Diagnostic Testing and Treatment Adventures on Monday Morning: A Wrap-Up

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In this, the final lecture of the 2nd annual Integrated Medicine for Mental Health Conference held in beautiful Sedona, Arizona on September 17 - 18th, Dr. Cady summarizes four presenters, and 8 different lectures, into key concepts to be applied by the integrated and functional medicine practitioner on Monday a.m. This lecture aims to deal with the "My goodness, what do I do NOW?" question when a health care practitioner returns to his or her office and is overwhelmed with the amount of data heart at a conference such as this one.

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  • Consistent with candida
  • Immune modifications made to deprive microorganisms to not get enough tryptophan to “starve them out” Tryptophan can be converted to quinolinic acid which is excitotoxic and CAN CAUSE BRAIN DAMAGE. It also kills the cells that contain viruses, bacteria and parasites. Stress induces the enzymes that increase converstion of tryptophan to quninolinic acid Infection increases the conversion to quinolinic acid. Beta ayloid peptie also causes the induction of additional IDO and thus stimulates production of more quinolinic acid. This graphic shows how stress can be damaging by It was thought that there was ONE INGREDIENT in one batch of tryptophan (from japan) that caused EMS, but similar problems were found in with other types of typtophan Conversion of trytophan to 5-HTP is NOT REVERSIBLE which means that it is not possible for it to convert to quinolinic acid.
  • Not making enough serotonin in relationship to quinolinic acid. VMA – breakdown product of norepinephrine 5HIAA – breakdown product of serotonin (which is how serotonin: quinolinic acid ratio is approximated. HVA - breakdown product of dopamine; elevated in pheochromocytoma and neuroblastoma. Smokers show lower amounts of HVA.
  • Carbon monoxide: On average, about 170 people in the United States die every year from CO produced by non-automotive consumer products. These products include malfunctioning fuel-burning appliances such as furnaces, ranges, water heaters and room heaters; engine-powered equipment such as portable generators; fireplaces; and charcoal that is burned in homes and other enclosed areas. In 2005 alone, CPSC staff is aware of at least 94 generator-related CO poisoning deaths. Forty-seven of these deaths were known to have occurred during power outages due to severe weather, including Hurricane Katrina. Still others die from CO produced by non-consumer products, such as cars left running in attached garages. The Centers for Disease Control and Prevention estimates that several thousand people go to hospital emergency rooms every year to be treated for CO poisoning. Source US Consumer Product Safety Commission. http://www.cpsc.gov/cpscpub/pubs/466.html accessed 09 08 2011.
  • Diagnostic Testing and Treatment Adventures on Monday Morning: A Wrap-Up

    1. 1. Diagnostic Testing and Treatment Adventures on Monday Morning: A Wrap-Up Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Professor – University of Southern Indiana Adjunct Professor – Indiana University School of Medicine Integrative Medicine for Mental Health Conference Sedona, Arizona - September 17-18, 2011
    2. 2. Orientation <ul><li>WHAT DO YOU DO ON MONDAY A.M.? </li></ul><ul><li>Conventional & functional testing </li></ul><ul><li>Diagnostic testing reviewed based both on lecture organization and themes </li></ul><ul><ul><li>Clinical rationale for specific tests emphasized </li></ul></ul><ul><li>Colleagues at this symposium liberally quoted and cited. </li></ul>
    3. 3. “ Real doctoring”: The Chance to Change Patient’s BRAINS
    4. 4. “ But my patients don’t know about this and aren’t asking for it….” <ul><li>“ It’s not the consumers’ job to know what they want.” </li></ul><ul><li>- Steve Jobs </li></ul>
