Integrative Practitioner Forum

The Integrative Practitioner Forum provides an ongoing structure for local health care providers, faculty and students to learn from and network with each other. For practitioners, it is an opportunity to ask the questions that need to be asked, present their findings regarding integrative health practices, and share their successes and challenges in addressing the needs of patients.

Not all the views presented during a practitioner forum represent the views of the Medical Center, the College of Nursing and Health Sciences or the Larner College of Medicine at the University of Vermont. Our hope is that these talks facilitate discussions of complex issues that affect patients in our community. We encourage you to listen to the video presentations to obtain a full understanding of the speakers’ content and recognize there are different approaches to addressing these issues. We invite dialogue around evidence-informed and evidence-based health care practices. Tick Borne Illness: what you need to know

Bridging the information gap: Prevention, Diagnosis and Treatment

Ronald Stram MD Founder and Medical Director Introduction How We Get There: SUPPORTING YOURSELF

PATIENT STORIES

SYMPTOMS AND TREATMENT

3 4 PATIENT STORIES 9 Year Old Boy From Buffalo, New York

Loved to play football, soccer, all sports

- At 7 years old, he developed severe joint pain - Saw several rheumatologists, took multiple drugs - Finally tested for Lyme Disease after 1 year - POSTITIVE 10 out of 10 bands

Began proper treatment – 75% improved 5 PATIENT STORIES 35 Year Old Female From New Zealand

Middle school teacher – unable to remember lesson plans, could not work Musculoskeletal joint pain Headache, Memory loss Abdominal pain, Chest pain Began proper treatment – 95% better 6 LYME – The Big Picture Symptoms: Physical Exam: Common Lab Results: Labs to Order: Imaging to Order: Tier 1: Flu like symptoms, migratory joint - Unexplained tachycardia - Possible low WBC CBC/CMP, G6PD, C4A, 1. CT with and without pain - Low or mildly high temperature 36 - 37.5 C - Otherwise typically Homocysteine (then contrast Tier 2: Fatigue, Cognitive dysfunction, - Musculoskeletal joint pain, tenderness normal labs MTHFR if abnormal), Vit D, 2. MRI w/ and w/out memory loss - Occipital tenderness B12, B6, Armin Labs/ contrast Tier 3: Neurological symptoms, POTS - Abdominal tenderness Igenex, EBV, TSH, Iron

TX ROUND 2: “Restorative Phase” TX ROUND 4: 0% Patient enters 1. Off all abx for 2-4 weeks 0% “IV THERAPY” better practice with 2. IV Myers –nutritional vitamin tx better 1. Rocephin 2g 4-5x per wk Treatment Plan: symptoms 3. Glutathione push/NAC 2. Includes oral antibiotics/ Patient will always be on the gut 4. CS Therapy/Acupuncture 3. Supplements 50% protocol 50% better 5. Naturopath Appointment 4. Persister drugs 1. CS therapy 1x/week better 2. Acupuncture 1x/week DURATION: 2 months DURATION: 1 month 100% 3. Nutrition Appointment (Plant 100% better Based Paleo, Gluten Free, Anti better Inflammatory) 4. Antibiotics according to chart TX ROUND 3: “Herbal Phase” Supplements: 0% 1. Continue oral abx at a Gut Protocol better tapered down dosing for 2 months (if necessary) 0% 2. Overlap last round of abx Antimicrobial herbs TX ROUND 1: better - Cats Claw/Samento with herbal regimen 1. Minocycline/Doxy 3. Taper off abx while on - Japanese Knotweed 2. Plaquenil/Flagyl 50% Repeat TX 50% better better herbal regimen - Andrographis ROUND 1 for 3. + or – Amoxicillin/ 4. Ensure you continue - Artemisia additional 3 Azithromycin lifestyle changes (diet, etc) - Grapefruit seed extract months 100% 4. Gut protocol and better 5. TCM Consultation - Banderol supplements 100% DURATION: 6 months IF TREATMENT FAILS: DURATION: 3 months better Co-infection testing (up to 2 abx combos) Differential diagnosis The Symptoms of Lyme in Tiers

Tier 1 Tier 2 Tier 3

SYMPTOMS SYMPTOMS SYMPTOMS • Flu Like Symptoms • Fatigue • Neurological symptoms • Migratory joint pain • Cognitive dysfunction • POTS • Headache • Memory Loss

Typically appear within 1-2 weeks of Appear after 3 months of infection Appear in the more severe cases of infection, or cyclically throughout Lyme disease, typically after infected infection more than 6 months/years without treatment

