Tuesday, March 31, 2009

Neurology Consult Service and Neurosurgery

I will be spending the next three weeks on various inpatient neurology teams: consult service this week and next week, and then inpatient neuro the last week. There is not much difference between the consult and inpatient services in terms of what we do. The main thing that distinguishes them is whether neuro is the primary team that admits the patient (inpatient), versus the secondary team that comes to see the patient at the request of the primary team (consult). Most of the consults are made by the surgery and medicine teams for patients with delirium. It's not the most interesting patient population in the world, because we had plenty of delirious patients when I was on medicine and surgery. But it's ok.

Yesterday morning, I had neurosurgery clinic, and that was a good experience for a couple of reasons. First, I got out of having to go round on the consults. Second, the patients were not seeing a surgeon for delirium! The surgeon had a cool operation planned for that afternoon, which she said I could scrub for if I wanted. I got permission from my resident to go scrub, and it was one of the most amazing things I have ever seen since I started medical school.

The patient was a teacher who began having headaches several months ago. The headaches got worse and worse, and he also started having seizures even though he had never been diagnosed with epilepsy before. An MRI of his brain showed that he had an enormous tumor. The surgeon had already operated on him once but couldn't get all of the tumor out because it was too close to vital brain structures. So the patient had come back to have a special surgery done where a neurologist would help the neurosurgeon figure out how much tumor debulking (removal) could be done without affecting the patient's mental functioning.

Although the patient had gotten local anesthetic, he was awake while the surgeon was working on removing the tumor. He had to be awake so that the neurologist could test his cognition. While the surgeon was cutting away slices of his tumor and brain, the neurologist had him doing tasks like counting, identifying pictures on notecards, reading words, and performing mathematical calculations. At one point, the patient was counting, "20, 21, 22, 22, 22, 27...." When that happened, the neurologist told the neurosurgeon not to cut any deeper. There was still tumor left, but the surgeon couldn't remove any more of it without putting the patient at risk. So at that point they starting closing the wound and the surgery was over.

One thing you may be wondering is whether the patient was in a lot of pain while the surgeon was cutting into his brain. Although all of your body's pain receptors go to the brain, there are no pain receptors in the brain itself. So once the surgeon had removed the patient's scalp, skull, and dura (the tough covering of the brain), the patient didn't feel any pain in his brain. Also, after the neurologist told the neurosurgeon to stop cutting, the anesthesiologist did put the patient to sleep so that he wouldn't have any pain while they were replacing his skull and scalp.

Today was a regular day on consult service, and as I said before, we mainly got a bunch of delirium consults. I did an H&P (history and physical) on one patient, which can be a pain sometimes if the patient is delirious. That's because they aren't the most reliable historians, and sometimes they don't want to cooperate with being examined. But I didn't have any problem with that today. Also, I don't have to preround tomorrow because I have a second morning of neurosurgery clinic. That's the last opportunity I will have to escape being on consult, unfortunately.

I should mention that I really like my senior resident, but the attending seems kind of unenthusiastic about neurology and even life in general. I'm feeling like this could be a long two weeks.

Friday, March 27, 2009

LCME Site Visit and Neuro Rotation

Case's LCME review began on March 22. (Remember, the LCME is the organization that accredits all American and Canadian allopathic medical schools.) The review took place over several days because the committee members had to meet with various faculty, administrators, and students on both campuses. I attended the clinical student meeting, which was held over at Case during lunchtime on Wednesday. Since I was scheduled to have outpatient neurology clinics that day, I was given permission to leave the morning clinic half an hour early and come back to afternoon clinic an hour late. Unfortunately, somehow no one told my afternoon preceptor that I would be late, so I had some explaining to do once I got to his clinic!

After all the flurries of emails we got from the administration, the meeting itself was kind of anticlimactic. There were two other CCLCM upperclassmen, as well as several UP upperclassmen and several reviewers. I think the reviewers are all administrators of some type at other medical schools. Most of the questions they asked us were pretty basic things, like who we would contact if we got stuck by a needle (depends on the hospital, but at CCF, you call the exposure hotline). Surprisingly, the reviewers wanted to know if our rotations required more than 80 hours per week. That work-week limit is actually for residents, not medical students, but Case has an 80 hour work-week rule in place for us anyway. We also got asked about why the OB/gyn rotation had received such low evaluations by M3s and M4s in both programs. I haven't done OB/gyn yet, so I couldn't add much to this discussion. But I was already dreading it based on the horror show stories I've heard from friends, and today's discussion didn't do much to allay my fears. :-P

It will take a couple of months for the reviewers to decide whether our school can be reaccredited. Once the LCME decides that we've passed muster, Case will be accredited until the 2016-2017 academic year. That's a long time. To put it in perspective, I will be done not only with residency but even with fellowship by then, assuming I do a fellowship.

