For years we were under the impression that fat was bad. But things aren’t always so black-and-white. There are different types of fat, some better for us than others. Here’s the lowdown on the better-for-you fats — olive oil, safflower oil, almond butter and more — and ways to incorporate them into your favorite dishes.
“Good” Versus “Bad” Fat
“Good” fat is primarily composed of healthier unsaturated fat and can be found in foods like canola oil, olive oil, peanut oil and avocados. The healthier unsaturated fats can further be divided into polyunsaturated and monounsaturated. "Bad" fat is mostly composed of artery-clogging saturated fat and can be found in foods such as butter, ice cream and eggs. In everyday cooking, focus on adding those healthier fats, while moderating the less-healthy ones.
Hello, Good Fats!
Any type of food containing fat will have a good number of calories. For example, a tablespoon of any oil contains 120 calories and 14 grams of fat. So no matter which type of fat you choose (from oil, avocado or nuts), portions still matter in order to keep calories under control.
Olive Oil
This oil is extracted from a fruit (yes, olives are a fruit!). Olive oil varies in color and flavor depending on the variety of the tree, ripeness of the olives, type of soil and climate. This monounsaturated fat has a low smoke point and is good for low- to medium-heat cooking and for enhancing flavor in dishes after they have been cooked (like in dressings).
Recipe to try: Cowboy Beans
Sunflower Oil
This polyunsaturated oil is pressed from sunflower seeds. It has a pale yellow color and a very mild flavor. It also supplies more of the antioxidant vitamin E than any other vegetable oil. It has a relatively high smoke point, which makes it versatile for cooking at higher temperatures or drizzling over ready-to-eat foods (like salad or popcorn).
Recipe to try: Chile Lime Popcorn
Safflower Oil
This golden-hued polyunsaturated fat is made from a plant that resembles a feather. It has a relatively high smoke point and can be used for high-heat cooking, like stir-frying.
Recipe to try: Parsnip Salad
Almond Butter
A 2-tablespoon serving of almond butter has around 200 calories, 18 grams of fat (mostly unsaturated) and 4 grams of protein. It's an excellent source of vitamin E, magnesium and manganese. It's also chock-full of nutrients like fiber, calcium, iron, B vitamins, potassium and zinc. When buying almond butter, read the ingredient list and avoid varieties with added sugar, salt or hydrogenated oils.
Recipe to try: Mini Almond Butter and Strawberry Muffins
Peanut Oil
This pale yellow monounsaturated oil has a subtle peanut flavor and scent. It's traditionally used in Asian dishes to help bring out the flavor. It has a high smoke point, which is good for searing and stir-frying.
Recipe to try: Spicy Beef Stir-Fry
Avocado
This fruit is brimming with heart-healthy monounsaturated fat and is free of cholesterol and sodium. It also contains the antioxidant lutein, which can help keep eyes in tip-top shape. A serving of avocado is 1/5 of the fruit, which contains over 20 vitamins, minerals and phytochemicals (talk about packed with nutrition!).
Recipe to try: Broccoli and Cheddar-Stuffed Potato Skins with Avocado Cream
This aromatic oil is light yellow in color and is a byproduct of wine making. Because of its clean and mild flavor, it can be used in a variety of dishes. It also has a high smoke point, making it perfect for high-heat cooking methods like stir-frying, baking, sauteing and frying. Each tablespoon of grapeseed oil contains 25 percent of the daily recommended amount of the antioxidant vitamin E, and it also contains oligomeric proanthocyanidins (OPCs), which add to its antioxidant powers.
Recipe to try: Homemade Mayonnaise (enjoy in moderation)
Toby Amidor, MS, RD, CDN, is a registered dietitian and consultant who specializes in food safety and culinary nutrition. She is the author of The Greek Yogurt Kitchen: More Than 130 Delicious, Healthy Recipes for Every Meal of the Day.
Toby Amidor 04 Jan, 2015
enclosure:
In our transition to medical school as first-year medical students, one significant part of our learning has been adopting the dress of the medical profession. Twice a week, in our first-year practice of medicine course, we wear professional attire and don our white coats, the famous symbol of the medical profession. As we learn how to interview and interact with patients, the white coats encourage us to fully embrace our new professional roles as physicians in training.
Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.
Nathaniel Fleming 05 Jan, 2015
Meagan 02 Jan, 2015
Menghilangkan kulit bersisik dengan ampas kelapa memang jarang kita dengar. Ampas kelapa yang sudah tidak terpakai lagi karena sudah diambil santan biasanya dibuang begitu saja. Banyak orang tidak  tahu jika ampas kelapa bermanfaat untuk menghaluskan kulit bersisik. Sehingga ampas kelapa dianggap sudah tak memiliki manfaat lagi kemudian dibuang. Dalam ampas kelapa mengandung minyak alami. Kandungan minyak alami ini bermanfaat untuk melembabkan kulit sehingga membantu menghaluskan kulit bersisik.
