrating shams (minimal acupuncture) involve shallow insertion of acupuncture needles into actual acupuncture points with minimal stimulation or into sham point stimulation (applying same needling techniques but in areas where there is no documentation of acupuncture points or meridians). Nonpenetrating shams have also been developed, and these can either be sensorial sham (applying a toothpick or a filament on the skin surface of acupuncture points simulating needle sensations), or visual sham (applying placebo needles [e.g., Streitberger needle] that visually shorten when pressed onto the skin).

Using the above “controlling” techniques, acupuncture has been validated in various clinical trials. Thus far, the strongest evidence supporting acupuncture efficacy is pericardium-6 (PC-6) acupoint stimulation for PONV prophylaxis. The PC-6 acupoint Neiguan, translated as “inner gate,” is commonly used to treat nausea and vomiting in traditional Chinese medicine.^1,5 This acupoint is located 5 cm proximal from the wrist between the palmaris longus and flexor carpi radialis. A meta-analysis²² has demonstrated the efficacy of PC-6 for the treatment of PONV in sham-controlled trials. Subsequently, a Cochrane Database article in 2004²³ showed that acupuncture stimulation at PC-6 is superior to pooled antiemetic prophylaxis in preventing nausea. An updated Cochrane review²⁴ surveyed 40 clinical trials (a total of 4858 participants) and found that compared with sham treatment, PC-6 acupoint stimulation is as effective as conventional antiemetics (e.g., droperidol,²⁵ ondansetron,²⁶ and others).²⁷ PC-6 acupuncture can also complement antiemetics in reducing PONV. More importantly, the side effects associated with PC-6 acupoint stimulation were minor and self-limiting.²⁴ Although the number needed to treat (NNT) for PONV with acupuncture ranged from 34 to 5 patients, this is similar to NNT for conventional antiemetics. For example, the NNT for nausea for IV droperidol 0.5 to 0.75 mg is 4.8 (95% confidence interval [CI], 3.0–12) and for vomiting is 10 (95% CI, 4.6 to −51).²⁸ Similarly, metoclopramide 10 mg IV, a commonly used drug to prevent nausea and vomiting in the perioperative period, has an NNT of 30.²⁹ Direct comparison between acupuncture and IV ondansetron reveals that the NNT for nausea (0–6 hours) is 4 (95% CI, 2.0–11.4) vs 5 (95% CI, 2.3–120.6), respectively, and for vomiting (0–6 hours) the NNT is 6 (95% CI, 3.0–84.7) vs 5 (2.9–21.0), respectively.³⁰ Comparing acupuncture versus IV ondansetron, the NNT for nausea (0–24 hours) is 20 (95% CI, 3.7 to −5.8) vs 27(95% CI, 3.9 to −5.5) respectively, and the NNT for vomiting (0–24 hours) is 18 (95% CI, 3.7 to −6.4) vs 9 (95% CI, 3.1 to –11.2).³⁰

Acupuncture has also been investigated as an adjunct for acute postoperative pain and various chronic pain conditions. A recent review article³¹ included 15 randomized controlled trials that compared acupuncture with sham controls in managing postoperative pain. The investigators found that patients in the acupuncture group required less cumulative opioid consumption (the average cumulative opioid consumption was −3.14 mg [95% CI, −5.15 to −1.14], −8.33 mg [95% CI, −1.06 to −5.61], and −9.14 mg [95% CI, −16.07 to −2.22] at 8, 24, and 72 hours, respectively). As a result, acupuncture-treated patients had a lower incidence of opioid-related side effects, such as nausea (risk ratio [RR]: 0.67; 95% CI, 0.53–0.86), dizziness (RR: 0.65; 95% CI, 0.52–0.81), sedation (RR: 0.78; 95% CI, 0.61–0.99), pruritus (RR: 0.75; 95% CI, 0.59–0.96), and urinary retention (RR: 0.29; 95% CI, 0.12–0.74), as compared with sham control groups.³¹