8 VARIATION:

9 Lyme: What to Look For Step 2

• LABS TO ORDER • IMAGING • CBC/CMP, G6PD, • CT with and without • PHYSICAL EXAM Homocysteine (then contrast •Unexplained MTHFR if abnormal), • MRI with and without tachycardia Vit D, B12, B6, MDL, contrast •Low or mildly high Acutix labs/IGeneX, temperature EBV, TSH, Iron (36-37.5 C) • Common lab results •Musculoskeletal joint • Possible low WBC, Step 3 pain otherwise normal •Occipital tenderness •AbdominalStep tenderness 1

10 The Diagnosis

CLINICAL LYME DIAGNOSIS

Blood Testing Symptoms False negatives, and History Continued disease state, Undiagnosed Lyme, Misdiagnosis Current testing is indirect and NOT always reliable– therefore, a clinical

diagnosis is required. 11 Lyme: How to Treat

General Treatment Supplements/Herbs 1. Craniosacral therapy 1x/week Gut Protocol, plus: Buehners, Cowden, Zhang herbals 2. Acupuncture 1x/week - Cats Claw/Samento 3. Nutrition Appt (Plant Based Paleo, - Japanese Knotweed Gluten Free, Anti Inflammatory) - Andrographis 4. Antibiotics as prescribed by LLMD - Artemesia - Grapefruit seed extract 5. Physical Activity - Banderol 12 Gut microbiota Gut Microbiota Modulates Adaptive Cell Therapy via CD8α Dendritic Cells and IL-12 Authors: MireiaUribe-Herranz, Kyle Bittinger, St avros Rafail, Sonia Guedan,Stefano Pierini, Ceylan Tanes, Alex Ganetsky, Mark A. Morgan, Saar Gill,Janos L. Tanyi, Frederic D. Bushman, Carl H. June, and Andrea Facciabene

Collectively, our findings demonstrate an important role played by the gut microbiota in the effectiveness treatment by altering the gut microbiota. Fecal Transplants Made (Somewhat) More Palatable

OpenBiome, the first stool bank in the country which distributes fecal samples from healthy donors to help cure people with tenacious C. difficile infections. Microbiome GUT PROTOCOL

One of the most important components to patients’ success is a healthy gut

Probiotics are key: short chain fatty acid butyrate by lactic acid bacteria stimulates GST production in intestinal cell wall.

16 PROBIOTIC ENEMA GUT PROTOCOL

The best time for taking an Enema is in the evening, just before bed. 17 Nutrition

Anti Ketogenic Paleo Diet Inflammatory Diet Diet

18 Lifestyle: Nutrition

Effects of a very low-fat, vegan diet in subjects with rheumatoid arthritis. Conclusion: Patients with moderate-to-severe RA, who switch to a very low- fat, vegan diet can experience significant reductions in RA symptoms McDougall J1, Bruce B, Spiller G, Westerdahl J, McDougall M. J Altern Complement Med. 2002 Feb;8(1):71-5.

A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens. Rheumatology (Oxford). 2001 Oct;40(10):1175-9. Hafström I1, Ringertz B, Spångberg A, von Zweigbergk L, Brannemark S, Nylander I, Rönnelid J, Laasonen L, Klareskog L. Balancing Treatment

Detoxification

Treatment

20 Detoxification

•Naturally Existing (toxins) mold •Man Made (toxicants) heavy metal exposure •Air (smog, chemical compounds) Sources of •Food, water •Carpets •Pharmaceuticals Toxins/Toxicants •Bacteria die-off during treatment

•Supplements •Glutathione •NAC Means of •Chlorophyll related supplements: cilantrogen, charcoal •Infrared Sauna /LOW LEVEL LIGHT THERAPY •HBOT Detoxification •Hydration •Physical activity