Cara menggunakan ampas kelapa untuk menghaluskan kulit juga cukup mudah. Anda bisa mengggosokan ampas kelapa pada kulit anda yang telah dibersihkan terlebih dahulu, Diamkan selama 10 menit kemudian bilas menggunakan air bersih. Lakukan perawatan ini secara rutin 3 kali seminggu.
Dengan menggunakan ampas kelapa secara teratur maka, secara berangsur-angsur kulit bersisik akan lembut kembali. Dengan memanfaatkan bahan yang sudah tidak terpakai lagi ternyata bisa memberi manfaat untuk kulit kita. Selama bisa menggunakan perawatan alami, jadi tidak perlu menggunakan bahan-bahan kimia untuk menghaluskan kulit. Karena yang alami pasti lebih baik untuk tubuh dan kulit kita.
admin 20 Jun, 2014
Berikut ini merupakan beberapa gejala awal penyakit usus buntu yang timbul dan dialami oleh seseorang yang mengalami keluhan penyakit usus buntu.
Penyakit Usus Buntu merupakan suatu peradangan yang terjadi pada usus buntu, yang diakibatkan karena penyumbatan usus buntu yang disebabkan oleh benda keras di dalam tinja atua bebagai macam infeksi yang terjadi sehingga menyebabkan cabang kelenjar getah bening membengkak. Jika tidak segera diatasi dengan baik, maka usus buntu bisa pecah, kemudian menjadikan kantung meradang pada bagian luar usus sehingga akan timbul nanah. Pada tahapan yang lebih parah, benda yang berasal dari usus buntuk akan masuk pada rongga perut sehingga dapat menyebabkan peradangan yang serius dan berbahaya bagi keselamatan jiwa penderitanya.
1. Sakit Di Bagian Pusar
Gejala pertama penyakit usus buntu adalah rasa tidak nyaman atau sakit pada bagian pusar. Rasa sakit ini selanjutnya akan bergerak ke perut bagian bawah secara perlahan.
2. Rasa Sakit Yang Semakin Parah
Awalnya rasa sakit akan terasa biasa saja, namun dalam hitungan jam bisa menjadi semakin parah dan semakin parah. Rasa sakitnya bahkan bisa sangat intens. Biasanya seseorang akan mengalami kesulitan untuk melakukan aktivitas apapun ketika merasa sakit ini.
3. Demam
Penyakit usus buntu disertai dengan demam yang bersamaan dengan rasa sakit pada bagian perut, ketika situasi menjadi semakin parah, demampun akan semakin tinggi.
4. Mual dan muntah
Gejala awal penyakit usus buntu adalah timbulnya rasa mual yang disertai dengan muntah. Awalnya mungkin ini terlihat seperti penyakit yang lainnya yang lebih ringan, namun jika hal ini tidak berhenti lebih dari 12 jam, sebaiknya anda harus periksakan kondisi demikian kepada dokter.
5. Diare
Dalam banyak kasus usus buntu, sakit perut yang parah biasanya bersamaan dengan diare. Kotoran yang dikeluarkan biasanya mengandung lendir. Jika hal ini terjadi pada anda, segera lakukalah pemeriksaan ke dokter.
6. Kembung dan Sering Buang Gas
Kembung dan sering buang gas memang tampak seperti bukan gejala dari penyakit yang berbahaya. Namun dalam keadaan ini, gejala perut kembung dan seringnya buang gas pada penderita penyakit usus buntu akan disertai dengan sakit pada perut bagian bawah.
7. Nyeri Pada Perut
Untuk melakukan tes sederhana bahwa anda memiliki keluhan penyakit usus buntu, cukuplah mudah, anda cukup tekan perut bagian bawah sebelah kanan, kemudian lepaskan. Jika anda mengalam rasa sakit saat tekanan dilepas, maka itu merupakan gejala dari penyakit usus buntu.
Terima kasih anda telah menyimak artikel yang saya sajikan mengenai Gejala Awal Penyakit Usus Buntu. Semoga dengan mengetahui gejala awal penyakit usus buntu tersebut, kita dapat melakukan langkah pencegahan makanan dan pengobatan dari sekarang, dengan tujuan agar terhindar dari bahaya penyakit usus buntu itu sendiri.
