Can Allithiamine Help Neuropathy Patients

Today's post from doctorvolpe.com (see link below)is a very interesting piece of new information about a topical cream (or capsules) called Allithiamine, which is a form of Vitamin B1. It is already used as a component of a commonly found version, Bentofiamine but Allithiamine is purely the fat-soluble B1 vitamine and it is commonly used to treat ADHD and Autism, as well as being a cosmetic cream. The point is that it has been shown to provide some dramatic results for people suffering from neuropathy. Now as with all these things, it's wise to err on the side of caution but talking it over with your neuropathy doctor and trying it yourself if you can get hold of it, will prove whether it can help you or not. Tomorrow's video post talks about the same thing and if you're interested, it must be worth while looking at both posts before coming to any conclusions. After that, doing your own research is also advisable.

Allithiamine found to reverse neuropathy 
Dr. Arturo M. Volpe May 20th, 2003

Allithiamine is a fat-soluble form of vitamin B-1. Although vitamin B-1 (thiamin) is most commonly found in its water-soluble form, allithiamine is also a naturally occurring form of this vitamin and is found in many foods, including garlic.

Since it is fat-soluble, allithiamine has the advantage of being excreted at a much slower rate than the common form of thiamin. In addition, while thiamin in any form is associated with health of the nervous system, the fat-soluble form is far more effective in promoting recovery of a damaged nervous system.

The reason for this may be that the nervous system is, in large part, made up of fat. Nerves are encased in a protective fatty cover known as the myelin sheath. Efficient functioning of the nerves is largely dependent on the health of this sheath. Because allithiamine is fat-soluble, it dissolves more easily and is better absorbed in these fatty regions of the nervous system where it can promote recovery.

Vitamin B-1 deficiency is widespread in our society due to the prevalent high-carbohydrate diets. This vitamin is consumed when carbs are digested and used (metabolized) in the body, so the more carbs we eat the more thiamin we need. However refined carbs are a poor source of thiamin and when they become the major component of the diet, people exhaust their thiamin reserves without replenishing them, so they become deficient. In our country some carbohydrate products are enriched with thiamin for this very reason, but the amount added is probably inadequate, at least for a segment of the population (besides, many carbohydrates like French fries are not enriched).

An extreme form of chronic vitamin B-1 deficiency is seen in alcoholics. Alcohol is metabolized like a carbohydrate but provides no nutrients at all and thus robs the body of many vitamins, especially thiamin. This extreme deficiency can lead to a form of dementia known as Wernicke-Korsakoff psychosis that is treated with daily vitamin B-1 injections.

Diabetics are also often deficient in thiamin, although their deficiency is usually not severe enough to cause dementia. A prevalent symptom of deficiency in diabetics is polyneuropathy, a condition characterized by loss of sensation in the extremities. An early sign of this condition is “burning” feet, which explains why many diabetics (and alcoholics) often cannot tolerate sleeping with a blanket covering their feet.

Derrick Lonsdale, MD has found thiamin deficiency to also be prevalent in children with ADHD and autism. Dr. Lonsdale discovered that thiamin deficiency tends to manifest in children as hyperactivity and a sensitivity to touch that he calls “touch-me-not syndrome.”

A recent double-blind controlled study of allithiamine supplementation was performed in Germany on diabetic patients who suffered from polyneuropathy. Patients in the active treatment group were given oral supplements of allithiamine (actually benfotiamine, a form of allithiamine) plus vitamins B-6 and B-12 that have synergistic actions. After the 12-week duration of the study, all patients who received the vitamin combination showed significant improvements. Additional progress was observed nine months later in a group who continued to take the vitamins after the study was completed. Incidentally, no side effects were reported in this study (“A benfotiamine-vitamin B combination in treatment of diabetic polyneuropathy” Exp Clin Endocrinol Diabetes 1996; 104 (4): 311-6).

Allithiamine is also very effective as a piece of the treatment puzzle in children with ADHD and autism when there is a pre-existing deficiency. Although oral administration is highly effective, this vitamin has a viciously bad taste and it is usually administered as a cream to children who are too small to swallow pills.

http://doctorvolpe.com/neuropathy/allithiamine/

DRINKING BEET ROOT JUICE BEFORE EXERCISE BENEFITS HEART PATIENTS

A small yet significant study shows that beetroot juice improves exercise function in chronic obstructive pulmonary disease (COPD) patients.

The new research by Wake Forest University looked at a small group of COPD patients who drank beetroot juice as compared to a placebo drink before exercise.

“The intent of this study was to determine if acute ingestion of beetroot juice, which is rich with nitrates, prior to exercising could improve the exercise capacity of COPD patients,” said Michael Berry, chair of Wake Forest’s department of health and exercise science.

COPD makes it difficult for patients to breathe and worsens over time.

In turn, they tend to limit their activities, become more sedentary, and lose fitness and physical function.

The findings showed overall that those patients who drank beetroot juice were able to extend their exercise time and had reduced exercise diastolic and resting systolic blood pressures.

“This is the first study to demonstrate beneficial effects of dietary nitrite supplementation on exercise performance and blood pressure in patients with COPD,” he added. One of the benefits of exercise is that if you get positive results, you are more likely to continue doing it.

“If beetroot juice positively impacts those results, it could motivate COPD patients to continue to be physically active and improve their health,” he added.

The research appeared in the journal Nitric Oxide: Biology and Chemistry.