21 Vitamin C: powerful antioxidant , pro-oxidant and detoxifier Vitamin C is a commonly used water-soluble vitamin. Although many mammals can produce vitamin C, humans must obtain vitamin C from foods and other sources. ➢Involved in tyrosine metabolism and is a cofactor in the synthesis of carnitine, thyroxin, norepinephrine, dopamine, and tryptophan. ➢Vitamin C metabolic processes includes oxidation- reduction reactions and cellular respiration, carbohydrate metabolism, synthesis of lipids and proteins, catabolism of cholesterol to bile acids, conversion of folic acid to folinic acid, and iron metabolism. ➢Vitamin C deficiency can cause fatigue, personality changes, and decline in psychomotor performance and motivation within 84 to 97 days. Phase I - Safety Trial of Intravenous Ascorbic Acid in Patients with Severe Sepsis Journal of Translational Medicine, 2014; 12: 32. Authors: Alpha A Fowler III, Aamer A Syed, Shelley Knowlson, Robin Scult horpe, Don Fart hing, Christine DeWilde, Christine A Fart hing, Terri L Larus, Erika Martin, Donald F Brophy and Seema Intravenous ascorbic acid infusion may positively impact multiple organ failure and biomarkers of inflammation and endothelial injury. In ascorbic acid infused 1 patients there was no significant rise in thrombomodulin , suggesting attenuation of vascular endothelial injury “LYME TRAVEL MAP” TX ROUND 2: “Restorative Phase” 1. Off all antibiotics for 2-4 weeks TX ROUND 4: 2. IV Myers – nutritional vitamin 0% 0% “IV THERAPY” better treatment better 1. Rocephin 2g 4-5x 3. Glutathione push/NAC per week Patient enters 4. Craniosacral Therapy and/or 50% 50% 2. Includes oral better practice with Acupuncture better antibiotics symptoms 5. Naturopath Appointment 3. HBOT *Consider alternate diagnosis* 100% 100% 4. Supplements better DURATION: 1 month better And/or persister drugs

DURATION: 2 monthsTX ROUND 3: “Herbal Phase” 0% 1. Continue oral abx at a better tapered down dosing for TX ROUND 1: 0% 2 months (if necessary) better 1. Ceftin/Mino/Doxy 2. Overlap last round of abx with herbal regimen 2. Plaquenil/Flagyl/Tin 50% 50% Repeat TX 3. Taper off abx while on 3. + or – Amoxicillin/ better ROUND 1 for better herbal regimen Azithro/Clarithromyc additional 3 in months 100% 4. Ensure you continue better 4. Gut protocol and lifestyle changes (diet, supplements , 100% etc) better 5. TCM Consultation IF TREATMENT Oregano oil DURATION: 3 months FAILS: DURATION: 6 months Co-infection, mold (up to 2 abx combos) heavy metal testing Expand Differential diagnosis CO-INFECTIONS: The Symptoms of Babesia in Tiers

Tier 1 Tier 2 Tier 3

SYMPTOMS SYMPTOMS SYMPTOMS • Drenching sweats/chills • Testicular pain/pelvic pain • Axillary pain • Air Hunger • Urinary frequency • Rib pain • Severe headache • Kidney issues • Chest pain

Typically appear within 1-2 weeks of Appear after 3 months of infection Appear in the more severe cases of infection, or cyclically throughout Babesia, typically after infected more infection than 6 months without treatment

25 Babesia: What to Look For

• PHYSICAL EXAM Step 2 • Head palpitation • LABS TO ORDER • IMAGING pain • CBC/CMP, G6PD, Homocysteine (then • CT with and • Inflamed (hot) tissue MTHFR if abnormal), Vit D, without contrast • Occipital tenderness B12, B6, specialty labs, IGeneX, EBV, TSH, Iron • MRI with contrast • Air hunger that is not • Common lab results consistent with • Low WBC oxygen saturation • High Platelet • Mild Anemia Step 3 • Creatinine levels Step 1

26 Babesia: How to Treat

General Treatment : Supplements: 1. Craniosacral therapy 1x/week Gut protocol 2. Acupuncture 1x/ week Artemesia Cryptolepsis 3. Nutrition Appointment Pinella 4. Antibiotics Teasel root 5. Physical Activity Magnesium CBD oil Liposomal Artemesia

27 CO-INFECTIONS: TX ROUND 2: “Restorative Phase” 1. Off all antibiotics for 2-4 weeks BABESIA 2. IV Myers – nutritional vitamin TX ROUND 4:“IV 0% 0% better treatment better 1.Rocephin 2g 4-5x /wk 3. Glutathione push/NAC 2.IV Zithromax 2x/wk Patient enters 4. Craniosacral Therapy and/or 3.IV Atovaquinone / 50% better Acupuncture 50% Artemesi practice with better symptoms 5. Naturopath Appointment 1. Includes oral *Consider alternate diagnosis* antibiotics and 100% better DURATION: 1 month 100% supplements better DURATION: 2 months TX ROUND 3: “Herbal Phase” 0% 1. Continue oral abx at a better tapered down dosing for 0% 2 months (if necessary) TX ROUND 1: better 2. Overlap last round of 1. Coarten/Malarone/ abx with herbal regimen 50% 50% Mepron/ Quinine Repeat TX 3. Taper off abx while on better ROUND 1 for better 2. Clindamycin/ herbal regimen Zithromax additional 3 months 100% 4. Ensure you continue 3. Gut protocol and better lifestyle changes (diet, supplements 100% etc) better 5. TCM Consultation IF TREATMENT DURATION: 3 months FAILS: (up to 2 abx combos) DURATION: 6 months Co-infection testing Differential diagnosis CO-INFECTIONS: The Symptoms of Bartonella in Tiers

