The challenge of rational medicine’s journey from patient- to pathogen-specific

Recently, the New England Journal of Medicine (NEJM) released their 200th anniversary article titled, “Therapeutic Evolution and the Challenge of Rational Medicine,” by Greene et al. [1].  This article gives us a walkthrough of how medicine has evolved in the past 200 years: specifically, from patient-centered in approximately the first century and a half, to pathogen-centered in the last fifty or so years. Traditionally, western doctors had an in-depth knowledge of herbs — and a wide range of (often bizarre) treatments, ranging from the application of the “Devil’s dung” plant to the practice of bloodletting, i.e. “breathing a vein,” to assist in the curing of a disease. While some of these treatments are arguably questionable, specifically the well-versed knowledge of traditional western doctors focused more on the human perspective, and, as a result, may have been a vital ingredient to the overall well-being of the patient. This component appears lost today — where our healers are efficaciously oriented toward targeting a specific pathogen, with very specific aims. This compartmentalization of focus (generating doctors with specific knowledge about specific subjects) leaves patients with any other possible ailments or concerns to hang in the dark. While the light of the brilliant doctor who shines in his specific field of focus may isolate and treat the primary cause of a disease, the flashlight he is shining with on the patient may just as well blind the patient to any other factors just as important that could improve general well-being. The flashlight will of course cast shadows of its own. As the article in NEJM subtly points out, there can be no medicine without both therapeutic enthusiasm and therapeutic skepticism, and skepticism has flourished in the rationale of science ever since the chilling specter emerged from medicines such as thalidomide, Diethylstilbestrol, Vioxx, and Avandia [ibid]. These drugs were developed for specific purposes, i.e. to prevent morning tiredness, to act as an antidiabetic, etc., and while the focus of developing these drugs may have been done through well intention, the outcomes clearly revealed something menacing lurking in the shadows.

“As the locus of disease has narrowed from the afflicted person to the molecular mechanism, and the target of magic bullets has followed suit, physicians have faced regular reminders of the limits of the reductionist approach.” [1]

As we have been endlessly discovering smaller and smaller particles; and smaller and smaller actions that lead to larger reactions, one might wonder if this approach is the best to solely focus on. What may be an additional approach more fitting for our new century?  The Shanghai Center for Systems Biomedicine has released an interesting article titled, “Toward new drugs for the human and non-human cells in people,” by Zhao et al. [2]. This explores the realization that the human body is only sparsely comprised of actual “human” cells. There is in fact a multitude of lifeforms that live within us and work in synergy with our body. For example, our metabolism is aided by lifeforms such as veillonella, bifidobacteria, and lactobacilli. Zhao et al. explain that humans are “superorganisms” due to the fact that we are 10% human cells and 90% microbes (primarily in the intestines).

“‘Super'” in that sense means ‘above and beyond.’ Scientists thus are viewing people as vast ecosystems in which human, bacterial, fungal and other cells interact with each another.” [2]

Therefore, when microbes significantly affect our genetic actions and reactions through gene regulation; i.e. on and off switching, this directly affects our immune response — and thus affects how diseases or disorders manifest. Due to this complexity, scientists realize how the reductionist approach can certainly fail — as all individuals will have a different response to treatment. We are complex beings and thus require complex interventions, and that certainly does not mean we should delve further to find even smaller particles or specialize ourselves even more. We should, on the contrary, seek a more holistic approach. For example, our own nutrition, diets, medications, mental state and physical activity (or lack thereof) completely affect the manifestation of our microbe populations within our bodies — and thus completely affect which genes are expressed and which are not. There is nature just as much as there is nurture.  The so called “functional metagenomics” proposed by Zhao et al. [2] for developing new medicines that affect our microbes (and I say “our” for simplicity, because these organisms work together with us) are showing promise through traditional Chinese medicine  (TCM) — an archaic yet thriving art of medicine that continues to prosper and grow in popularity even among the general scientific community as time passes. In the case of gene-environment reactions, most chronic conditions are involved. Here, Zhao et al. claim the gut microbiome is vital and TCM is tailored to target both the host as well as the synergistic microbes — thus being a holistic medicine, as treatments are not specifically tailored such as the conventional drug approach, which targets in an isolated fashion typical receptors within the “druggable genome.”

It appears that for the next age — moving on from an efficacious, isolated approach in primary care — we are not going back to a patient-centered approach which began in traditional western rational science, but rather a “super organismic” track that attempts to integrate as many human and non-human factors as possible.

