Medicinas alternativas

#Suplementos suspeitos: #medicamentos vendidos sem receita podem causar #lesão hepática

Postado em

Os riscos dos suplementos de ervas e dietéticos

Diante de novos estudos que relatam toxicidade hepática e lesões hepáticas agudas devido a um espectro em expansão de drogas e produtos à base de ervas, fica cada vez mais claro que os suplementos dietéticos não regulamentados representam um risco para os consumidores.

Ingredientes não rotulados em vários compostos podem causar lesão hepática, especialmente em produtos para musculação ou perda de peso. Esses suplementos não são regulados pelo mesmo processo utilizado para medicamentos, e não são testados quanto à segurança. Além disso, o conteúdo desses produtos não regulamentados é muitas vezes desconhecido para o paciente.

Várias apresentações no Liver Meeting deste ano serviram para destacar a incidência, aumentar o conhecimento, e definir o risco dessas potenciais toxinas hepáticas.

Salvo um requerimento para fiscalização e aprovação pela US Food and Drug Administration (FDA) os suplementos dietéticos e à base de ervas podem ser rotulados incorretamente ou conter ingredientes não rotulados, como contaminantes químicos e microbianos, adulterantes farmacêuticos ou outros compostos com potencial de toxicidade hepática conhecido.

Navarro e colegas[1] analisaram os conteúdos e determinaram a frequência de rotulagem incorreta em mais de 340 amostras de suplementos coletadas em um estudo prospectivo conduzido pela Drug-Induced Liver Injury Network (DILIN) ao longo dos 12 anos de existência do grupo. A rede documentou a lesão hepática induzida por drogas (LHID) em aproximadamente 1800 pacientes, dos quais 375 relataram ingerir suplementos dietéticos fornecendo amostras para análise. Os ingredientes de cada produto, conforme determinado por análise química (cromatografia líquida e espectrometria de massa), foram comparados com os ingredientes listados na embalagem do produto.

A rotulagem incorreta foi detectada com frequência; na verdade, apenas 44% dos suplementos tinham rótulos que refletiam com precisão os conteúdos detectados. Além disso, foi observado que os produtos continham toxinas hepáticas, tais como esteroides anabolizantes ou farmacêuticos.

Os autores relataram que as taxas de rotulagem incorreta foram de 80% para produtos esteroides, 54% para suplementos vitamínicos e 48% para ingredientes botânicos. Com base no uso proposto, as taxas de rotulagem errada foram mais comuns para os produtos utilizados para musculação (79%), perda de peso (72%), “aumento de energia” (60%) e saúde geral e bem-estar (51%). Os pesquisadores da DILIN encontraram taxas semelhantes de rotulagem incorreta para os produtos considerados responsáveis pela lesão hepática por meio de um processo estruturado de avaliação de causalidade (o método de avaliação da causalidade Roussel Uclaf, RUCAM).

Lesão hepática por suplementos ayurvédicos e à base de ervas

Em um estudo realizado em Kochi, na Índia, 1440 pacientes durante um período de um ano foram considerados pelo RUCAM como tendo lesão hepática persistente devido à ingestão de suplementos ayurvédicos e de ervas.[2] O uso mais comum desses suplementos foi para tratamento de dispepsia/sensação distensão abdominal (30%) e para aumento do apetite (22%). Destaca-se que 33% das pessoas afetadas consumiram esses produtos conforme prescrito por curandeiros tradicionais não regulamentados.

Fadiga, anorexia e icterícia foram observadas no início da doença em 96% dos pacientes, prurido em 44%, e febre em 30%. Encefalopatia hepática foi detectada na admissão em 30%, ascite em 37% e auto-anticorpos positivos em 37%. Seis pacientes morreram (22%), incluindo um pós-transplante.

Na biópsia ou autópsia, os autores observaram padrões hepatocelulares, colestáticos e mistos em 60%, 7% e 33% dos pacientes, respectivamente; os pesquisadores observaram especificamente inflamação lobular/portal em 74%, hepatite de interface em 60%, necrose em 52%, fibrose em 67% (cirrose em 22%) e colestase em 63%. Idade avançada, razão internacional normalizada (RNI) mais elevada e níveis mais baixos de albumina sérica de base, bem como a presença de necrose e esteatose na biópsia, predisseram mortalidade na ausência de cirrose.

Philips e colaboradores[3] realizaram uma análise química e toxicológica de amostras de drogas ayurvédicas e à base de ervas obtidas de um subconjunto desses pacientes. Eles analisaram especificamente o conteúdo de metais pesados e procuraram compostos orgânicos hepatotóxicos voláteis. A análise química completa revelou arsênio em 58% das amostras sólidas, cádmio em 36%, mercúrio em 64%, chumbo em 73% e antimônio em 9%. O conteúdo de arsênio foi significativamente associado à mortalidade. Também foram detectados pentano (71%), ciclopentano (59%), ciclobutano (35%) e dimetilamina (24%).

Essas observações indicam que os suplementos ayurvédicos e de ervas aprovados e tradicionais podem causar diferentes graus de lesão hepática. Esses compostos podem conter um alto teor de vários metais pesados e compostos orgânicos voláteis. O consumo desses produtos, que muitas vezes foram obtidos de curandeiros tradicionais não regulamentados e não registrados, pode levar a toxicidade hepática e mortalidade graves.

Embora a identificação clínica de pacientes em risco possa agilizar o tratamento definitivo e, possivelmente, o transplante hepático em tempo hábil, a prevenção pela conscientização, e políticas reguladoras mais rígidas, poderiam reduzir a lesão hepática e evitar o transplante hepático.

LHID em crianças

As causas e desfechos da LHID em crianças não são bem estabelecidos ou previsíveis.

