Psoriasis: A new perspective

 

Traditional Chinese Medicine avers that for a patient to become completely healed, the doctor must treat the ben or root problem. If he/she treats only the biao (external manifestation of the root problem) the patient might improve temporarily but not be completely healed.

In the Allergy Research Group newsletter, Focus, an article entitled “Is Psoriasis a Bowel Disease”, raises the question, is psoriases only a skin disease or is the root problem intestinal? Dr. Haines Ely is a clinical professor of dermatology at U. C. Davis. His premise is that the origin of psoriasis is dysbiosis of the gut, and that abnormal bacterial endotoxins leak from the gut into the bloodstream causing the inflammatory reactions in psoriatic patients.

He first arrived at this explanation when he observed similarities between psoriasis patients and patients who underwent gastric bypass surgery who had complications of flu-like symptoms, arthralgia (joint pains), and skin lesions. Both groups had high antibodies to peptidoglycan, found in bacterial cell wall. They stimulate immune cells and induce inflammation. Both groups also had non-alcoholic fatty liver disease (NAFLD), often associated with gut dysbiosis. Both groups also had decreased levels of bile acids.

Dr. Ely treats psoriatic patients with a five-pronged approach.

  • Diagnose and treat abnormal gut bacteria
  • Break up bacterial endotoxins with bile acids- this will prevent the release of cytokines causing inflammation
  • Dietary control: avoid hot spices and alcohol and eat high fiber, low fat foods such as vegetables and fruits
  • Inhibit absorption of endotoxins produced by the abnormal gut bacteria with bioflavanoids, e.g. quercetin
  • Heal the liver. In this condition, the liver is overwhelmed by endotoxins and peptidoglycans from the gut. silymarin present in milk thistle seeds can heal the liver.

According to Dr. Ely, the current approach to treating psoriasis is directed at suppressing cytokines without addressing what is stimulating cytokine production causing inflammation. In other words, it is , in TCM terms, treating the biao (external manifestation) without treating the ben .(root problem).

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Lasik Surgery: Some Precautions

 

Lasik stands for laser in situ keratomileusis. It is touted to give you perfect vision and eliminate the need for wearing glasses or contact lenses. The procedure involves cutting (with laser) a flap on ones cornea, lifting it up, removing some underlying tissue from the stroma (underlayer) of the cornea to flatten it, and replacing the flap, which should stay in place and heal. A successful surgery would give you 20/20 vision in a matter of days. Sounds great, but here are some potential negatives.

Potential Complications

  • dry eyes
  • glare, halo effect, or double vision
  • decreased vision in dim lighting
  • astigmatism
  • problems with flap: infection, tearing, poor healing
  • under- or over-correction
  • vision loss
  • corneal ectasia- cornea becomes thicker than before

You are not a good candidate if you have any of the following:

  • severe myopia or hyperopia (near-sighted or far-sighted)
  • depression or chronic pain conditions, e.g. fibromyalgia, migraine headaches, irritable bowel syndrome (these seem to be correlated with a higher incidence of post-op pain and dry eyes)
  • autoimmune disease
  • dry eyes
  • keratoconus (or if it runs in your family)
  • unstable vision from medication, hormonal changes, age, etc.
  • keratitis, uveitis, herpes simplex involving the eyes, glaucoma, cataracts
  • large pupils
  • presbyopia
  • engage in contact sports involving blows to the face

Glasses might still be needed in your future

  • if you are middle age and have presbyopia, where the lens is no longer so flexible, you may require reading glasses
  • if you are old and need cataract surgery, the altered corneal surface might make it difficult to accurately measure for intraocular lens for implant.

While there might be much hype about the benefits of lasik, one must consider the risks and that the benefits are time limited.

The Opioid Epidemic

 

Those who cannot remember the past are condemned to repeat it.

George Santayana

There has been a multitude of public discourse about America’s opioid epidemic, but little mention is made of how it evolved. If we do not heed history, we risk repeating it. A recent 60 minute segment on the subject covered how an FDA whistle blower exposed the failure of FDA to enforce regulations on the supply and distribution of narcotics to retailers such as pharmacies. This is downstream to the epidemic, no mention is made of how the demand for the drugs skyrocketed in the last 20 years. The upstream cause is the change in the prescribing habits of physicians. In a previous blog dated 6/1/17, I alluded to the set of circumstances that might have led to the practice of over-prescribing opioids by American physicians.