This week, I also had some neuro peds clinics that were kind of awkward. Since I haven't had peds yet, I don't know very much about the development of children, and the pimping was pretty painful for me. One child's parents had brought their 14-month-old toddler in because the child wasn't walking yet. The attending asked me in front of the parents if this was normal or not. Beats me! I have no idea what age children normally learn to walk. It's not like I have any kids at home to study! (For the record, children learn to walk around age 12 months, but it is not considered to be a problem unless they're still not walking after around 15-18 months.)

On my last day in the headache clinic, I had a patient with trigeminal neuralgia. This is a pain syndrome that occurs in the distribution of the fifth cranial nerve (the trigeminal nerve). The patient gets an intense, shooting pain down one or more branches of the nerve. Commonly, the second branch (V2), which innervates the middle of the face, is affected. (See picture.) It's not known exactly why trigeminal neuralgia occurs, but it may be associated with a blood vessel compressing the nerve. When I examined the patient, I unfortunately reproduced her pain, even though I tapped her face lightly.

One other thing I learned was that I haven't been using the reflex hammer correctly. My preceptor explained that it should be more of a movement in the wrist, and I've apparently been using my entire arm too much. I practiced on several patients, and she said I am starting to get the hang of it. Who ever knew that hitting people's tendons with a hammer could require such perfection of technique!

Tuesday, March 24, 2009

Starting Neuro Rotation

This is my first week on neurology. So far, it's been really intense! Not that I expected it to be a cakewalk, but the Block III* administrator went out of her way several times to warn us about not missing conferences, and to emphasize that we have to go straight from the conferences to our clinical responsibilities. We have conferences twice a day (morning and noon), and I'm on outpatient this week, so there's really not any downtime for me to read about my patients or catch up with my logs. I feel frustrated, because by the time I get home at night, I've already seen too many patients to even remember them all.

I went to talk to my physician advisor about this problem, because it was making me feel a little stressed. Now, my PA is not the type of person who would ever condone slacking, but she did suggest that I could probably take a little time here and there to chill out and read. We agreed that I certainly should not ever miss any of the required clinical time or the teaching conferences specifically created for the students, but that maybe missing the resident-oriented conferences once in a while might be ok. I thought that was a fair compromise, and it is helping me relax and enjoy the rotation a little more.

The actual clinic part has been pretty interesting so far. There are several different kinds of specialized neuro clinics, and I think it's kind of random which ones we get assigned to work in. Some of the other students are doing Parkinson's or MS clinics, which I didn't get. But I have a couple of days of headache clinic, and it's really interesting. There is a program at CCF called IMATCH, which is for patients who have chronic headaches. It's common to see patients with medication rebound headaches. These are chronic headaches that are due to taking too much pain medication. If the patient tries to stop taking the medications, the headaches come back with a vengeance, so they keep taking more and more of them. That just feeds the vicious cycle.

IMATCH patients spend three weeks coming to the headache clinic. In the first week, they start by getting a multidisciplinary evaluation by neurologists and psychologists. This is to help determine what kind of help they will need to overcome their headaches, or at least to learn to manage the pain to a tolerable level. For the rest of the first week, the patients lie in a dark room, where they get IV infusions of pain medicine. This is tapered down over time to help break their dependence on pain meds. Patients also get physical therapy and counseling to help them cope better with the discomfort and manage headaches more effectively.

For the record, I have a lot of sympathy for people who have migraines. I get migraines myself, but sometimes I have to go out and do things anyway even though I have a migraine. If I take medicine to abort the headache to a more dull pain, I can usually do my work even with that background level of pain. It's not the most comfortable, but it's doable. So I asked my preceptor how bad a person's migraines have to get before they become so crippling that the patient can't function normally anymore. She told me that the difference between me and the patients who get seen at the clinic is that I have pain, but they have a pain syndrome. The pain controls their lives, and they feel too helpless to live their lives normally. She also explained that it was important to make the patient's expectations more realistic. Even when I take pain medications, I understand that the headache may not go away completely, and I don't expect to be completely pain-free. Apparently some patients have difficulty coping with any pain at all.

I have one more day in the headache clinic this week. Even though the headache clinic is really interesting, I'm kind of disappointed that I won't get to do all of the other clinics too. But I'm glad that I had some time to see how the IMATCH program works. Plus, the preceptors who work in the headache clinic are really good and like to teach. I can already tell that neurologists are impressively smart and knowledgeable about medicine.