References

1. Jeremy A. Greene, M.D., Ph.D., David S. Jones, M.D., Ph.D., and Scott H. Podolsky. M.D. Therapeutic Evolution and the Challenge of Rational Medicine. N Engl J Med 2012; 367:1077-1082. September 20, 2012. DOI: 10.1056/NEJMp1113570

2. Zhao L, Nicholson JK, Lu A, Wang Z, Tang H, Holmes E, Shen J, Zhang X, Li JV,  Lindon JC. Targeting the human genome-microbiome axis for drug discovery: inspirations from global systems biology and traditional Chinese medicine. J Proteome Res. 2012 Jul 6;11(7):3509-19. Epub 2012 Jun 5.

Chronic disease prevention or care: Few of the several benefits of massage

  The benefits of complementary and alternative medicine (CAM) (including massage) are readily apparent and have been shown, for
example, through a systematic review to be safe, efficacious vs. placebo, and cost-effective [1].

Massage is a treatment which has been shown to be efficacious when used on the practitioners themselves [2].
Regarding chronic care, pain was reduced and mood improved for nursing home residents with cancer [3]. Massage is recommended to
be integrated in physical therapy for elderly; especially nowadays with the rising elderly population requiring prevention or treatment of
arthritic conditions [4].  And among a large proportion of veterans experiencing non-cancerous chronic pain, CAM appears to have a
broad appeal after responses indicated that almost all in the study had a willingness to try CAM; with massage being the most preferred
option [5].

Massage thus appears to have a benefit for both practitioners (they need care too!) and patients and is promising for chronic and elderly care. Due to its obvious cost-effectiveness (if you want to scratch out any expensive oils and just consider the most important tool: hands); ability to reduce pain and stress; and even the possibility of preventing or treating inflammation, blockages or arthritic manifestation, massage should be an essential component in general health and should be considered for incorporation into all forms physical therapy wherever possible.

References

1: Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, Gagnier J, Ammendolia C, Dryden T, Doucette S, Skidmore B, Daniel R, Ostermann T, Tsouros S. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine forneck and low-back pain. Evid Based Complement Alternat Med. 2012;2012:953139.

2: Jensen AM, Ramasamy A, Hotek J, Roel B, Riffe D. The Benefits of Giving a Massage on the Mental State of Massage Therapists: A Randomized, ControlledTrial. J Altern Complement Med. 2012 Sep 4.

3: Hodgson NA, Lafferty D. Reflexology versus Swedish Massage to Reduce Physiologic Stress and Pain and Improve Mood in Nursing Home Residents with Cancer: A Pilot Trial. Evid Based Complement Alternat Med. 2012;2012:456897. Epub 2012 Jul 24.

4: Hardt R. [Special features of physical therapy for elderly rheumatic patients]. Z Rheumatol. 2012 Jul;71(5):396-402. German.

5: Denneson LM, Corson K, Dobscha SK. Complementary and alternative medicine use among veterans with chronic noncancer pain. J Rehabil Res Dev. 2011;48(9):1119-28.

Music Therapy: A Chronic Care Paradigm

Could music therapy be used for treatment of chronic conditions? Could it even prevent them from arising? Let us explore.

The biological effects of music therapy through clinical research have been explored before the turn of the century by GR Watkins of University of Illinois at Chicago, USA. In 1997, he both reviewed and confirmed the usefulness of the effects of music therapy on anxiety, blood pressure and heart rate.

Taking into consideration the death tolls from cardiovascular disease — the largest worldly contributor to chronic disease deaths — we need to find ways to maintain a healthy heart. We definitely can – for example – reduce our trans-fatty acids intake, but there are several pieces to the puzzle. Let us see if anything more recent has discovered similar phenomena as was discovered by Watkins.

A meta-analysis in year 2012, conducted by RS Loomba et al., apparently discovered the same phenomena as Watson’s findings, but here they report major effects. They mention the purported effects of music therapy on relieving anxiety and statistically reveal significant decreases both in systolic and diastolic blood pressure as well as heart rate. With these findings, further studies should triangulate these effects of music therapy after being incorporated into chronic disease prevention and chronic care management  programs. Finally, allopathic facilities should aim for integrative care initiatives and involve music therapy as part of holistic treatment — particularly for those who seek complementary or alternative modes of treatment.