TOPIC

The Phoney War Condemning Neuropathy Patients To Further Torture

Today's excellent article from pbs.org (see link below) looks more closely at what the author calls a civil war in the medical community over painkillers and their current use. It's not a war on drugs; it's a war about drugs! Many neuropathy patients, especially in the US (but not exclusively), are victims of this phoney war because the drugs they rely on to keep their pain under control are now being denied to them by over-zealous doctors who are following a trend, or giving in to pressure, rather than carefully controlling how their patients use the drugs they're prescribed, thus keeping them safe. It's a massive political issue as well, with the media largely weighing in on the side of the 'ban all strong painkillers' faction. The point is that, everyone agrees that it would be better if we weren't having to use opioids and other strong medications on a daily basis but they've been prescribed and they work where others have no effect and there's currently no alternative. So where does that leave the patient until the science catches up and safer drugs are discovered and marketed? In severe pain and between a rock and a hard place, that's where!

A ‘civil war’ over painkillers rips apart the medical community
BY Bob Tedeschi, STAT January 21, 2017

PALO ALTO, Calif. — For Thomas P. Yacoe, the word is “terrifying.”

Leah Hemberry describes it as “constant fear.”

For Michael Tausig Jr., the terror is “beyond description.”

All three are patients struggling with chronic pain, but what they are describing is not physical agony but a war inside the medical community that is threatening their access to painkillers — and, by extension, their work, their relationships, and their sanity.

Two years after the United States saw a record 27,000 deaths involving prescription opioid medications and heroin, doctors and regulators are sharply restricting access to drugs like Oxycontin and Vicodin. But as the pendulum swings in the other direction, many patients who genuinely need drugs to manage their pain say they are being left behind.

Doctors can’t agree on how to help them.

“There’s a civil war in the pain community,” said Dr. Daniel B. Carr, president of the American Academy of Pain Medicine. “One group believes the primary goal of pain treatment is curtailing opioid prescribing. The other group looks at the disability, the human suffering, the expense of chronic pain.”

Pain specialists say there is little civil about this war.

“There’s almost a McCarthyism on this, that’s silencing so many people who are simply scared,” said Dr. Sean Mackey, who oversees Stanford University’s pain management program.

“The thing is, we all want black and white. We don’t do well with nuance. And this is an incredibly nuanced issue.”

READ NEXT: How do we decrease addiction to opioids but still treat millions with chronic pain?

Nuance does not matter to people like Tausig, 43, who has been unable to work or socialize since 2008, when the last of his five spinal reconstruction surgeries left him in constant pain.

He last got a taste of life without opioids a few years ago, when his pharmacy’s corporate parent imposed opioid-distribution limits, forcing him to find a new one.

“Those three days were among the worst of my life,” he said. “I wandered the house at night, legs shaking like a whirling mass of putty, sleepless and without respite from the pain.”

Now, with regulators and health industry leaders continuing to bear down on opioids, and the arrival of a new president whose statements indicate that he might further restrict opioid distribution, Tausig’s worries have deepened.

“It’s put the fear of God in me.”

The medical community’s battle over painkillers burst out into the open in late 2015, when the New England Journal of Medicine published a commentary in which two doctors argued that chronic pain patients should focus not on reducing the intensity of their pain, but on their emotional reactions to it.

The authors, Dr. Jane C. Ballantyne, the president of Physicians for Responsible Opioid Prescribing, and Dr. Mark D. Sullivan, argued patients should pursue “coping and acceptance strategies that primarily reduce the suffering associated with pain and only secondarily reduce pain intensity.”

The pair argued that patients who mainly focus on pain intensity tend to escalate their doses of opioids and worsen their quality of life.

On NEJM’s website, the comments section devolved to a flame war more suited to YouTube than the staid pages of the nation’s top medical journal, with some accusing the authors of a lack of compassion, and others lauding them for a sane approach to public health and addiction prevention.

READ NEXT: Treating chronic pain: When ‘How much does it hurt?’ isn’t enough

But the comments also laid bare a fundamental problem in the debate over opioid treatments: Neither side has much evidence about the benefits or consequences of long-term use because almost no such studies exist.

A few studies have identified a litany of side effects beyond addiction. One survey, by palliative care doctors Mellar P. Davis and Zankhana Mehta, pointed to symptoms including increased risk of depression, anxiety, cognitive impairment, and sleep apnea, among other issues. Patients with lung disease were also more likely to die when their treatment included opioids, according to the survey’s authors, who practice at Geisinger Health System.

Stanford’s Mackey said those risks are important to recognize. But, he said, nearly 15,000 people die a year from anti-inflammatory medications like ibuprofen. “People aren’t talking about that,” he said.

On a Monday morning last month, Mackey entered an exam room to greet one of his patients who uses opioids: an 81-year-old physician with a bad back.

The doctor, who agreed to be interviewed on condition of anonymity, said he’d routinely cycled to work until relatively recently, when a degenerative spinal condition worsened. Surgery in October failed to help, and now, he told Mackey, he can only get out of bed if he takes five opioid pills at dawn and sleeps another half-hour before rising.

The doctor wanted to find a way to address his back problem without the painkillers, which, he said, cloud his thinking.

Mackey spent nearly 30 minutes with him, talking about scans, symptoms, and previous treatments. He planned a follow-up consult in January, when another set of test results would arrive.

READ NEXT: For some chronic pain patients, ‘without opioids, life would be torture’

Over lunch, Mackey reviewed the case.

“Do you get any sense from him of drug-seeking behavior?” he asked. “Is he selling this stuff on the street or trying to score some synthetic fentanyl or heroin? No. All he wants to do is be more functional so he can see patients and be relevant and have a life.”

Mackey also wasn’t sure the opioids were causing the cloudiness. The patient’s cognitive issues could be the result of non-opioid medications he takes before sleeping, so dialing down the opioids without first exploring other options might harm him more. Without them, his pain would be so severe he would be relegated to bed.

“If you’re 81 and you stop getting out of bed, it’s a slippery slope,” he said.

Mackey, a past president of the American Academy of Pain Medicine, has built Stanford’s pain center into one of the nation’s most comprehensive and well-funded pain research operations. But he said doctors being trained there have grown increasingly fearful about prescribing opioids.

