First of all, I'm absolutely delighted and honored to help kick off
this inaugural session for my dear friend, Dr. William Silvers. I've known
him since we were both younger. I was trying to think this afternoon how
long we've known each other, and I can honestly say I think I've known him
longer than I haven't, at least certainly from a professional standpoint,
and I've had the greatest of respect for what William does, what he has done,
the passion he has for his patients. He's always looked for the very best
that he could do for his patients, and integrative medicine is something that
just grew out of that. In regard to what B.J. was saying about Phaser
Triplett, Triplett was the first
allergist immunologist in Mississippi who was trained formally as allergy
immunology, started the Mississippi Allergy and Immunology Clinic, which is
now the Allergy Asthma Immunology Clinic in Jackson. They have eight providers
in that group. They're very helpful to us in our training program. Our fellows
love them, and in fact, three of our former fellows are their partners now,
so we have a very great relationship. When Dr. Triplett passed away,
his family honored me in 2012 by endowing our Phaser Triplett senior chair,
and I'm the inaugural holder of that chair, and I've been very blessed with
the benefits it's provided. We've been able to do and promote some very good
research as a result of that, and I'll actually show you a little bit of that
tonight and again tomorrow. Let me just give a word or two of introduction
about this as we get started. I've been involved, probably in integrative
medicine, really came at it in a little bit different way in that I got
involved in some basic sciences that related to a field called psychoneuroimmunology,
and again, I'll have more to say about that tomorrow morning in the lecture
and a bit tonight, but from that grew into the whole idea of the idea of
patient-centeredness. As BJ mentioned, I did my Allergy Immunology Fellowship
with Phil Lieberman in Memphis, and from the first day I met Phil,
it was very clear that this brilliant, scientifically sound individual still
kept the patient at the forefront of what he did, and he instilled that in me
as many of my other clinical mentors did as well, and so I was looking for
ways to exercise that and getting involved in the idea of integrative medicine.
I began to see patients, particularly in the late 80s and the early 90s,
who began to come to me and tell me about things that they were interested
in using to make their allergies or their asthma better, and some of these
related to things that I thought were kind of off the wall, actually,
until I decided to sit and listen to them, and I was amazed at the consistency
that I heard from many of my patients and actually began to ask questions
and found there were a lot of them that really engaged in this,
but what I want to make sure that you understand tonight is that neither
tonight or tomorrow morning will be as an advertisement for complementary
and alternative medicine techniques.
For the majority of people in this call, that will not be something that you will
actively promote or engage in.
What I want to do is to really focus on what integrative medicine means,
what it is, and how from that may flow some of these other modalities,
and to point out, I suspect that many, if not most of you on the call,
if you are patient-centered in what you do, you're already practicing integrative
medicine in some form or fashion in your practice.
So I invite you to be skeptical of what I have to say, but try not to be cynical.
Keep an open mind, look at the evidence, see what's presented both tonight
and again tomorrow morning.
If you can, I've been very impressed in seeing the pedigrees of the folks
that will be on the call for the panel discussion tomorrow afternoon,
because I don't know all of them, but I'm very impressed with them.
I've taken the time to read some of what they've done, and I think that you can
come away from this tonight and tomorrow changed in your thinking,
changed in your thinking of the idea that you can put feet to what I hope is true
for all of us, that we want to do what the very best is for our patients,
and we want to do it as individually or collectively as necessary.
I don't have any relevant disclosures for this lecture.
I have a bunch of disclosures, but nothing applies to this lecture.
Let's begin by talking about health, that word.
Health is a state of complete physical, mental, and social well-being,
and is not merely the absence of disease or infirmity, and that's a WHO definition.
It cannot, therefore, be attained or maintained solely by pills or procedures.
Physicians and other healthcare providers, too often, we allow patients to come to us
expecting to walk away with some form of a remedy, and the remedy is either thought
of as a prescription or something that we have done to them.
It involves the initiation of maintenance of homeostasis, a word that all of us
learned probably in public school and certainly when we were in college,
and it can be influenced by multiple non-physical components,
such as the outlook of the individual.
Are they optimistic?
Are they pessimistic?
By the provider-patient relationship, which can include the entire healthcare team,
all of us who practice, whether we're in academia, whether we're in community
practice, all of us know that our staff can make us or break us,
and so the whole team becomes very important in relating to our patients.
And then the recognition of the relationship between spirituality and health.
I'll have some words to say about that as well.
There are some major challenges in Western society that are related to our health,
that are not going away, and in fact, if anything, are getting worse.
Chronic disease is increasingly prevalent.
This is the follow-up or the fallout, if you will, or the fact that we can keep
people alive that 50 or 75 years ago would have died much earlier in their life.
It very much translates to someone in my generation.
I turned 70 this last year, and I never believed that I would be 70 because it
seems like it was 10 years ago when I was just getting out of training in my 30s.
Time flies.
Time flies, particularly when you're having fun, and I've been blessed with that
very much, but hypertension, cardiovascular disease, diabetes,
metabolic syndromes that come from that, cancer, and even allergy and asthma,
which has increased in prevalence almost 30% in the last couple of decades.
Unfortunately, Mississippi, if you look this up for all four of these,
Mississippi is number one per capita in negative outcomes for all four of these
major illness categories, so we live and breathe this every day in this state
with our patients.
Most, if not all, chronic disease have an inflammatory and immune component.
I'm an immunologist by training.
This is my lecture, so I can say that.
Now, whether other people might disagree with it, but think about it.
Think about all the different categories of diseases that we know about,
we learned in medical school, maybe we take care of today.
How many of them don't have something to do with an immune or an inflammatory
component?