References

1: Watkins GR. Music therapy: proposed physiological mechanisms and clinical implications. Clin Nurse Spec. 1997 Mar;11(2):43-50. Review. PubMed PMID: 9233140.
2: Loomba RS, Arora R, Shah PH, Chandrasekar S, Molnar J. Effects of music on systolic blood pressure, diastolic blood pressure, and heart rate: a meta-analysis. Indian Heart J. 2012 May-Jun;64(3):309-13. PubMed PMID: 22664817.

The effects of ginkgo extract on dementia

More than half of the elderly with dementia are over age 80 in high-income countries. Alzheimer’s — a purportedly incurable disease starting with mild memory loss and ending with severe brain damage and death — is the most common form of dementia. Indeed, progress for treating such conditions has not had much haste. Perhaps something is hiding within the alternatives — some formula or combination that may change a dreary caterpillar into a fluttering  butterfly. Antioxidants, Asian ginseng, cat’s claw, ginkgo, and grape seed extract have all been proposed as alternatives for treating Alzheimers and dementia. Let us, for example, focus on the extract from the ginkgo biloba leaf from the ginkgo tree — a unique plant species widely known and particularly respected both for its use in traditional medicine and for its symbolism in China, Korea, and Japan.

In addition to its explored potential effects such as improved blood flow, prevention of oxidative cell damage from free radicals (i.e. “aging”), and prevention of platelet aggregation and blood clotting, ginkgo has been purported to act with nootropic, or memory enhancing, properties. A double-blind, randomized, placebo-controlled study conducted by the National Institute on Aging and the National Center for Complementary and Alternative Medicine (NCCAM), of the National Institutes of Health, USA, found some promising results for ginkgo extract as treatment for dementia. Ginkgo biloba extract in this study was able to show an indication of reduced risk of progression of dementia and a smaller decline in memory when compared to the placebo group. It followed 118 volunteers age 85 or older who used 80 mg of ginkgo extract three times per day over a time period of 42 months.

To conclude, ginkgo extract has large potential for treating dementia, but an evidence base just as large is required. Broad clinical trials must commence to address the effectiveness of this treatment.

References

NCCAM (2012) Alzheimer’s disease and CAM. Retrieved May 9th, 2012, from: http://nccam.nih.gov/health/providers/digest/alzheimers.htm

NCCAM (2012) Pilot study provides new insight on effect of ginkgo extract on dementia in the elderly. Retrieved May 9th, 2012, from: http://nccam.nih.gov/research/results/spotlight/022608.htm

Country case for chronic disease: Japan and its staggeringly low cardiovascular death rates

(Yoshikazu Tsuno/AFP/Getty Images)

“Noncommunicable diseases (NCDs), primarily cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, are responsible for 63% of all deaths worldwide (36 million out of 57 million global deaths)” – World Health Organization, 2011

Noncommunicable diseases – also referred to as chronic diseases – remain the number one global cause of deaths worldwide and cardiovascular disease (CVD) or heart disease remains at the top of the pedestal. Chronic diseases significantly concern the elderly, as 75% of 36 million global deaths attributable to chronic disease occurred beyond age 60 in 2011. In this report, we must highlight Japan – the country with the highest average elderly age yet the lowest cases of heart disease.

As early as 1981, Professor Geoffrey Rose of Epidemiology wrote an article in the British Medical Journal about taking the action of preventing CVD. He showed staggeringly low numbers of how Japan in 1968 had just over 100 deaths per 100,000 population attributable to coronary heart disease (CHD), whereas before the United States was able to drop their rates considerably over time, in 1968 they had the highest number – with over 800 deaths per 100,000 population. Sweden was around the middle, with approximately 450 deaths per 100,000 population. Further, Rose adds, “The Japanese owe their low rates not to their genes but to their way of life: when they move to America they rather quickly acquire American rates.” In addition to affirming Japan’s low death ratio, the United States and Australia had shown drops of 25% till year 1977, indicating that therapeutic advancements and prevention strategies can considerably reduce the deaths from CHD – which represent approximately half of CVD deaths (Iso, 2008). Japan has been able to keep their low CHD death ratio similar with a slight drop till 1977 (Rose, 1981) and has considerably dropped further – with over a 50% drop from this time frame to year 2000, having now around 37 deaths per 100,000 population (Iso, 2008). Dr. Hiroyasu Iso of Social and Environmental Medicine wrote in the Journal of the American Heart Association that Japan still has the lowest CHD ratio of high-income countries – between one-third and one-fifth that of the United States.