DiPaola e colaboradores[4] analisaram as características de apresentação, etiologias e desfechos de crianças com lesões suspeitas que foram inscritas em estudos da DILIN. Eles analisaram todos os casos (n = 69) que envolveram crianças menores de 18 anos com suspeita de LHID que foram inscritas ao longo de um período de 12 anos. Dos 57 casos considerados como LHID por meio de opinião consenso de especialistas (RUCAM), 14 foram considerados LHID definitiva, 30 como LHID altamente provável e 13 como LHID provável. Esses casos constituíram o grupo de estudo.

A duração mediana da terapia medicamentosa foi de 140 dias (intervalo, 5-569 dias). No início, o nível sérico médio de alanina aminotransferase foi de 411 U/L, com fosfatase alcalina de 203 U/L e bilirrubina total de 3,3 mg/dl. Os pesquisadores registraram características imunoalérgicas como febre (37%), lesões cutâneas (25%), e eosinofilia periférica (15%). Os antimicrobianos foram os agentes mais frequentemente implicados (51%), seguidos de antiepilépticos (21%). Os principais agentes implicados foram minociclina, valproato, azitromicina e isoniazida.

No geral, 63% das crianças foram hospitalizadas e três submetidas a transplante devido a insuficiência hepática aguda dentro de três semanas após o início da LHID. Entre as 49 crianças acompanhadas por pelo menos seis meses, 16% tiveram exames hepáticos persistentemente anormais. Assim, embora a maioria dos casos de LHID em crianças tenha sido autolimitada e benigna, 5% dos casos de insuficiência hepática aguda necessitaram de transplante e a doença hepática crônica ocorreu em outros 16% dos casos.

É possível prever a LHID?

Índices padrão usados para prever os desfechos de pacientes com LHID não são ideais porque não são específicos para o fígado, ou informativos do ponto de vista do mecanismo. Assim, não são suficientemente preditivos do desfecho. Isso destaca a necessidade de opções mais precisas.

Uma apresentação descreveu novos biomarcadores que poderiam coletivamente fornecer informações prognósticas e mecanicistas em pacientes com suspeita de LHID. Vários biomarcadores candidatos foram quantificados por Church e colaboradores[5] em amostras séricas coletadas pela DILIN dentro de duas semanas após o início da doença de 145 pacientes com suspeita de LHID. O desfecho foi considerado “adverso” se os pacientes necessitassem de um transplante hepático ou morressem dentro de seis meses como consequência do episódio de LHID.

A regressão logística demonstrou que níveis elevados de queratina 18 (K18) total, queratina 18 clivada por caspase, alfa-fetoproteína, osteopontina, proteína de ligação a ácidos graxos 1, e receptor de fator estimulante de colônia de macrófagos foram significantemente preditivos de um desfecho adverso. O “índice apoptótico” sérico, e a razão entre queratina 18 clivada por caspase e queratina 18 total, também foram inversamente correlacionados com um desfecho adverso. A RNI, conforme esperado, foi o melhor preditor isoladamente, seguido por osteopontina.

A análise de regressão múltipla resultou em um modelo preditivo que incluiu RNI, bilirrubina total, aspartato aminotransferase, osteopontina e K18. Este modelo apresentou maior especificidade (0,98) do que a “Lei de Hy” ou uma pontuação no modelo para doença hepática terminal maior que 20 (cujas especificidades foram de 0,64 e 0,73, respectivamente).

Certos biomarcadores também foram correlacionados com achados histopatológicos hepáticos. O grau de inflamação foi significativamente relacionado com o receptor do fator estimulante de colônia de macrófagos, enquanto a extensão da necrose coagulativa/confluente foi significativamente correlacionada com alfafetoproteína e osteopontina. O escore semiquantitativo de necrose foi inversamente relacionado com o índice apoptótico.

Os pesquisadores propõem que a incorporação dos novos biomarcadores candidatos em medidas tradicionais de lesão hepática poderia potencialmente permitir uma melhor predição de resultados em pacientes com LHID. Além disso, os novos biomarcadores podem fornecer uma “biópsia líquida” para avaliar o grau de inflamação e a forma de morte dos hepatócitos.

Anúncios

#Tobacco Companies Forced to Admit That #Smoking Is Deadly

Postado em

Major US tobacco companies are finally having to admit that they have been deceiving the public about the dangers of tobacco.

Tobacco companies have been ordered by the courts to begin publishing “corrective statement” advertisements in major news outlets based in the United States.

The advertisements, which began running on November 26, will have to explain the adverse health effects of smoking and second-hand smoke, along with other topics.

However, the statements not only will focus on the health problems associated with tobacco use but will also require companies to admit that they “intentionally designed cigarettes with enough nicotine to create and sustain addiction.”

These “corrective” statements must be disseminated via television and newspaper advertisements, and a schedule for the topic and dates of presentation has been set up.

“The most important thing about these ads is that they remind the public and policymakers that the tobacco industry is a rogue industry, build on a mountain of lies,” said Vince Willmore, vice president of communications at Campaign for Tobacco-Free Kids. “They are a reminder that the horrific toll that cigarettes have taken did not happen by accident and are the result of the illegal and deceitful practices of the tobacco industry.”

In an interview, Willmore told Medscape Medical News the hope is that the corrective statements will spur elective officials to take strong corrective action.

“The main goal is to inform the public about health harms related to cigarette smoking and to inform them of the behavior of the tobacco industry and then start a conversation,” he said. “There has been a lot of coverage about these statements, and that in and of itself is very beneficial in informing the public.”

Long Court Process

The proposed ads are the culmination of a long-running lawsuit that the US Department of Justice filed against the tobacco companies nearly 20 years ago, in 1999. A landmark 2006 judgment and opinion by US District Judge Gladys Kessler ruled that tobacco companies had violated civil racketeering laws (RICO) and engaged in a decades-long conspiracy to deceive the public about the health effects of smoking and their marketing to children.

In her 2006 verdict, Judge Kessler ruled that the tobacco companies “have marketed and sold their lethal products with zeal, with deception, with a singleminded focus on their financial success, and without regard for the human tragedy or social costs that success exacted…. Over the course of more than 50 years, defendants lied, misrepresented and deceived the American public, including smokers and the young people they avidly sought as ‘replacement’ smokers about the devastating health effects of smoking and environmental tobacco smoke.”