“In many cases that can be healthy, but I’d like to see a thoughtful, balanced approach,” he said. “Opioids are a tool — they’re more often a fourth- or fifth-line option for me.”

Mackey recalled the case of a patient who had crushed his foot in an accident and undergone 10 surgeries that failed to diminish his “burning, terrible pain.” The patient now relies on opioids.

“People will say, ‘This guy’s on way, way too much opioid medication, you have to take him off,’” Mackey said. “But guess what: He gets up every morning and goes to work and does his job, and he’s been on the same regimen for years and years and tried everything else first.”

Even some of Mackey’s colleagues have issues with that kind of thinking.

Dr. Anna Lembke, who practices alongside Mackey at Stanford’s pain clinic and is chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, published a book about the opioid crisis last year. It was titled: “Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.”

Lembke believes that long-term opioid use can cause patients to perceive pain even after the original cause of pain has cleared. Some patients, she said, find themselves free of pain only once they have endured the often agonizing effects of opioid withdrawal.

“That’s what we’re seeing again and again,” she said.

Lembke believes people with chronic pain who have taken opioids daily for long periods may never be able to break their dependence on the drugs, and may need permanent doses of medications like Suboxone, which is commonly given to people with opioid addictions.

But chronic pain patients who have not yet started on opioids, she said, should only take them intermittently — “like every three days or so” — to avoid addiction.

The American culture has grown too intolerant of pain, Lembke said.

“Whether it’s surgery or women going into childbirth, there’s an alarmist reaction to pain, and it’s contagious and makes more people anxious, which makes the pain worse,” she said. “We’re terrified to experience pain.”

Those who experience chronic pain say these views embolden clinicians, pharmacists, and others to treat them like addicts and criminals.

Hemberry, a 36-year-old multimedia specialist in Leavenworth, Wash., suffers from a connective-tissue disorder called Ehlers-Danlos syndrome and trigeminal neuralgia, an often-excruciating nerve condition for which she occasionally takes opioids.

She heard Lembke interviewed on NPR recently and was bereft. “Every pain patient is now an addict and a failure,” Hemberry said.

Last March, the Centers for Disease Control and Prevention issued guidelines for opioid prescriptions. Those guidelines focused on addiction prevention, opioid trafficking, and medication diversion, and included stern cautions against using the drugs for chronic pain.

To Hemberry, the guidelines seemed reasonable. “But many doctors and administrators have taken a hard-line ‘no opiate’ stance,” she said, and go to absurd lengths to enforce it.

Earlier this winter, Hemberry recalled, she went to the emergency room with a migraine headache, a frequent symptom of her medical conditions. She was seeking a saline drip — one of the few treatments that has helped her pain — and said she wasn’t seeking opioids.

The nursing staff nonetheless grilled her on her medications and chided her for taking too many pills, even though her daily medications are non-narcotic. She turned her head at one point and started sobbing.

Others report a similar lack of empathy.

“What people forget is, those who end up on opioid pain management have usually tried everything else unsuccessfully,” said Yacoe, 61, who suffers from chronic migraines. “I stayed away from opioids for decades. It was really and truly a last resort.”

Some clinicians trace the early roots of the opioid crisis not to the pharmaceutical industry’s marketing of controlled-release morphine pills, but to a 1986 study of 38 non-cancer patients performed by palliative care doctors at Memorial Sloan Kettering Cancer Center.

Most were treated with oxycodone, methadone, or levorphanol in small daily doses — less than half the surgeon general’s current recommended starting dose — and 24 reported acceptable or adequate pain relief, while two patients developed “management” problems with the drugs. (Both had histories of substance abuse.)

According to Carr, of the American Academy of Pain Medicine, the conservative opioid treatment approach used in the study, and the modest benefits reported, reflect the current practices and expectations of many doctors.

But a growing number, he said, are being pressured into a zero-tolerance policy.

“Because if one isn’t anti-opioid enough, there’ll be protests,” said Carr, who is also founding director of Tufts University’s Pain Research, Education, and Policy Program.

Other experts note that, as opioid restrictions tighten, the medical system and insurance industry have done little to support opioid-withdrawal efforts, help more physicians learn how to help patients manage pain, or enable access to alternative therapies.

In some cases, patients seeking to treat their pain have turned to street drugs like heroin or synthetic fentanyl, while others have instead chosen suicide. (In one high-profile case recently, a man who committed suicide left behind notes saying he could find no help for his chronic pain; at least two of the roughly 20 patients interviewed for this article said they had considered suicide because of their pain.)

Everyone wants the number of opioid overdoses to fall. But patients like Tausig don’t want to be made to suffer.

Tausig, a single father of two teens, said that every month he needs to fill a prescription, he’s fearful it will be denied.

Whenever he thinks he might meet with a new pharmacist or clinician, he dresses neatly to hide his tattoos. He said he thinks they can cause people to rush to judgment or even stigmatize him as an addict.

“You’ve got the wars on the medical side, but then you’ve got the governmental people stepping in, who have no idea,” Tausig said. “All they know is drugs: bad.

“They don’t see a struggling single dad in the most expensive place in the US who’s just trying to get through the day.”

This article is reproduced with permission from STAT. It was first published on Jan. 17, 2017. Find the original story here.

http://www.pbs.org/newshour/rundown/painkillers-controversy-doctors/

You Wont Believe What Goes On In Neuropathy Patients Shoes!

Today's light-hearted post from totalfootcare.ca (see link below) should carry a government health warning because it's pretty much a wake-up call for people living with neuropathy in their feet. Because of that dratted numbness that fools you into thinking you know what's going on under your feet (because you can still feel the burning and tingling that goes on in other layers), you can so easily miss sharp objects that lurk inside your shoes. Read this article: you'll know why this is important!!
 