  • litigation- large lawsuits against those who underprescribed  pain medication for terminally ill patients
  •  legislation- In California, physicians, in order to renew their licenses  were required to take training in “pain  management”, which advocated liberal use of narcotics for not just terminal cancer pain, but all pain.  Pain laws  laws promoting generous use of opioids without regard to their real risk of addiction have been passed in many states and have yet to be rescinded.

Now, I discovered,an addition to the list is the pharmaceutical industry’s intentional campaign to promote opioid prescribing and use.

Big Pharma’s Campaign of Misinformation

To The Prescribing Physician: Opiods are safe

  •  A recent article entitled Smoke ’em Out, in Bloomberg Business Week uncovers who really fueled the opioid movement.  It recounts how Purdue, the maker of Oxycontin embarked on a campaign through industry-funded experts, pamphlets, online publications and medical educational programs as well as direct sales representative marketing, to intentionally mislead physicians as to the safety of their product. In the past, Oxycontin was prescribed for postoperative patients and terminal cancer patients, a relatively small market. With intensive marketing, and selling the notion that ordinary backaches, headaches and arthritis needed treatment with opioids, sales for Oxycontin rose from $45 million in 1996 to over $1.5 billion in 2002.

To The General Public:  Pain is a Disease Entity.

I often hear people say, “ I am a chronic pain patient,” and they seem very satisfied that their medical problem has been “diagnosed.” Pain is a symptom, not a disease. The cause can be inflammation, ischemia (poor blood supply), muscle spasm, or a space occupying lesion. Treatment should be directed at the cause, not the symptom. If one treats the symptom only, it would mean an endless dependence on the symptom- relieving drug, and that is how the epidemic evolved. It has become very profitable for the pharmaceutical industry but a disaster for society.

Solutions

Lawsuits against large pharmaceutical companies are warranted and may help against this “war on addiction,” but the misinformation that Big Pharma has promulgated needs to be reversed by correct information.

Training– the experts on addiction, recommend that doctors should be trained in the addictive properties of opioids. While that is a valuable first step, it offers little to address the problem of chronic pain, when opioids or other drugs are the only option doctors know. Somehow they need to be trained to recognize the efficacy of non-drug methods of treatment. The most common conditions now being over-treated with opioids- back pain, headaches, and arthritis, involving the musculoskeletal system, can be successfully treated without drugs. This information has not been widely publicized because there is no profit incentive to do so. Very little is taught in medical schools about the musculoskeletal system. Most primary doctors, when confronted with musculoskeletal pain, send the patient for imaging, or refer them to an orthopedist or physical therapist , and prescribe pain medication. Most of the conditions involve soft tissue: ligaments, discs, tendons, not bones. Most can be treated with acupuncture, acupressure and other physical modalities. We can learn from the Canadian medical system. Physcial therapists, who are the most informed about the musculoskeletal system, are, in Canada, allowed to perform acupuncture, whereas in the United States, they are not allowed to insert needles. If we adopt the Canadian system, it would greatly expedite treating these cases. Short of that, at least we can educate the medical community that non-drug treatments are effective and far safer than opioids.

Rehabilitation

Most addiction experts point to the need of placement in rehab centers and treatment with drugs such as Methadone, Suboxone, and Naltrexone. The program is enormously expensive and may entail ongoing need for drugs. Little mention has been made about acupuncture, a safe, inexpensive form of treatment for addiction. This method was discovered in 1972 by Dr. Wen in Hong Kong. In 1977, the method was adopted by the Lincoln Clinic in New York City as part of their detoxification program. In 1985 , the National Acupuncture Detoxification Association (NADA) protocol, using  acupuncture points on the ear was adopted in the U.S., and many rehabilitation facilities have been able to train staff to administer it. The treatment is inexpensive, free of side effects, and can be done in an outpatient setting. Research shows that acupuncture when used as adjunctive therapy to Methadone enables  lowering the dosage of Methadone required.