Acupuncture analgesia also has been investigated as a treatment for chronic pain conditions. Another systematic review with 31 randomized controlled trials found that acupuncture may have a specific analgesic effect in treating chronic headache patients because the combined response rate in the acupuncture group was significantly higher compared with sham acupuncture either at the early (8 weeks) follow-up period (RR: 1.19; 95% CI, 1.08–1.30] or late (6 months) follow-up period [RR: 1.22; 95% CI, 1.04–1.43]). Acupuncture was also superior to medication therapy for headache intensity (weighted mean difference [WMD]: −8.54 mm; 95% CI, −15.52 to −1.57), headache frequency (WMD: −0.70; 95% CI, −1.38 to −0.02), physical function (WMD: 4.16; 95% CI, 1.33–6.98), and response rate (RR: 1.49; 95% CI, 1.02–2.17).³² A recent individual patient meta-analysis of 29 randomized control trials with 17,922 patients indicated that acupuncture was statistically superior to control for all analysis (P < 0.001).³³ In this report, effect sizes between acupuncture and sham were 0.37, 0.26, and 0.15 for musculoskeletal pain, osteoarthritis (OA), and chronic headache, respectively.³³These significant differences between true and sham acupuncture indicate that acupuncture is more effective than placebo. The authors concluded that acupuncture is effective for the treatment of chronic pain and is therefore a reasonable treatment option.³³ Colquhoun and Novella⁴ commented that real acupuncture was better than sham; however, by a small amount that lacked any clinical significance.⁴ While there is ongoing debate regarding the specific analgesic effect of acupuncture, the effect sizes reported are on par with standard accepted pharmacologic therapy for chronic pain. For example, a meta-analysis of 23 trials (10,845 patients) estimated that the analgesic efficacy of nonsteroidal anti-inflammatory drugs, including cyclooxygenase-2 inhibitors, in osteoarthritic knee pain was 1.01 cm (95% CI, 0.74–1.28) on a 10 cm visual analog scale, just 15.6% better than placebo.³⁴ Thus, the effect size of nonsteroidal anti-inflammatory drugs versus placebo for pain reduction is similar to real acupuncture versus sham acupuncture in reduction of pain in OA knee pain patients. These data highlight the comparable effect sizes of acupuncture and conventional pharmacologic treatments for knee OA. Another aspect of therapeutic intervention that is as important, if not more so, is the potential to cause harm or adverse effects as a result of treatment. There is significant harm and the potential for even death caused by conventional medications leading to the withdrawal of some medications from use by regulatory authorities over the years.^35,36 This is in sharp contrast to the safety record of acupuncture performed by trained acupuncturists.^37–39

Furthermore, epidemiologists have evaluated the cost effectiveness of acupuncture in the management of various chronic pain conditions.^40–43Acupuncture was found to improve health-related quality of life at a small additional cost and was relatively cost-effective compared with a number of other interventions.⁴⁰ A pragmatic trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain demonstrated that acupuncture plus routine care was associated with marked clinical improvements and was relatively cost-effective.⁴¹ Acupuncture was also found to improve quality of life and was cost-effective as a treatment for other pain conditions (dysmenorrheal, OA, and neck pain).^42,43 Moreover, neuroscientists have applied brain imaging techniques, e.g., functional magnetic resonance imaging (fMRI) and positron emission tomography to explore the neural correlates of acupuncture as an antiemetic and an analgesic. Using fMRI, neuroscientists have identified specific brain regions related to PC-6 stimulation that further suggest that the antiemetic effects of acupuncture may be distinct from sham or placebo effects.^44,45

Napadow et al.⁴⁶ demonstrated cortical amplification and altered primary somatosensory digit somatotopy in patients suffering from carpel tunnel syndrome that can be corrected or normalized by a series of acupuncture treatments. The results of this study demonstrate that acupuncture shows promise in inducing beneficial cortical plasticity manifested by more focused digital representations. After controlling for noncutaneous somatosensory and cognitive elements of acupuncture, a subsequent study further demonstrated that acupuncture treatment for carpel tunnel syndrome patients cannot be explained as merely a placebo effect.⁴⁷