The decline of CHD deaths in Japan is attributable to the decline of mean systolic blood pressure levels and the prevalence of smoking. However, an issue is arising with a high prevalence of western fast-food diets increasing the mean serum total cholesterol and triglyceride levels (Iso, 2008). It is curious as to how Japan started with such a low ratio of deaths from CHD, and as we have heard from Professor Rose, it is due to their lifestyle. Is this lifestyle perhaps significantly affected by the practice of Complementary and Alternative Medicine (CAM) or Traditional Medicine (TM) involving the use of exercise, herbs, or other techniques? In order to explain a counterbalance for a high-fat-intake diet, I recommend collaboration with a national research organization such as the Japan Society of Oriental Medicine to investigate how the effects of Japanese Traditional Medicine, i.e. Kampo, derived from Chinese Traditional Medicine might be attributable to the low incidence of CHD deaths in Japan.

According to Dr. Johan von Schreeb of Karolinska Institute’s Public Health Sciences, approximately 1/3^rd of Japan’s population is over age 60 and the country has the highest average aged population in the world – leading with 84 as the mean age of life expectancy. Prevention of chronic diseases is on the forefront of today’s world, with so many medical advances leading not only high-income countries but countries all over the world to jolt up in life expectancy. And as life expectancy rises, so does the demand for prevention of chronic disease. Is there a golden formula somewhere out in the Far East that could face this issue? As the country with the leading population of elders, perhaps there really is something about Japan that the world could need.

References

The Epoch Times. Image Retrieved April 4th, 2012: http://www.theepochtimes.com/n2/world/40000-japanese-aged-100-over-survey-says-22351.html

World Health Organization. 10 FACTS ON NONCOMMUNICABLE DISEASES. September 2011. Retrieved March 29th, 2012: http://www.who.int/features/factfiles/noncommunicable_diseases/facts/en/index.html

Schreeb, Johan von. Lecture on Disasters & Relief. January, 2012. Karolinska Institutet, Solna, Stockholm. IHCAR Department of Public Health Sciences.

Hiroyasu, Iso. 2008. Changesin Coronary Heart Disease Risk Among Japanese. Journal of the American Heart Association 118:2725-2729.

Rose, Geoffrey. 1981. Strategy of prevention: lessons from cardiovascular disease. British Medical Journal 282:1847-1851.

Time to spin the wheel: A call for integrative medicine initiatives

With the push of Dr. Andrew Weil of the US — establisher of the field of integrative medicine (IM) — we need to move from a system of mere disease management to one that keeps people healthy, and, importantly, to have them stay that way. Deterioration of health only implies more work for those whom are part of care. If the elderly, for example, are able to take better care of themselves in this coming age, exhaustive effort will not be required for the dwindling amount of elderly care providers in contrast to the rising elderly population. There may quite be something to be found from a holistic perspective. One can, for example, take an antibiotic that rids away a pathogen, but it can very well come back again with a biological system somehow suppressed. What problem caused the initial unbalance from homeostasis? Was it the pathogen that was the primary problem, or rather, did it take advantage of a weakened system hindered by a certain state of psychology, mental/physical stress, and/or inadequate nutrition?

The path to finding the answer is a complex one. However, as IM uses so many perspectives and does not centralize treatment, this scientific, holistic process aims for both treating a condition and preventing it from arising again. This includes not only treating individuals by getting as deep as the bones of their body — in other words, physically — but to affect the whole core of their consciousness and unconsciousness — mentally and, arguably, spiritually. As several unconventional modes of treatment are spiritual, the very thought of integrating them into science brings up a vast dilemma. To even utter the word “spiritual” in the common scientific community is to be met as a black sheep, and thus, blunt skepticism has always been the barrier to the emergence of IM. The importance behind this is to understand the science behind the spirituality and to translate that language into what may be more “proper” to say. What an energy medicine practitioner might call the person’s “aura” may very well be the same thing as that person’s electro-photonic vibration response or “energy field,” present in all life forms. Methods to see this bio-electric field have been present now for over three-quarters of a century, starting with the Russian inventor, Kirlian; with more reliable adaptations present through Dr. Korotkov. It has been purportedly discovered in the late 90’s (see here, page 7) — not of course revealed through conventional science — that this bio-field appears to express our condition of health and went even so far as to diagnose patients based on their bio-field expression as based on the color and shape of the phenomena. This has also been purported by Dr. Ignatov of Bulgaria, whom has revealed highly controversial results regarding the bio-field phenomena of energy medicine practitioners.