Untuk Obat Usus Buntu KLIK DISINI
Agen Resmi : Jln. Noenoeng Tisna Saputra Kota Tasikmalaya – 46115, Indonesia
SMS & Telp : 081320494019
PIN BB : 27d08152
acemaxs 03 Jan, 2015
Apa Itu Glaukoma
Faktor risiko terjadinya glaukoma:
Gejala glaukoma akut antara lain:
Ace Maxs terbuat dari bahan-bahan alami yang telah teruji secara klinis serta diolah dengan tekhnologi modern dan higienish untuk menjamin kualitas dan kuantitas kandungan di dalamnya. Ace Maxs terbuat dari dua bahan utama ekstrak kulit manggis dan daun sirsak ,serta dipadukan dengan madu dan bahan alami pilihan lainnya untuk menjadikan satu komposisi yang tepat untuk penyembuhan penyakit mata glaukoma. Anda juga tidak perlu ragu dan khawatir dengan legalitas obat ini ,karena Ace Maxs sudah terdaftar di dep Kes RI P-IRT No 113317506253 sehingga aman untuk dikonsumsi.
Ace Maxs mengandung zat xanthone dan sitotoksik yang dihasilkan dua bahan utama Ace Maxs yang berkhasiat membuang racun dalam tubuh ,menyeimbangkan sistem kekebalan tubuh, serta memulihkan saraf mata ,dan memperlancar peredaran darah yang terjepit penyebab mata glaukoma. Kandungan dalam kulit manggis berfungsi untuk membersihkan kotoran dalam tubuh termasuk lendir yang menutupi lensa mata. Sedangkan daun sirsak banyak digunakan sebagai obat tradisional untuk menyembuhkan sakit kepala atau migren dan menurunkan tekanan darah tinggi yang merupakan indikasi bahwa kandungan yang terdapat dalam daun sirsak dapat menyegarkan sel saraf, dan mengatur sirkulasi membuang semua racun dalam tubuh.
Ace Maxs ini sangat cocok dikonsumsi oleh berbagai kalangan, seperti penderita diabetes, jantung, darah tinggi, karena tidak menyebabkan efek samping dan ketergantungan. Dengan berbagai khasiat keutamaan Ace Maxs, maka tidak heran para ahli merekomendasikannya sebagai Obat Herbal Glaukoma Akut paling aman dan efektif. Untuk itu segera atasi penyakit yang anda derita dengan obat herbal Ace Maxs yang sudah terbukti dan teruji khasiatnya.
Jika berminat pesan caranya gampang, cukup kirimkan sms sesuai contoh format beserta kode pemesanan berikut dibawah atau KLIK DISINI.
Contoh Format Pemesanan Ace Maxs
"Setiap pemesanan Wajib mencantumkan ( TOA ) Kode Produk untuk mempermudah pelayanan kami"
Catatan :
Himbauan untuk para pelanggan kami atau yang berminat pesan, kami sarankan agar selalu mencantumkan kode pemesanan seperti contoh format pemesanan diatas, agar tidak terjadi kesalahan atau ke keliruan dalam mengirimkan produk yang anda pesan
Link Sumber : http://acemaxs31.com/obat-glaukoma-alami/
acemaxs 29 Dec, 2014
The East West School of Planetary Herbology offers correspondence courses to train home herbalists, health professionals and clinical herbal practitioners. Here you can learn from two of the world's most respected and influential herbalists, alternative health pioneer and American Herbalist Guild founder Dr. Michael Tierra, O.M.D., and clinical herbalist/acupuncturist Lesley Tierra,L.Ac., AHG.
Our herbalist training course is the only one that teaches Planetary Herbology, a unique approach to herbal medicine which integrates plants and diagnostic tools from the three major healing traditions of the world. Staffed by a talented faculty of professional herbalists, the East West herbology correspondence course offers its students distance and on-site education from the very best experts in the field. They really do learn from the best and become the best.
Since its founding in 1980, East West School of Planetary Herbology has graduated the largest number of leaders in the herbal industry.
Our herbalist training offers several levels of in-depth online training courses along with supplemental books, CDs, DVDs, webinars, weekly chats, and a private student discussion forum. On this site you'll also find Planetary Herbal Formulas and other items in our store, and research articles
Get free sample lesson Learn more
Herbs are not only our first medicine; they are also the source for many things we need for our survival, including food, shelter, clothing and medicine, all of which reflect the profound relationship between humanity and the plant kingdom.