    5. 5. Functional testing – will deal with later <ul><li>IgG Food sensitivity </li></ul><ul><li>Organic Acid Testing </li></ul><ul><li>Comprehensive Fatty Acids </li></ul><ul><li>Urine or hair for heavy metals. </li></ul><ul><li>Amino acids - plasma </li></ul>
    6. 6. Conventional testing, “plus” <ul><li>Adults – depression, fatigue </li></ul><ul><ul><li>TSH, FT4, FT3, Rev T3, min. </li></ul></ul><ul><ul><li>Free/Total Testosterone </li></ul></ul><ul><ul><li>DHEA- SULFATE </li></ul></ul><ul><ul><li>IGF-1 </li></ul></ul><ul><ul><li>CBC (complete?) with </li></ul></ul><ul><ul><ul><li>Iron, ferritin, TIBC </li></ul></ul></ul><ul><ul><li>Cholesterol </li></ul></ul><ul><ul><li>25-OH Vitamin D </li></ul></ul><ul><li>WOMEN </li></ul><ul><ul><li>Estradiol </li></ul></ul><ul><ul><li>Progesterone </li></ul></ul><ul><li>More subtle: </li></ul><ul><li>Infectious: </li></ul><ul><ul><li>ASO, Anti-DNAse </li></ul></ul><ul><ul><li>Candida IgG, IgA, IgM </li></ul></ul><ul><ul><li>Clostridia titers </li></ul></ul><ul><li>Inflammation </li></ul><ul><ul><li>HS – C-RP </li></ul></ul><ul><ul><li>ESR/Westergren sed rate </li></ul></ul>
    7. 7. Additional conventional labs (Greenblatt & Shaw, rev by Cady) for basis of Integrative Tx <ul><li>Folate </li></ul><ul><li>B12 (MMA!!)* </li></ul><ul><ul><li>{irritability, apathy, pers. Changes, etc.} </li></ul></ul><ul><li>RBC Zn, RBC Mg* </li></ul><ul><ul><li>(Zn taste test) </li></ul></ul><ul><li>Copper/Ceruloplasmin </li></ul><ul><li>Serum serotonin + spot urine 5HIAA & creatinine </li></ul><ul><ul><li>Allows calc of serotonin: 5HIAA ratio </li></ul></ul><ul><li>Celiac testing: </li></ul><ul><ul><li>Antigliadin Ab, IgG, IgA, IgM </li></ul></ul><ul><ul><li>Tissue transglutaminase </li></ul></ul><ul><li>“ Functional” conventional </li></ul><ul><ul><li>Homocysteine (def of FA, B6, B12 and Omega 3) </li></ul></ul><ul><ul><li>Methylmalonic acid (for B12) </li></ul></ul>
    8. 9. 334 (217) citations on “DHEA with energy” – as of 07 29 2011
    9. 11. Unexplained chronic cough and vitamin B-12 deficiency. <ul><li>Am J Clin Nutr. 2011 Mar;93(3):542-8. Bucca CB et al. </li></ul><ul><li>“ This study suggests that Cbl-D [cobalamin deficiency] may contribute to chronic cough by favoring sensory neuropathy as indicated by laryngeal hyperresponsiveness and increase NGF expression in pharyngeal biopsies of Cbl-D patients.” </li></ul>
    10. 13. Magnesium mementos – from Dr. Greenblatt <ul><li>One of the first minerals to disappear with: </li></ul><ul><ul><li>Processed food </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><li>Decreased by EtOH , caffeine , sodas , meds </li></ul><ul><li>Considered “anti-stress” mineral </li></ul><ul><ul><li>Decreases cortisol (rel to sleep disruption) </li></ul></ul><ul><ul><li>Relaxes muscles, prevent cramps (sleep disruption) </li></ul></ul><ul><ul><li>Decreases anxiety ; improves sleep </li></ul></ul>
    11. 14. Slide from Dr. Greenblatt
    12. 15. Zinc deficiency – from Dr. Greenblatt, Cady <ul><li>Physiology </li></ul><ul><li>Influences carbonic anhydrase </li></ul><ul><ul><li>Used to form acid salts in mucosa====dec intrinsic factor === dec B12 </li></ul></ul><ul><li>Required for some enzymes </li></ul><ul><ul><li>Lipase, amylase, pepsin, carboxypeptidase </li></ul></ul><ul><ul><li>Therefore, low Zn = low nutrient absorption </li></ul></ul><ul><li>NEEDED FOR HAPPY TESTICLES! </li></ul><ul><li>Manifested in </li></ul><ul><li>Anorexia </li></ul><ul><li>ADD/ADHD </li></ul><ul><li>Amenorrhea </li></ul><ul><li>EFA metabolism problems </li></ul><ul><li>Changes in opioid receptors </li></ul><ul><li>GI symptoms (bloating, dec appetite, meat avoidance) </li></ul><ul><li>LOW TESTOSTERONE </li></ul>
    13. 16. Van Tiggelen, CJ - Journal of Orthomol. Psychiatry vol 13, no. 2, 97-104.