We live in an increasingly obese and sedentary society, and those go hand in
hand, and obesity, as I know we all know, is itself an inflammatory condition.
There are lots of adipokines that have negative impact on the outcomes in our
patients.
There are increasing levels of societal stress, come from economic challenges,
come from environmental challenges, and even come from philosophical challenges.
Those of us, again, who are older can remember a time where the idea of agreeing
to disagree or civil discourse was something that was most common, and the idea
of yelling and screaming and the overwhelming passions that seemed to so much
characterize the discourse and the political process today were exceptions, not
the rule, and it seemed like in many ways that has flipped.
Recent studies that have been published have indicated this is a major stressor
for most Americans, regardless of what their philosophical or political views
are, and it is something that I believe very strongly has the potential to have
very significant adverse health effects.
Western medicine is increasingly technology-driven.
That's a good thing, but unfortunately, the bad thing is that it's often minimized
the whole-person approach of body, mind, and spirit, so the idea would be to try
to return to some sort of balance using our technology, using it as well as we
can wherever we can, but also reminding ourselves that we're treating individuals,
not biochemistry numbers, and certainly not a bag of physiological manifestations.
Now, I want to share with you this Hippocratic Oath.
This is a version of a Hippocratic Oath that was actually written by the dean of
the medical school at Tufts and recited at the 1964 Tufts commencement, and I want you
to get this from the concept of an integrative medicine perspective.
I swear to fulfill to the best of my ability and judgment this covenant.
I will apply, for the benefit of the sick, all measures which are required, avoiding
those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is an art to medicine as well as science, and that warmth,
sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will remember that I do not treat a fever chart or a cancerous growth, but a sick human
being whose illness may affect the person's family and economic stability.
My responsibility includes these related problems if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
This had a major impact on me when I first saw this probably 20 years ago, and I've kept
it with me, I've shared it with medical students, I've shared it with residents, and it is something
that I believe very passionately as a clinician and as a physician scientist, it's important
for me to believe and to adhere to.
So what about this term integrative medicine?
My stars, if we had time and it was in a live audience, I would stop and I would ask people
to tell me what they thought this meant, and there would be a variety of things.
But what it does, again, a WHO definition is it puts the patient at the center and addresses
the full range of physical, emotional, mental, social, spiritual, and environmental influences
that affect a person's health.
Again, this is not my definition, this comes from the World Health Organization.
The therapeutic goal is to treat the whole patient using whatever evidence-based therapy,
be it conventional, complementary, and all alternative that addresses the patient's needs.
Now it's important to understand that while CAM, complementary and alternative medicine,
CAM can be a component of integrative medicine, it is much more.
Integrative medicine is much more than just using CAM.
If you get nothing else out of tonight's talk, if you say, I had enough and I wanted to watch
some television or whatever, if you can get that statement correct, that integrative medicine
is more than CAM.
CAM is a component, but it's not even a fundamental component, if you hear me out through the
rest of this evening.
Medicines are defined by the components of body, mind, and spirit.
Some people like to use the word soul, but they're interchangeable and I'll show you
this in just a second.
It is in fact the original personalized medicine.
This approach to care has been recorded from the earliest medical history.
Hippocrates famously said and was recapitulated by Sir William Osler at the end of the 19th
century, it is far more important to know what person the disease has than what disease
the person has.
With that mindset, there are other things that came from Hippocrates and others, such
as let food be the medicine and medicine be the food, in other words, that diet is important.
I think we know that walking is man's best friend, exercise is important, and a wise
man should consider that health is the greatest of human blessings and learn how by his own
thought to derive benefit from his illnesses, in other words, an optimistic outlook.
Others had thoughts as well, Mamanides, a famous Egyptian physician, famously said the
success of relieving the patient depends upon an intimate knowledge of the total patient.
He also had some things to say about respiratory disease, mental suffering impedes well-being
and adversely affects the respiratory organs.
Integrative medicine principle is focused on the patient and has been that way from
antiquity.
I've done these talks and done this sort of writing and so on long enough that I've
had patients say, well, sure, it was easy for Hippocrates, it was easy for Mamanides,
they didn't have anything else.
Number one, that's not true.
They had a lot of things that they used.
Were they effective?
Maybe certainly not like they are now with what we have choices while, but it wasn't
just that they could only do this.
It was a component of this as the central part of their medical practices.
What about complementary and alternative medicine or CAM?
Let's talk just very briefly about the basics.
Complementary means used together with conventional medicine.
Alternative means used in place of conventional medicine.
You can have complementary, which is what most of the therapies are, they're add-ons
rather than alternative that's used when something is not there.
However, it's important to understand that what is considered to be complementary alternative
medicine continually changes.
The National Center for Complementary and Integrative Health, which used to be the National
Center for Complementary and Alternative Medicine in CAM, says newer therapies that are proven
to be safe and effective become adopted into conventional health care.
Let me ask the question, and obviously there's no one to respond to this, so it's a rhetorical
question, all of mine are going to be denied.
How many people have at least dabbled in the idea of treating vitamin D deficiency or insufficiency
in asthma?
How many people are aware of the fact that vitamin D levels tend to be lower in our African
American colleagues when you keep our patients, when we keep all other parameters controlled,
their numbers will tend to be lower.
And asthma, all things being kept level, asthma in an African American tends to be worse and
more difficult to control, more severe, et cetera, compared to other racial counterparts.
So is there a relationship between those?
The literature is full of that question.
How many of you use H2 blockers along with H1 blockers in the treatment of chronic urticaria?
And I dare say for the clinicians in the audience, the overwhelming majority do.
But interestingly enough, there is no FDA approved indication for the use of H2 blockers.
It's something that's done sort of as standard of care and common, but it's therefore a complementary
medicine therapy.