But in the 21st century it seems that we have come a long way in achieving control and dominion over the unpredictable elements of nature, which in the past had such a determining influence over the daily course of our lives. One may even excuse our inadvertent arrogance each time we forget about the intimate role that plants play in our daily lives, which includes their serving as the basis for at least 25% of all pharmaceutical drugs. Of further thoughtful consideration is this: in a world which today seeks to lessen its dependence on petroleum, the remaining 75% of all pharmaceutical drugs are derived from petrochemicals.
Plan-e-tar-y her-bol-o-gy -noun
Only in times of crisis are most of us reminded of the importance of being less dependent on highly industrialized, technological systems as our source for food and medicine. This is especially true if we realize the extent to which our food chain is compromised by the heavy-handed use of artificial fertilizers, pesticides, herbicides, and genetically modified foods.
What we face now is a world health crisis. For too many, mainstream medicine remains inaccessible due to the rising cost of health care insurance. Add to that the inability of conventional medicine to offer a satisfactory solution for many diseases. Then there's the plethora of adverse side effects from prescription drug use. Given all of the above, it's easy to see how a $15 billion-a-year alternative health care business was born. That hefty figure represents what people are willing to pay out of pocket; most alternative health care is still not funded by insurance.
In response to this state of affairs, many people consciously make the choice to assert their birthright to find out how herbs might serve their personal, family, and community health needs.
To learn more on staying healthy, sign up for our newsletter, like us on Facebook, and follow our blog. If you're considering becoming an herbalist, please download a free sample lesson below or give us a call. We're happy to discuss the herbalist training options we provide. To your health!
anne.of.courtenay@gmail.com (Anne de Courtenay) 31 May, 2008
A nice plant of Bocking 14 Russian Comfrey (Symphytum x uplandicum)
Symphytum x uplandicum (Russian Comfrey) from Horizonherbs.com
blissgardener 08 Jul, 2014
Katolen Yardley, MNIMH Medical Herbalist will be speaking on the Holistic Approach to Mental Health: discussing nutrition and herbal medicine support.
Date: Saturday October 25, 2014
Location: Vancouver Convention Centre Meeting Rooms 10-12, Vancouver BC
For more information visit: www.hans.org
Katolen Yardley 11 Oct, 2014
A hand full of blueberries, blackcurrants and dried goji berries
Chia seeds
Coconut rice milk
Mix 2 tablespoons of the chia and the berries in 100ml of Coconut rice milk. Leave overnight in the fridge.
Chicken & alfalfa sprout sandwich
2 Slices sprouted whole wheat bread
2 Slices chicken
Alfalfa sprouts
Mustard
Simple but healthy and delicious sandwich which is easy to take to work or when you are short of time!
Salmon & Parsley Salsa
A bunch of parsley
1 Clove garlic
A small green chili
2 Spring onions
1 Table spoon apple cider vinegar
1 Fillet of wild salmon
1 Tablespoon extra virgin olive oil
Put the parsley, garlic, chilli, spring onions and cider vinegar in a processor and blend until fully blended. Season to taste. Pan fry the Salmon skin down until crispy and put in a hot oven for 3 minutes until cooked.
Serve with the green salsa.
Margo Marrone 04 Jan, 2015
Every once in awhile, you come across a book that resonates such truth that it compels you to pause and reevaluate your decisions; and then inspires you to implement significant yet necessary changes in your life. Let me introduce you to Jesse Hardin's The Enchanted Healer: treasure map to your soul's desires, field guide for identifying your authentic self, and handbook for transmitting your message to the world – unadulterated.
When – not if – you read this book, prepare yourself for a journey that may take some time. Jesse Hardin's The Enchanted Healer will accompany you along a quest that is equal parts educational, inspirational, and transformational. As your guide along this journey, Hardin reacquaints you with the enchanted world that is all around us: a world that appears mundane if only for our inability or unwillingness to tune into our senses and wake up to the present moment. He offers numerous strategies and practices for excavating the scripts that prevent us from fully embracing our authentic selves. He then helps us follow those breadcrumbs back to our wholeness. This is the truth-telling, paradigm-shifting, honesty-inducing book we've all been waiting for.
Awareness, Sensing, and Feeling
One of the key takeaways from this book is the importance of embracing the present moment and having a heightened awareness of our surroundings – a philosophy that is endorsed by numerous somatic therapies and spiritual traditions around the world. His application of these practices in the context of healing modalities offers a fresh perspective on why sharpening our sensory awareness is of utmost importance: "It is crucial for healers to not become complacent, inured, or for any reason get in the habit of feeling less and numbing out more. The efficacy of our lives and practices hinges on our sensitivities, our innate and developed senses, our ability to notice, feel and respond” (p. 83).