*Note that Block III in the new curriculum is an eight week block for neurology and psychiatry. I am part of the last group of students going through the old curriculum, which didn't have a Block III, but we are taking these two rotations with the first group of students going through the new curriculum. Don't worry about it if you're confused, because all of us are, too. :-P

Saturday, March 21, 2009

Master CCLCM Match List

This post contains the combined match list for all CCLCM graduation years by specialty and hospital. I will keep updating this list as future classes match.

-Cleveland Clinic (2009)

-Yale (2009)

Emergency Medicine
-Cincinnati (2009)

General Surgery
-Brown (2009)
-Wash U (2009)

Internal Medicine
-Beth Israel (Harvard--2009)
-Cornell (2009)
-Duke (2009)
-Michigan (2009)
-Stanford (2009)
-UNC (2009)
-Vanderbilt (2009)
-Yale (2009)

-Emory (2009)
-George Washington (2009)

-Beth Israel (Harvard--2009)
-U. Hawaii (2009)

-Cleveland Clinic (2009)
-UCSD (2009)

-Hospital for Special Surgery (Cornell-2009)
-UCSD (2009)
-Utah (2009)

-Mass General (Harvard--2009)

-CHOP (U Penn--2009)
-Duke (2009)

Rad Onc
-Rochester (2009)

-U Penn (2009)

-Cleveland Clinic (2009)
-Wake Forest (2009)

Friday, March 20, 2009

End of Rads

On Wednesday, I finished writing my teaching case report, which is on something kind of esoteric that the attending will hopefully find interesting. I'm still not at all enthusiastic about rads, but I can honestly say that I feel a little more comfortable with reading films. So at least that's something--not that it makes me feel any better about having my circadian rhythm knocked totally out of whack because of sitting in a dark room all morning. Adding to my general sense of misery, it seems like the UH radiology department is one giant petri dish these days. Whatever it was that was going around has now come around to me, and I've been sick all week.

At least it's over now. I'm sure in another week or two I'll be on call, and I'll start looking back on these last two weeks as some kind of nirvana of getting out by 1 PM every day. But wow, as important as knowing how to read films is, I can't imagine a specialty that could possibly be more effective at inducing me to fall asleep instantly than radiology. I honestly don't know how people do it for an entire career. But the radiologists have my utmost respect, not only because they enjoy this stuff, but because they have an extremely impressive command of anatomy. In particular, they have a very good sense of where tiny objects like blood vessels are located in three-dimensional space, which is something that I often don't quite have the knack for.

The LCME site visit starts this weekend, and the administration is tense on both campuses. All week long, Dean Franco has been sending us emails about LCME things, reminding us about what we have to do, how to act, etc., over and over. I've reached the point where I don't read the emails any more. It's not like an LCME site visit is something you can study for, and it's not like I'm going to jeopardize Case's accreditation by behaving unprofessionally at the meeting!

Thursday, March 19, 2009

2009 CCLCM Match List

Match Day! Things were pretty quiet in the UH radiology department today, since all of the M4s were gone for match day. We found out today how our own first graduating CCLCM class did in the match. All of the students matched.* For those who are interested, here is the much-anticipated 2009 CCLCM Match List:

-Cleveland Clinic


Emergency Medicine

General Surgery
-Wash U

Internal Medicine
-Beth Israel (Harvard)

-George Washington

-Beth Israel (Harvard)

-Cleveland Clinic

-Hospital for Special Surgery (Cornell)

-Mass General (Harvard)

-CHOP (U Penn)

Rad Onc

-U Penn

-Cleveland Clinic
-Wake Forest

*You may have noticed that there are only 29 CCLCM students who entered the match. One student in the first class left med school at the end of the first year, and two others have postponed entering the match in order to earn additional degrees.

You may also be interested in reading the Cleveland Plain Dealer's article about the first CCLCM match.

Friday, March 13, 2009


This week, I started a two-week radiology elective at UH. I had wanted to do it at CCF, but the radiologists there only let people do rads for four weeks. I can't do four weeks since I have to start my next core block of rotations in two weeks. This was probably a blessing in disguise, because radiology has to be the most boring rotation I have ever done.

Picture this: we come in at 8 AM each morning for an hour-long conference that mainly consists of people throwing films up and droning on about them. The room is nice and warm and dark. Actually, so are the rooms where the radiologists read the slides. Some of the residents enjoy teaching, but many basically ignore us. So I've been spending most of my mornings either reading or dozing off, depending on my inclination.