Hydroxychloroquine in chronic urticaria, many of you, if not most of you have put patients,
at least in the past, on Plaquenil and gained control in chronic urticaria that before we
have the choices of some of the monoclonal antibodies.
And now if your patient's insurances are like my patient's insurances, a lot of time the
insurance company says no until they fail these other things.
So the idea of using these are in fact complementary and alternative medicine.
There's not an herb in this.
There's not a yoga in this.
There's not acupuncture in this.
This is complementary and alternative medicine at its heart.
Now don't think I'm making fun of that stuff.
I'm not.
I'm going to come to it in just a minute and show you some of the evidence that would suggest
that it might be useful.
What about allopathic medicine attitudes toward complementary and alternative medicine?
Generally the best you can hope for is neutral.
They tend to be negative.
There are very few advocates relative to critics, but I think this not only may change, I think
it's beginning to change.
Ignorance and what I mean by ignorance is I don't mean this as a derogatory term, but
ignorance of the process because it's not commonly taught.
I do the lectures on complementary and alternative medicine at our medical school, in our medical
students.
They get one in the first year and they get a second one in the second year.
One is in microbiology in the first year and the second one is in pharmacology in the
second year.
That's it.
I will tell you that our school is in the minority.
If you go through all the medical schools in the U.S., there are a large number of them
where there is no formal education in complementary and alternative medicine.
There are possible reasons for this attitude as well.
Some suggest that it's not evidence-based and in some cases they've got a case, particularly
if you get online and see what are the latest, newest things to use to treat that are complementary
and alternative.
One of the big things is, well, there are a whole bunch of different things, different
kinds and so on, but an issue is that if you look at it online, almost invariably, not
100%, but almost invariably somebody is trying to sell you something.
It might be a probiotic.
Probiotics are real big right now and, in fact, there are a lot of really good research
going on.
If you looked and did a Medline search, PubMed search, rather, shows you how old I am, say
Medline, a PubMed search, because I did it this afternoon and looked and simply put in
the word probiotic and allergy.
There were 667 articles published within the last five years on that topic alone.
Of that number, about 590 of them are in primary English language.
I say that because in Europe and Asia, the use of complementary or alternative medicine
is actually higher in the public than it is here in the United States, but the English
literature is even more robust in how probiotics as a complementary or alternative therapy
is actually being used to manage allergic disease.
The other is the worry about it could be potentially dangerous, either because it's directly toxic.
Some of the folk medicines and herbal therapies that are, particularly from other countries,
their quality is not controlled.
There have been reports of evidence of toxic compounds, mercury-based compounds, pesticides,
et cetera, found in these, but the other, I think that even more concerned that the
average provider might have is the concern that if a patient decides to embrace complementary
and alternative medicine, that she or he will withdraw from taking effective therapies,
maybe because it's too expensive, maybe it's because they like the natural approach or whatever.
So there is a genuine concern about the withdrawal if somehow it's perceived that the provider
is promoting the idea of complementary or alternative medicine in the management of their illness.
There's also the possibility of a negative impact on the physician-patient relationship
because the patients may decide to self-treat or they may actually seek alternative providers,
naturopaths, homeopaths, et cetera.
That I know of, there are four natural paths in Mississippi that are registered and they're
interesting individuals. They're very nice people. They're very interested in the health
of their patients, but their approach, of course, lacks the scientific rigor that the things that
we would do, but their patients swear by them and they swear by them because they say that
they feel better and some of them are patients who have asthma, some of them are patients who
have chronic urticaria, some of them are patients that have recurrent infections, which makes you
wonder if they have immunodeficiency but typically are not really worked up for that,
and these individuals do take good care of them at least from the interaction with them and the
listening to them and the putting them at the center of what they do. What about caring for
patients with allergy and asthma? Of course, we know they have a high level of morbidity
and a very low level of mortality, but it's not zero. The care that we give is aimed primarily
at quality of life to minimize or eliminate symptoms, maximize the activities of daily
living, athletics, scholarship, et cetera, and we make ourselves feel good about this in that we
have objective measures that we seek to normalize. We want their FEV1 to be normal. We want their
hive count to be low. We want their rhinitis symptoms to resolve. All of these things are
things that we're aimed at, but what the patient wants to do is they want to feel better and they
want to be happy about themselves to go about what they want to do on a regular basis.
A word or two about spirituality and health, and I think this is an important thing, particularly
in the premise that I'm giving that they are related. Spirituality is the way people find
meaning and purpose as to how they experience their connectedness to self, others, or the
significant or sacred. It is a universal human characteristic. It is not, let me say it again,
it is not specifically associated with any religious tradition. An atheist has a spiritual
side according to this concept. One's relationship with the transcendent can be expressed through
attitudes, habits, practices, and can be manifest certainly as religion, but also in the arts,
in humanism, cultural beliefs, and practices. It is in fact the inner life of a person, and this
was put together by an oncologist named Puchinsky and published back in 2012, a very nice paper that
he wrote about in the idea of medical spirituality issues. This is an interesting thing that goes
along with it because here was a study that was done now quite some years ago, but they took a
group of college graduates beginning at time zero, and they followed them. They measured with the
Minnesota multi-phasic personality inventory optimism pessimism scale. They determined that
a person was either optimistic, sort of in the middle, or pessimistic, and they simply looked at
all cause mortality over the next four years. You see here that the end for this was almost 7,000
individuals, and the relative risk of dying early in the pessimistic group was in fact
about 46%, a 1.46 relative risk for earlier mortality. Now, how much are we talking about
death-wise? You're talking about a survival difference of about 0.95 compared to about 0.91,
so you'd only talk about 4%. But 4% of 7,000 people is a lot, and 4% of 323 million population
in the United States is a lot more. We look at this, and in fact, 4% is more than the individuals
who have died from COVID-19 in the last year. In terms of the population of the United States,
and certainly the population of the world, that percentage is lower than that.