Dhond et al.⁴⁸ found verum stimulations produced more extensive modulation of limbic and paralimbic regions than sham stimulations in healthy volunteers. Pariente et al.⁴⁹ explored brain processing during verum, covert sham and overt sham needling at acupoint LI-4 in pain patients using positron emission tomography. These investigators suggested that activity within the insular cortex may be responsible for the specific effect of acupuncture, whereas modulation of the dorsolateral prefrontal cortex, rostral anterior cingulate cortex, and periaqueductal gray may be related to expectation.⁴⁹ Kong et al.⁵⁰ used both behavior assessment and fMRI to examine patient expectations and the physiological effect of acupuncture in a group of healthy volunteers. They found that conditioning positive expectation can amplify acupuncture analgesia as detected by subjective pain sensory rating changes and objective fMRI signal changes in response to calibrated noxious stimuli. In addition, while both verum and sham acupuncture can have analgesic effects, only verum acupuncture significantly inhibited the brain responses to calibrated pain stimuli.⁵⁰ The researchers indicated that acupuncture stimulation (a peripheral to central modulation) may inhibit incoming noxious stimuli, while a top-down modulation, expectancy (placebo/sham) may work through the emotional circuit.⁴²Furthermore, Harris et al.⁵¹ found that while both verum and sham acupuncture produced similar levels of pain relief in fibromyalgia patients, the brain pathways of the 2 effects were quite different. The data were consistent with sham acupuncture evoking an increased release of endogenous opioids (consistent with mechanisms operative in placebos), whereas verum acupuncture increased receptor affinity and/or number.⁵¹ In aggregate, these neuroimaging studies provide strong evidence that verum and sham acupuncture stimulations have very different neural correlates, although they both can engender analgesic effects.

In conclusion, clinical trials support the efficacy of acupuncture in reducing PONV and postoperative pain; however, evidence supporting acupuncture as a treatment for chronic pain conditions is mixed. It should be noted that acupuncture trials in chronic pain have concluded that acupuncture treatment is often superior to standard of care or wait list controls and that acupuncture has minimal side effects and is cost effective.^37–43 Brain imaging studies have demonstrated that there are different neural correlates between verum and sham acupuncture stimulation.^44–51 Additionally, all clinical trials and many research studies have assumed that the acupuncture effect is equal to the “needle” effect, failing to recognize that factors in addition to specific effects of needling are also important contributors to the therapeutic effect of acupuncture in the setting of chronic pain.

Last, acupuncture is an ancient medical intervention first developed in an era when there were no laboratory tests, technology, or science of anatomy. The reason that the practice of acupuncture has survived for thousands of years is because it has evolved over time, with changes ranging from the number of acupuncture points to the practice techniques. Instead of criticizing this ancient art with arguments culled from modern medicine and science, physicians and scientists should try to integrate current knowledge into this ancient, yet ever-evolving practice so it may be used to treat conditions for which pharmaceutical interventions are ineffective and/or potentially dangerous.^35,36 Over the last decade, there has been a growing green movement and eco-sustainability trend as well as an increased awareness that the same medication may not be effective in treating every patient with the same biomedical diagnosis. This “new age-integrative medicine^”52–55 in Western culture promotes a patient-oriented medical practice that complements the ancient Chinese theory behind acupuncture practice. Overall, acupuncture practice should not be seen as a placebo intervention or merely a needle therapy, but a medical option that not only treats disorders but also fosters a greater awareness of how harmonic interactions between self, family, work, and environment play a role in promoting health and restoring order.

Source:
http://www.anesthesia-analgesia.org

 

Scientists Officially Link Processed Foods To Autoimmune Disease.

 

The modern diet of processed foods, takeaways and microwave meals could be to blame for a sharp increase in autoimmune diseases such as multiple sclerosis, including alopecia, asthma and eczema.
A team of scientists from Yale University in the U.S and the University of Erlangen-Nuremberg, in Germany, say junk food diets could be partly to blame.

‘This study is the first to indicate that excess refined and processed salt may be one of the environmental factors driving the increased incidence of autoimmune diseases,’ they said.

Junk foods at fast food restaurants as well as processed foods at grocery retailers represent the largest sources of sodium intake from refined salts.

The Canadian Medical Association Journal sent out an international team of researchers to compare the salt content of 2,124 items from fast food establishments such as Burger King, Domino’s Pizza, Kentucky Fried Chicken, McDonald’s, Pizza Hut and Subway. They found that the average salt content varied between companies and between the same products sold in different countries.

