Food Allergies in Kids (Kelso, 12/18/2024)

 A recording of this week's Grand Rounds is available HERE

This was an excellent presentation by a pediatric allergist, Dr. John Kelso. I learned a lot, but I'm a little behind on writing up a summary.

Check back for my notes shortly.

Physiologic Birth in the Hospital (Saedi-Kwon, 12/11/24)

 A recording of this presentation is available HERE

Thanks to Dr. Ryley Saedi-Kwon for her presentation this week on Physiologic Birth. As usual, a recording of the presentation is available above. Dr. Saedi-Kwon covered a wide range of birth topics, see my highlights below.

Physiologic Birth, as outlined in a 2012 consensus statement of US midwifery organizations includes:

  • Spontaneous onset and progression of labor
  • Includes biological & psychological conditions that promote effective labor
  • Results in the vaginal birth of the infant and placenta
  • Results in physiological blood loss
  • Facilitates optimal newborn transition through skin-to-skin contact
  • Supports early initiation of breastfeeding

2018 systematic qualitative review found that

  • Most wanted a physiological labor and birth while acknowledging that birth can be unpredictable and frightening and they may need to ‘go with the flow’

  • Small minority birth was physical process that should be conducted as quickly and painlessly as possible


What matters to birthing patients is:
  • Giving birth to a healthy baby in a clinically and psychologically safe environment
  • Practical and emotional support from birth companions and competent, reassuring, kind clinical staff
  • Individualized care
  • Sense of personal achievement and control through active decision-making
Birth Setting
Possible birth settings include hospital, home, or birth center birth. There are advantages and disadvantages to all three settings, and may patients' options are limited/controlled by financial and insurance decisions rather than personal decision-making. Whereas the hospital setting has demonstrated benefit in "high risk" deliveries, there is plenty of data showing that both home birth and birth center birth can be just as safe in "low risk" patients. Whereas hospitals offer expert and facile access to testing and timely interventions, they tend to be less private, less comfortable and allow limited freedom of movement. Birth centers have demonstrated less interventions and some improved outcomes with similar safety outcomes to hospital birth in a select patient population.
   

Racial and ethnic disparities exist. As we know, BIPOC women have increased rates of maternal mortality but also have increased rates of discrimination and mistreatment in the hospital setting, including higher rates of feeling "pressured into interventions". In one study, 30% of BIPOC patients experience mistreatment during hospital birth compared to 6.6% of patients who delivered in a birth center. 
***

There are many evidence-based and non-evidence based interventions patients and providers use/recommend to promote physiologic birth. These very across the stages of labor. Dr. Saedi-Kwon reviewed briefly the use and evidence for these interventions/options:

First stage of labor

"natural birth preparation" or "natural induction"
  • Red raspberry tea 
  • Dates
  • Castor oil
  • Primrose oil
Pain Management is an important consideration for laboring patients. IVs, medications, and pharmaceutical interventions can have a tethering effect for women, and non-pharmacological interventions have some high level evidence. These include:
  • Continuous labor support (i.e. doulas and/or partner support): associated with decreased length of labor, increased rates of vaginal birth, reduced procedural deliveries, decreased pain medications and increased patient satisfaction. Continuous labor support also allows someone to be present who is advocating for the patient during their labor. Of note, Medi-Cal now covers doula services. 
  • maternal position: upright and walking has demonstrated better outcomes
  • hydrotherapy/water immersion: decreases anxiety and improves pain without any evidence of harm 
  • counter pressure: mixed data but some studies show improved pain scores
How can we limit interventions in birth?
  • Delayed admission to L&D
  • Outpatient cervical ripening: pharm or non-pharm placed in the hospital (misoprostol or foley) with return in 12-24 hour for recheck
    • Whereas current guidelines do recommend immediate induction of labor if a patient has PROM, 95% of patients with PROM will go into spontaneous labor within 24-48 hours
  • Intermittent auscultation for fetal monitoring (via doppler)
2nd Stage of Labor
  • Perineal massage: metanalysis found a decrease rates of 3rd and 4th degree lacerations, more significant in primigravida
    • starting at 34 weeks, 3-9 o'clock posterior perineum, clean hands, lubricant (water-based or food based oil)
    • can by done by partner or self
    • even as infrequently as 1-2x week has benefit
  • Warm compresses held to perineum during/between pushing also has some evidence of decreased 3rd/4th degree lacerations
  • "Hands on" vs. "Hands poised" position (by provider): mixed evidence, comparing the two, hands on shows no reduction in anal sphincter injury
  • Pushing (studies done in patients with epidurals)
    • immediate vs. delayed, immediate pushing does decrease length of second stage and reduces rates of chorioamnionitis, but there is no different in vaginal operative delivery, laceration, or post-partum hemorrhage
    • open vs. closed glottis: closed glottis does again decrease length of second stage but does also increase risk of abnormal post partum urodynamics
    • opening the pelvis with knees wide (traditional lithotomy) vs. with internal rotation of the knees: internal rotation does increase size of pelvic outlet
    • pushing position: upright and side lying (as opposed to lithotomy) does increase rates of intact perineum
3rd Stage of Labor
    • Delayed cord clamping increased final blood volume of neonate by 20-30% and has proven benefit in neonates, >120 seconds
      • in very preterm neonates (<28 weeks), cord milking may be preferred to allow for urgent resuscitation for non-vigorous infants
    • To decrease rates of postpartum hemorrhage (PPH): 
      • Pitocin at delivery of anterior shoulder decreases rates of severe PPH
      • cord traction with counterpressure on uterus (risks are cord avulsion (5%)and uterine inversion (<0.1%), both of which are rare
And, finally, Dr. Saedi-Kwon ended her presentation with this beautiful montage from the National Association to Advance Black Birth - Black Birthing Bill of Rights. Please check them out HERE.