    14. 17. Zinc & Testosterone, reprise <ul><li>Low Zinc- associated with low testosterone </li></ul><ul><ul><li>Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto, W.Y. (2000). Low serum testosterone level as a predictor of increased visceral fat in Japanese-American men. International Journal of Obeisty and Related Metabolic Disorders, 24, 485-491. </li></ul></ul><ul><li>Per USDA, 60% of US men between 20 – 49 years of age do not get enough . </li></ul><ul><li>Fast food = low zinc = testicular tissue inflammation = dec. testosterone </li></ul><ul><ul><li>El-Sewedy MM et al. J Pharm Pharmacol. 2008 Sept;60 (9):1237-42. </li></ul></ul>
    15. 18. Low Vitamin D linked to depression [Muhlestein JB et al. Am Heart J, 2010; 159(6):1037-43. (citation from Dr. Shaw] <ul><li>7,358 patients >/= 50 yoa with CV diagnosis and NO HX of depression </li></ul><ul><li>“ Vitamin D levels were significantly associated with an increased risk of depression, compared with optimal vitamin D levels.” </li></ul><ul><li>Optimal level: > 50 ng/ml </li></ul><ul><ul><li>Normal 31 – 50 ng/ml </li></ul></ul><ul><ul><li>Low: 16 – 30 ng/ml; “very low = < 15 ng/ml </li></ul></ul>
    16. 19. <ul><li>Serum 25-OHD in 117 Swedish patients </li></ul><ul><li>Only 14.5% had recommended levels (over 75 nmol/L) </li></ul><ul><li>High level of vitamin D deficiency among psychiatric patients </li></ul><ul><li>Lowest levels of 25-OHD found among patients with autism and schizophrenia </li></ul>Low serum levels of 25-hydroxyvitamin D (25-OHD) among psychiatric out-patients in Sweden Humble, Gustafsson and Bejerot, 2010, Journal of Steroid Biochemistry & Molecular Biology [cited from Dr. Woeller’s presentation]
    17. 20. “ Too much of a good thing is…. WONDERFUL.” Mae West
    18. 21. <ul><li>Association with major depression and suicide </li></ul><ul><li>29,133 men 50-69 yoa followed for 5-8 years </li></ul><ul><li>“ Low serum total cholesterol was associated with low mood and subsequently a heightened risk of hospital treatment due to a major depressive disorder and death from suicide” </li></ul>Excessively low cholesterol is NOT necessarily “wonderful.” Partonenm T et al, Br J Psychiatry.1999 Sept;175:259-62.