Despite their internal knowledge, the tobacco companies (from 1964 onward) continued to deny and distort the serious health effects of smoking, said Judge Kessler. Even as recently as 2005 (the year before the judgment), they still refused to admit that smoking was linked to serious health problems.

The tobacco industry was also well aware that smoking and nicotine are addictive, but they publicly denied it and “continue to do so,” she ruled. They have “concealed and suppressed research data and other evidence that nicotine is addictive.”

In 2006, Judge Kessler ordered the tobacco companies to publish corrective statements on the five topics about which they deliberately mislead the public:

  • The adverse health effects of smoking;
  • The addictiveness of smoking and nicotine;
  • The lack of significant health benefits from smoking “low tar,” “light,” “ultra light,” “mild,” and “natural” cigarettes (which have been deceptively marketed as less harmful than regular cigarettes);
  • The manipulation of cigarette design and composition to ensure optimum nicotine delivery; and
  • The adverse health effects of exposure to secondhand smoke.

However, during the 11 years since the ruling, the tobacco companies have repeatedly filed appeals and have tried to modify and delay publication of the corrective statements. The US Supreme Court declined to hear their appeal in 2010, and the appeal process finally ended this year, with the result that the tobacco companies were ordered to begin running the corrective statement ads.

The new court-ordered advertisements for television must contain one of the five corrective statements and run five times per week for 1 year, for a total of 260 spots. The ads must run during prime time (7 to 10 pm) and on one of the three major networks.

For newspapers, tobacco companies must purchase five full-page ads in the first section of the Sunday edition of the 50+ newspapers specified by the court. These include papers published in the Hispanic media and African American/community papers. Each of the ads will contain one of the five corrective statements.

Reacting to the news, the University of Texas MD Anderson Cancer Center in Houston issued a statement applauding the action, noting that it will be a significant step toward informing Americans about the addictive power of cigarettes and the harms of tobacco use.

“Although we have made tremendous progress in terms of reducing tobacco use, the CDC [Centers for Disease Control and Prevention] recently reported that 20% of adults in the U.S. still use tobacco products,” Ernest Hawk, MD, vice president and chair, Division of Cancer Prevention and Population Sciences at MD Anderson, said in a statement.

“It’s clear that we must continue to educate the public about the dangers of tobacco use, and these statements will be an important part of that process,” added Dr Hawk.

Big Tobacco Changing Its Stripes?

The ads are coming at time when tobacco companies are resorting to a variety of measures to thwart progress in smoking cessation and reduction.

Philip Morris International, for example, is trying to rebrand itself as part of the solution by funding the Foundation for a Smoke-Free World, as reported previously by Medscape Medical News. Philip Morris will provide $80 million annually over the next 12 years, and the foundation will focus on funding critical research and finding ways to speed up science-based solutions to the current public health crisis involving 1 billion smokers worldwide.

While some have applauded the measure, many experts are skeptical at what appears to be an apparent conflict of interest. In a Lancet editorial commenting on Philip Morris putting up the funds for this Foundation, Martin McKee, CBE, MD, DSc, from the Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, United Kingdom, and colleagues wrote: “Anybody who believes that they really do want to see a smoke-free world is, we argue, living in a fantasy world.” In its reaction to the announcement, the American Cancer Society commented that the involvement of Philip Morris in this endeavor was just “a continuation of a decades-long effort to paint over tobacco’s role in spreading death and misery around the globe.” The company has the power to make a difference, they noted: It should “stop selling cigarettes.”

At the same time, while government health policies to control tobacco use are gaining strength globally, the tobacco industry is not about to back off that quickly.

Instead, it has produced new products to replace conventional cigarettes ― electronic cigarettes (e-cigarettes), electronic nicotine delivery systems (ENDS), and novel “heat not burn” (HNB) devices. Although these products claim to be less toxic than cigarettes, no epidemiologic data are yet available on lung cancer or other diseases.

The tobacco companies “lie and pretend to be reformed…and say that they want to see people stop smoking cigarettes,” commented Willmore. “But at the same time, they are trying to interfere with efforts to control the use of tobacco, and continue to aggressively market and promote their products.”

More Steps Needed

In July, the US Food and Drug Administration unveiled a new comprehensive plan for regulating tobacco and nicotine that will “serve as a multi-year roadmap to better protect kids and significantly reduce tobacco-related disease and death.”

Included in their plan is to begin a public dialogue about lowering nicotine levels in combustible cigarettes to nonaddictive levels. Given that 90% of smokers begin before they are 18 years old, lowering nicotine levels could decrease the likelihood of addiction as well as helping current smokers to quit.

“That would help prevent kids from getting addicted,” said Willmore, “And there are a lot more steps we would like them to take, such as banning menthol cigarettes and putting graphic warnings on cigarette packs.”

Smoking rates are still high in parts of the United States, he added, and in some specific populations. “We need to reduce smoking and the death and disease it causes, in all states and for all Americans.”

Medscape Medical News © 2017

Cite this article: Tobacco Companies Forced to Admit That Smoking Is Deadly – Medscape – Nov 28, 2017.

#Acupuntura para #dor crônica: avanços sem precedentes

Postado em

Pauline Anderson

SAN DIEGO — As últimas duas décadas viram “avanços sem precedentes” no uso da acupuntura para tratar a dor, com um “aumento rápido” no número e na qualidade de estudos relacionados publicados, de acordo com um médico que é praticante experiente de acupuntura.

“No momento, temos uma base bem sólida para a eficácia da acupuntura” para cefaleia, osteoartrite (OA) e condições musculoesqueléticas, disse Farshad M. Ahadian, professor de anestesiologia da University of California, em San Diego.

“Eu acho justo dizer que a acupuntura está aqui para ficar. Será uma adição permanente às nossas opções de recursos”.