At noon, there is a second conference, similar to the first. By then, I am usually too hungry to doze off, so I read my radiology case book. This is not a required book. I just bought it on my own so that I could hopefully learn something about radiology. After lunch, all of the med students clear out. That is the best part of each day.

So far, I have rotated through ultrasound, chest imaging, ER/bone, nuclear medicine (by far the most interesting), and CT. But overall, the interesting : boring ratio is way too low for this rotation to be of much use. It's not just me who feels this way--one of the other med students dropped the rotation altogether a couple of days ago.

Besides boring me to death, this rotation is totally disrupting my circadian rhythm. After I've been dozing off in a dark room all morning, it's not so easy to fall asleep at a reasonable hour that night!

Friday, March 06, 2009

CAM Paper Part IX: Conclusion and References

Although some physicians may be skeptical about the benefits of CAM, they should still educate themselves about CAM for several reasons. First, a significant proportion of patients seen in a primary care setting would like to try CAM or are already using it. These patients may ask their physicians for advice about CAM therapies they have seen on the internet or heard about from friends. One survey study found that patients who use CAM expect their physicians to be knowledgeable about CAM and to make referrals for CAM treatments as appropriate.(4)

Second, patients are often misinformed about CAM modalities, and they are at significant risk of making misguided decisions based upon unreliable information.(2) Informed physicians are in a better position to empower their patients to make informed decisions about the pros and cons of CAM. Physicians can also play a significant role in guiding patients away from harmful CAM therapies, as well as steering them toward alternative CAM therapies that do not interact with conventional drugs that patients may also be taking.

Finally, a physician who is indifferent or openly negative about CAM may undermine the trust between patient and physician by making it difficult for the patient to initiate a discussion about CAM. There is evidence that younger physicians tend to regard CAM more positively compared to older physicians, which may facilitate discussion of CAM by younger physicians.(3) However, all physicians should be prepared to objectively discuss CAM with patients, even physicians who are skeptical about the benefits of CAM. Approaching patients who inquire about CAM with a nonjudgmental attitude provides the physician with an opportunity to improve the therapeutic relationship while educating the patient.

1. Barnes PM, Powell-Griner E, McFann K, Nahin RL: Complementary and alternative medicine use among adults: United States, 2002. Seminars in Integrative Medicine 2004; 2: 54-71

2. Ernst E: How the public is being misled about complementary/alternative medicine. J R Soc Med 2008; 101: 528-530

3. Sewitch MJ, Cepoiu M, Rigillo N, Sproule D: A Literature Review of Health Care Professional Attitudes Toward Complementary and Alternative Medicine. Complementary Health Practice Review 2008; 13: 139-154

4. Ben-Arye E, Frenkel M, Klein A, Scharf M: Attitudes toward integration of complementary and alternative medicine in primary care: Perspectives of patients, physicians and complementary practitioners. Patient Education and Counseling 2008; 70: 395-402

5. Riccard C, Skelton M: Comparative analysis of 1st, 2nd, and 4th year MD students' attitudes toward Complementary Alternative Medicine (CAM). BMC Research Notes 2008; 1: 84

6. Moyer CA, Rounds J, Hannum JW: A meta-analysis of massage therapy research. Psychol Bull 2004; 130: 3-18

7. Ernst E: Chiropractic: A Critical Evaluation. Journal of Pain and Symptom Management 2008; 35: 544-562

8. Keating JCC, K. H.; Grod, J. P.; Perle, S. M.; Sikorski, D.; Winterstein, J. F.: Subluxation: dogma or science? Chiropractic & Osteopathy 2005; 13: 17-26

9. Miller K: The evolution of professional identity: the case of osteopathic medicine. Social Science & Medicine 1998; 47: 1739-1748

10. Gevitz N: Center or Periphery? The Future of Osteopathic Principles and Practices. J Am Osteopath Assoc 2006; 106: 121-129

11. Ernst E: Acupuncture – a critical analysis, Journal of Internal Medicine, Blackwell Publishing Limited, 2006, pp 125-137

12. Martin DP, Sletten CD, Williams BA, Berger IH: Improvement in Fibromyalgia Symptoms With Acupuncture: Results of a Randomized Controlled Trial. Mayo Clinic Proceedings 2006; 81: 749-757

13. Shapiro K: Natural Products: A Case-Based Approach for Health Care Professionals. Washington, D.C., American Pharmacists Association, 2006

14. Clark K: Nutrition Strategies for Managing Joint Pain, The Professionals’ Guide to Diet, Nutrition and Healthy Eating IDEA Health & Fitness Association, 2004, pp 62-65