The Funniest Things I’ve Found in Patients’ Shoes… That Demonstrate Why Neuropathy is No Laughing Matter
Written by: HealthyFeet

Web Feet is a quarterly blog posted by Registered Chiropodist David Murphy. Dave has ten years’ experience in his field and works at Kawartha Total Foot Care Centre’s main clinic in Bobcaygeon, Ontario as well as the practice’s sites at Lakefield Physiotherapy & Foot Health Clinic and the Curve Lake First Nation Health Centre.

There’s a moment of wonder for every chiropodist before reaching into a patient’s shoes at what discoveries might be revealed. From pennies to pins and everything in between, I’ve seen my share of “shoe treasures” over the years. The sheer oddness of some of them may bring a smile to one’s face, but for people with diabetes and diminished sensation caused by peripheral neuropathy, the result can be anything but amusing – skin ulcers, serious infections, even amputations.

Here are a few examples of some shoe finds this year, and they make clear just how important it is for people with reduced sensation to check the insides of their footwear regularly.

1. Tacky Tricks
Shortly into back-to-school season, I removed the insole of one particular teacher’s shoes to reveal a bevy of thumb tacks! Unbeknownst to her, it seems she was the subject of some classroom pranksters. This “joke” could have become decidedly not funny very quickly had the tacks remained undiscovered.

2. Ho, Ho, Hold on a Minute!
The holidays are such a wonderful time full of tradition. Last season, a patient visited me shortly after the family’s annual Christmas tree cutting adventure. Just as he finished telling me that his work boots are the most comfortable boots he has ever owned, I reached in and pulled out a branch with an entire clump of pine needles that would rival any of Charlie Brown’s Christmas trees. Needless to say we went on to further sensation testing.

3. One Piña Colada Please… Hold the Cocktail Umbrella
A patient returned last winter from some fun in the sun with what I thought was a sliver embedded in his sole, perhaps picked up on a long walk on the beach. On closer examination of his deck shoes, I realized that I was right about the sliver but wrong about its origin. It was from an umbrella – a cocktail umbrella to be precise. Perhaps the next time the customs agent asks you to remove your footwear on return from your favorite all-inclusive winter destination you may also want to use this opportunity to check the insides of your shoes for unwanted stowaways!

4. Dog Gone It!
Attention pet owners… knick, knack, paddy whack give a dog a bone? This four legged member of the family used its owner’s shoe as a cozy hiding spot for a favourite bone. Unfortunately for the pet owner who was unaware of what was hiding in his Hush Puppies, the shards of fragmented bone had caused a severe infection by the time I discovered them.

5. Automatic Toe-nition
My last recollection is one that was quite remarkable and humorous to everyone involved… initially. This particular patient could not understand why on earth he could still start his car (push button ignition) when his keys had been missing for days, even leaving him to wonder perhaps about artificial intelligence or some sort of electromagnetic disturbance. He had even involved his mechanic who was also very puzzled. It was only when his wife noticed the bleeding in his socks that she checked his shoes and the mystery was solved. There they were – his full set of keys pushed into the end of his shoe. The patient was completely unaware, felt nothing, not even the bottle opener also attached to his key collection. The sad ending to this story is that complications developed and progressed to the point that his great toe required amputation.

These examples illustrate the severity and potentially life-changing impact of neuropathy. It’s something we see and treat regularly at Kawartha Total Foot Care Centre.

Know the Warning Signs and Your Risks for Neuropathy

Neuropathy can range from a mild tingling or a “pins and needles sensation,” to sharp stabbing pain, and complete numbness. This occurs when the nerves in the feet that supply the brain with sensory information are damaged. Neuropathy can result from a variety of factors such as chemical toxicity, alcoholism, and chemotherapy. However, the most common cause by far of neuropathy and neuropathic changes in feet is diabetes.

In diabetics, the neuropathic changes are caused by the fluctuating blood sugar levels. The inconsistent blood sugar levels, over time, erode the insulating layers that cover the nerves, leading to altered or complete loss of sensation.

Prevention is the Best Medicine

Don’t let a nail in your shoe be the wake-up call to give your neuropathy proper consideration.

1. If you have been previously diagnosed with neuropathy, are diabetic, or have a family history of diabetes, it’s critical to have your feet examined and cared for regularly by a Registered Chiropodist. This assessment should include a full clinical vascular and neurological exam, dermatological exam, biomechanical evaluation, and a footwear assessment, along with ongoing foot medical care.

2. If you are a diabetic, controlling your blood sugar is crucial, having a healthy balanced diet and active lifestyle is a necessity, and getting enough restful sleep is essential in preventing or delaying neuropathic changes.

3. Self Examinations – use your hand and a mirror to check your feet as well as the inside of your footwear daily. This will become habitual and will likely prevent any close calls from becoming a more serious matter later on.

4. For those individuals who have diabetes and/or neuropathy and find their symptoms progressing or find they are having a big impact on daily life, then certain medications may provide benefit. Be sure to measure your blood sugar regularly – you can’t manage what you don’t measure! Bring these results to your family doctors and/or endocrinologist regularly and work with them to manage your condition.

5. At Kawartha Total Foot Care Centre, we have had success with weekly infrared light therapy sessions. This form of treatment helps treat the symptoms of neuropathy and although results are very specific to the individual, it may be the difference between keeping up with your normal daily activities or not.

My earlier stories might be a dose of lighthearted humour, but I know first-hand that neuropathy is no laughing matter. Remember that while we may not be able to reverse nerve damage, chiropodists can certainly help patients to better manage symptoms, prevent impacts from neuropathic foot changes, and improve quality of life.

http://www.totalfootcare.ca/the-funniest-things-ive-found-in-patients-shoes-that-demonstrate-why-neuropathy-is-no-laughing-matter-2/

COPD PATIENTS BREATHE EASIER WITH LUNG FLUTE

Patients with chronic obstructive pulmonary disease (COPD) report improved symptoms and health status when they use a hand-held respiratory device called the Lung Flute®, according to a new study by the University at Buffalo. Usually caused by smoking, COPD, which includes chronic bronchitis and emphysema, is the third leading cause of death in the U.S.