O Dr. Ahadian apresentou os dados no 28º Encontro Anual da Academy of Integrative Pain Management (AIPM).

Crise dos opioides

Para alcançar seu “potencial total”, os clínicos precisam “integrar completamente” a medicina convencional com terapias alternativas, o que inclui a acupuntura, disse o Dr. Ahadian aos presentes no encontro.

Ela pode ser cada vez mais importante devido a dois “desafios críticos realmente importantes”: a crise dos opioides e o envelhecimento da população.

“A epidemia de opioides está em curso há duas décadas e não se vislumbra um fim. E não acredito que acordamos para as implicações que o envelhecimento da população tem para a prevalência de dor crônica”.

Durante a apresentação o Dr. Ahadian revisou parte da extensa literatura sobre acupuntura para dor crônica. Entre 1997 e 2010, mais de 600 estudos clínicos relacionados foram publicados.

Uma revisão recente, que o Dr. Ahadian descreveu como “uma das análises mais academicamente rigorosas”, foi financiada independentemente pelo National Institute for Health Research, no Reino Unido.

Após triar quase 1000 publicações, os pesquisadores selecionaram 29 dos ensaios clínicos randomizados controlados de maior qualidade. Os estudos compararam acupuntura verdadeira com acupuntura simulada (agulha que não penetrou na pele ou agulha nos pontos errados) ou ausência de acupuntura (tratamento médico padrão) em quase 18 mil pacientes.

Os autores realizaram uma meta-análise individual de dados de pacientes, que o Dr. Ahadian disse ser “única” para esse tipo de pesquisa.

“Em vez de 29 pontos de dados, eles realmente tinham quase 18.000 pontos de dados, então foi um meio muito mais poderoso de coleta dados”.

A análise mostrou que a acupuntura foi estatisticamente superior tanto à acupuntura simulada quanto à não realização de acupuntura em várias condições que cursam com dor, incluindo dor cervical e lombar, osteoartrite (OA) do joelho, cefaleia e migrânea (todos os P para o efeito geral = 0,001).

O tamanho do efeito para a acupuntura simulada foi “um pouco menor” do que para a não realização de acupuntura, disse o Dr. Ahadian.

“Isso ressalta o poderoso efeito do placebo associado a qualquer tipo de modalidade física, incluindo a acupuntura”, afirmou. Ele acrescentou que isso apresenta “desafios para a pesquisa de acupuntura”.

A análise também confirmou que a acupuntura teve “efeitos clinicamente significativos, o que é importante”, disse o Dr. Ahadian.

Resultados clinicamente significativos

Outras pesquisas já mostraram que a acupuntura aumenta a conectividade funcional.

“A dor crônica pode levar a padrões anormais ou a desregulação da conectividade funcional em vários centros cerebrais”, explicou o Dr. Ahadian. Ele acrescentou que a acupuntura “pode ajudar a modular e a normalizar” a conectividade funcional.

Ele destacou outro estudo que incluiu pacientes com OA do joelho, de moderada a grave, que nunca haviam realizado acupuntura e não haviam realizado nenhuma intervenção nos últimos seis meses. Os pacientes foram aleatoriamente designados para receber acupuntura verdadeira ou acupuntura simulada.

Cada participante recebeu seis tratamentos em um período de um mês. Eles também foram submetidos a ressonância magnética funcional.

Usando uma escala validada, a pontuação de desfechos em lesão e OA do joelho (sigla em inglês, KOOS), os pesquisadores descobriram que a interação entre grupos (real em relação a simulada) e tempo (início do estudo em relação ao desfecho) foi significativa para as pontuações da subescala KOOSpara dor (P = 0,025), função em esporte (P = 0,049) e qualidade de vida (P = 0,039).

A análise demonstrou melhorias estatisticamente significativas na conectividade funcional na rede frontal parietal direita e na rede de controle executivo, “que são os centros cerebrais que se acredita desempenharem um papel significativo no processamento da dor”, disse o Dr. Ahadian.

Ao mesmo tempo, houve uma redução na conectividade da rede motor sensorial, disse ele. “Estes são padrões esperados com o melhor controle da dor”.

Os resultados foram clinicamente significativos, observou o Dr. Ahadian. O estudo descobriu que após o tratamento, o aumento da conectividade funcional foi correlacionado positivamente com as alterações nos escores de dor de KOOS.

Na medicina tradicional chinesa, acredita-se que dor e doença são causadas por uma obstrução ao fluxo normal de qi (energia vital). Pode ser que a conectividade funcional esteja relacionada com o qi, disse o Dr. Ahadian.

“Será que, quando falamos sobre a remoção essas obstruções, o que estamos falando é na verdade melhorar a conectividade funcional?”

O Dr. Ahadian enfatizou que encontrar terapias alternativas eficazes para tratar a dor crônica é cada vez mais importante em uma era caracterizada por aumento significativo de mortes relacionadas a opioides. Em 2015, houve 33.091 casos no Estados Unidos, disse ele.

Outro fator que deve estimular a pesquisa de terapias efetivas para dor é o aumento da população idosa. A porcentagem daqueles com idade igual ou superior a 65 anos foi de 13% em 2012, mas espera-se que aumente para 20% em 2050. A incidência de dor crônica aumenta com a idade.

Treinamento

Ao abordar uma pergunta de um membro da audiência sobre treinamento, o Dr. Ahadian fez referência à American Academy of Medical Acupuncture (AAMA), a sociedade profissional de médicos que incorporaram a acupuntura na prática clínica.

De acordo com o site da AAMA, os requisitos de adesão foram estabelecidos de acordo com as diretrizes de treinamento criadas pela Federação Mundial de Sociedades de Acupuntura-Moxabustão reconhecida pela Organização Mundial da Saúde (OMS).

Outros membros ficaram curiosos sobre o número ótimo de tratamentos de acupuntura e tempos de resposta.