15. Wheatley D: Medicinal plants for insomnia: a review of their pharmacology, efficacy and tolerability. J Psychopharmacol 2005; 19: 414-421

16. Westfall RE: Use of anti-emetic herbs in pregnancy: women's choices, and the question of safety and efficacy. Complementary Therapies in Nursing and Midwifery 2004; 10: 30-36

Thursday, March 05, 2009

CAM Paper Part VIII: Herbal Remedies III

Several herbs are used to treat nausea, most commonly ginger, peppermint, and cannabis. All three have been shown to have mild anti-emetic properties for chemotherapy, motion sickness, and post-operative nausea. Only ginger has been shown in clinical trials to be effective for morning sickness, but anecdotal reports suggest that peppermint and cannabis smoking are also effective for morning sickness. Cannabis in particular has a long history of being used to treat chemotherapy-induced and HIV drug-induced nausea. Ginger and peppermint should be used cautiously in pregnancy due to a possible risk that they promote menstruation. There does not appear to be any contraindication for the use of cannabis in low to moderate doses.(16)

Cold and Flu
The most popular herbal remedy used to treat cold symptoms is echinacea; in fact, echinacea is the most popular herbal remedy on the U.S. market in general. Although it is very popular and has a long history of use, echinacea may not be very efficacious against cold symptoms. Some studies did find that echinacea could shorten the duration of a cold by one or two days. In addition, there is no evidence that echinacea can be used prophylactically to prevent colds. There are few side effects due to echinacea, but people who are allergic to ragweed and other pollens may be at risk of having an allergic reaction.(13)

Other popular natural products use to treat colds include vitamin C and zinc. These two agents may provide a modest decrease in cold symptoms, but the evidence in favor of either agent is not very strong. Vitamin C is generally safe, although it may cause GI symptoms at very high doses. Zinc can cause anosmia (loss of the sense of smell) if taken intranasally. As with echinacea, neither zinc nor vitamin C can be used as a prophylactic to prevent catching a cold.(13)

Common natural products used to treat the flu include elderberry and ginseng. Elderberry appears to have reasonably good efficacy in reducing the duration of flu symptoms based upon the results of two clinical trials. The main side effect is GI symptoms. Ginseng may be useful as prophylaxis against the flu based on two preliminary trials. However, it has some potentially troublesome side effects, including insomnia and possibly cardiac effects. Oscillococcinum is a popular homeopathic remedy used to treat the flu. Since it contains no active ingredient and is considered to be a placebo, there is no contraindication against it.(13)

Cholesterol Reduction and Cardiovascular Disease
Common natural products used to lower cholesterol include dietary oats, psyllium fiber, soy, plant sterols, policosanol, garlic, and omega-3 fatty acids. The effect of eating oatmeal is very mild, yielding a drop in LDL of about 6 mg/dL. One clove of fresh garlic per day can lower total cholesterol about 5%. Psyllium, plant sterols and soy can decrease LDL about 10%. Policosanol, a waxy substance that can be made from beeswax, can decrease LDL around 20%, and also increase HDL about 20%. Omega-3 fatty acids are used to lower triglycerides. None of these compounds has any major side effects, but policosanol, garlic, and omega-3 fatty acids could possibly increase some people’s risk of bleeding.(13)

Along with garlic and omega-3 fatty acids, other compounds used for primary and secondary prevention of cardiac disease include coenzyme Q10, hawthorn, arginine, and carnitine. Coenzyme Q10 decreases blood pressure and improves heart failure symptoms, and has few side effects. It should not be used concurrently with doxorubicin. Hawthorn appears to improve heart failure symptoms and increase exercise capacity. It may potentiate the effects of digoxin. The amino acids arginine and carnitine are well-tolerated and improve exercise capacity in patients with heart failure. Vitamin E should not be recommended, as it does not decrease the risk of cardiovascular disease. In fact, the mortality rate increases with high dose vitamin E.(13)

Wednesday, March 04, 2009

CAM Paper Part VII: Herbal Remedies II

Benign Prostatic Hyperplasia
Saw palmetto extract can be used to treat benign prostatic hyperplasia (BPH). It inhibits 5-α-reductase, the same enzyme inhibited by the prescription drug finasteride, thereby preventing the conversion of testosterone to dihydrotestosterone. Studies show that saw palmetto is efficacious and generally well-tolerated. Other natural products used to treat BPH include pygeum and stinging nettle. Pygeum works by a different, poorly understood mechanism. The limited published data support its efficacy, and it is well-tolerated. There is no evidence to support the use of stinging nettle for BPH.(13)