The Lung Flute, manufactured by Medical Acoustics, (Buffalo), uses sound waves to break up mucus in the lungs. The device allows patients to clear lung mucus simply by blowing into the hand-held respiratory device, which produces a low frequency acoustic wave.

Published on Sept. 23 in Clinical and Translational Medicine, the 26-week study demonstrates that patients using the Lung Flute experience less difficulty breathing and less coughing and sputum production than a control group, which saw no change in COPD symptoms.

"This study confirms that the Lung Flute improves symptoms and health status in COPD patients, decreasing the impact of the disease on patients and improving their quality of life," says Sanjay Sethi, MD, principal author of the study and professor and chief, division of pulmonary, critical care and sleep medicine in the Department of Medicine, UB School of Medicine and Biomedical Sciences.

The device is approved by the Food and Drug Administration (FDA) to treat COPD and other lung diseases characterized by retained secretions and congestion. It also is approved by FDA to obtain deep lung sputum samples for "laboratory analysis and pathologic examination."

Colleagues of Sethi's in the UB medical school are now studying the Lung Flute for use in improving symptoms in asthma. The device is also being investigated for diagnostic use in tuberculosis and lung cancer.

The study followed 69 patients with COPD for six months; it was conducted at the Veterans Affairs Western New York Healthcare System (Buffalo VA) by researchers at the UB medical school.

"This study confirms and extends the results of a previous, 8-week study of 40 patients that was conducted in 2010 to obtain FDA approval for the Lung Flute," says Sethi, whose clinical practice is at the Buffalo VA.

He has led a series of clinical trials demonstrating the safety and efficacy of the Lung Flute, including those that played a key role in the FDA's approval of the device for diagnostic and therapeutic uses.

Improvement in the current study was demonstrated by responses reported by patients on the Chronic COPD Questionnaire, which assesses changes in COPD symptoms and the St. George's Respiratory Questionnaire, which measures quality of life. On both questionnaires, patients using the Lung Flute reported significant improvements.

In addition, the Body-Mass Index, Airflow Obstruction, Dyspnea and Exercise Capacity (BODE) score was measured repeatedly in the study. "The BODE index provides a more comprehensive assessment of COPD patients," explains Sethi. "As the disease worsens, the BODE index goes up as it did in the control group. But for patients using the Lung Flute, the BODE index stayed flat."

Sethi adds that the study points to a potential decrease in exacerbations, flare-ups of respiratory symptoms, as a result of using the Lung Flute. Researchers are planning longer-term studies that will focus specifically on how the device affects exacerbations, a key part of what makes COPD patients sicker and leads to health care utilization.

Sethi notes that while similar devices have been developed for cystic fibrosis, the Lung Flute is the only one that has undergone extensive testing specifically for COPD patients. In a previous study comparing a device developed for cystic fibrosis with the Lung Flute, the Lung Flute was superior for COPD patients.

"All therapeutic studies on using the Lung Flute for COPD have been done here in Buffalo," says Sethi. "We have the biggest database by far on using the device in COPD. The Lung Flute is the only one that has been tested and been clearly shown to benefit COPD patients."

The research is the result of a partnership between UB and Medical Acoustics.

"Medical Acoustics has worked closely with UB's medical school since the company's founding in 2002," says Frank Codella, chief executive officer at Medical Acoustics. "We are very fortunate to have had access to UB's vast resources, including medical researchers of the caliber of Sanjay Sethi and his team, to lead many of the Lung Flute's clinical trials.

"Dr. Sethi is recognized as one of the leading COPD research professionals in the United States," Codella continues. "His research has resulted in the Lung Flute receiving FDA clearances for both obtaining deep lung sputum samples for diagnostic use and for airway clearance therapy as well as a series of Phase IV studies such as the one being reported this week."

Adds Sethi: "The people at Medical Acoustics are open-minded and I was willing to help because I saw an unmet medical need. Our relationship satisfies my goal of getting therapies to patients, while it helps the company succeed, satisfying their goals of creating a viable business. That's the way academia and industry partnerships should work."

The Savage Reality Of Cost Cutting For Chronic Pain Patients

Today's post from theguardian.com (see link below) is a UK post providing an alarming foretaste of what may be to come in many other countries, in these days of cuts to health services and cuts in support for chronic pain patients. We all know that cuts are happening across the world, in a vague and on-going response to the financial crisis of 2008 and nowhere are those cuts deeper than in the health systems of individual countries. Faceless bureaucrats are desperately searching for corner-cutting savings within their own systems and the first things they aim for are what they call 'fringe benefits' to patients suffering a wide range of illnesses. Therefore, if the medication or treatment is not directly saving lives, or worse, not likely to raise much opposition because they are only relevant to smaller patient groups, they make easy targets. Many of the cuts listed here are directly relevant to neuropathy patients. You may well say that this is a UK problem and that other countries would either never provide these free of charge anyway, or would never cut them because they are of proven benefit to patients (it all depends on how rich your health budgets are) but the fact is that slowly but surely, savage cuts are being made and it will only get worse. If your only aim is to balance a budget then you don't care if small groups of patients are adversely affected. This is what happens when civil servants take over health systems and they are thrown open to market forces. So many neuropathy patients depend on their gluten-free diets, or Lidocaine patches, or many other creams, supplements etc because they know from personal experience how much their symptoms are reduced. Unfortunately, it's the way of the world at the moment. All you can do is protest but it may not do you much good - you're a file number on a computer and you're budgeted for: the fact that your health is on the line is of little interest to the accountants. God help us if we ever want medical marijuana added to our 'subsidised' list. The problem is that cutting these subsidies means increased health costs further down the line, as patients' conditions worsen and they need more expensive treatment but that never enters the equation. It's a hard world and it's getting harder.