U.S. fast foods are often more than twice as salt-laden as those of other countries. While government-led public health campaigns and legislation efforts have reduced refined salt levels in many countries, the U.S. government has been reluctant to press the issue. That’s left fast-food companies free to go salt crazy, says Norm Campbell, M.D., one of the study authors and a blood-pressure specialist at the University of Calgary.

Many low-fat foods rely on salt–and lots of it–for their flavor. One packet of KFC’s Marzetti Light Italian Dressing might only have 15 calories and 0.5 grams fat, but it also has 510 mg sodium–about 1.5 times as much as one Original Recipe chicken drumstick. (Feel like you’re having too much of a good thing? You probably are.

Bread is the No. 1 source of refined salt consumption in the American diet, according to the Centers for Disease Control and Prevention. Just one 6-inch Roasted Garlic loaf from Subway–just the bread, no meat, no cheeses, no nothing–has 1,260 mg sodium, about as much as 14 strips of bacon.

How Refined Salt Causes Autoimmune Disease

The team from Yale University studied the role of T helper cells in the body. These activate and ‘help’ other cells to fight dangerous pathogens such as bacteria or viruses and battle infections.

Previous research suggests that a subset of these cells – known as Th17 cells – also play an important role in the development of autoimmune diseases. In the latest study, scientists discovered that exposing these cells in a lab to a table salt solution made them act more ‘aggressively.’

They found that mice fed a diet high in refined salts saw a dramatic increase in the number of Th17 cells in their nervous systems that promoted inflammation. They were also more likely to develop a severe form of a disease associated with multiple sclerosis in humans.

The scientists then conducted a closer examination of these effects at a molecular level. Laboratory tests revealed that salt exposure increased the levels of cytokines released by Th17 cells 10 times more than usual. Cytokines are proteins used to pass messages between cells.

Study co-author Ralf Linker, from the University of Erlangen-Nuremberg, said: ‘These findings are an important contribution to the understanding of multiple sclerosis and may offer new targets for a better treatment of the disease, for which at present there is no cure.’ It develops when the immune system mistakes the myelin that surrounds the nerve fibres in the brain and spinal cord for a foreign body.

It strips the myelin off the nerves fibres, which disrupts messages passed between the brain and body causing problems with speech, vision and balance.

Another of the study’s authors, Professor David Hafler, from Yale University, said that nature had clearly not intended for the immune system to attack its host body, so he expected that an external factor was playing a part.

He said: ‘These are not diseases of bad genes alone or diseases caused by the environment, but diseases of a bad interaction between genes and the environment.‘

Humans were genetically selected for conditions in sub-Saharan Africa, where there was no salt. It’s one of the reasons that having a particular gene may make African Americans much more sensitive to salt.

‘Today, Western diets all have high salt content and that has led to increase in hypertension and perhaps autoimmune disease as well.’

The team next plan to study the role that Th17 cells play in autoimmune conditions that affect the skin.

‘It would be interesting to find out if patients with psoriasis can alleviate their symptoms by reducing their salt intake,’ they said.

‘However, the development of autoimmune diseases is a very complex process which depends on many genetic and environmental factors.’

Stick to Good Salts

Refined, processed and bleached salts are the problem. Salt is critical to our health and is the most readily available nonmetallic mineral in the world. Our bodies are not designed to processed refined sodium chloride since it has no nutritional value. However, when a salt is filled with dozens of minerals such as in rose-coloured crystals of Himalayan rock salt or the grey texture of Celtic salt, our bodies benefit tremendously for their incorporation into our diet.

“These mineral salts are identical to the elements of which our bodies have been built and were originally found in the primal ocean from where life originated,” argues Dr Barbara Hendel, researcher and co-author of Water & Salt, The Essence of Life. “We have salty tears and salty perspiration. The chemical and mineral composition of our blood and body fluids are similar to sea water. From the beginning of life, as unborn babies, we are encased in a sack of salty fluid.”

“In water, salt dissolves into mineral ions,” explains Dr Hendel. “These conduct electrical nerve impulses that drive muscle movement and thought processes. Just the simple act of drinking a glass of water requires millions of instructions that come from mineral ions. They’re also needed to balance PH levels in the body.”

Mineral salts, she says, are healthy because they give your body the variety of mineral ions needed to balance its functions, remain healthy and heal. These healing properties have long been recognised in central Europe. At Wieliczka in Poland, a hospital has been carved in a salt mountain. Asthmatics and patients with lung disease and allergies find that breathing air in the saline underground chambers helps improve symptoms in 90 per cent of cases.