Menopause Symptoms
Black cohosh and soy are two commonly used natural products that may provide some relief to post-menopausal women suffering from symptoms like hot flashes, night sweats, vaginal dryness, mood disturbance, and poor sleep. Soy, as mentioned previously, has few side effects except that there is potentially a risk in women with a history of breast cancer due to the phytoestrogens. Black cohosh is thought to work by stimulating estrogen receptors, although it is not an estrogen analog. As with soy, there is a possible risk due to black cohosh in women with a history of breast cancer. In addition, black cohosh has been associated with liver damage in rare cases. Other natural products sometimes used to treat menopausal symptoms include dong quai and evening primrose oil. Neither of these extracts has been shown to have any efficacy.(13)

Although bioidentical hormone replacement therapy (BHRT) is actually a synthetic product, some women prefer it since the hormones are identical to the hormones present in pre-menopausal women. In contrast, prescription drugs like Premarin, which actually is a natural product, contain different estrogens that are not present in humans. BHRT is customized for each woman, which may help decrease the incidence of side effects. As with conventional hormone replacement therapy, BHRT should be used at the lowest possible dose for the shortest required amount of time. The risks of BHRT are thought to be similar to the risks due to HRT, possibly including increased chances of cardiovascular events, breast cancer, endometrial cancer, and clots.(13)

St. John’s Wort is a popular natural product used to treat depression. The extract contains several compounds that are thought to affect mood, probably by inhibiting reuptake of monoamines. This mechanism of action is similar to the mechanism of TCAs. However, there is also evidence that the active components of St. John’s wort affect other neurotransmitters like GABA and glutamate as well. There is evidence that St. John’s wort is effective in mild to moderate depression, but not in severe depression. Common side effects include GI upset, skin reactions, and sexual side effects. More worrisome is that St. John’s wort has many interactions with other drugs since it induces multiple CYP 450 enzymes. St. John’s wort may also be teratogenic and should not be used by pregnant women. Finally, since St. John’s wort prevents the reuptake of serotonin, it should not be used along with serotonergic prescription drugs such as MAOIs and SSRIs because of the possibility of serotonin syndrome.(13)

Other natural products that are used for depression include SAMe, inositol, and omega-3 fatty acids. The data for SAMe suggests that it has some efficacy in depression, but SAMe can cause a manic episode if it is taken by bipolar patients. The data on omega-3 fatty acids also are suggestive of efficacy in depression. However, the data for inositol are too preliminary for it to be recommended currently. Regardless of which agent is given, any patient with depression, especially major depression, requires psychiatric care.(13)

Insomnia and Anxiety
The sleep-inducing properties of kava kava are well known. Kava kava extract rapidly induces sleep and does not seem to cause any long-term side effects during the day following its use. Although kava kava appears to be efficacious in treating anxiety and insomnia, it has been banned in several countries due to its potential to cause serious side effects. Specifically, several case reports of patients who developed hepatitis severe enough to require a liver transplant have been published. At this time, kava kava is still available in the United States as an unregulated dietary supplement. However, it should not be used by alcoholics or other patients who have liver disease.(15)

Valerian is a safer and therefore more promising alternative to kava kava for insomnia and anxiety. It appears to induce a natural sleep pattern after being used for several weeks, and there is no evidence that it is habit-forming or has any significant side effects other than causing vivid dreams. The one potential downside of valerian is that the onset of action is several weeks, and patients may need to use a stopgap hypnotic like a benzodiazepine while waiting for the valerian to take effect. However, although valerian does not seem to effectively induce sleep acutely, it does aid with maintaining good sleep patterns over the long term. It also appears to decrease sleep latency and increase the amount of slow-wave sleep, both of which promote a greater feeling of being well-rested the following day. These qualities may make valerian useful as a treatment for chronic insomnia, especially in the elderly.(15)

Another promising herbal treatment for insomnia and anxiety is aromatherapy with essential oils like lavender and chamomile. Lavender is commonly used as the oil rather than ingested, while chamomile is usually ingested as a tea. In both cases, it appears to be inhalation of the essential oil that produces the hypnotic effect.(15)

Tuesday, March 03, 2009

CAM Paper Part VI: Herbal Remedies I

Herbal remedies and other natural products were used by 19% of adults during the past 12 months according to a 2002 survey.(1) The ten most commonly used herbal remedies were echinacea, ginseng, ginkgo biloba, garlic supplements, glucosamine, St. John’s wort, peppermint, flax and fish oils, ginger, and soy.(1,13) Other commonly used herbal remedies include chamomile, bee pollen, kava kava, valerian, and saw palmetto.(1) Some common natural products are described below in relation to the conditions they are used to treat.