 

Osteopathic Manipulation in the Hospital (Earl, 12/4/2024)

A recording of this presentation is available HERE.  

Many thanks to Dr. Connie Earl for a FANTASTIC Grand Rounds presentation this week on Osteopathic Manipulation in the Hospital. Dr. Earl, who previously ran the Forestville Wellness Center through West County Health Centers, is currently doing a year of extra "residency" training on Osteopathic and Neuromuscular Medicine (ONMN) at Maine Medical Center. She shared with us her passion for Osteopathic Manipulation (OMM/OMT) and a TON of what she described as "really weird studies that demonstrate ways in which OMN may be used in the hospital setting".

As an allopathic-trained physician, I admit I am often envious of the anatomy knowledge and tremendous skills of my osteopathic colleagues-- and I can tell you from personal experience that Dr. Earl has amazing clinical skills (and hands!)

For those of us less familiar with OMT, she started with the four principles of osteopathy: 

  1. The body is a unit; the person is a unit of body, mind and spirit.

  2. The body is capable of self-regulation, self-healing and health maintenance.

  3. Structure and function are reciprocally interrelated.

  4. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation and the interrelationship of structure and function.


Aren't these principles cool?  


Dr. Earl also contrasted OMT with allopathic medicine, which often focuses on treating/curing/preventing the disease; whereas osteopathy focuses on what we can do to protect the host. 

Well-structured randomized control trials of OMT are extremely challenging to create because of a wide variety of methodological variants. For example, OMT is a response to a personal and individual host. If you protocolize an OMT intervention (in order to standardize it), you are already compromising the validity of the treatment. OMT techniques vary widely, sham OMT is challenging to replicate, and many studies include trainees of varied levels of experience. 

Where she is currently training at Maine Medical Center, a 700 bed Level 1 Trauma Center, the OMN service typically treats 60-70 patients. These include patient post-CABG, poly-trauma patients, patients after GI surgeries, NICU babies, term babies and mothers, and more. 

Founding father of OMT, AT Still, is famous for his evocative quotes. One that captures another important tenet of OMT is a focus on the lymphatics system: "We strike at the source of life and death when we go to the lymphatics."


Dr. Earl shared some really amazing and interesting observational data of OMT during the 1918 Flu Pandemic, in which there was a remarkable 6% death rate for all-comers. Observational studies found that patients treated with OMT (there was no influenza treatment at the time) had closer to a 0.25% death rate. Dr. Earl stressed that these were not RCTs, and yet. . .OMT has been associated with improved respiratory function, supporting increased circulation and increased lymphatic flow. All of which certainly could have biologic plausibility in terms of helping with viral respiratory illness. 

Canine and rat studies both demonstrate improvement in lymphatic pumps with OMT. Human studies, whose lymphatic pumps are a little more challenging to study, demonstrate increased tidal volumes. 