What about stress, anxiety, depression, worry? Can the mind impact disease activity? I think we
know an association between anxiety, depression, and asthma. In adults, asthma panic disorder
occurs in 6% to 24% of patients. In pediatric adolescent asthma, anxiety disorders are present
in a third, and depression is present in as much as two-thirds of asthma outpatients,
and the decrease in pulmonary function can correlate with anxiety or depression scores.
These are classic studies, but there is nothing that's been published to suggest that these are
not as true today as they were when they were first published. I want to take you through a case,
and we're going to go through this as a clinical case to show you the point that I have about how
things other than just the, quote, standards of care that we offer can be a benefit to a patient
if we keep that patient at the center of our concern and care. This is a 25-year-old African
American male PhD molecular biologist who presents with a chief complaint of chronic cough,
mild dyspnea, and fatigue. Began approximately three months ago, within six weeks of moving
to Denver from Jackson, Mississippi, JSU, to begin his postdoctoral fellowship, supposed to be at his.
History of asthma began at age two, which spontaneously resolved by age nine. He was
accompanied by allergic rhinitis symptoms, which have continued throughout his life.
He moved to an older apartment with three other roommates, and within days, cough developed
always worse when he was in his apartment. He discovered that the previous tenants had three
cats. He had gone to the University Health Center and was diagnosed with bronchitis. Now, hopefully,
the University of Colorado Health Center doesn't do this, but Jackson State University Health Center
does this because this is based on a patient that I actually saw, University of Mississippi. Most
university things tend to underdiagnose asthma unless they ask the right questions, and he was
given the classic generic cocktail, Cipro for 10 days and prednisone for five days,
advised to continue his over-the-counter daily for ticosone nasal spray and fexafinidine.
His symptoms improved significantly by day three. Of course, thank you, prednisone, and he stopped
all of his medications by day six. Within a week of completing the prednisone, the cough had returned
even worse than before, especially at night, waking him from sleep. He wheezed only at the
end of forced expiration during coughing paroxysms but was now concerned that his cough could be
asthma since his brother's asthma started as a cough some years before, so he sought subspecialty
care. He had some other historical information the review systems was negative except for
admitting mild depression from loneliness after moving from the mid-south to Colorado
and anxiety about beginning studies at a new school. He acknowledged a desire to develop
new friends and become involved in a local church as he had been in Mississippi. His physical exam,
he had a mild cough throughout the exam, especially was talking and deep breathing.
Pertinent negatives, he had a clear skin, no tracheal sensitivity, no wheezing. His pertinent
positives were boggy turbinates and allergic shiners, oropharyngeal cobblestoning, and midfield
and in-expertory wheeze on forced expiration only. His barometry, his ratio was down a bit
at the bottom of normal, his FPV1 was 81% predicted, and he had some significant
reversibility after bronchodilator administration. His allergy skin testing wasn't an allergist
office, so he had to get allergy skin testing, was positive for oak tree, ragweed, cat dust mite,
both DF and DP, and aspergillus species. So his diagnosis was cough secondary to asthma,
which was defined as moderate persistent. His combined seasonal and perennial allergic
rhinitis, and it was complicated by chronic stress and existential challenges leading to
increased anxiety, worry, and depression. The medications he was given was a Budesonide inhaler,
two pups BID, started on 10 milligrams a day of Montelukas, Vexifinidine, one a day continued,
and the fluticasone, which was already using. His viral control measures were the typical for
dust mites, dehumidifiers, and dusting and vacuuming in his bedroom while wearing an L
air filter mask, and the discussion with his patient was to establish his interest in being
referred to student counseling service for anxiety, depression, assessment, and management,
and to a local youth adult pastor for spiritual counseling. So let's talk a little bit about some
of the integrative therapies for allergy and asthma that have been used, that are being used,
and a little bit about why they might be useful. First is diet and nutrition. Diet is a modifiable
factor. A Mediterranean diet demonstrated protection from wheezing independent of exercise
and obesity. Children and adolescents eating fast food more than three times a week had an
increased risk of severe asthma. Rhino conjunctivitis and asthma, while those who had more than three
servings of fruit a week were less likely to have severe asthma. What about herbal-based therapies?
There's some basic information about the herbals that may be of use to you. It's one of the fastest
growing segments of the health care industry, and some people would put health care industry
in quotes. 2001, these are U.S. numbers, $4.2 billion was spent for herbs and botanical revenues.
Estimated that says 12, that's supposed to be updated in 2019, which was the last year,
$12.8 billion had been spent. Used for virtually all categories of illness, for therapy,
for supplemental, to promote health care, or for prophylaxis itself to actually prevent.
People will come in telling you that, I take X herbal preparation to keep myself from getting
asthma, and therefore I don't need my inhaled steroid. Now, that patient's going to have to
have some counseling, that patient's going to have to have some discussion, but we as providers need
to take note of the fact that that patient is saying that their symptoms are fine. Are they
poor perceivers, or has their asthma somehow changed from the last time that we saw them?
The mechanism of effectiveness can range from the placebo effect, the expectancy that this is going
to work, to a pharmacological effect. There are some bases for increasing popularity of the herbals.
Again, dissatisfaction with the allopathic approach, the health care team that's spending
and less time with them as individual patients, or the pharmaceutical choices that they have,
the concern about the potential side effects. I don't know about you, but I do spend some time
with patients that are new onset asthma and rhinitis. When I prescribe either intranasal
or inhaled corticosteroids, it's not uncommon to see their eyes get a little bit big because of the
steroidophobia, and it still extends into other health care providers as well. Then, of course,
many of these meds are not cheap, even with the copay and pharmacy programs that many people have.