The epidemic is serious and requires more scrutiny than what has so far been shared with the public.

Questions to ask before an MRI

With the known advantages  of advanced imaging techniques,  often doctors can be  glib about ordering CT scans and MRI’s. With CT scans, most patients know of the danger of ionizing radiation, and many pro-active patients know to ask, “Is it absolutely necessary?” The following question might be, “How about doing an MRI instead?” With new knowledge about the complications of contrast material injected for an MRI, additional questions should be,”Are you going to use Gadolineum contrast material? Is it absolutely necessary?”

Gadolineum Based Contrast Agents (GBCA) Use

Gadolineum is a heavy metal injected into the bloodstream in the form of a dye which enhances the images obtained in an MRI. This enhancement helps the radiologist visualize tumors, inflammation, and blood vessels better. It is used in 40-50% of all MRI’s performed in the U.S. It is usually not needed when imaging bones and joints.

Unintended Consequences:Post Injection GBCA Tissue and Organ Deposits

After injection, the metal is eliminated by the kidney, but even when kidney function is normal, some of it does remain deposited in various tissues and organs, including the brain, bone, and skin. There are two types of chemical structures for gadolineum: linear and macrocyclic. Of the two, the linear type seems to be more readily deposited in the brain than the macrocyclic.

Nephrogenic Systemic Fibrosis

We have known since about 2006 that these deposits occur. Do they cause any adverse effects? So far, the only condition that is known is a rare one called Nephrogenic Systemic Fibrosis (NSF). Initially it was thought that the metal deposited in the skin causes fibrosis which impedes joints from normal movement. Later, it has been found that fibrosis can occur in other organs as well. There is no known effective treatment. Mortality is about 30%. The triad of risk factors for NSF are:

  • Impaired Kidney Function (NSF occurs in 4% of cases where there is this risk factor)
  • GBCA injection (onset of NSF can be delayed up to about 6 months)
  • Conditions that lead to inflammation: infection, trauma, thrombosis, malignancy, recent surgery, especially liver transplantation

What happens to the deposits in the brain? Up to now, 2017, there have been no known adverse effects but research on rats with GBCA deposits in the brain are ongoing.

This information is is yet another reminder of the need to use caution whenever performing any kind of procedure. It is also a call to patients to become more pro-active in asking questions before undergoing a procedure.

Contact Sports and the Brain

In general, our society has shown great diligence in pursuing prevention of many serious diseases such as diabetes mellitus, cardiovascular disease, cancer, and infectious diseases. We adhere to diet, exercise, early monitoring, vaccination schedules and use of lipid lowering drugs. There is one preventable condition, however, that we have been slow to recognize. That is Chronic Traumatic Encephalopathy (CTE). It is the delayed result of multiple traumatic brain injuries, commonly known as concussions. A prime example would be the Parkinson’s Disease suffered by the great heavyweight champion, Muhammed Ali.

Symptoms and Signs

  • cognitive impairment
  • short term memory loss
  • emotional instability: depression, impulsive behavior, irritability, aggression suicidal and even homicidal tendencies,
  • speech and motor impairment
  • related conditions are Alzheimer’s disease, Amyotrophic Lateral Sclerosis, Parkinsonism, Fronto-temporal Degeneration

Diagnosis- clinical signs can point to it but the diagnosis is established only at autopsy. Findings are:

  • brain atrophy- decrease in weight
  • neuronal loss (decrease in number of cells)
  • Tau deposits

Disease Process-CTE is thecumulative result of multiple traumatic brain injuries which may not necessarily involve a direct blow to the head. The brain sits in fluid in the skull. Any force which may cause the brain to abut against the skull, commonly acceleration-deceleration in nature, occurring in any number of contact sports, can cause injury to brain cells. The cell wall can be disrupted and leak out some of its content, which may explain the presence of Tau deposits. The axons, or fibers that interconnect brain cells can also be stretched, torn and injured as well.