Here are some examples of patients cared for by OMN providers at Maine Medical Center:
  • post-CABG patients: improved peripheral circulation, improved cardiac indices, decreased time to dc (1/2 day), decreased time to first BM, increased functional independence
  • post-sternotomy patients:: decreased pain, LOS, increased mean inspiratory volume
  • GI surgeries, especially ileus: decreased LOS, decreased time to flatus, less pain, decreased time to first stool, decrease use of opioids
  • IBS/constipation: decreased pain, bloating, constipation and increased quality of life
  • Inpatient pediatric patients
    • breast/chest feeding: latch issues, increased exclusive breastfeeding, better milk transfer, decreased pain
    • birth trauma: hypoglossal nerve trauma/compression, hyoid connections and torticollis
    • premature neonates/NICU for feeding tolerance
Let me know if you want references to any of the OMT studies. I have them!

Perianal Disease: Not Everything down there is a Hemorrhoid (Cortez, 11/20/2024)

 A recording of this presentation is available HERE

Many thanks to Dr. Allen Cortez for an excellent presentation on perianal disease. I learned a lot and was really impressed by how much Dr. Cortez, a long-time local general surgeon, knows and cares about a region of the body that many people are pretty uncomfortable talking about. I recommend you watch his presentation, the link above. 

My notes:

Hemorrhoids are extremely common -- 5-10% of the population, >2.2 million people per year with over 2 million prescriptions per year that add up to over $43 million in healthcare costs. But many patients are being treated for hemorrhoids when there may be other things going on down there, including: fissures, fistula, abscess, pruritis, and rectal prolapse. 

Dr. Cortez reminded us to go back to the basics: 1) listen to the patient (e.g. hemorrhoids generally don't hurt, so if the patient is complaining of pain, broaden your ddx) and 2) examine the patient.

Fiber

Encourage fiber! All our patients need more fiber. And fiber isn't good for just the perianal region. Fiber decreases risk of cardiovascular disease, decreases risk for colon cancer. "The best fiber out there is the one you'll take". Really, the only downside is increased flatulence.

Fiber options abound, including: psyllium husk, benefiber (can sprinkle on yogurt), fiber capsules or gummies (e.g. Kirkland brand, 2-4 gummies 2x per day, with LOTS of water).

Once you start a fiber supplement, don't make any changes for 5 days.

Miralax is good too, but it shouldn't replace fiber. Use miralax PRN for constipation. 

Dr. Cortez reminded us that the increased pressure of diarrhea can also contribute to hemorrhoids. The goal is ONE nice big healthy bowel movement per day, no more than 4-5 minutes sitting on the pot. It is better to return 3 or more times than sit for prolonged period of time on the toilet.

When you are going to examine a patient for perianal complaints: put them in L lateral decubitus (better to see than lithotomy). Look externally for tags, fissures/openings, thickened skin, ulcerations, masses. If you see a fissure stop there (you can make it worse). Use anoscopy and a digital exam to check for tone, masses, blood, etc. 

Dr. Cortez is not a fan of donuts for any perianal condition. In his eloquent words: "Gravity tries to push your liver right out your butt"

Hemorrhoid Treatment 

1) Banding (in office), no prep, effective, can be done several times, no downtime, no severe pain

2) Hemorrhoidectomy (surgical) is always a last resort, very pain ful but most effective. Stapled hemorrhoidectomies are not superior.

Thrombosed hemorrhoids, which present as big purple extremely painful lumps should be unroofed in first 2-3 days for pain control (in ED or office). If it has been > 5 days, healing is equivalent and intervention is not indicated.

Fissures

Perianal fissures, which are tears in the anoderm exposing the sphincter muscles, are extremely painful. Patients may describe symptoms as "crapping out glass" or "jamming a knife in my butt". 73% present midline posteriorly. If you visualize a lateral fissure, that patient needs a work-up, including testing for Crohn's, HIV, syphillis, TB and more. 



Acute fissures (< 6 months) can be treated with fiber, fiber and fiber, as well as hydration and sitz baths. This takes time! Topicals can sooth and manage symptoms, including topical nitroglycerine. Dr. Cortez's preferred topical is compounded diltiazem/nifedipine cream (locally can get compounded at Dollar Drug). Can be rx'd TID.

Chronic fissures (>6 months) require treatment with chemo-denervation, including Botox, which is effective and stops spasm. Some people need surgical intervention: with sphincterotomy or anocutaneous flap.