Enquanto alguns especialistas aconselham aos pacientes que eles precisam realizar até 20 sessões para saber se o tratamento está funcionando, “na minha experiência, se não for observada alguma resposta positiva dentro de cerca de quatro ou cinco sessões, talvez seja necessário pensar duas vezes” disse o dr. Ahadian.

Ele observou que “nem todo mundo responde bem à acupuntura”.

Alguns fatores podem reduzir a “capacidade de resposta à acupuntura. A acupuntura depende de um sistema nervoso intacto para promover seu efeito, portanto, se os pacientes tiverem neuropatia periférica significativa ou outras neuropatias, podem não ser tão responsivos”, disse ele.

Uma vez que os pacientes respondem, o Dr. Ahadian disse que tenta aumentar o intervalo entre tratamentos enquanto mantém os resultados.

“Nosso objetivo na medicina não é ‘casar’ o paciente com nosso consultório e fazê-los consultar o tempo todo”, disse ele.

“Se eu não conseguir uma eficácia persistente, ou uma eficácia razoável, que dure um mês, então eu posso desaconselhar ou talvez precise descobrir como mudar minha terapia”.

Em um discurso em outro local do encontro da AIPM, o coronel aposentado do Exército dos EUA, Gregory D. Gadson, que perdeu as duas pernas devido à explosão de uma bomba, enquanto ele servia em Bagdá, em 2007, e agora sofre de dor crônica, disse que ainda recebe ocasionalmente “acupuntura de campo de batalha”.

Quando perguntado pelo Medscape sobre “acupuntura de campo de batalha”, o Dr. Ahadian explicou que a modalidade envolve uma breve sessão usando agulhas pequenas na pele da orelha, para bloquear a dor. O tratamento pode ser administrado em apenas cinco minutos, e está sendo usado para tratar membros feridos do exército dos EUA.

Dr. Ahadian relatou que recebe apoio de pesquisa como pesquisador principal de Boston Scientific e Mainstay Medical.

28º Encontro Anual da Academy of Integrative Pain Management (AIPM). Apresentado em 22 de outubro de 2017.

#Acupuncture for #Chronic Pain: Unprecedented Advances

Postado em

Pauline Anderson

SAN DIEGO — The last two decades have seen “unprecedented advances” in the use of acupuncture to treat pain conditions, with a “rapid rise” in the number and quality of related published studies, according to a physician who is an experienced acupuncture practitioner.

“Right now, we have a pretty solid foundation for the efficacy of acupuncture” for headache, osteoarthritis (OA), and musculoskeletal conditions, said Farshad M. Ahadian, MD, clinical professor of anesthesiology, University of California, San Diego.

“I think it’s fair to say that acupuncture is here to stay. It’s going to be a permanent addition to our tool box.”

Dr Ahadian presented the data here at the Academy of Integrative Pain Management (AIPM) 28th Annual Meeting.

Opioid Epidemic Rages On

To reach their “full potential,” clinicians need to “fully integrate” conventional medicine with alternative therapies, which includes acupuncture, Dr Ahadian told meeting delegates.

This may be increasingly important because of two “really important critical challenges”:  the opioid epidemic and the aging population.

“The opioid epidemic has been raging for two decades, and there seems to be no end in sight. And I don’t think we have woken up to the implications that an aging population has for the prevalence of chronic pain.”

During his presentation, Dr Ahadian reviewed some of the extensive literature on acupuncture for chronic pain. Between 1997 and 2010, over 600 related clinical trials were published.

One recent review,  which Dr Ahadian described as “one of the most academically rigorous” analyses, was independently funded by the National Institute for Health Research in the United Kingdom.

After screening almost 1000 publications, researchers selected 29 of the highest-quality randomized controlled trials. The studies compared true acupuncture with sham acupuncture (needling that did not penetrate the skin or needling at the wrong points) or no acupuncture (standard medical care) in almost 18,000 patients.

The authors carried out an individual patient data meta-analysis, which Dr Ahadian said was “unique” for this kind of research.

“Instead of 29 data points, they actually had almost 18,000 data points, so it was a much more powerful means of gathering data.”

The analysis showed that acupuncture was statistically superior to both sham acupuncture and nonacupuncture across several pain conditions, including neck and lower back pain, OA of the knee, headache, and migraine (all P for overall effect = .001).

The effect size for sham acupuncture was “a little bit smaller” than for nonacupuncture, said Dr Ahadian.

“That underscores the powerful effect of placebo that is associated with any type of physical modality, including acupuncture,” he said. He added that this presents “challenges for acupuncture research.”

The analysis also confirmed that acupuncture had “clinically meaningful effects, which is important,” said Dr Ahadian.

Clinically Meaningful Results

Other research has shown that acupuncture increases functional connectivity.

“Chronic pain can lead to abnormal patterns or disruption of functional connectivity in various brain centers,” explained Dr Ahadian. He added that acupuncture “can help modulate and help normalize” functional connectivity.

He pointed to another study  that included patients with moderate to severe knee OA who were acupuncture naive and had not had any interventions in the prior 6 months. Patients were randomly assigned to receive true acupuncture or sham acupuncture.

Each participant received six treatments over a 1-month period. They also underwent functional MRI.

Using the validated Knee injury and OA Outcome Score (KOOS), researchers found that the interaction between groups (real vs sham) and time (baseline vs endpoint) was significant for the KOOS subscale scores for pain (P = .025), function in sport (P = .049), and quality of life (P = .039).

The analysis demonstrated statistically significant improvement in functional connectivity in the right frontal parietal network and the executive control network, “which are the brain centers that are felt to play a significant role” in processing pain, said Dr Ahadian.

At the same time, there was decreased connectivity in the sensory motor network, he said. “These are patterns that you would expect with improved pain control.”

The results were clinically meaningful, noted Dr Ahadian. The study found that after treatment, the increase in functional connectivity was positively correlated with changes in KOOS pain scores.

In traditional Chinese medicine, pain and illness are believed to be caused by an obstruction to the normal flow of qi (vital energy). It might be that functional connectivity is correlated to qi, said Dr Ahadian.