The Enchanted Healer is truly a guidebook; Hardin illustrates several techniques and practices that modern health practitioners can use to support their journeys back to mindfulness and awareness. These techniques are simple, but not necessarily easy, and Hardin's teachings have a way of getting to the heart of everything you've been avoiding in a refreshingly disarming way. The work is clearly laid out, and the journey awaits; the only way out of the darkness is through the tunnel of transformation.
Healing, Re-patterning, and Conscious Creation
Healing the healer is an ambitious task, but Jesse Hardin's The Enchanted Healer boldly embraces the challenge, and the result is quite remarkable. Even the seasoned self-help junkie will encounter new tools and techniques for the soulful introspection and mindful exploration of new terrain. These include such things as story, sexuality, totems, and sacred indulgence to name a few. A common thread connecting these various healing modalities is the importance of releasing limiting beliefs and re-patterning the stories we tell ourselves in order to activate meaningful changes in the world: "The effective healer will be the one who not only senses and comprehends who and what they are trying to help, the clients, medicines and the illnesses, but who also knows intimately the extent of their own healing knowledge and skills, the limits of their comprehension or abilities, their habits and filters, feelings and needs, motivations and style." (p. 111) From this standpoint, anything is possible including the conscious creation of our selves, our communities, and our healing paradigms.
Metamorphosis, Transformation, and Embracing Your Authentic Self
One of the most poignant elements of this book is the soul-shaking contribution of Kiva Rose. Rose brings a raw authenticity as she shares her personal journey through the tunnel of metamorphosis and self-discovery. She notes, "If we are untrue to our own nature, we cheat both ourselves and those we seek to help. While adaptation to new circumstances can be not only necessary but commendable, it must not be at a cost to our integrity as medicine people and allies of the plants." (p. 255) Her beautiful and moving prose effectively illustrates how going against the grain can be a powerful expression of love and creativity, especially when it reflects the true desires of your deepest self.
The Enchanted Healer is best read with your heart wide open, senses alert, and mind flexible enough to allow for changes to occur. This book invites your authentic self to play a central role in your work as a healer; work that matters because it offers a profound opportunity for you to share your deepest gifts with the world.
I found The Enchanted Healer to be a refreshing rule breaker and paradigm shifter, and arguably one of the most thorough guidebooks for transformation in the contemporary herb world. So consider this: are you ready for change and open to receiving transformation? If so, get your copy of this must-have book and embark upon your own journey towards finding your true medicine.
If you’d like to subscribe to the free Herbaria Newsletter by Jesse Hardin and Kiva Rose, then please visit this page and click subscribe on the left hand tab.
Melanie Pulla 09 Oct, 2014
tattvasherbs 07 Nov, 2014
Like acupuncture, Weebles wobble, but they don’t fall down.
The practice of medicine, particularly our pharmaceutical and surgical interventions, involves a constant struggle between risk and benefit. If the physiology or anatomy of the human body is altered, even with the best of intentions, there is always a potential downside. There are certainly instances where the risk to benefit ratio is extremely favorable or unfavorable and the right recommendation is obvious, and unfortunately there are times when it isn’t entirely obvious what the next step should be. But there has been a trend of steady progress in regards to improved safety and efficacy over the past several decades.
The treatment of pain has of late been one of those areas where the picture is becoming a bit less cloudy. We are learning more and more about the potential negative outcomes related to the long term use of opioid medications, such as physical dependence, addiction and even chronic pain. The way that these drugs have been prescribed in many patients has caused more harm than expected, and in some instances more hurt than help. Doctors generally strive to alleviate pain and suffering but, once again, good intentions don’t decrease risk.
In the neonatal and young infant population, the management of pain has had a rocky history. I’ve written about pediatric pain in the past, in particular the potential difficulties in managing acute pain. I won’t go into detail (read my prior post), but we have truly come a long way since the days of performing major surgery on newborns without any analgesia at all. There are areas where we need to do better, however. Children are still less likely than adults to be adequately treated for pain.
But things have improved. And as more children receive appropriate management for pain, the side effects of that management must increasingly be dealt with by healthcare professionals, the patients and their families. One of the issues that is typically observed and managed in neonatal and pediatric intensive care units is physical dependence and the subsequent occurrence of withdrawal symptoms.
No different than with adults, children experience pain for a variety of reasons, and some require the use of opioid medications for extended periods of time. Physical dependence with opioids can occur after just five to seven days of daily exposure. In the setting of the intensive care unit, there are children that are sometimes on medications for pain and sedation for weeks and even longer.