    19. 22. From Dr. Woeller
    20. 23. The TWO TESTING SLIDES, REVIEW… <ul><li>Adults – depression, fatigue </li></ul><ul><ul><li>TSH, FT4, FT3, Rev T3, min. </li></ul></ul><ul><ul><li>Free/Total Testosterone </li></ul></ul><ul><ul><li>DHEA- SULFATE </li></ul></ul><ul><ul><li>IGF-1 </li></ul></ul><ul><ul><li>CBC (complete?) with </li></ul></ul><ul><ul><ul><li>Iron, ferritin, TIBC </li></ul></ul></ul><ul><ul><li>Cholesterol </li></ul></ul><ul><ul><li>25-OH Vitamin D </li></ul></ul><ul><li>WOMEN </li></ul><ul><ul><li>Estradiol </li></ul></ul><ul><ul><li>Progesterone </li></ul></ul><ul><li>More subtle: </li></ul><ul><li>Infectious: </li></ul><ul><ul><li>ASO, Anti-DNAse </li></ul></ul><ul><ul><li>Candida IgG, IgA, IgM </li></ul></ul><ul><ul><li>Clostridia titers </li></ul></ul><ul><li>Inflammation </li></ul><ul><ul><li>HS – C-RP </li></ul></ul><ul><ul><li>ESR/Westergren sed rate </li></ul></ul>
    21. 24. Review slide – 2 of 2 <ul><li>Folate </li></ul><ul><li>B12 (MMA!!)* </li></ul><ul><ul><li>{irritability, apathy, pers. Changes, etc.} </li></ul></ul><ul><li>RBC Zn, RBC Mg* </li></ul><ul><ul><li>(Zn taste test) </li></ul></ul><ul><li>Copper/Ceruloplasmin </li></ul><ul><li>Serum serotonin + spot urine 5HIAA & creatinine </li></ul><ul><ul><li>Allows calc of serotonin: 5HIAA ratio </li></ul></ul><ul><li>Celiac testing: </li></ul><ul><ul><li>Antigliadin Ab, IgG, IgA, IgM </li></ul></ul><ul><ul><li>Tissue transglutaminase </li></ul></ul><ul><li>“ Functional” conventional </li></ul><ul><ul><li>Homocysteine (def of FA, B6, B12 and Omega 3) </li></ul></ul><ul><ul><li>Methylmalonic acid (for B12) </li></ul></ul>
    22. 25. Functional testing – NOW we will review <ul><li>IgG Food sensitivity </li></ul><ul><li>Organic Acid Testing </li></ul><ul><li>Comprehensive Fatty Acids </li></ul><ul><li>Urine or hair for heavy metals. </li></ul><ul><li>Amino acids - plasma </li></ul>
    23. 26. Food allergies - What to be looking for… <ul><li>Obvious GI problems </li></ul><ul><li>Atypical presentations </li></ul><ul><li>KNOWN associations (autism) </li></ul><ul><li>Symptoms varying with diet </li></ul><ul><li>Excess ABX use (candida) </li></ul><ul><li>Lack of normal progression in treatment </li></ul>
    24. 28. Bipolar Disord. 2010 Dec;12(8):834-42. Immune activation by casein dietary antigens in bipolar disorder. Severance EG, et al <ul><li>Casein IgG seropositivity conferred odds ratios of: </li></ul><ul><li>3.97 for bipolar disorder (n = 75, 95% CI); </li></ul><ul><li>5.26 for the bipolar I subtype (n = 56, 95% CI) </li></ul><ul><li>3.98 for bipolar disorder with psychosis (n = 54, 95% CI) </li></ul><ul><li>Lithium and/or antipsychotic medication did not significantly affect anti-casein IgG levels. </li></ul><ul><li>Casein IgG measures correlated with severity of manic phase of disorder </li></ul>
    25. 29. Schizophr Res . 2011 May ;128(1-3):51-5. Epub 2011 Mar 4. <ul><li>855 dx w/schizophrenia vs. 1165 age matched controls – d/c’ed from service </li></ul><ul><li>For those whose IgG (via ELISA) to casein INCREASED from first to second level , there was an 18% increase in hazard ratio of schizophrenia per unit increase </li></ul><ul><li>“ first report to ID association between risk of schizophrenia and elevated antibodies to bovine casein PRIOR TO DISEASE ONSET.” </li></ul>
    26. 30. No. Not necessarily. <ul><li>So am I OK if the IgG test for casein is negative? </li></ul>
    27. 32. “ Candida antibodies frequent cross-react with virtually every human tissue such as brain, thyroid, liver, heart.” - William S. Shaw, Ph.D.