“Could it be that when we talk about removing these obstructions, what we’re talking about is actually improving functional connectivity?”

Dr Ahadian stressed that finding effective alternative therapies to treat chronic pain is increasingly important in an era characterized by skyrocketing opioid-related deaths. In 2015, there were 33,091 such deaths in the United States, he said.

Another factor that should stimulate the search for effective pain therapies is the growing elderly population. The percentage of those aged 65 years and older was 13% in 2012 but is expected to rise to 20% by 2050. The incidence of chronic pain increases with age.

Training

In addressing a query from an audience member about training, Dr Ahadian referred him to the American Academy of Medical Acupuncture (AAMA), the professional society of physicians who have incorporated acupuncture into their medical practice.

According to the AAMA website, membership requirements have been established in accordance with training guidelines created by the World Health Organization–recognized World Federation of Acupuncture-Moxibustion Societies.

Other delegates were curious about the optimal number of acupuncture treatments and response times.

While some experts advise patients they need to try up to 20 treatments to know whether the treatment is working, “in my experience, if you don’t have some positive response within maybe 4 or 5 treatments, you may need to think twice,” said Dr Ahadian.

He noted that “not everybody is a great acupuncture responder.”

Certain factors may reduce a patient’s “acupuncture responsiveness. Acupuncture relies on an intact nervous system to cause its effect, so if patients have significant peripheral neuropathy, or other neuropathies, they may not be as responsive,” he said.

Once patients do respond, Dr Ahadian said he attempts to increase the interval between treatments while sustaining the results.

“Our goal in medicine is not to marry the patient to our office and have patients come in all the time,” he said.

“If I can’t get persistent efficacy, or reasonable efficacy, lasting a month, then I may advise against it or I may need to figure out how to change my therapy.”

In a keynote address elsewhere at the AIPM meeting, retired US Army Colonel Gregory D. Gadson, who lost both legs due to a roadside bomb blast while serving in Baghdad in 2007, and now suffers chronic pain, said he still receives occasional “battlefield acupuncture.”

When asked by Medscape Medical News about “battlefield acupuncture,” Dr Ahadian explained that it involves a brief session using small needles in the skin of the ear to block pain. The treatment can be administered in as little as 5 minutes and is being used to treat wounded US service members.

Dr Ahadian reports that he receives principal investigator research support from Boston Scientific and Mainstay Medical.

Academy of Integrative Pain Management (AIPM) 28th Annual Meeting. Presented October 22, 2017

#Heart disease patients benefit from #Indian yoga with #aerobic exercise

Postado em

Patients with coronary heart disease (CHD) may benefit from learning Indian yoga and making it part of their daily routine together with aerobic exercise, research suggests.

As part of a new study, 750 patients who had previously been diagnosed with CHD were asked to complete either aerobic exercise (n=225), Indian yoga n=(240), or both yoga and aerobic exercise (n=285). Each group did three, six-month sessions of yoga and/or aerobic exercise.

Patients in the combined yoga and aerobic exercise group showed a two-times greater reduction in blood pressure, body mass index and cholesterol compared to the other groups. Patients in this group also showed significant improvement in left ventricular ejection fraction, diastolic function and exercise capacity. There was no significant difference in reductions in blood pressure, total cholesterol, triglycerides, low-density lipoprotein, and weight and waist circumference between the exercise-only and yoga-only groups.

“Heart disease patients could benefit from learning Indian yoga and making it a routine part of daily life,” said Sonal Tanwar, a scholar in preventative cardiology, and Naresh Sen, a consultant cardiologist, both at HG SMS Hospital, Jaipur, India.

The findings were presented at the 8th Emirates Cardiac Society Congress in collaboration with the American College of Cardiology Middle East Conference.

American College of Cardiology. Press Release. Yoga and Aerobic Exercise Together May Improve Heart-Disease Risk Factors. 19 October 2017. Available from: http://www.acc.org/about-acc/press-releases/2017/10/19/08/47/yoga-and-aerobic-exercise-together-may-improve-heart-disease-risk-factors

Tanwar S & Sen N. Better cardiovascular outcomes of combine specific Indian yoga and aerobic exercise in obese coronary patients with type 2 diabetes. Presented at the 8th Emirates Cardiac Society Congress in collaboration with the American College of Cardiology Middle East Conference October 19-21, 2017 in Dubai. Abstract ID:ECS2017-A-1139

#Auriculoterapia: o que o médico precisa saber

Postado em

mulher com dor no ouvido

Auriculoterapia: o que o médico precisa saber

auriculoterapia constitui uma parte importante da Medicina Tradicional Chinesa, sendo atualmente um ramo na especialidade da Acupuntura, e foi oficializada pela Organização Mundial de Saúde como uma terapia de microssistema.

É um método que conseguiu impor-se pelos resultados obtidos e por ser pouco invasivo, o que faz com que seja bem aceito pelos pacientes. Consiste na estimulação mecânica de pontos específicos do pavilhão auricular para aliviar dores e/ou tratar problemas físicos e psíquicos. Além disso, pode ajudar a diagnosticar doenças através da observação de alterações nestes pontos.

O pavilhão auricular é considerado uma parte muito importante do corpo humano por constituir um microssistema, podendo refletir todas as mudanças fisiopatológicas dos órgãos e vísceras, dos membros, tronco, dos tecidos e dos órgãos dos sentidos. Quando se produz um estado patológico em qualquer parte do corpo humano isto é refletido na orelha com reações positivas de caráter e localidades diferentes, específicos a cada enfermidade.

Pontos auriculares são zonas específicas distribuídas na superfície auricular que refletem fielmente a atividade funcional de todo o organismo. A maioria desses pontos tem a característica de tornarem-se reativos ante um processo patológico em sua zona correspondente no corpo. Todas as regiões e órgãos do corpo humano estão representados então na orelha, como se a orelha fosse um feto em posição cefálica (de cabeça para baixo).