The American Academy of Pediatrics, in their 2014 clinical report on the subject, provides the following definition for physical dependence:
Physical dependence is a state of adaptation that is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
Withdrawal symptoms occur when there is less of the drug in the patient’s system, which happens for essentially three reasons. As the patient recovers, opioid pain medication dosing is often decreased or spaced out. Intravenous medications are switched to oral formulations, which isn’t always a predictable transition. And sometimes the absorption of medications is decreased because of illness or injury to the gastrointestinal tract. Also, as referred to in the above definition, a medication that blocks the action of another drug, such as naloxone (Narcan) used for opioid overdose, can lead to withdrawal symptoms even when there hasn’t been a drop in the blood level.
Not every pediatric patient experiences withdrawal, and when they do it can be mild enough to escape the awareness of caregivers or to be blamed on something else. Is the baby fussy because of mild withdrawal from morphine, or is it just gas, for example. Of course the symptoms of more serious conditions can be blamed on withdrawal as well. When significant withdrawal does occur, it can interfere with recovery of the patient, expose them to increased risk of medication side effects and increase caregiver anxiety tremendously.
The most common and obvious changes seen during withdrawal in children are behavioral. Anxiety, agitation, difficulty sleeping and jitteriness are frequent examples. Also common in withdrawal are stiffening of the muscles, nausea and vomiting, poor feeding/appetite, increased respiratory and heart rate, elevated body temperature, sweating, and elevated blood pressure.
Allow me to plant a seed and point out that there can be significant subjectivity to the assessment of most of these manifestations when caring for neonates and older infants. Was that just a little spit up or should we count it as an episode of vomiting? Is the baby not interested in the bottle because of withdrawal or because premature infants who have been ill sometimes just need more time to work up on feeds? Is the baby agitated, or just a little overstimulated? Perception is reality in the case of withdrawal.
There are validated assessment tools, the most well-known probably being the modified Neonatal Abstinence Scoring System and the Withdrawal Assessment Tool-1 (WAT-1), that can used to help determine if an infant is undergoing symptoms of withdrawal. These tools can be used in the setting of potential withdrawal from opioids or benzodiazepine medications. The WAT-1, which I’ll focus on for reasons that will soon become clear, involves eleven items with a total possible score of twelve and is performed every twelve hours by a nurse caring for the patient.
It breaks down as follows:
I hope it doesn’t sound like I am trying to say that an assessment like the WAT-1 is worthless. It definitely isn’t. It is an improvement over previous methods which were much more cumbersome, involving many more items and more frequent assessments. And it is certainly less subjective than relying solely on the clinical judgement of the nurses and physicians. Although, tools like the WAT-1 are validated by comparing them to just such previous methods. They all must be taken with a grain of salt. Their greatest benefit is likely the fact that their use forces us to consider the possibility of withdrawal and to approach it systematically.
The best approach to withdrawal in the pediatric population, and I imagine in adult patients as well, is anticipation and prevention of withdrawal if at all possible. If a child has been on a daily opioid for more than one week, although there are reports of withdrawal occurring after only five days, the medication should probably not be discontinued abruptly. And an assessment tool like the WAT-1 should be used consistently and as recommended.
It is common practice in hospitals to take into account how long the patient has been on a daily opioid, how high the doses are at the time weaning begins, concurrently administered medications (benzodiazepines, paralyzing agents, etc.), and the patient’s overall medical condition. It is also standard of care to follow an approved weaning protocol, generally with only one drug (if the patient is on more than one associated with withdrawal) being weaned at a time and the rapidity of the wean being determined by the length of time the patient had been on the drug. Naturally there are potential individual differences between patients, so signs and symptoms of withdrawal trump following a strict algorithm.
A typical approach would be to transition the patient to a stable dose of a longer-acting form of the drug to be weaned, and then to decrease the amount by 10%-20% every couple of days if excessive rescue medication dosing hasn’t been needed. An approved assessment tool should be used to determine signs or symptoms of withdrawal and the need to delay a decrease in dosing or to give rescue dosing of a short-acting version of the drug being weaned. A WAT-1 score greater than or equal to three, for example, is a typical cut-off for consideration of rescue dosing. Depending on the individual circumstances it can take a few days to weeks for a child to be successfully weaned and ready for discharge home.
No, no there isn’t.
Weaning babies off of these medications can go smoothly or be a frustrating roller coaster ride. I confidently speak for parents, patients and medical professionals when I say that we would all love a safe and effective means of weaning these medications more quickly and with less occurrence of withdrawal. If such a means exists, there is no reason to think that it would consist of placing tiny steel needles through the skin or pressing on the ears in order to manipulate the flow of nonexistent mystical energy through nonexistent pathways in the human body.