    28. 33. Organic Acid Testing – adapted from Shaw, multiple presentations <ul><ul><li>Candida (increased carboxycitric) </li></ul></ul><ul><ul><ul><li>{associated with schizophrenia, Alz. Dz, SLE, Fibro, CFS , HIV, Depression, Colitis, PMDD, seizures, GI symptoms </li></ul></ul></ul><ul><ul><li>Clostridia ( increased HPHPA , altered DA/NE (METABOLITES) ratio , Phenylpropionic acid ) </li></ul></ul><ul><ul><ul><li>{psychosis, autism} </li></ul></ul></ul><ul><ul><li>Serotonin issues: </li></ul></ul><ul><ul><ul><li>Quinolinic acid/quinolate, 5HIAA </li></ul></ul></ul><ul><ul><li>Neurotransmitters: </li></ul></ul><ul><ul><ul><li>NE (tested via VMA) </li></ul></ul></ul><ul><ul><ul><li>Dopamine (tested via HVA) </li></ul></ul></ul><ul><ul><li>Vitamins: B vitamins, C, etc. </li></ul></ul>
    29. 35. Serotonin Quinolinic acid Gamma Interferon From immune System due to infection Kills cells containing bacteria, viruses, parasites. May also damage infectious organisms themselves. IDO causes drastic reduction in tryptophan for protein synthesis needed by infected cells and infectious organisms-tryptophan at very low levels Beta amyloid peptide-Alzheimer’s Excess tryptophan Causes failure to Kill infectious agents Cortisol Stress Reaction is NOT reversible
    30. 37. Before treatment (depression) HVA/VMA= 2.58 (Excess dopamine)
    31. 38. After treatment HVA/VMA= 1.38
    32. 39. Essential Fatty Acids – relevant for: <ul><li>“ Psych” </li></ul><ul><li>Depression </li></ul><ul><li>Bipolar depression </li></ul><ul><li>Schizophrenia </li></ul><ul><li>Autism </li></ul><ul><li>AD(H)D </li></ul><ul><li>Learning disabilities </li></ul><ul><li>“ Medical” </li></ul><ul><li>Seizures </li></ul><ul><li>Rheumatoid arthritis (& anything with inflammation) </li></ul><ul><li>Coronary heart disease (or health maintenance) </li></ul>
    33. 40. Do YOU Need an EFA panel?
    34. 41. c. 10- 20X Omega 6:3
    35. 42. <ul><li>Su, et al. Eur Neuropsychopharmacol 2007 </li></ul><ul><ul><li>9.6 g/day of DHA and EPA for 8 weeks in double blind, placebo controlled trial showed significantly decreased depression scores on the Hamilton Rating Scale </li></ul></ul><ul><li>Nemets, et al. Am J Psychiatry 2006 </li></ul><ul><ul><li>EPA and DHA supplements significantly improved symptoms of major depressive disorder in children between 6-12 yrs of age </li></ul></ul><ul><li>Mamalakis, et al. Pharmacol Biochem Behav 2006 </li></ul><ul><ul><li>An inverse relationship exists between EPA levels in adipose tissue and depression in adolescents </li></ul></ul>Fatty Acid Deficiency and Depression (from Dr. Woeller)
    36. 43. “ That which does not kill me…. Can make me SICK.” Toxins and depression <ul><li>Lead </li></ul><ul><li>Mercury </li></ul><ul><li>(Arsenic, cadmium) </li></ul><ul><li>Organophosphate pesticides </li></ul><ul><li>Carbon monoxide </li></ul><ul><li>Acetaminophen </li></ul><ul><li>Hexachlorophene-Phisohex </li></ul>
    37. 44. Metals analysis – useful to rule in or r/o toxins
    38. 45. Case study presented by Dr. Shaw: 20 yo college student with bizarre symptoms, elbow pain, mental confusion, shaking episodes, flat affect
    39. 47. <ul><li>Manganese -an essential element- 6X upper limit of normal -most abnormal result </li></ul><ul><li>Mercury - 4X upper limit of normal </li></ul><ul><li>Arsenic - 2X upper limit of normal </li></ul><ul><li>Uranium - 4X upper limit of normal </li></ul>Summary of Tests
    40. 48. <ul><li>Disorientation </li></ul><ul><li>Loss of memory </li></ul><ul><li>Anxiety </li></ul><ul><li>Bipolar symptoms </li></ul><ul><li>Violent or abnormal behavior </li></ul><ul><li>Tremors, Parkinson symptoms </li></ul><ul><li>Sources: gasoline, water, tea, cocaine </li></ul><ul><li>Symptoms all cleared by medication to remove toxic chemicals in 2 weeks-chelation </li></ul><ul><li>EDTA suppositories, DMSA </li></ul>Summary of Symptoms of Manganese Toxicity
    41. 49. Nevin R: How Lead Exposure Relates to Temporal Changes in IQ, Violent Crime, and Unwed Pregnancy. Environ Res, 2000; 83:1-22.
