Our Daughter's Wedding is Magical
I know that weddings are wonderful events – there is so much celebrating, getting together with the family, feasting, dancing, and pictures. Our daughter, Affinity, has a large circle of friends, many of whom came from the group who studied together in Florence, Italy, during their junior year. Affinity has been to most of their weddings and many more of friends and relatives – so she has experienced simple and lavish affairs as well as local and destination events. When she began planning with her fiancé, Jeff Wellington, we knew that the wedding would be some combination of simple, lavish, local, and destination. They chose a site that my wife, Deborah, and I thought was unusual – an apple orchard near Mt. Hood. An outdoor wedding for late September in Oregon seemed dicey, with our famous Pacific Northwest clouds and rain. Would the families from New York and Minnesota come to Portland and then travel to the city of Hood River on the Columbia River?
Affinity and Jeff Wellington just married at Mt. Hood Organic Farms,
in Parkdale, Oregon. Photo by Austin Walsh.
When the RSVPs came in, there was no doubt that families and friends were willing to travel and spend an extended weekend. Somehow the weather took an unusual turn this year and Oregon had a dry summer that continued into fall. All the wedding events were outside and a Friday-night wind blew away any smoke from nearby forest fires. One of the wonderful touches was that the officiant for the wedding ceremony was Father Bruno, a professor who instructed Affinity and her friends at the Gonzaga Florence program. We know that Affinity and Jeff's planning was an overwhelming success – everything came out better than expected. It was magical!
Jonathan and Deborah Collin; Affinity and Jeff Wellington; Sam Collin
Multiresistant TB Poses a Big Threat in India
The headline in the Sept 8–9 Wall Street Journal says it all: "A Woman's 'Untreatable' TB Echoes Around the World." Tuberculosis has been a major killer of humanity through the centuries – it has been particularly disturbing when the population increased in cities during the latter 19th and early 20th century. Older books referred to the disease as "consumption," because individuals ravaged with the disease progressively became emaciated. As antibiotics developed in the 1930s, TB was generally brought under control, especially in the Western nations. Unfortunately, despite massive public health programs with widespread distribution of antibiotics, Mycobacterium tuberculosis has evolved increasing resistance to antibiotics. India and China currently have the largest numbers of active cases of tuberculosis, with estimates of 2.3 million in India and 1.0 million in China of 8.8 million cases worldwide. The World Health Organization estimates that the US has 13,000 cases. The story in the WSJ is an eye-opener: a woman who has been under treatment with two to four antibiotics since her case was diagnosed in 2006 is now showing resistance to 12 antibiotics. Her TB load during the past 6 years, as scaled from 0 to 4, has run between 2 and 4; it is currently 0 on an experimental regimen. However, the drugs brought on a psychotic reaction that led her to beat up her teen-aged son. It is unclear whether she will be able to continue the regimen because of expense and the red tape that she faces in procuring treatment. And she represents only one of a growing number of resistant cases that may be untreatable.
The concern of contagion from public exposure has led the UK to institute required TB testing for all Indians seeking travel visas to stay in England. TB does not have the same level of contagion of a viral disease such as influenza or smallpox. Nevertheless, it is spread through respiratory transmission and continued direct contact; for medical personnel there is a high risk of infection when doing surgery or autopsy. Hence, there is now increasing concern about exposure of the public to individuals with TB. One administrator described the public health situation as though India were sitting on an atomic bomb. The need to institute effective means to manage multiresistant TB is critical. Part of the problem is economic: treatment with "nonresistant" TB can be provided for only $10 for six months; treatment lasting two years for "resistant" TB can easily exceed $2000. Given the alarming development of increasing multiresistance, the India government has offered $100 million to bolster clinics and public health programs for TB treatment. However, the opinion of the World Health Organization is that this is insufficient to control the situation.
The WSJ article offers a poignant story of the difficulty for patients who have the disease but face challenges with doctors and bureaucracies. The case profiled is a 40-year-old woman who six years earlier sought care when she had a chronic cough and began to cough up blood. Her diagnosis of TB was made promptly and she was administered a few antibiotics. However, despite adherence to the program, her TB level continued to score 2 to 3-plus, indicating inadequate control of her TB. After a year of treatment, her physician ordered a test for drug resistance: she showed resistance to 9 antibiotics. The World Health Organization has recognized 17 effective drugs to treat TB, of which the first tier are more effective and have fewer adverse effects. Despite having a test demonstrating resistance for most of her drug regimen, she was continued on antibiotics that were demonstrated to be resistant. One of the more effective second-tier medications, capreomycin, was not used because it was "expensive" – 200 rupees, or $4, per injection. When the patient sought a second opinion and presented her test for drug resistance to an "expert," he ignored her list, dismissing the lab as unreliable. She received another opinion, and her new physician provided her a regimen better suited for her condition. It appeared as though her treatment was effective, although her skin darkened and she began to develop recurrent itching. Because of the itching, she was advised by the physician to stop her regimen and she quit the medication for four months. Then she began after two years of control to cough up blood once again. When she sought medical help from another expert, he also ignored the drug resistance testing that she had undertaken. This physician stated that he preferred to recommend treatment based on his clinical judgment. Seeking yet another physician's care, she was offered another multidrug program, this time including the capreomycin that was not prescribed two years earlier. Her TB count, however, remained high. When she then had a drug resistance scan, she was found to be resistant to not 9 but 12 drugs, and these 12 included all the ones considered effective for resistant cases. The fact that she was resistant to all 12 drugs, making her essentially untreatable, was brought to the attention of the Indian public health authorities. Initially, the possibility that her TB was untreatable was dismissed. However, further testing did bear out that she was resistant to all antibiotics. Her most recent consultant offered her two experimental drugs additionally to the four drugs that she had been using. This regimen was effective in lowering her TB score; however, she developed psychosis and severe burning in her feet, harsh adverse effects from the experimental medication. She has returned to her home in the country far from Mumbai and has received only a one-month supply of medication by courier (in India the policy is that patients receive their medication in person at the clinic so that TB workers can see that the medication is used). She is optimistic that she may survive – a possibility that seems remote.