Risk factors:

  • developing brain- the brain is not mature until age of 25, making children and young adults vulnerable
  • female- women are more vulnerable

Activities that increase risk

  • Boxers and football players-In a report in 2009 of 47 cases proven by autopsy to have CTE, 90% were in athletes, 85% boxers and 11% football players whose careers lasted 14-23 years
  • Other high impact sports include ice hockey and soccer, also victims of domestic violence are at risk

Prevention

  1. Avoid sports that involve repeated concussions: Boxing is at the top of the list since the object of the sport is to cause traumatic brain injury to the opponent. Football is a close second.
  2. Improve Concussion Monitoring
    • When to quit the sport- it has been established that a total of 3 concussions increases the risk of long term neuro-cognitive deficit. This recommendation probably is not stringent enough. Any concussion should be regarded seriously. Studies have shown that there is some brain shrinkage among football players who have not even been diagnosed with concussion.
    • When to return to the game- this is an area still being researched. Pre-concussion baseline tests of brain function should be done on all athletes. There is an online program called XLNT Brain (xlntbrain.comthat enables athletes, coaches, and parents to evaluate concussions.

Chronic Traumatic Encephalopathy is a relatively new discovery that should awaken us to some real risks involved in some of our most revered national pastimes. We need to weigh the risk as well as the benefits of sports such as boxing and football.

The Marijuana Controversy

At present, 26 states and District of Columbia have legalized marijuana. The topic is fraught with controversy. Proponents tout the benefits without paying attention to the risks of widely available marijuana. Opponents raise warnings about the risks without recognizing the benefits. In medicine, we must always consider the risks as well as the benefits of any treatment in light of specific circumstances.

Cannabis sativa is a plant containing 483 compounds. Besides the most well recognized, form, delta 9 tetrahydrocannabinoid (THC) with mind-altering effects, there is cannabinol (CBD) without mind-altering effects. Cannabinol (CBD) has been tested to treat childhood epilepsy. Sometimes they are used separately and other times in combination. FDA has approved two drugs: Dronabinol and Nabilopne, both containing THC and CBD. They are being studied for effects on nausea and anorexia.

Medical Uses

Neurological Disorders: the following conditions respond to Cannabis

  • neuropathic pain- common in HIV/AIDS, and a side effect of cancer chemotherapy
  • childhood epilepsy
  • spasticity of multiple sclerosis- cannabis seems to diminish the patients perception of spasticity and urinary frequency

Glaucoma– while Cannabis does lower the intraocular pressure, the benefit for glaucoma is limited because of several factors: concomitant lowering of blood flow to the eye, short duration of action requiring extremely frequent applications, and development of resistance to the drug

Cancer- Cannabis potentiates the cancer-killing effect of radiation therapy
Pain– Cannabis has analgesic properties that seem to be synergistic with opiods. The positive outcomes are that for cancer patients, the dosing for opioids can be lowered. Incidentally, where marijuana use has increased because of legalization, heroin use seems to be dropping.

Nausea and Anorexia– so far, there are conflicting reports on the efficacy of Cannabis for these conditions

Risks

There are cannabinoid receptors in the brain (Cb1 receptors) and other organs (Cb 2 receptors) Side effects therefore involve multiple organ systems

Mental State:

  • altered senses (heightened color perception)
  • altered sense of time
  • altered mood
  • paranoia
  • impaired body movement
  • altered cognitive functions: impaired problem solving, verbal, and math skills, impaired memory

Especially vulnerable are developing brains, e.g. adolescent brains (which do not reach maturity until about 22 years). During pregnancy, a mother who smoked marijuana can transmit these impairments to her baby. Cannabis can also be passed to baby through breast milk.

  • psychosis- there is a link between cannabis use and schizophrenia (for individuals predisposed to schizophrenia, cannabis use can precipitate its onset), depression, and suicidal ideation

Respiratory– smoking marijuana entails more tar deposited in the respiratory tract than cigarettes resulting in chronic bronchitis. It is not yet known to cause COPD. Second hand smoke may affect vulnerable individuals like asthmatics, but not a normal person unless smoking occurs in an extremely enclosed area.