GPs to stop prescribing omega-3 oils, gluten-free food and cough medicine
Denis Campbell , Matthew Weaver and Haroon Siddique Tuesday 28 March 2017 08.33 BST First published on Tuesday 28 March 2017 00.59 BST
 
NHS also removes medication for upset stomachs, haemorrhoids and erectile dysfunction from list of prescribed items

Gluten-free food will be on the banned list.
 
The NHS is to stop giving patients travel vaccinations, gluten-free foods and some drugs that can be bought over the counter in an attempt to rescue its ailing finances.

Simon Stevens, the chief executive of NHS England, announced the changes in an interview with the Daily Mail in which he detailed new efforts to get better value for money so that money saved could instead be spent on promising therapies that have recently been developed.

NHS services face 'impossible' budget crisis, health trusts warn


 GPs will be told to not prescribe medications such as those for upset stomachs, travel sickness and haemorrhoids in the drive to eliminate waste from the NHS’s £120bn annual budget.

Stevens said: “We’ve got to tackle some of the waste which is still in the system. The NHS is a very efficient health service but like every country’s health service there is inefficiency and waste.

“There’s £114m being spent on medicine for upset tummies, haemorrhoids, travel sickness, indigestion, [and] and that’s before you get to the £22m-plus on gluten-free that you can also now get at Morrisons, Lidl or Tescos.

“Part of what we are trying to do is make sure that we make enough headroom to spend money on innovative new drugs by not wasting it on these kind of items.”

Next month, NHS England will start reviewing 10 items that it says are “ineffective, unnecessary [and] inappropriate for prescription on the NHS, or indeed unsafe”, which together cost the service £128m a year. The Department of Health is expected to then issue new guidance advising GPs that they are not prescribed.

They include omega 3 and fish oils; the painkiller fentanyl: lidocaine medicated plasters; a tablet used to treat high blood pressure called doxazosin MR; and a drug called tadalafil, which is used to treat erectile dysfunction, along with gluten-free foods and travel vaccines.

NHS Clinical Commissioners, which represents England’s 209 NHS clinical commissioning groups (CCGs) – the GP-led bodies that hold health budgets locally – has asked NHS England to look into whether the 10 items are a good use of scarce cash when the NHS is undergoing the tightest budgetary squeeze in its 69-year history.

Many other common medications could soon be added to the banned list. NHS England said: “In light of the financial challenges faced by the NHS, further work will consider other medicines which are of relatively low clinical value or priority or are readily available over the counter and in some instances, at far lower cost, such as treatment for coughs and colds, antihistamines, indigestion and heartburn medication and suncream. Guidance will support clinical commissioning groups in making decisions locally about what is prescribed on the NHS.”

Frontline doctors said the idea should help the NHS to prioritise spending but they called for safeguards to protect vulnerable groups.

Prof Helen Stokes-Lampard, the chair of the Royal College of General Practitioners, said: “We do welcome these proposals but cautiously. I think a blanket ban might well introduce some unfair problems.”

Speaking to BBC Radio 4’s Today programme, she added: “The difficulty is when people don’t pay prescription charges, so they are entitled to free medication on the NHS, and that’s when they’ll be difficult conversations. GPs don’t want to be rationing. It is time that country needs these difficult conversations but we mustn’t put at risk the health of the vulnerable.”

Dr Amanda Doyle, the NHS Clinical Commissioners co-chair, said: “The NHS is in quite constrained financial circumstances and what we are trying to do is prioritise our spend. We are currently spending hundreds of millions of pounds on things we would generally consider to be low priority for funding and we are looking at ways of reducing that spending so we can direct the funding in to things that take a higher priority.”

Are you affected by the NHS stopping gluten-free prescriptions?

But Norman Lamb, the Liberal Democrats’ shadow health secretary, said: “This creeping retreat of the NHS should not be happening without a national discussion about how we can afford a modern, efficient and effective health and care system. We do have to confront tough choices about whether we all pay more or whether the NHS does less but the public should be part of that discussion. And the bottom line is that this is intended to save £1bn over two years when we face a shortfall of over £10bn by 2020. This does not solve the massive problem we face.”

NHS bosses hope the moves could ultimately save as much as £400m a year. The service is facing serious financial problems. NHS trusts in England recorded a deficit of £2.45bn last year and are expected to end this financial year almost £1bn in the red again, despite repeated warnings to get their finances in order.

An NHS spokesman said: “New guidelines will advise CCGs on the commissioning of medicines generally assessed as low priority and will provide support to clinical commissioning groups, prescribers and dispensers.

“The increasing demand for prescriptions for medication that can be bought over the counter at relatively low cost, often for self-limiting or minor conditions, underlines the need for all healthcare professionals to work even closer with patients to ensure the best possible value from NHS resources, whilst eliminating wastage and improving patient outcomes.”

Stevens’ money-saving initiative is a foretaste of a major initiative he will unveil on Friday. He will announce details of his long-awaited “delivery plan” to fulfil his pledge, first made in October 2014 in his Five Year Forward View modernisation blueprint, to radically transform how the health service works by 2020 so that it delivers better care and closes the £22bn gap that is expected to open up in its own finances by then in order to remain sustainable.

He will give the go-ahead to between six and 10 of the 44 sustainability and transformation plans (STP), one covering each part of England, which are intended to implement his ideas, which centre on moving a lot of care out of hospitals and treating patients closer to home and keeping them healthier so that they avoid expensive £400-a-night unnecessary stays in hospital.

Read more The STP plans have proved very controversial because they could see dozens of hospitals lose key services, such as their A&E or maternity unit.