With such a deep delving down into the rabbit hole and due to the way health care can be radically changed as a result, it can be understandable why IM has not been explored conventionally. However, this borders on ignorance, and the hindrance in exploring the mysteries of “those other treatments” is truly, at heart, unscientific. It is the heart of science to constantly explore the unknown; to challenge, test, or alter existing theories, and to aim for the discovery of those more universal. There is surely a lack of this regarding IM. For example, the National Institute of Complementary Medicine in Australia states,

Notwithstanding these factors, there is no current profile on integrated care initiatives; compendiums of examples and their benefits or information collected on a regularised and agreed basis to enable trends to be monitored and comparisions of health and cost benefits to be made.   Yet this information is required to inform future research choices and priorities as well as clinical practice.

Henceforth, with already-present tools available to quantify holistic treatment, a call should be sent forth to researchers and policy- and decision-makers in healthcare to create initiatives for researching and promulgating an evidence base to evaluate the effectiveness of integrative care.

References

Integrative medicine
http://www.relaxedpolitics.com/2009/08/integrative-or-holistic-medicine-the-future-of-health-care-a-debate/

Kirlian photography (Korotkov)
http://kirlianresearch.com/

More advanced stages of Kirlian photography and discoveries (Korotkov)
http://thiaoouba.com/choice.pdf

More discoveries from Kirlian photography (Ignatov)
http://www.reikiprofessionals.com/uploads/First_results.pdf

National Institute of Complementary Medicine
http://www.nicm.edu.au/content/view/59/57/

Massage and Acupuncture: Application of the Science of Touch

        

Hands can make tools, and hands can be tools themselves.

When one really takes time to think about it, hands are incredible. The science of touch is a rarely discussed topic, primarily due to the sensitivity the topic entails when taking some cultural and social norms into consideration. But the fact is, without touch, we would not be here. It is proven that babies do not develop properly if they do not have skin contact. Apparently, touch is required as a triggering mechanism for promulgation of brain activity, emotional response, as well as the immune system.The touch of a newborn baby’s hand forms tears in the eyes, and the touch of an elder’s hand cannot help but make one think of the wisdom one can learn of the world. The touch of hands have incredible potential. Just as they have let us discover fire, craft tools, and even use smartphones, they have been used in treatment for as long as history can recall.

Two such forms of the application of hands for treatment include massage and acupuncture. While massage involves direct skin contact through the hands, guided by fluid movements, acupuncture involves the intuition of the hands to gently guide needle tools serving as extensions of the hands — affecting meridians of the body that are stimulated through touch. Without the needle tools, this is known as acupressure.

According to the American News Report, studies have shown that, for massage, treatment is effective for treating pain regarding inflammation after exercise (reducing inflammation of acutely damaged skeletal muscle), osteoarthritis knee pain (pain reduction), chronic low back pain (significant pain reduction), and fibromyalgia (pain reduction and improved quality of life). Exhaustive amounts of studies exist for acupuncture, and publications from the China Academy of Chinese Medical Sciences revealed, for example, the potential of acupuncture treatment for depression as well as chronic fatigue syndrome (CFS). Regarding CFS, acupuncture has shown to significantly improve quality of life.

These are just two methods of the science of touch, but this is an almost endless avenue to explore. Ready for an adventure? The skies are the limits… but not for the hands. Hands built space programs.

Hands are incredible.

__________

References

Greenville Hospital System. The Magic Hour. Retrieved May 24th, 2012 from: http://www.ghswomens.org/the-magic-hour.php

American News Report. Studies Show Massage Relieves Chronic Pain. Retrieved May 24th, 2012 from:
http://americannewsreport.com/studies-show-massage-relieves-chronic-pain-8814326.html

PubMed. Development of studies on on neurochemical mechanism of acupuncture underlying improvement of depression. Retrieved May 24th, 2012 from: http://www.ncbi.nlm.nih.gov/pubmed/22073894

PubMed. A meta analysis on randomized controlled trials of acupuncture treatment of chronic fatigue syndrome. Retrieved May 24th, 2012 from: http://www.ncbi.nlm.nih.gov/pubmed/20209981

PubMed. Randomized controlled study on influence of acupuncture for life quality of patients with chronic fatigue syndrome. Retrieved May 24th, 2012 from: http://www.ncbi.nlm.nih.gov/pubmed/19873911