Fear of side effects of the conventional therapies themselves,
control issues over maintaining their own health. Many of our patients, more so, particularly in the
younger population, they're not very good at coming in and saying, Doc, what do you want me to do?
They can come in. They're educated individuals, and they have educated themselves, perhaps
erroneously, with internet best things. WebMD, which is generally okay, sometimes is not.
They'll know, and it's not uncommon for them to come in, and it's clear they've read it.
Some of them will actually bring the article with them that they've downloaded from the
net, or they'll show it to you on their device, because if you express any sort of skepticism to
them, because it's on the internet, it must be true, is not a completely unrealistic attitude
that many of our patients have. The perception of safety and effectiveness, that combination there,
that balance is oftentimes not there, particularly if the patient has some unrealistic expectancy
of effectiveness that the first dose should essentially take care of their problems.
And then the appeal of the natural approach. It's hard to get around that one, because they,
the idea of being natural, but I think, again, this is where engagement with them in a discussion
becomes important. The key is, though, that takes time, and it may be time that not all of us either
have or are willing to spend with the patient who has this approach. What about physical activity?
In exercise and asthma, Cochran review of physical training for asthma showed good exercise
tolerance and improved maximum oxygen uptake. Quality of life is significantly improved for
those exercising with asthma, and four out of five reviewed studies and mirroring models demonstrate
reduced remodeling and airway inflammation with low to moderate aerobic exercise.
Exercise and asthma are a positive thing. They do not create the problems that many people think,
and in fact, most of us, I think, would encourage our patients to do asthma,
but I raise the question, how many of us bring it up in the conversation?
If the patient doesn't mention it, do we mention it? Do we say,
do you get any exercise unless we're asking about exercise and symptoms? We ask them if
they get good exercise. It's a stress manager. It can help their lungs develop increased muscle tone.
It's a good cardiovascular therapy. There's very little downside to a good exercise program
in patients except those with the most severe forms of asthma. Indeed, the current state of
research here published in the current opinion analogy and clinical immunology review a couple
of years ago, strong evidence that it is safe, no excess risk for exacerbation, and consistent
improvements in symptoms and asthma-related quality of life. Now, more research needs to be
done. Most of us will promote swimming because I was trained that swimming is the best exercise
for an asthma patient. It keeps their airways hydrated. It's good cardiovascular training.
There's very little downside except that if somebody is, their asthma is unstable,
you don't necessarily want them trying to be swimming out in the deep end where they
might get into trouble. Walking, cycling, et cetera, there's not a lot of work in children
compared to adults, and then there's not been good work to look at the mechanism of action
for the positive impact of exercise on asthma. Does it reduce airway inflammation? Is the airway
hyperreactivity related to cardiometabolic changes? And what about the respiratory muscle changes?
Are they better because they can breathe better? Are they better because they have less airway
obstruction? Or is it some combination of that? Allergists are aware of the strong evidence in
favor of physical activity. This is a very important point. This is a study published in the
WAO journal of 280 clinicians, European primarily clinicians, who had been in practice for
quite a while. Let me back up on that. I'm sorry. For quite a while. I'll get that right in a minute.
What they showed was they were looking at different things that they agreed with and agreed that there
was good evidence, not much evidence or negative evidence, psychological well-being, helping in
weight control, reducing asthma risk, improving asthma control, reducing incidence of allergic
rhinitis, and improving rhinitis control. While the evidence is not particularly strong there,
what you see is that allergists tend to be aware of this evidence of them. What you see is that
it is less than of it being aware. There's a lot of them being unaware, but it still shows you
that we've got work to do to demonstrate to our colleagues that just a good exercise physical
activity program has a positive benefit to allergic and asthmatic disease. Also, promote
physical activity is important in overall care. If you look at this, they all agree that that's true,
but being aware of what its benefit is, is still lacking. What about yoga and asthma as a physical
exercise? The literature has variability regarding the therapeutic effectiveness of yoga in patients
with asthma, but when used as an adjunct to standard asthma treatment, there were significant
improvements in quality of life stores. Some studies also demonstrated improvement in pulmonary
function tests, and here was a simple study that was done and published of a group of a very small
study, only 20 individuals, 12 women that were participating in yoga for 10 weeks, twice a week
for an hour that had mild to moderate asthma compared to eight standard of care, and they
took the St. George's respiratory questionnaire given before and after. If you see this with yoga,
their score went down. As the score goes down, that's a good thing for the St. George's. It is
a good thing. Lower scores is good. Upper scores is bad. In the control group, the symptoms
improved in the treatment group, their activity improved in the treatment group, the impact of
asthma on their daily life decreased in the group, and the total score decreased, which was considered
to be a positive thing. The implications for clinical practice for yoga, in particularly yoga
forms that include breathing exercise, seems to be more effective than usual care for alleviating
asthma. Non-yoga breathing exercises seem to be an effective intervention at least for improving
patient-reported outcomes in some asthma patients. Complex yoga or yoga breathing interventions can
be considered, sorry, can be considered ancillary interventions or alternatives to other breathing
exercises for asthma patients interested in complementary interventions. I wonder how many
of us ever even ask our patients if they participate in yoga, and then the ones that
tend to do that a lot are these providers who already would also ask their patients about or
would prescribe for them breathing exercises to improve their respiratory muscle function.
That's a question for us all to think about. Acupuncture, this is a study that was published
in the Annals a few years ago looking at its potential for seasonal allergic rhinitis.