Perianal abscess

Perianal abscesses can also be extremely painful. 30-70% of abscesses have an accompanying fistula. 40-50% will develop a fistula over time.

 Treatment of perianal abscess is I&D, and usual management with packing is not effective because the skin often heals over before the abscess heals. Instead make a BIG incision (this may require sedation-- need to happen in ED?) and may need an initial packing but then should probably not be packed . Perianal abscesses can occur in several locations: ischiorectal, intersphincteric, perianal and supralevator. No antibiotics are indicated once drainage (i.e. source control) is achieved. Many fistulas will heal themselves and not all perianal abscesses need CT imaging. But if you are concerned, send to surgeon for further assessment. 

Malignancy

Finally, malignancies can present in the perianal region and the only way to diagnose them is to look for them. These can include squamous cell carcinomas and melanomas. See images below for some examples. 



Vaping: Medicine or Menace (Ling, 11/13/2024)

 A recording of this presentation is available HERE.

***

This was a mind-blowing and practice-changing Grand Rounds this week -- so much to learn and understand about vaping (aka e-cigarettes) as primary care providers. The speaker, Dr. Pamela Ling, is the Director of the UCSF Center for Tobacco Research and Education, and she shared so much valuable data and on-the-ground information about the current state of vaping. The title of her talk was Vaping: Medicine or Menace?

Here's what I learned:

First off, the vaping industry is rapidly evolving. Unfortunately, the science, while forthcoming, lags behind an agile and sneaky industry. The first e-cigarettes came on the market in 2009 and looked like little "fake cigarettes" (they even featured a puff of smoke). Now, vapes come in a shapes and sizes and with increasingly concentrated (and flavored) solutions and changing delivery devices. 

E-cigarettes create an aerosol by using a battery to heat up liquid that usually contains nicotine, flavoring, and other additives. Users inhale this aerosol into their lungs. E-cigs can also be used to deliver cannabinoids, such as marijuana and other drugs. 

OMG check this out! These are vaping products confiscated from high schools in California and North Carolina (1000 products from 25 high schools) from an MMWR publication.


While cigarette smoking levels are down in California (and SoCO), vaping is on the rise, and the youngest have the highest rates.



In fact, SoCo teens seem to have higher rates of vaping than California teens overall.


And, unsurprisingly for those of us who care for marginalized populations, more vulnerable kids (based on gender identity, race, etc) have even higher rates of e-cigarette use



Note that while Sonoma County average of e-cigarette use is 12%, certain groups have MUCH higher rates, namely: SoCo gender questioning kids and kids who identify as black/African American, and Native American.

In addition to vaping nicotine, cannabis is increasingly popular; almost as many people use cannabis as tobacco now in the US. And while smoking is still the most common way to consume cannabis, edibles and vaping are both increasing.



Of note, older generation vapes contained far LESS nicotine. Newer vapes include chemicals that make higher concentrations more palatable and more appealing. As you can see in the image below, whereas older versions (The JUUL) contained the equivalent of about 1 pack of cigarettes, newer versions (e.g. Flum pebble) now contain up to 30 packs of cigarettes. This leads to increased nicotine consumption and dependence. And because of price controls and taxation cigarettes, vaping can save money, which certainly also influence habits and behaviors. Whereas a carton of cigarettes may cost upward of $50-85, a single vape (the equivalent of 3 cartons) costs less than $20 online. 

The same is true for rising THC concentrations in cannabis vapes. 

Do E-cigarettes help people quit smoking?

It is important to understand that there is SOME evidence of the use of e-cigarettes to promote smoking cessation, though the evidence is weak at best. E cigarettes are not approved by the FDA for smoking cessation, though they are recommended by the UK NHS due to this evidence. Under RCT conditions, earlier generations of vape products have been shown to be more effective than nicotine replacement therapy. You can see this data below summarized in the Cochrane review below. 

This has not borne out in population level observational studies-- in other words, when used as a consumer product, e-cigarettes do not help with cessation. Also important to note that the e-cig market is evolving extremely rapidly and the products are increasingly appealing to young people (this is not a coincidence).

Isn't vaping better for us than smoking?

Stella Tomassi and colleagues published a study of young adult vapers who never smoked compared to smokers using quantitative PCR to detect DNA damage (as a marker for future cancer).  They found a dose-dependent formation of DNA damage in oral cells of vapers who had never smoked tobacco cigarettes as well as exclusive cigarette smokers. They also found more damage seen in heavier users, users of pod vapes and sweet flavors) independent of nicotine levels.  