But thanks to a team of pediatric anesthesiologists at Stanford University, there is now another in a very long line of studies seemingly designed to be positive and to serve as fodder for believers looking for some science, any science, to hold up as proof of their beloved alternative medical belief system. This “research” was published in the October issue of Medical Acupuncture, a journal which has been discussed in the pages of Science-Based Medicine before, and not in a good way. The Editor-in-Chief happens to be Richard Niemtzow, the man who brought us “battlefield acupuncture.”
The authors start off by lamenting the need for painful procedures in young infants and the possible repercussions of poorly managed pain in the very young, such as an amplified pain response down the road. This is true…sort of. Some neonates exposed to a few painful experiences, such as heel sticks or circumcision, may have an exaggerated response to the jab from routine immunizations during the first year of life. But babies who experience repeated and prolonged pain, such as those riding vents for weeks or having major surgeries, are actually at risk of having blunted responses to pain during the first year of life. What is clear however, is that pain causes remodeling of our response to it, perhaps for a long time, and we should do our best to reduce it whenever it is safe and possible to do so.
They also point out the downsides to our new and improved approach to pain management, which to be honest is simply the fact that we have an approach to pain management at all in neonates. But, as I discussed above, it can lead to dependence and withdrawal as well as possible acute side effects with overdoses such as respiratory suppression and death. They mention the possible need for adding additional medications to the mix, like clonidine, to help manage withdrawal. I didn’t get into that in detail, but it’s true. And like every other drug, there are potential risks when prescribed.
So far, so good.
The authors then go off track, although not unexpectedly, when they begin to praise the successes of acupuncture for withdrawal. They state that there is a long history of safety and efficacy starting with the incidental discovery of the indication in 1972 when “acupuncture anesthesia” was performed on a man addicted to opium in China. As Dr. Atwood’s excellent four part series explains, acupuncture anesthesia was and is a fiction, and anything associated with it is highly suspect.
They describe the protocol for acupuncture detoxification as established by the National Acupuncture Detoxification Association (NADA), which initially involved multiple points on the body and ears as well as electrical stimulation. Because of logistical issues and “reasons of efficiency in clinics”, both the electricity and the body points were eventually abandoned, luckily without any negative impact on the effectiveness of the treatments. That’s curious. The current NADA protocol consists of “bilateral ear acupuncture of the following five points: Kidney; Liver; Lung; Shen Men; and Sympathetic.
They claim that acupuncture treats anxiety, pain and agitation in a variety of pediatric contexts. After admitting that the only prior study related to pediatric withdrawal, which involved using acupressure in neonates suffering from abstinence syndrome, did not work, they point out the “suggestive trend toward less need for pharmacologic support.” All of this is used to bolster their case for an “exploration of the feasibility and efficacy of performing acupuncture on infants in the ICU.”
The authors enrolled ten neonates and infants in the study with the goal of determining the feasibility and efficacy of acupuncture as part of the management of withdrawal in the ICU. They obtained IRB approval from Stanford and informed consent from caregivers. These infants had few similarities. They were on different doses of medications or were on different medications entirely. One was on a ventilator and still getting doses of a paralyzing agent. They were at varying stages of their wean off of medications, and had extremely different reasons for why they were on these medications in the first place.
The treatment protocol consisted of NADA-approved ear points but they also threw in some body points to “help stabilize symptoms of autonomic dysfunction.” They state this without a reference, as if it’s just a well-accepted thing that doctors do. Like stating that “fevers were treated with standard dosing of acetaminophen.” The authors did their own acupuncture and inserted the needles until they felt the De Qi sensation. After needling the babies, acupressure beads were placed on the points for 24 hours or until the next session. The NADA protocol they were supposedly following only calls for 30 minutes. All but one of the subjects had five sessions. That one went home after three days.
The authors report that all ten of the patients improved while receiving acupuncture and acupressure. Based on WAT-1 assessments, they needed fewer doses of rescue medications and their opioid and/or benzodiazepine infusions were weaned. There were no major complications, although one child suffered a minor skin abrasion from an acupressure bead. And although the nature of the study did not permit any statistical analysis, a survey of bedside caregivers (nursing, physicians, parents) revealed universal belief that the patients benefited from the intervention. The authors even provide several comments from the surveys, such as “Can we please do this for other patients?” and “She really likes her acupuncture.”
So to sum up, ten babies received an intervention for a highly-subjective process, and were assessed without any blinding using a tool that is very susceptible to placebo. The authors of the study, two pediatric anesthesiologists, performed the intervention themselves at the bedside for all to see and included in their methods for no clear reason a means to make sure that anyone assessing the patients during a different shift knew which babies were involved. Then to cap it off, they included a likely non-anonymous survey that is even more subjective than the WAT-1 as part of their evidence for efficacy. I would have been shocked if the results were any less positive.