Na prática clínica, podemos observar uma grande diversidade de pavilhões auriculares que variam quanto ao tamanho e a forma, mas em todos se encontram distribuídos os pontos auriculares, seguindo os mesmos princípios.

Em caso de doença, reações se manifestam fielmente no ponto ou área específica da região comprometida, através de mudanças morfológicas, da coloração da pele, dor à exploração táctil, presença de edemas ou cordõeszinhos detectados na palpação, mudanças na resistência elétrica, eczemas ou telangiectasias.

Todas estas reações podem aparecer antes que a enfermidade se manifeste e também desaparecer depois da cura da doença. Os pontos diagnosticados como positivos são selecionados para o tratamento, utilizando a estimulação mecânica.

O tratamento consiste na colocação, após assepsia rigorosa, de um material esférico e de superfície lisa, que pode ser um pequeno cristal ou mais comumente sementes de mostarda, presos à pele com pequenos pedaços de esparadrapo, de forma que façam pressão nos pontos auriculares.

Na prática clínica, tem se verificado que ao estimular um ponto auricular podemos nos deparar com diferentes manifestações sentidas pelo paciente, como sensação de corrente, energia que corre pelo corpo, calor que corre pelo pavilhão da orelha e que se reflete em partes específicas do corpo. O paciente deve estimular as esferas várias vezes ao dia, evitando molhar e deslocar o esparadrapo. As esferas assim colocadas podem permanecer por um período máximo de sete dias, e observa-se um período mínimo de 24 horas com a orelha livre para refazer o tratamento.

Esta técnica não deve ser empregada caso o pavilhão da orelha esteja machucado, com úlceras ou eczemas, e o paciente deve ser orientado a procurar o médico caso ocorra dor acentuada, prurido, sangramentos e edemas. É preciso observar também os cuidados de higiene geral do paciente, pois vivemos num país quente e úmido, o pavilhão auricular é muito sensível e o material orgânico utilizado (sementes) pode facilitar a proliferação bacteriana.

A auriculoterapia é especialmente indicada quando o paciente não deseja ou está impedido de usar agulhas de acupuntura por qualquer motivo, e também como complemento à terapia com agulhas para continuar o tratamento em casa. De todas as formas, é sempre bom enfatizar que a acupuntura, qualquer que seja a técnica empregada, é uma terapia complementar e não substitui o tratamento convencional da medicina ocidental.

 

Autora:

#The Need for Incorporating #Emotional Intelligence and #Mindfulness Training in #Modern Medical Education

Postado em

Hakeem J Shakir; Chelsea L Recor; Daniel W Sheehan; Renée M Reynolds

Although the study of medicine and the tradition of medical students gaining clinical experience on hospital wards have not significantly changed over the years, the experience of physicians practicing in the current climate has changed dramatically. Physicians are confronted with increasing regulations aimed at improving quality of care and are often overwhelmed by their position in a tug-of-war between administrators, staff, colleagues and most importantly, patients. With more than half of the US physicians experiencing professional burnout, questions arise regarding their mental health and work-life balance. Blendon et al[1] reported an overall decline in the public’s confidence and trust in physicians, which may be explained by cultural changes as well as displeasure with medical leaders’ responses to healthcare needs. As the next generation of physicians emerges in this evolving healthcare environment, adaptation to new practices and regulations will be imperative. Emotional intelligence (EI) and mindfulness provide a possible solution to the struggles physicians will invariably face.

The term EI, which refers to a person’s ability to recognise, discriminate and label their own emotions and those of others, was coined by Salovey and Mayer and popularised by Goleman.[2,3] Mindfulness is the process by which an individual actively observes his or her thoughts and feelings without judgement.[4] With foundations in Eastern meditation, mindfulness is now an accepted method of stress reduction in Western culture.[4]

The practice and employment of synergistic EI and mindfulness is grossly lacking from medical school curricula, postgraduate training and continuing medical education (CME) programmes. The systemic deficiency of both EI and mindfulness in healthcare has become more apparent as studies have demonstrated high burnout rates,[5] increasing public mistrust in physicians[1] and disheartening data indicating that 300–400 physicians commit suicide each year; a surprising figure that equals approximately one physician per day.[6]

Identifying a patient’s primary emotion and conveying empathy in the staged, standardised patient settings found commonly in medical education are helpful but not entirely accurate tests of one’s EI and are insufficient for the modern physician. EI and mindfulness are tested most aptly during the trainwreck situations that are not uncommon in healthcare settings. These are the moments in which the patient is acutely deteriorating, the nurses and staff are overworked and unhappy and the patient’s frightened family members are gathered around the room. Here, the physician is required to both identify and adapt to the intense emotions of all parties involved and respond to these emotions in an appropriate manner. However, some may argue in favour of managing the task or crisis at hand rather than the people involved in the particular event. Effective physicians, like effective politicians, businessmen and academics, who subscribe to the notion of separating people from tasks, could perhaps be more effective if they routinely incorporate EI into problem solving. Moreover, focus should be shifted to training physicians to understand their own personalities. Personalities certainly vary among physicians, but physicians with insight into their own EI may cater their interactions to patients by acknowledging their own pre-existing personality traits. Therefore, different personality types may be able to navigate similar situations in disparate but successful fashions. A physician with EI and mindfulness training will be able to do this successfully while still acknowledging their own emotional reactions to this difficult situation.

Physician performance is influenced by interactions with the system as a whole. Therefore, medical schools, residency programmes and CME programmes should enhance existing curricula with EI courses and mindfulness training. EI combined with mindfulness must be taught from the beginning of medical school in anticipation of the realities that students will undoubtedly face as they advance to clinical years. Junior medical students are generally required to take a course that prepares them for scenarios that they may encounter in their upcoming clinical rotations and clinical medicine. As described earlier, this course usually employs actors portraying standardised patients with an illness and often an underlying emotional issue that must also be addressed. Theoretically, the concept is quite practical; however, it does not adequately prepare the student for enough aspects of clinical reality. The reality sometimes unbeknownst to new doctors can be found in, for example, the situation a new resident faces while delivering bad news to a real patient. A hysterical family member in the background or a dispute among family members about treatment options may be unaccounted for in medical school scenarios. Unlike the staged situation where predictability prevails, newly graduated doctors are often thrust into emotionally laden, high stakes interactions with patients and family members, nurses, staff and sometimes colleagues. Early immersion through shadowing and mentorship programmes could better prepare students for what lies ahead in the real clinical environment.