The 10 items under review (and cost to NHS) are as follows:

• Liothyronine, used to treat underactive thyroid £30.9m

• Gluten-free foods £21.9m

• Lidocaine plasters, for reducing nerve-pain £17.6m

• Tadalafil, for erectile dysfunction £10.5m

• Fentanyl, used for terminally ill patients, including those with cancer £10.1m

• Co-proxamol, painkiller, £8.3m

• Travel vaccines £9.5m

• Doxazosin, for high blood pressure, £7.1m

• Rubs and ointments £6.4m

• Omega 3 and fish oils £5.7m

Clinical Commissioning Groups have also suggested savings could be made on other products, including the following*:

• Hayfever remedies £37m

• Indigestion/heartburn remedies £27m

• Suncream £1.4m

• Cold and cough remedies £1.2m

* Figures taken from NHS Digital’s Prescription Cost Analysis England 2015.

https://www.theguardian.com/society/2017/mar/28/nhs-draws-up-list-of-items-to-be-banned-from-prescriptions

How Neuropathy Patients Should Be Tested And Diagnosed

Today’s post from podiatrytoday.com (see link below) takes a good look at diagnosing neuropathic problems. Many of you will be familiar with several aspects of these processes but maybe not all. It seems to me that this is a good blue print for how people presenting neuropathic symptoms should be examined, tested and diagnosed. The problem is that doctors are busy people and may not follow through with all these tests, yet they perhaps should, if they are interested in accurate diagnosis and prognosis. Thanks to the unique symptoms and features of neuropathy, this blog always supports the doctor who listens to a patient's story and background and makes a correct neuropathy diagnosis based on pretty much those alone. However, if demands are made on him or her to 'prove' their diagnosis for bureaucratic reasons or record keeping, then the least they can do is conduct a thorough examination and this article demonstrates how that should be done. Neuropathy patients may learn quite a bit about their disease just by reading this guide for health professionals.

Mitigating Some Guesswork In Treating Neuropathic Pain
Wednesday, 05/20/15 | 1018 Issue Number: Volume 28 - Issue 6 - June 2015
Author(s): Cynthia Cernak, DPM, Eric M. Larsen, DPM, and Robert H. Odell, MD, PhD
 
Diabetic Neuropathy
 
Neuropathies take many forms depending on anatomic location. A mononeuropathy affects a single spinal or peripheral nerve with the cause likely to be a distinct anatomic lesion (such as lesions due to disc disease or tarsal tunnel syndrome). Systemic neuropathies often cause symmetrical issues in the limbs. Common causes are diabetes, alcohol, chemotherapy, etc.

Accordingly, let us take a closer look at the differentiation and treatment of distal neuropathies. Peripheral neuropathies come from damage or diseases affecting nerves that produce symptoms related to dysfunction in the nerve itself. This is in contrast to nociceptive pain, in which the nerve’s performance is normal.

Consider the following patient. A 76-year-old female presents with diabetes and a HgbA1c of 7.6. The patient was in a severe car crash 15 years ago and has had low back pain since. She had breast cancer five years ago and had chemotherapy. The patient describes the pain as an “aching, burning pain” that makes it hard to sleep. She notes there is some reduction of the pain with walking. The patient reports seeing three other doctors who could not help address her pain.

The most crucial elements of the history are the symptoms and location of the neuropathy. See “A Guide To Signs And Symptoms Of The Onset Of Neuropathy” at right. It is important to document positive and negative findings because improvement in any of these can be valuable in tracking the progress of your patient.

Perhaps more crucial to the diagnosis, in our opinion, is the location of neuropathy. If it is peripheral, circumferential and roughly symmetric, one can be reasonably sure there is a systemic cause (such as diabetes or a toxin). The causes of asymmetric neuropathies, which are prevalent in the lower extremities, are typically associated with isolated lesions. Causes include disc disease, trauma and entrapments.

A proper history is crucial to find a cause. Did the patient work in an environment where she would have been exposed to heavy metals? Was she exposed to Lyme disease? One must know the social history and nutritional history to look for vitamin deficiencies of B6, B12, folate, vitamin D, etc.

Two useful tools are a peripheral arterial disease questionnaire and the neuropathy function index. These are easy surveys that will help in triaging, treatment and measuring a patient’s progress. 

How does one differentiate among the various causes of peripheral neuropathy? 
Developing an algorithmic approach can save time and medical resources. Ordering tests to rule out all possible causes could be very expensive. Clinical judgment can help narrow the list of possibilities.

Conducting An Effective Physical Examination
The physical examination should include a limited back exam and full lower extremity exam. As part of the foot exam, we utilize several objective tests. Standard tests include the Semmes Weinstein monofilament test, the Rydel-Seiffer eight-point vibration scale, sensory testing with a sharp and a dull instrument, temperature testing, Tinel’s sign, two-point discrimination, and pressure specified sensory testing. While exhaustive and time-consuming, these tests will serve to map the location (e.g. proximal spread) and quantitate the nature and severity of the neuropathy. These tests are quite useful in tracking a patient’s progress.

The loss of vibration and/or light touch sensation around the entire limb may mean undiagnosed diabetes or idiopathic peripheral neuropathy. Often, these findings represent a decrease in the function of the small nerve fibers. If these findings are confined to a single dermatome, one should suspect a lumbar radiculopathy, a more proximal entrapment syndrome or another type of neuropathy.

What Diagnostic Testing Can Reveal About The Cause Of Neuropathy
Blood tests can be useful in finding a specific cause for neuropathy. Hemoglobin A1c reflects the average blood sugar and can track a patient’s adherence over three months. To maximize the treatment of neuropathy, an HgbA1c of 7.0 or below should be the goal. The GlycoMark test (GlycoMark, Inc.) is a blood test that reports a two-week average measure of the maximum blood glucose.

Nutritional screening is important because the B vitamins and vitamin D are often deficient. Clinicians should check blood levels to minimize potential toxicity if patients are taking high doses of fat-soluble vitamins.