There are three possible explanations for the results of this study that I can think of. One is that acupuncture and/or acupressure works, not only for withdrawal from opioids but also benzodiazepines, and in a patients with a variety of medical histories. Or we accept that acupuncture functions as a theatrical placebo and the biased perception of the caregivers led to the infants receiving fewer rescue medications and continuing on their weans. If this is the case, which in my opinion it almost certainly is, some or all of the infants may not have received medication that they truly needed. Finally, it all may just be the result of random factors. Placebo didn’t play a role, acupuncture doesn’t work, the process of withdrawal and weaning is highly variable and this was a very small number of subjects.
Regardless, I would love to have been privy to those IRB discussions and to the informed consent process. The latter isn’t described in the paper unfortunately. But this was not one of those papers where the researchers attempt to come up with a scientific-sounding explanation for the proposed benefits of acupuncture. In addition to the “De Qi” reference, they state that “children may require less stimulation than adults because their Qi may be more responsive to stimuli.” So did they really discuss Qi with the parents? Did they mention that a better study looking at this very issue, which was published in the same journal in 2011 and even cited by the authors, showed no benefit whatsoever?
Although merely a collection of ten worthless anecdotes published in a journal that warps the concept of peer review beyond all meaning or recognition, there are already individual acupuncture practices touting it as evidence that acupuncture “truly is for everyone!”
Stanford researchers have found that acupuncture helps newborns in intensive care. Acupuncture has been effective for pain relief and sedation, the study showed. "High doses of opioids and benzodiazepines are often required for neonates and infants for the purposes of pain management and sedation. Cessation from medications lead to withdrawal symptoms and irritability. The researchers cite acupuncture's documented ability to reduce pain, irritability and withdrawal symptoms in adults."
Here is a website offering continuing medical education credits based on the study.
This study, a painfully unnecessary attempt to determine the feasibility and efficacy of acupuncture in neonatal and pediatric intensive care unit patients at risk of withdrawal, was a complete waste of time. You cannot determine efficacy at all based on it and the question of feasibility was answered a long time ago. This study added nothing to our understanding of withdrawal or even of acupuncture.
Considering the reams of research showing that there are no benefits associated with the insertion of needles into, or pressing on, particular points on the body beyond placebo, it never should have happened. But it can’t be undone. It’s out there, adding to the cultural inertia of acupuncture. It will find its way to more websites and it will be cited in future poorly designed studies. Although less of a fuss was made about this paper than I would have expected, there are almost certainly many more people that are believers now because of it.
Although many forms of alternative medicine are like this to varying degrees, acupuncture really is the best Weeble of the bunch. It has proven time and time again to be able to right itself despite devastating blows in the literature. It’s nearly ubiquitous in academic centers and the modality that shruggies will usually cite when pressed for a reason for their lack of motivation. It’s widely accepted by the public as legitimate. Acupuncture doesn’t appear to be going anywhere anytime soon. In the meantime, why don’t you make supporting the Society for Science-Based Medicine one of your resolutions for 2015.
Clay Jones 02 Jan, 2015
This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors
Neurology, Emergency Medicine
Neurology, Emergency Medicine
Pediatrics, Emergency Medicine
Pediatrics, Gastroenterology
Pre-hospital/Retrieval, Neurology
Emergency Medicine, Neurology
Hamaekers AE, Henderson JJ. Equipment and strategies for emergency tracheal access in the adult patient. Anaesthesia. 2011 Dec;66 Suppl 2:65-80. PMID: 22074081
Emergency Medicine, Resuscitation
Pre-Hospital/Retrieval, Emergency Medicine
Trauma, Ophthalmology, Emergency Medicine
Rowh AD et al. Lateral Canthotomy and Cantholysis: Emergency Management of Orbital Compartment Syndrome. J Emerg Med 2014. PMID: 25524455
 | The list of contributors |  | The R&R ARCHIVE |
 | R&R Hall of famer You simply MUST READ this! |  | R&R Hot stuff! Everyone’s going to be talking about this |
 | R&R Landmark paper A paper that made a difference |  | R&R Game Changer? Might change your clinical practice |
 | R&R Eureka! Revolutionary idea or concept |  | R&R Mona Lisa Brilliant writing or explanation |
 | R&R Boffintastic High quality research |  | R&R Trash Must read, because it is so wrong! |
 | R&R WTF! Weird, transcendent or funtabulous! |
That's it for this week…
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Anand Swaminathan 31 Dec, 2014