TB remains a primary concern in assessing the patient with chronic cough and is a worrisome infectious disease with multiantibiotic resistance. It would behoove us to consider administering "immune enhancement" regimens including vitamins, minerals, nutraceuticals, and herbs to prevent exposure to TB from causing infection.
AANP Meeting Milestone of Naturopathic Progress
The August 2012 meeting of the American Association of Naturopathic Physicians (AANP) in Bellevue, Washington, was well attended by over 500 ND physicians and sponsored by opposition a large number of supplement manufacturers, diagnostic laboratories, medical suppliers, insurance companies, and physician services. Progress continues to be made, with legislatures authorizing licensure, as in Puerto Rico, and expanded insurance coverage and physician scope of service, as in Vermont. However, some states continue to oppose licensure, as in New York. Naturopathic physicians in attendance planned ongoing efforts to ensure licensure of naturopathic medicine throughout the US. Additionally, special training is being offered to train NDs to appropriately market their practices in their communities through typical press and television/radio media as well as social media and on physician "rating" sites on the Internet. Expanded inclusion in insurance programs as well as Medicare has ensured greater patient access to naturopaths. The AANP continues to lobby federal legislators to bring about national acceptance for naturopathic health care. The opening of a new campus for Bastyr University in San Diego reflects increasing student enrollment at naturopathic schools and the recognition of naturopathic medicine as "mainstream" postgraduate education.
Lectures at the AANP meeting offered a wide spectrum of clinical, diagnostic, and research review. Robert Steisfeld, NMD, discussed the results of experimentation with pantethine in managing cardiovascular disease risk with effective reduction of elevated cholesterol. Jonathan Wright, MD, reviewed intriguing concepts in assessing male and female risk for cancer by measuring the activity of hormone metabolites. Wright explained the role that depressed adrenal functioning may play in developing glaucoma. He also advised assessment of aldosterone in patients with hearing loss and tinnitus.
Vitamin A and D in the Treatment of Colds
Dr. Wright suggested that I might want to reprint an old-time study of vitamins A and D's role in treating colds:
112 patients with colds received a cod-liver oil concentrate. The dosage contained 150,000 units of vitamin A and 15,000 units of vitamin D on the first day and one-third of these amounts on the second day. If symptoms remained, two-thirds of the original dose was given on the third day. After the first 24 hours, 30.3% of the patients were symptom-free and an additional 51.8% were almost symptom-free, for a total of 82.1% cured or almost cured. Using this treatment, many patients have avoided colds by stopping them in their prodromal stage. No adverse effects of the treatment were seen.2
Primer on Treating Pneumonia and COPD
Jeremy Mikolai, ND, and Martin Milner, ND, have authored two major articles on treating respiratory disease in this issue. The first article focuses on diagnosis and treatment of community-acquired pneumonia. What is impressive about this article is that it would be an appropriate read for a hospital-based physician updating clinical evaluation tools including office oximetry, lab testing, diagnostic imaging, bacteriology cultures, and criteria for hospitalization. Mikolai and Milner recommend antibiotic treatment and advise multiantibiotic therapy depending on severity of the pneumonia process with coexistent conditions. What distinguishes this paper from an article for "standard of care" medicine is the employment of naturopathic modalities in treatment of infection. The authors review the need for mucolytics and expectorants, antimicrobials, and supportive therapies. A case study provides detailed treatment approaches for managing a patient with pneumonia.
Mikolai and Milner's second article considers an unusual case of COPD in a young individual. The authors again present an excellent primer for understanding respiratory disease. The diagnosis of obstructive disease found in COPD is distinguished from restrictive disease seen in pulmonary fibrosis. Mikolai and Milner provide a very understandable and simple explanation for pulmonary function testing that is useful to follow the case study. The young person's COPD is complicated by anxiety disorder and drug dependency. The authors monitor the changes in pulmonary function status as the patient's treatment is continued, offering an objective basis to monitor the case.
Dr. Mikolai is a third-year Heart & Lung Resident under the mentorship of Dr. Milner at the Center for Natural Medicine. Drs. Mikolai and Milner are actively working to create the first ND clinical fellowship in cardiology.
Jonathan Collin, MD
1. Anand G. A woman's "untreatable" TB echoes around the world. Wall Street Journal. September 8–9, 2012. http://online.wsj.com/article/SB10000872396390444273704577633431646496346.html.
2. Crampton, CW. Vitamin A in the treatment of colds. NY State J Med. 1944;44:162–166.