Ginkgo biloba is an extract from the leaves of the ginkgo tree that contains multiple natural products. It is used to treat Alzheimer’s dementia instead of or along with acetylcholinesterase inhibitors like donepezil. Studies have found that modest memory improvement can occur with use. The mechanism of action of ginkgo biloba is not known, but it is thought to be related to the extract’s anti-inflammatory properties. In addition, the flavonoid component of the extract is an antioxidant that scavenges the free radicals thought to be involved in the pathology of dementia. The most commonly reported side effect of ginkgo biloba is gastrointestinal symptoms. However, ginkgo biloba antagonizes anti-platelet factor, thereby inhibiting platelet aggregation. Thus, physicians should be aware of the potential for bleeding with ginkgo biloba use, especially if the patient is taking anticoagulants. In addition, gingko should be discontinued for several days before the patient undergoes elective surgery.(13)

Other natural products sometimes used for treatment of dementia include huperzine A and high dose vitamin E. Huperzine A is a natural acetylcholinesterase inhibitor that appears to be as effective in treating dementia as prescription acetylcholinesterase inhibitors. There is some evidence that high dose vitamin E may slow dementia progression. However, the doses required for this use are toxic. Thus, vitamin E should not be recommended to patients for the treatment of dementia.(13)

Glucosamine and chondroitin are the most popular natural products used to treat arthritis. Both are normal components of cartilage. Glucosamine may stimulate synthesis of proteoglycans and glycosaminoglycans by chondrocytes, as well as inhibit cartilage breakdown. Chondroitin also stimulates chondrocytes to synthesize cartilage components, as well as having anti-inflammatory properties. Not only do both supplements show efficacy against pain in clinical trials of moderate to severe osteoarthritis, but glucosamine may even retard progression of the disease. Since they have different mechanisms of action, glucosamine and chondroitin are often used together. The onset of action for both compounds requires several weeks, and patients should take other pain-relievers such as NSAIDs in the interim. In addition, diabetic patients taking glucosamine may have an increase in blood sugar levels. Chondroitin appears to have some anti-coagulant activity, and this should be considered in patients taking prescription anticoagulants. Chondroitin is contraindicated in men with prostate cancer since one of its components (versican) is overexpressed in prostate cancer.(13)

Other natural products used in the treatment of osteoarthritis include S-adenosylmethionine (SAMe), capsaicin, avocado/soybean oils, and omega-3 oils. SAMe appears to be effective for symptom reduction. However, it is expensive, and the quality of supplements is highly variable. In addition, SAMe should be avoided in patients who are taking other serotonergic drugs, as well as in patients with bipolar disease. Capsaicin is effective for relieving limb osteoarthritis and other musculoskeletal conditions. Its biggest advantage is that it is topically applied. Avocado/soybean oils appear to be beneficial for osteoarthritis, have no side effects, and can be used along with glucosamine/chondroitin.(13) Omega-3 fatty acids are found in fish and flaxseed oils. There is some evidence that they have anti-inflammatory effects. Although osteoarthritis is not initially an inflammatory disease, many patients do develop an inflammatory component as the disease progresses. Omega-3 fatty acids may have an anti-coagulant effect in high doses (over 3 grams), which should be considered in patients on prescription anti-coagulants.(13,14)

The most common supplements taking to prevent onset or progression of osteoporosis are calcium and vitamin D. However, natural products like soy and ipriflavone are also used. Ipriflavone has the strongest evidence in favor of its use, but its effects are significantly less than those of prescription drugs like bisphosphonates. In addition, ipriflavone may increase the concentration of other drugs by inhibiting cytochrome P450 enzymes, and it can cause lymphocytopenia in some patients.(13)

There is less evidence in favor of increased consumption of soy-based foods for decreasing the risk of osteoporosis. However, soy consumption has multiple other benefits. These include improvement of post-menopausal symptoms and a decreased cholesterol level. In addition, there are no side effects due to eating soy, with the possible exception of women with a history of breast cancer due to phytoestrogens present in soy. In general, natural products like ipriflavone and dietary supplements like soy can be used to help prevent development of osteoporosis. However, women who already have osteoporosis will almost certainly require a prescription drug like a bisphosphonate.(13)