Comprehensive neuropathy testing includes: lead, mercury, arsenic levels, vitamin B6 level, B12 levels, a Lyme titer, RPR (rapid plasma reagin) syphilis test and complete blood cell count with differential to evaluate for possible anemia. Comprehensive testing should be individualized to each case and be the decision of each practitioner. Bear in mind that testing can be very expensive and may not influence treatment.

The “standard” in objective nerve testing remains nerve conduction/electromyography (EMG), especially if one suspects nerve entrapment. We believe there is little evidence for ordering these tests in diagnosing systemic neuropathies. Often, the report states “diffuse peripheral polyneuropathy with both axonal and demyelinating features,” which one would already know.

The A-delta nerve conduction study, a relatively new test for small fiber neuropathy, has been in use for over 10 years. We believe this test is more useful to evaluate efficacy of the neuropathy treatment but it is not widely available at this time.

The epidermal nerve fiber density test is a new gold standard that has emerged for the diagnosis of peripheral neuropathy.1 Physicians and labs advocate using one to three biopsy sites with a 2 mm punch biopsy. Common testing sites are: the proximal thigh (10 cm from the hip), the distal thigh (10 cm from the knee), 10 cm above the lateral malleolus and on the lateral midfoot. Systemic neuropathies often show a decrease in small nerve fiber density and this simple test can quantify improvement in neuropathy.

What You Should Know About Diabetic Neuropathy Treatments
Nutritional. Alpha lipoic acid, vitamin B complexes and vitamin D supplementation have shown improvement in neuropathic symptoms in numerous studies. According to a Cochrane Review in 2008, most studies did not show significant improvement in peripheral neuropathy using vitamin B only.2 
Using epidermal nerve biopsy, Jacobs found that a combination of L-methylfolate, methylcobalamin and pyridoxal 5’-phosphate (Metanx, Pamlab) decreased neuropathic symptoms and showed an increase in epidermal nerve fiber density.3

Pharmacological. Gabapentin (Neurontin, Pfizer) received FDA approval in 1993 and has been the subject of multiple double-blind studies. According to Moore and colleagues, the number needed to treat ranged between 4.8 to 8.7.4 Sixty-six percent of patients experienced adverse events and 12 percent withdrew because of adverse events. Serious events were no more common in the treatment group than placebo (4 percent).

Pregabalin (Lyrica, Pfizer) received FDA approval in 2004. Finnerup and coworkers state that the number needed to treat ranged from 3.3 to 4.7.5 In studies, 22 to 38 percent of patients taking pregabalin experienced adverse events with rare withdrawal from therapy due to side effects.5

Compound creams. An enticing treatment option to prevent systemic side effects, compound creams have shown mixed results for us. To our knowledge, no high-powered studies have demonstrated efficacy with compound creams.
 Most compounding pharmacies use their own specific combinations, which makes it difficult to determine which compounds are most effective and in determining the number needed to treat.

Current Insights On An Emerging Treatment
Combined electrochemical treatment (CET) has shown promising results in several small studies.6-9 We have covered our current treatment protocol in other previous published papers.7,8 These studies have shown up to 80 percent of patients experiencing significant relief from their neuropathic symptoms.6-8 

Before and after epidermal nerve biopsies have proven that combined electrochemical treatment increases the epidermal nerve fiber density. The combined electrochemical treatment shows very impressive results in comparison to traditional therapies for systemic neuropathies.

Larger studies are needed to improve the acceptance of combined electrochemical treatment by third-party payers. As long-term patient success continues to be documented at substantially reduced overall costs for neuropathy treatment, the third-party payers will be more forthcoming with appropriate reimbursement.

Dr. Cernak is affiliated with Weil Foot & Ankle Institute in Kenosha, Wis.
Dr. Larsen is affiliated with Weil Foot & Ankle Institute in Kenosha, Wis.
Dr. Odell is affiliated with Neuropathy & Pain Centers of America in Las Vegas.

References
Saperstein DS, Levine TD. Diagnosing small fiber neuropathy through the use of skin biopsy. Practical Neurology. 2009; 8(1):37-40
Ang CD, Alviar MJM, Dans AL, Bautista-Velez GGP, Villaruz-Sulit MVC, Tan JJ, Co HU, Bautista MRM, Roxas AA. Vitamin B for treating peripheral neuropathy. Cochrane Database Syst Rev. 2008; 16(3):CD004573.
Jacobs AM, Cheng D. Management of diabetic small-fiber neuropathy with combination L-methylfolate, methylcobalamin, and pyridoxal 5’-phosphate. Rev Neurol Dis. 2011; 8(1-2):39-47.
Moore RA, Wiffen PJ, Derry S, McQuayHJ. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2011 16;(3):CD007938
Finnerup NB, Jensen TS. Clinical use of pregabalin in the management of central neuropathic pain. Neuropsychiatric Disease Treat. 2007; 3(6):885-891.
Odell RH, Sorgnard RE. New device combines electrical currents and local anesthetic for pain management. Practical Pain Management. 2011; 11(6):52-68
Cernak C, Marriott E, Martini J, Fleischmann J. Electric current and local anesthetic combination successfully treats pain associated with diabetic neuropathy. Practical Pain Management. 2012; 12(3):23-36.
Cernak C, Odell R, Carney P. Can combined electrochemical treatment have an impact for diabetic peripheral neuropathy? Podiatry Today. 2014; 27(7):20-24.
Carney PM. Quantum theory treats neuropathy better than pharmacology. The Pain Practitioner. 2014: 28-31
For further reading, see “Can Combined Electrochemical Treatment Have An Impact For Diabetic Peripheral Neuropathy?” in the July 2014 issue of Podiatry Today.

http://www.podiatrytoday.com/mitigating-some-guesswork-treating-neuropathic-pain