It was a fairly small study. This is out of Australia, and what they did was had ended up
by going down through here. They had 88 versus 87 randomized into a real acupuncture versus a sham
acupuncture. I think probably everybody knows acupuncture uses the meridians and their acupoints
that are necessary to be needled. It's a very well-described exercise or activity that's done
by a trained professional. Indeed, in Mississippi, and I suspect it's this way in most states,
they have a board and actually have to pass a board exam to be able to practice acupuncture
in the state. What they got were weekly treatments, three times a week for four weeks. They
had various dropouts you see here, and then they did follow-ups weekly for four more weeks,
and then analyzed with an intent-to-treat analysis in the two groups. What this is important to show
you was the grass pollen. This is done over a three-year period of time. The grass pollens
were fairly low after treatment one. They were increasing, so they were moving into the grass
season. You saw this peak right about the time they had the fourth treatment, and then it had
one dip, but then tended to vary and was still there in the follow-up period of time. What they
showed in the red is the sham group, the blue is the actual acupuncture group, was that there's
a substantial decrease in the weekly medication score that persisted after the actual intervention
was stopped for the four-week follow-up period. The sneezing score was blunted, only statistically
significant right in this area here, but it was blunted throughout the regimen after about week
two in the acupuncture group versus the sham group. What about psychological and spiritual-based
interventions? The psychological stressor sources, there's a lot. This is Juan Soledon's
figure that was published in his paper late last year in the Annals. Stress perception,
stressful life events, conflicts, history of physical or sexual abuse, anxiety-depression
symptoms, caregiver anxiety, family chaos, infrastructure, intra-familial violence,
home insecurity, community levels, neighborhoods, stress-violent crime, gun violence, poverty,
school stress, peer stress, racism and discrimination. The result of this increased
asthma incidence, increased asthma symptoms, increased emergency department hospitalizations,
missed school days, poor academic performance, decreased asthma symptom control, and decreased
adherence to therapy. All of these are things that happen. Here's an intervention that Laurie
Burt from U-Mass did now published now almost a decade ago, but it's still
used in a more practical way than this was done pragmatically. This was a mindful-based stress
reduction study in an active group with 42 versus a weekly healthy living course where they watched
videos and talked about things for good health, living, diet, exercise, et cetera. It was eight
weekly two and a half hour sessions. That's certainly not pragmatic for a clinician,
but I'll show you in a moment something that's a whole lot less than that. Mindfulness training
is to learn to recognize and discriminate between components of experience, including thoughts,
feelings, and sensations such as dyspnea to develop a non-reactive awareness of the
experience and sensation so you don't panic and you don't go nutso when you begin to feel
a little shorter breath, an anxiety reaction which is not uncommon for our patients even if
they try to hide it. The meditation with focus on control breathing to control and slow down
their breathing and stretching to develop personal spatial awareness during their movement.
In result of MBSR is to reduce perceived stress and the disease-related stress in symptoms,
and it was practiced for these individuals after the completion of this training session
for eight weeks. They practiced for 30 minutes a day, six days a week for a year,
and here's what they found. The red is the active group. The blue is the control group.
These were not well controlled asthma patients. Only seven percent of them were well controlled
and remember that it was an eight-week process, so from the time of study entry at 10 weeks,
there's not really much of a difference here, but by six months there's a very strong difference,
a much higher percentage of controlled asthma patients that persisted to 12 months after
initiation of the study which was not there in the control group. Looking at their overall asthma
quality of life score, there was a reasonable increase in both of them that sort of persisted
up through six-month period of time, but then got even better. Remember these folks are practicing
30 minutes a day, six days a week, and they continue to do that throughout the 12 months
of the study compared to these folks that are back to standard of care. They're essentially
finished at the end of that, and then the last one of these is looking at the perceived stress
score which is exactly what it sounds like. It's a questionnaire that gives you an idea of how much
stress the individual perceives that they're under. Not much difference in the first six months,
but now that was blunted, it went down, and it stayed down for the 12 months in the active group
compared to the control group. So let's go back to our case for a moment. He was followed up one
month later, and the symptoms had essentially abated. The cough was gone, the dyspnea had
resolved, the fatigue was much better, but was still having some trouble sleeping due to anxiety,
depression, and social struggles, but he was not waking up or using his short-acting bronchodilator
agent. He had become active in counseling at the student counseling office and was now involved in
a young adult church group. He was using the medications as prescribed. His repeats barometry
now showed an FBB1 of 103% with a ratio of 92. It was suggested that he continue counseling
his medications and begin allergen immunotherapy for tree dust mites and cap.
Most of you know this fellow. My dear friend and hopefully all of yours, Richard Weber,
the president of the college back in 2013, was quoted as saying,
The opportunity for allergists in the immunology portion of their practice
is that it encompasses the entire human body, requiring a holistic approach of looking at the
whole person rather than just a small part of their anatomy. Patients want physicians who take
a holistic approach, which places allergists in an excellent position for the future. So in this,
this is my last slide of how I believe that we should consistently work as it relates to
our patient in an integrative approach to allergy and asthma care, regardless of whether you have
any intention of learning more about and getting involved in some of these complementary alternative
medicine therapies. And hear me out. First is our typical conventional assessment. We all do this
pretty well. History and physical exam, review our medications, including asking people about,
do they take herbals or other things that would be considered CAMP? Because many of those people
won't think of them because they're not prescription medicines. Questions about their diet, their
activity, exercise, lifestyle choices, appropriate labs or procedures. We all do this and I think we
do it pretty well. We could do more with asking people about CAMP, but I think the other ones are
done reasonably well. But what about a psychological assessment? Do we look for or ask them about
underlying psychosocial stressors? Is everything going on in school? Are there any problems at
home? Are you having any relational issues? Is there issues related to perceived stress, worry,
anxiety, or depression? And then a spiritual assessment. This is the one that makes people,
again, when I'm in audiences looking at people, it makes people squirm the most. But allow me to
tell you what I'm asking. I'm not asking you to ask them if they go to church or synagogue
or mosque. I'm asking you to ask them about their assessing of their meaningfulness. Do they think
their life is worthwhile? Are they satisfied with their life? Do they have aspirations or are they
just sort of discouraged and sitting there? Look at their non-cognitive behavior. See what they
look like as well as what they say to look for evidence of existential disturbance or crisis.