Tier 1 Tier 2 Tier 3

SYMPTOMS SYMPTOMS SYMPTOMS • Bruising • Psych issues • Worsening of Tier 1 and 2 • Neuropathy • Panic Attacks symptoms • Burning tongue • Ocular Headache • Fevers • Electric nerve impulses • Small joint pain • GI Issues (in children)

Typically appear within 1-2 weeks of Appear after 3 months of infection Appear in the more severe cases of infection, or cyclically throughout Bartonella, typically after infected more infection than 6 months without treatment

29 Bartonella: What to Look For

• PHYSICAL EXAM Step 2 • Stretch marks •LABS TO ORDER • IMAGING • Plantar pain •CBC/CMP, G6PD, • CT with and • Lymphadenopathy Homocysteine (then without contrast MTHFR if abnormal), • History of cat or • MRI with contrast Vit D, B12, B6, animal scratches or • Also, psych consult flee exposure Galaxy labs, IGeneX, EBV, TSH, Iron • Common lab results •Conventional positive Step 3 Step 1 bartonella testing

30 Bartonella: How to Treat

Supplements: Gut Protoco General Treatment : MC-BARl 1. Craniosacral therapy 1x/week bLt Fish Oil 2. Acupuncture 1x/ week Magnesium Kava 3. Nutrition Appointment Calm PRT 4. Antibiotics Rhodolia Holy Basil 5. Physical Activity Milk Thistle Resveratrol Plus Hawthorne Japanese Knotweed

31 CO-INFECTIONS: TX ROUND 2: “Restorative Phase” 1. Off all antibiotics for 2-4 weeks BARTONELLA 2. IV Myers – nutritional vitamin TX ROUND 4: 0% 0% better treatment better “IV THERAPY” 3. Glutathione push/NAC 1. IV Rocephin 4x/wk Patient enters 4. Craniosacral Therapy and/or 2. IV Bactrum4x/wk 50% better Acupuncture 50% 3. IV Zithro/Levaquin practice with better symptoms 5. Naturopath Appointment 4. Includes oral *Consider alternate diagnosis* antibiotics/ 100% better DURATION: 1 month 100% supplements better DURATION: 2 months TX ROUND 3: “Herbal Phase” 0% 1. Continue oral abx at a better tapered down dosing for 0% 2 months (if necessary) TX ROUND 1: better 2. Overlap last round of 1. Doxcycline/ Zithro abx with herbal regimen 50% 50% 2. Bactrum/Rifampin/ Repeat TX 3. Taper off abx while on better ROUND 1 for better Cipro herbal regimen 3. Pharma/ Herbal additional 3 months 100% 4. Ensure you continue psychiatric better lifestyle changes (diet, treatment 100% etc) Counseling better 5. TCM Consultation IF TREATMENT 4. Gut protocol and FAILS: supplements DURATION: 6 months Co-infection testing Differential DURATION: 3 months diagnosis (up to 2 abx combos) PZA for Persistent Infection PZA:

1. More effectively kills older, persistent bacteria under low oxygen conditions 2. Poor activity for growing bacteria

Mechanism of Action: - Disrupts cell membrane and energy transport - Blocks protein synthesis Side Effects: Hepatotoxicity

Duration: 2 months (protocol based on current tuberculosis therapy)

33 HBOT: Indications and treatment protocols Focused Infrared therapy: Indications and focused protocols THE PLAN THE GLOBAL APPROACH – WHY?? Goal: Tying everything together

Decreased Spiritual Increased resilience for stress Connections positive outcomes SUPPORT

Enhances your Less toxic and Food is Non pharmaceutical SUPPLEMENTATION body’s natural more medicine ally in the fight Improve treatment GUT function sustainable against bacteria Generate Increase your immune & Good bacteria function results PROTOCOL NUTRITION

Short term attack Kill the bugs! Targets specific for long term PRESCRIPTION bacteria efficacy MEDICATION

36 Keep

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