With the proper training, medical students could learn how to effectively deal with these challenges in an emotionally intelligent manner. Dobkin and Hutchinson[7] suggested that mindfulness training was useful for medical and dental students; however, there were many unanswered questions with respect to the timing of training in the trajectory of the physician’s career. Residency training programmes have undoubtedly changed in recent times with Accreditation Council for Graduate Medical Education regulations on work hours and an increased focus on resident health. Nevertheless, more specific strategies are required to promote mental health.

The current climate in medicine, rife with regulation and litigation, encourages physicians to behave less as healers and more as salesmen with the patients as their customers and administrators assuming the roles of bosses. Medical students and residents, immersed in the process of learning how to doctor, are sometimes naïve and unaware of the post-training responsibilities required in real-world practice. In addition to taking care of patients, physicians are required to run their practices, paying attention to billing and collections, management of staff and maintaining licensures. Although physicians contend with these responsibilities and duties mandated by the system, EI and mindfulness continue to be underemphasised.

In following the unwritten rule that the customer is always right, physicians are begrudgingly thrust into a vulnerable role. Furthermore, modern physicians in the USA find themselves pressured to comply with policies that have no evidence base as hospitals maintain accreditations or Press-Ganey scores at any cost. Simultaneously, physicians must interact with potentially unhappy colleagues, dissatisfied staff and patients who may feel they do not get enough physician contact. EI and mindfulness strategies that emphasise conflict management and self-compassion should be taught formally within leadership courses and CME offerings to support the practicing physician in navigating this difficult environment.

Ambady and Rosenthal[8] discovered that when people watched 30 s soundless clips of real physician-patient interactions, their judgements of the physician’s kindness predicted whether that physician would be sued rather than the outcome of the procedure or care. To further touch on the litigious climate of medicine, Robbennolt[9] has suggested that many physicians have not been trained effectively in communicating with patients, especially with regard to apologising after making mistakes, thus leading to potential malpractice suits. Of course, physician hubris is not the sole factor in malpractice suits and some adverse events merit litigation. Physicians still struggle though, coping with denial and having difficulty acknowledging their errors like any lay person may. A paradigm shift might better prepare the physician for some of the difficulties he or she will undoubtedly encounter. What should differentiate physicians from the public, aside from the medical knowledge they have been privileged to garner through years of schooling, is EI and the employment of mindfulness strategies. The combination of these attributes may enable physicians to better realise what factors may be in or out of their control in addition to more effectively communicating possible mistakes made. Furthermore, EI and mindfulness provide physicians with one technique, among many others, which can aid in handling truly stressful moments.

Techniques employed by physicians to contend with overwhelming feelings of anxiety are not limited to EI and mindfulness. Self-compassion and stress inoculation training are examples of two other strategies that can certainly enhance medical education. Neff[10] has described self-compassion as ‘perceiving one’s experiences as part of the larger human experience rather than seeing them as separating and isolating’. She goes on to define it as having ‘an emotionally positive self-attitude that should protect against the negative consequences of self-judgement, isolation and rumination’. Stress inoculation training is a form of cognitive behavioural therapy that can serve as a preventative strategy by preparing individuals and/or exposing them to stressful situations so that they may develop familiarity and ultimately ‘resistance’ to certain stressors.[11] In addition to both EI and mindfulness, these two methods may serve as tools in the modern physicians’ armamentarium. Physicians must understand that they assume an inherent burden that may not be entirely understood by everyone around them. Any of the potential stressors that accompany being a physician, specifically fatigue coupled with the overarching responsibility of caring for a sick human being are not experienced by all members of the healthcare team. This further highlights the need for increased EI and mindfulness training. Nurses and other hospital employees may encounter a less than approachable and short-tempered physician poorly coping with fatigue and other stressors. Adding to the workloads and stress borne by modern physicians are non-patient care tasks that are painstakingly time-consuming. In American medical practice, it has been shown that for every hour physicians provide direct clinical face-time to patients, nearly 2 additional hours are spent on documentation and desk work within the clinic day.[12] Outside actual office hours, physicians spend another 1–2 hours of personal time each night doing additional computer and other clerical work.

The importance of maintaining mindfulness while being overworked should be impressed on medical students, residents and physicians. Unfortunately, a paucity of sufficient coping mechanisms and physicians’ oblivion to their emotional states and reactions leads to tenuous relationships with peers that should be avoidable.

The physician is looked on as the leader of the healthcare team, thus making the roles of EI and mindfulness integral for his or her leadership success. As Mayer[13] points out, ‘EI, however, is not agreeableness. It is not optimism. It is not happiness. It is not calmness. It is not motivation. Such qualities, although important, have little to do with intelligence, little to do with emotions and nearly nothing to do with actual EI.’ The EI and mindfulness attributes required of a physician in a critical situation are the ability to sense the impending panic and potential fear of the other people involved and react appropriately along with recognising their own emotions. The manner in which physicians carry themselves is sensed by those around them, but more importantly should be sensed by themselves. Employment of mindfulness strategies coupled with higher EI translates to better care by a reassured team. Although learning these tools can and may occur on the job, more opportunities should be afforded to physicians in anticipation of the challenges that lie ahead. The art of medicine encompasses the ability to adeptly navigate challenging situations with emotional equanimity. Equipping next-generation and practicing physicians with tools to enhance their EI and mindfulness by providing training while they are medical students and residents as well as throughout their professional life can only improve the field of medicine.