And then from that, you can construct a comprehensive management program that is sensitive,
respectful, and non-judgmental in its approach, and that may include conventional or CAMP
interventions. And if not, you may be able to appropriately refer them. As this case that we
described tonight was to a ministering staff member, if that is the tradition that the
individual wants to follow, a list of these people in most towns and cities is available.
You don't have to participate in the religious tradition at all or the same one, but you can
help link them up with that. There are psychologists that are very capable of this. We're hoping to
desensitize and decriminalize the word psychosomatic because the word psychosomatic
simply means mind, body, and like it or not, we cannot disconnect that connection. And I end
with that, and thanks everyone very much for your attention. I will hand back the share,
and if there are any questions in the time that we have left, I'll be happy to answer. Thank you.
Thank you so much, Dr. Marshall. That was wonderful. And anyone for questions,
you're welcome to unmute yourself and ask them directly. If you prefer to ask them in the chat,
you can do that too. Hi, this is Dr. Murtekrishna from Fort Collins. Thank you, Dr. Marshall,
for a wonderful summary of this excellent program. And you see these patients in allergy
practices, for example, self-climbed foot allergies, or as you mentioned, one of the
cases somewhat not exactly that respiratory symptoms, but not related to asthma, skin
conditions, a lot of GI symptoms, and there is a lot of self-climbed, you know, the gluten
sensitivity in the last 10 years or so. So when we evaluate as physicians, traditional, you know,
allopathic medicines, we go through some of the basic investigations that you mentioned briefly,
and it becomes negative when we tell the patient, of course, then we just leave it at that level,
because they don't have a real disease. And they may have one of these things that you discussed
today in our lab. So I think if there is a, you know, somewhat of a clinic or referrals where
we can make these patients go because in regular allergy practices, you will not be able to handle
their, you know, anxiety or depression or other nutritional problems they have or something.
So if there is a clinic where these patients can be referred, otherwise they'll look for some other,
you know, CAM or alternative medicine themselves. So can you comment on that?
At some places, these clinics are available where we can refer these patients to check it out?
I think that's a superb question. Thank you very much for asking that question. I tell the story
when I give this talk, particularly in the medical school, I tell a story of Mrs. Smith comes to see
me, and she says she doesn't feel good. And so I asked her what's wrong. Well, I'm tired all the time.
I get short of breath easy, I ache, I hurt and so on. And so I'm a good doctor, and I'm medicine
trained. So I'm also doing my internal medicine stick along with her. And so I take a good history,
I examine her, I do the appropriate testing, everything comes back normal. Am I being a
kind physician when I walk back into our, I bring her back to the office later on and I say, Mrs.
Smith, good news, there's nothing wrong. Well, Mrs. Smith wouldn't have come to see me if there
wasn't something wrong. Clearly there's something wrong. The fact that I can't find it doesn't make
it unreal. And the fact that it may not fit into the category of the disease that we talk about
is in the same thing. Some of you may know, and apparently from what I saw at the beginning,
this is going to be really interesting next month, as you're going to talk about COVID vaccines and
so on. There is an NIH research opportunity announcement that we have responded to with our
colleagues at the Mayo Clinic about a condition that many of you would have heard of as long-haul
COVID, but is also now called post-acute sequelae of coronavirus infection or PASC.
And we are in collaboration with all three of the Mayo campuses. We form a four-institution
network that is looking at this and we have a standard way. We take these people that are
symptomatic and we're very conservative in that number and that unlike the Europeans who don't
really diagnose this for 120 days, we diagnose it generally after 30 days and even there's some that
maybe they're just not that we can get an early start on. But one of the components of this is
not just the organ specific, the chronic cough or the exercise and tolerance with breathing,
et cetera, but it's what's called a central sensitization syndrome. And these are the
nondescript symptoms like profound fatigue and brain fog and myalgias and arthralgias. And
for those of us who are old enough when chronic fatigue syndrome was chronic fatigue and immune
dysfunction syndrome, which was that way for about 10 years in the 90s, they called it CIFIDS and
immunologists saw a lot of CIFIDS patients. I did because nobody knew what to do with them
and they had these nondescript illnesses. I think that what my experience has been with these
individuals that has been so helpful is the candor of telling them, I don't know what's
wrong with you, but clearly I acknowledge that something is just by validating their illness
and not immediately passing them off to the latest mental health professional. They may
well ultimately end there and a fair percentage of them do, but they would not to ultimately
pass them off. On the other hand, not to be to the point where we're spending $20,000,
$50,000 of laboratory money getting reams after reams after reams of normal data. Then we found
an abnormal one and feel compelled to go after it and never really give them anything that's better.
What's being reported in the COVID associated past patients is that with supportive care,
truly supportive care, many of these people ultimately get better. The minority of them
after three or six months, the minority of them are still symptomatic. You're not helping everyone.