Dr Hendel believes too few minerals, rather than too much salt, may be to blame for health problems. It’s a view that is echoed by other academics such as David McCarron, of Oregon Health Sciences University in the US. He says salt has always been part of the human diet, but what has changed is the mineral content of our food. Instead of eating food high in minerals, such as nuts, fruit and vegetables, people are filling themselves up with “mineral empty” processed food and fizzy drinks.

Study Source:

This is the result of a study conducted by Dr. Markus Kleinewietfeld, Prof. David Hafler (both Yale University, New Haven and the Broad Institute of the Massachusetts Institute of Technology, MIT, and Harvard University, USA), PD Dr. Ralf Linker (Dept. of Neurology, University Hospital Erlangen), Professor Jens Titze (Vanderbilt University and Friedrich-Alexander-Universitat Erlangen-Nurnberg, FAU, University of Erlangen-Nuremberg) and Professor Dominik N. Muller (Experimental and Clinical Research Center, ECRC, a joint cooperation between the Max-Delbruck Center for Molecular Medicine, MDC, Berlin, and the Charite — Universitatsmedizin Berlin and FAU) (Nature, doi: 
http://dx.doi.org/10.1038/nature11868
)*. In autoimmune diseases, the immune system attacks healthy tissue instead of fighting pathogens.

Source: Prevent Disease

 

 

 

No magic answer for Achilles tendinopathy.

“Although they are trendy money spinners, best evidence shows little effectiveness”—An attention grabbing subheading to an editorial by Nic Maffulli in the BMJ commenting on an intriguing randomised controlled trial (RCT) from New Zealand on the use of autologus blood injections in treating Achilles tendinopathy. It doesn’t work.

Evidence based sports medicine was radical new thinking when Tom Best and I first began to think about it. Care of the athlete had evolved empirically. Few asked questions. For example, when our university research group first began to study ice, perhaps the most commonly used treatment in soft tissue injury, there was little quality evidence to inform treatment; the duration of each application, over what period of time, the temperature of the ice (melting iced water is 0 degrees Celcius),  if it mattered if you were fat or thin etc. Clinicians then began to ask about the evidence for the tests used in clinical examination, the effectiveness of prevention, the appropriate management of common conditions. Where we thought there was certainty, there was little evidence. This RCT on Achilles tendinopathy is an important trial because it asked serious questions about a treatment that had become commonplace yet seemingly evidence free.

Much of what we think is fact in sport is hype, based often on weak science, but mostly on extrapolation from observation. People in sport are forever looking for that extra added magic ingredient to set them apart. Complicit and gullible because they want to believe.  They follow the training programme, wear the headband, chase the logo the champions wear. It is no surprise that they take the drink, buy the supplement, wear the shoe, or do the exercise endorsed by champions. Ever susceptible, suggestible—looking for an easy way, its human nature.  So, it was no surprise to see the hype surrounding yet another product on the margin. This was the next big thing—an injection to cure one of the most common and troublesome injuries.

Its great to see good quality research and more is needed. But, research is expensive and its almost impossible to justify research in sports medicine when competing for funds with cancer, cardiology, and other core medical topics.  There is an evidence vacuum and in sports medicine there is huge pressure to do something. And, always someone looking for the magic answer.

Sourc: BMJ

 

 

Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians.

This study highlights one of the main dilemmas of modern medicine; namely, the threshold at which a clinician performs an investigation, particularly where this involves receiving a radiation dose such as computed tomography scan. The dilemma lies between not missing significant pathology and not utilising resources unnecessarily plus potentially increasing the patient’s future risk of cancer. In most specialities there are guidelines, from a variety of bodies including the national institute of clinical excellence and national specialty societies, which help determine the investigative pathway of patients. However, individual patients often present with a constellation of signs, symptoms and risk factors which may not fit within the guidelines. An example would be the young patient with a strong family history of coronary disease and first degree relatives presenting with myocardial infarction or death below the age of 40, with very atypical chest pain which is clearly non-cardiac in nature. A further example would be the patient who is in complete remission from cancer but notices vague intermittent bloating in the abdomen despite being very well with a normal clinical examination, ultrasound abdomen and blood profile. Some clinicians may just re-assure the patient whilst others may perform a coronary CT angiogram in the former case and CT abdomen in the latter case. Often the real-world decision making is based partly on clinical judgement of the physician but also increasingly on managing expectations and re-assuring patients. Patients should be made aware of the dose of radiation they receive and what implications this has on their future risk of cancer so they can be fully informed about the risks and benefits of their chosen pathway.