Recent studies of the epigenetic effects of tobacco smoking and e-cigarette use found similar changes in DNA methylation among people using cigarettes and people using e-cigarettes, changes that were associated with lung carcinogenesis.

While we do not have direct human data on vaping and lung cancer outcomes, these newer biomarkers of DNA damage and epigenetic changes are likely to be informative for lung cancer risk.

When people switch completely from cigarettes to e-cigs, there is definitely a decline in those biomarkers. So maybe vaping IS better than cigarette smoking. Unfortunately, many people try to convert to vaping but then continue intermittently also smoking cigarettes. Interestingly, the evidence shows that these "dual users" do not reduce their exposures to carcinogens.  

In terms of cardiovascular disease: a recent study published in NEJM 2024 found that CV disease risk from vaping was NO different than CV disease risk from smoking. So for CV risk the answer is NO.

But here's perhaps one of the most important take home points: dual use (using BOTH vapes and cigarettes) is definitely the worst for patients. Check out this summary table below showing the risk of disease appears higher for dual users. . .


Dr. Ling's closing advice to clinicians:

  • Ask about vaping to engage in a cessation conversation
  • Ask about both nicotine and cannabis vaping
  • Encourage to treat nicotine vapes like any tobacco product
  • Encourage complete switching not dual use
  • Longer term transition off vaping products (using nicotine-replacement)

Ariel Thomas-Urlik, MPH from the Sonoma County Department of Public Health, who helped make this presentation possible, also shared some local information about local laws aimed at preventing widespread sales of nicotine products to children and adults.  

Did you know that SoCo has a minimum price of $10/pack for cigarettes? No coupons or discounts are allowed to be applied. 

Also California law currently prevents flavored tobacco products from being sold in physical retail stores, and a new law going into effect this week prohibits County of Sonoma do NOT ALL e-cigarette sales in physical retailers that sell tobacco (cannabis dispensary do not apply). While retailers continue to sell, DPH is using volunteer decoys to catch retailers who are violating this law. There is less access in SoCo, and we know that when access goes down, people become more interested in quitting. 

A new state law CA AB3218 which goes into effect on January 1, 2025 makes online purchase of vapes illegal in the state of California!

Methadone in Hospitalized Patients (Bowen & Aguilar 11/6/2025)

 A recording of this presentation is available HERE

Deep gratitude for our two Addiction Medicine Fellows, Drs. Bianka Aguilar and Anna Bowen, for an important and concrete presentation this week on Methadone in Hospitalized patients. They will be back in the spring with another Addiction Medicine presentation!

Here are my favorite pearls:

1) Starting methadone in the hospital decreases self-directed (AMA) discharges (30% vs. 59.6%), reduces all-cause readmission rates (27% vs. 41%), and decreases risk of endocarditis, osteomyelitis, and septic arthritis. I was taught that we should be "cautious" in the hospital about starting methadone if there wasn't a long-term plan for follow-up, but this is no longer true. If a patient is motivated to start methadone and it is indicated, we should do it. There are many new algorithms that can cross taper people easily from methadone to buprenorphine IF they are unable to get methadone through an outpatient treatment center.

2) Fentanyl in our drug supply has changed the treatment of opioid use disorder (OUD).  Recent studies are showing the methadone may be superior to buprenorphine in terms of treating OUD in fentanyl users. Methadone for OUD also appears to have higher retention rates. 


3) Traditional methadone induction involved weeks of up titrating doses until methadone was at therapeutic levels; newer studies, particularly in the fentanyl era, have found that quick starts--  higher starting doses, 30-40mg on D#1, and quicker up-titrating, increasing by 10-15mg, per day is safe and effective.