The NIH study is to do deep phenotyping of these individuals because the next research opportunity
announcement that will be out probably at the end of the summer, beginning of the fall will be
related to interventions and what they're trying to do for this. What you describe,
I believe is much, much more common than we acknowledge. What these individuals will
typically do if we're dismissive of them is that they will seek out the alternative providers
and they will land in the natural past office, they will land in the homeopaths office,
they will land in the chiropractor's office without any musculoskeletal individual. These
individuals very often, they come out of those offices just delighted. Thank you, doctor. You
have saved my life because you're listening to me. The one thing that I would say is that we have
to invest enough into being willing to listen to the people. I do not believe that you have to spend
two hours with the patients. You can have a defined 20 to 25 minute interaction with them
and it's amazing how well they'll walk out of there because you have validated
that you agree that they're ill. You just haven't been able to tell them yet the exact etiology.
That's my approach to that. Thank you.
Thank you, Dr. Murthy. Any additional questions for Dr. Marshall?
If I could, Galen, thanks very much for giving us this review and putting the patient in the center
and also for your seminal work with the stress and the immune responses. I just got to say that
it was given your paper talking about skin testing being improved with the new skin
it improved with patients through the MBSR program that I did a program
at the Denver Botanic Gardens with a instructor from Boulder from the Naropa Institute actually
who had trained in Boston at UMass with John Kabat-Zinn, et cetera, that you're talking about
the MBSR mindfulness-based stress reduction. As I told the fellows at the Journal Club at
CU, I haven't taken a sleeping medication since then because the breathing and the medication
is so helpful. I just wanted two questions. One is besides MBSR, which is a significant investment
of time, are there other recommendations that you give your patients regarding breathing,
relaxation exercises, stress reduction techniques that they can easily take with you? Number one.
Number two, to the physicians, do you have references online that if people come in
with a concoction of all kinds of supplements that they can look up
what the safety efficacy, the value is, et cetera? To answer the first one, a teaser for tomorrow
morning will show you some data from something called a behavioral activation that is a one-hour
training that can be done in the office. The patient takes that home with them and they use
it. It's based upon MBSR, but it's different from MBSR. They've now gone to the University of Toledo,
but they were at our place for some years. I still collaborate with one of them there, a fellow
named Matt Tull. Matt and his wife Kim Gratz, who are both clinical psychologists, develop this.
The value of it is that it's so pragmatic. The real value of it is that again,
behavioral activation is a little bit different than mindfulness-based stress reduction in that
what they're doing is that they're catching themselves though in the moment. They are,
if you will, calming themselves down and it involves breathing. It involves stretching. It
is an immediate abbreviated form, I guess, that some people would acknowledge based on yoga,
but it works very well for our patients. I think the key is one of the things that we do
is that really early on in people, particularly in somebody that we might think have, for example,
vocal cord dysfunction, maybe they have defined asthma, but clearly their exacerbations are
coming more from VCD. One of the things we'll do is contract with them to agree that they're
going to delay the use of their reliever for a minute. We teach them that same galactic pull
that everyone knows where there's sort of a counter pull. We go through the thing about
Charlie Harson, the leg, and these are Charlie Harson, the retinoid muscles. While that's a
little, I think the purest particularly in Denver probably might jump on me a little bit, it works.
In a high percentage of these individuals, when they begin to realize that in fact it's anxiety
that has brought on these attacks and it is put there where they can see it and understand it,
it's absolutely amazing. It's almost transformative of them. Then they engage in this.
Doesn't cost them any extra money. It's something they can do repeatedly and we've seen over and
over the ACT scores improved substantially in these individuals, particularly because their use
of short-acting bronchodilator goes from almost daily to virtually zero. The second one is that
yes, there are several websites that exist that give people good information and that the docs
can use. Bill, you might be better equipped to give all the current information. We have it
available to us, but I guess I've done this long enough now and I also look at it in the literature
to see if there's stuff that's new in these areas. When they come talk to us about it,
I can give them information and then direct them to what's available. This is something that
the integrative medicine committees for both the college and the academy should be pressing
their boards for. This happened for a little while, fell out of vogue for a while and hopefully
come back again. If we're going to ask our colleagues to become more educated about these,
we need to be able to provide them the resources where it's readily available for them to
access that information.
Yeah, I might just say that for my colleagues here,
there are two online resources, I think. I would go to number one and to send patients to would be
the National Center for Complementary Integrative Health at the NIH. That's classic and
evidence-based, et cetera. The other one that is more detailed to supplements, I'd recommend that
you at least put in your, as an arrow in your quiver if you're confronted with patients coming
in with certain supplements that you're not familiar with, is the naturaldatabase.com. It's
the National Center for Complementary Medicines and it's put out and it's vetted by the same
people who do the pharmacist newsletter. We had explored them for the Academy years ago and then
for the college and they've got all these people in these little cubicles looking at the data,
et cetera, and they have nice safety efficacy profiles of all of the supplements. There's a
free version that's simple and then there's a paid-for version that the Academy may still have. The
college had it at one point, the Academy then picked it up. I don't know if it's back to the
college or the Academy now, but one of our two major societies has that as a, or at least as of
last year or so, has that as a member benefit and you don't have to pay for anything.
I'll try to find out which one has it before tomorrow morning, actually. Those are two
resources, I think, that are valuable to direct patients toward and to search out yourself for
the questions that may confront you.
Thank you. That was wonderful. I can't think of a better way as an introduction to
the William Silver's integrative allergy immunology respiratory wellness program.
I do hope that everyone who can, can join for tomorrow's sessions as
BJ had previously shared. If you need any of those links, please reach out to us
at the Colorado Allergy and Asthma Society or directly through BJ in his email.
Before we adjourn for this evening, any additional questions or comments?
Please, those that can attend tomorrow, enjoy those sessions. Otherwise, we look forward to
seeing you in May on the May 11th for the next session of the Colorado Allergy and Asthma Study.
Thank you, Dr. Marshall.
Great pleasure. Enjoyed it.