Source: BMJ

 

 

Outcomes of Medical Emergencies on Commercial Airline Flights.

BACKGROUND

Worldwide, 2.75 billion passengers fly on commercial airlines annually. When in-flight medical emergencies occur, access to care is limited. We describe in-flight medical emergencies and the outcomes of these events.

METHODS

We reviewed records of in-flight medical emergency calls from five domestic and international airlines to a physician-directed medical communications center from January 1, 2008, through October 31, 2010. We characterized the most common medical problems and the type of on-board assistance rendered. We determined the incidence of and factors associated with unscheduled aircraft diversion, transport to a hospital, and hospital admission, and we determined the incidence of death.

RESULTS

There were 11,920 in-flight medical emergencies resulting in calls to the center (1 medical emergency per 604 flights). The most common problems were syncope or presyncope (37.4% of cases), respiratory symptoms (12.1%), and nausea or vomiting (9.5%). Physician passengers provided medical assistance in 48.1% of in-flight medical emergencies, and aircraft diversion occurred in 7.3%. Of 10,914 patients for whom postflight follow-up data were available, 25.8% were transported to a hospital by emergency-medical-service personnel, 8.6% were admitted, and 0.3% died. The most common triggers for admission were possible stroke (odds ratio, 3.36; 95% confidence interval [CI], 1.88 to 6.03), respiratory symptoms (odds ratio, 2.13; 95% CI, 1.48 to 3.06), and cardiac symptoms (odds ratio, 1.95; 95% CI, 1.37 to 2.77).

CONCLUSIONS

Most in-flight medical emergencies were related to syncope, respiratory symptoms, or gastrointestinal symptoms, and a physician was frequently the responding medical volunteer. Few in-flight medical emergencies resulted in diversion of aircraft or death; one fourth of passengers who had an in-flight medical emergency underwent additional evaluation in a hospital. (Funded by the National Institutes of Health.)

 

Source: NEJM

Propofol Procedural Sedation Is Safe.

No adverse outcomes occurred among 1000 adult propofol procedural sedation episodes.

To determine the safety of propofol for emergency department (ED) procedural sedation, researchers retrospectively applied a sedation adverse-event reporting tool to 1008 consecutive patients (age range, 15 to 97 years) who underwent procedural sedation at a single ED in the U.K. over a 5-year period. Sentinel events included oxygen saturation <75% for any length of time or <90% for more than 60 seconds, apnea lasting longer than 60 seconds, aspiration event, need for intubation, cardiovascular collapse, permanent neurologic disability, and death. Most patients were sedated for orthopedic procedures (77%) and cardioversion (9%). Monitoring included pulse oximetry, non-invasive blood pressure measurement, respiratory rate, and electrocardiography; nasal capnography was adopted near the end of the study period.

A total of 73 adverse events were reported: 11 sentinel, 34 moderate, 25 minor, and 3 minimal risk. Sentinel events included six episodes of prolonged hypotension (>60 seconds) requiring brief vasopressor support, and five episodes of hypoxia, all but one of which resolved with assisted ventilation. One patient with unstable ventricular tachycardia underwent cardioversion, vomited, and became hypoxic, necessitating intubation for airway protection and altered mentation. He was found to have a saddle pulmonary embolism and distal aortic thrombus; he survived to hospital discharge. No adverse outcomes related to procedural sedation were identified.

Comment: Several patients with sentinel adverse events had significant underlying medical comorbidities. Fortunately, no patients suffered any adverse outcomes related to the procedural sedation, but this study reminds us that proper monitoring, including capnography, and careful patient selection are crucial to ensure the safety of this procedure. Patients at high risk for adverse events, such as those with significant cardiopulmonary comorbidity, and those with difficult airways should be evaluated for possible sedation in the operating room.

 

Source: Journal Watch Emergency Medicine