Heart– marijuana causes tachycardia (rapid heart beat) and increases the risk of heart attacks after the first sixty minutes of smoking

Endocrine– associated with infertility

Social

  • increased school drop-out rate
  • increased absence from job, accident and injury rate

Addiction

  • 10-30% of users will become addicted
  • association with use of other addictive chemicals, e.g. alcohol and tobacco. It has not been associated with subsequent use of harder drugs

Considering the above, so far we can conclude that cannabis does offer benefits mainly for some neurological conditions like childhood epilepsy and multiple sclerosis and for pain control because of its synergistic effects with opioids. These conditions involve specific segments of the population. When possible, the non- THC cannabinoid, if effective, should be the treatment chosen. But for the healthy young adolescent, who use cannabis for its psycho-active component, the risks far outweigh any benefit. Since it is legalized in so many states, there should be regulations on its sale as there are for tobacco and alcohol.

These are our current societal problems

  • opioid addiction epidemic
  • motor vehicle fatalities from impaired drivers
  • homelessness
  • dismal world scholastic ranking (in math, we rank 25th out of 34 nations)

Unregulated widespread use of marijuana can only make them worse.

Our Toxic Environment

 

All progress is precarious, and a solution of one problem brings us face to face with another problem”  Martin Luther King Jr.

In the 1967 classic motion picture, The Graduate, a family friend , Mr. Mc Guire, told Ben, the new college graduate, “I want to say one word to you. Plastics. There is a great future in plastics.”

It is now 50 years later, and we are realizing the havoc that plastics, along with other synthetics have caused.

Problems

At the pump

  • Lead- since the 1970’s it has been phased out of gasoline, and no longer present since 1996
  • Benzene- still present in gasoline. The advice is to avoid topping off, and when pumping gas, stand upwind from the nozzle.

Outdoors

  • Insect Repellent- those containing DEET which is a central nervous system depressant
  • Various Pesticides
  • Plastic bags are invading the oceans and harming sea life

At the Beauty Salon

  • Nail products: plasticizers contain phthalate, harmful to the endocrine system and reproductive organs of fetuses, readily transmitted through the placenta from mother to fetus. Toluene a solvent for polish remover, Artificial nails- ethyl methacrylate- can cause eye and skin irritation and dizziness

At Home

  • Volatile Organic Compounds (VOC)- in paint and glue used for flooring or wood furniture, e.g. formaldehyde in particle board
  • Brominated Flame Retardant- found in foam products sold before 2005. Present in most mattresses, carpet pads, couches (in California, all couches were made with these chemicals until 2014 when the standard changed)
  • Lead- used in paints of homes built before1978
  • Chloroform- is byproduct of chlorine in water mixed with organic matter
  • Dioxin – in many household cleaning products
  • Plastic containers and tin cans – Bisphenol A (found in lining of tin cans) and Polyvinyl Chloride (indicated by recycle code 3 or V on bottom of plastic container)
  • Phthalates- in air fresheners, personal care products such as lotions, conditioners
  • Paraffin- in candles, when burned releases carcinogens. Also, scented candles can contain lead

In Food

  • Mercury- found in tuna, king mackerel, tile fish, sword fish, shark, orange roughy, marlen, white albacore
  • Volatile compounds concentrate in the fat of red mead and poultry
  • Pesticides- the dirty dozen are foods with heavy concentrations if not grown organically: apples, celery, collard green, U.S. grown blueberries, grapes (imported), bell pepper, kale, lettuce, nectarines, peaches, potatoes, strawberries, spinach

Practical Measures -A lot has to do with avoidance

  • For home improvement, look for VOC free and water based products
  • For upholstered furniture, select “flame-retardant-free”
  • Avoid dry cleaning clothes
  • Avoid using teflon or scotch guard cookware
  • Avoid canned foods and beverages
  • Avoid heating foods with plastic containers
  • Use non-toxic personal products and household cleaners
  • Wet mop and dust floors and furniture
  • Remove shoes when entering the house to avoid spreading outside toxics indoors
  • Choose foods keeping in mind how they are affected by toxics
  • Acquire some indoor plants to absorb CO2 and emit oxygen

Progress comes with a price. Indeed, Dr. King’s words ring true.