4) While methadone is known to lengthen the QT interval, not everyone on methadone needs serial or even baseline EKG monitoring. Most guidelines recommend an EKG at initiation of methadone only for patients with other cardiac risk factors (e.g. known prolonged QT, CAD, CHF, etc.)  AND once methadone doses near 100mg daily. This is a dose response side effect. We should remember to look at other medications that can also prolong QTc to see if those can be altered/discontinued. A QTc of >500 is not an absolute contraindication to treating with methadone, but the clinical scenario merits review (e.g. medication review)

4) Some people are "rapid metabolizers", meaning that single daily dose of methadone may be insufficient to help with cravings and treat their opiate use disorder. This is known to be true in pregnancy, but can also occur in some patients. Rapid metabolizing most often manifest as someone who appears appropriately treated by a certain methadone dose by 2-4 hours after their dose (maybe even a little sedated), but then 12 hours later is experiencing s/sx of withdrawal or cravings. We can potentially help their case to receive methadone BID by checking "peak" (2-4 hours after the dose) and "trough" (right BEFORE their dose) serum level of methadone.




Practical tips for methadone in hospitalized patients:

  • Consult the addiction medicine fellows (on call schedule on Epic)
  • Document a 1 year history of OUD
  • Use the COWS score to monitor s/sx of withdrawal
  • We have 2 Methadone clinics in Santa Rosa: DAAC and SRTP. When initiating methadone, contact one of these clinics ASAP to arrange intake.
  • There is a federal 3 day exception for patients being discharged from the hospital, to whom we can prescribe methadone. Current local help is available via Creekside Pharmacy vs. SSRRH ER.
  • Offer all patients naloxone on discharge. 
  • Use the California Bridge website for help, including guidelines and algorithms.


  • Keep your eye out for newer studies showing quick start algorithms
  • Toronto Perinatal Addiction Medicine Team



Integrative Approach to Anxiety and Depression (Brown, 10/30/2024)

A recording of this presentation is available HERE.

Many thanks to Dr. Andrew Brown, who gave an excellent Grand Rounds presentation this week on Integrative Approach to Anxiety and Depression. Anyone in primary care knows that we do a lot of management of psychiatric disorders in the primary care setting, often with very little specialty support. Many patients are interested in pursuing not just standard medical therapy (SSRI + cognitive behavioral therapy), but also integrative modalities.

Dr. Brown laid out the evidence for a wide range of non-pharmaceutical and non-psychotherapy treatments for anxiety and depression. The bottom line is that there are many, many, many integrative options with a range of small to moderate to strong evidence for the management of anxiety/depression. Put your seatbelts on. And don't use too many at once!

Integrative modalities, for the purpose of this talk include 

  • lifestyle/behavioral 
  • nutrition 
  • supplements and 
  • physical practices

Lifestyle/behavioral

Exercise works! The USPSTF recommends 2.5 hours/week of aerobic exercise for overall improved health. And good news, exercise can improved depression!  Some exercise modalities may be better than others, including: include walking/jogging/yoga/strength training. The more "intense" the better. However, in a 2023 review article, ANY regular exercise, regardless of type, setting, or supervision decreased depression scores by 5-7 points. 

There is not much evidence for exercise in anxiety, with a different review paper finding a benefit of exercise for anxiety in 7 of 25 studies and no benefit in the remaining 18.

It should come as no surprise that substance use and substance use disorders are frequent comorbidities with anxiety and depression. Note in the chart below:

  • 16% of people with anxiety disorder also have SUD
  • 16% of people with an adjustment disorder also have SUD
  • 16% of people with depression also have SUD
Nicotine and tobacco, alcohol, and yes, even marijuana>>worsen anxiety

Sleep and anxiety/depression, as we know, have a bidirectional relationship. Treating the underlying cause of sleep helps (e.g. sleep disordered breathing). If you target insomnia, you improve mental health.

Social support helps too. Social support and connectedness -- perhaps even via online platforms-- helps depression and anxiety, even in people with a diagnosed social anxiety disorder!

Time spent in the natural world, including activities like "forest bathing", nature-based treatment, gardening, wilderness time, outdoor adventuring all have a positive effect on mood and anxiety. Many of the studies looking at time in nature are Korean studies, and plenty show positive effect, which is durable (at least up to 12 weeks after the outdoor time). One study even found that LOOKING at images of nature had a positive impact on mood. 

Nutrition 

Eating a healthy diet improves depression and anxiety! And there are plenty of different healthy diets that have been shown to improve mood in a 2021 Systematic Review: a diet high in fruits/veggies, a diet with less calories, a diet high in omega-3 fatty acids, probiotics, a diet rich in dietary minerals, and a ketogenic diet. Even eating breakfast works!


What doesn't work? An unhealthy diet: insufficient protein, high fat, lots of carbs/sugars, and a diet low in tryptophan (which is found in protein-rich foods, not just turkey).