    42. 50. Arch Gen Psychiatry. 2009;66(12):1313-1319. Average blood lead levels were 1.61 micrograms per dL. One-fifth of participants had lead levels of 2.11 micrograms per dL, which made them 2.3 times more likely to develop major depressive disorder and 4.9 times more likely to develop panic disorder compared to other participants. Normal < 5.0 micrograms per dL.
    43. 52. Cady Wellness Institute patient <ul><li>7 year old biracial child. Dx’ed with ADHD before appointment. </li></ul><ul><li>Serious reactions to stimulants. </li></ul><ul><li>Chronically thin, but “eats as much as my fifteen year old.” </li></ul><ul><li>Lives at home with mother and father (who works at a smelter) </li></ul><ul><li>Mental Status Examination: obviously hyper. Chatty. Somewhat obnoxious. </li></ul><ul><li>Psych testing – normal IQ </li></ul>
    44. 53. Hair analysis (instead of Organic Acids) done d.t. staff error! <ul><li>Later learned of clothes washing and bathing practices, and derioration of child from early development to present </li></ul>
    45. 54. Metals analysis – not just for toxins <ul><li>Chromium – related to depression </li></ul><ul><li>Magnesium & Zinc – related to multiple psychiatric issues/conditions </li></ul>
    46. 56. Plasma amino acids
    47. 57. Bonehead obvious things to do:
    48. 58. Mental Health Support zeebra formulations Lithium Orotate DiZorb Methyl-Folate Daily Resource New Beginnings Nutritionals 913-754-0458 www.nbnus.com
    49. 59. <ul><li>Omega 3 (EPA & DHA) from cold water fish </li></ul><ul><li>Omega 6 gamma linolenic acid (GLA) from Evening Primrose Oil </li></ul><ul><li>Omega 9 (from Olive Oil) </li></ul><ul><li>Recommended Dose - 3 capsules daily with food </li></ul><ul><li>EPA (325mg), DHA (180mg), GLA (63mg) </li></ul>Balance Plus (from Dr. Woeller)
    50. 60. From Chet Holmes - Grow Your Business 10X web presentation
    51. 61. “ If you’re going to be thinking anyway, you might as well thing big.” - Donald Trump
    52. 62. Perhaps the ability not only to acquire the confidence of the patient, but to deserve it, to see what the patient desires and needs, comes through the sixth sense we call intuition, which in turn comes from wide experience and deep sympathy for and devotion to the patient , giving to the possessor remarkable ability to achieve results. ...William J. Mayo, 1935
    53. 63. Extra slides for further background follow in notes  See also: www.slideshare.com Contact info: Louis B. Cady, M.D. www.cadywellness.com Office: 812-429-0772 E-mail: [email_address] [email_address]
    54. 65. The Great Plains Laboratory, Inc. 175 compounds screened 73 different toxic chemicals Single morning urine October 2011
    55. 66. <ul><li>Markers for a wide range (73) toxic chemicals including: </li></ul><ul><li>Organophosphate pesticides - malathion, parathion, and many others - 28 total pesticides </li></ul><ul><li>Plasticizer contaminants - phthalates, 24 common compounds </li></ul><ul><li>Styrene - mandelic and phenylglyoxylic acids </li></ul><ul><li>Pyrethroid insecticides - permethrin, cypermethrin, and deltamethrin </li></ul><ul><li>Vinyl chloride </li></ul>

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