Monday, March 02, 2009

CAM Paper Part V: Acupuncture

Although the practice of acupuncture is commonly associated with traditional Chinese medicine, there is evidence that acupuncture actually dates back several thousand years in the histories of both Eastern and Western medicine. The Chinese conception of acupuncture revolves around the idea of qi, or vital energy. More specifically, traditional Chinese medicine holds that health is a state of balance between two opposing forms of qi called yin and yang. According to this theory, each person inherits a form of qi that circulates throughout 14 meridians (channels) in the body, thereby nourishing and defending it. Diseases are thought to be caused by a disturbance or blockage of qi, which leads to an imbalance of yin and yang. Thus, the purpose of acupuncture is to correct this energy disturbance and bring yin and yang back into balance.(11)

Several theories have been proposed to explain how acupuncture alleviates pain, and there is some evidence in the literature that supports these ideas. Examples include stimulation of A delta fibers in the skin, activation of enkephalin-producing interneurons, release of endorphins, activation of descending pain control pathways, and modulation of the pain control center in the brain. In addition, modern practitioners sometimes associate yin and yang with the sympathetic and parasympathetic divisions of the autonomic nervous system.(11)

Acupuncture involves inserting fine needles into any of 365 specific points on the meridians. (The number of points was chosen to correspond to the number of days in a year.) Needles may be used alone therapeutically, or they may be used along with electrical stimulation, ultrasound, or heat. Conditions that are commonly treated with acupuncture include back pain, myofascial pain, and arthritis. There is some evidence that acupuncture is useful for treating some forms of pain and certain other conditions, including fibromyalgia, nausea and chronic back pain.(11,12) However, other conditions do not appear to be effectively treated with acupuncture, such as headaches.(11)

Despite the existence of multiple studies showing improvement in several conditions after acupuncture treatment, there is a strong possibility that acupuncture is mainly effective due to the placebo effect. The original acupuncture studies showing efficacy were necessarily performed unblinded; that is, both the patient and the acupuncturist knew whether or not the patient had received acupuncture. However, when sham acupuncture is used as a control in acupuncture-naïve patients (a single-blinded design), most studies show no difference in improvement between the groups. Patients who choose to try acupuncture commonly cite the possibility that it will help, curiosity, and their belief that conventional medicine will not help. Thus, it appears that the patient’s beliefs about the effects of acupuncture have a strong effect on their subjective perception of pain.(11)

I was able to observe the importance of patient belief in the effectiveness of acupuncture. Those patients who had the most confidence in the treatment reported the greatest relief of their symptoms. The acupuncturist, a practitioner of traditional Chinese medicine, mainly treated patients suffering from chronic pain conditions such as osteoarthritis. He attributed his patients’ problems to “weakness” in certain organs, especially the liver, kidneys, and heart. Beyond that, the acupuncturist did not really explain the causes of the patient’s problem or how his therapies worked. He did not ever mention concepts such as qi, yin, and yang. In fact, when patients directly asked him how he knew a particular organ was weak, he would respond that his diagnosis was based on prior experience. Essentially, he was asking the patients to trust his judgment without any explanation at all. Unsurprisingly, the more skeptical patients did not benefit as much from their treatments.

Each acupuncture treatment began with an examination of the patient’s energy. If the acupuncturist felt that the patient’s energy was low, he would have the patient go into a special room set aside for raising energy. Here, the patient would be asked to hold a metal bar in each hand. The metal bar was connected to a machine that provided electrical stimulation. The patient would sit holding the bars for several minutes, and would then be moved to another room for the acupuncture treatment. After having the patient lie down, the acupuncturist would insert needles one by one, usually in the patient’s feet, legs, hands, and arms. Some patients also got needles in their ears, forehead, and neck. It was not made clear how the acupuncturist decided where the needles were needed. Finally, the needles were connected to a machine that provided electrical stimulation.

Along with needles, the acupuncturist used several other modalities. For example, he asked one patient whom he diagnosed with a weak heart to take a Chinese herbal remedy that he said would strengthen her heart. The bottle’s label was printed in Chinese, and there was no way for the patient or me to know what was in it. She asked him what it did, but all he would say was that it would help her weak heart. Another patient who was diagnosed with a weak liver was treated with a magnet placed over the right side of her abdomen. The acupuncturist also manipulated this patient’s energy level by passing his hands over her body without touching her. This patient had full faith in the efficacy of acupuncture, and she reported having significant pain relief.

I came away from this experience feeling very skeptical of acupuncture for at least two reasons. First, unlike the chiropractor, the acupuncturist made no pretense of being a physician or using science in his treatments. His diagnoses of weak organs do not have any correspondence with any diseases recognized in Western medicine. Even more discomforting, the acupuncturist made no effort to offer explanations or education. In fact, he discouraged patient questioning by simply saying that he knew what he was doing based on experience. It is possible that this implicit command to just trust him was at least in part a cultural disconnect, but his attitude would probably not be acceptable to many Western patients.