Supplements

Many many botanicals are used to treat symptoms of depression anxiety. Four that Dr. Brown highlighted with moderate/strong evidence for positive effect are:
  • Kava Kava (Piper methysticum): 50-70mg TID, mixed evidence, some concern for hepatoxicity
  • St. John's Wort (Hypericum perforatum): strong evidence in depression, 500-1800mg/day. A 2017 Meta-analysis found it to be equivalent to SSRIs (of note, not safe to take at same time as SSRIs)
  • Saffron (Crocus sativus): 30-200mg/day, strong evidence for depression and anxiety, $$ cost can be an issue, also concerns regarding first trimester SAB in early pregnancy
  • Lavender (Lavandula angustifolia): "a few drops", moderate evidence, compared to lorazepam in a trial of preoperative patients was found to be "equivalent". SE: gynecomastia

Probiotics: studies show a small but consistent positive effect in depression/anxiety (not enough to be used as monotherapy, but consider for adjunct)

Vitamin Supplements
Dr. Brown highlighted five vitamins with some efficacy in depression/anxiety:
  • Vitamin D: stronger evidence in depression (than anxiety)
  • B Complex, found in dark/green/leafy veggies, may be good adjunct
  • Zinc: dose response benefit in depression and anxiety
  • Magnesium: strong evidence as either monotherapy OR adjunct, depression more than anxiety, change of 4 points on GAD7 or PHQ9, so may be good choice for mild-mod depression/anxiety
Physical Practices

Dr. Brown finished up his presentation talking about a range of physical practices that, again, have some evidence for treatment of depression and/or anxiety, specifically:
  • Acupuncture: 2024 Meta-analysis found that acupuncture was BETTER than SSRIs for depression, particularly if electro-acupuncture techniques are used. Most studies indicate that a combination of SSRI and acupuncture decreases rates of remission. There is less evidence for acupuncture in anxiety.
  • Acupressure: no evidence for durable benefit, but may be good for episodic symptoms (and can be self-done)
  • Progressive Muscle Relaxation: strong evidence in pre-procedural anxiety and symptoms report for patients. There are a wide range of muscle relaxation techniques, many can be taught in just a few minutes in the office setting
  • Breathwork: Once again, there are many different breath practices. Two easy ones to teach in the office are: Box, 4-7-8 (see images below). Both have been shown to help with symptom management



Finally, do Apps work? Apps tend to be cheap and easy for patients to get, particularly in a low resource. According to Dr. Brown. There have been 50+ studies, including an RCT, looking at apps for physical practice changers, and they have shown a significant but small/moderate effect on depression/anxiety. So consider apps an option too!


References:
  • de Noronha, S.I.S.R., de Moraes, L.A.G., Hassell, J.E. et al. High-fat diet, microbiome-gut-brain axis signaling, and anxiety-like behavior in male rats. Biol Res 57, 23 (2024). https://doi.org/10.1186/s40659-024-00505-1

  • Fatemi, F., Siassi, F., Qorbani, M. et al. Higher dietary fat quality is associated with lower anxiety score in women: a cross-sectional study. Ann Gen Psychiatry 19, 14 (2020). https://doi.org/10.1186/s12991-020-00264-9

  • Mohit Kumar, Babita Bhatt, Chitralekha Gusain, Nayan Mahajan, Mahendra Bishnoi, Sex-specific effects of ketogenic diet on anxiety-like behavior and neuroimmune response in C57Bl/6J mice, The Journal of Nutritional Biochemistry, Volume 127 (2024). https://doi.org/10.1016/j.jnutbio.2024.109591.

  • Haduch, A.; Bromek, E.; Kuban, W.; Daniel, W.A. The Engagement of Cytochrome P450 Enzymes in Tryptophan Metabolism. Metabolites 2023, 13, 629. https://doi.org/10.3390/metabo13050629

  • Gregory L. Stonerock, Rahul P. Gupta, James A. Blumenthal, Is exercise a viable therapy for anxiety? Systematic review of recent literature and critical analysis, Progress in Cardiovascular Diseases, Volume 83, 2024, Pages 97-115, https://doi.org/10.1016/j.pcad.2023.05.006.

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Food Allergies in Kids (Kelso, 12/18/2024)

 A recording of this week's Grand Rounds is available HERE .  This was an excellent presentation by a pediatric allergist, Dr. John Kels...